DOCSLIB.ORG

Improving the Clinical Outcome in Stroke Patients Receiving Thrombolytic Or Endovascular Treatment in Korea: from the SECRET Study

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Improving the Clinical Outcome in Stroke Patients Receiving Thrombolytic Or Endovascular Treatment in Korea: from the SECRET Study Journal of Clinical Medicine Article Improving the Clinical Outcome in Stroke Patients Receiving Thrombolytic or Endovascular Treatment in Korea: from the SECRET Study Young Dae Kim 1 , Ji Hoe Heo 1, Joonsang Yoo 1,2, Hyungjong Park 1,2, Byung Moon Kim 3, Oh Young Bang 4, Hyeon Chang Kim 5 , Euna Han 6 , Dong Joon Kim 3, JoonNyung Heo 1 , Minyoung Kim 1, Jin Kyo Choi 1, Kyung-Yul Lee 7, Hye Sun Lee 8 , Dong Hoon Shin 9 , Hye-Yeon Choi 10, Sung-Il Sohn 2 , Jeong-Ho Hong 2, Jang-Hyun Baek 11,12, Gyu Sik Kim 13, Woo-Keun Seo 4 , Jong-Won Chung 4, Seo Hyun Kim 14, Tae-Jin Song 15, Sang Won Han 16 , Joong Hyun Park 16, Jinkwon Kim 7,17 , Yo Han Jung 18, Han-Jin Cho 19, Seong Hwan Ahn 20 , Sung Ik Lee 21, Kwon-Duk Seo 13,21 and Hyo Suk Nam 1,* 1 Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Korea; [email protected] (Y.D.K.); [email protected] (J.H.H.); [email protected] (J.Y.); [email protected] (H.P.); [email protected] (J.H.); [email protected] (M.K.); [email protected] (J.K.C.) 2 Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu 41931, Korea; [email protected] (S.-I.S.); [email protected] (J.-H.H.) 3 Department of Radiology, Yonsei University College of Medicine, Seoul 03722, Korea; [email protected] (B.M.K.); [email protected] (D.J.K.) 4 Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; [email protected] (O.Y.B.); [email protected] (W.-K.S.); [email protected] (J.-W.C.) 5 Department of Preventive Medicine, Yonsei University College of Medicine, Seoul 03722, Korea; [email protected] 6 College of Pharmacy, Yonsei Institute for Pharmaceutical Research, Yonsei University, Incheon 21983, Korea; [email protected] 7 Department of Neurology, Gangnam Severance Hospital, Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul 06273, Korea; [email protected] (K.-Y.L.); [email protected] (J.K.) 8 Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul 06273, Korea; [email protected] 9 Department of Neurology, Gachon University Gil Medical Center, Incheon 21565, Korea; [email protected] 10 Department of Neurology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul 05278, Korea; [email protected] 11 Department of Neurology, National Medical Center, Seoul 04564, Korea; [email protected] 12 Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul 03181, Korea 13 Department of Neurology, National Health Insurance Service Ilsan Hospital, Ilsan 10444, Korea; [email protected] (G.S.K.); [email protected] (K.-D.S.) 14 Department of Neurology, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; [email protected] 15 Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul 07804, Korea; [email protected] 16 Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul 01757, Korea; [email protected] (S.W.H.); [email protected] (J.H.P.) 17 Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam 13496, Korea 18 Department of Neurology, Changwon Fatima Hospital, Changwon 51394, Korea; [email protected] 19 Department of Neurology, Pusan National University School of Medicine, Busan 49241, Korea; [email protected] 20 Department of Neurology, Chosun University School of Medicine, Gwangju 61453, Korea; [email protected] J. Clin. Med. 2020, 9, 717; doi:10.3390/jcm9030717 www.mdpi.com/journal/jcm J. Clin. Med. 2020, 9, 717 2 of 15 21 Department of Neurology, Sanbon Hospital, Wonkwang University School of Medicine, Sanbon 15865, Korea; [email protected] * Correspondence: [email protected]; Tel.: +82-2-2228-1617; Fax: +82-2-393-0705 Received: 23 January 