CLINICAL STUDIES
Adenosine as an adjunct to thrombolytic therapy for acute myocardial infarction
Results of a multicenter, randomized, placebo-controlled trial: the Acute Myocardial Infarction STudy of ADenosine (AMISTAD) Trial
Kenneth W. Mahaffey, MD, FACCa*    || ¶ #,
Joseph A. Puma, DOa* || ¶ #,
N. Alejandro Barbagelata, MD*,
Marcelo F. DiCarli, MD,
Massoud A. Leesar, MD,
Kevin F. Browne, MD,
Paul R. Eisenberg, MD||,
Roberto Bolli, MD,
A. Cecilia Casas, MSa* || ¶ #,
Victor Molina-Viamonte, MD¶,
Cesare Orlandi, MD¶,
Roger Blevins, PharmD¶,
Raymond J. Gibbons, MD, FACC#,
Robert M. Califf, MD, FACCa* || ¶ #,
Christopher B. Granger, MD, FACCa* || ¶ # for the AMISTAD Investigators
a Duke Clinical Research Institute, Durham, North Carolina, USA
* Favaloro Foundation, Buenos Aires, Argentina
Harper Hospital, Detroit, Michigan, USA
University of Louisville, Louisville, Kentucky, USA
The Watson Clinic, Lakeland, Florida, USA
|| Washington University, St. Louis, Missouri, USA
¶ Medco Research, Inc., Research Triangle Park, North Carolina, USA
# The Mayo Clinic, Rochester, Minnesota, USA
Manuscript received September 17, 1998;
revised manuscript received June 17, 1999,
accepted August 12, 1999.
Reprint requests and correspondence: Dr. Kenneth W. Mahaffey, Duke Clinical Research Institute, PO Box 17969, Durham, North Carolina 27715
mahaf002{at}mc.duke.edu
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Abstract
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OBJECTIVES
The Acute Myocardial Infarction STudy of ADenosine (AMISTAD) trial was designed to test the hypothesis that adenosine as an adjunct to thrombolysis would reduce myocardial infarct size.
BACKGROUND
Reperfusion therapy for acute myocardial infarction (MI) has been shown to reduce mortality, but reperfusion itself also may have deleterious effects.
METHODS
The AMISTAD trial was a prospective, open-label trial of thrombolysis with randomization to adenosine or placebo in 236 patients within 6 h of infarction onset. The primary end point was infarct size as determined by Tc-99 m sestamibi single-photon emission computed tomography (SPECT) imaging 6 ± 1 days after enrollment based on multivariable regression modeling to adjust for covariates. Secondary end points were myocardial salvage index and a composite of in-hospital clinical outcomes (death, reinfarction, shock, congestive heart failure or stroke).
RESULTS
In all, 236 patients were enrolled. Final infarct size was assessed in 197 (83%) patients. There was a 33% relative reduction in infarct size (p = 0.03) with adenosine. There was a 67% relative reduction in infarct size in patients with anterior infarction (15% in the adenosine group vs. 45.5% in the placebo group) but no reduction in patients with infarcts located elsewhere (11.5% for both groups). Patients randomized to adenosine tended to reach the composite clinical end point more often than those assigned to placebo (22% vs. 16%; odds ratio, 1.43; 95% confidence interval, 0.71 to 2.89).
CONCLUSIONS
Many agents thought to attenuate reperfusion injury have been unsuccessful in clinical investigation. In this study, adenosine resulted in a significant reduction in infarct size. These data support the need for a large clinical outcome trial.
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Abbreviations and Acronyms
| | AMISTAD | = Acute Myocardial Infarction STudy of ADenosine | | CORE | = Collaborative Organization for RheothRx Evaluation (trial) | | MI | = myocardial infarction | | SPECT | = single-photon emission computed tomography | | TIMI | = Thrombolysis In Myocardial Infarction (trial) |
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Reperfusion therapy for acute myocardial infarction (MI) has been shown to reduce mortality (1). Angiographic data show that earlier and more complete reperfusion is related to improved survival (2). At the same time, reperfusion itself may result in deleterious effects, including myocyte death, microvascular injury, myocardial stunning and arrhythmias, although the clinical relevance of these phenomena is debatable (3). There is an excess of mortality in the day after thrombolytic therapy, which may in part be related to "reperfusion injury" (1). The mechanism of reperfusion injury has not been completely delineated but is thought to result from multiple processes, including production of oxygen free radicals, changes in intracellular calcium homeostasis, recruitment of neutrophils, complement activation, disturbed endothelial function, impaired cellular energetics and damage to the extracellular collagen matrix (3,4).
