Acute Coronary Syndromes Clinical Management Update ...medicaltrends.org/PDF/LR Brochure ACS.pdf ·...

Acute Coronary SyndromesClinical ManagementUpdate & Future Trends

Editors-in-chief:� Anthony N. DeMaria, MD, MACC� Christopher P. Cannon, MD, FACC

2011 Edition

Clinical CardiologySeries

Medical Trends

Brochure ACC Acute Coronary:Maquetación 1 23/07/10 18:08 Página 2

We welcome you to Acute Coronary Syndromes:Clinical Management Update and FutureTrends, a program belonging to the ACC ClinicalCardiology Series.

In this work, we have endeavored to bring you athorough but manageable compilation on AcuteCoronary Syndromes, a subject which hascommanded rapidly growing attention in recentyears.

The substantial volume of information appearingevery year online, in medical literature and themajor congresses is a major drawback that keepsmost busy clinicians from being updated on allthe new data and evaluating the real importanceof each new piece of evidence and information.

In this sense, the Clinical Cardiology Series hasbeen developed with individual programs that summarize, among the most recently publishedclinical information, that knowledge that theclinicians must know in order to be aware of themost recent advances in the pathology. Theselection of this information has been trusted to amajor expert assigned by the American College ofCardiology, and the major weight of the contentsconsists of official information generated by theACC, with a warranty for scientific rigour andtranscendence.

We have divided the content into three volumes,covering burden of disease and risk assessmentfirst, then diagnostic aspects, and finallytherapeutic approaches, both lifestyle andpharmacologic.

Each of these three sections will commence with an overview of the current state of knowledge drawn from primary publications by recognized leading experts in the field. They include the text of the most pertinent reviewarticles on these subjects, a more extensive bibliography of other important articles, and a thorough presentation of practice guidelines and other cornerstones of evidence, which would logically influence a practitioner’s approach to patients.

In putting these volumes together, we have tried to prepare the materials in a fashion that willallow you to encompass the current state ofknowledge in this important subject at a pace andin an order that fits most appropriately with thebusy clinician’s schedule and preferred manner oflearning.

The print version of each program issupplemented by an online version. Every reader will be provided with an access password to the site, where all the coreinformation of the program will be included,plus constantly updated editorials, reviews,articles, video presentations, clinical cases, andmore, all in a very selective and periodical manner,guided by a well-reputed expert in the clinicalarea.

We hope you find ACC’s Acute CoronarySyndromes: Clinical Management Update andFuture Trends a useful tool in providing you withthe best current thinking to help manage yourpatients successfully.

Editors’ Note


Clinical Cardiology SeriesAcute Coronary SyndromesClinical Management Update and Future Trends

© American College of Cardiology Foundation

This program has been designed and developed by Medical Trends under permission and supervision of the American College of Cardiology Foundation.

Edited by Medical Trends

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted -in any form, electronicor mechanical- photocopied, recorded or otherwise, without the prior written permission of the copyright owner.

Editors-in-chief:Anthony N. DeMaria, MD, MACCChristopher P. Cannon, MD, FACC

The contents of this program may include information regarding the use of products that may be inconsistent with or outside the FDA approved labeling for these products in the United States. Physiciansshould note that the use of these products outside current approved labeling is considered experimentaland they are advised to consult the prescribing information for these products.


�� Clinical Management Update

and Future Trends

��

Epidemiology,Pathophysiology,

Diagnosis, and Risk Stratification

��

Non ST-SegmentElevation Acute

Coronary Syndromes

��

ST-SegmentElevation Acute

Myocardial Infarction

�� Clinical ManagementUpdate & Future TrendsST-Segment Elevation AcuteMyocardial Infarction


2011 Edition

Medical Trends

�� Clinical ManagementUpdate & Future TrendsNon ST-Segment ElevationAcute Coronary Syndromes


2011 Edition

Medical Trends

�� Clinical ManagementUpdate & Future TrendsEpidemiology, Pathophysiology,Diagnosis, and Risk Stratification


2011 Edition

Medical Trends


Contents

� Peter Libby, MD, FACC

Pathophysiology of Plaque Rupture/Erosion

Recent clinical and basic investigations have transformed our concepts of the pathogenesis of theacute coronary syndromes (ACS). Until the past few years, a hydraulic or hemodynamic approachdominated our thinking about the mechanisms of unstable angina or acute myocardial infarction(AMI). Currently, the role of thrombosis as the critical factor in arterial occlusion has reassumedprimacy as the predominant mechanism of the transition from chronic stable to acute coronaryischemia.

