An Early and Complete Reperfusion Strategy for Acute Myocardial Infarction Using Fibrinolysis and Subsequent Transluminal Therapy. The FAST Trial.

he goal of reperfusion therapy for acute myocardial infarction (AMI) is to reestablish Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow 1 in the epicardial infarct-related artery and myocardial reperfusion as early as possible. [2][3][4] Although thrombolytic therapy has the advantage of shortening the time to reperfusion, the rate of achieving TIMI grade 3 flow remains unsatisfactory. In contrast, primary percutaneous coronary intervention (PCI) has the advantage of a higher rate of TIMI grade 3 flow, but the delays prior to reperfusion can be substantial. Therefore, thrombolytic therapy immediately followed by PCI has lately attracted considerable attention as an alternative strategy. [5][6][7][8] Although pre-interventional patency in patients with primary PCI is reported to predict a favorable outcome, 9,10 little is known about the significance of early pre-interventional reperfusion using thrombolytic drugs. We prospectively examined the relationship of infarct size and left ventricular function to TIMI grade flow at 45 min after thrombolysis followed by immediate PCI if the grade flow of the infarct-related artery was TIMI grade 2 flow or less. Methods Study PopulationThe study group comprised 134 consecutive patients (mean age 60±9 years [range 36-80]; 113 men, 21 women) admitted to hospital within 6 h of symptom onset from August 2000 through August 2002. Patients were required to have typical chest pain lasting at least 20 min, associated with ST-segment elevation of at least 1.0 mm in at least 2 limb leads, or at least 2.0 mm in at least 2 contiguous precordial leads. Patients were excluded if they had shock, previous cerebrovascular disease, active bleeding lesions, or any other condition that contraindicated thrombolytic therapy. All patients were given 162 mg oral aspirin, 5,000 units intravenous heparin, and 800,000 units (approximately half the standard dose) intravenous monteplase. Monteplase is a mutant tissue plasminogen activator developed in Japan that can be given as a single-bolus intravenous injection. It is characterized by a long alpha half-life and rapid restoration of TIMI grade 2 or 3 flow. 11 Eighty-five patients were also given 200 mg oral sarpogrelate hydrochloride, a serotonin receptor antagonist, as an antiplatelet drug. 12 The protocol was approved by the internal review board of the hospital and all the patients provided written informed consent. Coronary AngiographyCardiac catheterization was performed immediately after medication. We prospectively evaluated TIMI grade flow in the infarct-related artery 45±3 min after thrombolysis. If TIMI grade flow at this time was 0, 1, or 2, immediate PCI, and 50 patients with TIMI grade 3 flow (group T3) were treated conservatively after thrombolysis. Although the door-to-balloon times did not differ in groups T0 and T2, group T2 had lower peak creatine kinase, a higher rate of complete (≥70%) ST resolution and better regional wall motion at discharge as compared with group T0, similar to group T3 (group T2, group T3 vs group T0...

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confidence: 99%

Significance of Thrombolysis in Myocardial Infarction (TIMI) Grade 2 Flow Early After Thrombolysis Followed by Immediate Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction.

Okuda

Kimura

Kosuge

et al. 2003

“…If TIMI grade 22 0, 1 or 2 flow was observed in the infract-related artery, emergency percutaneous coronary intervention (PCI) was immediately performed. 23,24 If hemodynamic improvement was not seen in cases of acute coronary syndrome (ACS) with ST depression, emergency coronary angiography was performed immediately, followed by PCI or coronary arterial bypass graft surgery if necessary. If hemodynamic improvement did occur in cases of ACS with ST depression, coronary angiography was performed 12-48 h later, followed by PCI or coronary arterial bypass graft surgery if necessary.…”

Section: Treatment Of Cardiogenic Shockmentioning

confidence: 99%

Prognostic Value of Blood Glucose in Patients With Cardiogenic Shock

Tada

Nagao

Tanjoh

et al. 2006

Self Cite

Background Although an elevated blood glucose has prognostic value in cardiovascular disease, few data are available regarding its prognostic value for patients across the spectrum of cardiogenic shock. Method and Results A total of 81 patients with cardiogenic shock whose blood glucose and adrenaline were measured on arrival at the emergency room (ER) were enrolled in this prospective study. The primary endpoint was death from any cause in hospital. The rate of death was 12.3% (10/81), and the glucose level was lower among patients who were discharged alive than among those who died (8.7±3.7 mmol/L vs 13.8±6.7 mmol/L, p<0.001). The unadjusted rate of death increased in a stepwise fashion among patients in increasing quartiles of glucose level (p<0.05). The blood glucose level of 9.2 mmol/L had the highest combined sensitivity and specificity for the identification of death. In the multiple logistic-regression analysis for the primary outcome, the adjusted odd ratio for a glucose level of 9.2 mmol/L or more was 5.8 (95% confidence interval, 1.0-32.8, p=0.047). There was a significant positive correlation between the glucose and adrenaline levels (R=0.726, p<0.0001). Conclusion The measurement of blood glucose level on ER arrival provides predictive information for use in risk stratification across the spectrum of cardiac emergencies complicated by cardiogenic shock. (Circ J 2006; 70: 1064 -1069

