Oliver Koeth

Efficacy and safety of enoxaparin in unselected patients with ST-segment elevation myocardial infarction.

In randomized clinical trials the low-molecular-weight heparin enoxaparin has been shown to reduce ischemic complications in patients with acute ST elevation myocardial infarction (STEMI) treated with fibrinolysis. Little is known about the use and efficacy of enoxaparin in unselected patients with STEMI in clinical practice. In a retrospective analysis of the prospective ACOS registry we compared the outcomes of patients with STEMI treated with enoxaparin or unfractionated heparin. A total of 6,299 patients with STEMI < 12 hours were included in this analysis, 609 (10%) were treated with enoxaparin and 5,690 (90%) with unfractionated heparin. In the multivariable propensity score analysis enoxaparin was associated with a reduction in the combined endpoint of death and non-fatal reinfarction in the entire group (odds ratio 0.59; 95% CI 0.43-0.80) and the subgroups of patients treated without early reperfusion (odds ratio 0.65, 95% CI 0.43-0.97), fibrinolysis (odds ratio 0.64; 95% CI 0.33-1.26) and primary percutaneous coronary intervention (odds ratio 0.33; 95% CI 0.15-0.72). There was no significant increase in severe bleeding complications with enoxaparin (6.5% versus 5.5%, p = 0.4). In clinical practice in unselected patients with STEMI treated with or without early reperfusion therapy early treatment with enoxaparin compared to unfractionated heparin is associated with a significant reduction of the combined endpoint of inhospital death and reinfarction without a significant increase in severe bleeding complications.

Guideline-recommended secondary prevention drug therapy after acute myocardial infarction: predictors and outcomes of nonadherence:

Background Guideline-recommended pharmacotherapy after myocardial infarction (MI) has been shown to reduce cardiovascular morbidity and mortality. Our objectives were to determine factors of, and to measure outcomes associated with nonadherence after MI. Design Multicentre, prospective, observational study (Acute Coronary Syndromes Registry). Methods We analyzed data of 11 823 consecutive hospital survivors of acute MI and evaluated their discharge medication with the five following drugs: acetyl salicylic acid, clopidogrel, β-blocker, angiotensin-converting enzyme inhibitor/sartan and statin. Patients receiving less than four drugs (group 1, n = 3439, 29.1%) were compared with those receiving 4–5 drugs (group 2, n = 8384, 70.9%). The impact of clinical, demographic and treatment factors on not prescribing each of these five drugs at discharge was investigated by using multiple logistic regression models. Results Patients of group 1 were older, had more comorbidities, more frequently suffered a nonST elevation MI and less often received reperfusion therapy. In the multivariate analysis, group 1 was associated with an increased risk for death at 1-year follow-up [odds ratio (OR): 1.6, 95% confidence interval (CI): 1.4–1.9]. After adjustment for confounding variables chronic oral anticoagulation was the strongest predictor for not receiving acetyl salicylic acid (OR: 19.6, 95% CI: 15.9–24.0) at discharge, no percutaneous coronary intervention within 48 h for not receiving statin (OR: 2.1, 95% CI: 1.9–2.4) and clopidogrel (OR: 10.4,95% CI: 9.4–11.5), chronic obstructive lung disease for not receiving β-blocker (OR: 4.2,95% CI: 3.6–4.9) and chronic renal insufficiency for not receiving angiotensin-converting enzyme inhibitor/sartan (OR: 2.8, 95% CI: 2.2–3.5). Conclusion In clinical practice guideline-adherent secondary prevention drug therapy is linked with an improved 1-year survival. Comorbidities and no interventional treatment were strong negative predictors for guideline-adherent discharge medication.

Efficacy and safety of enoxaparin in combination with and without GP IIb/IIIa inhibitors in unselected patients with ST segment elevation myocardial infarction treated with primary percutaneous coronary intervention

AIMS We sought to determine the efficacy of enoxaparin in unselected patients with STEMI treated with primary percutaneous coronary intervention in clinical practice. METHODS AND RESULTS In a retrospective analysis of the prospective MITRA-plus registry we compared the outcomes of patients with primary PCI and either enoxaparin or unfractionated heparin. A total of 2,655 patients with STEMI < 12 hours were included in this analysis, 374 (14%) were treated with enoxaparin and 2,281 (86%) with unfractionated heparin. In the univariate analysis enoxaparin reduced mortality (1.6% versus 6.0%, < 0.001), fewer non-fatal reinfarctions (1.9% versus 3.8%, p = 0.05) and no significant difference in major bleeding (5.6% versus 7.2%, p = 0.2) was observed. In the multivariable propensity score analysis enoxaparin was associated with a reduction in the combined endpoint of death and non-fatal reinfarction (odds ratio 0.42; 95% CI 0.2-0.8). This advantage was observed both in subgroups without (odds ratio 0.33 95% CI 0.1-0.8) and with GP IIb/IIIa inhibitors (odds ratio 0.44, 95% CI 0.2-1.0). CONCLUSIONS Our data suggest that in unselected patients with STEMI treated with primary PCI enoxaparin compared to unfractionated heparin reduces the combined endpoint of in-hospital death and reinfarction and does not increase severe bleeding complications.

