Direct percutaneous transluminal coronary angioplasty in acute myocardial infarction. Predictors of short-term outcome and the impact of coronary stenting

Vogt, A.; Niederer, W.; Pfafferott, C.; Engel, H.-J.; Heinrich, Karl-Wilhelm; Merx, W; Jehle, J; Neuhaus, Karl-Ludwig

doi:10.1053/euhj.1997.0835

Cited by 24 publications

(10 citation statements)

References 16 publications

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“…For example, national surveys have been undertaken of the early management of acute myocardial infarction in Sweden [3] , Germany [4] and France [5,6] , and of coronary artery bypass graft surgery in the U.K. [7] . However, few surveys have been undertaken on a pan-European basis and none has addressed the acute management of the whole spectrum of acute coronary syndromes.…”

Section: Introductionmentioning

confidence: 99%

The ENACT study: a pan-European survey of acute coronary syndromes

Fox¹

2000

European Heart Journal

208

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AimThe European Network for Acute Coronary Treatment (ENACT) study was designed to collect prospective information across Europe on the relative frequency, diagnosis and management of the whole spectrum of acute coronary syndromes.Methods Cardiologists, who were respondents to mailings sent out to 17 European countries with the target of reaching one centre per million inhabitants, completed a prospective patient record, each physician providing information on 10 consecutive patients with a working diagnosis on admission of acute coronary syndrome, and a questionnaire.Results A total of 390 responses were received (0·91/10 6 population) with data on 3092 patients in 29 countries. The patient population comprised 1431 (46%) with an initial working diagnosis of unstable angina/non-ST-segment elevation myocardial infarction, 1205 (39%) with myocardial infarction and 445 (14%) with suspected acute coronary syndrome. The ratio of unstable angina to myocardial infarction was 1·2:1 and this was similar across Europe. An initial diagnosis of myocardial infarction was more likely to be confirmed than unstable angina or suspected acute coronary syndrome. There were wide variations in the rates of angiography and percutaneous coronary intervention across Europe. Most unstable angina patients received aspirin, nitrates and heparin (unfractionated heparin 44% intravenous, 16% subcutaneous; low-molecular-weight heparin 50%). Overall, 50% of unstable angina patients and 34% of myocardial infarction patients received lowmolecular-weight heparin and 6% and 8% respectively received a glycoprotein IIb/IIIa inhibitor, but there were large inter-country differences. There were also national differences in the use of calcium antagonists, angiotensinconverting enzyme inhibitors and beta-blockers. ConclusionThe ENACT study provides robust data, for the first time, on the relative frequency of unstable angina and acute myocardial infarction across Europe. It provides insight into differences in management across Europe and a reference benchmark of current treatment.

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Section: Introductionmentioning

confidence: 99%

The ENACT study: a pan-European survey of acute coronary syndromes

Fox¹

2000

European Heart Journal

208

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“…These figures represent 698 PTCAs p.m.p in 1992 and 1,537 in 1996, or about 85% of the US rate for 1996. The percentage of PTCA procedures using stents also increased from 1% in 1992 to 53% in 1997 [2,12]. Banz and Schwicker [13] conducted a further analysis for Germany, using patient outcomes based on the BENE-STENT II clinical trial and 1995 unit cost data for Germany.…”

Section: Germanymentioning

confidence: 99%

International review of the utilisation and cost of percutaneous transluminal coronary angioplasty

Lecomte¹,

McKenna²,

Kennedy³

et al. 2001

The European Journal of Health Economics (HEPAC)

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We reviewed information published between 1990 and March 2001 to ascertain trends in the utilisation of percutaneous transluminal coronary angioplasty (PTCA) and to determine the availability of cost data.Our review encompassed Australia, Canada, France, Germany, Italy, Sweden, the United Kingdom, and the United States.The number of PTCAs increased in all countries studied during the 1990s.While the rate of PTCA use in all European countries lags behind that of the US, Germany and France are approaching the US rate, and the uptake of PTCA among European countries is increasing rapidly after a slow start.With regard to PTCA cost data, direct international comparisons are difficult since patient populations, methodological factors, and the timing and location of each study contributed to the differences observed between and within the studies reviewed. The increasing number of patients receiving PTCA emphasises the need for accurate cost data.

