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Biomedical subjects

Felix Zijlstra

Publications and source records attributed to Felix Zijlstra.

At least 91 records · Page 5Linked to original sources
PubMed2004

Comparison between ticlopidine and clopidogrel in patients with ST-segment elevation myocardial infarction treated with coronary stenting.

Controversy still surrounds the question, which antiplatelet drug should be added to aspirin in patients undergoing coronary stent implantation. The aim of the current study was to compare ticlopidine and clopidogrel in a consecutive series of patients with ST-segment elevation myocardial infarction (STEMI) treated with primary stenting. Our population is represented by 883 consecutive patients with STEMI undergoing primary stenting from April 1997 to October 2001. All clinical, angiographic, and follow-up data were prospectively collected. A total of 523 patients on clopidogrel were compared with 360 patients on ticlopidine after primary stenting. Except for age and statin therapy, no difference in demographic and clinical characteristics was observed between the two groups. Patients on clopidogrel had a higher rate of successful reperfusion (80.7% vs 73.1%, p = 0.008). No difference was observed between the two groups at both 30-day and 1-year follow-up. These data were confirmed after correction for age, successful reperfusion and statin therapy. This study shows no difference in long-term clinical outcome between clopidogrel and ticlopidine as adjunctive antiplatelet therapy in patients with STEMI undergoing stent implantation.

Aged↗
PubMed2004

The predictive value of cumulative lactate dehydrogenase release within the first 72 h of acute myocardial infarction in patients treated with primary angioplasty.

BACKGROUND: In patients with acute myocardial infarction, estimation of infarct size by cumulative lactate dehydrogenase release at 72 h (LDHQ(72)) is a simple and widely used method. Our objective was to study the value of estimating infarct size, by the cumulative release of LDH over 72, 60, 48 and 36 h in predicting left ventricular ejection fraction (LV(ef)) and cardiac death at 1 year. METHODS: In the Zwolle Infarction Study infarct size estimated as LDHQ was calculated in 1224 patients treated with primary percutaneous coronary intervention for acute myocardial infarction between December 1993 and June 2001. Patients were categorized as having small (LDHQ(72)<800 U/L), medium (LDHQ(72) 800-2500 U/L) or large (LDHQ(72)>2500 U/L) myocardial infarction. RESULTS: LDHQ(72) was closely correlated with LDHQ(60), LDHQ(48) and LDHQ(36) (r = 0.998, 0.993 and 0.987, respectively, P <0.0001). The relations between LDHQ infarct size classification and mean LV(ef) (51% vs 45% vs 35%, P <0.001) or cardiac death at 1 year (0-0.3% vs 0.7-1% vs 6-8%) showed a similar pattern, irrespective of whether LDH was measured up to 36, 48, 60 or 72 h. CONCLUSION: Infarct size classification based on LDHQ(36) is an objective and widely available method for early risk stratification in patients treated with primary angioplasty for acute ST-segment elevation myocardial infarction.

Aged↗
PubMed2004

PET for evaluation of differential myocardial perfusion dynamics after VEGF gene therapy and laser therapy in end-stage coronary artery disease.

UNLABELLED: The purpose of this study was to appraise the value of PET in the assessment of the effect of supposedly proangiogenic new therapies such as gene therapy with vascular endothelial growth factor (VEGF) gene and endomyocardial laser therapy. METHODS: Thirty-five patients with end-stage coronary artery disease and class III (Canadian Cardiovascular Society) angina were included. Myocardial ischemia was evaluated with dipyridamole PET scanning and exercise tolerance with bicycle ergometry. Ten patients were treated with naked plasmid DNA encoding for human VEGF165 (VEGF) and 12 patients were treated with laser therapy (direct myocardial revascularization [DMR]) using an electromechanical mapping system. Thirteen patients were treated with standard medical therapy (control). RESULTS: In both active treatment groups, angina was reduced in most subjects, except in 2 VEGF and 5 DMR patients. In the control group, no improvement in anginal classification was found, except in 3 subjects. On the PET scan, solely in the VEGF group, the stress perfusion was significantly improved (from 57 +/- 33 to 81 +/- 55 mL/min/100 g; P = 0.031). Furthermore, in the VEGF group, the number of ischemic segments was reduced from 274 +/- 41 to 234 +/- 48 segments (P = 0.004) but not in the DMR group (from 209 +/- 43 to 215 +/- 52 segments) or in the control group (from 218 +/- 18 to 213 +/- 28 segments). Bicycle exercise duration showed slight nonsignificant changes in the VEGF group (from 3.6 +/- 2.0 to 4.6 +/- 2.1 min), in the DMR group (from 5.1 +/- 1.5 to 4.7 +/- 1.3 min), and in the control group (from 3.3 +/- 1.8 to 3.5 +/- 2.3 min). CONCLUSION: PET showed that intramyocardial gene therapy with the human VEGF165 gene in contrast to laser DMR treatment effectively reduces myocardial ischemia.

