Treatment of acute myocardial infarction:
Gespeichert in:
| Format: | Buch |
|---|---|
| Sprache: | English |
| Veröffentlicht: |
Philadelphia [u.a.]
Saunders
1995
|
| Schriftenreihe: | Cardiology clinics
13,3 |
| Schlagworte: | |
| Online-Zugang: | Inhaltsverzeichnis |
| Beschreibung: | XI S., S. 283 - 471 Ill., graph. Darst. |
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| 245 | 1 | 0 | |a Treatment of acute myocardial infarction |c Neal S. Kleiman, guest ed. |
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Datensatz im Suchindex
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|---|---|
| adam_text | TREATMENT OF ACUTE MYCX RIJIAI IMARCTION
CONTENTS
Foreword xiii
Michael H. Crawford
Preface xv
Neal S. Kleiman
Rapid Diagnosis of Acute Myocardial Infarction 283
Thomas M. Guest and Allan S. Jaffe
Recently, there has been increased emphasis on developing strategies to
detect the presence of myocardial injury as early as possible in patients
who present with chest discomfort. At present the ideal method for the
very early and very rapid diagnosis of acute infarction is still elusive,
making it difficult to implement strategies in large numbers of patients.
With further research and conjoint biochemical and imaging approaches,
however, it is likely that the early diagnosis of infarction and detection of
ischemia will be possible.
Arterial Thrombosis for the Clinician: Pathobiology and
Emerging Concepts 295
Richard C. Becker
The prevention and treatment of coronary atherosclerosis and thrombosis
are linked closely by common pathobiologic features. Patient care will
undoubtedly benefit from an increased knowledge of disease mechanisms
and clinical expression.
Streamlining the Triage System for Acute Myocardial Infarction 311
Charles Maynard and W. Douglas Weaver
The full benefits of thrombolytic therapy can be realized if and only if
treatment is delivered as quickly as possible. Streamlining the triage sys¬
tem for acute myocardial infarction not only will increase the numbers of
patients treated with thrombolytic therapy, it ultimately will reduce mor¬
tality and morbidity from acute myocardial infarction by limiting loss of
heart muscle. Reducing the time to treatment, however, is a daunting task,
given that both patient and hospital delays contribute to the underutiliza
CARDIOUX. Y CLINICS
VDT TIMP 13 . MITMRFR % • ATIHIKT 1Q « vii
tion or inefficient use of thrombolytic therapy. In particular, patient delays
can be difficult to attenuate, given that human behavior is complex and
that designing interventions to change behavior is not only challenging
but also expensive. The emergency medical system is the linchpin of an
efficient triage system in that it is associated with reduced patient delays
as well as reduced treatment delays. In addition, decisions to implement
acquisition of electrocardiograms or deliver thrombolytic treatment in the
field will be faced by administrators and policy makers in the years to
come. Finally, without adequate community support to maintain and
improve the triage system, the full benefits of thrombolytic therapy cannot
be realized.
Direct Angioplasty in Acute Myocardial Infarction:
State of the Art and Current Controversies 321
Mark C. G. Horrigan and Eric J. Topol
Although direct angioplasty may have been undervalued in the past, its
utility in the treatment of acute coronary occlusion is now firmly estab¬
lished, and it unquestionably will remain an integral component of myo¬
cardial reperfusion therapy. As refinements in angioplasty equipment,
cardiovascular support techniques, and adjunctive therapy occur, the chal¬
lenge facing cardiologists in the 1990s will be to define the most effective
role for direct angioplasty in the treatment of acute myocardial infarction.
Risk Benefit of Thrombolysis 339
Maarten L. Simoons
In larger trials the relative reduction in mortality rates brought about by
thrombolytic therapy is similar among various subgroups. Accordingly,
the absolute mortality reduction by thrombolytic therapy is largest in
patients with the greatest expected mortality in the placebo groups. Simi¬
larly, the additional benefit by accelerated tissue plasminogen activator
(TPA) is proportional to the expected mortality without thrombolytic
therapy. Using logistic regression analysis a table has been developed
predicting the survival benefit from thrombolytic therapy in groups of
patients with different baseline characteristics. A table also has been devel¬
oped to predict the risk of intracranial hemorrhage from thrombolytic
therapy. Using these two tables, an individual risk/benefit assessment can
be made. In most patients the benefits of thrombolytic therapy far exceed
the risk of intracranial hemorrhage. Similarly, the advantage of more
intensive therapy (accelerated TPA) exceeds the slightly increased bleeding
risk. The model presented can help to allocate different modes of reperfu¬
sion therapy to individual patients, accounting for limited resources.
