Faculty Bibliography

This paper provides a comprehensive up-to-date review of the medical and invasive management of patients with non- ST-segment elevation acute coronary syndromes (NSTE-ACS). The authors have summarized findings from key clinical trials published recent years that contribute to clinicians' understanding of how best to optimize therapy. The goals for the management of NSTE-ACS are rapid and accurate risk stratification, appropriate and institution-specific triage to interventional versus medical strategies and optimal pharmacologic therapy--all of which provide for a smooth and seamless transition of care between the emergency department and the cardiology service. High-risk features or absolute treatment trigger criteria that support more aggressive medical therapy (i.e., addition of small-molecule GP IIb/IIIa inhibitor to a core regimen of aspirin, enoxaparin, and in most cases, clopidogrel) and/or that would direct clinicians toward percutaneous, mechanical/interventional strategies as the preferred modality include, but are not limited to, the presence of one or more of the following: (1) elevated cardiac markers (troponin and/or CK-MB); (2) elevated levels of inflammatory markers (particularly CRP > 3 microg/dl); (3) age > 65 years; (4) presence of ST-T wave changes; (5) TIMI Risk Score greater than or equal to 4; (6) diabetes; and/or (7) clinical instability in the setting of suspected NSTE-ACS.Specific clinical, ECG and/or biochemical trigger points modulate the aggressiveness of both the medical therapy and the propensity to perform early angiography with or without subsequent revascularization in patients with NSTE-ACS. Although additional refinements and changes in ACS management are still to come, evidence-based strategies suggest that prompt mechanical revascularization is associated with the best possible clinical outcomes, particularly for patients with high-risk features and in whom benefits of adjunctive, pharmacoinvasive antithrombotic therapies can be consolidated. Patient transfer for cardiac catheterization/percutaneous coronary intervention (PCI) is strongly recommended in patients who manifest high-risk features and/or aggressive treatment trigger criteria, so that this high-risk subgroup may receive definitive, interventional and/or cardiology-directed specialty care at appropriate sites of care. When available, interventional management is preferred in these patients. The importance of safe and effective anticoagulation in the spectrum of management strategies has been confirmed, and the evidence in support of enoxaparin and other antithrombotic agents has been reviewed. Dosing recommendations for enoxaparin use in the setting of PCI have been issued by the CATH Panel and have been summarized in this consensus report. Similar recommendations have been presented for the use of oral antiplatelet agents and GP IIb/IIIa antagonists. The addition of statins, ACE-inhibitors and beta-blockers is also stressed as part of a comprehensive secondary cardioprotective strategy for patients with coronary heart disease

BACKGROUND:Prior studies of atheroablation (directional atherectomy, rotational atherectomy and laser angioplasty) have demonstrated either no advantage or worse outcomes relative to conventional balloon angioplasty. Because these techniques are still required in a minority of patients, we hypothesized that the use of drug-eluting stents (DES) would minimize the rate of major adverse cardiac events (MACE) after atheroablation. METHODS:From 2,252 percutaneous coronary intervention procedures, 212 patients were extracted using case control matching and were analyzed to compare the rate of MACE across four groups (DES with atheroablation, bare-metal stent (BMS) with atheroablation, DES without atheroablation, bare-metal stent without atheroablation). A Cox proportional hazards model was constructed to determine predictors of MACE after adjustment for potential confounders. Internal validation was performed with bootstrapping. RESULTS:There were 36 patients, 42 patients, 63 patients and 71 patients in each of the groups, respectively. The incidence of 30-day and 6-month MACE was numerically lowest among patients who received DES after atheroablation, although the differences did not reach statistical significance (30-day MACE: 0% DES with atheroablation, 4.8% BMS with atheroablation, 3.2% DES without atheroablation, 8.5% BMS without atheroablation; 6-month MACE: 2.8% DES with atheroablation, 19.0% BMS with atheroablation, 6.4% DES without atheroablation, 16.9% BMS without atheroablation). After adjustment, the use of atheroablation was not a predictor of MACE. CONCLUSIONS:This study suggests that in situations where directional atherectomy, rotational atherectomy or laser angioplasty is required to optimize stenting, the use of DES can minimize MACE associated with atheroablation.

OBJECTIVE:To determine patterns and outcomes of drug-eluting stents (DES) use in clinical practice. BACKGROUND:DES are technology associated with superior outcomes. The initial limited availability and high cost of DES had the potential to influence their use. METHODS:Data from the American College of Cardiology-National Cardiovascular Data Registry were examined to describe the patterns of DES use in 408,033 percutaneous coronary intervention (PCI) procedures at 383 sites. Predictors of DES use were determined, and inhospital outcomes were examined. RESULTS:From April 2003 through December 2004, the proportion of procedures using DES increased from 19.7% to 78.2%. DES use increased across all patient groups and hospital types, but adoption was slower among older patients and those without health insurance. DES use varied among hospitals such that use was lower at rural and low-volume hospitals. Multivariable regression demonstrated a progressive decrease in the odds of DES use as age increased. White race, female sex, presence of insurance, diabetes mellitus, PCI of de novo lesion, PCI at a high volume center, and PCI at a suburban hospital were significant predictors of DES use. The availability of a second DES product did not influence the adoption patterns. Inhospital outcomes with DES were excellent. CONCLUSIONS:Access to DES was influenced by demographic, socioeconomic, and hospital characteristics. Further study is needed to determine if the availability of another DES platform or increased overall availability of DES impacts favorably on PCI practice patterns.