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Context: The optimal pharmacological strategy for bridging the delay between admission and performance of percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (MI) is not known., Objective: To assess whether early administration of reteplase plus abciximab produces better results compared with abciximab alone in patients with acute MI referred for PCI., Design, Setting, and Patients: Open-label, randomized controlled study conducted from May 3, 2001, through June 2, 2003, of 253 patients who were admitted to 13 community hospitals without catheterization facilities (n = 186) and to 5 hospitals with catheterization facilities (n = 67), with the diagnosis of an ST-segment elevation acute MI within 12 hours from onset of symptoms., Interventions: Patients received intravenously either the combination of a half-dose reteplase (two 5-U boluses, 30 minutes apart) with a standard dose of abciximab (0.25 mg/kg bolus, 0.125 microg/kg per minute infusion [maximum 10 microg/min for 12 hours]) or the standard dose of abciximab alone; all patients were then transferred for PCI., Main Outcome Measure: Final infarct size according to a single-photon emission computed tomography study with technetium Tc 99m sestamibi performed between 5 and 10 days after randomization in 228 patients (90.1% of entire sample)., Results: Of the 253 patients enrolled, 125 were assigned to reteplase plus abciximab and 128 to abciximab alone. The median (interquartile range) of the final infarct size of the left ventricle was 13.0% (3.0%-28.0%) in the reteplase plus abciximab group and 11.5% (3.0%-26.3%) in the abciximab-alone group (P =.81). The mean difference in final infarct size of left ventricle between the reteplase plus abciximab group and the abciximab group was 1.3% (95% confidence interval [CI], -3.1% to 5.7%). Within 6 months after randomization, the composite secondary end point of death, recurrent MI, or stroke occurred in 8 patients (6.4%) in the reteplase plus abciximab group and 6 patients (4.7%) in the abciximab group (relative risk, 1.4; 95% CI, 0.5-3.9; log-rank P =.56). Major bleeding complications were observed in 7 patients (5.6%) in the reteplase plus abciximab group and 2 patients (1.6%) in the abciximab group (P =.16)., Conclusion: Early administration of reteplase plus abciximab does not lead to a reduction of infarct size compared with abciximab alone in patients with acute MI referred for PCI.

To study the temporal relationship of occlusion and reperfusion we examined 16 patients (14 m, 2f) with variant angina for the occurrence and time course of arrhythmias with episodes of ST-elevation (n = 82). The patients underwent frequency-modulated ambulatory ECG recording, episodes of ST elevation were defined, and the arrhythmias were counted before, during and after each episode. In 10 patients (group A) no or only infrequent extrasystoles occurred. Of the other 6 patients (group B), one had a-v block II degree, 5 had frequent (greater than 2/min) ventricular or supraventricular premature beats, 3 with couplets or runs of VPB. Patients of group A and B did not differ in age, severity of fixed coronary stenoses and ventricular ejection fraction. There was a tendency towards a greater incidence of higher ST-elevations (greater than 2 mm) in group B (4 of 6 patients versus 2 of 10 in group A, p = 0.09). The relationship of arrhythmias and ST changes showed different patterns: the maximum of arrhythmias occurred during the episode in 3 patients, during and after the episode in 2 patients and only after the episode in 1 patient. Potentially dangerous arrhythmias are frequent in patients with variant angina and persist beyond the ST segment changes in one half of the affected patients.

The occurrence of unstable angina pectoris, despite medical treatment, is generally regarded as an ominous prognostic sign and an indication for invasive diagnosis and revascularization. We investigated 38 consecutive patients with severe unstable angina with a mean of 2.5 days of continuous two-channel, frequency modulated Holter monitoring for ST segment analysis. In 16 patients, transient ischaemic episodes (more than 0.1 mV lasting more than 1 min) occurred despite maximal medical treatment: 82% of the episodes were silent. Compared to the 22 patients without ischaemic episodes there were no significant differences in prevalence of risk factors, numbers of vessels diseased (69% vs. 74% triple-vessel disease) or ejection fraction (54 +/- 15% vs. 53 +/- 16%). The 30-day prognosis, however, varied: of 16 patients with ischaemic episodes, 14 (88%) had a subsequent cardiac event (death, AMI, PTCA or CABG) compared to only 10 of 22 patients (45%) without ischaemic episodes (P less than 0.02 for all events, P less than 0.1 for death/AMI only). Transient ischaemic episodes, predominantly silent, are frequent in patients with severe unstable angina. Objective evidence of ongoing ischaemia despite medical treatment has a guarded short-term prognosis. 'Stabilization' of unstable angina may be incomplete as long as transient ischaemia at rest can still be detected.

