(Circulation. 2000;101:239.)
© 2000 American Heart Association, Inc.
Clinical Investigation and Reports |
Abciximab Improves Both Epicardial Flow and Myocardial Reperfusion in ST-Elevation Myocardial Infarction
Observations from the TIMI 14 Trial
From the Cardiovascular Division, Brigham and Women’s Hospital (J.A.d., E.M.A., C.H.M., R.P.G., S.A.C., E.B.), Boston Mass; University of California at San Francisco Medical Center (C.M.G., S.A.M.), San Francisco; Centocor (K.A.), Malvern, Pa; Eli Lilly Inc (J.S.), Indianapolis, Ind; Heart Center (M.J.F.), Sarasota, Fla; Afdeling Cardiologie (R.V.), Amsterdam, the Netherlands; and Universitair Zikenhuis Gasthuisberg (F.V.), Leuven, Belgium.
Correspondence to James A. de Lemos, MD, Brigham and Women’s Hospital, Division of Cardiology, 75 Francis Street, Boston, MA 02115. E-mail jdelemos{at}rics.bwh.harvard.edu
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionReferences |
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Background—In the presence of ST-elevation myocardial infarction, patients with successful epicardial reperfusion (TIMI 3 flow) but persistent ST elevation on a 12-lead ECG are at high risk for subsequent death and left ventricular dysfunction. In the TIMI 14 trial, a dose-ranging angiographic study, combined therapy with abciximab plus reduced-dose tPA enhanced the speed and efficacy of epicardial reperfusion. We determined whether the combination of abciximab plus reduced-dose tPA provided additional benefit in terms of myocardial reperfusion, as evidenced by greater resolution of ST elevation.
Methods and Results—All 346 patients with interpretable baseline
and 90-minute ECGs, treated with either tPA alone or abciximab plus
reduced-dose tPA (combination therapy), were included. Patients
receiving combination therapy (n=221) had a 59% rate of complete
(
70%) ST resolution at 90 minutes versus 37% in those treated with
tPA alone (n=125) (P<0.0001). When the analysis
was limited to patients with TIMI 3 flow, patients treated with
combination therapy (n=151) remained significantly more likely to
achieve complete ST resolution than those receiving tPA alone (n=80)
(69% versus 44%; P=0.0002).
Conclusions—Combination therapy with abciximab and reduced-dose tPA improves myocardial (microvascular) reperfusion, as reflected in greater ST-segment resolution, in addition to epicardial flow. This finding may translate into improved clinical outcomes by enhancing myocardial salvage.
Key Words: myocardial infarction • thrombolysis • reperfusion • electrocardiography • microcirculation
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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The benefits of thrombolytic therapy for ST-elevation myocardial infarction (MI) have been attributed to the reestablishment of normal (TIMI grade 3) flow in the epicardial infarct-related artery (IRA).1 2 Recent studies, however, have suggested that the achievement of TIMI grade 3 flow in the IRA is not in and of itself indicative of successful myocardial reperfusion.3 Myocardial contrast echocardiography has shown that even in the presence of normal epicardial flow after primary percutaneous intervention (PCI), impaired myocardial perfusion is associated with poor recovery of left ventricular function.4 5 6 Resolution of ST-segment elevation on the surface ECG correlates closely with findings at contrast echocardiography.7 The failure of ST resolution following successful primary PCI is associated with reduced left ventricular function and increased mortality.8 9 10 These observations suggest that persistent ST elevation is a marker of microvascular dysfunction and tissue injury and that ST-segment analysis yields prognostic information which is distinct from that provided by the coronary angiogram.11
Abciximab has recently been shown to improve the recovery of microvascular function in patients treated with primary stenting for MI.12 In the TIMI 14 trial, the combination of abciximab and reduced-dose alteplase (tPA) resulted in a significant improvement in TIMI grade 3 flow rates and TIMI frame counts at 60 and 90 minutes when compared with tPA alone.13 We sought to determine whether the combination of abciximab and reduced-dose tPA also enhanced resolution of ST elevation.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Study Population
As previously described,13 the TIMI 14 trial compared 4 different thrombolytic regimens on angiographic signs of reperfusion in patients with ST-elevation MI: accelerated dose tPA alone, abciximab plus reduced doses of tPA, abciximab plus reduced doses of streptokinase, and abciximab alone. In the present analysis, abciximab plus reduced-dose tPA was compared directly with tPA alone, and the different doses of tPA plus abciximab were combined. All patients received concomitant aspirin and adjunctive intravenous heparin.