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“…The same was observed in the International Shock Registry, reflecting significant selection bias in that patients in relatively better condition will be taken to the cathlab whereas apparently hopeless 1Medizinische Klinik II, Klinikum Kassel. keit (nach kardiogenem Schock) heraus [37]. Hieraus muf3 geschlossen werden, da6 die erfolglose PTCA nicht etwa indifferent ist (indem alles so bleibt wie ohne Intervention), sondern den Table 1.…”

Section: Treatment Of Acute Myocardial Infarction -Direct Ptca or Thrunclassified

“…Im Register der ALKK wurden 1994 nur in 4,1% der Infarkt-PTCA Stents implantiert; seitdem hat die Hfiufigkeit auf 65% im Jahr 1998 zugenommen. Gemessen am abschliegenden TIMI-FluB im Infarktgef~if3 hat diese gravierende Anderung der interventionellen Strategie jedoch keine relevante Verbesserung bewirkt [37]. In einer frª Auswertung der Registerdaten bis Mitte 1997 konnte auch keine Verbesserung des klinischen Ergebnisses durch Stents festgestellt werden; die Sterblichkeit der Patienten mit und ohne Stents betrug 9,9 vs. 11,6%.…”

Section: M5gliche Verbesserungen Der Direkten Infarm-ptcaunclassified

Therapie des akuten Myokardinfarkts — Primäre PTCA oder Thrombolyse?

Vogt

Neuhaus

1999

Herz

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Since reperfusion of the infarct-related coronary artery has been established as a mainstay in the treatment of acute myocardial infarction (AMI) mechanical recanalization by direct angioplasty has been used as an alternative to the standard treatment with thrombolysis. Direct PTCA is more efficient than thrombolysis in terms of reperfusion rates, whereas thrombolysis is more readily available. Thrombolysis reduces mortality from AMI by approximately 25%. The clinical efficacy is strongly time-dependent, and treatment within the first hour of AMI improves survival by nearly 50% by preventing transmural infarction in a significant proportion of the patients. The disadvantage of thrombolysis is its limited efficacy in terms of rapid, complete and sustained patency of the infarct vessel yielding optimal results in only 50% of the patients. Direct PTCA is generally agreed to be more efficient to recanalize the infarct vessel, but its clinical advantage remains controversial. The first randomized studies of direct PTCA in AMI from highly specialized centers in selected patients reported success rates of coronary reperfusion up to 97% resulting in a trend to less death and reinfarction, but the differences were significant only in a metaanalysis of these small studies. The real world of direct PTCA has been depicted by a large registry in Germany of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK) now including more than 4,000 direct PTCA-procedures since 1994. In this registry, the success rate of direct PTCA was 87% as defined by a final TIMI-grade 3 perfusion of the infarct vessel which is close to the data of the MITI-registry and the GUSTO IIb study. Failed PTCA was associated with an exceptionally high mortality rate of 36% confirming earlier observational reports. The non-randomized comparison of thrombolysis and direct PTCA in the MITI-registry showed no differene in survival or reinfarction rates, and the randomized GUSTO IIb substudy of direct PTCA versus front-loaded alteplase showed a small advantage in death and reinfarction rates at 30 days which dissipated over time leaving no significant clinical advantage of direct PTCA over thrombolysis at 6 months. Thus, in myocardial infarction in general the advantage of direct PTCA over thrombolysis is at best minimal. The reason is very probably the longer time lag until the procedure is started, the lower success rate as compared to the first reports of some specialized centers, and the clearly negative impact of failed PTCA on survival. Moreover, the immediate success of direct PTCA seems to be overestimated by the operator as demonstrated by comparison of central and local estimates of the TIMI flow rates in GUSTO IIb. Improvements of direct PTCA in AMI might be possible by coronary stenting which has markedly increased to more than 60% during the last year in the ALKK-registry. This was accompanied by a slight decrease in death and reinfarction rates. Further improvements can be expected from GP IIb/IIIa platelet antagonists which are...

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Direct percutaneous transluminal coronary angioplasty in acute myocardial infarction. Predictors of short-term outcome and the impact of coronary stenting

Cited by 24 publications

References 16 publications

The ENACT study: a pan-European survey of acute coronary syndromes

The ENACT study: a pan-European survey of acute coronary syndromes

International review of the utilisation and cost of percutaneous transluminal coronary angioplasty

Therapie des akuten Myokardinfarkts — Primäre PTCA oder Thrombolyse?

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