Adenosine has been studied extensively as a cardioprotective agent. It has been shown to replenish high-energy phosphate stores in endothelial cells and myocytes (5–9), to inhibit oxygen free radical formation (10–12), to inhibit neutrophil activity and accumulation (10–14) and to improve microvascular function (15). In addition, adenosine has been shown to participate in myocardial ischemic preconditioning, which may be particularly important because MI in humans commonly is caused by dynamic coronary occlusion with intermittent periods of blood flow (16–19). In animal models of reperfusion injury, adenosine has consistently reduced infarct size, improved left ventricular function and improved coronary blood flow (15,20–26).
Despite substantial investigation of adenosine in animal models of reperfusion, only a few studies have evaluated adenosine in patients with acute coronary syndromes. Small clinical studies have shown that adenosine is associated with smaller infarcts at six-week follow-up (27) and less "no-reflow" phenomenon, congestive heart failure and Q-wave MI (28) in patients undergoing primary angioplasty for acute MI and reduced ST segment shift, lactate production, and ischemic symptoms in patients undergoing elective angioplasty (29).
The Acute Myocardial Infarction STudy of ADenosine (AMISTAD) trial was designed to test the hypothesis that adenosine would reduce the size of MI measured by single-photon emission computed tomographic (SPECT) imaging with Tc-99 m sestamibi in patients undergoing thrombolysis.
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Methods
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Study organization.
The AMISTAD trial was a prospective, open-label, placebo-controlled, randomized study to evaluate the safety and efficacy of adenosine as an adjunct to thrombolytic therapy in the treatment of acute MI. Patients were enrolled at 19 centers in the U.S., Argentina and Canada (see Appendix for complete list of investigators).
Patient population.
Patients presenting within 6 h of the onset of chest pain (consistent with ischemia, lasting at least 20 min, and not relieved by sublingual nitroglycerin) who had ST segment elevation >0.1 mV in two contiguous leads, in whom the clinical decision was made to treat with thrombolytic therapy, were eligible for enrollment. The criteria for exclusion were age <18 years or >79 years, women known or suspected to be pregnant, lactation, dipyridamole treatment within the past 24 h, systolic blood pressure <100 mm Hg, cardiogenic shock (systolic blood pressure <90 mm Hg with rales or cardiac index <2.2 L/min/m2), underlying condition in which hypotension may be poorly tolerated (such as severe aortic stenosis or cerebrovascular disease), history or clinical evidence of bronchospastic lung disease or prior bronchodilator therapy, second-degree or greater atrioventricular block without functional pacemaker, left bundle branch block, sustained bradycardia (<60 beats/min for >20 min), current enrollment in other investigational drug studies and patients unlikely to be available for follow-up (at four to six weeks). All patients gave informed consent for participation and the study was approved by the institutional review board at each hospital.
Trial design.
Enrollment began in December, 1994 and ended in July, 1997. Eligible patients were stratified by MI location (anterior or nonanterior as assessed by the site investigator) and then randomly assigned to adenosine (Adenoscan, Fujisawa USA, Inc., Deerfield, Illinois) given by peripheral intravenous infusion at 70 µg/kg/min for 3 h or placebo (normal saline at 70 µg/kg/min for 3 h). The protocol initially specified that the primary end point was to be myocardial salvage determined from sequential (acute and 5 to 12 days later) SPECT myocardial perfusion imaging with Tc-99 m sestamibi. Because of slow enrollment related to difficulty in obtaining the acute image, the protocol was modified by an amendment in August 1995 such that the primary end point became final infarct size as determined by SPECT myocardial perfusion imaging with Tc-99 m sestamibi five to seven days after enrollment. The enrollment goal also was adjusted. Secondary end points were: 1) myocardial salvage index in patients with both acute and final images, and 2) a composite clinical end point reported by the site investigators. Myocardial salvage index was defined as: [myocardium at risk (acute image) – final infarct size (final image)]/(myocardium at risk). The composite clinical end point consisted of death, reinfarction, congestive heart failure, cardiogenic shock or stroke.
Patient recruitment and treatment.
Investigators or study coordinators telephoned or faxed a 24-hour-a-day, 7-day-a-week randomization center to review the eligibility of patients and to receive treatment assignments.
By protocol, the adenosine infusion was to begin before thrombolytic therapy was given. In patients undergoing acute cardiac imaging, SPECT imaging was to be performed within 6 h after injection of Tc-99 m sestamibi (20- to 30-mCi dose), which was to be injected before thrombolytic therapy began (accelerated alteplase or streptokinase per institutional protocol).
