management of patients with stemi raffaele bugiardini
DESCRIPTION
om: Thank you …….. Today I will talk about “Management of UA”,an issuue in which there is still much room for uncertainty. CAD is the killer n 1. Everybody knows that Pts with suspected ACS must be evaluated rapidly. Because. Management of patients with STEMI Raffaele Bugiardini. - PowerPoint PPT PresentationTRANSCRIPT
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Management of patients with STEMI
Raffaele Bugiardini
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Myocardial Ischemia
• Spectrum of presentation– silent ischemia– exertion-induced angina– unstable angina– acute myocardial infarction
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Acute Coronary Syndrome
• The spectrum of clinical conditions ranging from:– unstable angina– NSTEMI (non-Q wave MI)– STEMI (Q-wave MI)
• Characterized by the common pathophysiology of a disrupted atheroslerotic plaque
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Unstable Angina - Definition
Clinical Circumstance
A—Develops in Presence of Extracardiac Condition That
Intensifies Myocardial Ischemia (Secondary UA)
B—Develops in Absence of Extracardiac Condition (Primary
UA)
C—Develops Within 2 wk of AMI
(Postinfarction UA)
I—New onset of severe angina or accelerated angina; no rest pain
II—Angina at rest within past month but not within preceding 48 h (angina at rest, subacute)
III—Angina at rest within 48 h (angina at rest, acute)
IA IB IC
IIA IIB IIC
IIIA IIIB IIIC
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New definition: Myocardial Infarction(2000)
-------------------------------------------------------------------------
Acute, evolving or recent AMI
Established MI
-------------------------------------------------------------------------The Joint European Society of Cardiology/American Collegeof Cardiology Committee. JACC 2000, 36:959-69
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---------------------------------------------------------------------------At least 2 of 3 criteria fulfilled:
1) POSITIVE CLINICAL HISTORY“Crushing” substernal chest with or withoutradiation to jaw or down the left arm
2) POSITIVE EKG
3) CARDIAC “ENZYME” ELEVATIONS---------------------------------------------------------------------------
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INITIAL EVALUATION AND MANAGEMENT
Patients with suspected IHD must be evaluated rapidly
The physician then must place the evaluation in the context of 2 critical questions:
•Are the symptoms a manifestation of ACS?
•If so, what is the prognosis?
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Are the symptoms a manifestation of ACS ?
If so, what is the prognosis ?
om:
Most of you are GP and frequently recive telephone calls from pts who are concerned that their symptoms may reflect haert disease. Most of these calls regarding chest disconfort do not rapresent an emergency,
some yes.
There are two critical questions:
om:
Most of you are GP and frequently recive telephone calls from pts who are concerned that their symptoms may reflect haert disease. Most of these calls regarding chest disconfort do not rapresent an emergency,
some yes.
There are two critical questions:
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“The presence or absence of the traditional risk
factor ordinarily should not be used to determine
whether an individual patient should be admitted
or treated for ACS.
However, the presence of these risk factors does
apper to relate to poor outcomes in patients with
established ACS.”
ACC/AHA Practice Guidelines 2002
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PERFORM
----------------------------------------------------------------------------
1) History2) Physical examination
Use this information to create ==> DIFFERENTIALDIAGNOSIS
----------------------------------------------------------------------------
What is in your differential diagnosis of chest pain?
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Differential Diagnosis of Prolonged Chest Pain
• AMI• Aortic dissection• Pericarditis• Atypical angina pain
associate with hypertrophic cardiomyopathy
• Esophageal, other upper gastrointestinal, or biliary tract disease
• Pulmonary disease– pneumothorax– embolus with or without
infarction– pleurisy: infectious,
malignant, or immune disease-related
• Hyperventilation syndrome
• Chest wall– skeletal– neuropathic
• Psychogenic
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High Likelihood Low LikelihoodIntermediate Likelihood
History
Examination
ECG
Cardiac Markers
Typical Angina CAD history
Transient MR Hypotension Diaphoresis, Pulmonary Edema
New ST-segment deviation or T-wave inversion
cardiac TnI, TnT or CK-MB
Typical Angina, Age >70 yrs, Sex M,
Diabetes Mellitus
Extracardiac vascular disease
Fixed Q waves Abnormal ST or T-waves not documented to be new
Normal
Probable ischemic symptoms
Recent cocaine use
T wave flattering
Normal
Likelihood that Signs and Symptoms Represent an Unstable Angina
Modified from Braunwald E et all 1994; AHCPR Pub. 94-0602
T wave flattering or inversion in laeds with dominant R
Chest disconfort by palpitation
Normal
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Risk Stratification Non Invasive Stress Testing
• LOW RISK PTS • INTERMEDIATE RISK PTS
free of ischemia at rest and of CHF for a minimum
2 - 3 days12 - 24 hours
ACC/AHA Practice Guidelines 2002
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Are the symptoms a manifestation of ACS ?
