One-Year Outcomes After Low-Dose Intracoronary Alteplase During Primary Percutaneous Coronary Intervention
2020; Lippincott Williams & Wilkins; Volume: 13; Issue: 2 Linguagem: Inglês
10.1161/circinterventions.119.008855
ISSN1941-7632
AutoresAnnette Maznyczka, Peter McCartney, Hany Eteiba, John P. Greenwood, Douglas Muir, Saqib Chowdhary, Anthony Gershlick, Clare Appleby, James Cotton, Andrew Wragg, Nick Curzen, Keith G. Oldroyd, Mitchell Lindsay, Margaret McEntegart, J. Paul Rocchiccioli, Aadil Shaukat, Richard Good, Stuart Watkins, Keith Robertson, Christopher J. Malkin, Lynn Martin, Lynsey Gillespie, Robin A.P. Weir, Thomas J. Ford, Mark C. Petrie, Aengus Murphy, Colin J. Petrie, Nitish Ramparsad, Kirsty Wetherall, Keith A.A. Fox, Ian Ford, Alex McConnachie, Colin Berry,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoHomeCirculation: Cardiovascular InterventionsVol. 13, No. 2One-Year Outcomes After Low-Dose Intracoronary Alteplase During Primary Percutaneous Coronary Intervention Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBOne-Year Outcomes After Low-Dose Intracoronary Alteplase During Primary Percutaneous Coronary InterventionThe T-TIME Randomized Trial Annette M. Maznyczka, MBChB (Hons), Peter J. McCartney, MBChB, Hany Eteiba, MD, John P. Greenwood, PhD, Douglas F. Muir, MBChB, Saqib Chowdhary, PhD, Anthony H. Gershlick, MBBS, Clare Appleby, PhD, James M. Cotton, MD, Andrew Wragg, PhD, Nick Curzen, PhD, Keith G. Oldroyd, MD (Hons), Mitchell Lindsay, MD, Margaret McEntegart, PhD, J. Paul Rocchiccioli, MD, Aadil Shaukat, MBBS, Richard Good, MD, Stuart Watkins, MD, Keith Robertson, PhD, Christopher Malkin, MD, Lynn Martin, BN, Lynsey Gillespie, PhD, Robin A. Weir, MD, Thomas J. Ford, MBChB, Mark C. Petrie, MBChB, Aengus Murphy, MD, Colin J. Petrie, PhD, Nitish Ramparsad, MSc, Kirsty Wetherall, BSc, Keith A. Fox, MBChB, Ian Ford, PhD, Alex McConnachie, PhD, Colin Berry, PhD and for the T-TIME Group Annette M. MaznyczkaAnnette M. Maznyczka British Heart Foundation Glasgow Cardiovascular Research Centre (A.M.M., P.J.M., K.G.O., T.J.F., M.C.P., C.B.), University of Glasgow, United Kingdom. West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.M.M., P.J.M., H.E., K.G.O., M.L., M.M., J.P.R., A.S., R.G., S.W., K.R., L.M., M.C.P., C.B.). , Peter J. McCartneyPeter J. McCartney British Heart Foundation Glasgow Cardiovascular Research Centre (A.M.M., P.J.M., K.G.O., T.J.F., M.C.P., C.B.), University of Glasgow, United Kingdom. West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.M.M., P.J.M., H.E., K.G.O., M.L., M.M., J.P.R., A.S., R.G., S.W., K.R., L.M., M.C.P., C.B.). , Hany EteibaHany Eteiba West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.M.M., P.J.M., H.E., K.G.O., M.L., M.M., J.P.R., A.S., R.G., S.W., K.R., L.M., M.C.P., C.B.). , John P. GreenwoodJohn P. Greenwood Leeds University and Leeds Teaching Hospitals NHS Trust, United Kingdom (J.P.G.). , Douglas F. MuirDouglas F. Muir James Cook University Hospital NHS Trust, Middlesbrough, United Kingdom (D.F.M., C.M.). , Saqib ChowdharySaqib Chowdhary Manchester University NHS Foundation Trust, United Kingdom (S.C.). , Anthony H. GershlickAnthony H. Gershlick Leicester University Hospitals NHS Trust, United Kingdom (A.H.G.). , Clare ApplebyClare Appleby Liverpool Heart and Chest Hospital NHS Foundation Trust, United Kingdom (C.A.). , James M. CottonJames M. Cotton Wolverhampton University Hospital NHS Trust, United Kingdom (J.M.C.). , Andrew WraggAndrew Wragg Barts and The London Hospital, London, United Kingdom (A.W.). , Nick CurzenNick Curzen University Hospital Southampton Foundation Trust and School of Medicine, University of Southampton, United Kingdom (N.C.). , Keith G. OldroydKeith G. Oldroyd British Heart Foundation