ECG and Angiographic Analyses
Standard 12-lead ECGs were obtained at baseline and 90 minutes
(range, 80 to 120 minutes). All ECGs were analyzed by a single
investigator (J.A.d.) blinded to treatment assignment and angiographic
and clinical endpoints, using a hand-held electronic caliper (Fowler,
Inc.). The ST segment was measured 20 ms after the J point, and the sum
of ST deviation was measured at baseline and 90 minutes using
previously described methods.14 The percent resolution of
ST deviation from baseline to 90 minutes was calculated, and
categorized using Schröder’s 3-component definition: complete
(70%) ST resolution, partial (30% to 70%) ST resolution, and no
(
30%) ST resolution.15
Coronary angiography was performed 90 minutes (range, 80 to 100 minutes) after initiation of study drug. Whenever possible, angiography was also performed at 60 minutes. Except in cases of rapid and progressive hemodynamic deterioration, coronary interventional procedures were not performed before the 90-minute angiogram. All coronary angiograms were analyzed in an Angiographic Core Laboratory at the University of California at San Francisco by investigators who were blinded to treatment assignment, ST resolution, and clinical end points. Flow in the IRA was analyzed by a single observer (C.M.G.) and reported using the TIMI flow grading system16 and the corrected TIMI frame count.17
Statistical Analysis
Categorical variables were compared using Fisher’s exact
and Cochran-Armitage trend tests. Continuous variables were
compared using the Mann-Whitney U test. Stratified
analyses were performed to assess for the relationship between
TIMI flow grade, ST-segment resolution, and treatment assignment.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Of the 444 patients with interpretable baseline and 90-minute ECGs and 90-minute angiograms, 125 patients received tPA alone, 221 patients received abciximab plus reduced-dose tPA (combination therapy), 79 patients received abciximab plus reduced-dose streptokinase, and 19 patients received abciximab alone. Baseline characteristics were similar between the tPA alone and combination therapy groups, and the overall TIMI 14 study population (Table 1
). TIMI 3 flow rates were 64% in the
tPA alone group, 68% in the combination therapy group (76% in the 71
patients receiving 50 mg tPA and 65% in the 150 patients receiving
other doses of tPA), 46% in the abciximab plus streptokinase group,
and 42% in the abciximab alone group.
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Median ST resolution was significantly greater in patients in the
combination therapy group versus the tPA alone group (76% versus 57%;
P=0.004). Additionally, patients receiving combination
therapy had a significantly higher rate of complete (70%) ST
resolution (59% versus 37%; P<0.001) (Table 2).
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When the analysis was limited to patients with TIMI grade 3
flow at 90 minutes (Table 2
), patients treated with combination
therapy had significantly greater median ST resolution (82% versus
60%, P=0.004) and a higher probability of complete ST
resolution (69% versus 44%; P=0.0002) than patients
treated with tPA alone. Among patients with TIMI grade 3 flow at 90
minutes, the rates of complete ST resolution were comparable between
patients receiving abciximab plus 50 mg tPA (70%; n=54), abciximab
plus other doses of tPA (68%; n=97), abciximab plus streptokinase
(56%; n=36), and abciximab alone (63%; n=8). ST resolution was
significantly greater in both abciximab plus tPA subgroups than in the
tPA alone group (P=0.01 and P=0.001,
respectively) (Figure).
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In an analysis restricted to patients with a corrected TIMI
frame count <28 frames at 90 minutes (below the upper limit of normal
for patients without an acute MI),17 median ST resolution
(89% versus 60%, P=0.0008) and the rate of complete ST
resolution (75% versus 44%, P=0.0004) were greater in
patients receiving combination therapy versus those receiving tPA alone
(Table 2). Finally, among patients with a patent (TIMI 2 or 3
flow) IRA at 60 minutes, those treated with abciximab had greater ST
resolution at 90 minutes than those treated with tPA alone
(P=0.03) (Table 2).
There was no difference observed in overall 30-day mortality between patients in the combination therapy and tPA alone groups (3.6% versus 3.2%; P=NS). However, mortality was significantly lower in patients with greater ST resolution: 1.1% in 176 patients with complete ST resolution, 4.7% in 86 patients with partial ST resolution, and 7.1% in 84 patients with no ST resolution (P=0.01 for trend).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Combination therapy with abciximab plus reduced-dose tPA significantly improved myocardial (microvascular) reperfusion, as reflected in the resolution of ST elevation on the 12-lead ECG. Even among patients with TIMI grade 3 flow and a normal corrected TIMI frame count (<28), the addition of abciximab resulted in greater ST resolution. This effect appears to be largely independent of the thrombolytic agent and dose used and suggests an additional mechanism by which abciximab may improve outcomes in patients with acute MI.