2020; Accepted: 2 March 2020; Published: 6 March 2020 Abstract: We investigated whether there was an annual change in outcomes in patients who received the thrombolytic therapy or endovascular treatment (EVT) in Korea. This analysis was performed using data from a nationwide multicenter registry for exploring the selection criteria of patients who would benefit from reperfusion therapies in Korea. We compared the annual changes in the modified Rankin scale (mRS) at discharge and after 90 days and the achievement of successful recanalization from 2012 to 2017. We also investigated the determinants of favorable functional outcomes. Among 1230 included patients, the improvement of functional outcome at discharge after reperfusion therapy was noted as the calendar year increased (p < 0.001). The proportion of patients who were discharged to home significantly increased (from 45.6% in 2012 to 58.5% in 2017) (p < 0.001). The successful recanalization rate increased over time from 78.6% in 2012 to 85.1% in 2017 (p = 0.006). Time from door to initiation of reperfusion therapy decreased over the years (p < 0.05). These secular trends of improvements were also observed in 1203 patients with available mRS data at 90 days (p < 0.05). Functional outcome was associated with the calendar year, age, initial stroke severity, diabetes, preadmission disability, intervals from door to reperfusion therapy, and achievement of successful recanalization. This study demonstrated the secular trends of improvement in functional outcome and successful recanalization rate in patients who received reperfusion therapy in Korea. Keywords: reperfusion; therapy; ischemic stroke; outcome 1. Introduction Stroke is one of the diseases with the highest burden worldwide. Although the age-standardized risk of stroke or case fatality has been improving, there is still an increase in the absolute number of stroke or stroke-related death [1]. The Global Burden of Disease Study demonstrated that the burden of cerebrovascular disease increased over several decades and ranked second in the highest burden of diseases in 2015 [2]. Intravenous tissue plasminogen activator (IV t-PA) therapy and endovascular treatment (EVT) are established treatments for eligible patients with acute ischemic stroke [3,4]. Although these modalities can lead to successful recanalization, which is a strong determinant of a good outcome [5], many patients who received reperfusion therapy did not achieve a favorable outcome [6]. Over the past decades, there has been an improvement in the stroke care program, imaging techniques, treatment devices, and experience in EVT. As a result, overall outcome of reperfusion therapy for acute ischemic stroke could be improved at a national level [7]. In Korea, there have been improvements in the care system for acute stroke patients, including easy and rapid accessibility to medical services, establishment of stroke units or centers, and acute stroke codes for reperfusion therapy [8–10]. Considering these secular trends in the stroke care system, clinical and radiologic outcomes after reperfusion therapy might have changed in Korea. We investigated whether there was an annual change in outcomes in patients who received IV t-PA therapy or EVT in Korea. We also determined which factors had played a role in these changes using the nationwide thrombolytic and EVT registry. J. Clin. Med. 2020, 9, 717 3 of 15 2. Materials and Methods 2.1. Patients Inclusion The study population was derived from the Selection Criteria in Endovascular Thrombectomy and thrombolytic therapy (SECRET) registry (Clinicaltrials.gov NCT02964052, https://clinicaltrials.gov/ct2/ show/NCT02964052?term=NCT02964052&rank=1). The SECRET registry is a nationwide multicenter registry for exploring the selection criteria of