BACKGROUND:/st> Patients with a recently implanted coronary drug-eluting stent (DES) who need urgent surgery are at increased risk of surgical bleeding unless clopidogrel is discontinued beforehand, but clopidogrel discontinuation has been associated with a high rate of adverse events due to stent thrombosis. This pilot study tested the hypothesis that the i.v. perioperative administration of the short-acting antiplatelet agent tirofiban allows the safe withdrawal of clopidogrel without increasing the rate of surgical bleeding. METHODS:/st> Phase II study with a Simon two-stage design. RESULTS:/st> Thirty patients with a recently implanted DES [median (range) 4 (1-12) months] and high-risk characteristics for stent thrombosis underwent urgent major surgery or eye surgery. Clopidogrel was to be withdrawn 5 days before surgery, and tirofiban started 24 h later, continued until 4 h before surgery, and resumed 2 h after surgery until oral clopidogrel was resumed. The use of aspirin was decided by the surgeon. There were no cases of death, myocardial infarction, stent thrombosis, or surgical re-exploration due to bleeding during the index admission, with a risk estimate of 0-11.6%(one-tail 97.5% CI). There was one case of thrombolysis in myocardial infarction (TIMI) major and one of TIMI minor bleeding in the postoperative phase; another four patients were transfused without meeting the TIMI criteria for major or minor bleeding. CONCLUSIONS:/st> In patients with a recently implanted DES and high-risk characteristics for stent thrombosis needing urgent surgery, a 'bridging strategy' using i.v. tirofiban may allow temporary withdrawal of oral clopidogrel without increasing the risk of bleeding.

Over the past 20 years, the widespread use of pharmacological and mechanical reperfusion therapies, as well as a faster delivery of care, has considerably improved survival in acute coronary syndromes. Primary percutaneous coronary intervention (PCI), in particular, has improved the long-term prognosis of patients with ST-segment elevation myocardial infarction. There are, however, particular subgroups of individuals (elderly patients, women and patients with chronic kidney disease) that require special management during PCI because of their higher risk profile and the presence of numerous other concomitant pathologies. To date, a general consensus on the management of these patients in different phases of their clinical course is still lacking, but it is largely acknowledged that patients with the highest risk profile are often denied a reperfusion treatment.

OBJECTIVES: The aim of this report was to evaluate 12-month outcomes of facilitated percutaneous coronary intervention (PCI) in the FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events) trial. BACKGROUND: Treatment delays remain common for patients with primary PCI leading to studies evaluating possible benefit of "facilitated" PCI. In the FINESSE trial, no reduction in the 90-day primary ischemic end point and an increase in bleeding were observed with both facilitated approaches, although modest favorable trends were seen for some patient subgroups. METHODS: A total of 2,452 patients with ST-segment elevation myocardial infarction (MI) and anticipated 1 to 4 h delay until catheterization were randomized to reduced-dose reteplase + abciximab, abciximab alone, or placebo, followed by expedited primary PCI. Placebo-treated patients received abciximab in the cath lab. One-year mortality was a pre-specified secondary end point. RESULTS: One-year mortalities in the 3 groups noted in the preceding text were 6.3%, 7.4%, and 7.0%, respectively (p = NS), representing 1.1%, 1.9%, and 2.5% increments since the 90-day outcome (p = 0.053 for combination treatment vs. primary PCI). A favorable trend with combination treatment was seen for patients with anterior MI (p = 0.09), but no other specified groups benefited or tended to benefit. Independent baseline correlates of 1-year mortality were systolic blood pressure <100 mm Hg, prior MI, age, Killip class >1, anterior MI, body mass index </=25 kg/m(2), heart rate >100 beats/min, and no statin use. CONCLUSIONS: These results suggest that widespread utilization of the facilitated approaches tested cannot be justified, but that high-risk patient groups such as patients with anterior MI may deserve further study.(The FINESSE trial; NCT00046228).

An aggressive pharmaco-interventional approach has been shown to improve long-term outcome among high-risk patients with acute coronary syndromes without ST-segment elevation (NSTEACS). However, these patients continue to represent a minority among those enrolled in clinical trials, thus precluding the possibility to further improve therapeutic efficacy. Target populations that are not adequately addressed by the majority of therapeutic trials are mainly the elderly and those with reduced renal function, who all show unfavorable outcome after an episode of NSTEACS. In order to allow comparison among different studies, a prerequisite for the planning of meaningful trials should be a uniform definition of the study end points besides mortality, particularly with reference to recurrent myocardial infarction, and rehospitalization owing to cardiovascular instability or severe bleeding. In addition to trial design issues, improvements in the regulatory rules for drug development and in hospital networking conceal significant opportunities to improve treatment of NSTEACS.