Glasgow Cardiovascular Research Centre (A.M.M., P.J.M., K.G.O., T.J.F., M.C.P., C.B.), University of Glasgow, United Kingdom. West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.M.M., P.J.M., H.E., K.G.O., M.L., M.M., J.P.R., A.S., R.G., S.W., K.R., L.M., M.C.P., C.B.). , Mitchell LindsayMitchell Lindsay West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.M.M., P.J.M., H.E., K.G.O., M.L., M.M., J.P.R., A.S., R.G., S.W., K.R., L.M., M.C.P., C.B.). , Margaret McEntegartMargaret McEntegart West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.M.M., P.J.M., H.E., K.G.O., M.L., M.M., J.P.R., A.S., R.G., S.W., K.R., L.M., M.C.P., C.B.). , J. Paul RocchiccioliJ. Paul Rocchiccioli West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.M.M., P.J.M., H.E., K.G.O., M.L., M.M., J.P.R., A.S., R.G., S.W., K.R., L.M., M.C.P., C.B.). , Aadil ShaukatAadil Shaukat West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.M.M., P.J.M., H.E., K.G.O., M.L., M.M., J.P.R., A.S., R.G., S.W., K.R., L.M., M.C.P., C.B.). , Richard GoodRichard Good West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.M.M., P.J.M., H.E., K.G.O., M.L., M.M., J.P.R., A.S., R.G., S.W., K.R., L.M., M.C.P., C.B.). , Stuart WatkinsStuart Watkins West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.M.M., P.J.M., H.E., K.G.O., M.L., M.M., J.P.R., A.S., R.G., S.W., K.R., L.M., M.C.P., C.B.). , Keith RobertsonKeith Robertson West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.M.M., P.J.M., H.E., K.G.O., M.L., M.M., J.P.R., A.S., R.G., S.W., K.R., L.M., M.C.P., C.B.). , Christopher MalkinChristopher Malkin James Cook University Hospital NHS Trust, Middlesbrough, United Kingdom (D.F.M., C.M.). , Lynn MartinLynn Martin West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.M.M., P.J.M., H.E., K.G.O., M.L., M.M., J.P.R., A.S., R.G., S.W., K.R., L.M., M.C.P., C.B.). , Lynsey GillespieLynsey Gillespie Greater Glasgow and Clyde Health Board, United Kingdom (L.G.). , Robin A. WeirRobin A. Weir University Hospital Hairmyres, East Kilbride, United Kingdom (R.A.W.). , Thomas J. FordThomas J. Ford British Heart Foundation Glasgow Cardiovascular Research Centre (A.M.M., P.J.M., K.G.O., T.J.F., M.C.P., C.B.), University of Glasgow, United Kingdom. , Mark C. PetrieMark C. Petrie British Heart Foundation Glasgow Cardiovascular Research Centre (A.M.M., P.J.M., K.G.O., T.J.F., M.C.P., C.B.), University of Glasgow, United Kingdom. West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.M.M., P.J.M., H.E., K.G.O., M.L., M.M., J.P.R., A.S., R.G., S.W., K.R., L.M., M.C.P., C.B.). , Aengus MurphyAengus Murphy University Hospital Monklands, NHS Lanarkshire, United Kingdom (A.M., C.J.P.). , Colin J. PetrieColin J. Petrie University Hospital Monklands, NHS Lanarkshire, United Kingdom (A.M., C.J.P.). , Nitish RamparsadNitish Ramparsad Robertson Centre for Biostatistics, Institute of Health and Wellbeing (N.R., K.W., I.F., A.M.), University of Glasgow, United Kingdom. , Kirsty WetherallKirsty Wetherall Robertson Centre for Biostatistics, Institute of Health and Wellbeing (N.R., K.W., I.F., A.M.), University of Glasgow, United Kingdom. , Keith A. FoxKeith A. Fox Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.F.). , Ian FordIan Ford Robertson Centre for Biostatistics, Institute of Health and Wellbeing (N.R., K.W., I.F., A.M.), University of Glasgow, United Kingdom. , Alex McConnachieAlex McConnachie Robertson Centre for Biostatistics, Institute of Health and Wellbeing (N.R., K.W., I.F., A.M.), University of Glasgow, United Kingdom. , Colin BerryColin Berry Correspondence to: Colin Berry, PhD, British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, 126 University Pl, University of Glasgow, Glasgow G12 8TA, Scotland, United Kingdom. Email E-mail Address: [email protected] British Heart Foundation Glasgow Cardiovascular Research Centre (A.M.M., P.J.M., K.G.O., T.J.F., M.C.P., C.B.), University of Glasgow, United Kingdom. West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.M.M., P.J.M., H.E., K.G.O., M.L., M.M., J.P.R., A.S., R.G., S.W., K.R., L.M., M.C.P., C.B.). and for the T-TIME Group Originally published11 Feb 2020https://doi.org/10.1161/CIRCINTERVENTIONS.119.008855Circulation: Cardiovascular Interventions. 