patients who would benefit from reperfusion therapies. The SECRET registry was started on May 2016. This registry consisted of four parts: (1) clinical information, (2) information on reperfusion therapy, (3) comorbidities, and (4) imaging data. The clinical information section includes the demographics, vascular risk factors, previous medication status, laboratory findings, and neurologic status or premorbidity before stroke. In the reperfusion therapy section, the information on time parameters, angiographic findings before and after treatment, devices used during the procedure, periprocedural complications, and concomitant thrombolytic agents used was collected. The modified Rankin scale (mRS) at discharge and after 90 days, along with mortality within 6 months, was determined in each patient during the follow-up. If a patient died, we also assessed the cause of death. For the comorbidities section, we determined the presence of the component of the Charlson comorbidity index (CCI) for each patient. In the stroke population, we used a modified version of the CCI, which consisted of 19 diseases, including myocardial infarction, congestive heart failure, peripheral vascular disease, previous stroke, atrial fibrillation, dementia, depression, chronic pulmonary disease, ulcer disease, mild liver disease, moderate or severe renal disease, connective tissue disease or rheumatic disease, anemia, diabetes, acquired immune deficiency syndrome, cancer, leukemia, lymphoma, and metastatic cancer [11]. The imaging data section included the occlusion site, infarction core, collateral status, and thrombus characteristics on thin-section computed tomography (CT). The imaging findings were ascertained by the imaging adjudication committee (6 stroke neurologists and 4 neuroradiologists). The audit was conducted every two weeks, and the data
Load more

Recommended publications
  • The Role of Low-Molecular-Weight Heparin in the Management of Acute Coronary Syndromes Marc Cohen, MD, FACC Newark, New Jersey
    CORE Metadata, citation and similar papers at core.ac.uk Provided by ElsevierJournal - ofPublisher the American Connector College of Cardiology Vol. 41, No. 4 Suppl S © 2003 by the American College of Cardiology Foundation ISSN 0735-1097/03/$30.00 Published by Elsevier Science Inc. doi:10.1016/S0735-1097(02)02901-7 The Role of Low-Molecular-Weight Heparin in the Management of Acute Coronary Syndromes Marc Cohen, MD, FACC Newark, New Jersey A substantial number of clinical studies have consistently demonstrated that low-molecular- weight heparin (LMWH) compounds are effective and safe alternative anticoagulants to unfractionated heparins (UFHs). They have been found to improve clinical outcomes in acute coronary syndromes and to provide a more predictable therapeutic response, longer and more stable anticoagulation, and a lower incidence of UFH-induced thrombocytopenia. Of the several LMWH agents that have been studied in large clinical trials, including enoxaparin, dalteparin, and nadroparin, not all have shown better efficacy than UFH. Enoxaparin is the only LMWH compound to have demonstrated sustained clinical and economic benefits in comparison with UFH in the management of unstable angina/ non–ST-segment elevation myocardial infarction (NSTEMI). Also, LMWH appears to be a reliable and effective antithrombotic treatment as adjunctive therapy in patients undergoing percutaneous coronary intervention. Clinical trials with enoxaparin indicate that LMWH is effective and safe in this indication, with or without the addition of a glycoprotein IIb/IIIa inhibitor. The efficacy demonstrated by enoxaparin in improving clinical outcomes in unstable angina/NSTEMI patients has led to investigations of its role in the management of ST-segment elevation myocardial infarction.