Also by protocol, intravenous lidocaine was to be given before thrombolytic therapy began, according to individual institutional protocol, to achieve and maintain therapeutic levels for  6 h. A previous study (23) had reported that adenosine was associated with reduced infarct size in dogs after coronary occlusion and reperfusion only when given with lidocaine.
Adenosine infusion rates were to be reduced by decrements of 10 µg/kg/min if side effects occurred. After resolution of any side effect, the infusion rate was to be increased in increments of 10 µg/kg/min to the maximum tolerated dose, but not to exceed 70 µg/kg/min. Other cardiac medications, diagnostic procedures, cardiac interventions or revascularization procedures were at the discretion of the physician.
The final infarct size was to be determined by Tc-99 m sestamibi SPECT image performed 6 ± 1 days after enrollment. A follow-up clinic visit or telephone contact occurred four to six weeks after hospital discharge.
Nuclear imaging technique and equipment.
All imaging data were submitted to the Nuclear Core Laboratory (Mayo Clinic Foundation, Rochester, Minnesota), which was blinded to treatment assignment. Imaging equipment and image-acquisition technique at each site were validated by this core laboratory using a cardiac phantom (30). For single-headed gamma camera systems, images were acquired using either a "step-and-shoot" mode or a continuous mode and a circular orbit. Between 30 and 32 images were acquired in a 64 x 64-word mode matrix. Image time was 40 s. For a multihead SPECT system, acquisition was performed over 360° every 6°. Data were stored in a 64 x 64-word mode matrix. The time per image was 30 s. Data were sent to the laboratory on floppy diskettes and included raw planar data, the most recent 30 M count flood image and the most recent center-of-rotation study.
Statistical analysis.
The target sample size of 300 patients was based on an assumption of a 35% reduction in the final infarct size associated with adenosine with a power of 80% at the alpha = 0.05 level. The prespecified primary end point was final infarct size, using multivariable regression modeling to adjust for covariates: MI location, time from enrollment to determination of the final infarct size, use of revascularization procedures, type of thrombolytic therapy, use of lidocaine, interaction between treatment and MI location and interaction between treatment and type of thrombolytic therapy. Modeling techniques used the ranks of the final infarct size data due to anticipated asymmetry in the distribution of these data. This analysis was based on an intent-to-treat strategy for patients who had a final infarct size determination. Variables with significance at the p  0.05 were retained in the model.
Further techniques were used to compare the final infarct size between treatment groups. First, comparisons were performed based on the Wilcoxon rank-sum test. Second, imputation techniques were used to account for patients with missing final infarct size data. Patients who died before assessment of the final infarct size were assigned the largest infarct-size rank for the group defined by MI location, and patients with data missing for other reasons were assigned the median rank of the infarct size for the group defined by MI location. Categorical variables were summarized as percentages and continuous variables as medians with 25th and 75th percentiles.
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Results
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Baseline characteristics.
A total of 236 patients were enrolled. The baseline clinical and historical characteristics were similar between treatment groups (Table 1). The study drug was given to 93% of patients in the adenosine group and 94% of placebo patients. Table 2 shows the time to thrombolytic treatment and details of study drug infusion. The median duration of study drug infusion was similar between the two groups. For patients assigned adenosine, the median (25th, 75th) ratio of total dose received to the total expected dose based on body weight was 1 (0.93, 1.01). The study drug was started before thrombolytic therapy in 39% of patients in both treatment groups. Lidocaine was given to 74% of adenosine patients and 68% of placebo patients. Patients assigned adenosine therapy tended to receive thrombolysis later after symptom onset than patients assigned placebo (200 min vs. 172 min) reflecting a later arrival at the hospital after symptom onset and not a delay in treatment after arrival (Table 2).
Data completeness.
The numbers of patients with determination of myocardium at risk, final infarct size or both are shown in Table 3. A total of 197 (83%) patients had assessment of final infarct size (Fig. 1). The number of days to final infarct size assessment was similar between the two groups; six (5,7) days for adenosine versus six (6,7) days for placebo. Of the 39 patients with missing final infarct size data, 11 patients had died and 28 were missing data for other reasons: refusal by the patient or physician (7 patients), unacceptable image quality (3 patients) or technical problems with data acquisition during imaging (18 patients). Missing data were not associated with MI location, thrombolytic agent or treatment assignment.
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Figure 1 Stratification and randomization scheme showing the number of patients in each treatment arm and number of patients with determination of final infarct size.
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Infarct size.
