ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention—summary article: A report of the American college of cardiology/American heart association task force on practice guidelines(ACC/AHA/SCAI writing committee to update the 2001 guidelines for percutaneous coronary intervention)

Aspirin in COVID-19: Pros and Cons

Since its emergence, the COVID-19 pandemic has been ravaging the medical and economic sectors even with the significant vaccination advances. In severe presentations, the disease of SARS-CoV-2 can manifest with life-threatening thromboembolic and multi-organ repercussions provoking notable morbidity and mortality. The pathogenesis of such burdensome forms has been under extensive investigation and is attributed to a state of immune dysfunction and hyperinflammation. In light of these extraordinary circumstances, research efforts have focused on investigating and repurposing previously available agents that target the inflammatory and hematological cascades. Aspirin, due to its well-known properties and multiple molecular targets, and ought to its extensive clinical use, has been perceived as a potential therapeutic agent for COVID-19. Aspirin acts at multiple cellular targets to achieve its anti-inflammatory and anti-platelet effects. Although initial promising clinical data describing aspirin role in COVID-19 has appeared, evidence supporting its use remains fragile and premature. This review explores the notion of repurposing aspirin in COVID-19 infection. It delves into aspirin as a molecule, along with its pharmacology and clinical applications. It also reviews the current high-quality clinical evidence highlighting the role of aspirin in SARS-CoV-2 infection.

Serum Zinc-α2-Glycoprotein Levels Were Decreased in Patients With Premature Coronary Artery Disease

Objectives: To explore serum zinc-α2-glycoprotein (ZAG) changes in patients with or without premature coronary artery disease (PCAD) and its association with several cardiovascular risk factors. Methods: A total of 3,364 patients who were undergone coronary angiography in Peking Union Medical College Hospital were screened. According to the degree of coronary artery stenosis, the number of 364 patients with PCAD (age <55 years in males and <65 years in females) and 126 age and gender matched patients without premature coronary artery disease (NPCAD) were recruited in our present study. In addition, 182 age and gender matched healthy controls were also enrolled. Serum ZAG levels were determined by enzyme-linked immunosorbent assay (ELISA) method. Results: Serum ZAG were significantly lower in the PCAD (8.03 ± 1.01 vs. 8.78 ± 1.89 μg/mL, p < 0.05) and NPCAD groups (8.28 ± 1.61 vs. 8.78 ± 1.89 μg/mL, p < 0.05), respectively, when compared with the controls. Multiple regression analysis showed that PCAD was independently associated with serum ZAG levels (B = -0.289, p = 0.002). The probability of PCAD in subjects with low tertile ZAG levels was 2.48-fold higher than those with high tertile levels after adjusting for other confounders [OR = 3.476, 95% CI 1.387-8.711, p = 0.008]. This phenomenon was more likely to be observed in male subjects with BMI <24 kg/m². The receiver operating curve (ROC) analysis showed a weak diagnostic performance of serum ZAG for PCAD (AUC = 0.659, 95% CI 0.612-0.705, p < 0.05). At the cutoff value of 7.955 μg/mL serum ZAG, the sensitivity and specificity for differentiating patients with PCAD from controls were 50.5 and 78.0%, respectively. The combination of ZAG with other clinical variables including age, gender, BMI, SBP, FBG, TC, HDL-C, Cr, and Urea had significantly improved the diagnosis accuracy with a sensitivity of 82.6%, a specificity of 95.0%, and AUC of 0.957 (95% CI, 0.940-0.975, p < 0.05). Conclusion: Serum ZAG levels were firstly found to be decreased in Chinese PCAD patients. Subjects with lower ZAG levels were more likely to have PCAD, especially for male subjects with BMI <24 kg/m². ZAG might be the potential diagnostic biomarkers for PCAD patients, and the combination of ZAG and clinical variables had higher discriminative performance.

