Circulation, Vol 89, 1545-1556, Copyright © 1994 by American Heart Association
BACKGROUND: Although coronary thrombosis plays a critical role in the
pathogenesis of unstable angina and non-Q-wave myocardial infarction
(NQMI), the effects of thrombolytic therapy in these disorders is not
clear. Also, the role of routine early coronary arteriography followed by
revascularization has not been established. METHODS AND RESULTS: Patients
(n = 1473) seen within 24 hours of ischemic chest discomfort at rest,
considered to represent unstable angina or NQMI, were randomized using a 2
x 2 factorial design to compare (1) TPA versus placebo as initial therapy
and (2) an early invasive strategy (early coronary arteriography followed
by revascularization when the anatomy was suitable) versus an early
conservative strategy (coronary arteriography followed by revascularization
if initial medical therapy failed). All patients were treated with bed
rest, anti-ischemic medications, aspirin, and heparin. The primary end
point for the TPA- placebo comparison (death, myocardial infarction, or
failure of initial therapy at 6 weeks) occurred in 54.2% of the TPA-treated
patients and 55.5% of the placebo-treated patients (P = NS). Fatal and
nonfatal myocardial infarction after randomization (reinfarction in NQMI
patients) occurred more frequently in TPA-treated patients (7.4%) than in
placebo-treated patients (4.9%, P = .04, Kaplan-Meier estimate). Four
intracranial hemorrhages occurred in the TPA-treated group versus none in
the placebo-treated group (P = .06). The end point for the comparison of
the two strategies (death, myocardial infarction, or an unsatisfactory
symptom-limited exercise stress test at 6 weeks) occurred in 18.1% of
patients assigned to the early conservative strategy and 16.2% of patients
assigned to the early invasive strategy (P = NS). In the latter, the
average length of initial hospitalization, incidence of rehospitalization
within 6 weeks, and days of rehospitalization all were significantly lower.
CONCLUSIONS: In the overall trial, patients with unstable angina and NQMI
were managed with low rates of mortality (2.4%) and myocardial infarction
or reinfarction (6.3%) at the time of the 6-week visit. These results can
be achieved using either an early conservative or early invasive strategy,
the latter resulting in a reduced incidence of days of hospitalization and
of rehospitalization and in the use of antianginal drugs. The addition of a
thrombolytic agent is not beneficial and may be harmful.
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Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction. Results of the TIMI IIIB Trial. Thrombolysis in Myocardial Ischemia
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M. C. Kim, A. Kini, and S. K. Sharma Refractory angina pectoris: Mechanism and therapeutic options J. Am. Coll. Cardiol., March 20, 2002; 39(6): 923 - 934. [Abstract] [Full Text] [PDF]
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L. Pilote, C. Lauzon, T. Huynh, D. Dion, R. Roux, N. Racine, S. Carignan, J. G. Diodati, C. Levesque, F. Charbonneau, et al. Quality of Life After Acute Myocardial Infarction Among Patients Treated at Sites With and Without On-site Availability of Angiography Arch Intern Med, March 11, 2002; 162(5): 553 - 559. [Abstract] [Full Text] [PDF]
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D. B. Mark and T. H. Lee Conservative Management of Acute Coronary Syndrome: Cheaper and Better for You? Circulation, February 12, 2002; 105(6): 666 - 668. [Full Text] [PDF]
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R. A. Harrington and E. Magnus Ohman Early invasive strategy for acute coronary syndromes without persistent ST-segment elevation: Has the time come for 'drive-through' angiography? Eur. Heart J., February 1, 2002; 23(3): 191 - 194. [Full Text] [PDF]
