Use In Acute Coronary Syndromes Research Articles

Coronary computed tomography angiography in acute chest pain: A sustainable model with remote support

PurposeTo propose a sustainable model of coronary computed tomography angiography (CCTA) use in acute coronary syndrome (ACS) in emergency department (ED) using a partially based teleradiology reporting model. We also analyzed impact of the protocol on short- and long-term patient’s outcome. MethodsDuring a 12-month period, 104 consecutive patients admitted to the ED for acute chest pain (ACP) with low-to-intermediate risk of ACS were selected and underwent CCTA. Medical reporting was based on a model combining on-site physician and a remote radiologist supported by a web client-based teleradiology system, covering a 24/7 service. CCTA findings were correlated with the incidence of major adverse cardiovascular events (MACEs) over a 5-year follow-up. ResultsCCTA ruled-out CAD in 76 patients (73.1%). Moderate (7.7%) to severe (19.2%) CAD was identified in 28 patients who were directly referred to functional tests or invasive angiography. The mean discharge time was 10.8 ± 5.8 h; patients with absent to mild disease were safely and quickly discharged. Remote reporting using a teleradiology platform was performed in 82/104 cases (78.9%), with slight impact on patient’s discharge time (10.4 ± 5.6 vs. 12.1 ± 6.1 h, p: 0.24). MACEs at 6-month and at 5-year follow-up were 0.96% (n = 1/104) and 15.5% (n = 14/90). ConclusionCCTA assessment of patients with ACP enables to quickly rule-out ACS, avoiding waste of time and resources, to identify patients with obstructive CAD which should be referred to subsequent tests and to stratify the risk of MACEs at short and long time. A partial teleradiology based 24/7 CCTA service is feasible and sustainable, even in small ED.

Heparin use in acute coronary syndromes and cardiovascular interventions: habit or evidence based?

Heparin use in acute coronary syndromes and cardiovascular interventions: habit or evidence based?

Prospective Evaluation of Routine Percutaneous Left Ventricular Assist Device Use in Acute Coronary Syndrome Related Cardiogenic Shock (ACS-CS) – The Melbourne Cardiogenic Shock Initiative

The Melbourne Cardiogenic shock initiative is a single-arm, prospective, multicentre study to assess the outcomes in patients with ACS-CS treated with a percutaneous left ventricular assist device (pLVAD).

Роль фракційного резерву кровоплину при визначенні тактики реваскуляризації в пацієнтів з ішемічною хворобою серця

In the light of the latest technologies, it is impossible to imagine the development of medicine and, in particular, cardiac surgery, without the use of minimally invasive treatments. Endovascular revascularization interventions have been used for over 20 years, and today they have become the «gold» standard for a number of coronary lesions. This review presents a large number of studies and evidence confirming the use of measuring the physiological parameters of coronary blood flow (fractional flow reserve) for the treatment of chronic coronary heart disease and the possibility of their use in acute coronary syndrome. In addition, there is evidence of the use of the method of instantaneous wave-free ratio, which is carried out without the use of vasodilators, thus eliminating their side effects. Despite the high informativeness and reliability of the fractional flow reserve methodology, its use is insufficient in clinics in Ukraine and the world as a whole. This technique is used to determine significant hemodynamic changes in the blood supply to the myocardium in the so-called «intermediate stenosis» of the coronary artery. Determining fractional flow reserve is a fairly simple and affordable method of diagnosis and, consequently, the correct treatment of coronary heart disease. The introduction of fractional flow reserve in routine practice will not only change the quantitative side of cardiac surgery and endovascular interventions, but also improve the quality of life of patients and reduce the economic costs of coronary heart disease treatment.