2020;13:e008855Microvascular obstruction (MVO), which represents failed myocardial reperfusion, occurs in about half of patients treated with standard primary percutaneous coronary intervention (PCI) and predicts a worse prognosis.1 Distal embolization and microvascular thrombosis contribute to MVO. In the T-TIME trial (Trial of Low-Dose Adjunctive Alteplase During Primary PCI; NCT02257294),2 we hypothesized that low-dose intracoronary fibrinolysis with alteplase, in patients with adequate anticoagulation undergoing primary PCI, would reduce MVO extent as assessed by contrast-enhanced cardiovascular magnetic resonance imaging. We found that MVO did not differ with alteplase versus placebo.2 Here, we report the efficacy and safety of intracoronary alteplase at 1 year.From August 2016 to December 2017, patients with acute ST-segment–elevation myocardial infarction from 11 UK hospitals were prospectively enrolled. The trial design and main results have been described previously.2 T-TIME was an investigator-initiated, double-blind, parallel-group, randomized, placebo-controlled clinical trial. Patients were eligible if they presented with persistent ST-segment–elevation or recent left bundle branch block, ≤6 hours from symptom onset, and either an occluded culprit artery or impaired flow (Thrombolysis in Myocardial Infarction flow grade 2) with Thrombolysis in Myocardial Infarction thrombus grade ≥2. The study was approved by the West of Scotland Research Ethics Committee (reference: 13-WS-0119). Informed consent was obtained.Patients were randomized to placebo, alteplase 10 mg, or alteplase 20 mg, on a 1:1:1 basis. The intervention was administered before stent implantation by manual infusion of the 20-mL volume of study into the culprit artery proximal to the lesion. Serious adverse events with potential relevance to the predefined clinical outcomes were adjudicated by a blinded clinical event committee. Analysis of efficacy outcomes was according to treatment as randomized. Analysis of major bleeds was based on treatment received. Logistic regression (adjusted for infarct location) was used to assess for treatment effects. Statistical analyses were performed with Rv3.2.4, according to a prespecified statistical analysis plan.Four hundred and forty patients (mean age, 61±10 years; 85% men) were randomized to placebo (n=151), alteplase 10 mg (n=144), and alteplase 20 mg (n=145; Figure). At 1 year, there was no difference in major adverse cardiac events with alteplase 20 mg (n=15 [10.3%]) versus placebo (n=16 [10.6%]; OR [odds ratio], 0.96 [95% CI, 0.45–2.04]) or with alteplase 10 mg (n=22 [15.3%]) versus placebo (OR, 1.52 [95% CI, 0.76–3.05]). There was no difference in spontaneous major adverse cardiac events (major adverse cardiac events excluding myocardial infarction associated with revascularization) at 1 year with alteplase 20 mg (n=14 [9.7%]) versus placebo (n=16 [10.6%]; OR, 0.89 [95% CI, 0.42–1.91]) or with alteplase 10 mg (n=18 [12.5%]) versus placebo (OR, 1.19 [95% CI, 0.58–2.46]). Myocardial infarction associated with revascularization occurred in 2, 4, and 1 patients at 1 year, randomized to placebo, alteplase 10 mg, and alteplase 20 mg, respectively (log-rank P=0.351).Download figureDownload