Ticagrelor in Peripheral Artery Disease Endovascular Revascularization (TI-PAD): Challenges in clinical trial execution

There is limited evidence to guide clinical decision-making for antiplatelet therapy in peripheral artery disease (PAD) in the setting of lower extremity endovascular treatment. The Ticagrelor in Peripheral Artery Disease Endovascular Revascularization Study (TI-PAD) evaluated the role of ticagrelor versus aspirin as monotherapy in the management of patients following lower extremity endovascular revascularization. The trial failed to recruit the targeted number of patients, likely due to aspects of the design including the lack of option for dual antiplatelet therapy, and inability to identify suitable patients at study sites. In response, the protocol underwent amendments, but these changes did not adequately stimulate recruitment, and thus TI-PAD was prematurely terminated. This article describes the rationale for TI-PAD and challenges in trial design, subject recruitment and trial operations to better inform the conduct of future trials in PAD revascularization. ClinicalTrials.gov Identifier: NCT02227368.

Association of serum gamma-glutamyltransferase and premature coronary artery disease

BACKGROUND

Serum gamma-glutamyltransferase (GGT) has been introduced as a predictive factor for cardiovascular disease. In this study, we investigated the association of serum GGT and premature coronary artery disease (CAD) in candidates for coronary angiography.

METHODS

In this cross-sectional study, we enrolled male subjects aged ≤45 years and female subjects ≤55 years who were candidates for elective coronary angiography due to typical chest pain or a positive non-invasive test. Baseline characteristics were recorded for all the participants and serum levels of blood glucose, lipid profile and GGT were measured. Patients were divided into CAD and non-CAD groups based on angiography for further comparisons.

RESULTS

From a total of 367 patients (age 45.1 ± 6.1 years, 161 males [43.9%]), 176 (47.9%) patients had premature CAD. A high level of GGT was significantly associated with the presence of CAD (p < 0.001). A 10-unit increase in GGT could strongly predict the presence of premature coronary artery disease (OR: 13.34, 95% CI: 7.19-24.78; p < 0.001) after adjustment for confounders. The area under the receiver operating characteristic curve for GGT was 80.9% (range 76.5-85.3) and the sensitivity and specificity of GGT at a cut-point of 22.5 IU/l was 80.1% and 70.2%, respectively. Diagnostic accuracy of GGT was 74.9%. The positive predictive value and negative predictive value for GGT was 71.3 and 79.3, respectively.

CONCLUSION

We observed that GGT levels in patients with typical chest pain or positive non-invasive tests could predict the presence of premature CAD in young patients.

Point-of-care testing of clopidogrel-mediated platelet inhibition and risk for cardiovascular events after coronary angiography with or without percutaneous coronary intervention

High-on-treatment platelet reactivity (HPR) during antiplatelet treatment with clopidogrel is associated with increased risk for adverse cardiovascular events after percutaneous coronary intervention (PCI). Recent studies have indicated that the point-of-care platelet function test Plateletworks can predict such events. The objectives were to investigate the incidence of HPR, to identify correlating variables, and to assess if platelet function testing could predict adverse cardiovascular events. Observational, prospective, single-center study of 491 patients on clopidogrel and aspirin who underwent coronary angiography with or without PCI between October 2006 and May 2011. Platelet reactivity was measured with adenosine diphosphate-induced single-platelet function testing (Plateletworks). A cutoff of 82.3% aggregation was established and used to define HPR. Patients were followed for 3 months, and the primary end-point was myocardial infarction. Secondary end-points included stent thrombosis, death, rehospitalization, and a composite of myocardial infarction, death, and stent thrombosis. One hundred and ninety-six of the 491 patients had HPR. This group had a higher BMI (P < 0.001), and had more often received their clopidogrel loading dose within 6-24 h before coronary angiography (P = 0.001). At 3 months follow-up, the event rates of myocardial infarction and rehospitalization, respectively, were higher in HPR patients [5.1 vs. 1.7%, odds ratio (OR) 3.12, 95% confidence interval (CI) 1.05-9.27, P = 0.03; and 23.0 vs. 14.2%, OR 1.80, CI 1.13-2.86, P = 0.01, respectively]. Testing with Plateletworks identified patients at increased risk of myocardial infarction and rehospitalization within 3 months after coronary angiography with or without PCI.

