American heart journal
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American heart journal · Jun 2006
Randomized Controlled Trial Multicenter StudyEvaluation of a novel anti-ischemic agent in acute coronary syndromes: design and rationale for the Metabolic Efficiency with Ranolazine for Less Ischemia in Non-ST-elevation acute coronary syndromes (MERLIN)-TIMI 36 trial.
Despite advances in antithrombotic therapies and invasive technology, the risk of recurrent ischemic complications in patients with non-ST-elevation acute coronary syndromes (NSTE-ACSs) remains substantial. Ranolazine is a novel agent that inhibits the late sodium current thereby reducing cellular sodium and calcium overload and has been shown to reduce ischemia in patients with chronic stable angina. ⋯ MERLIN-TIMI 36 will evaluate the role of ranolazine in the acute and chronic management of patients presenting with NSTE-ACS.
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American heart journal · Jun 2006
ReviewRole of fibrinolytic therapy in the current era of ST-segment elevation myocardial infarction management.
In patients presenting with ST-elevation myocardial infarction, early, effective reperfusion of the culprit artery is needed to salvage myocardium, maintain left ventricular function, and reduce mortality. According to American College of Cardiology/American Heart Association guidelines for the treatment of these patients, the time from medical contact (i.e., firm ST-elevation myocardial infarction diagnosis) to initiation of fibrinolytic therapy (door-to-needle time) should be 30 minutes, and the time from medical contact to percutaneous coronary intervention (PCI) (door-to-balloon time) should be 90 minutes. Because many patients present to hospitals that are not equipped to administer PCI, door-to-balloon time often falls far short of the ideal. When PCI is not readily available, efficient prehospital treatment with t-PA-based fibrinolytic agent formulations that can be delivered in a bolus and do not require weight-based adjustment may reduce mortality rates and result in outcomes similar to PCI when administered promptly.
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American heart journal · Jun 2006
The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) study: design, rationale, and run-in phase.
Changes in the treatment of coronary artery disease both surgically and percutaneously have rendered the major randomized trials historical. Furthermore, the restrictive criteria of previous trials excluded most patients treated in daily practice. Although coronary surgery is still considered the current, evidence-based, gold-standard treatment of left main (LM) and 3-vessel coronary disease, the added benefit of drug-eluting stents has further expanded the use of percutaneous coronary intervention (PCI) beyond less complex populations in daily practice. ⋯ By replacing most traditional inclusion and exclusion criteria with the real-world decision between the cardiothoracic surgeon and the interventionalist, this study will define the roles of CABG and PCI using drug-eluting stents in the contemporary management of LM and 3VD. Results of the run-in phase were used by the steering committee to determine eligibility and to project enrollment for each site.
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American heart journal · Jun 2006
Door-to-drug and door-to-balloon times: where can we improve? Time to reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI).
To better understand hospital performance in door-to-drug and door-to-balloon times for patients with STEMI, we examined hospital-level variation in key subintervals of door-to-drug time (door-to-electrocardiogram [ECG] and ECG-to-drug) and of door-to-balloon time (door-to-ECG, ECG-to-lab, lab-to-balloon). We sought to identify achievable subinterval times based on the experience of top performing hospitals. ⋯ Substantial national attention is being directed at improving time to treatment of patients with STEMI. These data suggest achievable subinterval times for hospitals seeking to improve performance in this important quality indicator.
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American heart journal · Jun 2006
Comparative StudyFeasibility and benefit of prehospital diagnosis, triage, and therapy by paramedics only in patients who are candidates for primary angioplasty for acute myocardial infarction.
Despite data showing that time to treatment is very important in ST-elevation myocardial infarct patients, unacceptable long delays to reperfusion remain present in daily life practice. We sought to evaluate the feasibility and effect of improving logistics by early infarct diagnosis in the ambulance and immediate triage to a percutaneous coronary intervention (PCI) center performed by paramedics only without interference of a physician. ⋯ Early, prehospital infarct diagnosis, triage, and therapy in the ambulance with direct transportation to the nearest PCI center, performed by trained paramedics only, is feasible in 95% of patients. Ambulance triage resulted in earlier diagnosis and initiation of therapy and was independently associated with a better left ventricular function and clinical outcome, as compared with triage and transportation from a referral non-PCI center.