PowerPointFigure. Screening, randomization, treatment, and follow-up at 1 y. MRI indicates magnetic resonance imaging; and STEMI, ST-segment–elevation myocardial infarction.Major adverse cardiovascular and cardiac events, defined as cardiovascular death, nonfatal myocardial infarction, or unplanned hospitalization for stroke, or transient ischemic attack, did not differ between treatment groups at 1 year (alteplase 20 mg [n=10 (6.9%)] versus placebo [n=7 (4.6%)]: OR, 1.54 [95% CI, 0.57–4.16]; or alteplase 10 mg [n=9 (6.3%)] versus placebo: OR, 1.38 [95% CI, 0.50–3.83]). Similarly, there was no difference in the composite of all-cause mortality and heart failure hospitalization, with alteplase 20 mg (n=13 [9.0%]) versus placebo (n=14 [9.3%]; OR, 0.95 [95% CI, 0.43–2.12]) or with alteplase 10 mg (n=19 [13.2%]) versus placebo (OR, 1.48 [95% CI, 0.71–3.12]). There was no difference in heart failure hospitalizations at 1 year with alteplase 20 mg (n=10 [6.9%]) versus placebo (n=13 [8.6%]; OR, 0.76 [95% CI, 0.32–1.84]) or with alteplase 10 mg (n=15 [10.4%]) versus placebo (OR, 1.22 [95% CI, 0.55–2.72]). There was no difference in all-cause death at 1 year, with placebo (n=1 [0.7%]), alteplase 10 mg (n=6 [4.2%]), or alteplase 20 mg (n=3 [2.1%]; log-rank P=0.127). Bleeding Academic Research Consortium type 3-5 bleeds occurred in 1, 2, and 2 patients, with placebo, alteplase 10 mg, and alteplase 20 mg (log-rank P=0.792).In summary, clinical outcomes at 1 year were not improved by adjunctive, low-dose, intracoronary fibrinolysis. Bleeds were uncommon (1.1%) and consistent with what would be expected in a contemporary primary PCI population. These results should be interpreted as exploratory because the T-TIME trial was designed but not powered to examine 1-year clinical outcomes.Potential for harm with facilitated PCI, using full- or half-dose fibrinolytic therapy given intravenously pre-PCI, was shown in the ASSENT-4 (Assessment of the Safety and Efficacy of a New Treatment Strategy With PCI)3 and FINESSE (Facilitated Intervention With Enhanced Reperfusion Speed to Stop Events)4 trials. Intravenous fibrinolytic therapy pre-PCI improved initial culprit artery patency but increased residual thrombus, ischemic complications, and major bleeds, compared with standard primary PCI.5 These results could be explained by inadequate anticoagulation, compounded by any paradoxical prothrombotic effects of lytic therapy in P2Y12 inhibitor naive patients.Current trials of adjunctive intracoronary fibrinolysis during primary PCI include RESTORE-MI (Restoring Microcirculatory Perfusion in STEMI; NCT03998319), STRIVE (Adjunctive Low-Dose tPA in Primary PCI for STEMI; NCT03335839) and OPTIMAL (Optimal Coronary Flow After PCI for Myocardial Infarction; NCT02894138). Further research should build on the new knowledge arising from T-TIME, to elucidate which patient groups might benefit.In conclusion, low-dose intracoronary alteplase administered early during primary PCI did not improve clinical outcomes. Further research is warranted to identify new treatments for MVO.AcknowledgmentsWe acknowledge the clinical staff and the patients who participated in this project. Responsible individual at the Data Coordinating Center: Alex McConnachie. Data Coordinating Centers: Robertson Centre for Biostatistics, Glasgow Clinical Trials Unit, University of Glasgow. Dr Eteiba, Dr Greenwood, Dr Muir, Dr Chowdhary, A.H. Gershlick, Dr Appleby, Dr Cotton, Dr Wragg, and Dr Curzen were local principal investigators, obtained informed consent and randomized patients, collected data, interpreted the results, and contributed to the manuscript. A.M. Maznyczka and P.J. McCartney contributed to screening and enrollment, collected the data, undertook data analyses, and