Early Invasive Procedures Research Articles

The Cost-Effectiveness of Early Invasive Procedures for Acute Coronary Syndrome in Low-Income Regions: A Prospective Cohort Study in Pakistan.

Background Acute coronary syndrome (ACS) is a significant cause of mortality and morbidity globally, necessitating effective intervention strategies. Early invasive procedures such as percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are often recommended for high-risk patients. However, their cost-effectiveness in low-income regions remains uncertain, particularly in Pakistan, where healthcare resources are limited. Objective This study aims to evaluate the cost-effectiveness of early invasive procedures compared to standard care for ACS in low-income regions of Pakistan. Methods We conducted a prospective cohort study from January 1, 2021, to January 31, 2021, at four major hospitals in Pakistan: Army Cardiac Center Combined Military Hospital (CMH) Lahore, National Institute of Cardiovascular Diseases in Karachi, Lady Reading Hospital in Peshawar, and Mardan Medical Complex. The participants included 436 patients diagnosed with ACS aged 18 years or older and presenting within 24 hours of symptom onset. The patients were divided into two groups: the early invasive procedure group (n = 218) and the standard care group (n = 218). The primary outcome was the 30-day mortality rate. Secondary outcomes included recurrent myocardial infarctions, hospital readmissions, healthcare costs, and procedural complications. Data were analyzed using SPSS version 25.0 (IBM SPSS Statistics, Armonk, NY), employing descriptive statistics, chi-square tests, independent t-tests, and Kaplan-Meier survival analysis. Results The early invasive procedure group showed a mortality rate of 18 (8%) compared to 33 (15%) in the standard care group, demonstrating a significant reduction in mortality (p = 0.01). Additionally, the average healthcare cost was significantly lower in the early invasive group, with mean costs of Pakistani rupee (PKR) 187,200 (US dollar {USD} 1,200) compared to PKR 280,800 (USD 1,800) in the standard care group (p < 0.01). Recurrent myocardial infarctions occurred in 11 (5%) of the early invasive group versus 26 (12%) in the standard care group (p < 0.05). Hospital readmission rates were lower in the early invasive group, 22 (10%) compared to 39 (18%) in the standard care group (p < 0.05). Healthcare costs were significantly lower in the early invasive group, with mean costs of PKR 187,200 (USD 1,200) compared to PKR 280,800 (USD 1,800) in the standard care group (p < 0.01). Conclusion Early invasive procedures for ACS significantly improve survival rates, reduce complications, and lower healthcare costs in low-income regions of Pakistan. These findings suggest that such strategies should be considered in resource-limited settings to optimize patient outcomes and healthcare resource utilization.

Pivotal Decision for Acute Coronary Syndrome Patient with Left Main Coronary Artery Disease, When to Choose PCI over CABG

Background: Surgery is acceptable as a standard treatment of Left Main Coronary Artery (LMCA) Disease in a stable angina condition. But, in Acute Coronary Syndrome (ACS) setting, LMCA intervention is a still clinical challenge in many cardiac centers. Percutaneous coronary intervention (PCI) has emerged as a suitable alternative to coronary artery bypass grafting (CABG) for high-risk complex coronary artery disease (CAD) scenario. This study aimed to outline the management of NSTEMI patient include LMCA disease. Case presentation: A 72-year-old male presented with persistent chest pain, with a confirmed NSTEMI. A coronary angiography was done and revealed Three Vessel Disease (TVD) and Left Main (LM) CAD with highly calcified stenosis in the distal LM and Left Anterior Descending (LAD). An early invasive procedure was successfully performed for severely calcified LAD artery and distal LM lesions, using proper selection of several bail-out pre-dilatation difficult attempts such as scoring ballon and rotational atherectomy (RA). We observed the aftercare period, which showed no subsequent ACS events. Conclusion: Managing ACS patients requires careful consideration and risk assessment before deciding on revascularization procedures, especially in high-risk case such as LMCA disease. PCI can be an effective treatment strategy for this population but require good consideration of patient’s anatomical factors, comorbidities, the availability of appropriate skill and equipment. Keyword: Acute Coronary Syndrome, Coronary Artery Bypass Graft Surgery, Left Main Coronary Artery, Percutaneous Coronary Intervention.