ST Resolution as a Marker of Myocardial Reperfusion
Resolution of ST elevation on the 12-lead ECG has long been used
as a noninvasive indicator of infarct artery patency after
thrombolysis.18 19 20 We recently reported
that patients with complete ST resolution, as defined by Schröder
et al,15 had a 94% probability of patency of the IRA and
a very low risk of short-term mortality. However, failure of ST
resolution did not accurately predict an occluded IRA.14
Previously, the failure of ST resolution despite a patent IRA had been
considered to be a false-negative result of the 12-lead ECG. Emerging
evidence, however, suggests that in these patients the ECG, rather than
the angiogram, may better reflect the adequacy of myocardial
reperfusion.
Several large trials have evaluated the relationship between ST resolution and subsequent mortality. The GISSI investigators have reported a strong correlation between 4-hour ST resolution and mortality.21 Schroeder et al found that patients with complete ST resolution 180 minutes after thrombolysis had a mortality of 2.2% versus 3.4% in patients with partial resolution and 8.8% in patients with no ST resolution.15
After primary PCI for acute MI, persistent ST elevation is associated with poor recovery of left ventricular function and increased mortality, even in patients with TIMI grade 3 flow in the IRA.8 9 10 22 In addition, contrast echocardiography,4 6 positron emission tomography,23 nuclear scintigraphy,24 and Doppler flow wire12 studies have shown that myocardial (microvascular) no reflow is associated with extensive infarction, poor recovery of left ventricular function, and increased mortality even after "successful" PCI (TIMI grade 3 flow). In a recent study, Santoro et al have linked failure of ST resolution with myocardial no reflow seen with contrast echocardiography.7 In the present study, we observed that greater ST resolution 90 minutes after thrombolytic therapy is associated with reduced short-term mortality. Taken together, these mechanistic and outcome studies suggest that in the presence of a patent IRA, failure of ST resolution is indicative of inadequate myocardial reperfusion.
The Effect of Abciximab on Myocardial Reperfusion
Results of the current analysis suggest that abciximab
improves myocardial reperfusion and may improve microvascular function
when given with reduced-dose thrombolytic therapy. One
earlier study has evaluated the effect of GP IIb/IIIa inhibition on
microvascular perfusion in the setting of myocardial infarction: this
study reported improvement in Doppler peak flow velocity over 14
days in patients treated with PCI.12
Several mechanisms may account for the benefits seen with abciximab.
First, this effect may be due to more rapid restoration of epicardial
blood flow and reduced tissue injury and necrosis. In the TIMI 14
trial, the improvement in perfusion of the IRA seen with abciximab plus
tPA was even greater at 60 than at 90 minutes,13
suggesting that abciximab enhances the speed as well as the extent of
epicardial reperfusion. However, even when the analysis was
restricted to patients with a patent IRA at 60 minutes, those treated
with abciximab plus tPA demonstrated a higher incidence of complete ST
resolution at 90 minutes. In addition, although patients treated with
abciximab alone and abciximab plus streptokinase were less likely than
those treated with tPA alone to achieve TIMI grade 3 flow, among
patients who did achieve TIMI 3 flow, ST resolution tended to be
greater in the abciximab-treated patients (see Figure). This
finding suggests that the effect of abciximab on microvascular
perfusion, as opposed to the effect seen with epicardial flow, may be
similar across different thrombolytic agents and
doses.
Second, abciximab may prevent microvascular obstruction caused by the formation of platelet emboli or distal microthrombi.25 The activation of platelets appears to be promoted by fibrinolysis, due in part to the exposure of clot-bound thrombin.26 By blocking platelet aggregation, abciximab may prevent the adverse effects of thrombolytic therapy on platelet function. Finally, it is possible that the interaction of abciximab with receptors other than the GP IIb/IIIa receptor, such as the vitronectin receptor27 28 or Mac-1,29 may prevent leukocyte-mediated reperfusion injury at the time of epicardial reperfusion.
Conclusions
Combination therapy with abciximab and reduced-dose tPA improves
myocardial (microvascular) reperfusion in addition to epicardial flow.
This effect may translate into improved left ventricular
function and enhanced survival.
