Invasive Treatment May Be More Effective Than Conservative Approach for
Heart Attack Patients Presenting to Hospital More Than 12 Hours After
Symptom Onset

CHICAGO - Invasive treatment including stenting may have better
outcomes than conventional treatments for heart attack patients who
arrive at the hospital more than 12 hours after symptoms began,
according to a study in the June 15 issue of JAMA.

what?? you are advocating "invasive interventional treatment"???  thought
you thought all such was a waste of money..not to mention..not effective

BTW...this is VERY old news....

not that you would know that..

by the time a study like this is published...it may be standard of care in
most top notch cardiac centers..

In patients with acute ST-segment elevation myocardial infarction
(STEMI - a certain finding on an electrocardiogram, suggesting a heart
attack), numerous studies have demonstrated that early reperfusion
(restoration of blood flow) within 12 hours of symptom onset is
associated with increased myocardial (heart muscle) salvage,
preservation of left ventricular function, and improved survival,
according to background information in the article. Due to
time-dependent reduction in the efficacy of thrombolysis
(administration of medications to help dissolve blood clots), the
application of this reperfusion method after 12 hours from symptom
onset of acute myocardial infarction (MI, heart attack) offers little
or no benefit and may be even harmful. Between 8.5 percent to 40
percent of patients with acute MI present late after symptom onset,
thus being no longer eligible for thrombolysis.

Despite efforts to reduce time to presentation, recent studies have
demonstrated that time-to-arrival at the hospital after the onset of
symptoms has not changed or has even increased. Several findings
suggest that reperfusion therapy may be beneficial even among patients
with acute MI who present late after symptom onset. Current guidelines
do not recommend reperfusion treatment in these patients.  No
specifically designed studies have addressed the role of primary
percutaneous coronary intervention (PCI) in patients with STEMI
presenting more than 12 hours after symptom onset.

Albert Schömig, M.D., of Technische Universität, Munich, Germany, and
colleagues conducted a study to assess whether an invasive strategy
based on PCI with stenting is associated with reduction of infarct
(dead tissue from lack of blood) size in patients with acute STEMI
presenting more than 12 hours after the symptom onset, compared with a
conventional conservative treatment strategy.

The study, conducted from May 23, 2001, to December 15, 2004, included
365 patients aged 18 to 80 years, without persistent heart attack
symptoms admitted with the diagnosis of acute STEMI between 12 and 48
hours from symptom onset.  Patients were randomized to receive either
an invasive strategy (n=182) based predominantly on coronary stenting
plus the intravenous medication abciximab or a conventional
conservative treatment strategy (n=183), which included an intravenous
infusion of heparin.

The researchers found that the final left ventricular infarct size was
significantly smaller in patients assigned to the invasive group
(median, 8.0 percent) vs.  those assigned to the conservative group
(median, 13.0 percent). The average difference in final left
ventricular infarct size between the invasive and conservative groups
was ?-6.8 percent. The outcomes of death, recurrent MI, or stroke at 30
days occurred in 8 patients in the invasive group (4.4 percent) and 12
patients in the conservative group (6.6 percent) (a 33 percent lower
risk of these outcomes for patients in the invasive group).

"This finding increases the level of evidence in support of the
invasive strategy and deserves consideration when current treatment
guidelines for this category of patients will be reassessed," the
researchers conclude.

(JAMA. 2005;293:2865-2872.

Editor's Note: This work was supported by grants from Deutsches
Herzzentrum, Munich, Germany, as well as by unrestricted research
grants from Lilly Deutschland GmbH, Bad Homburg, Germany, and Guidant
Advanced Cardiovascular Systems Inc., Santa Clara, Calif.

~~~~~~~~~~~~~~~~~~~

Editorial: Acute PCI for ST-Segment Elevation Myocardial Infarction -
Is Later Better Than Never?

In an accompanying editorial, Raymond J. Gibbons, M.D., and Cindy L.
Grines, M.D., of Mayo Clinic and Foundation, Rochester, Minn.; and
William Beaumont Hospital, Detroit, comment on the findings of Schomig
et al, the BRAVE-2 trial.

"Should the next update of STEMI Clinical Practice Guidelines consider
PCI to be generally indicated (a class I indication) for all patients
presenting with STEMI after 12 hours? Probably not yet. Existing
guidelines consider the presence of ongoing symptoms after 12 hours to
be a class IIa indication for PCI. On the basis of BRAVE-2, it would
seem appropriate to expand this class IIa indication. Although it seems
reasonable to consider acute PCI in all patients with STEMI who present
12 hours or longer after the onset of chest pain, regardless of whether
they have ongoing pain, this single small trial does not provide
sufficient evidence to warrant a class I indication. Such an indication
would require confirmation at least in a second small trial using
infarct size as an end point or preferably in a larger trial using
clinical end points."

"Should patients with STEMI presenting after 12 hours be considered
'medical emergencies' requiring acute mobilization of the
catheterization laboratory in the middle of the night? Probably not.
Although the BRAVE-2 investigators proceeded with urgent PCI in the
patients who were included in this trial, the trial results do not
reveal whether this urgency was justified."

"The BRAVE-2 trial results are a noteworthy challenge to existing dogma
and an important contribution to current knowledge. However, the
results do not yet justify a revolution in clinical practice," the
authors conclude.

(JAMA. 2005;293:2930-2932.

Editor's Note: For the financial disclosures of the authors, please see
the JAMA editorial.