Silent ischemia, the most common expression of atherosclerotic heart disease, affects approximately 30–50% of patients during their activities of daily living. The present review provides a comprehensive and practical summary of current knowledge on perioperative myocardial ischemia through MEDLINE searches up to June 2005, using keywords including “silent ischemia,” “transient ischemia,” and “Holter monitoring.” Holter monitoring (i.e., continuous ambulatory ST-segment monitoring) is an effective tool for assessing the frequency and duration of silent transient myocardial ischemia, particularly in patients who are post-acute myocardial infarction (MI), those with acute coronary syndromes (ACS), and in patients in the acute post-operative period. Holter monitoring allows for further risk stratification of patients who have a positive exercise ECG by collecting long-term ECG data on ischemic and arrhythmic events while patients perform routine activities. Both the presence and increased duration of transient ischemia as detected by continuous ST-segment Holter monitoring are associated with increased rates of coronary events and mortality. Holter monitoring may aid in the identification of patients and subgroups of patients with ACS who may derive the greatest benefit from antiplatelet and antithrombotic therapy. Indeed, many ongoing and upcoming trials of pharmacotherapy include ischemia on Holter monitoring as an endpoint. [ABSTRACT FROM AUTHOR]

Aims Early and complete reperfusion is the main treatment goal in ST-elevation myocardial infarction (STEMI). The timely optimal reperfusion strategy might be a pre-hospital initiated pharmacological reperfusion with subsequent facilitated percutaneous coronary intervention (PCI). This approach has been compared with pre-hospital combination-fibrinolysis only to determine whether either one of these methods offer advantages with respect to final infarct size. [ABSTRACT FROM PUBLISHER]

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Aims Determination of the influence of therapy with bisoprolol and nifedipine on the heart rate variability of patients from the Total Ischemic Burden Bisoprolol Study and examination of the prognostic value. Methods and Results Four hundred and twenty-two patients with stable angina were included. The heart rate variability was determined over a period of 24h. Parameters determined: standard deviation of the mean of all corrected RR intervals, standard deviation of all 5min mean cycle lengths, square root of the mean of the squared differences of successive corrected RR intervals. Nifedipine reduced the mean values of all heart rate variability parameters tested. Square root of the mean of the square differences of successive corrected RR intervals increased under bisoprolol. Standard deviation of the mean of all corrected RR intervals and standard deviation of all 5min mean cycle lengths increased from low baseline values and declined from higher baseline values. The increase in heart rate variability under therapy was accompanied by a tendency towards a better prognosis. Patients with an increase in heart rate variability and simultaneous complete suppression of ischaemia under therapy displayed no serious events in the course of one year. Conclusions The increase in the heart rate variability, which can be regarded as prognostically favourable, was predominantly observed under bisoprolol. The parameter constellation of an increase in heart rate variability and complete ischaemia suppression on the 48-h Holter ECG was associated with the greatest benefit. [ABSTRACT FROM PUBLISHER]

AimsTo assess the ability of clinical characteristics, ad-mission ECG and continuous ST segment monitoring in determining long-term prognosis in unstable angina.MethodsTwo hundred and twelve patients with unstable angina (mean age 59 years), presenting within 24h of an acute episode of angina were recruited at three hospitals and treated with standardized medical therapy. All patients kept chest pain charts and underwent ST segment monitoring for 48h. The occurrence of death, myocardial infarction, and need for revascularization was assessed over a median follow-up of 2·6 years.ResultsThe risk of death of myocardial infarction was greatest in the first 6–8 weeks after admission. Admission ECG ST depression and the presence of transient ischaemia predicted increased risk of subsequent death or myocardial infarction, whereas a normal ECG predicted a good prognosis. In 14 patients, ST segment monitoring provided the only evidence of recurrent ischaemia, and 72% of this group suffered an adverse event. Transient ischaemia and a history of hypertension were the most powerful independent predictors of death or myocardial infarction.ConclusionsAdverse events in unstable angina occur early after admission and can be predicted by clinical and ECG characteristics, and by the presence of transient ischaemia during ST segment monitoring. Risk stratifi-cation by these simple assessments can identify patients with unstable angina at high risk. [ABSTRACT FROM PUBLISHER]