If so, what is the prognosis ?
om:
Most of you are GP and frequently recive telephone calls from pts who are concerned that their symptoms may reflect haert disease. Most of these calls regarding chest disconfort do not rapresent an emergency,
some yes.
There are to critical questions:
om:
Most of you are GP and frequently recive telephone calls from pts who are concerned that their symptoms may reflect haert disease. Most of these calls regarding chest disconfort do not rapresent an emergency,
some yes.
There are to critical questions:
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0 2 4 6 8 10 12 14
15
20
25
30
35
40
10
5
Heparin
Enoxaparin
Time since enrollment (months)
Combined Endopoint
Goodman SG, J AM Coll Cardiol 2000;36:693-8
The ESSENCE Study
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TIMI risk score
1- age > 65 yrs
2- > 3 coronary risk factors
3- more that 2 angina events within 24 hrs
4- prior angiographic obstruction
5- aspirin (in the 7 prior days)
6- ST-segment deviation
7- elevated cardiac markers
Antman EM et al. JAMA 2000;284:835-42
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15
20
25
30
35
40
10
5
Validation of TIMI Risk Score and Assessment of Treatment Effect According to Score in ESSENCE
Antman E, JAMA 2000;284:835-42
45
0/1 2 6/73 4 5
7.27.311.6
9.5
15.8
12
16.8
12.4
31
18.3
38.1
20
Rat
e of
Com
posi
te E
nd P
oint
%
No. of Risk Factors
Unfractionated Heparin (n=1564)
Enoxaparin (n=1607)
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Tools for risk stratificationinitial management
• Age and History
• Symptoms
• Standard ECG
• Biochemical Markers
• Continous ECG
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Q waveQ waveInverted T waveInverted T wave
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Types of lesions: Inferior
• Often RCA• Potential involvement of
RV dx
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Lateral
• Often LCX
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Septal
• Certainly LAD
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Anterior
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Posterior ! no ST ELEVATION
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• Derivazioni destre
• Sospettato coinvolgimento del ventricolo destro in infarto POSTERIORE
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Up to you ….
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Right Side Chest leads
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Acute?
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Q waves inlateral wallmyocardialinfarction
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Example:
ECG alone is not sufficient for
diagnosis!
The pazient had MI in 1989 , and subsequent evolution in aneurysm
of the LV!
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CARDIAC MARKERS:------------------------------------------------------------------------------
Cardiac enzymescreatine kinase (CK)aspartate aminotransferase (AST)lactate dehydrogenase (LD)
Structural proteinscardiac troponin T (cTnT) cardiac troponin I (cTnI)
Oxygen-binding proteinsmyoglobin
-----------------------------------------------------------------------------
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0
1
2
3
4
3.1
1.7
2.4
1.4
4
2.6
3.7
2.5
0.4 0.5
1.00.8
All Pts All Pts All PtsNo CK-MB Elevation
No CK-MB Elevation
No CK-MB Elevation
Enrolled 0 to 6 hr
after Pain Onset Enrolled > 6 to 24 hr
after Pain Onset Enrolled 0 to 24 hr
after Pain Onset
Risk Ratio
95% Confidence Interval
1.8
0.6-5.5
1.8
0.4-7.6
9.5
2.2-4146
5.5
1.1-29.7
3.8
1.7-8.5
3.0
0.97-9.2
Mortality Rates at 42 Days According to the Time From Onset of Pain to Study Enrollment and the Baseline Cardiac Troponin I
