Primary Angioplasty in Acute Myocardial Infarction (eBook)

Preface 6
Contents 8
Contributors 10
Overview, Rationale, and Lexicon: Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction 12
References 15
Comparison of Reperfusion Strategies for ST Elevation Acute Myocardial Infarction: Primary Coronary Intervention Versus Fibrinolysis 20
Historical Background 20
Comparison of Clinical Outcomes 21
Clinical Outcomes from Randomized Trials 21
Clinical Outcomes from Registries 23
Comparison of Angiographic Outcomes and Myocardial Salvage 25
Angiographic Outcomes 25
Myocardial Salvage 26
ACC/AHA and ESC Guidelines for Reperfusion in STEMI 27
Fibrinolysis Versus Transfer for Primary PCI in Patients Presenting to Non-PCI Hospitals 28
Primary PCI as a Reperfusion Strategy 30
Conclusions 31
References 32
Operator and Site Requirements for Primary Coronary Intervention 37
General Considerations 38
Prehospital Phase 38
Staffing Issues 39
Pharmacological Requirements 40
Operator and Institutional Requirements 41
Requirement for On-site Surgical Backup 44
Primary PCI: Community Versus Tertiary Care Hospital 48
The Case for Community Hospital Primary PCI 48
The Case for Transfer to a Tertiary Care Hospital for Primary PCI 49
Performance Improvement: Strategies for Decreasing Door to Balloon Times 50
Quality Assurance: Audit and Peer Review 51
Conclusions 52
References 53
Primary Coronary Intervention: The Technical Approach 57
Introduction 57
Initial Contact 57
Pre-Procedure Evaluation 58
Entry into the Catheterization Laboratory 59
Coronary Angiography 60
Crossing the Lesion 60
Coronary Intervention 62
Multilesion PCI During Primary Angioplasty 64
Arrhythmia Management 65
Mechanical Complications of Infarction and Intervention 65
Thrombotic Complications 66
Alternative Devices 68
Conclusions 69
References 69
Primary Coronary Intervention in Community Hospitals with Off-Site Cardiac Surgery Backup: Rationale and Steps to Quality 74
Primary Coronary Intervention at Hospitals Without Cardiac Surgery: Role and Rationale 74
Justification for Primary Coronary Intervention Programs in Hospitals Without Cardiac Surgery 76
Key Program Elements for Hospitals Considering Primary Pci with Off-Site Cardiac Surgery Backup 79
Interdisciplinary Acute Myocardial Infarction Quality Improvement Team 79
Primary PCI Care Plans 81
Ongoing Interdisciplinary Efforts to Reduce D2B Times 84
Conclusions 87
References 88
Reducing System and Process Barriers: The RACE to Improve Door to Balloon Performance 93
Introduction 93
Systematic Barriers to Care 93
Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments 94
Funding, Leadership, and Oversight 95
Organization and Development 96
Implementation and Interventions 99
Results 103
Appendix 104
References 107
Rescue Coronary Intervention for Failed Thrombolysis 108
Introduction 108
Technical considerations 109
Key clinical factors supporting the rescue angioplasty approach 110
The evidence behind rescue PCI 111
Observational studies and retrospective subgroup analyses 111
Randomized Clinical Trials 111
Role of Delayed PCI in patients with ST-segment elevation MI 116
Conclusions 117
References 118
Facilitated Percutaneous Coronary Intervention 121
Introduction 121
Fibrinolysis-Facilitated PCI 122
Fibrinolysis Alone 122
Meta-Analyses 123
Reduced-Dose Fibrinolysis with Glycoprotein IIb/IIIa Inhibitors 125
Meta-Analysis 126
Non-Fibrinolysis-Facilitated PCI 127
High Dose Heparin 127
Glycoprotein IIb/IIIa Receptor Antagonists 128