Table 4 shows the results of the multivariable regression modeling for all patients with known final infarct size, with and without imputation of missing infarct size data. There was a statistically significant treatment benefit with adenosine therapy (p = 0.03). There also was a significant interaction between treatment and MI location (p = 0.03), indicating that the treatment effect was significantly greater in patients with anterior MI. After imputing the missing final infarct sizes, the p value for the treatment effect of adenosine was 0.07.
Final infarct size, myocardium at risk and myocardial salvage index data are shown in Table 5 and Figures 2 and 3. For all patients, there was 33% relative reduction in final infarct size in patients assigned adenosine compared with the placebo group (p = 0.085 by Wilcoxon rank-sum test). Moreover, patients with anterior MI assigned to adenosine had a 67% relative reduction in final infarct size (p = 0.014 by Wilcoxon rank-sum test). There was no reduction in the final infarct size observed in patients with nonanterior MI (p = 0.96 by Wilcoxon rank-sum test). Among the 62 (26%) patients with an acute sestamibi image, the myocardium at risk was similar between treatment groups. There was also a nonsignificant improvement in myocardial salvage index for patients assigned adenosine versus control (0.49 vs. 0.17, p = 0.098 by Wilcoxon rank-sum test). There was a significantly higher myocardial salvage index in the patients with anterior MI assigned adenosine compared with placebo patients (0.62 vs. 0.15, p = 0.015 by Wilcoxon rank-sum test). The effect of adenosine on final infarct size was similar among patients treated with alteplase versus streptokinase and patients with and without lidocaine use.
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Figure 2 Box-and-whisker plots of the final infarct size as a percentage of the left ventricle by treatment group and infarct location. The boxes represent the 25th and 75th interquartile ranges; vertical lines represent the 5th and 95th percentiles. The median values are shown above the horizontal lines.
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Figure 3 Myocardial salvage index = (myocardium at risk – final infarct size)/(final infarct size). See Figure 2 for description of box-and-whisker plots.
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Clinical outcomes and adverse events.
Table 6 shows the secondary end point data for the composite in-hospital end point. There was no significant difference in clinical outcomes between treatment groups, and the overall number of events was small. However, there was a nonsignificant excess of deaths (10 vs. 6), reinfarctions (7 vs. 3), congestive heart failure (13 vs. 8) and cardiogenic shock (6 vs. 4) in the adenosine patients. The composite end point was reached in 22 patients in the adenosine group compared with 16 in the placebo group (odds ratio 1.43, 95% confidence intervals 0.71 to 2.89). There was a tendency toward a greater excess of adverse events with adenosine in the nonanterior MI group.
Additional in-hospital cardiovascular events are shown in Table 7. There was slightly more bradycardia, heart block, hypotension and ventricular arrhythmias in the adenosine patients, especially those with nonanterior MI. There was no observed difference in the number of adverse events by type of thrombolytic therapy or use of lidocaine.
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Discussion
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The principal finding of this study was that a 3-h adenosine infusion resulted in a significant reduction in infarct size determined by SPECT cardiac imaging (p = 0.03 after adjustment for covariates of infarct size). In patients with anterior MI, there was a striking 67% (p = 0.014 by Wilcoxon rank-sum test) reduction in infarct size in patients assigned adenosine therapy versus placebo. No reduction in infarct sizes in patients with nonanterior MI was shown.
Despite the reduction in left ventricular infarct size in the adenosine group, in-hospital clinical outcomes were similar between the two treatment groups. However, there was a tendency toward more adverse clinical events in the patients assigned adenosine compared with placebo although the overall number of events was small.
Previous clinical studies.
In addition to a large amount of experimental evidence to support adenosine as a cardioprotective agent, two small randomized trials have suggested a benefit from adenosine in patients with acute MI or in patients undergoing elective angioplasty. Intracoronary adenosine in patients undergoing primary angioplasty for acute MI was associated with a higher postprocedure Thrombolysis In Myocardial Infarction (TIMI) flow grade (2.18 ± 1.25 vs. 2.7 ± 0.4, p < 0.01), less no-reflow phenomenon (0 patients vs. 6 patients), fewer Q-wave MIs (50% vs. 80%, p = 0.047), and less congestive heart failure (0% vs. 20%, p = 0.035) (28). Intracoronary adenosine during elective angioplasty was associated with significantly fewer ST segment changes, lower chest pain scores and less lactate production (29). The adenosine A1 receptor mediates ischemic preconditioning (16), and adenosine has been shown to reduce the effects of later ischemia both in animal models (16–18) and in human coronary angioplasty (29). However, a study in patients with acute MI treated with primary angioplasty and intravenous adenosine showed no improved myocardial salvage by discharge versus historical controls (27).
Adenosine as a coronary vasodilator.