Correlation between point-of-care platelet function testing and bleeding after coronary angiography according to two different definitions for bleeding

Platelet function testing could be useful when assessing the risk for bleeding during treatment with antiplatelet drugs. This has been indicated in several studies, including the Antiplatelet Therapy for Reduction of Myocardial Damage During Angioplasty-Bleeding (ARMYDA-BLEEDS) study, which demonstrated that testing with a point-of-care assay correlated with bleeding events after percutaneous coronary intervention. To standardize bleeding definitions, the Bleeding Academic Research Consortium (BARC) published a consensus report, which is in need of data-driven validation. Hence, the investigators conducted an observational, prospective, single-center study of 474 patients receiving clopidogrel and aspirin who underwent coronary angiography with or without percutaneous coronary intervention from October 2006 to May 2011. Platelet reactivity was measured with adenosine diphosphate-induced single-platelet function testing (Plateletworks) at the start of coronary angiography. The primary end point was the 30-day incidence of bleeding as defined by BARC and ARMYDA-BLEEDS. The aim of the present study was to investigate the relation between on-treatment platelet reactivity and the 30-day incidence of bleeding complications according to the BARC and ARMYDA-BLEEDS definitions. Patients in the first platelet aggregation quartile had a higher frequency of type 2 or higher BARC bleeding and ARMYDA-BLEEDS-defined bleeding <30 days after coronary angiography compared with the fourth quartile (16.9% vs 6.7%, p = 0.014, and 8.5% vs 1.7%, p = 0.016, respectively) and the third quartile (16.9% vs 7.7%, p = 0.031, and 8.5% vs 2.6%, p = 0.048, respectively). In conclusion, patients with low on-treatment platelet reactivity at the time of intervention had a significantly higher incidence of bleeding according to the BARC and ARMYDA-BLEEDS definitions <30 days after coronary angiography with or without percutaneous coronary intervention.

Access to care for patients with time-sensitive conditions in Pennsylvania

STUDY OBJECTIVE

Collective knowledge and coordination of vital interventions for time-sensitive conditions (ST-segment elevation myocardial infarction [STEMI], stroke, cardiac arrest, and septic shock) could contribute to a comprehensive statewide emergency care system, but little is known about population access to the resources required. We seek to describe existing clinical management strategies for time-sensitive conditions in Pennsylvania hospitals.

METHODS

All Pennsylvania emergency departments (EDs) open in 2009 were surveyed about resource availability and practice patterns for time-sensitive conditions. The frequency with which EDs provided essential clinical bundles for each condition was assessed. Penalized maximum likelihood regressions were used to evaluate associations between ED characteristics and the presence of the 4 clinical bundles of care. We used geographic information science to calculate 60-minute ambulance access to the nearest facility with these clinical bundles.

RESULTS

The percentage of EDs providing each of the 4 clinical bundles in 2009 ranged from 20% to 57% (stroke 20%, STEMI 32%, cardiac arrest 34%, sepsis 57%). For STEMI and stroke, presence of a board-certified/board-eligible emergency physician was significantly associated with presence of a clinical bundle. Only 8% of hospitals provided all 4 care bundles. However, 53% of the population was able to reach this minority of hospitals within 60 minutes.

CONCLUSION

Reliably matching patient needs to ED resources in time-dependent illness is a critical component of a coordinated emergency care system. Population access to critical interventions for the time-dependent diseases discussed here is limited. A population-based planning approach and improved coordination of care could improve access to interventions for patients with time-sensitive conditions.

Acute Stent Thrombosis and Heparin Induced Thrombocytopenia in a Patient With ST-Segment Elevation Myocardial Infarction

Heparin is an essential drug in the treatment of acute coronary syndrome and it is used during percutaneous coronary intervention (PCI). Heparin-induced thrombocytopenia (HIT), albeit a serious complication of heparin therapy characterized by thrombocytopenia and high risk for venous and arterial thrombosis, has rarely been previously reported during PCI. We report a case of an acute stent thrombosis due to an unusual cause, HIT during primary PCI, in a patient with acute myocardial infarction.

Rationale and design of the DeFACTO (Determination of Fractional Flow Reserve by Anatomic Computed Tomographic AngiOgraphy) study

BACKGROUND

Coronary computed tomographic angiography (CTA) allows for noninvasive identification of anatomic coronary artery disease (CAD) severity but does not discriminate whether a stenosis causes ischemia. Computational fluid dynamic techniques applied to CTA images now permit noninvasive computation of fractional flow reserve (FFR), a measure of lesion-specific ischemia, but the diagnostic performance of computed FFR (FFR(CT)) as compared with measured FFR at the time of invasive coronary angiography remains unexplored.