Anginal symptoms alone are not a reliable guide to the extent of patients’ ischaemic heart disease and silent episodes of ischaemia are associated with increased morbidity and mortality. It is becoming apparent that effective treatment of ischaemia will have to target the pattern of ischaemic events seen in patients’ daily lives and treatment strategies are now being developed which aim to eliminate both silent and symptomatic episodes of ischaemia over the whole 24-h period. For example, the Circadian Anti-ischemia Program in Europe (CAPE) trial has shown that significant improvements in objective and subjective measures of ischaemia occurred over 24 h when the once daily, third-generation dihydropyridine calcium antagonist amlodipine was added to background medical therapy. In addition, the Canadian Amlodipine/Atenolol in Silent Ischemia Study (CASIS) has clearly shown the complementary effects of combination therapy with amlodipine and the long-acting β-blocker atenolol. Ongoing and future outcome studies will determine the impact of such approaches on the prognosis for patients with ischaemic heart disease. (Eur Heart J 1996; 17 (Suppl G): 64–68) [ABSTRACT FROM PUBLISHER]

The relative value of ambulatory ST segment monitoring for assessing prognosis following acute myocardial infarction is currently uncertain. Ambulatory monitoring was performed in 177 patients at a mean of 38 days (range 22–93) post-myocardial infarction and its prognostic value was compared with exercise treadmill testing (n=170). Cardiac events (myocardial infarction, cardiac death or coronary revascularisation) were noted during at least 1 year of follow-up. The presence or absence of ST depression on ambulatory nonitoring did not predict increased fatal or non-fatal cardiac events although more severe ST depression had some predictive power: after adjusting for clinical variables and coronary prognostic indices, the duration/24 h (P=0·03) and magnitude (P=0·007) of ST depression had independent value. ST deviation on exercise testing was associated (P<0·05) with increased events (19/90; 21% vs 7/80; 9%) and in patients with a positive exercise test ST depression on ambulatory monitoring did not identify any additional events (8/41; 20% vs 11/49; 22%). No factor available from ambulatory monitoring was predictive of outcome once variables from exercise testing were taken into account. Ambulatory ST segment monitoring performed in the late recovery phase (1–3 months) after acute myocardial infarction is inferior to exercise testing for predicting prognosis and does not increase the predictive power of an exercise test. Ambulatory monitoring may only be indicated in patients unable to perform an exercise test. [ABSTRACT FROM PUBLISHER]

Radionuclide techniques have added substantial information to aid detection and heighten the clinical significance of silent ischaemia. While non-invasive assessment of myocardial perfusion, metabolism and wall motion have increased the knowledge of the pathophysiology of silent ischaemia, radioisotope techniques may provide information far beyond that obtained by electrocardiographic criteria alone. Whether patients with silent ischaemia should be treated can only be inferred from indirect evidence suggested by preliminary trials. Only randomized, controlled, clinical trials will yield the definite answers as to the effects of treatment on clinical outcome. [ABSTRACT FROM PUBLISHER]

Seventy-nine patients with angiographically documented coronary artery disease were studied with exercise ECG and Holter ECG for ischaemic ST segment changes. Fifty-four patients (68.3%) had ischaemia on exercise, 48 patients (62.0%) had ischaemic ST segment depression during Holter monitoring. Twenty-four (30%) of the patients with a positive exercise test and 30 (61%) with a positive Holter ECG were asymptomatic during the test, 83.7% of the total count of 456 episodes of spontaneous ischaemia during Holter monitoring were silent. Forty-four patients (55.7%) had ischaemic ECG changes during exercise and Holter ECG, 20 patients (25.3%) were negative on both tests. Ten (12.7%) had only a positive exercise lest and five (6.3%) only a positive Holter ECG. The sensitivity of Holter monitoring for the detection of ischaemia in patients with coronary artery disease is comparable to the sensitivity of the exercise ECG. [ABSTRACT FROM PUBLISHER]