BACKGROUND: The role of emergency reperfusion therapy in patients with ST-elevation myocardial infarction (STEMI) resuscitated after an out-of-hospital cardiac arrest (OHCA) has not been clearly established yet. The aim of this study was to evaluate the in-hospital and postdischarge outcomes of STEMI patients surviving OHCA and undergoing emergency angioplasty (percutaneous coronary intervention [PCI]) within an established regional network. METHODS: We prospectively collected data on 2,617 consecutive patients with STEMI treated with emergency PCI in 2005; in-hospital and 6-month outcomes of 99 patients who had experienced OHCA were compared with those of 2,518 patients without OHCA. The OHCA patients also underwent a cerebral performance evaluation after 12 months. RESULTS: OHCA patients were at higher clinical risk at presentation (cardiogenic shock 26% vs 5%, P <.0001). Percutaneous coronary intervention was successful in 80% of the OHCA and 89% of the non-OHCA patients (P = NS). In-hospital mortality rates were 22% and 3%, respectively (P <.0001). Independent predictors of in-hospital mortality among OHCA patients were longer delay between the call to the emergency medical system and the start of cardiopulmonary resuscitation (odds ratio [OR] 3.5, P =.03), nonshockable initial rhythms (OR 10.5, P =.002), cardiogenic shock (OR 3.05, P =.035), and a Glasgow Coma Scale score of 3 on admission (OR 2.9, P =.032). The 6-month composite rate of death, myocardial infarction, and revascularization among OHCA patients surviving the acute phase was comparable to that of non-OHCA patients (16% vs 13.9%, P = NS), and 87% of them showed a favorable neurologic recovery after 1 year. CONCLUSIONS: Resuscitated OHCA patients undergoing emergency PCI for STEMI have worse clinical presentation and higher in-hospital mortality compared to those without OHCA. However, subsequent cardiac events are similar, and neurologic recovery is more favorable than reported in most previous series.

BACKGROUND: The optimal treatment strategy for elderly patients presenting with ST-elevation myocardial infarction is still controversial and few investigations have studied this high-risk population in a community setting. METHODS: We analyzed data from the BLITZ survey on patients with any acute myocardial infarction admitted to the Italian Coronary Care Unit (CCU) network, in order to assess current treatment strategies among unselected patients older than 75 years presenting with ST-elevation myocardial infarction. We also evaluated the 30-day rates of major adverse cardiovascular events (death/re-myocardial infarction/stroke) relative to different treatment strategies. RESULTS: The registry included 1959 patients, of whom 529 (27%) were over 75 years old. According to the ECG on admission, 296 of these patients (56%) were classified as having ST-elevation myocardial infarction: 26 (8.8%) underwent primary percutaneous coronary intervention, 101 (34.1%) were treated with systemic thrombolysis, and the remaining 169 (57.1%) did not receive any early reperfusion therapy. At 30-day follow-up, the cumulative rate of major adverse cardiovascular events was not significantly different among the three treatment modality groups (31.4, 27.7, and 23.1% among no reperfusion, thrombolysis and primary percutaneous coronary intervention groups, respectively; P = 0.59). On multivariable analysis, age [odds ratio (OR) x 5-year increment 1.5; 95% confidence interval (CI) 1.2-2.0; P = 0.007], Killip class II-IV at admission (OR 3.7; 95% CI 2.1-6.3; P < 0.0001), and coronary multivessel disease (OR 2.4; 95% CI 1.1-5.3; P = 0.03) were the only independent predictors of major adverse cardiovascular events. CONCLUSION: In a nationwide clinical practice, the vast majority of patients older than 75 years presenting with ST-elevation myocardial infarction does not receive any early reperfusion treatment and presents a significant incidence of major clinical events at 30 days.

INTRODUCTION: A relevant proportion of patients with ST-segment elevation myocardial infarction may develop cardiogenic shock after presentation, and the identification of these patients would be very important in order to improve their outcome. The aim of the current study was to identify, among patients in the BLITZ-1, the clinical predictors, and describe the outcome of patients who developed cardiogenic shock during hospitalization. METHODS: The study was a nationwide survey of patients admitted to a coronary care units for an acute myocardial infarction with or without ST-segment elevation myocardial infarction in October 2001. The 30-day follow-up was conducted by hospital visits and concerned major cardiac events occurred from hospital discharge. RESULTS: A total of 1345 patients presenting with ST-segment elevation myocardial infarction or left bundle branch block/pacemaker were included in this analysis. A total of 97 patients (7.2%) had cardiogenic shock, 26 patients at presentation, whereas 71 patients (73.2%) developed shock during hospital stay.Mortality was 71.8% among patients who developed cardiogenic shock during hospitalization as compared with 65.4% among those who were already in shock upon admission (P = 0.54). By multivariable analysis, we identified Killip class more than 1, lower systolic blood pressure at presentation, older age, unsuccessful reperfusion and diabetes as independent predictors of developing shock during hospitalization. CONCLUSION: The present study shows that the largest proportion of cardiogenic shock complicating ST-segment elevation myocardial infarction is observed after initial hospitalization, particularly in patients with Killip class more than 1, low systolic blood pressure at presentation and advanced age. The identification of these patients may help in preventing this complication by more aggressive pharmacological therapies, mechanical haemodynamic support, as well as coronary revascularization.

We describe four cases of patients with multiple coronary drug eluting stent implantation who underwent major surgery (cardiac and noncardiac) early after stent implantation and needed premature interruption of dual antiplatelet therapy. The transitory withdrawal of oral antiplatelet therapy was accomplished without complications with the use of an IIb/IIIa glycoprotein inhibitor (Tirofiban).