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Acknowledgments |
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This study was supported by a grant from Centocor, Malvern, Pa.
Received June 8, 1999; revision received August 20, 1999; accepted August 26, 1999.
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References |
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B. R. Chaitman and M. J. Lim No reflow and the quest to achieve optimal perfusion during the acute phase of myocardial infarction J. Am. Coll. Cardiol., July 21, 2004; 44(2): 313 - 315. [Full Text] [PDF]
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G. De Luca, A. W.J van't Hof, M.-J. de Boer, J. P. Ottervanger, J. C.A Hoorntje, A.T.M. Gosselink, J.-H. E Dambrink, F. Zijlstra, and H. Suryapranata Time-to-treatment significantly affects the extent of ST-segment resolution and myocardial blush in patients with acute myocardial infarction treated by primary angioplasty Eur. Heart J., June 2, 2004; 25(12): 1009 - 1013. [Abstract] [Full Text] [PDF]
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H. Kunichika, O. Ben-Yehuda, S. Lafitte, N. Kunichika, B. Peters, and A. N. DeMaria Effects of glycoprotein iib/iiia inhibition on microvascular flow after coronary reperfusion: A quantitative myocardial contrast echocardiography study J. Am. Coll. Cardiol., January 21, 2004; 43(2): 276 - 283. [Abstract] [Full Text] [PDF]
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R. A. Kloner and W. Dai Glycoprotein IIb/IIIa inhibitors and no-reflow J. Am. Coll. Cardiol., January 21, 2004; 43(2): 284 - 286. [Full Text] [PDF]
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S. Savonitto, P.W. Armstrong, A.M. Lincoff, G. Jia, C.A. Sila, J. Booth, P. Terrosu, C. Cavallini, H.D. White, D. Ardissino, et al. Risk of intracranial haemorrhage with combined fibrinolytic and glycoprotein IIb/IIIa inhibitor therapy in acute myocardial infarction: Dichotomous response as a function of age in the GUSTO V trial Eur. Heart J., October 2, 2003; 24(20): 1807 - 1814. [Abstract] [Full Text] [PDF]
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T. Heitzer, I. Ollmann, K. Koke, T. Meinertz, and T. Munzel Platelet Glycoprotein IIb/IIIa Receptor Blockade Improves Vascular Nitric Oxide Bioavailability in Patients With Coronary Artery Disease Circulation, August 5, 2003; 108(5): 536 - 541. [Abstract] [Full Text] [PDF]
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L. J. Feldman, P. Coste, A. Furber, P. Dupouy, M. S. Slama, J.-P. Monassier, C. Tron, A. Lafont, M. Faraggi, D. Le Guludec, et al. Incomplete Resolution of ST-Segment Elevation Is a Marker of Transient Microcirculatory Dysfunction After Stenting for Acute Myocardial Infarction Circulation, June 3, 2003; 107(21): 2684 - 2689. [Abstract] [Full Text] [PDF]
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P. W. Armstrong, D. Collen, and E. Antman Fibrinolysis for Acute Myocardial Infarction: The Future Is Here and Now Circulation, May 27, 2003; 107(20): 2533 - 2537. [Full Text] [PDF]
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K.M.J. Marques and C.A. Visser Myocardial contrast echocardiography in the assessment of pharmacologic intervention of the reperfusion injury Eur. Heart J., January 1, 2003; 24(1): 19 - 20. [Full Text] [PDF]
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M. Marzilli, G. Sambuceti, R. Testa, and S. Fedele Platelet glycoprotein IIb/IIIa receptor blockade and coronary resistance in unstable angina J. Am. Coll. Cardiol., December 18, 2002; 40(12): 2102 - 2109. [Abstract] [Full Text] [PDF]
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A. M. Lincoff, R. M. Califf, F. Van de Werf, J. T. Willerson, H. D. White, P. W. Armstrong, V. Guetta, W. B. Gibler, J. S. Hochman, C. Bode, et al. Mortality at 1 Year With Combination Platelet Glycoprotein IIb/IIIa Inhibition and Reduced-Dose Fibrinolytic Therapy vs Conventional Fibrinolytic Therapy for Acute Myocardial Infarction: GUSTO V Randomized Trial JAMA, November 6, 2002; 288(17): 2130 - 2135. [Abstract] [Full Text] [PDF]