� Christopher P. Cannon, MD, FACC, and Amit Kumar, MD

Unstable Angina: Clinical Presentation and Risk Stratification

Unstable angina is a condition at the center of the spectrum of myocardial ischemia. These rangefrom chronic stable angina to acute ST-segment elevation myocardial infarction (STEMI). Amongpatients who present with ischemic symptoms, without ST elevation, depending on the durationand severity of ischemia, myocardial necrosis occurs, and the patient is classified as having an nonST-segment elevation myocardial infarction (NSTEMI). Because the pathophysiology of UA is similarto that of NSTEMI, they are considered together.

� David A. Morrow, MD, MPH, FACC

Biomarkers

Cardiac biomarkers are noninvasive indicators that may be used to assist in the diagnosis, riskstratification, and management of patients with suspected CVD. Ongoing research continues torapidly expand available data regarding new cardiac markers, as well as new assays and uses forestablished markers. Optimal clinical use of these markers requires selection based on the specificadvantages and disadvantages of each marker, and details of the individual clinical presentation.

� Jeffrey L. Anderson, MD, FACC, FAHA; Cynthia D. Adams, RN, PhD, FAHA;

Elliott M. Antman, MD, FACC, FAHA, et al.

ACC/AHA 2007 Guidelines for the Management of Patients With UnstableAngina/Non–ST-Elevation Myocardial Infarction

- Overview of the acute coronary syndromes - Management before UA/NSTEMI and onset of UA/NSTEMI - Onset of UA/NSTEMI - Clinical assessment - Early risk stratification

Epidemiology, Pathophysiology,Diagnosis, and Risk Stratification1


� Peter Libby, MD; Paul M. Ridker, MD, MPH; Göran K. Hansson, MD, PhD, for the Leducq Transatlantic Network

on Atherothrombosis

Inflammation in Atherosclerosis. From Pathophysiology to Practice

Until recently, most envisaged atherosclerosis as a bland arterial collection of cholesterol, complicatedby smooth muscle cell accumulation. Multiple independent pathways of evidence now pinpointinflammation as a key regulatory process that links multiple risk factors for atherosclerosis and itscomplications with altered arterial biology. This review provides an update of the role of inflammationin atherogenesis and highlights how translation of these advances in basic science promises to changeclinical practice.

� Marc P. Bonaca, MD; Philippe Gabriel Steg, MD; Laurent J. Feldman, MD, et al.

Antithrombotics in Acute Coronary Syndromes

Antithrombotic agents are an integral component of the medical regimens and interventionalstrategies currently recommended to reduce thrombotic complications in patients with acutecoronary syndromes (ACS). During the last several years a number of new antithrombotictreatments have been introduced, and new data regarding established therapies have come to light. In this work we review recent data regarding clinically available antiplatelet andanticoagulation agents used in the treatment of patients with ACS.

� Kai M. Eggers, MD, PhD; Bo Lagerqvist, MD, PHD; Per Venge, MD, PHD, et al.

Prognostic Value of Biomarkers During and After Non–ST-Segment Elevation AcuteCoronary Syndrome

Different biomarkers reflect different aspects of the pathobiology in non–ST-segment elevation acutecoronary syndrome (NSTE-ACS). However, there is little information regarding their relative prognosticvalue during the time course of disease. The aim of this study was to assess risk prediction by differentbiomarkers in patients with an ongoing NSTE-ACS and after clinical stabilization.

� Roxana Mehran, MD; Stuart J. Pocock, PhD; Eugenia Nikolsky, MD, PhD, et al.

A Risk Score to Predict Bleeding in Patients With Acute Coronary Syndromes

Hemorrhagic complications have been strongly linked with subsequent mortality in patients with acutecoronary syndromes. The aim of this study was to develop a practical risk score to predict the risk andimplications of major bleeding in acute coronary syndromes.

� Adam N. Mather, MBBS; Timothy A. Fairbairn, MBChB; Nigel J. Artis, MBChB, et al.