Abstract 14577: Electrocardiogram Parameters for Predicting the Severity of Coronary Artery Disease in Non-ST Segment Elevation Acute Coronary Syndrome

Background: Quantitative electrocardiogram (ECG) parameters have been found to correlate with severity of coronary artery disease (CAD). Thus, it may serve the purpose of risk stratifying patients with non-ST segment elevation acute coronary syndrome (NSTEACS). But little is known about the accuracy of each parameter.So, this study was done to assess the correlation of ECG parameters with severity of CAD in patients with NSTEACS and to compare the diagnostic accuracy among them. Methods: 178 patients with NSTEACS with left ventricular ejection fraction &gt;50% were selected for the study after excluding patients with heart failure, arrhythmia, prior myocardial infarction or revascularisation. P wave peak time (PWPT), corrected QT dispersion (cQTd) and QT dispersion ratio (QTDR) was calculated in all patients. CAD severity was assessed visually by coronary angiography and calculating the syntax score. Results: PWPT, cQTd and QTDR were increased significantly in patients with left main (LM) or triple vessel disease (TVD) than others. These parameters also showed a strong positive correlation with the syntax score ( P&lt;.001 ). Among these parameters, cQTd showed the best diagnostic accuracy (76% sensitivity and 64% specificity) to detect LM or TVD with a cut-ff value of 74 ms. Conclusion: PWPT, cQTd and QTDR may help to identify high risk patients with NSTEACS and early invasive procedure can be done to salvage a large area of myocardium at jeopardy. These may be particularly helpful to the physicians in periphery who have limited resources. Keywords: coronary artery disease, non-ST segment elevation acute coronary syndrome, P wave peak time, corrected QT dispersion, QT dispersion ratio

A systematic review of treatment options for post-prostatectomy incontinence

PurposeUrinary incontinence remains common in men after prostatectomy. Current guidance suggests early corrective surgery to those that are still incontinent after trying Pelvic Floor Muscle Therapy, however, other treatments are now available. This review aims to evaluate all currently available treatment options for men with post-prostatectomy incontinence (PPI).MethodsA search of MEDLINE and CENTRAL databases on 2/2/2021 produced 879 articles. Any study evaluating incontinence before and after a treatment protocol was eligible for inclusion. After screening, 17 randomized control trials were included, and pre-defined data points were collected. Due to heterogeneity, pooled analysis was not possible, and a descriptive synthesis was produced in accordance with PRISMA guidelines. Cochrane Risk of Bias (RoB) tool was used to evaluate all studies. The search protocol and methods for this study was registered on the PROSPERO database before the search began, ID:(CRD42021229749).Results3/17(18%) of studies focussed on pharmacotherapy, 2/17(12%) on vibration therapies, 8/17(47%) on pelvic floor muscle therapy (PFMT), 3/17(18%) on electrical stimulation (ES), and 1/17 (6%) on extracorporeal magnetic innervation (ExMI) as their main intervention. The use of Duloxetine, Solifenacin, PFMT, ES, and ExMI all show effective reduction in incontinence in men suffering from PPI. No study in this review evaluated surgical managements for PPI.ConclusionA large number of treatments are available for PPI using an array of different methods. For this reason, a variety of treatments could be considered before early invasive procedures, to prevent unnecessary surgery and its associated negative complications.

Sonographic septation: a useful diagnostic predictor of complicated parapneumonic effusion

Sonographic septation is associated with prolonged hospitalization and increased mortality in patients diagnosed with empyema. However, it is unknown whether sonographic septation is associated with complicated parapneumonic effusion (CPPE) or...

Fat Grafting and the Palpable Breast Mass in Implant-Based Breast Reconstruction: Incidence and Implications

Background: Fat grafting is a powerful and increasingly used technique in breast reconstruction. However, fat necrosis can lead to palpable postoperative changes that can induce anxiety and lead to unplanned diagnostic studies. The authors’ aim in this study was to evaluate the incidence, type, and timing of these unanticipated studies; the specialty of the ordering provider; and the factors that trigger the ordering process. Methods: A retrospective chart review was conducted for patients from 2006 to 2015 who underwent fat grafting as part of implant-based breast cancer reconstruction and had at least 1-year follow-up after fat grafting. Results: From 2006 to 2015, 166 patients underwent fat grafting as part of implant-based breast reconstruction. Forty-four women (26.5 percent) underwent at least one imaging procedure. Thirteen women (7.8 percent) underwent 17 biopsies. For a palpable mass, the initial imaging test most commonly ordered was ultrasound, followed by mammography/ultrasound. The percentage of patients with a diagnosis of fat necrosis on mammography, ultrasound, and biopsy was 4.2, 12.7, and 5.4 percent, respectively. Seven patients (4.2 percent) had distant metastases. Tissue diagnosis of local recurrence was never identified. Mean follow-up was 2.4 years. Conclusions: Fat-grafting sequelae may lead to early unplanned invasive and noninvasive procedures initiated by a variety of providers. In this study, fat grafting had no impact on local recurrence rate. As use of fat grafting grows, communication among breast cancer care providers and enhanced patient and caregiver education will be increasingly important in optimizing the multidisciplinary evaluation and monitoring of palpable breast lesions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Intra-atrial re-entrant tachycardia in patients with congenital heart disease: factors associated with disease severity.