Coronary Artery Disease↗
PubMed2004

Glucose-insulin-potassium infusion as adjunctive therapy in myocardial infarction: current evidence and potential mechanisms.

BACKGROUND: In ST-elevation myocardial infarction (STEMI) there is conflicting evidence that mortality, morbidity and infarct size is reduced by therapies influencing myocardial metabolism, such as infusion of glucose-insulin-potassium (GIK). Several clinical trials with GIK have already provided insight into the magnitude of this effect. The aim of this article was to review randomized trials on adjunctive GIK infusion in STEMI. METHODS: Randomized trials comparing GIK with placebo or untreated controls in patients with STEMI were identified by electronic and manual searches. A systematic analysis of all data was performed, with regard to inclusion criteria, dose of GIK and additional use of reperfusion therapy. Thirteen trials, involving 4992 patients, were included. RESULTS: Overall, hospital mortality was 10.8% after GIK compared to 12.9% in controls (p = 0.02). GIK infusions were in particular effective when a high dose was used and if given as an adjunct to reperfusion therapy. In patients with heart failure on admission, GIK may have worse effects. In all analyzed trials, GIK infusion caused only mild adverse effects, although fluid overload may be a problem in certain patients. CONCLUSIONS: GIK may reduce mortality in patients with STEMI, particularly if a high dose is used and when GIK is administered as an adjunct to reperfusion therapy. However, all studies had a relative small sample size and additional large randomized trials are certainly needed before a definite conclusion can be made. The limited evidence currently available does not warrant GIK therapy to be applied in patients at the present time.

Acute Disease↗
PubMed2003

Usefulness of elevated neopterin and C-reactive protein levels in predicting cardiovascular events in patients with non-Q-wave myocardial infarction.

The value of monocyte/macrophage activity as a prognostic factor in patients with non-Q-wave myocardial infarction (NQMI) has not yet been investigated. Moreover, scarce data are available on the long-term predictive value of markers of inflammation in patients who experience a NQMI. The present study aimed to determine the predictive value of neopterin, alone and in relation to levels of C-reactive protein, on the recurrence of major clinical cardiovascular events in patients who had a NQMI.

Aged↗
PubMed2003

Symptom-onset-to-balloon time and mortality in patients with acute myocardial infarction treated by primary angioplasty.

OBJECTIVES: The aim of the study was to evaluate the relationship between symptom-onset-to-balloon time and one-year mortality in patients with ST-segment elevation myocardial infarction (STEMI) treated by primary angioplasty. BACKGROUND: Despite the prognostic implications demonstrated in patients with STEMI treated with thrombolysis, the impact of time-delay on prognosis in patients undergoing primary angioplasty has yet to be established. METHODS: Our study population consisted of 1,791 patients with STEMI treated by primary angioplasty from 1994 to 2001. All clinical, angiographic and follow-up data were collected. Subanalyses were conducted according to patient risk profile at presentation and preprocedural Thrombolysis In Myocardial Infarction (TIMI) flow. RESULTS: A total of 103 patients (5.8%) had died at one year. Symptom-onset-to-balloon time was significantly associated with the rate of postprocedural TIMI 3 flow (p = 0.012), myocardial blush grade (p = 0.033), and one-year mortality (p = 0.02). A stronger linear association between symptom-onset-to-balloon time and one-year mortality was observed in non-low-risk patients (p = 0.006) and those with preprocedural TIMI flow 0 to 1 (p = 0.013). No relationship was found between door-to-balloon time and mortality. At multivariate analysis, a symptom-onset-to-balloon time >4 h was identified as an independent predictor of one-year mortality (p < 0.05). CONCLUSIONS: This study shows that, in patients with STEMI treated by primary angioplasty, symptom-onset-to-balloon time, but not door-to-balloon time, is related to mortality, particularly in non-low-risk patients and in the absence of preprocedural anterograde flow. Furthermore, a symptom-onset-to-balloon time >4 h was identified as independent predictor of one-year mortality.

Angioplasty, Balloon, Coronary↗
PubMed2003

Glucose-insulin-potassium infusion inpatients treated with primary angioplasty for acute myocardial infarction: the glucose-insulin-potassium study: a randomized trial.