Diagnostic Value of CMR in Patients With Biomarker-Positive Acute Chest Pain andUnobstructed Coronary Arteries

Cardiac magnetic resonance (CMR) imaging has the unique ability to characterize variouspathophysiological effects of acute myocardial injury. In this article, we present 6 cases whichdemonstrate the diagnostic value of multiparametric CMR assessment in the differential diagnosisof ischemic symptoms with raised biomarkers but unobstructed coronary arteries.

Acute Coronary Syndromes


Epidemiology, Pathophysiology, Diagnosis, and Risk Stratification

� Sunil V. Rao, MD; Mauricio G. Cohen, MD; David E. Kandzari, MD, et al.

The Transradial Approach to Percutaneous Coronary Intervention. HistoricalPerspective, Current Concepts, and Future Directions

Periprocedural bleeding complications after percutaneous coronary intervention (PCI) areassociated with increased short- and long-term morbidity and mortality. Although clinical trialshave primarily assessed pharmacological strategies for reducing bleeding risk, there is a mountingbody of evidence suggesting that adoption of a transradial rather than a transfemoral approach toPCI may permit greater reductions in bleeding risk than have been achieved with pharmacologicalstrategies alone. In this review, we examine the history of the transradial approach to PCI anddiscuss some of the circumstances that have hitherto limited its appeal.

� David D. Waters, MD, and Ivy Ku, MD

Early Statin Therapy in Acute Coronary Syndromes. The Successful Cycle of Evidence,Guidelines, and Implementation

That statins should be prescribed for patients before hospital discharge after an episode of acutecoronary syndrome (ACS) is a Level of Evidence: 1A recommendation of the ACC/AHA Joint TaskForce. This level of recommendation is based upon 2 clinical trials: the MIRACL and PROVE-IT trials.Comprehensive treatment programs in ACS patients that include initiation of statins beforehospital discharge have been shown to improve outcomes such as recurrent myocardial infarctionand total mortality at 1 year. Guidelines prove their utility when their implementation improvesoutcomes across a broad population at risk, such as in this instance.

� Richard O. Cannon, III, MD

Microvascular Angina and the Continuing Dilemma of Chest Pain With NormalCoronary Angiograms

Since initial reports over 4 decades ago, cases of patients with angina-like chest pain whosecoronary angiograms show no evidence of obstructive coronary artery disease and who have nostructural heart disease continue to be a common occurrence for cardiologists. Abnormalities incoronary flow and metabolic responses to stress have been reported by several groups, findingsconsistent with a microvascular etiology for ischemia and symptoms, but others have questionedthe presence of ischemia, even in patients selected for abnormal noninvasive testing. Despiteconsiderable efforts by many groups over 4 decades, the syndrome remains controversial withregard to pathophysiology, diagnosis, and management.

� Antonio Ceriello, MD; Stuart W. Zarich, MD, and Roberto Testa, MD

Lowering Glucose to Prevent Adverse Cardiovascular Outcomes in a Critical CareSetting

High admission blood glucose levels after acute myocardial infarction are common and associatedwith an increased risk of death in patients with or without diabetes. Hyperglycemia is associatedwith altered myocardial blood flow and energetics and can lead to a pro-oxidative/proinflammatorystate. The use of intensive insulin treatment has shown superior benefits in the treatment ofhyperglycemia versus glucose-insulin-potassium infusion, particularly in critical care settings.


INFLUENTIAL PAPERSSelected abstracts from highly relevant publications

LANDMARK CLINICAL TRIALSTrial results that have highly influenced scientific knowledge and practice

A prospective, multicenter, randomized trial to assess efficacy of pioglitazone on in-stent neointimal suppression in type 2 diabetes: POPPS (Prevention of In-StentNeointimal Proliferation by Pioglitazone Study)

Effect of irbesartan and enalapril in non-ST elevation acute coronary syndrome:results of the randomized, double-blind ARCHIPELAGO study

Efficacy of high-dose atorvastatin loading before primary percutaneous coronaryintervention in ST-segment elevation myocardial infarction: The STATIN STEMI trial

Prognostic value of mid-regional pro-adrenomedullin levels taken on admission anddischarge in non–ST-elevation myocardial infarction: The LAMP (Leicester AcuteMyocardial Infarction Peptide) II study



� Jeffrey L. Anderson, MD, FACC, FAHA; Cynthia D. Adams, RN, PhD, FAHA;

Elliott M. Antman, MD, FACC, FAHA, et al.