Intra-atrial re-entrant tachycardia (IART) is a common complication in patients with congenital heart disease (CHD) and is related to increased morbidity and mortality. Few reports have been published about factors associated to IART severity. The aim of this study is to analyse factors associated to severe clinical presentation of IART. Observational study of all consecutive CHD patients who underwent a first IART ablation from January 2009 to December 2015 (94 patients, 39.4% female, and age: 36.55 ± 14.9 years). Severe clinical presentation was defined as heart failure, syncope, shock, electromechanical dissociation (EMD), or aborted sudden death. The majority of patients had moderately or highly complex cardiac defect (90.4%). Types of IART included cavotricuspid isthmus(CTI) dependent in 51% (48), non-CTI-related in 22.3% (20), and both types in 27.7% (26). In 38 patients (40.4%), a severe event occurred and in 16 (17%), the symptoms included shock, syncope, sudden death, or EMD. In 21 (22.3%), severe symptoms were the first manifestation of IART. In multivariate analysis, transposition of the great arteries (TGA) with right systemic ventricle (OR 5.32, 95% C.I. 1.6-7.02, P = 0.0005) and severe dilation of the venous atrium (VsA) (OR 4.17; 95% CI 1.4-8.12, P = 0.0009) were factors independently associated with severity. In our series of 94 CHD patients with a high proportion of moderately to highly complex cardiac defects, severe consequences of IART were frequent. Transposition of the great arteries with systemic right ventricle and severe dilation of VsA were independently associated to severity. Early invasive procedures should be considered for these high-risk patients.

TCT-100 Asians suffer the highest in-hospital mortality rates after acute coronary syndrome despite high use of early invasive procedures

Guidelines prescribe universal recommendations for the early invasive treatment of acute coronary syndrome (ACS). However, differential outcomes of ACS by race in the modern era of drug-eluting stents (DES) are not well understood. We analyzed 835,070 hospitalizations for ACS from the Healthcare

Lung Cancer Mimicking Pulmonary Tuberculosis in a TB-Endemic Country: The Role of Early Invasive Diagnostic Procedures

SUMMARY Aim: This study aimed to investigate the impact of early invasive diagnostic procedures on detecting lung cancers that mimic pulmonary TB. Patients &amp; methods: Patients with an initial diagnosis of pulmonary TB, which was later revised to lung cancer, were included. Patients were classified into early and late intervention groups. Clinical characteristics, chest radiographic images, diagnostic procedures and outcomes were analyzed. Results: There were 53 patients with a revised diagnosis of lung cancer included. The time between diagnoses of TB and cancer for the early and late intervention group was 1.1 ± 1.1 and 5.5 ± 10.2 months, respectively (p = 0.01). For patients with advanced stage lung cancer, those received early interventions survived longer than those that did not receive early interventions (10.3 vs 3.3 months; p = 0.89). Conclusion: In a TB-endemic area, invasive diagnostic procedures may be helpful to avoid a misdiagnosis in patients with lung cancer mimicking pulmonary TB.

Effect of Contrast-Induced Nephropathy on the Long-Term Outcome of Patients with Non-ST Segment Elevation Myocardial Infarction