    [Show full text]
  • Reperfused STEMI Patients Lession from ISACS-TC
    What do to with late comer and/or non- reperfused STEMI patients Lession from ISACS-TC Raffaele Bugiardini Universita’ Alma Mater Studiorum Bologna Dubrovnik, 26-29 September 2013 International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-CT) Rationale and Design 1 • Mortality from cardiovascular disease has been decreasing continuously in the United States and many Western European countries, but it has increased or remained unchanged in many of the states of Eastern Europe. Analysis of this phenomenon has been hindered by insufficient information. • Much has been hypothesised about the ethnicity- and poverty-associated disparities in mortality when comparing Eastern with Western European countries. • Yet, identifying underlying causes for these worrisome geographic health patterns continues to challenge health care providers and researchers. International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-CT) Rationale and Design 2 Both a retrospective (over a one year period) and prospective (over a three year period) study which was designed in order to obtain data of patients with acute coronary syndromes in countries with economy in transition, and herewith control and optimize internationally guideline recommended therapies in these countries. There are a total of 132 Collaborating Centers in 17 transitional countries (Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Hungary, Kosovo, Moldova, Latvia, Lithuania, Poland, Russian Federation, Romania, Macedonia, Serbia, Slovakia, Slovenia,
    [Show full text]
  • Get with the Guidelines®-Stroke Is the American Heart Association's
    Get With The Guidelines®-Stroke is the American Heart Association’s collaborative performance improvement program, demonstrated to improve adherence to evidence-based care of patients hospitalized with stroke. The program provides hospitals with a Web-based Patient Management Tool™ (powered by QuintilesIMS), decision support, a robust registry, real-time benchmarking capabilities and other performance improvement methodologies toward the goal of enhancing patient outcomes and saving lives. This fact sheet provides an overview of the achievement, quality, descriptive, and reporting measures currently reported on via Get With The Guidelines-Stroke. Get With The Guidelines-Stroke is for patients with stroke and transient ischemic attack (TIA). The following is a list of the common stroke-related diagnoses included in Get With The Guidelines-Stroke: ICD-10: I60*; I61*; I63*; G45.0, G45.1, G45.8, G45.9 STROKE ACHIEVEMENT MEASURES ACUTE: • IV rt-PA arrive by 2 hour, treat by 3 hour: Percent of acute ischemic stroke patients who arrive at the hospital within 120 minutes (2 hours) of time last known well and for whom IV t-PA was initiated at this hospital within 180 minutes (3 hours) of time last known well. Corresponding measure available for inpatient stroke cases • Early antithrombotics: Percent of patients with ischemic stroke or TIA who receive antithrombotic therapy by the end of hospital day two. Corresponding measures available for observation status only & inpatient stroke cases • VTE prophylaxis: Percent of patients with ischemic stroke, hemorrhagic stroke, or stroke not otherwise specified who receive VTE prophylaxis the day of or the day after hospital admission. AT OR BY DISCHARGE: • Antithrombotics: Percent of patients with an ischemic stroke or TIA prescribed antithrombotic therapy at discharge.
    [Show full text]
  • Reperfusion Therapy in Acute Ischemic Stroke
    Bhaskar et al. BMC Neurology (2018) 18:8 DOI 10.1186/s12883-017-1007-y REVIEW Open Access Reperfusion therapy in acute ischemic stroke: dawn of a new era? Sonu Bhaskar1,2,3,4,6,7* , Peter Stanwell7, Dennis Cordato2,4,5, John Attia7,8 and Christopher Levi1,2,3,4,5,6* Abstract Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with acute ischemic stroke (AIS). In this paper, we present an extensive overview of intravenous and endovascular reperfusion strategies, recent advances in AIS neurointervention, limitations of various treatment paradigms, and provide insights on imaging-guided reperfusion therapies. A roadmap for imaging guided reperfusion treatment workflow in AIS is also proposed. Both systemic thrombolysis and endovascular treatment have been incorporated into the standard of care in stroke therapy. Further research on advanced imaging- based approaches to select appropriate patients, may widen the time-window for patient selection and would contribute immensely to early thrombolytic strategies, better recanalization rates, and improved clinical outcomes. Keywords: Stroke, Reperfusion therapy, Prognosis, Endovascular treatment, Neurointervention Background and up to 6–8 h for endovascular MT. The restriction on An overwhelming number of studies and clinical trials con- IV-tPA treatment beyond 4.5 h disqualifies the majority of firmtheefficacyofthrombolytictherapy,inagiventhera- stroke patients admitted beyond this time-window (around peutic window, in improving the clinical outcome and 85%), thereby drastically limiting the eligible population [7– recovery of acute ischemic stroke (AIS) patients [1–5]. The 10]. primary therapeutic goal for patients with AIS is the timely In this article, we review the literature on the various restoration of blood flow to salvageable ischemic brain reperfusion strategies available for AIS patients, and pro- tissue that is not already infarcted [6].
