(Circulation. 1995;91:37-45.)
© 1995 American Heart Association, Inc.
Articles |
Previous Angina Alters In-Hospital Outcome in TIMI 4
A Clinical Correlate to Preconditioning?
From The Heart Institute, Hospital of the Good Samaritan, and University of Southern California (R.A.K., T.S., K.P., L.J., R.M., S.B.) (Los Angeles); Brigham and Women's Hospital and Harvard Medical School (M.G., C.P.C., C.H.M., E.B.), Boston, Mass; and Research Triangle Institute (V.G.D., W.K.P.), Research Triangle Park, NC.
Background Ischemic preconditioning has been shown to reduce myocardial infarct size in experimental models, but its role in patients remains unclear. Angina before myocardial infarction reflects brief episodes of ischemia and may be a marker of preconditioning. As part of the Thrombolysis in Myocardial Infarction (TIMI) 4 study, we performed an analysis on the effect of a history of previous angina on in-hospital outcomes for patients with acute myocardial infarction.
Methods and Results Patients eligible for thrombolytic therapy were enrolled into the study. Data were collected from case report forms regarding previous history of angina, in-hospital outcome and 6-week follow-up. Two hundred eighteen patients had a history of previous angina at any time before acute myocardial infarction, and 198 patients did not have previous angina. Patients with any previous history of angina were less likely than with those without angina to experience in-hospital death (3% versus 8%) (P=.03), severe congestive heart failure (CHF) or shock (1% versus 7%, P=.006), or the combined end point of in-hospital death, severe CHF, or shock (4% versus 12%, P=.004). Moreover, patients with any history of angina were more likely to have a smaller creatine kinase (CK)-determined infarct size (119 versus 154 CK integrated units; P=.01) and were less likely to have Q waves on their ECG (57% versus 69%; P=.01). In the subset of patients who experienced angina within the 48 hours before infarction (compared with those who did not), there was a trend toward less likely in-hospital death (3% versus 6%; P=.09), a lower incidence of severe CHF or shock (1% versus 6% P=.008), a lower combined end point of death, CHF, or shock (3% versus 10%; P=.006), smaller infarct size assessed by CK (115 versus 151 CK units; P=.03), and a trend toward fewer Q-wave infarcts. However, patients with a history of previous angina did have a trend toward more recurrent ischemic pain. Of importance is that the beneficial in-hospital effects of previous angina were not dependent on angiographically visible coronary collaterals.
Conclusions Previous angina confers a beneficial effect on in-hospital outcome after acute myocardial infarction. The reasons for this benefit are uncertain, but one potential mechanism for this observation may be ischemic preconditioning.
Key Words: angina • clinical trials • infarction • ischemia
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F. Tomai, F. Crea, A. Gaspardone, F. Versaci, A. S. Ghini, C. Ferri, G. Desideri, L. Chiariello, and P. A. Gioffre Effects of naloxone on myocardial ischemic preconditioning in humans J. Am. Coll. Cardiol., June 1, 1999; 33(7): 1863 - 1869. [Abstract] [Full Text] [PDF]
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W. K. Laskey Beneficial Impact of Preconditioning During PTCA on Creatine Kinase Release Circulation, April 27, 1999; 99(16): 2085 - 2089. [Abstract] [Full Text] [PDF]
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M. Billinger, M. Fleisch, F. R. Eberli, A. Garachemani, B. Meier, and C. Seiler Is the development of myocardial tolerance to repeated ischemia in humans due to preconditioning or to collateral recruitment? J. Am. Coll. Cardiol., March 15, 1999; 33(4): 1027 - 1035. [Abstract] [Full Text] [PDF]
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J. E. Baker, P. Holman, and G. J. Gross Preconditioning in Immature Rabbit Hearts : Role of KATP Channels Circulation, March 9, 1999; 99(9): 1249 - 1254. [Abstract] [Full Text] [PDF]
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R. W. Landymore, A. J. Bayes, J. T. Murphy, and J. H. Fris Preconditioning prevents myocardial stunning after cardiac transplantation Ann. Thorac. Surg., December 1, 1998; 66(6): 1953 - 1957. [Abstract] [Full Text] [PDF]
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 R. H. Christenson and H. M. E. Azzazy Biochemical markers of the acute coronary syndromes Clin. Chem., August 1, 1998; 44(8): 1855 - 1864. [Abstract] [Full Text] [PDF]
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J. R. Kersten, T. J. Schmeling, K. G. Orth, P. S. Pagel, and D. C. Warltier Acute hyperglycemia abolishes ischemic preconditioning in vivo Am J Physiol Heart Circ Physiol, August 1, 1998; 275(2): H721 - H725. [Abstract] [Full Text] [PDF]
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R. A. Kloner, R. Bolli, E. Marban, L. Reinlib, and E. Braunwald Medical and Cellular Implications of Stunning, Hibernation, and Preconditioning : An NHLBI Workshop Circulation, May 19, 1998; 97(18): 1848 - 1867. [Full Text] [PDF]
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 H. Shiraki, T. Yoshikawa, T. Anzai, K. Negishi, T. Takahashi, Y. Asakura, M. Akaishi, H. Mitamura, and S. Ogawa Association between Preinfarction Angina and a Lower Risk of Right Ventricular Infarction N. Engl. J. Med., April 2, 1998; 338(14): 941 - 947. [Abstract] [Full Text] [PDF]