ACC/AHA 2007 Guidelines for the Management of Patients With UnstableAngina/Non–ST-Elevation Myocardial Infarction

- Anti-ischemic and analgesic therapy - Recommendations for antiplatelet/anticoagulant therapy in patients for whom diagnosis of UA/NSTEMI is likely or definite - Initial conservative versus initial invasive strategies - Coronary Revascularization

� Frederick G. Kushner, MD, FACC, FAHA, FSCAI; Mary Hand, MSPH, RN, FAHA;

Sidney C. Smith, Jr, MD, FACC, FAHA, et al.

2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 FocusedUpdate) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention(Updating the 2005 Guideline and 2007 Focused Update)

- Recommendations for the timing of angiography and antiplatelet therapy in UA/NSTEMI


Unstable Angina: Treatment Strategies

Two general approaches to the use of cardiac catheterization and revascularization in unstableangina/non-ST-elevation myocardial infarction (UA/NSTEMI) exist: an “initial” or “early” invasivestrategy, now known simply as the “invasive” strategy involving routine cardiac catheterization,and revascularization with PCI or CABG, depending on the coronary anatomy. Alternatively, a“conservative” approach can be undertaken, with initial medical management with catheterizationand revascularization carried out only if the patient demonstrates recurrent ischemia either at restor on a noninvasive stress test. The latter has also been termed an "ischemia-guided" or “selectiveinvasive” strategy.

Contents

Non ST-Segment Elevation Acute Coronary Syndromes 2



Unstable Angina: Medical Therapy

The objectives of medical treatment for patients with unstable angina/non-ST-elevation myocardialinfarction (UA/NSTEMI) are focused on stabilizing and "passivating" the acute coronary lesion,treatment of residual ischemia, and long-term secondary prevention. Antithrombotic therapy isused to prevent further thrombosis and allow endogenous fibrinolysis to dissolve the thrombus andreduce the degree of coronary stenosis. Long-term antithrombotic therapy is used to reduce therisk of developing future events and/or to prevent progression to complete occlusion of thecoronary artery. Anti-ischemic therapies are used primarily to reduce myocardial oxygen demand.

� Robert P. Giugliano, MD, SM, FACC, and Eugene Braunwald, MD, MACC

The Year in Non–ST-Segment Elevation Acute Coronary Syndrome

Acute coronary syndromes (ACS) account for approximately 1.6 million annual inpatient hospital discharges in the U.S. Approximately 80% of these are due to non–ST-segment elevations ACS (NSTE-ACS). In this year's review, we highlight publications and presentations between May 2006 and April 2007 in 6 areas: risk assessment, antithrombotic therapy, anti-ischemic therapy,percutaneous coronary intervention (PCI), lipid management, and selected patient subgroups.

� Nihar R. Desai, MD, MPH, and Deepak L. Bhatt, MD, MPH

The State of Periprocedural Antiplatelet Therapy After Recent Trials

The ability to mechanically dilate and treat stenoses in the coronary arteries opened a new chapterin cardiovascular medicine. Percutaneous coronary intervention (PCI) has been shown to improveoutcomes among patients with acute coronary syndromes as well as improve symptoms amongpatients with stable coronary artery disease. Adjunctive antiplatelet therapy plays a critical roleboth in the periprocedural setting as well as in the long-term management of atherothrombosis.Over the past several years, clinical trials of novel compounds and treatment strategies have further refined our pharmacotherapeutic approach.

� José Tuñón, MD; José Luis Martín-Ventura, PhD; Luis Miguel Blanco-Colio, PhD, et al.

Proteomic Strategies in the Search of New Biomarkers in Atherothrombosis

Extensive research has focused on the identification of novel plasma biomarkers to improve our abilityto predict cardiovascular events in atherothrombosis. In this article, we review several proteomic strategies carried out by our group and others, and we make a call for collaboration between cliniciansand experts in proteomics. This collaboration could greatly increase the likelihood of identifying newprognostic biomarker panels in atherothrombosis and other cardiovascular disorders.

� Manabu Kashiwagi, MD; Atsushi Tanaka, MD; Hironori Kitabata, MD, et al.