    [Show full text]
  • Association Between Timeliness of Reperfusion Therapy and Clinical Outcomes in ST-Elevation Myocardial Infarction
    ORIGINAL CONTRIBUTION Association Between Timeliness of Reperfusion Therapy and Clinical Outcomes in ST-Elevation Myocardial Infarction Laurie Lambert, PhD Context Guidelines emphasize the importance of rapid reperfusion of patients with Kevin Brown, MSc ST-elevation myocardial infarction (STEMI) and specify a maximum delay of 30 min- Eli Segal, MD utes for fibrinolysis and 90 minutes for primary percutaneous coronary intervention (PPCI). However, randomized trials and selective registries are limited in their ability to assess James Brophy, MD, PhD the effect of timeliness of reperfusion on outcomes in real-world STEMI patients. Josep Rodes-Cabau, MD Objectives To obtain a complete interregional portrait of contemporary STEMI care Peter Bogaty, MD and to investigate timeliness of reperfusion and outcomes. Design, Setting, and Patients Systematic evaluation of STEMI care for 6 months OTH PRIMARY PERCUTANEOUS during 2006-2007 in 80 hospitals that treated more than 95% of patients with acute coronaryintervention(PPCI)and myocardial infarction in the province of Quebec, Canada (population, 7.8 million). fibrinolysis are well-recognized treatmentsforST-segmenteleva- Main Outcome Measures Death at 30 days and at 1 year and the combined end point of death or hospital readmission for acute myocardial infarction or congestive Btion myocardial infarction (STEMI) in in- heart failure at 1 year by linkage to Quebec’s medicoadministrative databases. ternational guidelines, and benefits are 1,2 Results Of 1832 patients treated with reperfusion, 392 (21.4%) received fibrinoly- maximizedwhentreatmentoccursearly. Ͼ Although meta-analyses of randomized sis and 1440 (78.6%) received PPCI. Fibrinolysis was untimely ( 30 minutes) in 54% and PPCI was untimely (Ͼ90 minutes) in 68%.
    [Show full text]
  • Reperfusion Therapy for Acute Myocardial Infarction: Concepts And
    Curriculum in Cardiology Reperfusion therapy for acute myocardial infarction: Concepts and controversies from inception to acceptance Klaus Peter Rentrop, MD, FACC, FACP, and Frederick Feit, MD, FACC New York, NY More than 20 years of misconceptions derailed acceptance of reperfusion therapy for acute myocardial infarction (AMI). Cardiologists abandoned reperfusion for AMI using fibrinolytic therapy, explored in 1958, because they no longer attributed myocardial infarction to coronary thrombosis. Emergent aortocoronary bypass surgery, pioneered in 1968, remained controversial because of the misconception that hemorrhage into reperfused myocardium would result in infarct extension. Attempts to limit infarct size by pharmacotherapy without reperfusion dominated research in the 1970s. Myocardial necrosis was assumed to progress slowly, in a lateral direction. At least 18 hours was believed to be available for myocardial salvage. Afterload reduction and improvement of the microcirculation, but not reperfusion, were thought to provide the benefit of streptokinase therapy. Finally, coronary vasospasm was hypothesized to be the central mechanism in the pathogenesis of AMI. These misconceptions unraveled in the late 1970s. Myocardial necrosis was shown to progress in a transmural direction, as a “wave front,” beginning with the subendocardium. Reperfusion within 6 hours salvaged a subepicardial ischemic zone in experimental animals. Acute angiography provided in vivo evidence of the high incidence of total coronary occlusion in the first hours of AMI. In 1978, early reperfusion by transluminal recanalization was shown to be feasible. The pathogenetic role of coronary thrombosis was definitively established in 1979 by demonstrating that intracoronary streptokinase rapidly restored flow in occluded infarct-related arteries, in contrast to intracoronary nitroglycerine which rarely did.