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R. Spacek, P. Widimsky, Z. Straka, E. Jiresova, J. Dvorak, R. Polasek, I. Karel, R. Jirmar, L. Lisa, T. Budesinsky, et al. V_alue of First Day Angiography/Angioplasty I_n Evolving N_on-ST Segment Elevation Myocardial Infarction: An O_pen Multicenter Randomized Trial. The VINO Study Eur. Heart J., February 1, 2002; 23(3): 230 - 238. [Abstract] [Full Text] [PDF]
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E. Ronner, E. Boersma, K.M. Akkerhuis, R.A. Harrington, A.M. Lincoff, J.W. Deckers, K. Karsch, N.S. Kleiman, A. Vahanian, E.J. Topol, et al. Patients with acute coronary syndromes without persistent ST elevation undergoing percutaneous coronary intervention benefit most from early intervention with protection by a glycoprotein IIb/IIIa receptor blocker Eur. Heart J., February 1, 2002; 23(3): 239 - 246. [Abstract] [Full Text] [PDF]
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D. P. de Arenaza, A. Bakhai, M. Flather, P. Campbell, R. E. Gilbert, C. P. Cannon, and E. Braunwald Comparison of Early Invasive and Conservative Strategies in Patients with Unstable Coronary Syndromes N. Engl. J. Med., November 22, 2001; 345(21): 1573 - 1575. [Full Text] [PDF]
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D. H. Solomon, P. H. Stone, R. J. Glynn, D. A. Ganz, C. M. Gibson, R. Tracy, and J. Avorn Use of risk stratification to identify patients with unstable angina likeliest to benefit from an invasive versus conservative management strategy J. Am. Coll. Cardiol., October 1, 2001; 38(4): 969 - 976. [Abstract] [Full Text] [PDF]
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W. G. Kussmaul III Should we catheterize all patients with unstable angina? No--only the ones with coronary artery disease J. Am. Coll. Cardiol., October 1, 2001; 38(4): 977 - 978. [Full Text] [PDF]
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K. Klatte, B. R. Chaitman, P. Theroux, J. A. Gavard, K. Stocke, S. Boyce, C. Bartels, B. Keller, A. Jessel, and for the GUARDIAN Investigators Increased mortality after coronary artery bypass graft surgery is associated with increased levels of postoperative creatine kinase-myocardial band isoenzyme release: Results from the GUARDIAN trial J. Am. Coll. Cardiol., October 1, 2001; 38(4): 1070 - 1077. [Abstract] [Full Text] [PDF]
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H. Tomoda and N. Aoki Pathophysiology of Early Coronary Angioplasty with Stenting on Non-Q-Wave vs Q-Wave Myocardial Infarction Angiology, October 1, 2001; 52(10): 671 - 679. [Abstract] [PDF]
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G. GONZI, P. A. MERLINI, and D. ARDISSINO Invasive coronary revascularisation is better than conservative treatment in patients with acute coronary syndromes Heart, October 1, 2001; 86(4): 363 - 364. [Full Text] [PDF]
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E.M. Antman and K.M. Fox Foreword Eur. Heart J. Suppl., August 1, 2001; 3(suppl_J): J1 - J5. [PDF]
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H.H. Hod, N.S. Kleiman, R.F. Sequeira, and L.-M. Voipio-Pulkki Issues in cardiac intervention for UA/NSTEMI Eur. Heart J. Suppl., August 1, 2001; 3(suppl_J): J32 - J39. [Abstract] [PDF]
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L. Cronin, S. R. Mehta, F. Zhao, J. Pogue, A. Budaj, D. Hunt, and S. Yusuf Stroke in Relation to Cardiac Procedures in Patients With Non-ST-Elevation Acute Coronary Syndrome: A Study Involving >18 000 Patients Circulation, July 17, 2001; 104(3): 269 - 274. [Abstract] [Full Text] [PDF]
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A. G. G. Turpie and E. M. Antman Low-Molecular-Weight Heparins in the Treatment of Acute Coronary Syndromes Arch Intern Med, June 25, 2001; 161(12): 1484 - 1490. [Abstract] [Full Text] [PDF]
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C. P. Cannon, W. S. Weintraub, L. A. Demopoulos, R. Vicari, M. J. Frey, N. Lakkis, F.-J. Neumann, D. H. Robertson, P. T. DeLucca, P. M. DiBattiste, et al. Comparison of Early Invasive and Conservative Strategies in Patients with Unstable Coronary Syndromes Treated with the Glycoprotein IIb/IIIa Inhibitor Tirofiban N. Engl. J. Med., June 21, 2001; 344(25): 1879 - 1887. [Abstract] [Full Text] [PDF]