Clopidogrel in addition to aspirin reduces in-hospital major cardiac and cerebrovascular events in unselected patients with acute ST segment elevation myocardial

We sought to assess the effect of clopidogrel on in-hospital events in unselected patients with acute ST elevation myocardial infarction (STEMI). In a retrospective analysis of consecutive patients enrolled in the Acute Coronary Syndromes (ACOS) registry with acute STEMI we compared outcomes of either adjunctive therapy with aspirin alone or aspirin plus clopidogrel within 24 hours after admission.A total of 7,559 patients were included in this analysis, of whom 3,541 were treated with aspirin alone, and 4,018 with dual antiplatelet therapy. The multivariable analysis with adjustment for baseline characteristics and treatments showed that the rate of in-hospital MACCE (death, non-fatal reinfarction, non-fatal stroke) was significantly lower in the aspirin plus clopidogrel group,compared to the aspirin alone group in the entire cohort and all three reperfusion strategy groups (entire group odds ratio 0.60, 95% CI 0.49-0.72 , no reperfusion OR 0.69,95% CI 0.51-0.94,fibrinolysis OR 0.62,95% CI 0.44-0.88, primary PCI OR 0.54, 95% CI 0.39-0.74). There was a significant increase in major bleeding complications with clopidogrel (7.1% vs. 3.4%, p<0.001). In clinical practice early adjunctive therapy with clopidogrel in addition to aspirin in patients with STEMI is associated with a significant reduction of in-hospital MACCE regardless of the initial reperfusion strategy. This advantage was associated with an increase in major bleeding complications.

Clinical Benefit of Early Reperfusion Therapy in Patients With ST-Elevation Myocardial Infarction Usually Excluded from Randomized Clinical Trials (Results from the Maximal Individual Therapy in Acute Myocardial Infarction Plus [MITRA Plus] Registry)

Randomized clinical trials (RCTs) usually enroll selected patient populations that may not be representative for patients seen in everyday practice. Therefore, concerns have been raised regarding their external validity. For the present study we evaluated the MITRA Plus registry and included 20,175 patients with ST-elevation myocardial infarction. We defined RCT-ineligible patients as patients fulfilling >or=1 of the following criteria: age >or=75 years, prehospital delay >12 hours, prehospital cardiopulmonary resuscitation, cardiogenic shock, impaired renal function, and previous stroke. Those patients (n = 9,369, 46.4%) were compared to patients eligible for enrollment in RCTs (n = 11,806, 53.6%). Ineligible patients were older (p <0.0001), more often were women (p <0.0001), and more often had concomitant diseases (p <0.0001). Ineligible patients less often received early reperfusion therapy (p <0.0001), aspirin (p <0.0001), clopidogrel (p <0.0001), and statins (p <0.0001). Ineligible patients had a higher hospital mortality (20.1% vs 4.9%; p <0.0001) and a higher rate of nonfatal strokes (1.5% vs 0.4%, p <0.0001) compared to eligible patients. Early reperfusion therapy (thrombolysis and/or percutaneous coronary intervention [PCI]) in ineligible patients was associated with a significant decrease of hospital mortality (odds ratio 0.62, 95% confidence interval 0.49 to 0.79), with primary PCI being more effective than thrombolytic therapy (odds ratio 0.52, 95% confidence interval 0.41 to 0.65). In conclusion, about 50% of patients with ST-elevation myocardial infarction seen in clinical practice are usually excluded from RCTs. Hospital mortality in those patients is very high. Primary PCI improves the prognosis and is therefore the preferred reperfusion strategy in these patients.

Effect of chronic statin pretreatment on hospital outcome in patients with acute non-ST-elevation myocardial infarction.

Purpose: We sought to investigate the impact of prior statin therapy on in-hospital outcome in patients presenting with acute non-ST-elevation myocardial infarction. Methods and Results: We analyzed the data of consecutive patients with non-ST-elevation myocardial infarction who were prospectively enrolled in the German Acute Coronary Syndrome Registry between July 2000 and November 2002. Overall, 6358 patients were included, and we compared the patients who received statins before hospital admission (n = 1247, 19.6%) with those who did not (n = 5111, 80.4%). There was no age difference between the two groups; however, pretreated patients had a higher incidence of prior atherothrombotic events diabetes mellitus and renal insufficiency. The percentage of patients undergoing percutaneous coronary intervention and coronary artery bypass grafting was similar. Infarct size measured by peak creatine kinase level was lower in statin users (238 vs. 283U/L, P < 0.0001). After adjustment for confounding variables, a significant reduction of in-hospital death could be observed in patients on statins (odds ratio 0.65, 95% confidence interval 0.46-0.90). Conclusions: In clinical practice, pretreatment with statins was associated with smaller myocardial infarction size (peak creatine kinase level) and a significant reduction of hospital mortality. However, the data were obtained from an observational study, and the results need further prospective confirmation.