OBJECTIVE

We determined the diagnostic accuracy of noninvasive FFR(CT) for the detection and exclusion of ischemia-causing stenoses.

METHODS

DeFACTO (NCT01233518) is a prospective, international, multicenter study of 238 patients designed to evaluate the diagnostic performance of FFR(CT) for the detection of hemodynamically significant coronary artery stenoses identified by CTA, compared with invasive FFR as a reference standard. FFR values ≤ 0.80 will be considered hemodynamically significant. Patients enrolled in the DeFACTO study will undergo CTA, invasive coronary angiography, and 3-vessel FFR in the left anterior descending artery, left circumflex artery, and right coronary artery distributions. FFR(CT) will be computed with acquired CTA images, without modification to CTA image acquisition protocols and without additional image acquisition. Blinded core laboratory interpretation will be performed for CTA, invasive coronary angiography, FFR, and FFR(CT).

RESULTS

The primary endpoint of the DeFACTO study is the per-patient diagnostic accuracy of FFR(CT) for noninvasive assessment of the hemodynamic significance of CAD, compared with FFR during invasive coronary angiography as a reference standard. The secondary endpoints include additional per-patient as well as per-vessel diagnostic performance characteristics, including sensitivity, specificity, positive predictive value, and negative predictive value.

CONCLUSION

The DeFACTO study will determine whether the addition of FFR(CT) to conventional CTA improves the diagnosis of hemodynamically significant CAD.

Current concepts on antiplatelet therapy: focus on the novel thienopyridine and non-thienopyridine agents

Thienopyridines are a class of drug targeting the platelet adenosine diphosphate (ADP) 2 receptor. They significantly reduce platelet activity and are therefore clinically beneficial in settings where platelet activation is a key pathophysiological feature, particularly myocardial infarction. Ticlopidine, the first of the class introduced to clinical practice, was soon challenged and almost completely replaced by clopidogrel for its better tolerability. More recently, prasugrel and ticagrelor have been shown to provide a more powerful antiplatelet action compared to clopidogrel but at a cost of higher risk of bleeding complications. Cangrelor, a molecule very similar to ticagrelor, is currently being evaluated against clopidogrel. Considering the key balance of ischemic protection and bleeding risk, this paper discusses the background to the development of prasugrel, ticagrelor, and cangrelor and aims to characterise their risk-benefit profile and possible implementation in daily practice.

Aspirin and clopidogrel: efficacy and resistance in diabetes mellitus

Diabetes mellitus patients are characterized by enhanced platelet reactivity which exposes them to an increased risk of atherothrombotic events in the setting of acute coronary syndromes or percutaneous coronary interventions. Although aspirin and clopidogrel, used either solely or in combination, are associated with improved clinical outcomes in high-risk patients, diabetics patients treated with antiplatelet agents remain at higher risk of recurrent ischemic events. Recent laboratory findings suggest that this observation may be related to a reduced responsiveness or 'resistance' to these agents. In this chapter the efficacy of currently available oral antiplatelet agents in preventing ischemic events is reviewed. In addition, the antiplatelet 'resistance' phenomenon in the diabetic population and its impact on clinical outcomes is summarized. Finally, future developments in the field directed towards individualized treatment strategies and novel antiplatelet agents are examined.

Secondary prevention of diabetic patients with coronary artery disease in cardiac rehabilitation: risk factors, treatment and target level attainment

INTRODUCTION

Diabetic patients who have suffered from an acute coronary syndrome (ACS) or have had coronary artery bypass graft (CABG) surgery are at very high risk of recurrent cardiovascular events. Their prognosis, however, can be improved if the target values for blood pressure (BP < 130/80 mmHg) or low density lipoprotein cholesterol [LDL-C < 2.6 mmol/L (100 mg/dl), optionally < 1.8 mmol/L (70 mg/dl)] are achieved. It is not known what proportion of diabetic patients receives such stringent secondary prevention measures and achieves target level attainment for BP, lipids and glucose in cardiac rehabilitation (CR).