Background: Contrast-induced nephropathy (CIN) has been traditionally associated with increased mortality and adverse cardiovascular events. We sought to determine whether CIN has a negative impact on the long-term outcome of patients with non-ST segment elevation myocardial infarction (NSTEMI). Methods: A total of 312 consecutive patients (mean age 59 years, 76% male) who presented with NSTEMI and had undergone an early invasive procedure were retrospectively included. CIN was defined as either a 25% or 0.5-mg/dl increase in baseline serum creatinine (Cr) 72 h after the procedure. The primary endpoint of the study was mortality in the long-term follow-up (38 months, interquartile range 30-40). The secondary endpoint consisted of mortality and myocardial infarction (MI). Results: CIN developed in 30 (9.6%) patients. Independent predictors of CIN were the contrast volume-to-Cr clearance ratio, left ventricular ejection fraction and hemoglobin concentration. The primary (20 vs. 8.5%, p = 0.042) and secondary endpoints (33.3 vs. 17%, p = 0.029) were observed more frequently in patients with CIN during long-term follow-up. The unadjusted odds ratio (OR) of CIN was 2.55 [95% confidence intervals (CI) 1.04-6.24, p = 0.040] for mortality and 2.15 (CI 1.09-4.25, p = 0.028) for mortality/MI. However, after adjustment for confounding factors, CIN was not an independent predictor of either mortality (OR 1.62, CI 0.21-12.57, p = 0.646) or mortality/MI (OR 1.12, CI 0.31-4.0, p = 0.860). Conclusion: The effect of CIN on the long-term outcome of patients with NSTEMI was substantially influenced by confounding factors. CIN was a marker, rather than a mediator, of increased cardiovascular risk, and the baseline renal function was more conclusive as a long-term prognosticator.

CHA2DS2-VASc scoring system as an initial method for screening high-risk patients in acute myocardial infarction

Acute myocardial infarction (AMI) is associated with high early mortality and is frequently required an early invasive procedure or thrombolytic management. So, current guidelines recommend early risk stratification in order to obtain appropriate treatment [1,2]. Although, there have been several risk-stratification methods for acute myocardial infarction, most of them were difficult and inconvenient to apply [2–8]. On the other hand, CHA2DS2-VASc scoring system is used to estimate the risk of ischemic stroke in patient with atrial fibrillation (AF), but it included relevant cardiovascular risk factors and is very easy to calculate and memorize [9].

Small Cell Carcinoma Presenting with Massive Pleural Spread Mimicking Malignant Pleural Mesothelioma

Small cell carcinoma (SCC) predominantly spreading over the pleura is exceedingly rare and difficult to diagnose without proof of malignant effusion. A 65-year-old man presented with right pleural thickening and effusion and was diagnosed with SCC based on a thoracoscopic pleural biopsy. He received combined chemotherapy consisting of cisplatin and irinotecan hydrochloride, which resulted in a complete response. Seven months later, local relapse was observed. Thereafter, he received second-, third- and fourth-line chemotherapies and died of tumor progression 21 months after the diagnosis. Considering the possibility of SCC with pleural spread, performing early invasive procedures is important for diagnosing pleural malignancies.

Early High-Dose Rosuvastatin for Contrast-Induced Nephropathy Prevention in Acute Coronary Syndrome: Results From the PRATO-ACS Study (Protective Effect of Rosuvastatin and Antiplatelet Therapy On Contrast-Induced Acute Kidney Injury and Myocardial Damage in Patients With Acute Coronary Syndrome)

This study sought to determine if in addition to standard preventive measures on-admission, high-dose rosuvastatin exerts a protective effect against contrast-induced acute kidney injury (CI-AKI).Patients with acute coronary syndrome (ACS) are at high risk for CI-AKI, and the role of statin pre-treatment in preventing renal damage remains uncertain.Consecutive statin-naïve non-ST elevation ACS patients scheduled to undergo early invasive strategy were randomly assigned to receive rosuvastatin (40 mg on admission, followed by 20 mg/day; statin group n = 252) or no statin treatment (control group n = 252). CI-AKI was defined as an increase in creatinine concentration of ≥0.5 mg/dl or ≥25% above baseline within 72 h after contrast administration.The incidence of CI-AKI was significantly lower in the statin group than in controls (6.7% vs. 15.1%; adjusted odds ratio: 0.38; 95% confidence interval [CI]: 0.20 to 0.71; p = 0.003). The benefits against CI-AKI were consistent, even applying different CI-AKI definition criteria and in all the pre-specified risk categories. The 30-day incidence of adverse cardiovascular and renal events (death, dialysis, myocardial infarction, stroke, or persistent renal damage) was significantly lower in the statin group (3.6% vs. 7.9%, respectively; p = 0.036). Moreover, statin treatment given on admission was associated with a lower rate of death or nonfatal myocardial infarction at 6 month follow-up (3.6% vs. 7.2%, respectively; p = 0.07).High-dose rosuvastatin given on admission to statin-naïve patients with ACS who are scheduled for an early invasive procedure can prevent CI-AKI and improve short-term clinical outcome. (Statin Contrast Induced Nephropathy Prevention [PRATO-ACS]; NCT01185938).

