Coronary artery diseaseClinical Benefit of Early Reperfusion Therapy in Patients With ST-Elevation Myocardial Infarction Usually Excluded from Randomized Clinical Trials (Results from the Maximal Individual Therapy in Acute Myocardial Infarction Plus [MITRA Plus] Registry)
Section snippets
Methods
The Maximal Individual Therapy in Acute Myocardial Infarction Plus (MITRA Plus) registry is a German, prospective, multicenter, observational data pool of current treatment of acute MI. From 1992 to 2002, 21,175 consecutive patients were included in the MITRA Plus registry. The MITRA Plus registry consists of 4 consecutive subregistries that have been previously described: the 60 Minutes Myocardial Infarction Project (60-minute MIP),1 Maximal Individual Therapy in Acute Myocardial Infarction
Results
For the present study we evaluated the MITRA Plus registry and included 11,806 patients with STEMI eligible for enrollment in RCTs and 9,369 patients with STEMI usually excluded from RCTs. In total 53.5% of ineligible patients were >75 years old, 3.3% had a previous stroke, 13.1% prehospital cardiopulmonary resuscitation, 5.5% impaired renal function, 40.7% prehospital delay >12 hours, and in 11.0% STEMI was complicated by cardiogenic shock. Baseline characteristics and acute adjunctive
Discussion
Patients with STEMI included in RCTs represent a selected subgroup of patients with a low adverse event rate. This subgroup may therefore not be representative of patients encountered in everyday practice. About 50% of patients seen in clinical practice are usually excluded from RCTs. In the present study ineligible patients more often had concomitant diseases compared to eligible patients. In addition, ineligible patients less often received early reperfusion therapy and adjunctive
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Intramyocardial Hemorrhage and the “Wave Front” of Reperfusion Injury Compromising Myocardial Salvage
2022, Journal of the American College of CardiologyCitation Excerpt :Our findings beg the question: is myocardial hemorrhage a biomarker of more severe myocardial damage, an active mediator of infarct surge, or both? The risk of reperfusion hemorrhage is closely linked to ischemia duration; thus, it is not surprising that early reperfusion has been shown to yield significant clinical benefit (25-29). However, the present animal work following each animal as its own control clearly demonstrated that myocardial hemorrhage was the driver of infarct surge independent of ischemic time.
Clinical outcome and correlates of coronary microvascular obstruction in latecomers after acute myocardial infarction
2017, International Journal of CardiologyCitation Excerpt :The OAT trial demonstrated no benefit of late reperfusion in patients presenting > 3 days after myocardial infarction [5]. However, some trials and registries reported a benefit for late salvage of myocardium performed in a time window of 24–72 h [6–10]. Multiple mechanisms are involved in preservation of myocardial cell survival in the area at risk [11], such as preformed collateral vessels, as a consequence of chronic myocardial ischemia, and repetitive myocardial ischemia resulting in preconditioning, which increases the resistance of myocardium to ischemia, thus prolonging the time interval during which myocardium remains viable after coronary occlusion [3,12].
Characteristics and outcomes of patients with ST-segment elevation myocardial infarction excluded from the harmonizing outcomes with revascularization and stents in acute myocardial infarction (horizons-ami) trial
2013, American Journal of CardiologyCitation Excerpt :A gradient of risk was observed from the patients who were included in RCTs (lowest risk) to those ineligible (greatest risk), with a mortality rate of 3.6%, 7.1%, and 11.4% respectively (p = 0.001).2 Finally, similar findings were observed in >20,000 patients with STEMI from the Maximal Individual Therapy of Acute Myocardial Infarction (MITRA) Plus registry.19 The RCT-ineligible patients (46.4%) more often had baseline risk characteristics, less often received early reperfusion and other evidence-based therapies, and had greater in-hospital mortality (20.1% vs 4.9%, p <0.0001) compared to the eligible patients.
Reduction in treatment times through formalized data feedback: Results from a prospective multicenter study of ST-segment elevation myocardial infarction
2012, JACC: Cardiovascular InterventionsCitation Excerpt :For example, the association between longer treatment times and adverse outcomes may be exacerbated by longer procedure times in higher-risk patients. We addressed this in the present study by prospectively calculating a TIMI risk score (20) and by including all patients presenting with STEMI (21). Including high-risk patients, such as those in cardiogenic shock and those with cardiac arrest, may explain the greater overall in-hospital and 30-day mortality rates seen in the present study when compared with most recent trials and large registries.