interpreted the data. A.M. Maznyczka wrote the original draft of the manuscript. A.M. Maznyczka, T.J. Ford, and Dr Berry served as blinded primary reviewers of serious adverse events, of potential relevance. M.C. Petrie helped to design the charter for the clinical event committee, interpreted the data, and contributed to the manuscript. Dr Weir chaired the clinical event committee. Drs Weir, Murphy, and Petrie adjudicated clinical events, as part of the clinical event committee. Dr Oldroyd, Dr Lindsay, Dr McEntegart, Dr Rocchiccioli, A. Shaukat, Dr Good, Dr Watkins, Dr Robertson, and Dr Malkin obtained informed consent and randomized patients, collected data, interpreted the results, and contributed to the manuscript. L. Martin supported screening and enrollment, data collection, and event reporting. Dr Gillespie was the project manager for the trial. K.A. Fox chaired the Trial Steering Committee and contributed to the interpretation of the data and the manuscript. Dr Ford contributed to the study design, data analyses, and interpretation and contributed to the manuscript. Dr McConnachie, N. Ramparsad, and K. Wetherall analyzed and interpreted the data and contributed to the manuscript. Dr Berry conceived the study, obtained the funding, recruited and randomized patients, collected and assessed the data blind to treatment group assignment, and interpreted the results. Dr Berry is the chief investigator, and Dr Chowdhary, Dr Ford, Dr Greenwood, D.F. Muir, and Dr Oldroyd were coapplicants on the grant from the National Institute for Health Research–Efficacy and Mechanism Evaluation programme (reference: 12/170/45).Sources of FundingThis work was supported by a National Institute for Health Research–Efficacy and Mechanism Evaluation (NIHR-EME) programme grant (12/170/45), and Boehringer Ingelheim provided the study drugs. A.M. Maznyczka was funded by a Fellowship from the British Heart Foundation (reference: FS/16/74/32573). Dr Berry and M.C. Petrie are supported by British Heart Foundation RE/18/6/34217. The research was part supported by the National Institute for Health Research infrastructure at Leeds. The views expressed are those of the author(s) and not necessarily those of the National Health Surface, the National Institute for Health Research, or the Department of Health. The funder, NIHR-EME, coordinated peer review, approved the design of the study, and had oversight of its conduct and management. The University of Glasgow and Greater Glasgow and Clyde Health Board were independent cosponsors of the trial. The cosponsors shared oversight and responsibility for the design and conduct of the study; collection, management, research governance, analysis, and final approval of the manuscript. The sponsor did not have the right to preclude submission of the manuscript.DisclosuresA.M. Maznyczka reports fellowship from the British Heart Foundation (reference: FS/16/74/32573). Dr Curzen has received an unrestricted research grant and fees for lectures and consultancy from Abbott Vascular and Boston Scientific. K.A. Fox has received grants and personal fees from Bayer/Janssen, grants from AstraZeneca, and personal fees from Sanofi/Regeneron and Verseon. Dr McConnachie has received grants from the Medical Research Council/National Institute for Health Research–Efficacy and Mechanism Evaluation (NIHR-EME) program during the conduct of the study. Based on contracts with the University of Glasgow, Dr Berry has held research and consultancy agreements with Abbott Vascular, AstraZeneca, Boehringer Ingelheim, HeartFlow, GlaxoSmithKline,Novartis, Philips, and Siemens Healthcare. He has held grants from NIHR-EME (reference: 12/170/45) and the British Heart Foundation (reference: FS/16/74/32573 and RE/18/6/34217) in support of the current study. The other authors report no conflicts.FootnotesFor Sources of Funding and Disclosures, see page 3.Correspondence to: Colin Berry, PhD, British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, 126 University Pl, University of Glasgow, Glasgow G12 8TA, Scotland, United Kingdom. Email colin.