Nécrose de la pointe du nez secondaire à une injection d’acide hyaluronique

Hyaluronic acid (HA) is the most used dermal filler. Some complications associated with its use have been described, but most of them are rare and benign. We report an exceptional case of skin necrosis of the tip of the nose, in a 22-year-old patient, after HA injection. The initial appearance may occurred subsequent aesthetic sequels. After necrotic tissue excision, patient was followed in rapid succession. Daily local care has led to wound healing, without any important sequel. This rare complication reminds us that HA injections are not without risk, despite their apparent simplicity of use. Moreover, the case presented confirms the potential healing of the nasal tip, allowing treatment with wound healing, rather than other early invasive procedure.

Effects of immediate invasive strategy on occurrence of in-hospital major cardiovascular events in non-STEMI patients

Purpose: Current clinical practice guidelines for the management of NSTEMI patients suggest early invasive procedure, within 24h, if GRACE score is >140 and within 72h of admission in patients at lower risk, with GRACE score ≤140. The aim of this study was to investigate if immediate invasive strategy (<2h) is associated with lower in-hospital MACE rates. Methods: We randomized 323 non-STEMI patients into the immediate invasive strategy group (<2h after randomization, n=162) and the late invasive strategy group (2-72h after randomization, n=161). Patients with hemodynamic instability, heart insufficiency and life-threatening ventricular arrhythmia on admission, were excluded from the study. Results: The median time from randomization to angiography in the immediate group was 1.3h and 61.5h in the late group (p < 0.001). Baseline characteristics did not differ significantly between the two study arms, except for diabetes (33% in the late group vs. 22% in the immediate group, p = 0.024). GRACE score was not significantly different between the groups (132 vs. 129, p = 0.3). In-hospital MACE (cardiovascular death, re-infarction or stroke) occurred significantly less frequently in the immediate compared to the late study arm (3.1% vs. 11.8%, p = 0.003). After adjusting for the localization of myocardial infarction, sex, age and diabetes, the calculated odds ratio was 0.269 (95% CI 0.095-0.760, p = 0.013). The observed difference in in-hospital MACE was mainly due to lower rates of re-infarction in the immediate versus late group (1.9% vs. 9.3%, adjusted OR = 0.2, 95% CI 0.056 -0.736, p = 0.015). In-hospital rates of cardiovascular death and stroke were similar between the groups. Conclusion: Immediate invasive strategy in NSTEMI patients is associated with lower rates of in-hospital MACE, irrespective of baseline GRACE score.

Treatment disparities and effect on late mortality in patients with diabetes presenting with acute myocardial infarction: observations from the ACACIA registry

To compare the use of evidence-based pharmacological and invasive treatments and 12-month mortality rates between patients with and without diabetes who present with acute myocardial infarction (MI), and to explore the relationship between these treatments and late clinical outcomes. Prospective, nationwide multicentre registry: the Acute Coronary Syndrome Prospective Audit (ACACIA). Patients presenting to 24 metropolitan and 15 non-metropolitan hospitals with acute coronary syndrome (ACS) and a final discharge diagnosis of acute MI between November 2005 and July 2007. All-cause mortality at 12 months. Nearly a quarter of 1744 patients with a final diagnosis of acute MI had a history of diabetes on presentation. Patients with diabetes were older, with a greater prevalence of comorbidities than non-diabetic patients, and were less likely to be treated at discharge with evidence-based medications (aspirin, clopidogrel, a statin and/or a beta-blocker) or to receive early invasive procedures. After adjusting for baseline characteristics and therapeutic interventions, diabetes at presentation was independently associated with a higher mortality at 12 months after MI (hazard ratio, 1.79; 95% CI, 1.18-2.72; P=0.007). Early invasive management and discharge prescription of guideline-recommended medications were associated with a significantly reduced hazard of mortality at 12 months. Patients with diabetes have a higher risk than non-diabetic patients of late mortality following an acute MI, yet receive fewer guideline-recommended medications and early invasive procedures. Increased application of proven pharmacotherapies and an early invasive management strategy in patients with diabetes presenting with ACS might improve their outcomes. STUDY PROTOCOL NUMBER (SANOFI-AVENTIS): PML-0051.