“…In the patients evaluated in the present study, the final rate of TIMI-3 patency was 96%, the incidence of hemorrhagic complications requiring blood transfusion was 5% (as compared to 4% previously), and there were no cases of cerebral hemor- rhage observed. 9 In the PACT trial, a low-dose of t-PA was given to avoid hemorrhagic complication. A full-dose of mutant t-PA was given in the FAST 3 trial to achieve the high rate of early recanalization before PCI.…”

Section: Facilitated Percutaneous Coronary Interventionmentioning

confidence: 99%

“…The present study group has reported a favorable therapeutic outcome of this trial. FAST therapy, including FAST-1, 9 and FAST-2, 10 in which t-PA or mutant t-PA is used, reduced the incidence of myocardial damage with the risk of complications. In the FAST-3 trial, in which the relationship between the "Door-to-TIMI-3" time and the extent of myocardial salvage was also assessed, 11 the "Door-to-TIMI-3" time was confirmed to have considerable influence on the extent of the infarction, and based on the results of the trial, a "Door-to-TIMI-3" time of 55 min was recommended.…”

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confidence: 99%

Relationship Between the Generation and the Facilitated Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction-Analysis Based on the Fibrinolysis and Subsequent Transluminal Trial-

Watanabe

Nagao

Tani

et al. 2004

Self Cite

ne of the most important factors influencing the success of treatment of acute myocardial infarction (AMI) is the speed with which revascularization of the involved coronary arteries can be accomplished. According to the guidelines issued by the American Heart Association (AHA) and American College of Cardiology (ACC), patients under 75 years of age with myocardial infarction should be administered thrombolytic therapy within 30 min of "Door-to-Needle" time, or by percutaneous coronary intervention (PCI) within 90±30 min of "Door-toBalloon" time. [1][2][3][4] Since a report of favorable outcomes in the PACT trial, 5 facilitated PCI, in which PCI is conducted after anticipatory administration of thrombolytic therapy, has been drawing attention. 6-8 Facilitated PCI is considered to be a promising treatment strategy, based on the following consideration; the overall therapeutic outcome of AMI may be improved even at institutions where PCI cannot be Circulation Journal Vol.68, December 2004 performed, since a therapeutic outcome equivalent to or superior to that obtained by primary PCI may be achieved by anticipatory administration of a thrombolytic agent, followed by PCI at a suitable institution after the transfer of the patient. Group involved in the present study has devised a treatment strategy consisting of FAST therapy for patients in whom a diagnosis of AMI can be made immediately after arrival at the hospital. In the FAST therapy, intravenous administration of a mutant tissue-type plasminogen activator (t-PA), which can be administered rapidly as a bolus injection, is followed by coronary angiography, and then, PCI is conducted in patients in whom TIMI-3 has not been achieved as evaluated by the coronary angiography (CAG). The present study group has reported a favorable therapeutic outcome of this trial. FAST therapy, including FAST-1, 9 and FAST-2, 10 in which t-PA or mutant t-PA is used, reduced the incidence of myocardial damage with the risk of complications. In the FAST-3 trial, in which the relationship between the "Door-to-TIMI-3" time and the extent of myocardial salvage was also assessed, 11 the "Door-to-TIMI-3" time was confirmed to have considerable influence on the extent of the infarction, and based on the results of the trial, a "Door-to-TIMI-3" time of 55 min was recommended. Taking into consideration the present situation in Japan, in which the age of the population is steadily increasing, we investigated the limitations of the FAST-3 therapy imposed by age, the safety of the treatment protocol in various age groups, and the indications for the FAST-3 protocol. Background The purpose of the present study was to evaluate the efficacy and safety of facilitated percutaneous coronary intervention (PCI) in comparing young and elderly patients with acute myocardial infarction. Methods and ResultsThe present study enrolled 168 initial myocardial infarction patients within 12 h of the symptom onset between 40 and 80 years of age who were indicated on the fibrinolysis and subsequent transluminal ...