Adenosine is widely used as a safe pharmacological stress agent for detection of coronary artery disease (31–48). Adenosine may be detrimental in patients with acute coronary occlusion due to coronary steal, bradyarrhythmias and negative inotropic effects. The incidence of bradycardia, hypotension and atrioventricular block were relatively low in the current study but tended to be higher in patients with nonanterior MI, perhaps due to the higher vagal tone in this population. Despite these concerns, patients with acute MI treated with adenosine in this study had a significant reduction in infarct size. Theoretically, more specific targeting of adenosine receptor subtypes could be advantageous in maintaining myocardial protection while limiting potential side effects.
Other reperfusion injury agents.
Clinical trials of other agents that have shown promise in reducing infarct size have been disappointing when studied more rigorously in larger cohorts. Such agents have included prostacyclin (49), fluosol (50), magnesium (51), poloxamer 188 (RheothRx) (52) and trametazidine (53). Of particular importance in RheothRx, which in an early clinical study of 114 patients resulted in improved left ventricular function, reduced infarct size, fewer reinfarctions and no safety concerns (54). The larger Collaborative Organization for RheothRx Evaluation (CORE) trial (52) of over 3,000 patients found a trend towards worse outcome with RheothRx in the composite outcome of death, cardiogenic shock or reinfarction at 35 days (13.6% vs. 12.7%). There was a significant increase in renal dysfunction associated with RheothRx and higher rates of sinus tachycardia, atrial flutter, atrial fibrillation and heart failure.
Infarct location.
Patients were stratified by MI location at enrollment to ensure balance in baseline characteristics known to be strongly related to final infarct size (55). That infarctions were larger among patients with anterior MI was expected to result in a larger absolute reduction in infarct size with adenosine, but the finding of a statistically significant difference in the treatment effect according to MI location was unexpected.
Although the reason for the lack of treatment effect of adenosine in nonanterior MI is unknown, the trend towards more adverse events in this group is consistent with the hypothesis that an adverse effect related to more hypotension, bradycardia or ventricular arrhythmias may reduce the effectiveness of either thrombolysis or adenosine in reducing infarct size. Another possible explanation relates to collateral circulation. Collateral flow is an independent predictor of infarct size, and the impact of collateral flow is greater in patients with anterior MI (56,57). Since one of the proposed mechanisms of adenosine as a cardioprotective agent is through effects on the microvasculature (15), particularly collateral circulation, the lack of observed benefit in nonanterior MI in our study may relate to differences in collateral flow. Finally, the lack of benefit in the patients with nonanterior MI may simply have been due to chance.
The use of final infarct size carries the risk of imbalances in baseline myocardium at risk according to treatment group. Use of myocardial salvage index rather than the final infarct size has the advantage of allowing patients to act as their own controls (to account for heterogeneity in baseline characteristics such as previous MI). This is of particular concern in small trials. In our population, the numbers of patients with prior MI were similar between treatment groups. Although acute images were obtained in only 25% of patients, baseline images showed that myocardium at risk was equal between treatment groups according to MI location. Similarly, if the final infarct size in placebo-treated patients with anterior MI was higher than usual due to chance, this could explain a larger-than-expected apparent treatment effect of adenosine. Compared with other studies of reperfusion therapy, the infarct size in anterior MIs was similar to that observed in the CORE trial (52), which used the same core laboratory and enrolled patients with similar baseline clinical characteristics (S. Yusuf, personal communication, 1999).
Lidocaine.
Lidocaine was included in the study based on findings that adenosine reduced infarct size in a dog model of reperfusion injury only when given in conjunction with lidocaine (23). Moreover, most animal studies of adenosine for reperfusion injury have included lidocaine infusions (15,20–22). Although most patients did receive lidocaine as mandated by the protocol in this study, 26% did not, and there was no difference in the treatment effect of adenosine by lidocaine use. These data suggest that lidocaine need not be given in conjunction with adenosine.
Study limitations.
The relatively small sample size of this study limits the ability to assess the impact of adenosine on clinical outcomes. The 95% confidence intervals are wide and include a 25% increase in the composite clinical end point. Surrogate markers, such as infarct size, are useful for evaluating new therapies but also have limitations (58). Although infarct size might be expected to translate into clinical benefit, the negative results of the CORE trial (52,54) highlight the need for large, randomized trials to adequately assess the treatment effect on clinical outcomes.
This study does not provide insight into the optimal timing and dosing of adenosine. In the study, 50% of patients did not receive the study drug before thrombolytic therapy began. However, 75% of patients began treatment either before or within 5 min after thrombolysis began. To achieve maximum benefits of treatment, the drug theoretically should be started as early as possible but definitely before reperfusion, which typically does not occur immediately after thrombolytic therapy is started.