Tirofiban 128
Abciximab 129
Eptifibatide 130
Meta-Analysis 132
Discussion and Conclusions 132
References 135
Appendix: Trial GlossaryPACTPlasminogen-activator Angioplasty Compatibility TrialPRAGUEPRimary Angioplasty in patients transferred from General community hospitals to specialized PTCA Units with or without Emergency thrombolysisGRACIA-2Grupo de Análisis de la Cardiopatía Isquémica Aguda-2 (Primary versus facilitated PCI [tenecteplase plus stenting] in patients with ST-elevated myocardial infarction)ASSENT-4Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Interven 121
Therapies Targeted at Preserving Microvascular Integrity and Preventing Reperfusion Injury 140
Microvascular Obstruction and Reperfusion Injury 140
Imaging Microvascular Obstruction 142
Clinical Management of No Reflow 143
Endothelium-Independent Vasodilators 145
Nitroglycerin 145
Adenosine 145
Nitroprusside 147
Papaverine 148
Calcium Channel Blockers 148
Verapamil 149
Diltiazem 149
Nicardipine 150
Anticoagulants, Platelet Inhibitors, and Thromobolytics 150
Unfractionated Heparin 150
Thrombolytic Drugs with Primary PCI 151
GP IIb/IIIa Inhibitors 151
Clopidogrel 153
Other Drugs and Experimental Strategies 154
Surfactants 154
ATP-sensitive Potassium Channel Openers: Nicorandil and Diazoxide 155
Agents for Direct Myocardial Protection: Cariporide and Trimetazidine 156
Modulators of Free-radical Injury: Recombinant Human Superoxide Dismutase (h-SOD) and Fluosol 157
Other Strategies 158
Catheterization Technique 159
Considerations for Drug Delivery 159
Local Drug Delivery to the Arterial Wall 160
Ischemic Preconditioning and Postconditioning 161
Contrast Agents 162
Conclusions 163
References 163
Platelet Glycoprotein IIb/IIIa Receptor Blockade in Primary Coronary Intervention 173
Rationale for Utilization of Platelet Receptor Blockers in Acute Myocardial Infarction 173
Platelet Activity in Acute Myocardial Infarction - Thrombus Composition 173
Primary Angioplasty and Platelet Activation 174
Experimental Evidence - The Concept of Dethrombosis 175
The No-Reflow Phenomenon 177
Observational Data 178
The EPIC Trial 178
IMPACT-II and RESTORE Trials 179
The Mayo Clinic Registry 179
Data from Randomized Clinical Trials 180
The GRAPE Trial 180
The RAPPORT Trial 180
The Munich Experience 182
The ADMIRAL Trial 183
The CADILLAC Trial 184
The INAMI Study 186
The ACE Trial 186
Topol Pooled Analysis 187
The (TITAN)-TIMI 34 Trial 187
Montalescot Meta-Analysis 188
De Luca Meta-Analysis 188
Glycoprotein IIb/IIIa Inhibitors and Reduced dose Fibrinolytics 189
Future Directions 190
Upstream GP IIb/IIIa Inhibitor Administration and Facilitated PCI 190
Intracoronary GP IIb/IIIa Inhibitor Administration 190
Supplementary Recommendations 191
Heparin Dosing 191
Vasodilator Therapy 191
Sheath Removal 192
Summary and Conclusions 192
References 193
Cell Therapy in Acute Myocardial Infarction 199
Introduction 199
Preclinical Science 200
Clinical Trials, Cell Types, and Delivery Strategies 200
Autologous Whole Bone Marrow by Intracoronary Infusion 200
Circulating Progenitor Cells 202
Mesenchymal Stem Cells 202
Skeletal Myoblasts 203
Cardiac Stem Cells 204
Summary and Conclusions 204
References 204
Health Economics of Primary PCI 208
Introduction 208
Cost Analysis 209
Cost-Effectiveness Analysis 210
Economics of Primary PCI 212
Primary PCI vs. Thrombolysis 212
Economics of Primary PCI vs. thrombolysis in the current era 214
Conclusions 215
References 215
Subject Index 217