Selecting a Thrombolytic Agent 347
Harvey D. White
Selection of a thrombolytic agent for an individual patient depends on the
baseline clinical characteristics of the patient, in particular any risk factors
for stroke and the time from pain onset to presentation. Another important
factor is consideration of cost. The GUSTO trial showed that administration
of accelerated tissue plasminogen activator (TPA) within 6 hours of the onset
of pain resulted in a reduction in mortality rates across all subgroups when
compared with administration of streptokinase. The greatest benefit was seen
in those patients at greatest risk. Streptokinase may be considered the agent
of choice in patients with risk factors for stroke, patients treated more than 6
hours from symptom onset, and patients in whom the incremental benefit of
TPA is small and the cost/benefit ratio is likely to be high.
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Prediction of Myocardium at Risk: Clinical Significance
During Acute Infarction and in Evaluating Subsequent Prognosis 355
John J. Mahmarian
Noninvasive cardiac imaging is currently used to assess myocardial sal¬
vage following reperfusion therapy for acute myocardial infarction and to
stratify patients by risk for the development of subsequent cardiac events.
The latter is most important when deciding who might benefit from
coronary angiography and revascularization. This article summarizes the
roles of radionuclide angiography, two dimensional echocardiography,
and myocardial perfusion imaging in the clinical assessment and manage¬
ment of patients with acute myocardial infarction.
Angiotensin Converting Enzyme Inhibitors
Post Myocardial Infarction 379
James B. Young
Insight into the pathophysiology of myocardial infarction stimulated strat¬
egies to reduce peri infarct morbidity and mortality rates. A panoply of
procedures and therapeutic adventures has been employed over the last
several decades to achieve this end. With the creation of coronary care
units and drug infusion protocols to decrease ischemic burden, degree of
coronary obstruction, and arrhythmias, post myocardial infarction mortal¬
ity rates (hospital and long term) dropped from at least 30% to well under
10%. Because of the unique properties of angiotensin converting enzyme
(ACE) inhibitors, these drugs also have been studied in immediate, early,
and long term post myocardial infarction patients. It appears that capto
pril, enalipril, lisinopril, ramipril, and possibly other ACE inhibitors have
significant anti ischemic effects that result in myocardial as well as vascu¬
lar protection. Clinical trial experience helps guide practitioners with re¬
spect to rational utilization of ACE inhibitors in the post myocardial
infarction period.
Cardiogenic Shock 391
Mauro Moscucci and Eric R. Bates
Despite the advancements in the pharmacologic treatment of acute myo¬
cardial infarction, the mortality rate for cardiogenic shock has remained
between 70% and 80%, with cardiogenic shock accounting for 50,000 to
70,000 lives lost each year in the United States alone. The introduction of
thrombolytic therapy has not altered this outcome. More recent data sug¬
gest that an aggressive approach including pharmacologic and mechanical
hemodynamic support followed by emergency revascularization may
modify this grim prognosis.
Role of Angiography 407
H. Vernon Anderson
The multifaceted role and timing of coronary angiography in patients with
acute myocardial infarction are reviewed. Angiography is potentially a
critically important part of the overall evaluation of infarction patients.
Until recently, angiography was usually coupled with coronary angi
oplasty for lesions that were approachable. The emphasis has shifted to
the informational features of angiography and its use for patient triage to
either medical therapies, angioplasty, or coronary bypass surgery. Pres¬
ently angiography is the only methodology that can document the patency
status of the infarct related artery early after infarction onset. Data from
many large scale clinical trials are reviewed, as well as data from smaller
trials.