Troponin I 0.4 ng/mlTroponin I <0.4 ng/ml
P<0.05P<0.01
Antman EM N Engl J Med 1996; 335:1342-49
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0% 20% 40% 60% 80% 100%
1%
2%
3%
4%
5%
Patients with Ischemia on ECG
Mor
tali
ty
Negative TnINegative TnT
Relation between initial negative Troponin and ECG
Heidenreich J Am Coll Cardiol 2001;38:478-85
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NORMAL REST ECG
Normal LVEF 98 %
Abnormal LVEF 2%
Am Heart J 2000: 139:584
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Dea
th o
r M
I %
0 60 120 180 240 300 360
ST Elevation and Depression n=78
ST Depression Only n=216
ST Elevation Only n=93
T Wave Inversion Only n=287
No ST or T Wave Change n=237
Life table of cumulative risk and time of MI or death during 1 year of follow-up with regard to different types of ST-T segment change
Days
Nyman N, J Intern Med 1993;234:293-301
Dea
th o
r M
I %
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Recurrent angina
Duration of anginal episodes> 15 min
Pain-free interval < 1 h
Duration of TMI 60 min/24h
Duration of TMI 60 min/24h and high risk coronary lesion
High risk coronary lesion
88
37
24
83
88
80
32
92
92
75
59
89
46
75
67
68
58
83
80
69
65
87
88
88
Sensitivity Specificity
Positive predictive
value
Negative predictive
value(%) (%) (%) (%)
Prognostic Significance of different Clinical, ECG and Angiographic Variables for Identifying High Risk Pts with UA
Bugiardini R, J Am Coll Cardiol 1995; 25:597-604
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180
160
140
120
100
80
60
30
0
Symptoms Predictive of coronary events
Dur
atio
n of
TM
I at a
dmis
sion
(m
in/2
4 hr
s)
Relations among prognosis, duration of ischemia at admission and symptoms
Over 180
Yes YesNo No
Unfavorable clinical
Outcome Favorable clinical
Outcome Fatal or Non fatal MIOther clinical outcome
Bugiardini R, J Am Coll Cardiol 1995; 25:597-604
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Simplified TIMI risk score
CLASSES
Low Risk 0-
1
Intermediate Risk 2
High Risk 3
CRITERIA
a - age > 65 yrs
b- ST deviation > 0.5 mm
c- CK > 2 times normal
or TnT high
Holper EM et al Am J Cardiol 2001;87:1008-10
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Low (0/1) Inter (2) High (3)
1514.1
20.5
17.9
29.6
24.8
802 870 848 797 307 286
30
25
20
15
10
5
0
Unfractionated heparinEnoxaparin
Holper EM, Am J Cardiol 2001;87:1008-13
Eve
nt r
ate
at d
ay 4
3
Simplified TIMI risk score
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Chronic Stable Angina
Unstable Angina
0 100 200 300 400 500 600 700.5
1.0
.9
.8
.7
.6
Days
Eve
nt-f
ree
surv
ival
Florenciano-Sandez R. J Am Coll Cardiol 2001;38:1974-9
Prognostic value of low risk exercise test
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Duration (min)
% TMHR
Rate-pressure product
Positive clinical response
Positive ECG response
Positive result
Duke index
92 74
8013 7711
21,4817,079 20,9025,835
17 (16%) 40 (46%)
34 (32%)
41 (39%)
57 (66%)
64 (74%)
55 06
Patients With UA (n=105)
Patients With CSA (n=86)
p Value
0.0001
0.0001
0.0001
0.0001
0.0001
NS
NS
RESULTS OF THE EXERCISE TEST
Florenciano-Sandez R. J Am Coll Cardiol 2001;38:1974-9
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In patients with suspected ACS and negative
ECG-Exercise Stress Test, physycians should
proceede to pharmacological stress or cardiac
scintigraphy.
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100%
80%
60%
40%
20%
SPECT
Stress-Echo
Sensitivity Specificity
90%
81%
72%
89%
Comparison of Stress Echocardiography and Stress Myocardial Perfusion Scintigraphy for CAD
O’Keefe J Am J Cardiol 1995;75:25D-34D
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Do not judge yourself harshly.
Without mercy for ourselves we cannot
love the world.