[email protected]ac.ukReferences1. van Kranenburg M, Magro M, Thiele H, de Waha S, Eitel I, Cochet A, Cottin Y, Atar D, Buser P, Wu E, et al. Prognostic value of microvascular obstruction and infarct size, as measured by CMR in STEMI patients.JACC Cardiovasc Imaging. 2014; 7:930–939. doi: 10.1016/j.jcmg.2014.05.010CrossrefMedlineGoogle Scholar2. McCartney PJ, Eteiba H, Maznyczka AM, McEntegart M, Greenwood JP, Muir DF, Chowdhary S, Gershlick AH, Appleby C, Cotton JM, et al; T-TIME Group. Effect of low-dose intracoronary alteplase during primary percutaneous coronary intervention on microvascular obstruction in patients with acute myocardial infarction: a Randomized Clinical Trial.JAMA. 2019; 321:56–68. doi: 10.1001/jama.2018.19802CrossrefMedlineGoogle Scholar3. Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT-4 PCI) investigators. Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomised trial.Lancet. 2006; 367:569–578. doi: 10.1016/S0140-6736(06)68147-6CrossrefMedlineGoogle Scholar4. Ellis SG, Tendera M, de Belder MA, van Boven AJ, Widimsky P, Janssens L, Andersen HR, Betriu A, Savonitto S, Adamus J, et al; FINESSE Investigators. Facilitated PCI in patients with ST-elevation myocardial infarction.N Engl J Med. 2008; 358:2205–2217. doi: 10.1056/NEJMoa0706816CrossrefMedlineGoogle Scholar5. Zalewski J, Bogaerts K, Desmet W, Sinnaeve P, Berger P, Grines C, Danays T, Armstrong P, Van de Werf F. Intraluminal thrombus in facilitated versus primary percutaneous coronary intervention: an angiographic substudy of the ASSENT-4 PCI (Assessment of the Safety and Efficacy of a New Treatment Strategy With Percutaneous Coronary Intervention) trial.J Am Coll Cardiol. 2011; 57:1867–1873. doi: 10.1016/j.jacc.2010.10.061CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Maznyczka A, McCartney P, Duklas P, McEntegart M, Oldroyd K, Greenwood J, Muir D, Chowdhary S, Gershlick A, Appleby C, Eteiba H, Cotton J, Wragg A, Curzen N, Tait R, MacFarlane P, Welsh P, Sattar N, Petrie M, Ford I, Fox K, McConnachie A and Berry C (2021) Effect of coronary flow on intracoronary alteplase: a prespecified analysis from a randomised trial, Heart, 10.1136/heartjnl-2020-317828, 107:4, (299-312), Online publication date: 1-Feb-2021. Gorecka M, McCann G, Berry C, Ferreira V, Moon J, Miller C, Chiribiri A, Prasad S, Dweck M, Bucciarelli-Ducci C, Dawson D, Fontana M, Macfarlane P, McConnachie A, Neubauer S, Greenwood J, Swoboda P, Steeds R, Fairbairn T, Flett A, Green T, Cole G, McDiarmid A, Bunce N, Kanagala P, Bellenger N, Ninan T, Alfakih K and Moon J (2021) Demographic, multi-morbidity and genetic impact on myocardial involvement and its recovery from COVID-19: protocol design of COVID-HEART—a UK, multicentre, observational study, Journal of Cardiovascular Magnetic Resonance, 10.1186/s12968-021-00752-1, 23:1, Online publication date: 1-Dec-2021. Maznyczka A and Haworth P (2021) Adjunctive Intracoronary Fibrinolytic Therapy During Primary Percutaneous Coronary Intervention, Heart, Lung and Circulation, 10.1016/j.hlc.2021.02.016, 30:8, (1140-1150), Online publication date: 1-Aug-2021. February 2020Vol 13, Issue 2 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.119.008855PMID: 32069113 Originally publishedFebruary 11, 2020 KeywordsScotlandprognosisanticoagulantshumansfibrinolysisPDF download Advertisement SubjectsMortality/SurvivalMyocardial Infarction
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