METHODS

During 2003 to 2005, 11 973 diabetic (29.7%) and 28 370 non-diabetic patients (70.3%), predominantly after ACS (74 and 80%), were included in a nationwide registry. At entry and at discharge, patient characteristics, pharmacotherapy and blood pressure, lipids and blood glucose were recorded. In a mixed model approach, temporal changes between centres and within centres, respectively, were analysed.

RESULTS

At discharge, a lower proportion of diabetic patients achieved normalisation of BP (in 2005: <140/90 mmHg: 78.4 vs. 82.9% in non-diabetic patients, p < 0.001) or <130/80 mmHg (45.5 vs. 49.8%), respectively. LDL-C < 2.6 mmol/L was more frequently attained in diabetic patients (68.2 vs. 66.5%), as was LDL-C < 1.8 mmol/L (28.8 vs. 23.0%). Fasting blood glucose was not changed during the observation period, as at discharge almost a quarter of all diabetic patients exceeded the threshold value of 7.0 mmol/L (126 mg/dl). In 2005 at discharge, statin therapy was administered in 93% in both diabetics and non-diabetics, acetylic salicylic acid in 79% in diabetics vs. 80% in non-diabetic patients (clopidogrel: 41 vs. 45%).

CONCLUSION

Generally there is room for improvement in the management of cardiac risk factors for both patients groups. In diabetic patients in CR at high risk for recurrent cardiac events, in recent years an improvement of the lipid profile has been observed. Hypertension and glycaemia are still not optimally addressed.

Prasugrel compared with high loading- and maintenance-dose clopidogrel in patients with planned percutaneous coronary intervention: the Prasugrel in Comparison to Clopidogrel for Inhibition of Platelet Activation and Aggregation-Thrombolysis in Myocardial Infarction 44 trial

BACKGROUND

The increasing use of higher-than-approved doses of clopidogrel in clinical practice is based in part on the desire for greater levels of inhibition of platelet aggregation (IPA). Prasugrel is a new thienopyridine that is more potent than standard-dose clopidogrel in healthy subjects and patients with stable coronary artery disease. The relative antiplatelet effects of prasugrel versus high-dose clopidogrel in percutaneous coronary intervention patients are unknown.

METHODS AND RESULTS

Prasugrel in Comparison to Clopidogrel for Inhibition of Platelet Activation and Aggregation-Thrombolysis in Myocardial Infarction 44 (PRINCIPLE-TIMI 44) was a randomized, double-blind, 2-phase crossover study of prasugrel compared with high-dose clopidogrel in patients undergoing cardiac catheterization for planned percutaneous coronary intervention. The primary end point of the loading-dose phase (prasugrel 60 mg versus clopidogrel 600 mg) was IPA with 20 mumol/L ADP at 6 hours. Patients with percutaneous coronary intervention entered the maintenance-dose phase, a 28-day crossover comparison of prasugrel 10 mg/d versus clopidogrel 150 mg/d with a primary end point of IPA after 14 days of either drug. In this study, 201 subjects were randomized. IPA at 6 hours was significantly higher in subjects receiving prasugrel (mean+/-SD, 74.8+/-13.0%) compared with clopidogrel (31.8+/-21.1%; P<0.0001). During the maintenance-dose phase, IPA with 20 mumol/L ADP was higher in subjects receiving prasugrel (61.3+/-17.8%) compared with clopidogrel (46.1+/-21.3%; P<0.0001). Results were consistent across all key secondary end points; significant differences emerged by 30 minutes and persisted across all time points.

CONCLUSIONS

Among patients undergoing cardiac catheterization with planned percutaneous coronary intervention, loading with 60 mg prasugrel resulted in greater platelet inhibition than a 600-mg clopidogrel loading dose. Maintenance therapy with prasugrel 10 mg/d resulted in a greater antiplatelet effect than 150 mg/d clopidogrel.

Sex-specific effects of diabetes on adverse outcomes after percutaneous coronary intervention: trends over time

BACKGROUND

Diabetes is a stronger risk factor for coronary heart disease in women than in men. Whether diabetes also poses greater risks to women after percutaneous coronary intervention (PCI) has not been examined.

