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Stenting in acute MI: The Netherlands experience
Asia Pacific
Heart J 1997;6(1)
Proceedings
rates of 90% or more (Figure). Early trials of stenting for AM1 suggest this may be possible. Table. Results of GUSTO
IIb, primary
endpoints
2.
at 30 days.
t-PA 40 (7%)
Angioplasty
p value
Death
32 (5.7%)
0.37
Reinfarction Disabling stroke Any of the above
37 (6.5%) 5 (0.9%) 78 (13.7%)
25(4.5%) 1(0.2%) 54 (9.6%)
0.11
3.
0.13
4.
0.033
References 1.
5.
GUSTO Investigators. An international four thrombolytic strategies for acute
randomised myocardial
trial comparing infarction. New
of Coronary
Stenting ‘97 SUPPLEMENT
Engl J Med 1993;329:673-80. GUSTO Angiographic Investigators. The effects of tissue plasminogen activator, streptokinase or both on coronary artery patency, ventricular function and survival after myocardial infarction. New Engl J Med 1993;329:1615-22. Grimes CL, Browne KF, Macro J, et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. New Engl J Med 1993;328:673-9. Every NR, Parsons LS, Hlatky M, Martin JS, Weaver WD. A comparison of thrombolytic therapy with primary coronary angioplasty for acute myocardial infarction. New Engl J Med 1996;335:125360. GUSTO IIb Investigators. A comparison of recombinant hirudin with heparin for the treatment of acute coronary syndromes. New Engl J Med 1996;335:775-82.
Stenting In Acute MI: The Netherlands Experience Harry Suryapranata,
MD,
PhD,
Hospital De Weezenlanden,
Over the past decade, the benefits of early reperfusion therapy have been established. Thrombolytic therapy as well as PTCA are both considered effective treatment strategies in restoring the patency of the infarct-related artery (IRA). In a previous trial from our hospital we showed that primary PTCA in patients with AM1 is associated with: l l l l l
Zwolle, The Netherlands
within the first 6 months, remains disappointingly high (25-40%). The use of intracoronary stents may potentially overcome some major limitations of conventional PTCA. It has been postulated that coronary stents would create a larger and smoother intraluminal surface, by avoiding major dissections or the recoil phenomenon. A stent may improve the flow pattern and reduce platelet aggregation or thrombus formation. The hypothesis is that “adequate coronary blood flow is the best thrombolytic therapy”. An initially larger lumen may prevent clinically significant restenosis by allowing more space for tissue to grow during the healing process. Until recently, however, stenting has been avoided in the setting of AM1 because of the concern of potential stent thrombosis. In fact, the presence of intraluminal thrombus has been considered as a relative contraindication to stent implantation. Despite this concern, initial results of stent implantation in AM1 have been favourable. It has to be appreciated that current data are obtained from retrospective analysis of uncontrolled consecutive series of patients undergoing stent implantation as a bailout or rescue procedure. There is, so far, no randomised trial available on the merit of primary stenting in this setting. Therefore, a prospective randomised trial, comparing conventional PTCA with primary stenting in patients with AMI, has recently been initiated in our cantre. Data analysis of this on-going single centre trial is being undertaken.
a higher patency rate of the IRA a lower incidence of recurrent infarction a lower mortality rate a smaller infarct size, and consequently, better left ventricular function, when compared to intravenous streptokinase.
These findings are also confirmed when our data are combined with those from the PAM1 and the Mayo clinic trials, involving a total of almost 800 patients. In this pooled analysis, primary PTCA has been demonstrated to be superior to thrombolytic therapy with regards to mortality, recurrent infarction, incidence of stroke and recurrent ischaemia. Although the excellent results of primary PTCA are compelling, several areas for improvement remain. Pooled analysis from the PAMI, Mayo clinic, and the Zwolle trials has shown that recurrent ischaemia occurs in lo-15% of patients after initially successful PTCA. Furthermore, silent or clinically apparent reocclusion of the IRA before hospital discharge occurs in 5-10%. The late restenosis rate, necessitating repeat revascularisation
The QUEST Study Adam Cannon,
FRACP,
Townsville
General Hospital, Townsville, Queensland, Australia
The Gianturco-Roubin II stent (Cook) is a second generation intracoronary device. This model incorporates substantial design modifications to improve the stent’s performance. The Cardiac Departments of the Townsville General and Prince Charles Hospitals have undertaken the
QUEST Study to evaluate the performance and acute results of the GR-II stent, and to evaluate medium-term outcome with angiographic follow-up. The study also involves intracoronary ultrasound following deployment at the Prince Charles Hospital. The GR-II stent involves a number of modifications
67
Heart J 1997;6(1)
Proceedings
rates of 90% or more (Figure). Early trials of stenting for AM1 suggest this may be possible. Table. Results of GUSTO
IIb, primary
endpoints
2.
at 30 days.
t-PA 40 (7%)
Angioplasty
p value
Death
32 (5.7%)
0.37
Reinfarction Disabling stroke Any of the above
37 (6.5%) 5 (0.9%) 78 (13.7%)
25(4.5%) 1(0.2%) 54 (9.6%)
0.11
3.