Feasibility of Noninvasive Assessment of Thin-Cap Fibroatheroma by MultidetectorComputed Tomography

Plaque rupture and thrombus formation play key roles in the onset of acute coronary syndrome.Thin-cap fibroatheroma (TCFA) is recognized as a precursor lesion for plaque rupture, andmultidetector computed tomography (MDCT) angiography can potentially help identify plaquesprone to rupture. The purpose of this study was to investigate whether MDCT can noninvasivelyhelp assess TCFA.



Non ST-Segment Elevation Acute Coronary Syndromes

� Eugenia Nikolsky, MD, PhD; Gregg W. Stone, MD; Ajay J. Kirtane, MD, SM, et al.

Gastrointestinal Bleeding in Patients With Acute Coronary Syndromes: Incidence,Predictors, and Clinical Implications. Analysis From the ACUITY (Acute Catheterizationand Urgent Intervention Triage Strategy) Trial

Gastrointestinal bleeding (GIB) is a potential hemorrhagic complication in patients with acutecoronary syndromes (ACS) treated with antithrombotic and/or antiplatelet medications. The clinicaloutcomes associated with GIB in this setting have not been systematically studied. We assessed theincidence, predictors, and outcomes of GIB in patients with ACS.

� Marc S. Sabatine, MD; Elliott M. Antman, MD; Petr Widimsky, MD, et al.

Otamixaban for the Treatment of Patients With Non-ST-elevation Acute CoronarySyndromes (SEPIA-ACS1 TIMI 42): a randomised, double-blind, active-controlled, phase 2 trial

Otamixaban is an intravenous direct factor Xa inhibitor. We aimed to assess its efficacy and safetyin non-ST-elevation acute coronary syndromes and to identify the optimum dose range for furtherassessment in a phase 3 study.



Early versus delayed invasive intervention in acute coronary syndromes

Early versus delayed, provisional eptifibatide in acute coronary syndromes

Intravenous platelet blockade with cangrelor during PCI

Ticagrelor versus clopidogrel in patients with acute coronary syndromes

A first-in-man, randomized, placebo-controlled study to evaluate the safety andfeasibility of autologous delipidated high-density lipoprotein plasma infusions inpatients with acute coronary syndrome

Antithrombotic strategy in non–ST-segment elevation myocardial infarction patientsundergoing percutaneous coronary intervention: insights from the ACTION (AcuteCoronary Treatment and Intervention Outcomes Network) Registry

Impact of delay to angioplasty in patients with acute coronary syndromes undergoinginvasive management: analysis from the ACUITY (Acute Catheterization and UrgentIntervention Triage strategY) trial

5-Year Clinical Outcomes in the ICTUS (Invasive versus Conservative Treatment inUnstable coronary Syndromes) Trial: A randomized comparison of an early invasiveversus selective invasive management in patients with non–ST-segment elevationacute coronary syndrome


Reduction in recurrent cardiovascular events with intensive lipid-lowering statintherapy compared with moderate lipid-lowering statin therapy after acute coronarysyndromes: from the PROVE IT–TIMI 22 (Pravastatin or Atorvastatin Evaluation andInfection Therapy–Thrombolysis In Myocardial Infarction 22) trial

The efficacy and safety of prasugrel with and without a glycoprotein IIb/IIIa inhibitorin patients with acute coronary syndromes undergoing percutaneous intervention: aTRITON–TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by OptimizingPlatelet Inhibition With Prasugrel–Thrombolysis In Myocardial Infarction 38) analysis

Efficacy and safety of fondaparinux versus enoxaparin in patients with acute coronarysyndromes treated with glycoprotein IIb/IIIa inhibitors or thienopyridines: results fromthe OASIS 5 (Fifth Organization to Assess Strategies in Ischemic Syndromes) trial

Effect of intensive statin therapy on regression of coronary atherosclerosis in patientswith acute coronary syndrome: a multicenter randomized trial evaluated byvolumetric intravascular ultrasound using pitavastatin versus atorvastatin (JAPAN-ACS[Japan Assessment of Pitavastatin and Atorvastatin in Acute Coronary Syndrome]Study)



� Elliott M. Antman, MD, FACC, FAHA; Mary Hand, MSPH, RN, FAHA; Paul W. Armstrong, MD, FACC, FAHA, et al.