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W. E. Boden and R. G. McKay Optimal Treatment of Acute Coronary Syndromes -- An Evolving Strategy N. Engl. J. Med., June 21, 2001; 344(25): 1939 - 1942. [Full Text] [PDF]
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V. Mathew, M. Farkouh, D. E. Grill, L. H. Urban, J. T. Cusma, G. S. Reeder, D. R. Holmes Jr, and B. J. Gersh Clinical risk stratification correlates with the angiographic extent of coronary artery disease in unstable angina J. Am. Coll. Cardiol., June 15, 2001; 37(8): 2053 - 2058. [Abstract] [Full Text] [PDF]
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S. C. Smith Jr, J. T. Dove, A. K. Jacobs, J. Ward Kennedy, D. Kereiakes, M. J. Kern, R. E. Kuntz, J. J. Popma, H. V. Schaff, D. O. Williams, et al. ACC/AHA guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines): A report of the American College of Cardiology/ American Heart Association Task Force on practice guidelines (Committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty) endorsed by the Society for Cardiac Angiography and Interventions J. Am. Coll. Cardiol., June 15, 2001; 37(8): 2239 - 2239. [Full Text] [PDF]
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J Abdulla, B Brendorp, C Torp-Pedersen, L Kober, and on behalf of the TRACE study group Does the electrocardiographic presence of Q waves influence the survival of patients with acute myocardial infarction? Eur. Heart J., June 2, 2001; 22(12): 1008 - 1014. [Abstract] [PDF]
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C. J KNIGHT National Institute for Clinical Excellence guidance: too NICE to glycoprotein IIb/IIIa inhibitors? Heart, May 1, 2001; 85(5): 481 - 483. [Full Text]
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R. A. O'Rourke, J. S. Hochman, M. C. Cohen, C. L. Lucore, J. J. Popma, and C. P. Cannon New Approaches to Diagnosis and Management of Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction Arch Intern Med, March 12, 2001; 161(5): 674 - 682. [Abstract] [Full Text] [PDF]
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R. C. Becker, M. Burns, N. Every, C. Maynard, P. Frederick, F. A. Spencer, J. M. Gore, C. Lambrew, and for the National Registry of Myocardial Infarction Early Clinical Outcomes and Routine Management of Patients With Non-ST-Segment Elevation Myocardial Infarction: A Nationwide Perspective Arch Intern Med, February 26, 2001; 161(4): 601 - 607. [Abstract] [Full Text] [PDF]
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I.B.A Menown, J Allen, J.M. Anderson, and A.A.J Adgey ST depression only on the initial 12-lead ECG: early diagnosis of acute myocardial infarction Eur. Heart J., February 1, 2001; 22(3): 218 - 227. [Abstract] [PDF]
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The Organization to Assess Strategies for Ischemic Effects of long-term, moderate-intensity oral anticoagulation in addition to aspirin in unstable angina J. Am. Coll. Cardiol., February 1, 2001; 37(2): 475 - 484. [Abstract] [Full Text] [PDF]
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A. B. Greenbaum, R. A. Harrington, M. P. Hudson, C. M. MacAulay, R. G. Wilcox, M. L. Simoons, L. G. Berdan, A. Guerci, D. V. Cokkinos, M. M. Kitt, et al. Therapeutic value of eptifibatide at community hospitals transferring patients to tertiary referral centers early after admission for acute coronary syndromes J. Am. Coll. Cardiol., February 1, 2001; 37(2): 492 - 498. [Abstract] [Full Text] [PDF]
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British Cardiac Society Guidelines and Medical Pra and Royal College of Physicians Clinical Effectiveness Guideline for the management of patients with acute coronary syndromes without persistent ECG ST segment elevation Heart, February 1, 2001; 85(2): 133 - 142. [Full Text]
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