0.13
4.
0.033
References 1.
5.
GUSTO Investigators. An international four thrombolytic strategies for acute
randomised myocardial
trial comparing infarction. New
of Coronary
Stenting ‘97 SUPPLEMENT
Engl J Med 1993;329:673-80. GUSTO Angiographic Investigators. The effects of tissue plasminogen activator, streptokinase or both on coronary artery patency, ventricular function and survival after myocardial infarction. New Engl J Med 1993;329:1615-22. Grimes CL, Browne KF, Macro J, et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. New Engl J Med 1993;328:673-9. Every NR, Parsons LS, Hlatky M, Martin JS, Weaver WD. A comparison of thrombolytic therapy with primary coronary angioplasty for acute myocardial infarction. New Engl J Med 1996;335:125360. GUSTO IIb Investigators. A comparison of recombinant hirudin with heparin for the treatment of acute coronary syndromes. New Engl J Med 1996;335:775-82.
Stenting In Acute MI: The Netherlands Experience Harry Suryapranata,
MD,
PhD,
Hospital De Weezenlanden,
Over the past decade, the benefits of early reperfusion therapy have been established. Thrombolytic therapy as well as PTCA are both considered effective treatment strategies in restoring the patency of the infarct-related artery (IRA). In a previous trial from our hospital we showed that primary PTCA in patients with AM1 is associated with: l l l l l
Zwolle, The Netherlands
within the first 6 months, remains disappointingly high (25-40%). The use of intracoronary stents may potentially overcome some major limitations of conventional PTCA. It has been postulated that coronary stents would create a larger and smoother intraluminal surface, by avoiding major dissections or the recoil phenomenon. A stent may improve the flow pattern and reduce platelet aggregation or thrombus formation. The hypothesis is that “adequate coronary blood flow is the best thrombolytic therapy”. An initially larger lumen may prevent clinically significant restenosis by allowing more space for tissue to grow during the healing process. Until recently, however, stenting has been avoided in the setting of AM1 because of the concern of potential stent thrombosis. In fact, the presence of intraluminal thrombus has been considered as a relative contraindication to stent implantation. Despite this concern, initial results of stent implantation in AM1 have been favourable. It has to be appreciated that current data are obtained from retrospective analysis of uncontrolled consecutive series of patients undergoing stent implantation as a bailout or rescue procedure. There is, so far, no randomised trial available on the merit of primary stenting in this setting. Therefore, a prospective randomised trial, comparing conventional PTCA with primary stenting in patients with AMI, has recently been initiated in our cantre. Data analysis of this on-going single centre trial is being undertaken.
a higher patency rate of the IRA a lower incidence of recurrent infarction a lower mortality rate a smaller infarct size, and consequently, better left ventricular function, when compared to intravenous streptokinase.
These findings are also confirmed when our data are combined with those from the PAM1 and the Mayo clinic trials, involving a total of almost 800 patients. In this pooled analysis, primary PTCA has been demonstrated to be superior to thrombolytic therapy with regards to mortality, recurrent infarction, incidence of stroke and recurrent ischaemia. Although the excellent results of primary PTCA are compelling, several areas for improvement remain. Pooled analysis from the PAMI, Mayo clinic, and the Zwolle trials has shown that recurrent ischaemia occurs in lo-15% of patients after initially successful PTCA. Furthermore, silent or clinically apparent reocclusion of the IRA before hospital discharge occurs in 5-10%. The late restenosis rate, necessitating repeat revascularisation
The QUEST Study Adam Cannon,
FRACP,
Townsville
General Hospital, Townsville, Queensland, Australia
The Gianturco-Roubin II stent (Cook) is a second generation intracoronary device. This model incorporates substantial design modifications to improve the stent’s performance. The Cardiac Departments of the Townsville General and Prince Charles Hospitals have undertaken the
QUEST Study to evaluate the performance and acute results of the GR-II stent, and to evaluate medium-term outcome with angiographic follow-up. The study also involves intracoronary ultrasound following deployment at the Prince Charles Hospital. The GR-II stent involves a number of modifications
67