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B. S. Cain, D. R. Meldrum, X. Meng, B. D. Shames, A. Banerjee, and A. H. Harken Calcium Preconditioning in Human Myocardium Ann. Thorac. Surg., April 1, 1998; 65(4): 1065 - 1070. [Abstract] [Full Text] [PDF]
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R. A. Kloner, T. Shook, E. M. Antman, C. P. Cannon, K. Przyklenk, K. Yoo, C. H. McCabe, and E. Braunwald Prospective Temporal Analysis of the Onset of Preinfarction Angina Versus Outcome : An Ancillary Study in TIMI-9B Circulation, March 24, 1998; 97(11): 1042 - 1045. [Abstract] [Full Text] [PDF]
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 D. R. Meldrum Tumor necrosis factor in the heart Am J Physiol Regulatory Integrative Comp Physiol, March 1, 1998; 274(3): R577 - R595. [Abstract] [Full Text] [PDF]
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K. Hata, P. Whittaker, R. A. Kloner, and K. Przyklenk Brief Antecedent Ischemia Attenuates Platelet-Mediated Thrombosis in Damaged and Stenotic Canine Coronary Arteries : Role of Adenosine Circulation, February 24, 1998; 97(7): 692 - 702. [Abstract] [Full Text] [PDF]
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 E. R. Schwarz, J. Fleischhauer, H. Montino, R. Chakupurakal, M. Foresti, T. Schuetz, S. Sack, M. Mohri, M. Arras, W. Schaper, et al. Infarct Size Reduction by Ischemic Preconditioning is a Monophasic, Short-Lived Phenomenon in Anesthetized Pigs Journal of Cardiovascular Pharmacology and Therapeutics, January 1, 1998; 3(1): 63 - 70. [Abstract] [PDF]
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 H. Yokoshiki, M. Sunagawa, T. Seki, and N. Sperelakis ATP-sensitive K+ channels in pancreatic, cardiac, and vascular smooth muscle cells Am J Physiol Cell Physiol, January 1, 1998; 274(1): C25 - C37. [Abstract] [Full Text] [PDF]
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D. M Yellon, G. F Baxter, D. Garcia-Dorado, G. Heusch, and M. S Sumeray Ischaemic preconditioning: present position and future directions Cardiovasc Res, January 1, 1998; 37(1): 21 - 33. [Abstract] [Full Text] [PDF]
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G. Rioufol, M. Ovize, J. Loufoua, C. Pop, X. Andre-Fouet, and Y. Minaire Ventricular fibrillation in preconditioned pig hearts: role of K+ATP channels Am J Physiol Heart Circ Physiol, December 1, 1997; 273(6): H2804 - H2810. [Abstract] [Full Text] [PDF]
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M. V. Cohen, J. D. Thornton, C. S. Thornton, H. Sato, T. Miki, and J. M. Downey INTRAVENOUS CO-INFUSION OF ADENOSINE AND NOREPINEPHRINE PRECONDITIONS THE HEART WITHOUT ADVERSE HEMODYNAMIC EFFECTS J. Thorac. Cardiovasc. Surg., August 1, 1997; 114(2): 236 - 242. [Abstract] [Full Text]
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J. C. Cleveland Jr, D. R. Meldrum, B. S. Cain, A. Banerjee, and A. H. Harken Oral Sulfonylurea Hypoglycemic Agents Prevent Ischemic Preconditioning in Human Myocardium : Two Paradoxes Revisited Circulation, July 1, 1997; 96(1): 29 - 32. [Abstract] [Full Text]
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S. J. Kapadia, J. S. Terlato, and A. S. Most Presence of a Critical Coronary Artery Stenosis Does Not Abolish the Protective Effect of Ischemic Preconditioning Circulation, March 4, 1997; 95(5): 1286 - 1292. [Abstract] [Full Text]
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R. Ferrari, A. Cargnoni, P. Bernocchi, E. Pasini, S. Curello, C. Ceconi, and T.J.C. Ruigrok Metabolic Adaptation During a Sequence of No-Flow and Low-Flow Ischemia: A Possible Trigger for Hibernation Circulation, November 15, 1996; 94(10): 2587 - 2596. [Abstract] [Full Text]
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D. R. Meldrum, B. C. Sheridan, J. C. Cleveland Jr, D. A. Fullerton, A. Banerjee, and A. H. Harken Neutrophils Are Required for Endotoxin-Induced Myocardial Cross-Tolerance to Ischemia-Reperfusion Injury Arch Surg, November 1, 1996; 131(11): 1203 - 1208. [Abstract] [PDF]
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R. L. Engler and D. M. Yellon Sulfonylurea KATP Blockade in Type II Diabetes and Preconditioning in Cardiovascular Disease: Time for Reconsideration Circulation, November 1, 1996; 94(9): 2297 - 2301. [Full Text]
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V. Pasceri, G. A. Lanza, G. Patti, P. Pedrotti, F. Crea, and A. Maseri Preconditioning by Transient Myocardial Ischemia Confers Protection Against Ischemia-Induced Ventricular Arrhythmias in Variant Angina Circulation, October 15, 1996; 94(8): 1850 - 1856. [Abstract] [Full Text]
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Y. Birnbaum, K. Przyklenk, and R. A. Kloner Time Frame of Ischemic Preconditioning: Is It Clinically Relevant? Journal of Cardiovascular Pharmacology and Therapeutics, October 1, 1996; 1(4): 339 - 346. [PDF]
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D. R. Meldrum, J. C. Cleveland Jr., B. C. Sheridan, R. T. Rowland, A. Banerjee, and A. H. Harken CARDIAC PRECONDITIONING WITH CALCIUM: CLINICALLY ACCESSIBLE MYOCARDIAL PROTECTION J. Thorac. Cardiovasc. Surg., September 1, 1996; 112(3): 778 - 786. [Abstract] [Full Text]
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