METHODS

We examined 20586 PCI procedures at Emory University Hospitals (Atlanta, GA) between 1990 and 2003. Hazard ratios (HRs) for 1-year major adverse cardiac events were calculated comparing diabetic with nondiabetic patients by sex and study year. Data were adjusted for demographic and clinical factors using Cox proportional hazards models.

RESULTS

Despite increasing patient age and comorbidity burden, diabetic and nondiabetic men had a significant improvement in PCI outcomes between 1990 and 2003 (P < .001). Diabetic women also tended to have improved PCI outcomes over time (P = .073), but not nondiabetic women (P = .206). Overall, diabetes had a stronger association with adverse outcomes in women (HR 1.93, 95% CI 1.55-2.40) than in men (HR 1.26, 95% CI 1.09-1.47) (P = .002 for the interaction between sex and diabetes). The excess risk associated with diabetes in women, however, was largely driven by early study years (1990-1993). This excess risk associated with diabetes in women declined over time, and diabetes had a similar effect on outcomes in both women and men in more recent years (P = .010 for the interaction between sex, diabetes, and time).

CONCLUSIONS

Percutaneous coronary intervention outcomes of diabetic and nondiabetic men have improved in recent years. However, among women, diabetic patients had greater improvements in outcomes after PCI compared with nondiabetic patients. As a result, diabetes is no longer a stronger risk factor for adverse outcomes after PCI in women than in men.

Pharmacological antithrombotic adjuncts to percutaneous coronary intervention

Stent thrombosis is the major cause of early adverse events during percutaneous coronary intervention. Its incidence has fallen considerably in recent years, principally due to the introduction of effective antithrombotic therapies. The selection of an appropriate antithrombotic regimen is critical in achieving a balance between reducing ischaemic events and minimising bleeding complications in patients undergoing percutaneous coronary intervention. In this article, evidence for the role of antiplatelet and anticoagulant therapies is discussed, including the thienopyridines, glycoprotein IIb/IIIa receptor antagonists, direct thrombin inhibitors and pentasaccharides.

Current incidence and clinical outcomes of bivalirudin administration among patients undergoing primary coronary intervention for stent thrombosis elevation acute myocardial infarction

BACKGROUND

Multiple antithrombotic options are available for patients undergoing primary percutaneous coronary interventions for stent thrombosis elevation acute myocardial infarction. Current utilization and outcomes of antithrombotic agents for primary percutaneous coronary intervention, including bivalirudin, have not been defined.

METHODS

A total of 84 471 patients were reported from 439 hospitals to the National Registry of Myocardial Infarction-5 registry between April 2004 and June 2005. Consecutive patients undergoing primary percutaneous coronary interventions for stent thrombosis elevation acute myocardial infarction (n=7629 at 231 United States percutaneous coronary intervention capable hospitals) comprised the population analyzed. We examined antithrombotic strategies and the occurrence of adverse cardiac events stratified according to the use of bivalirudin. Logistic regression was performed to control for differences between three antithrombotic therapy treatment groups.

RESULTS

Glycoprotein IIbIIIa inhibitors were used nearly ubiquitously, but given prior to percutaneous coronary interventions in only 36% of patients. Less than one-quarter of patients received clopidogrel prior to percutaneous coronary interventions. Bivalirudin was used in 4.2% of patients (n=320) undergoing primary percutaneous coronary intervention during this time period. Patients treated with bivalirudin were more likely to be elderly (P=0.03), have a history of prior bleeding (P=0.003) and stroke (P=0.06). Major adverse events and bleeding complications were similar in antithrombotic therapy groups (bleeding: bivalirudin 7.8% versus nonbivalirudin 7.5%, P=0.85). The adjusted outcomes were also similar after confining the analysis to bivalirudin patients who had not received any glycoprotein IIbIIIa inhibitors (n=143).

CONCLUSIONS

Contemporary primary percutaneous coronary intervention includes mainly clopidogrel and eptifibatide initiated at the time of percutaneous coronary intervention. Patients who received bivalirudin were at higher risk and had similar adjusted outcomes as patients in the nonbivalirudin group. Optimization of primary percutaneous coronary intervention pharmacology requires future randomized clinical trials, examining the timing and type of adjunctive antithrombotic agents.