    [Show full text]
  • The Efficacy and Safety of Combination Glycoprotein Iibiiia Inhibitors And
    Interventional Cardiology The efficacy and safety of combination glycoprotein IIbIIIa inhibitors and reduced-dose thrombolytic therapy–facilitated percutaneous coronary intervention for ST-elevation myocardial infarction: A meta-analysis of randomized clinical trials Mohamad C.N. Sinno, MD, Sanjaya Khanal, MD, FACC, Mouaz H. Al-Mallah, MD, Muhammad Arida, MD, and W. Douglas Weaver, MD Detroit, MI Objective We reviewed the literature and performed a meta-analysis comparing the safety and efficacy of adjunctive use of reduced-dose thrombolytics and glycoprotein (Gp) IIbIIIa inhibitors to the sole use of Gp IIbIIIa inhibitors before percutaneous coronary intervention (PCI) in patients presenting with acute ST-segment elevation myocardial infarction (STEMI). Background Early reperfusion in STEMI is associated with improved outcomes. The use of reduced-dose thrombolytic and Gp IIbIIIa inhibitors combination before PCI in the setting of acute STEMI remains controversial. Methods We performed a literature search and identified randomized trials comparing the use of combination therapy–facilitated PCI versus PCI done with Gp IIbIIIa inhibitor alone. Included studies were reviewed to determine Thrombolysis in Myocardial Infarction (TIMI)-3 flow at baseline, major bleeding, 30-day mortality, TIMI-3 flow after PCI,and 30-day reinfarction. We performed a random-effect model meta-analysis. We quantified heterogeneity between studies with I2. A value N50% represents substantial heterogeneity. Results We identified 4 clinical trials randomizing 725 patients; 424 patients were pretreated with combination therapy before PCI, and 301 patients had Gp IIbIIIa inhibitor alone during PCI. Combination therapy–facilitated PCI was associated with a 2-fold increase in TIMI-3 flow upon arrival to the catheterization laboratory compared with the sole use of upstream Gp IIbIIIa inhibitors (192/390 patients [49%] versus 60/284 [21%]; relative risk [RR], 2.2; P b .00001).
    [Show full text]
  • Acute Reperfusion Therapies for Acute Ischemic Stroke
    Journal of Clinical Medicine Review Acute Reperfusion Therapies for Acute Ischemic Stroke Rajeel Imran, Ghada A Mohamed and Fadi Nahab * Department of Neurology, Emory University, Atlanta, GA 30322, USA; [email protected] (R.I.); [email protected] (G.A.M.) * Correspondence: [email protected] Abstract: The field of acute stroke treatment has made tremendous progress in reducing the overall burden of disability. Understanding the pathophysiology of acute ischemic injury, neuroimaging to quantify the extent of penumbra and infarction, and acute stroke reperfusion therapies have together contributed to these advancements. In this review we highlight advancements in reperfusion therapies for acute ischemic stroke. Keywords: ischemic stroke; thrombolysis; thrombectomy 1. Introduction Acute ischemic stroke continues to pose a significant challenge for our healthcare system. Approximately 795,000 people suffer a new or recurrent stroke each year just in the United States with current projections showing an additional 3.4 million adults having a new stroke by the year 2030 [1]. Approximately 85% of strokes are caused by an ischemic event and among those who survive a significant number require assistance with their daily activities [1]. Despite these grim numbers, there have been several notable advances in the past Citation: Imran, R.; Mohamed, G.A.; two decades that have transformed our approach to both diagnosis and treatment of Nahab, F. Acute Reperfusion patients with acute ischemic stroke. The widespread use of intravenous alteplase and Therapies for Acute Ischemic Stroke. now endovascular therapy has led to significant improvement in functional outcomes J. Clin. Med. 2021, 10, 3677. https:// with notable reductions in the rates of disability.
