![]() ![]() In TIMI IIIA, patients received baseline angiograms and were randomized in a double-blind manner to t-PA or placebo. All patients enrolled in the study received standard coronary care unit care, including bed rest and oxygen. The two clinical trials were initiated simultaneously in different groups of TIMI III clinical centers. Also, the value of routine, early coronary angiography followed by PTCA and/or CABG was still unclear in both these conditions. The results suggested a benefit, but the significance of this benefit and its relation to the risks and costs of therapy remained to be answered. Previous studies of thrombolytic therapy for unstable angina and non-Q-wave myocardial infarction were limited in number and size. Whether or not revascularization improved prognosis in these patients had not been established. Although the early prognosis was favorable, awareness that the longer-term prognosis was as serious as that following Q-wave myocardial infarction had led to increasing use of follow-up coronary angiography to identify patients for whom PTCA or CABG might be useful. Neither heparin therapy nor thrombolytic therapy was routinely employed, although knowledge of the role of thrombosis in some patients with this condition had raised the possibility that one or both approaches might be helpful. Prior to the TIMI III trial, patients with non-Q-wave myocardial infarction were usually treated in the same way patients with Q-wave myocardial infarction were treated prior to the advent of thrombolytic therapy. In many tertiary care hospitals, angiography followed by PTCA is frequently performed, whereas in community hospitals patients are often managed without angiography. The use of heparin is widespread but controversial. Initial conventional therapy for unstable angina consists of bed rest, oxygen, nitrates, beta-blockers, calcium antagonists, and aspirin. It has been observed in small numbers of patients that, unlike patients with chronic stable ischemia, patients with unstable angina or non-Q-wave myocardial infarction frequently have a thrombus in a major coronary artery. Second, ischemia is often associated with transient ST-segment depression or elevation, in contrast to the persistent ST-segment elevation characteristic of patients who develop Q-wave infarction. First, ischemia usually develops at rest or is precipitated by minimal exertion this differs from chronic stable angina, in which most ischemic episodes are precipitated by physical exertion or strong emotion and the resultant increase in myocardial oxygen demand. There is agreement, however, on two important features of unstable angina. Identification of patients experiencing unstable angina is more difficult, since numerous definitions of the condition have been offered. Once the results of creatine kinase measurements and serial electrocardiograms are available, the identification of patients experiencing non-Q-wave myocardial infarction is relatively simple. National summaries of hospital records indicate that 750,000 patients are hospitalized yearly with unstable angina and 250,000 with non-Q-wave myocardial infarction. ![]() Although others recover from the acute episode without subsequent infarction or reinfarction, they frequently have severe obstructive coronary artery disease and may be left with severe chronic stable angina. Some patients with unstable angina progress to acute myocardial infarction, and some of those with non-Q-wave infarction experience an unstable course with reinfarction. In the days and weeks following the onset of their disorder, their prognosis for survival is better than that of patients with Q-wave myocardial infarction but worse than that of patients with stable angina. Patients with non-Q-wave myocardial infarction and unstable angina fall between these two extremes. Such patients have a high incidence of thrombotic coronary artery occlusion and the early intravenous administration of thrombolytic agents has been shown to re-establish perfusion, limit the extent of left ventricular dysfunction, and reduce both early or in-hospital and late or one year mortality in this group. At the other end of the spectrum are patients with acute myocardial infarction who present with a discrete episode of prolonged chest pain accompanied by persistent ST-segment elevation. When studied by coronary arteriography, such patients usually have obstructive atherosclerotic disease with no evidence of fresh thrombosis. At one end of this spectrum are patients with chronic stable angina. Myocardial ischemic syndromes account for a large portion of the annual mortality and morbidity from all causes in industrialized countries and encompass a wide clinical-pathologic spectrum. TIMI IIIA and TIMI IIIB follow the contract-supported clinical trial, Thrombolysis in Myocardial Infarction (TIMI I, TIMI IIA, and TIMI II). Why Should I Register and Submit Results?. ![]()
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