Guidelines and Performance Measures for the Management of Acute Coronary Syndrome

BACKGROUND: Acute coronary syndrome (ACS) is caused by reduced perfusion of the myocardium and characterized by chest pain. The primary goals of treatment for ACS are to restore blood flow through occluded coronary arteries and prevent recurrent coronary events. Antiplatelet and anticoagulant therapies play a crucial role in the treatment of ACS by interrupting the thrombotic process. OBJECTIVES: To characterize the pathophysiology of ACS and to describe the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI); the use of antiplatelet and anticoagulant therapies for the treatment of STEMI, non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA), including patients who undergo percutaneous coronary intervention (PCI); and long-term antiplatelet therapy after an ACS episode. SUMMARY: The preferred reperfusion strategy in patients with STEMI is PCI if it can be performed within 90 minutes after arrival at the hospital. Patients with NSTEMI or UA also may undergo PCI. Thrombolysis is an alternative method of reperfusion for patients with STEMI but not for patients with NSTEMI or UA. Dual antiplatelet therapy with aspirin and the thienopyridine clopidogrel is recommended by the ACC/AHA for 12 months in patients with STEMI, NSTEMI, or UA, including patients with coronary stents. Platelet glycoprotein (GP) IIb/IIIa inhibitors are routinely used during PCI in patients with STEMI and NSTEMI. These agents should be used in addition to aspirin and clopidogrel in patients with NSTEMI and elevated troponin levels who undergo coronary intervention. Unfractionated heparin (UFH) or the low-molecular-weight heparin enoxaparin may be used in patients with STEMI undergoing reperfusion with thrombolytic agents or PCI and patients with NSTEMI or UA. There are substantial data on enoxaparin in the ACS arena, but UFH is preferred for patients who undergo coronary intervention because of greater ease of therapeutic monitoring and reversal of anticoagulant effects if bleeding complications arise. The pentasaccharide fondaparinux may become an alternative to UFH and enoxaparin for patients with STEMI and some patients with NSTEMI or UA. Fondaparinux is preferred for patients with NSTEMI or UA who are at increased risk for bleeding when a conservative approach is chosen, but it is not recommended for patients when an early invasive approach is chosen because of the risk of catheter-related thrombi. The direct thrombin inhibitor bivalirudin may be used for anticoagulation in patients with NSTEMI who undergo early invasive procedures, and GP IIb/IIIa inhibitor use may be avoided in some patients; however, upstream antiplatelet therapy with clopidogrel is also needed if these patients undergo PCI. Patients undergoing coronary stenting must receive dual antiplatelet therapy. CONCLUSIONS: Antiplatelet and anticoagulant therapies for patients with ACS are complex. Evidence-based guidelines facilitate the therapeutic decision-making process for these therapies in patients with ACS.

Applying Quality Measures and Guidelines in the Management of Acute Coronary Syndrome and Venous Thromboembolism