Focused Update of the ACC/AHA 2004 Guidelines for the Management of PatientsWith ST-Elevation Myocardial Infarction

Late-breaking clinical trials presented at the 2005 and 2006 annual scientific meetings of the ACC,AHA, and European Society of Cardiology, as well as selected otherdata, were reviewed by the standing guideline writing committee along with the parent Task Force and other experts to identifythose trials and other key data that might impact guidelines recommendations. On the basis ofthe criteria/considerations noted above, recent trial data and other clinical information were considered important enough to prompt a focused update of the 2004 ACC/AHA Guidelines for the Managementof Patients With ST-Elevation Myocardial Infarction.

� Frederick G. Kushner, MD, FACC, FAHA, FSCAI; Mary Hand, MSPH, RN, FAHA;

Sidney C. Smith, Jr, MD, FACC, FAHA, et al.

2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 FocusedUpdate) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention(Updating the 2005 Guideline and 2007 Focused Update).

- Recommendations for the use of glycoprotein IIb/IIIa receptor antagonists - Recommendations for the use of thienopyridines - Recommendations for the use of parenteral anticoagulants - Recommendations for triage and transfer for PCI - Recommendations for intensive glucose control in STEMI - Recommendation for thrombus aspiration during PCI for STEMI - Recommendations for the use of stents in STEMI

� Henry H. Ting, MD, FACC

ST-Elevation Myocardial Infarction: Initial Assessment and Therapy

In the United States, an estimated 600,000 patients will experience new myocardial infaction (MI), and 320,000 patients will have recurrent MIs every year. This module will focus on the rationale andstrategy for early assessment and risk stratification, factors contributing to delays in reperfusion therapy, gaps in the quality of reperfusion therapy, and how to select the optimal reperfusion regimenfor patients with ST elevation MI (STEMI).

Contents

ST-Segment Elevation Acute Myocardial Infarction 3


� Ellen Keeley, MD, MS

Primary PCI for STEMI

Primary percutaneous coronary intervention (PCI) is the reperfusion therapy of choice for patients whopresent with ST elevation MI (STEMI), provided it is performed quickly by experienced operators in high-volume centers. This module will: 1) review data from the randomized controlled trials of primaryPCI versus fibrinolytic therapy, and studies of adjunctive pharmacologic agents and devices; 2) differentiate the types of PCI performed in the setting of STEMI; and 3) provide an algorithm to helpthe reader determine the optimal reperfusion strategy according to specific clinical scenarios.

� John J. Warner, MD, FACC

Acute Myocardial Infarction: Fibrinolytic Regimens

Despite the growing emphasis on percutaneous coronary intervention (PCI), pharmacologic reperfusionremains an important therapy for patients experiencing an acute myocardial infarction (AMI). Manyhospital systems do not have cardiac catheterization laboratories, round-the-clock access to experi-enced interventional cardiologists, or the capability of routinely achieving a door-to-balloon time of < 90 minutes. Because time to reperfusion is critical in reducing mortality and morbidity, fibrinolyticagents should be administered within 30 minutes of arrival of a patient to the hospital. In order toachieve this system goal, and because the hemorrhagic complications of fibrinolytic therapy can be dev-astating, a rapid diagnosis of AMI and assessment of bleeding risk is important.

� Richard G. Bach, MD, FACC

Adjunctive Medical Therapy After MI

In the acute and convalescent phases of ST elevation myocardial infarction (STEMI), adjunctive medicaltherapy can have a powerful influence on short- and long term-outcome. Those adjunctive therapiesare directed primarily at reducing the risk of death, recurrent angina and infarction, and congestiveheart failure (CHF) by reducing ischemia, reducing the likelihood of arrhythmia, reducing adverse ventricular remodeling, and reducing the progression of atherosclerosis.

� Benjamin M. Scirica, MD, MPH, FACC

Acute Myocardial Infarction: Risk Assessment

The risk of death and major nonfatal complications following ST elevation myocardial infarction (STEMI)can vary many-fold depending on age, comorbidities, the timing and size of the infarct, and reperfusion strategy. Early identification, assessment, and risk stratification are the first steps in treatingpatients with STEMI to help manage their optimal therapy. This module will review several modalitiesused in risk-stratifying patients with STEMI: 1) ST-segment resolution or persistent elevation on the 12-lead ECG, 2) biomarkers, 3) clinical risk scores, and 4) noninvasive imaging.