OBJECTIVES: In this study we considered the question of whether adjunction of glucose-insulin-potassium (GIK) infusion to primary coronary transluminal angioplasty (PTCA) is effective in patients with an acute myocardial infarction (MI). BACKGROUND: A combined treatment of early and sustained reperfusion of the infarct-related coronary artery and the metabolic modulation with GIK infusion has been proposed to protect the ischemic myocardium. METHODS: From April 1998 to September 2001, 940 patients with an acute MI and eligible for PTCA were randomly assigned, by open-label, to either a continuous GIK infusion for 8 to 12 h or no infusion. RESULTS: The 30-day mortality was 23 of 476 patients (4.8%) receiving GIK compared with 27 of 464 patients (5.8%) in the control group (relative risk [RR] 0.82, 95% confidence interval [CI] 0.46 to 1.46). In 856 patients (91.1%) without signs of heart failure (HF) (Killip class 1), 30-day mortality was 5 of 426 patients (1.2%) in the GIK group versus 18 of 430 patients (4.2%) in the control group (RR 0.28, 95% CI 0.1 to 0.75). In 84 patients (8.9%) with signs of HF (Killip class > or =2), 30-day mortality was 18 of 50 patients (36%) in the GIK group versus 9 of 34 patients (26.5%) in the control group (RR 1.44, 95% CI 0.65 to 3.22). CONCLUSIONS: Glucose-insulin-potassium infusion as adjunctive therapy to PTCA in acute MI did not result in a significant mortality reduction in all patients. In the subgroup of 856 patients without signs of HF, a significant reduction was seen. The effect of GIK infusion in patients with signs of HF (Killip class > or =2) at admission is uncertain.

Age Factors↗
PubMed2003

Outcome of primary angioplasty for acute myocardial infarction during routine duty hours versus during off-hours.

OBJECTIVES: We sought to investigate the impact of circadian patterns in the onset of acute myocardial infarction (AMI) on the practice of primary angioplasty. BACKGROUND: A circadian variation in the time of onset of AMI with a peak in the morning hours has been described. METHODS: We studied 1,702 consecutive patients with acute ST-segment elevation myocardial infarction treated with primary angioplasty. We observed circadian variation in frequency of symptom onset, hospital admission, and first balloon inflation. Circadian patterns of symptom onset, hospital admission, and balloon inflation are similar. RESULTS: A majority of patients have symptom onset (53%), hospital admission (53%), and first balloon inflation (52%) during routine duty hours (0800 to 1800 h). There were no differences in baseline clinical characteristics or treatment delays between routine duty hours and off-hours patients. Hospital admission between 0800 and 1800 was associated with an angioplasty failure rate of 3.8%, compared with 6.9% between 1800 and 0800, p < 0.01. Thirty-day mortality was 1.9% in patients with hospital admission between 0800 and 1800, compared with 4.2% in patients with hospital admission between 1800 and 0800, p < 0.01. CONCLUSIONS: Circadian variations may have a profound effect on the practice of primary angioplasty. A majority of patients are treated during routine duty hours. Patients treated during off-hours have a higher incidence of failed angioplasty and consequently a worse clinical outcome than patients treated during routine duty hours.

After-Hours Care↗
PubMed2003

Frame count reserve.

BACKGROUND: The Doppler wire-derived (relative) coronary flow velocity reserve (CVR) that is used to evaluate functional significance of a coronary stenosis is a method performed only by interventional cardiologists. An angiographic method would be useful in the diagnostic catheterization laboratory. For this purpose, we investigated the relation between TIMI frame count reserve (FCR) and CVR. METHODS AND RESULTS: In 38 patients, (relative) FCR of left anterior descending (LAD) and left circumflex coronary artery (LCx) was calculated by using manual, synchronized contrast agent injections and compared with (relative) CVR. In addition, vessel length was measured with an intracoronary guidewire and frame count flow velocity was calculated and compared with average peak velocity. There was a strong correlation between FCR and CVR (r=0.62, P<0.001) and between relative FCR and relative CVR (r=0.84, P<0.001). The LAD was significantly longer than the LCx (mean, 14.3+/-1.6 cm versus 11.4+/-1.8 cm, P<0.001), and, therefore, TIMI frame count of LAD was significantly higher than of LCx (mean basal 32.5+/-15.1 versus 23.6+/-9.1 and hyperemic 12.1+/-6.6 versus 8.7+/-3.2, both P<0.02). However, all flow velocity measurements and estimations of volume flow were not different for LAD compared with LCx. There were also no differences between mean FCR and CVR of LAD or LCx, of both vessels compared with each other and between mean relative FCR and relative CVR. CONCLUSIONS: The (relative) frame count reserve can be used to estimate (relative) coronary flow velocity reserve.

Adenosine↗
PubMed2003

Angiographic assessment of reperfusion in acute myocardial infarction by myocardial blush grade.