BACKGROUND: Acute coronary syndrome (ACS) is caused by reduced perfusion of the myocardium and characterized by chest pain. The primary goals of treatment for ACS are to restore blood flow through occluded coronary arteries and prevent recurrent coronary events. Antiplatelet and anticoagulant therapies play a crucial role in the treatment of ACS by interrupting the thrombotic process. OBJECTIVES: To characterize the pathophysiology of ACS and to describe the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI); the use of antiplatelet and anticoagulant therapies for the treatment of STEMI, non-ST-segment elevation myo cardial infarction (NSTEMI), and unstable angina (UA), including patients who undergo percutaneous coronary intervention (PCI); and long-term antiplatelet therapy after an ACS episode. SUMMARY: The preferred reperfusion strategy in patients with STEMI is PCI if it can be performed within 90 minutes after arrival at the hospital. Patients with NSTEMI or UA also may undergo PCI. Thrombolysis is an alternative method of reperfusion for patients with STEMI but not for patients with NSTEMI or UA. Dual antiplatelet therapy with aspirin and the thienopyridine clopidogrel is recommended by the ACC/AHA for 12 months in patients with STEMI, NSTEMI, or UA, including patients with coronary stents. Platelet glycoprotein (GP) IIb/IIIa inhibitors are routinely used during PCI in patients with STEMI and NSTEMI. These agents should be used in addition to aspirin and clopidogrel in patients with NSTEMI and elevated troponin levels who undergo coronary intervention. Unfractionated heparin (UFH) or the low-molecular-weight heparin enoxaparin may be used in patients with STEMI undergoing reperfusion with thrombolytic agents or PCI and patients with NSTEMI or UA. There are substantial data on enoxaparin in the ACS arena, but UFH is preferred for patients who undergo coronary intervention because of greater ease of therapeutic monitoring and reversal of anticoagulant effects if bleeding complications arise. The pentasaccharide fondaparinux may become an alternative to UFH and enoxaparin for patients with STEMI and some patients with NSTEMI or UA. Fondaparinux is preferred for patients with NSTEMI or UA who are at increased risk for bleeding when a conservative approach is chosen, but it is not recom mended for patients when an early invasive approach is chosen because of the risk of catheter-related thrombi. The direct thrombin inhibitor bivalirudin may be used for anticoagulation in patients with NSTEMI who undergo early invasive procedures, and GP IIb/IIIa inhibitor use may be avoided in some patients; however, upstream antiplatelet therapy with clopidogrel is also needed if these patients undergo PCI. Patients undergoing coronary stenting must receive dual antiplatelet therapy. CONCLUSIONS: Antiplatelet and anticoagulant therapies for patients with ACS are complex. Evidence-based guidelines facilitate the therapeutic decision-making process for these therapies in patients with ACS. J Manag Care Pharm. 2008;14(6)(suppl S-a):S4-S13 Copyright © 2008, Academy of Managed Care Pharmacy. All rights reserved. PIOTR SOBIESZCZYK, MD, is Associate Director, Cardiac Catheterization Laboratory, Brigham and Women’s Hospital, Boston. AUTHOR CORRESPONDENCE: Piotr Sobieszczyk, MD, Associate Director, Cardiac Catheterization Laboratory, Brigham and Women’s Hospital, Cardiovascular Division, PBB-113, 75 Francis St., Boston, MA 02115. Tel.: 617.732.8898; Fax: 617.732.7122; E-mail: psobieszczyk@partners.org Author

Missing female births in India

Prenatal sex selection for non-medical reasons is a heated issue. Prenatal diagnosis involves an early invasive procedure such as chorionic villus sampling between 10 and 12 weeks of gestation or in the later stages ultrasonography or amniocentesis. In todays Lancet Prabhat Jha and colleagues present a large study of 1.1 million Indian households to examine the causes of missing girls at birth. In the UK after a second public consultation the Human Fertilisation and Embryology Authority reaffirmed its position opposing sex selection for nonmedical reasons. In India fetal sex determination and medical termination of pregnancy on the basis of fetal sex have been illegal since 1994. Under the law prenatal diagnostic scans are allowed for the detection of genetic abnormalities but sex determination tests are forbidden. Those caught are subject to a fine imprisonment and suspension of the medical practitioners licence. (excerpt)

Clinical performance of three cardiac troponin assays in patients with unstable coronary artery disease (a FRISC II substudy)

The assay of cardiac-specific troponins (cTroponins) is a sensitive and specific means to diagnose myocardial injury. Several assays for the measurement of cardiac-specific troponin I (cTnI), but only 1 for the assay of cardiac specific troponin T (cTnT), are commercially available. The aim of this study was to compare 3 of these assays (i.e., Access AccuTnI [cTnI], AxSym [cTnI], and Elecsys 3 rd generation [cTnI]) and their clinical performances in a group of patients (n = 1,763) with unstable coronary artery disease (Fragmin and fast Revascularisation during InStability in Coronary artery disease [FRISC II] trial). Clinical events after 1-year follow-up, such as death and death and/or acute myocardial infarction, were recorded and the effects of invasive or noninvasive treatment evaluated in relation to cTroponin levels. Overall the 2 cTnI methods showed good correlation (r s = 0.96), whereas correlations to the cTnT assay were somewhat lower (r s = 0.93). Patients with nonelevated levels, as measured with any of the 3 biomarkers, had a significantly better prognosis than patients with elevated levels (p <0.001). A cohort of 10% to 12.4% of patients with a poor prognosis was identified only by the Access AccuTnI assay. Invasive treatment reduced clinical events only in the group of patients with elevated cTroponin levels. We conclude that stratification of patients with unstable coronary artery disease by means of cTroponin measurements is important in clinical management. It is also apparent that assays with superior sensitivity, such as the Access AccuTnI, identify more patients with poor prognosis who are candidates for early invasive procedures.