� Emmanouil S. Brilakis, MD, PhD, FACC, and Subhash Banerjee, MD, FACC

Mechanical Complications of Myocardial Infarction on Carotid Stenting

Three major mechanical complications can occur after an acute myocardial infarction (AMI): 1) free wallrupture, 2) rupture of the interventricular septum, and 3) severe mitral regurgitation (which can be dueto papillary muscle rupture or due to other causes). RV infarction can also have severe hemodynamicconsequences, and will be discussed in this module. These complications are the result of myocardialnecrosis, dysfunction, and possible rupture at the area of infarction, and can all lead to cardiogenicshock, which is discussed separately.



ST-Segment Elevation Acute Myocardial Infarction

� Somjot S. Brar, MD; Martin B. Leon, MD; Gregg W. Stone, MD, et al.

Use of Drug-Eluting Stents in Acute Myocardial Infarction: A Systematic Review and Meta-Analysis

It is not known whether there are differences in outcomes between drug-eluting stents (DES) and bare-metal stents (BMS) for ST-segment elevation myocardial infarction (STEMI). The primary aim of theanalysis was to compare outcomes by stent type for death, myocardial infarction (MI), target vesselrevascularization (TVR), and stent thrombosis in randomized trials of STEMI. A secondary analysis wasperformed among registry studies.

� Marc Cohen, MD; Catalin Boiangiu, MD, and Mateen Abidi, MD

Therapy for ST-Segment Elevation Myocardial Infarction Patients Who Present Late or Are Ineligible for Reperfusion Therapy

Despite the wide contemporary availability of pharmacological and mechanical means of reperfusion,a very significant proportion of ST-segment elevation myocardial infarction (STEMI) patients are stillnot offered any reperfusion therapy, and some of them are considered "ineligible for reperfusion."Spontaneous reperfusion and contraindications to the use of fibrinolytics and/or mechanical reperfusion methods account only for a small part of these clinical situations.

� Ian S. Rogers, MD, MPH; Khurram Nasir, MD, MPH; Amparo L. Figueroa, MD, et al.

Feasibility of FDG Imaging of the Coronary Arteries. Comparison Between AcuteCoronary Syndrome and Stable Angina

Inflammation is known to play an important role in atherosclerosis. Positron emission tomography imaging with 18F-FDG provides a measure of plaque inflammation. This study tested the hypothesis that fluorodeoxyglucose (FDG) uptake within the ascending aorta and left main coronary artery (LM),measured using positron emission tomography (PET), is greater in patients with recent acute coronarysyndrome (ACS) than in patients with stable angina.

� Robert S. Schwartz, MD; Allen Burke, MD; Andrew Farb, MD, et al.

Microemboli and Microvascular Obstruction in Acute Coronary Thrombosis andSudden Coronary Death. Relation to Epicardial Plaque Histopathology

Epicardial coronary thrombosis often causes microemboli and microvascular obstruction. The consequences of myocardial microvessel obstruction and myocyte necrosis are substantial, yethistopathologic characterization of epicardial coronary artery plaque has been incompletely characterized. This study examined myocardial microvascular emboli, and related these to plaque in the coronary arteries supplying the microvessels.

� Raffaele Marfella, MD, PhD; Clara Di Filippo, PhD; Michele Portoghese, MD, et al.

Tight Glycemic Control Reduces Heart Inflammation and Remodeling During AcuteMyocardial Infarction in Hyperglycemic Patients

The molecular mechanisms by which tight glycemic control improves heart remodeling during acutemyocardial infarction (AMI) are still largely unknown. We analyzed the molecular mechanisms evokedby tight glycemic control during post-infarction remodeling in human hearts.


� Ivan C. Rokos, MD; William J. French, MD; William J. Koenig, MD, et al.

Integration of Pre-Hospital Electrocardiograms and ST-Elevation Myocardial InfarctionReceiving Center (SRC) Networks. Impact on Door-to-Balloon Times Across 10Independent Regions

The American College of Cardiology Door-to-Balloon (D2B) Alliance target is a > 75% rate of D2B ≤ 90 min. Independent initiatives nationwide have organized regional SRC networks that coordinate universal access to 9-1-1 with the pre-hospital electrocardiogram (PH-ECG) diagnosis ofSTEMI and immediate transport to a SRC (designated PPCI-capable hospital). The aim of this study wasto evaluate the rate of timely reperfusion for ST-elevation myocardial infarction (STEMI) with primarypercutaneous coronary intervention (PPCI) in regional STEMI Receiving Center (SRC) networks.