Patients assigned to adenosine showed a trend toward more adverse events, but the potential impact of a higher or lower dose is unknown. Whether adenosine has a greater or lesser benefit among later-presenting patients also is unknown. Animal models suggest that the benefit of adenosine may be time-dependent. Adenosine reduced infarct size when given (before reperfusion) after coronary occlusion for 40 to 90 min but not after occlusion for 180 min (15,20–22). Alternatively, in humans, prevention of reperfusion injury by adenosine could extend the period during which reperfusion therapy could have a net benefit.
Potential biases are inherent in open-label study designs such as that used in AMISTAD. However, the final infarct size was determined by an independent nuclear core laboratory that was blinded to treatment. As with any study that measures a surrogate end point, missing data also could have biased the results. The 39 patients (17%) who did not have final infarct size determination were unlikely to have biased the results, however, as the treatment effect persisted when these values were imputed.
Conclusions.
Attempts to prevent reperfusion injury in acute MI infarction have been marked by a series of disappointments. However, the reduction of infarct size in this study is encouraging and perhaps relates to the unique ability of adenosine to modify the cellular responses to injury and to participate in ischemic preconditioning. The results of the AMISTAD trial, including the reduction in infarct size in anterior infarctions as well as the lack of an observed trend towards clinical benefit, support the need for a trial designed specifically to assess clinical outcomes.
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Appendix
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The following centers and investigators collaborated in this study: Principal Investigators: Christopher B. Granger, Kenneth W. Mahaffey, Joseph A. Puma, Robert M. Califf. Coordinating Center: Duke Clinical Research Institute, Durham, North Carolina. Consortia: DUCCS; Joseph A. Puma, Galen S. Wagner; Favaloro Foundation: Alejandro Barbagelata, Luis D. Suarez, Graciela Mo, Silvia Galante, Abraham Chownik. Nuclear Core Laboratory: Raymond J. Gibbons, Michael K. O’Connor, Tammy Hudson. ECG Core Laboratory: Galen S. Wagner, Kathy Gates, Stephen Starr. Statisticians: A. Cecilia Casas, Sandra Stinnett. Project Manager: Lindsay R. Lambe. Investigators (number enrolled): J. Puma, D. Small, L. Jones, Galax, Virginia (46); A. Barbagelata, B. Mautner, D. Agranatti, E. Oqueli, Buenos Aires, Argentina (34); M. DiCarli, S. Jerome, S. Korba, Detroit, Michigan (24); S. Ramee, T. Collins, S. Jenkins, M. Prechac, New Orleans, Louisiana (20); M. Fortunato, S. Nusdeo, Buenos Aires, Argentina (18): C. Granger, K. Mahaffey, R. Califf, E. Berrios, C. Martz, P. Gottlieb, K. Quintero, Durham, North Carolina (13): N. Vijay, M. Washam, Denver, Colorado (12); T. Sacchi, R. Pereira, I. Dor, A. Major, Brooklyn, New York (11); M. Leesar, R. Bolli, T. Shahab, J. Lanter, Louisville, Kentucky (11): L. Simkins, R. Schneider, L. Orihuela, M. McLaughlin, W. Schneider, Margate, Florida (10); H. Iparraguirre, H. Grancelli, M. Rodriguez, Buenos Aires, Argentina (10); K. Browne, M. Roy, Lakeland, Florida (8); S. Hegde, J. Tallet, F. Pitman, Lumberton, North Carolina (5); P. Eisenberg, R. Gropler, J. Faszholz, St. Louis, Missouri (4); G. Lane, K. Doucette, Jacksonville, Florida (3); A. Riba, S. Dabbous, C. Draus, Dearborn, Michigan (2); V. Pearson, J. Sherman, W. Pitts, Rome, Georgia (2); P. Cohen, J. Imrie, K. Woo, R. Moore, Vancouver, British Columbia (2); R. Valentine, D. Brindley, S. Scott, Indianapolis, Indiana (1); R. Taillefer, A. Gagnon, Montreal, Quebec, Canada (0); D. Vorchheimer, M. Henzlova, I. Guzman, New York, New York (0); G. Heller, F. Kiernan, D. Fram, A. Ahlberg, Hartford, Connecticut (0); R. Jesse, C. Roberts, Richmond, Virginia (0); V. Lowe, M. Wittry, J. Fletcher, S. Purnell, St. Louis, Missouri (0); S. Stowers, T. Hilton, T. Abuan, Jacksonville, Florida (0). Sponsors: Medco Research, Inc. and Fujisawa USA, Inc.