CONTENTS ix
Thrombin Inhibitors in Acute Myocardial Infarction 421
Christopher P. Cannon
Thrombin inhibitors play an important role as part of current and potential
future thrombolytic antithrombotic regimens for acute myocardial in¬
farction. Heparin has been shown to improve infarct related artery patency
following tissue plasminogen activator (TPA) and is an integral adjunct to
front loaded TPA and aspirin, the regimen that has been demonstrated to
be superior to standard thrombolytic regimens. The initial experience with
direct thrombin inhibitors, such as hirudin and hirulog, as adjuncts to
thrombolytic therapy has shown promising results. Hirudin, compared
with heparin, provides a more consistent level of anticoagulation and
improved indices of coronary reperfusion and has shown favorable results
for clinical end points. Current larger phase III trials should allow testing
of the thrombin hypothesis, that more potent inhibition of thrombin
will translate into improved clinical outcome for patients with acute myo¬
cardial infarction.
Platelets and Platelet Inhibitors in Acute Myocardial Infarction 435
Suraj G. Kamat and Neal S. Kleiman
Platelets and platelet rich thrombi play a pivotal role in the pathogenesis
of acute myocardial infarction. A ruptured atherosclerotic plaque evokes a
hemostatic response that is mediated by platelets, its membrane receptors,
adhesive ligands, the presence or generation of platelet agonists, and the
activation of the coagulation cascade with fibrin generation. The inter¬
action of platelets with the coagulation and the fibrinolytic systems is
complex; new and exciting developments, however, in the ability to phar¬
macologically control platelet responses during thrombolysis in acute
myocardial infarction will enhance our understanding of these interactions
and will eventually translate into clinical benefit.
Cardiac Surgical Procedures Following Myocardial Infarction 449
Michael E. Sekela
Operative intervention during evolving or recent myocardial infarction is
now feasible with relatively low predicted mortality rates. This has been
made possible by rapid advancements in strategies of perioperative myo¬
cardial protection and myocardial resuscitation. Mechanical complications
and cardiogenic shock associated with myocardial infarction remain chal¬
lenging but now are associated with 85% to 90% predicted survival rates.
Early elective operative revascularization following myocardial infarct
results in low morbidity and mortality rates and no longer need be
avoided absolutely.
How Should Clinicians Interpret Clinical Trials? 459
Robert M. Califf
Given the rapid evolution of cardiovascular medicine, clinicians must sift
through an enormous array of information about new therapies in order
to determine how best to treat patients with ischemic heart disease. They
should first consider the evidence from randomized clinical trials, because
these trials eliminate bias and permit broad statistical analyses. If random¬
ized clinical trial data are not available, next in order of the strength of
their evidence are observational studies, historically controlled studies,
case series, and case reports. Clinicians must additionally ascertain that an
investigation has the elements of good design, including a clear question,
adequate sample size, appropriate inclusion and exclusion criteria, evi
dence that the right amount of data was collected carefully, and allowances
in the analyses for patients taking multiple therapies and randomized into
several clinical trials.
Index 469
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| spelling | Treatment of acute myocardial infarction Neal S. Kleiman, guest ed. Philadelphia [u.a.] Saunders 1995 XI S., S. 283 - 471 Ill., graph. Darst. txt rdacontent n rdamedia nc rdacarrier Cardiology clinics 13,3 Herzinfarkt (DE-588)4024654-1 gnd rswk-swf Therapie (DE-588)4059798-2 gnd rswk-swf (DE-588)4143413-4 Aufsatzsammlung gnd-content Herzinfarkt (DE-588)4024654-1 s Therapie (DE-588)4059798-2 s DE-604 Kleimann, Neal S. Sonstige oth Cardiology clinics 13,3 (DE-604)BV000008602 13,3 HBZ Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=006971169&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
| spellingShingle | Treatment of acute myocardial infarction Cardiology clinics Herzinfarkt (DE-588)4024654-1 gnd Therapie (DE-588)4059798-2 gnd |
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| title | Treatment of acute myocardial infarction |
| title_auth | Treatment of acute myocardial infarction |
| title_exact_search | Treatment of acute myocardial infarction |
| title_full | Treatment of acute myocardial infarction Neal S. Kleiman, guest ed. |
| title_fullStr | Treatment of acute myocardial infarction Neal S. Kleiman, guest ed. |
| title_full_unstemmed | Treatment of acute myocardial infarction Neal S. Kleiman, guest ed. |
| title_short | Treatment of acute myocardial infarction |
| title_sort | treatment of acute myocardial infarction |
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| topic_facet | Herzinfarkt Therapie Aufsatzsammlung |
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