    [Show full text]
  • Paradoxical Myocardial Infarction After Thrombolytic Therapy for Acute Ischemic Stroke
    Open Access Case Report DOI: 10.7759/cureus.16659 Paradoxical Myocardial Infarction After Thrombolytic Therapy for Acute Ischemic Stroke Billal Mohmand 1, 2 , Abeeha Naqvi 1 , Avneet Singh 3 1. Internal Medicine, Upstate University Hospital, Syracuse, USA 2. Internal Medicine, Syracuse Veterans Affairs Medical Center, Syracuse, USA 3. Cardiology, Upstate University Hospital, Syracuse, USA Corresponding author: Billal Mohmand, [email protected] Abstract Early reperfusion therapy with tissue plasminogen activator (tPA) for acute ischemic stroke has mortality benefits despite the risks. Myocardial infarction (MI) after the use of thrombolytic therapy is a rare complication. We report a 67-year-old woman with acute stroke who received tPA for acute ischemic stroke and subsequently developed ST elevation MI (STEMI), highlighting a rare and serious complication. Categories: Cardiology, Emergency Medicine, Neurology Keywords: acute st-elevation myocardial infarction, myocardial infarction , : acute coronary syndrome, tissue plasminogen activator (tpa), cerebro-vascular accident (stroke), : ischemic stroke, st-elevation myocardial infarction (stemi), systemic thrombolysis, coronary artery angiography, complication of treatment Introduction Early reperfusion therapy with tissue plasminogen activator (tPA) for acute ischemic stroke has long-term mortality benefits despite known risk factors [1]. Additionally, it is a viable option for ST elevation myocardial infarction (STEMI) when there is limited access to percutaneous coronary intervention (PCI). Myocardial infarction (MI) after tPA use is a rare complication with unknown incidence and rarely reported [2]. Our case represents the appropriate use of tPA for acute ischemic stroke per the inclusion criteria which is well documented in the literature, however, with an unexpected development of acute MI immediately following tPA administration. Despite this rare adverse effect, our case was unique from other reports as our patient had a positive outcome, while similar cases had fatal outcomes [3].
    [Show full text]
  • Current Role of Platelet Glycoprotein Iib/Iiia Inhibition in the Therapeutic Management of Acute Coronary Syndromes in the Stent Era
    Journal of Cardiology & Current Research Current Role of Platelet Glycoprotein IIb/IIIa Inhibition in the Therapeutic Management of Acute Coronary Syndromes in the Stent Era Review Article Abstract The pathophysiology of acute coronary syndromes (ACS) is characterized by Volume 5 Issue 5 - 2016 disruption of atherosclerotic plaques, activation and aggregation of platelets, and formation of an arterial thrombus. Thrombus formation can result in 1 either transient or persistent occlusion giving rise to the spectrum of ACS. This Department of Health Sciences’s Investigation, Sanatorio Metropolitano, Fernando de la Mora, Paraguay syndrome defines rapidly evolving symptoms of myocardial ischemia ranging 2Cardiology Division, First Department of Internal Medicine, from unstable angina pectoris to non-Q-wave myocardial infarction to Q-wave Clinic Hospital, Asunción National University, San Lorenzo, myocardial infarction. An early pharmacological strategy to reduce ischemic Paraguay complications of PCI was the use of parenteral glycoprotein (GP) IIb/IIIa inhibitors. *Corresponding author: Osmar Antonio Centurión, Professor of Medicine, Asuncion National University, The benefit of GP IIb/IIIa inhibitors in early studies was driven primarily by Department of Health Sciences’s Investigation, Sanatorio reductions in periprocedural myocardial infarction. Advances in both stent Metropolitano, Teniente Ettiene 215 c/ Ruta Mariscal design and adjunct pharmacology have led to improved outcomes in ACS and a Estigarribia,Fernando de la Mora, Paraguay, Tel: 595-21- diminished role for GP IIb/IIIa inhibitors as reflected in current PCI guidelines. 498200; Fax: 595-21-205630; Email: Current medical therapy with aspirin, clopidogrel, ticagrelol, prasugrel, and heparin provides important therapeutic benefits. The platelet GP IIb/IIIa receptor antagonists, by blocking the final common pathway of platelet aggregation, Received: March 07, 2016 | Published: May 03, 2016 are a breakthrough in the management of ACS.