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Acknowledgments
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The authors want to thank John Daniel for his expert editorial assistance and help with manuscript preparation.
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Footnotes
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This study was supported by Medco Research, Inc. (Research Triangle Park, North Carolina) and Fujisawa USA, Inc. (Deerfield, Illinois).
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Reduction of "no-reflow" phenomenon by intra-aortic balloon counterpulsation in a randomized magnetic resonance imaging experimental study
J. Am. Coll. Cardiol.,
April 7, 2004;
43(7):
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[Abstract]
[Full Text]
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J. Pernow, F. Bohm, E. Beltran, and A. Gonon
L-Arginine protects from ischemia-reperfusion-induced endothelial dysfunction in humans in vivo
J Appl Physiol,
December 1, 2003;
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[Abstract]
[Full Text]
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W. R. Tracey, W. P. Magee, J. J. Oleynek, R. J. Hill, A. H. Smith, D. M. Flynn, and D. R. Knight
Novel N6-substituted adenosine 5'-N-methyluronamides with high selectivity for human adenosine A3 receptors reduce ischemic myocardial injury
Am J Physiol Heart Circ Physiol,
December 1, 2003;
285(6):
H2780 - H2787.
[Abstract]
[Full Text]
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J. A. Auchampach, Z.-D. Ge, T. C. Wan, J. Moore, and G. J. Gross
A3 adenosine receptor agonist IB-MECA reduces myocardial ischemia-reperfusion injury in dogs
Am J Physiol Heart Circ Physiol,
July 11, 2003;
285(2):
H607 - H613.
[Abstract]
[Full Text]
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J. Vinten-Johansen, Z.-Q. Zhao, J. S. Corvera, C. D. Morris, J. M. Budde, V. H. Thourani, and R. A. Guyton
Adenosine in myocardial protection in on-pump and off-pump cardiac surgery
Ann. Thorac. Surg.,
February 1, 2003;
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[Abstract]
[Full Text]
[PDF]
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S. R. Dixon, R. J. Whitbourn, M. W. Dae, E. Grube, W. Sherman, G. L. Schaer, J. S. Jenkins, D. S. Baim, R. J. Gibbons, R. E. Kuntz, et al.
Induction of mild systemic hypothermia with endovascular cooling during primary percutaneous coronary intervention for acute myocardial infarction
J. Am. Coll. Cardiol.,
December 4, 2002;
40(11):
1928 - 1934.
[Abstract]
[Full Text]
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D. P. Faxon, R. J. Gibbons, N. A. F. Chronos, P. A. Gurbel, F. Sheehan, and HALT-MI Investigators
The effect of blockade of the CD11/CD18 integrin receptor on infarct size in patients with acute myocardial infarction treated with direct angioplasty: the results of the HALT-MI study
J. Am. Coll. Cardiol.,
October 2, 2002;
40(7):
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[Abstract]
[Full Text]
[PDF]
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H. R. Cross, E. Murphy, R. G. Black, J. Auchampach, and C. Steenbergen
Overexpression of A3 adenosine receptors decreases heart rate, preserves energetics, and protects ischemic hearts
Am J Physiol Heart Circ Physiol,
October 1, 2002;
283(4):
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[Abstract]
[Full Text]
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C.-K. Wong, J.K. French, M.W. Krucoff, W. Gao, P.E. Aylward, and H.D. White
Slowed ST segment recovery despite early infarct artery patency in patients with Q waves at presentation with a first acute myocardial infarction. Implications of initial Q waves on myocyte reperfusion
Eur. Heart J.,
September 2, 2002;
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[Abstract]
[Full Text]
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R. M Fryer, J. A Auchampach, and G. J Gross
Therapeutic receptor targets of ischemic preconditioning
Cardiovasc Res,
August 15, 2002;
55(3):
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[Abstract]
[Full Text]
[PDF]
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N. J. Goswami, J. M. Moody Jr, and S. R. Bailey
Percutaneous Mechanical Reperfusion During Acute Myocardial Infarction
J Intensive Care Med,
July 1, 2002;
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[Abstract]
[PDF]
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A. J Flood, L. Willems, and J. P Headrick
Coronary function and adenosine receptor-mediated responses in ischemic-reperfused mouse heart
Cardiovasc Res,
July 1, 2002;
55(1):
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[Abstract]
[Full Text]
[PDF]
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S. C. Smith Jr, D. Faxon, W. Cascio, H. Schaff, T. Gardner, A. Jacobs, S. Nissen, and R. Stouffer
Prevention Conference VI: Diabetes and Cardiovascular Disease: Writing Group VI: Revascularization in Diabetic Patients
Circulation,
May 7, 2002;
105
(18):
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[Full Text]
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A D Kelion, T P Webb, M A Gardner, O J M Ormerod, G L Shepherd, and A P Banning
Does a selective adenosine A1 receptor agonist protect against exercise induced ischaemia in patients with coronary artery disease?