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J. Dong, G. Ndrepepa, C. Schmitt, J. Mehilli, S. Schmieder, M. Schwaiger, A. Schomig, and A. Kastrati Early Resolution of ST-Segment Elevation Correlates With Myocardial Salvage Assessed by Tc-99m Sestamibi Scintigraphy in Patients With Acute Myocardial Infarction After Mechanical or Thrombolytic Reperfusion Therapy Circulation, June 25, 2002; 105(25): 2946 - 2949. [Abstract] [Full Text] [PDF]
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M. Aschermann and P. Widimsky I have an acute myocardial infarction: open my coronary artery, stent it and keep full flow! Eur. Heart J., June 2, 2002; 23(12): 913 - 916. [Full Text] [PDF]
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S. J. Brener, U. Zeymer, A. A. J. Adgey, T. R. Vrobel, S. G. Ellis, K.-L. Neuhaus, N. Juran, T. B. Ivanc, E. M. Ohman, J. Strony, et al. Eptifibatide and low-dose tissue plasminogen activator in acute myocardial infarction: The integrilin and low-dose thrombolysis in acute myocardial infarction (INTRO AMI) trial J. Am. Coll. Cardiol., February 6, 2002; 39(3): 377 - 386. [Abstract] [Full Text] [PDF]
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S. H. Rezkalla and R. A. Kloner No-Reflow Phenomenon Circulation, February 5, 2002; 105(5): 656 - 662. [Full Text] [PDF]
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C. Loubeyre, M.-C. Morice, T. Lefevre, J.-F. Piechaud, Y. Louvard, and P. Dumas A randomized comparison of direct stenting with conventional stent implantation in selected patients with acute myocardial infarction J. Am. Coll. Cardiol., January 2, 2002; 39(1): 15 - 21. [Abstract] [Full Text] [PDF]
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J. A. Barrabes, D. Garcia-Dorado, M. Mirabet, R.-M. Lidon, B. Soriano, M. Ruiz-Meana, P. Pizcueta, J. Blanco, Y. Puigfel, and J. Soler-Soler Lack of effect of glycoprotein IIb/IIIa blockade on myocardial platelet or polymorphonuclear leukocyte accumulation and on infarct size after transient coronary occlusion in pigs J. Am. Coll. Cardiol., January 2, 2002; 39(1): 157 - 165. [Abstract] [Full Text] [PDF]
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Y. Fu, S. Goodman, W.-C. Chang, F. Van de Werf, C. B. Granger, and P. W. Armstrong Time to Treatment Influences the Impact of ST-Segment Resolution on One-Year Prognosis: Insights From the Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT-2) Trial Circulation, November 27, 2001; 104(22): 2653 - 2659. [Abstract] [Full Text] [PDF]
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I. B. A. Menown and A. A. J. Adgey Cardioprotective therapy and sodium-hydrogen exchange inhibition: current concepts and future goals J. Am. Coll. Cardiol., November 15, 2001; 38(6): 1651 - 1653. [Full Text] [PDF]
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J. A. de Lemos and E. Braunwald ST segment resolution as a tool for assessing the efficacy of reperfusion therapy J. Am. Coll. Cardiol., November 1, 2001; 38(5): 1283 - 1294. [Abstract] [Full Text] [PDF]
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G MANOHARAN and A A J ADGEY Glycoprotein IIb/IIIa inhibitors and acute coronary syndromes: summary report of the full submission to NICE, and beyond Heart, September 1, 2001; 86(3): 259 - 261. [Full Text] [PDF]
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G. W. Stone, D. Cox, E. Garcia, B. R. Brodie, M.-C. Morice, J. Griffin, L. Mattos, A. J. Lansky, W. W. O'Neill, and C. L. Grines Normal Flow (TIMI-3) Before Mechanical Reperfusion Therapy Is an Independent Determinant of Survival in Acute Myocardial Infarction: Analysis From the Primary Angioplasty in Myocardial Infarction Trials Circulation, August 7, 2001; 104(6): 636 - 641. [Abstract] [Full Text] [PDF]
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J. Llevadot, R. P. Giugliano, and E. M. Antman Bolus Fibrinolytic Therapy in Acute Myocardial Infarction JAMA, July 25, 2001; 286(4): 442 - 449. [Abstract] [Full Text] [PDF]
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P. W. Armstrong and D. Collen Fibrinolysis for Acute Myocardial Infarction : Current Status and New Horizons for Pharmacological Reperfusion, Part 2 Circulation, June 19, 2001; 103(24): 2987 - 2992. [Full Text] [PDF]