The Buddha
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Key Assumptions
• The euros available for health care are limited
• The medical profession must play a significant role in the critical evaluation of the use of diagnostic procedures and therapies
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PURSUIT Trial Investigator
0,9
0,91
0,92
0,93
0,94
0,95
0,96
0,97
0,98
0,99
1
30 60 90 120 150 180
Pro
b. o
f su
rviv
al
Days
N Engl J Med 1998;339:436-43
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280
210
180
150
120
90
60
30
0
280
210
180
150
120
90
60
30
0
(+) (o) (+) (o)
(+) (o)
In hospital adverse outcome
Complex morphology
Dur
atio
n of
TM
I at a
dmis
sion
(m
in/2
4 hr
s)
Dur
atio
n of
TM
I at a
dmis
sion
(m
in/2
4 hr
s)
Bugiardini R et al Am J Cardiol 1991;67:460-464
Relations among complex stenosis morphology, transient myocardial ischemia, and in-hospital outcome in pts with UA
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0 50 100 150 200 250 300 350
0.85
0.85
0.90
0.95
1.00
No ST Shift
ST Shift
P=0.0226
Days from Randomization
Eve
nt-f
ree
Sur
viva
l (P
ropo
rtio
n)
The Canadian ESSENCE ST Segment Monitoring Substudy
Goodman SG J Am Coll Cardiol 2000;36:1507-13
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Age > 65 years
Hypertension
Transient ischemia
Severe recurrent pain
4.66
7.10
11.87
0.00046.82
9.47
3.33
Multivessel disease
Complex lesion morphology
IC thrombus
0.03
0.0003
0.04
0.09
Independent predictors of multivessel disease, complex lesion morphology, intracoronary thrombus or either of
latter two
Patel DJ Eur Heart J 2001; 22:1991-96
Complex lesion or IC thrombus
Odds ratio p Value Odds ratio p Value Odds ratio p Value Odds ratio p Value
0.02
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If exercise ECG is so bloody good, why is it
abnormal so infrequently during
dobutamine echocardiography when
ischemia (inducible wall motion
abnormality) is present ?
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0.0
2.0
4.0
6.0
8.0
10.0
0.5
2.93.5
0.6
5.3
7.1
1.4
3.2
9.0H
ard
Eve
nt R
ate
per
Yea
r (%
)
Low Intermadiate High
Normal
Mild Abnl
Mod-Sev Abnl
Duke Treadmill Score
Rates of hard events per years as a function of the result of stress SPECT in pts with low, intermediate, and high Duke treadmill scores groups
Hachamovitch R, Circulation 2002; 105:823-829
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Clinical suspicion of ACS
Physical examination, echocardiogram, ECG monitoring, blood samples
Persistent ST-segment elevation
No Persistent ST-segment elevation
Thrombolysis
PCI
Aspirin, clopidogrel, LMW heparin, Beta-blockers, nitrates
High Risk Low Risk
Second troponin measurement
Glycoprotein IIb/IIIa, coronary angiography
Positive Negative
Stress Test, coronary angiography
Hamm CW Lancet 2001;358:1533-38
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•Early Conservative Strategy?
•Early Invasive Strategy?
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25%
20%
15%
10%
5%
0%
At Discharge At 1 Month At 1 Year
Comparison of Outcomes (death or MI in non-Q-wave MI) in VANQWISH
7.8%
3.3%
10.4%
5.7%
24%
18.6%
V Conservative (n=458)V Invasive (n=462)
Boden H, N Engl J Med 1998; 339:1091-9
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0 60 120 180 240 300 360
0.06
0.08
0.10
0.12
0.14
0.16
0.04
0.02
Non-invasive group
Time since start of open-label dalteparin (days)
FRISC II TRIAL
Wallentin L, Lancet 2000;356:9-16
Invasive groupProb
abil
ity
of d
eath
or
myo
card
ial i
nfar
ctio
n
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Early Invasive Strategy
• Recurrent angina-ischemia at rest or with low level activities despite intensive anti-ischemic therapy
• Elevated TnT or TnI
• New or presumably new ST-segment depression
• Recurrent angina/ischemia with CHF symptoms
• High-risk findings on noninvasive stress testing
• Depressed LV systolic function
• Hemodynamic Instability
• Sustained Ventricular Tachycardia
• PCI within 6 months
• Prior CABG ACC/AHA Practice Guidelines 2002
coronary angiographyclass I - Level Evidence A
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Early Conservative Strategy