BACKGROUND: Angiographic successful reperfusion in acute myocardial infarction has been defined as TIMI 3 flow. However, TIMI 3 flow does not always result in effective myocardial reperfusion. Myocardial blush grade (MBG) is an angiographic measure of myocardial perfusion. We hypothesized that optimal angiographic reperfusion is defined by TIMI 3 flow and MBG 2 or 3. METHODS AND RESULTS: In 924 consecutive patients with TIMI 3 flow after angioplasty for acute myocardial infarction, we prospectively studied the value of MBG. End points were death, MACE, enzymatic infarct size, and residual left ventricular ejection fraction. Follow-up was 16+/-11 months. Of the 924 patients, 101 (11%) patients had MBG 0 or 1. Mortality was significantly higher in patients with MBG 0 or 1 compared with patients with MBG 2 or 3 (relative risk, 4.7; 95% CI, 2.3 to 9.5; P<0.001). The combined incidence of MACE was higher in patients with MBG 0 or 1 compared with patients with MBG 2 or 3 (relative risk, 1.8; 95% CI, 1.1 to 2.8; P=0.009). Enzymatic infarct size was larger (1437+/-2388 versus 809+/-1672, P=0.001) and left ventricular ejection fraction was lower (37.7+/-10.6 versus 43.8+/-11.1, P<0.001) in patients with MBG 0 or 1 compared with patients with MBG 2 or 3. CONCLUSIONS: MBG is a strong angiographic predictor of mortality in patients with TIMI 3 flow after primary angioplasty. Enzymatic infarct size is larger and residual left ventricular ejection fraction is lower in patients with MBG 0 or 1 compared with MBG 2 or 3. Angiographic definition of successful reperfusion should include both TIMI 3 flow as well as MBG 2 or 3.

Angioplasty↗
PubMed2003

A comparison of two invasive strategies in patients with non-ST elevation acute coronary syndromes: results of the Early or Late Intervention in unStable Angina (ELISA) pilot study. 2b/3a upstream therapy and acute coronary syndromes.

BACKGROUND: Only few studies specifically addressed the effect of timing of angiography and/or pre-treatment with a glycoprotein 2b/3a receptor blocker in patients with non-ST elevation acute coronary syndromes (ACS) who undergo invasive treatment. METHODS: In a 2-year period, 220 patients with non-ST elevation ACS, were randomized to early angiography without tirofiban pre-treatment (Early strategy) or to delayed angiography after 24-48h pre-treatment with tirofiban (Late strategy). The first 48h after admission, CKmb levels were measured and enzymatic infarct size (LDHQ(48)) was assessed by the area under the LDH release curve. When PCI was performed beyond 48h, CKmb was measured 6 and 12h afterwards. RESULTS: Median time to angiography was 6 (Early) and 50 (Late) hours. PCI was performed in 130 patients (59%). In these patients, a patent (TIMI 2 or 3 flow) culprit vessel was more often present in the Late group compared to the Early group (66% vs 82% p=0.05). In patients with an elevated CKmb (n=96, 44%), LDHQ(48)was significantly lower in patients who underwent angiography after pre-treatment with tirofiban (629+/-503U/L (Early) vs 432+/-441U/L (Late), p=0.02). No difference in clinical outcome between the groups was observed at 30 days follow-up. CONCLUSION: This pilot study showed that a strategy of delayed angiography with concomitant pre-treatment with tirofiban is associated with improved angiographic outcomes and less initial enzyme release, compared to a strategy of immediate angiography without 2b/3a inhibitor pre-treatment. The use of an end point parameter, which assess total enzyme release over a given period of time, might be of special value in patients with non-ST elevation ACS, who undergo very early invasive treatment.

Angina, Unstable↗
PubMed2003

The prognostic importance of heart failure and age in patients treated with primary angioplasty.

BACKGROUND: Effective risk stratification is essential in the management of patients with acute myocardial infarction. Available models have not yet been studied and validated in patients treated with primary angioplasty for acute myocardial infarction. METHODS: The prognostic value of heart failure defined by Killip class and age upon admission and the impact of success and failure of the angioplasty procedure was studied in 1702 consecutive patients treated with primary angioplasty. FINDINGS: The combination of Killip class and age is a strong predictor of 30-day mortality and categorizes patients in subgroups with 30-day mortality risk ranging from 0.5 to 70%. Angioplasty failure results in a high 30-day mortality, in particular in patients with Killip class > or =II and/or age > or =70 years. A large majority of patients (72%), characterized by Killip class I and age <70 years, can be identified with a 0.5% risk of death at 30 days. INTERPRETATION: The presence of heart failure (Killip class) and age predicts 30-day mortality in patients on their way to the catheterization laboratory for primary angioplasty. This simple and effective early risk stratification, in combination with success and failure of the primary angioplasty, can be used to direct subsequent patient management.

Adult↗