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C. M. Gibson, J. A. de Lemos, S. A. Murphy, S. J. Marble, C. H. McCabe, C. P. Cannon, E. M. Antman, and E. Braunwald Combination Therapy With Abciximab Reduces Angiographically Evident Thrombus in Acute Myocardial Infarction : A TIMI 14 Substudy Circulation, May 29, 2001; 103(21): 2550 - 2554. [Abstract] [Full Text] [PDF]
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R.G. Wilcox ST-segment elevation resolution -- a surrogate for infarct vessel patency or myocardial perfusion, but a call for rescue? Eur. Heart J., May 1, 2001; 22(9): 722 - 724. [PDF]
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U Zeymer, R Schroder, U Tebbe, G.P Molhoek, K Wegscheider, and K.-L Neuhaus Non-invasive detection of early infarct vessel patency by resolution of ST-segment elevation in patients with thrombolysis for acute myocardial infarction. Results of the angiographic substudy of the Hirudin for Improvement of Thrombolysis (HIT)-4 trial Eur. Heart J., May 1, 2001; 22(9): 769 - 775. [Abstract] [PDF]
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E. Braunwald Foreword Eur. Heart J. Suppl., May 1, 2001; 3(suppl_A): A1 - A2. [PDF]
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A.M. Antman, J.A. de Lemos, and E. Braunwald Epicardial flow and myocardial reperfusion following abciximab and low-dose thrombolytic therapy for acute myocardial infarction Eur. Heart J. Suppl., May 1, 2001; 3(suppl_A): A8 - A13. [Abstract] [PDF]
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F.-J. Neumann Optimization of microvascular reperfusion in acute myocardial infarction Eur. Heart J. Suppl., May 1, 2001; 3(suppl_A): A21 - A25. [Abstract] [PDF]
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H.C. Herrmann, R.H. Li, and E.M. Ohman Facilitated percutaneous coronary intervention: results from the SPEED trial Eur. Heart J. Suppl., May 1, 2001; 3(suppl_A): A26 - A34. [Abstract] [PDF]
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B. R. Chaitman and S. R. Bitar Is ST segment elevation non-Q- wave myocardial infarction after thrombolytic therapy a new clinical entity that requires an invasive management strategy? J. Am. Coll. Cardiol., January 1, 2001; 37(1): 26 - 29. [Full Text] [PDF]
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P.W. Armstrong Reperfusion synergism: will it be both sustained and safe? Eur. Heart J., December 1, 2000; 21(23): 1913 - 1916. [PDF]
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J. G. Kingma Jr., S. Plante, and P. Bogaty Platelet GPIIb/IIIa receptor blockade reduces infarct size in a canine model of ischemia-reperfusion J. Am. Coll. Cardiol., December 1, 2000; 36(7): 2317 - 2324. [Abstract] [Full Text] [PDF]
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C. M. Gibson A union in reperfusion:: The concept of facilitated percutaneous coronary intervention J. Am. Coll. Cardiol., November 1, 2000; 36(5): 1497 - 1499. [Full Text] [PDF]
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J. Z. Ayanian and E. Braunwald Thrombolytic Therapy for Patients With Myocardial Infarction Who Are Older Than 75 Years : Do the Risks Outweigh the Benefits? Circulation, May 16, 2000; 101(19): 2224 - 2226. [Full Text] [PDF]
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J. Andrews, I. T. Straznicky, J. K. French, C. L. Green, A. C. P. Maas, M. Lund, M. W. Krucoff, and H. D. White ST-Segment Recovery Adds to the Assessment of TIMI 2 and 3 Flow in Predicting Infarct Wall Motion After Thrombolytic Therapy Circulation, May 9, 2000; 101(18): 2138 - 2143. [Abstract] [Full Text] [PDF]
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Abciximab Improves Myocardial Reperfusion Journal Watch Cardiology, February 18, 2000; 2000(218): 6 - 6. [Full Text]
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E. M. Antman, H. W. Louwerenburg, H. F. Baars, J. C.L. Wesdorp, B. Hamer, J.-P. Bassand, F. Bigonzi, G. Pisapia, C. M. Gibson, H. Heidbuchel, et al. Enoxaparin as Adjunctive Antithrombin Therapy for ST-Elevation Myocardial Infarction: Results of the ENTIRE-Thrombolysis in Myocardial Infarction (TIMI) 23 Trial Circulation, April 9, 2002; 105(14): 1642 - 1649. [Abstract] [Full Text] [PDF]
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