Heart,
February 1, 2002;
87(2):
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[Abstract]
[Full Text]
[PDF]
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B. G. Angeja, M. Gunda, S. A. Murphy, B. E. Sobel, A. C. Rundle, M. Syed, A. Asfour, S. Borzak, S. G. Gourlay, H. V. Barron, et al.
TIMI Myocardial Perfusion Grade and ST Segment Resolution: Association With Infarct Size as Assessed by Single Photon Emission Computed Tomography Imaging
Circulation,
January 22, 2002;
105(3):
282 - 285.
[Abstract]
[Full Text]
[PDF]
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J. A. Barrabes, D. Garcia-Dorado, M. Mirabet, R.-M. Lidon, B. Soriano, M. Ruiz-Meana, P. Pizcueta, J. Blanco, Y. Puigfel, and J. Soler-Soler
Lack of effect of glycoprotein IIb/IIIa blockade on myocardial platelet or polymorphonuclear leukocyte accumulation and on infarct size after transient coronary occlusion in pigs
J. Am. Coll. Cardiol.,
January 2, 2002;
39(1):
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[Abstract]
[Full Text]
[PDF]
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V. Stangl, G. Baumann, K. Stangl, and S. B Felix
Negative inotropic mediators released from the heart after myocardial ischaemia-reperfusion
Cardiovasc Res,
January 1, 2002;
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[Abstract]
[Full Text]
[PDF]
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R. A. Kloner and R. B. Jennings
Consequences of Brief Ischemia: Stunning, Preconditioning, and Their Clinical Implications: Part 2
Circulation,
December 18, 2001;
104(25):
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[Abstract]
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[PDF]
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I. B. A. Menown and A. A. J. Adgey
Cardioprotective therapy and sodium-hydrogen exchange inhibition: current concepts and future goals
J. Am. Coll. Cardiol.,
November 15, 2001;
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K. Mubagwa and W. Flameng
Adenosine, adenosine receptors and myocardial protection: An updated overview
Cardiovasc Res,
October 1, 2001;
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[Abstract]
[Full Text]
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R. T. Smolenski, O. Raisky, E. M. Slominska, H. Abunasra, K. K. Kalsi, J. Jayakumar, K. Suzuki, and M. H. Yacoub
Protection From Reperfusion Injury After Cardiac Transplantation by Inhibition of Adenosine Metabolism and Nucleotide Precursor Supply
Circulation,
September 18, 2001;
104
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I-246 - I-252.
[Abstract]
[Full Text]
[PDF]
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G. A. Beller
Coronary Heart Disease in the First 30 Years of the 21st Century: Challenges and Opportunities : The 33rd Annual James B. Herrick Lecture of the Council on Clinical Cardiology of the American Heart Association
Circulation,
May 22, 2001;
103(20):
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C.H. Davies
Revascularization for cardiogenic shock
QJM,
February 1, 2001;
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[Full Text]
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F L. Pasini, P. Capecchi, and T Di Perri
Adenosine and chronic ischemia of the lower limbs
Vascular Medicine,
November 1, 2000;
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243 - 250.
[Abstract]
[PDF]
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J. L. Anderson, J. Habashi, J. F. Carlquist, J. B. Muhlestein, B. D. Horne, T. L. Bair, R. R. Pearson, and N. Hart
A common variant of the AMPD1 gene predicts improved cardiovascular survival in patients with coronary artery disease
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October 1, 2000;
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[Abstract]
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D M Yellon and G F Baxter
Protecting the ischaemic and reperfused myocardium in acute myocardial infarction: distant dream or near reality?
Heart,
April 1, 2000;
83(4):
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[Full Text]
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M. B. Forman, J. V. Vitola, C. E. Velasco, J. J. Murray, R. K. Dubey, and E. K. Jackson
Sustained Reduction in Myocardial Reperfusion Injury with an Adenosine Receptor Antagonist: Possible Role of the Neutrophil Chemoattractant Response
J. Pharmacol. Exp. Ther.,
March 1, 2000;
292(3):
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[Abstract]
[Full Text]
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Adenosine Is Cardioprotective
Journal Watch Cardiology,
February 18, 2000;
2000(218):
8 - 8.
[Full Text]
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