    [Show full text]
  • Addendum 1. Low Molecular Weight Heparins for the Treatment of Acute Coronary
    Addendum 1. Low molecular weight heparins for the treatment of Acute Coronary Syndromes Background Cardiovascular diseases (CVD) are currently the leading cause of death in industrialized countries and are expected to become so in emerging countries by 2020 (1,2). Among CVD, coronary artery disease (CAD) is the most prevalent manifestation and is associated with high mortality and morbidity. Acute coronary syndromes (ACS) represents the major clinical manifestation of CAD, along with silent ischemia and stable angina pectoris. ACS share a common pathophysiological substrate, represented by acute complications of atherosclerotic plaque, with differing degrees of superimposed thrombosis and distal embolization. Patients with acute chest pain may show persistent ST‐segment elevation at EKG, that generally reflects an acute total coronary occlusion, ultimately leading to ST‐elevation myocardial infarction (STEMI). Alternatively, patients may present with acute chest pain without persistent ST‐segment elevation; EKG may show ST‐segment depression or T‐wave inversion, flat T waves, pseudo‐normalization of T waves, or no EKG changes. These clinical presentations of non‐ST‐elevation ACS may be further categorized into non‐ST‐elevation myocardial infarction (NSTEMI) or unstable angina (UA), based on troponins release (3,4). Data from a large registry on a 10‐year timeframe (1999‐2008) show that NSTE‐ACS is more frequent than STEMI, accounting for 66.1% and 33.1% of cases, respectively (5). The annual incidence is about 3 per 1000 inhabitants and it seems to be declining for STEMI (from 1.21 to 0.77 per 1000/year), but increasing for NSTEMI (from 1.26 to 1.32 per 1000/year) (4).
    [Show full text]
  • REPERFUSION THERAPY for ACUTE MYOCARDIAL INFARCTION Jason S
    REPERFUSION THERAPY FOR ACUTE MYOCARDIAL INFARCTION Jason S. Go, MD, FACC Interventional Cardiology and Peripheral Vascular Intervention Altru Health System DISCLOSURES • None CORONARY ARTERY DISEASE • Major cause of morbidity and mortality in developed countries • 2010 Heart disease and Stroke statistics • 17.6 mil with CHD • 8.5 mil with hx of MI • 10.2 mil with angina • 1/2 of all middle-age men and 1/3 of middle-age women will develop CHD • Responsible for 1/3 of all deaths among individuals > 35 years old CORONARY SYNDROMES • CAD with Stable angina • Unstable angina • Non-ST elevation MI (NSTEMI) • ST-elevation MI (STEMI) ST SEGMENT ELEVATION MYOCARDIAL INFARCTION • Presentation in up to 33% of ACS cases • Diagnosis based on typical ST changes • Usually represent an acute thrombotic occlusion of an epicardial coronary artery • Requires prompt recognition, triage, and reperfusion WHY REPERFUSION? • Addresses primary problem of acute STEMI • Improves outcomes REPERFUSION STRATEGIES • Pharmacologic Reperfusion • Fibrinolytic Therapy • Mechanical Reperfusion • Primary Percutaneous Coronary Intervention (Primary PCI) FIBRINOLYTIC THERAPY FIBRINOLYTIC THERAPY • Plaque rupture and thrombus formation remain the primary cause of acute vessel occlusion that leads to STEMI • Fibrinolytic therapy was a major advance in the treatment of acute STEMI since >90% of STEMI is due to plaque rupture and subsequent thrombus formation • Remains a viable option for reperfusion therapy due to the limited availability of Primary PCI therapy. FIBRINOLYTIC AGENTS • Streptokinase • Alteplase (tPA) • Reteplase (rPA) • Tenecteplase (TNK-tPA) FIBRINOLYTIC AGENTS • Streptokinase • single chain polypeptide derived from beta-hemolytic streptococcus • binds to plasminogen, forming a complex that becomes an active enzyme that cleaves peptide bonds on other plasminogen molecules • leading to plasmin activation • High doses are necessary to neutralize the plasma levels of antistreptococcal antibodies.
    [Show full text]