Fate of Patients With Prehospital Resuscitation for ST-Elevation Myocardial Infarction and a High Rate of Early Reperfusion Therapy (Results from the PREMIR [Prehospital Myocardial Infarction Registry])

Patients with acute ST-segment elevation myocardial infarction (STEMI) needing prehospital cardiopulmonary resuscitation (CPR) have a very high adverse-event rate. However, little is known about the fate of these patients and predictors of mortality in the era of early reperfusion therapy. From March 2003 through December 2004, 2,317 patients with prehospital diagnosed STEMI were enrolled in the Prehospital Myocardial Infarction Registry. One hundred ninety patients (8.2%) underwent prehospital CPR and were included in our analysis. Overall 90% of patients were treated with early reperfusion therapy, 56.3% received prehospital thrombolysis and 1/2 of these patients received early percutaneous coronary intervention after thrombolysis, 28.4% of patients were treated with primary percutaneous coronary intervention, and 5.3% received in-hospital thrombolysis. Total mortality was 40.0%. The highest mortality was seen in patients with asystole (63%) or pulseless electric activity (64%). Independent predictors of mortality were need for endotracheal intubation and older age, whereas ventricular fibrillation as initial heart rhythm was associated with survival. In conclusion, in this large registry with prehospital diagnosed STEMI, incidence of prehospital CPR was about 8%. Even with a very high rate of early reperfusion therapy, in-hospital mortality was high. Especially in elderly patients with asystole as initial heart rhythm and with need for endotracheal intubation, prognosis is poor despite aggressive reperfusion therapy.

Inferior ST-Elevation Myocardial Infarction Associated with Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TCM) is usually characterized by transient left ventricular apical ballooning. Due to the clinical symptoms which include chest pain, electrocardiographic changes, and elevated myocardial markers, Takotsubo cardiomyopathy is frequently mimicking ST-elevation myocardial infarction in the absence of a significant coronary artery disease. Otherwise an acute occlusion of the left anterior descending coronary artery can produce a typical Takotsubo contraction pattern. ST-elevation myocardial infarction (STEMI) is frequently associated with emotional stress, but to date no cases of STEMI triggering TCM have been reported. We describe a case of a female patient with inferior ST-elevation myocardial infarction complicated by TCM.

Midventricular form of takotsubo cardiomyopathy as a recurrence 1 year after typical apical ballooning: a case report

Takotsubo cardiomyopathy was first described in Japan and is characterized by transient left ventricular apical ballooning in the absence of a significant coronary artery disease.Caused by the clinical presentation including chest pain, electrocardiographic changes and elevated myocardial markers this syndrome is frequently misdiagnosed as an acute coronary syndrome. Recurrences of Takotsubo Cardiomyopathy, especially in variant regions of the left ventricle are rareWe describe a midventricular form of Takotsubo Cardiomyopathy as a recurrence 1 year after typical apical ballooning.

Primary percutaneous coronary intervention and thrombolysis improve survival in patients with ST-elevation myocardial infarction and pre-hospital resuscitation☆☆☆

BACKGROUND Patients with ST-elevation myocardial infarction (STEMI) surviving pre-hospital resuscitation represent a selected subgroup of patients with a very high adverse event rate. Only few data on the outcome of primary percutaneous coronary intervention (primary PCI) and thrombolysis in such patients are available. METHODS We analysed the Maximal Individual Therapy of Acute Myocardial Infarction (MITRA) Plus registry. 1529 survivors of pre-hospital resuscitation with STEMI were included. 593 (38.8%) of those patients did not receive early reperfusion therapy, 793 (51.9%) patients received thrombolysis and 143 (9.4%) patients received primary PCI. Hospital mortality in patients receiving primary PCI or thrombolysis was adjusted for confounding factors with a propensity score analysis. RESULTS Primary PCI as well as thrombolysis in survivors of pre-hospital resuscitation with STEMI were associated with a significant reduction of hospital mortality (OR: 0.29, 95% CI 0.17-0.50; and 0.74, 95% CI 0.54-0.99, respectively), while primary PCI was superior compared to thrombolysis (OR 0.50, 95% CI 0.30-0.84). CONCLUSION Reperfusion therapy improves mortality of patients with STEMI surviving pre-hospital resuscitation, while primary PCI seems to be more effective than thrombolysis.