� Caroline Medi, MBBS, FRACP; Gilles Montalescot, MD, PhD; Andrzej Budaj, MD, PhD, et al.

Reperfusion in Patients With Renal Dysfunction After Presentation With ST-SegmentElevation or Left Bundle Branch Block: GRACE (Global Registry of Acute CoronaryEvents)

Few data are available informing the treatment of STE myocardial infarction in the presence of renaldysfunction. We investigated the relative benefit of reperfusion strategies in renal dysfunction and ST-segment elevation/left bundle branch block (STE/LBBB).



Adding cilostazol to dual antiplatelet therapy achieves greater platelet inhibition thanhigh maintenance dose clopidogrel in patients with acute myocardial infarction: results ofthe Adjunctive Cilostazol Versus High Maintenance Dose Clopidogrel in Patients With AMI(ACCEL-AMI) Study

Safety and feasibility of adjunctive antiplatelet therapy with intravenous elinogrel, adirect-acting and reversible P2Y12 ADP-receptor antagonist, before primary percutaneousintervention in patients with ST-elevation myocardial infarction: The Early Rapid ReversAlof Platelet ThromboSis with Intravenous Elinogrel before PCI to Optimize REperfusion inAcute Myocardial Infarction (ERASE MI) pilot trial

Effect of high-dose intracoronary adenosine administration during primary percutaneouscoronary intervention in acute myocardial infarction: a randomized controlled trial

Primary percutaneous coronary angioplasty with and without eptifibatide in ST-segmentelevation myocardial infarction. A safety and efficacy study of integrilin-facilitated versusprimary percutaneous coronary intervention in ST-segment elevation myocardial infarction(ASSIST)

Rivaroxaban versus placebo in patients with acute coronary syndromes (ATLAS ACS-TIMI 46):a randomised, double-blind, phase II trial

Abciximab in patients with acute ST-segment-elevation myocardial infarction undergoingprimary percutaneous coronary intervention after clopidogrel loading. A randomizeddouble-blind trial



ST-Segment Elevation Acute Myocardial Infarction

Effect of intracoronary streptokinase administered immediately after primarypercutaneous coronary intervention on long-term left ventricular infarct size, volumes,and function

Thrombus aspiration during primary percutaneous coronary intervention improvesmyocardial reperfusion and reduces infarct size. The EXPIRA (thrombectomy with EXPortcatheter in Infarct Related Artery during primary percutaneous coronary intervention)prospective, randomized trial

Paclitaxel-eluting stents versus bare-metal stents in acute myocardial infarction

Efficacy and safety of immediate angioplasty versus ischemia-guided management afterthrombolysis in acute myocardial infarction in areas with very long transfer distances:results of the NORDISTEMI (NORwegian study on DIstrict treatment of ST-ElevationMyocardial Infarction)

The PASEO (PaclitAxel or Sirolimus-Eluting Stent Versus Bare Metal Stent in PrimaryAngioplasty) randomized trial

Longer-term follow-up of patients recruited to the REACT (Rescue Angioplasty VersusConservative Treatment or Repeat Thrombolysis) trial

Routine early angioplasty after fibrinolysis for acute myocardial infarction

Long-term outcome after drug-eluting versus bare-metal stent implantation in patientswith st-segment elevation myocardial infarction: 3-year follow-up of the randomizedDEDICATION (Drug Elution and Distal Protection in Acute Myocardial Infarction) trial

Strut coverage and vessel wall response to zotarolimus-eluting and bare-metal stentsimplanted in patients with st-segment elevation myocardial infarction: the OCTAMI(Optical Coherence Tomography in Acute Myocardial Infarction) study

Enoxaparin in primary and facilitated percutaneous coronary intervention: a formalprospective nonrandomized substudy of the FINESSE Trial (Facilitated INtervention withEnhanced Reperfusion Speed to Stop Events)

A randomized, double-blind, placebo-controlled, dose-escalation study of intravenousadult human mesenchymal stem cells (Prochymal) after acute myocardial infarction

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Randomized comparison of primary percutaneous coronary intervention with combinedproximal embolic protection and thrombus aspiration versus primary percutaneouscoronary intervention alone in ST-segment elevation myocardial infarction: the PREPARE(PRoximal Embolic Protection in Acute myocardial infarction and Resolution of ST-Elevation) study

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