Update on the management of cardiogenic shock

PURPOSE OF REVIEW

Cardiogenic shock is a life-threatening emergency that occurs frequently with acute coronary syndromes. If rapid myocardial reperfusion following acute myocardial infarction is not obtained, either with thrombolytics or by revascularization, cardiogenic shock frequently develops and the mortality rate is high. This review summarizes recent advances in the pathophysiology, incidence and treatment of cardiogenic shock. Particular attention is given to pharmacologic advances.

RECENT FINDINGS

Cardiogenic shock continues to occur in 5-10% of patients who suffer a myocardial infarction and the mortality remains over 50% in most studies. Treatment preference is referral to a cardiac center capable of reperfusion using multiple therapies. While no delay in reperfusion is acceptable, emphasis on implementing supportive treatment such as vasopressors, inotropes, and fluids remains critical. There is a wide variance in treatment standards despite established guidelines. Overall mortality from cardiogenic shock has decreased but the incidence remains unchanged.

SUMMARY

Emerging pharmacological interventions designed to counteract the underlying proinflammatory pathophysiologic mechanisms may, in combination with early revascularization, result in improved patient outcomes, but there is no magic bullet on the horizon. Attention to the timeliness of transport and treatment of patients with a focus on revascularization is required for cardiogenic shock patients.

Efficacy and Safety of Clopidogrel 600 mg Administered Pre-Hospitally to Improve Primary Percutaneous Coronary Intervention in Patients with Acute Myocardial Infarction (CIPAMI): Study Rationale and Design

Clopidogrel, in combination with acetylsalicylic acid, has become a mainstay of the pharmacological therapy for patients with acute coronary syndromes, especially in those undergoing percutaneous coronary interventions (PCI). While a series of studies has shown that pre-treatment with a loading dose of clopidogrel 300 or 600 mg prior to PCI is effective in reducing cardiovascular complications, the optimal dose and timing in various patient groups is still unclear. The primary objective of the present randomized, open-label Clopidogrel to Improve Primary percutaneous coronary Intervention in Acute Myocardial Infarction (CIPAMI) study is to evaluate the efficacy and the safety of a 600 mg loading dose of clopidogrel in addition to standard acetylsalicylic acid/heparin treatment in the pre-hospital setting in 654 patients with acute ST elevation myocardial infarction scheduled for primary PCI. The primary efficacy endpoint is the TIMI 2/3 patency of the infarct-related artery immediately prior to PCI. The rationale, design and methods of this study are described.

An examination of factors influencing the choice of therapy for patients with coronary artery disease

Background

A diverse range of factors influence clinicians' decisions regarding the allocation of patients to different treatments for coronary artery disease in routine cardiology clinics. These include demographic measures, risk factors, co-morbidities, measures of objective cardiac disease, symptom reports and functional limitations. This study examined which of these factors differentiated patients receiving angioplasty from medication; bypass surgery from medication; and bypass surgery from angioplasty.

Methods

Univariate and multivariate logistic regression analyses were conducted on patient data from 214 coronary artery disease patients who at the time of recruitment had been received a clinical assessment and were reviewed by their cardiologist in order to determine the form of treatment they were to undergo: 70 would receive/continue medication, 71 were to undergo angioplasty and 73 were to undergo bypass surgery.

Results

Analyses differentiating patients receiving angioplasty from medication produced 9 significant univariate predictors, of which 5 were also multivariately significant (left anterior descending artery disease, previous coronary interventions, age, hypertension and frequency of angina). The analyses differentiating patients receiving surgery from angioplasty produced 12 significant univariate predictors, of which 4 were multivariately significant (limitations in mobility range, circumflex artery disease, previous coronary interventions and educational level). The analyses differentiating patients receiving surgery from medication produced 14 significant univariate predictors, of which 4 were multivariately significant (left anterior descending artery disease, previous cerebral events, limitations in mobility range and circumflex artery disease).

Conclusion

Variables emphasised in clinical guidelines are clearly involved in coronary artery disease treatment decisions. However, variables beyond these may also be important factors when therapy decisions are undertaken thus their roles require further investigation.