American journal of cardiovascular drugs : drugs, devices, and other interventions
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Am J Cardiovasc Drugs · Jan 2001
Review Comparative StudyTenecteplase: a review of its pharmacology and therapeutic efficacy in patients with acute myocardial infarction.
Tenecteplase is a triple combination mutant variant of alteplase with high fibrin specificity and resistance to plasminogen activator inhibitor-1. The reduced rate of systemic clearance of the drug relative to alteplase allows tenecteplase to be given by rapid bolus injection to patients with acute myocardial infarction (AMI) with ST segment elevation. The efficacy of tenecteplase in AMI has been demonstrated in a phase I dose-ranging trial [Thrombolysis in Myocardial Infarction (TIMI) 10A], a nonblind phase II comparison with alteplase (TIMI 10B), and a randomized double-blind phase III comparison with alteplase in 16 949 patients [the second Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT-2) trial]. Patients also received aspirin and intravenous heparin in all trials. In TIMI 10A and 10B, TIMI grade 3 coronary flow was achieved after 90 minutes in 54.3 to 65.8% of patients receiving tenecteplase 30, 40 or 50 mg; in TIMI 10B, grade 3 flow was reported in 62.7% patients receiving alteplase (
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Available evidence of thrombolysis in acute ischemic stroke comes from a series of recent trials conducted in patients with acute stroke, and from a meta-analysis published in the Cochrane Library. The objective of this paper is to review the literature on tolerability and efficacy of thrombolytic therapy in patients with acute ischemic stroke, to find out what the level of evidence is for each thrombolytic drug, and what should consequently be done in the routine practice. This review is based on a bibliographic search of published meta-analyses of randomized trials, published randomized trials, and ongoing randomized trials, with the outcomes of disability, death, and symptomatic intracerebral hemorrhages (fatal or non-fatal). ⋯ Overall the use of alteplase in patients with acute stroke was associated with some benefit, but it significantly increased total mortality in two trials. Given the observed confidence interval (CI), the results are compatible with, in the best situtation, 203 advoided death or dependency and 61 avoided death per 1000 treated patients, and at worst 77 avoided death or dependency and 38 extra deaths per 1000 treated patients. Further trials aimed at validating more discriminant selection criteria are mandatory.
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Atrial fibrillation (AF) is the most commonly encountered sustained arrhythmia. Heart rate control, reduction of symptoms, and prevention of embolism are major goals of treatment. Whether the strategy of cardioversion with subsequent maintenance of sinus rhythm has an advantage over heart rate control is under active investigation. ⋯ Whether these approaches will reach clinical relevance merits further investigation. Intraoperative catheter ablation or surgical ablation (maze procedure) seems a promising approach for curing AF in patients undergoing cardiac surgery. Among all of the available treatment options, the most consistent proof of efficacy in reducing mortality and morbidity from AF exists for antithrombotic treatment.
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Am J Cardiovasc Drugs · Jan 2001
ReviewTransfusion medicine : support of patients undergoing cardiac surgery.
There is still no alternative that is as effective or as well tolerated as blood; nevertheless, the search for ways to conserve, and even eliminate blood transfusion, continues. Based on hemoglobin levels, practice guidelines for the use of perioperative transfusion of red blood cells in patients undergoing coronary artery bypass grafting have been formulated by the National Institutes of Health and the American Society of Anesthesiologists. However, it has been argued that more physiologic indicators of adequacy of oxygen delivery should be used to assess the need for blood transfusion. ⋯ Topical agents to prevent blood loss, such as fibrin glue and fibrin gel, and agents that alter platelet function, such as aspirin (acetylsalicylic acid) or dipyridamole, need further evaluation in patients undergoing cardiac surgery. Aprotinin has been shown to preserve hemostasis and reduce allogeneic blood exposure to a greater extent than the antifibrinolytic agents tranexamic acid and aminocaproic acid. Controlled clinical trials comparing the costs of these agents with clinical outcomes, along with tolerability profiles in patients at risk for substantial perioperative bleeding are needed.