Coronary angiography is reserved for patients with:
• Evidence of recurrent ischemia
- angina at rest or with minimal activity - dynamic ST-segment changes
• Strongly positive stress-test (despite vigorous medical therapy)
ACC/AHA Practice Guidelines 2002
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Early Invasive Strategy
• Recurrent angina-ischemia at rest or with low level activities despite intensive anti-ischemic therapy
• Elevated TnT or TnI
• New or presumably new ST-segment depression
• Recurrent angina/ischemia with CHF symptoms
• High-risk findings on noninvasive stress testing
• Depressed LV systolic function
• Hemodynamic Instability
• Sustained Ventricular Tachycardia
• PCI within 6 months
• Prior CABG ACC/AHA Practice Guidelines 2002
coronary angiographyclass I - Level Evidence A
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Angina
ECG
Cardiac Markers
IMA UA Possible UA
+ + +/- + + + - ?+ + - -
Reperfusion Therapy
CCU CPU Pharmacological test
Initial Clinical Presentation
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0.1 1 10 100Clinical TrialsAntmanHamm
OhmanLuscherSummary
Cohort StudiesGokhan CinHamm
HammMockel
PettijohnRavkilde
StubbsSummary
Ravkilde
The odds ratio for increased mortality with a positive troponin T for clinical trials and cohort studies
Heidenreich J Am Coll Cardiol 2001;38:478-85
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Age, by decade
Gender, female
S3 or rales
ST segment depression
Complicated angina
CK-MB < 5 IU/ml
CTnI, by category
1.51 (1.3,1.9)
0.9 (0.7, 1.5)
3.4 (1.2, 9.2)
2.0 (1.4, 3.0)
1.5 (1.0, 2.3)
1.4 (0.9, 2.0)
1.1 (0.8, 1.5)
Crude Relative Risk OR (95% CI)
Adjusted Relative Risk OR (95% CI)
p Value
0.0001
0.0004
0.03
0.2
0.5
0.02
0.9
Crude and adjusted Relative Risk of Death or Myocardial Infarction by 42 Days
CRP, by category 1.0 (0.9, 1.1) 0.3
1.5 (1.2, 1.8)
1.5 (0.3, 0.7)
1.6 (1.1, 2.5)
1.8 (1.2, 2.8)
1.3 (0.9, 2.0)
_
_
_
p Value
0.0004
0.03
0.004
0.2
0.6
_
_
_
Salomon J Am Coll Cardiol 2001;38:969-79
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Why are the guidelines so misleading?
• Composition of members
• Selection bias
• Peer pressure
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The purpose of this study was to compare the effects of
nitrates and calcium channel blockers on
electrocardiografic (ECG) ischemia during exercise in a
group of women admitted to our laboratories because of
the occurrence of effort angina associated with ST
depression. The results of this investigation demonstrate
that simply acquired ECG variables during exercise stress
testing on drugs contain diagnostic information, and may
reflect the underlying pathogenetic substrate of angina.
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16
18
20
22
24
26
28
Before ISDN After ISDN16
18
20
22
24
26
28
Before V After V
16
18
20
22
24
26
28
Before ISDN After ISDN16
18
20
22
24
26
28
Before V After V
NCA
CAD
RP
P (
103 U
) A
T 0
.1 m
V S
T
RP
P (
103 U
) A
T 0
.1 m
V S
T
p<0.001
p<0.001p<0.001
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ST
ST
RPP (103 U)
Baseline EST
EST on drug
RPP (103 U)
(mV)
(mV)
ISDN VerapamilNCA Patients
CAD Patients
2827262524232221201918
0.0
0.1
0.2
0.3
2827262524232221201918
0.0
0.1
0.2
0.3
28272625242322212019181716
0.0
0.1
0.2
0.3
2827262524232221201918
0.0
0.1
0.2
0.3
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200
300
400
500
600
700
Before ISDN After ISDN
NCACAD
Tim
e of
exe
rcis
e (s
ec)
Tim
e of
exe
rcis
e (s
ec)
200
300
400
500
600
700
Before V After V
200
300
400
500
600
700
Before ISDN After ISDN
200
300
400
500
600
700
Before V After V
p<0.001
p<0.001p<0.001
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PURSUIT Trial Investigator
0,9
0,91
0,92
0,93
0,94
0,95
0,96
0,97
0,98
0,99
1
30 60 90 120 150 180
Pro
b. o
f su
rviv
al
Days
N Engl J Med 1998;339:436-43
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TIMI Risk Score
0
5
10
15
20
25
30
35
40
45
0/1 2 3 4 5 6/7
4,7
8,3
13,2
19,9
26,2
40,9
N° of Risk Factors
Rat
e of
com
posi
te e
nd p
oint
%
Antman EM et al. JAMA 2000;284:835-42