Management of the Gastrointestinal System Bleeding Caused by Direct-Acting Oral Anticoagulants

Direct-acting oral anticoagulants include dabigatran, which is a thrombin inhibitor, and rivaroxaban, apixaban, and edoxaban, which are anti-Xa agents. These are administered in the secondary prophylaxis and treatment of venous thromboembolism (VTE) and pulmonary embolism (PE), in the prophylaxis of VTE that may develop after major elective orthopedic surgery, in reducing stroke and systemic embolism that may occur in non-valvular atrial fibrillation, whereas its use in acute coronary syndrome is still controversial. Although it is specified that direct-acting oral anticoagulants are as effective as heparin therapy and reduce the risk of bleeding due to all causes, many important studies have also reported that they increase the risk of gastrointestinal system (GIS) bleeding.

Parnaparin in surgery, vascular surgery and associated disciplines

Aliterature review is dedicated to the use of Parnaparin in various surgical specialties. Prevention and treatment of thromboembolic complications is the major indication for the use of Parnaparin. In the review, the authors dwell on comparative studies of the efficacy oflow molecular weight heparins and unfractionated heparin. They also discuss in detail pharmacokinetics and pharmacodynamics of Parnaparin, its structure and effect on hemostasis components. Due tolack of direct comparative studies of variouslow molecular weight heparins, the authors provide reviews based on the network meta-analysis, which allowed them to identify the advantages of a specificlow molecular weight heparin by indirect comparison.There are few direct comparative studies of variouslow molecular weight heparins in theliterature, which does not allow for an objective assessment of their advantages and disadvantages. The authors do not only provideliterature data on direct comparative studies, but also show data on indirect comparisons (network meta-analysis). They analysed the efficacy of Parnaparin and otherlow molecular weight heparins for the prevention of thromboembolic complications, treatment of deep vein thrombosis and post-thrombophlebitic syndrome. The issues of the efficacy of Parnaparin in chronic arterial insufficiency and use in acute coronary syndrome are highlighted separately. The final part of the review is concerned with a promising, butlittle-known area of prophylaxis of restenosis and prevention of atherosclerosis progression. Experimental studies have allowed us to state that Parnaparin is one of the most effectivelow molecular weight heparins as far as thromboembolic complications are concerned. Parnaparin significantly reduces frequency of DVT events and, at the same time, decreases major bleeding risk as compared with unfractionated heparin. No dose adjustment is required in obese patients. Dose adjustments are based not on body weight but on risk factors for thrombosis, and obesity is only one of them to be considered to choose a dose. Amonglow molecular weight heparins, Parnaparin is one of the most potent drugs that reduces the proliferative and migratory capacity of smooth muscle cells; however, further research is needed to assess the prospects of using Parnaparin for the prevention of restenosis.

The Role of Direct Oral Anticoagulant in Patients with Acute Coronary Syndrome on Single or Dual Antiplatelet Regime: Review of Opportunities and Challenges

Despite the developments of single or dual antiplatelet therapy consisting of aspirin and/or clopidogrel, prasugrel or ticagrelor, post-acute coronary syndrome a room for potential improvement towards optimal prevention persist. The addition of a direct oral anticoagulant to the antiplatelet treatment of patients with the acute coronary syndrome is clinically practiced in cases where anticoagulation is indicated by high thromboembolic risk. The main objective of this review was to explore the role of supplementation with a direct oral anticoagulant to antiplatelet (aspirin or P2Y12 inhibitor) in patients with the acute coronary syndrome. We have searched the Medline for studies involving direct oral anticoagulant use in acute coronary syndrome. We have reviewed specific relevant 9 meta-analyses between the years 2012 to 2019. Our review of nine meta-analyses has revealed that the addition of direct oral anticoagulant to antiplatelet therapy compared with antiplatelet alone was beneficial about the composite endpoints of major ischemic events in patients with the acute coronary syndrome. Furthermore, the combined regimen of single antiplatelet plus direct oral anticoagulant is as effective as the triple regimen of dual antiplatelet plus direct oral anticoagulant and results in less bleeding. Cardiologists should balance the efficacy with a higher risk of bleeding with more intensified DOAC therapy. Better risk characterization and timely adaptation of the regime to the patient's need should be tested. Recurrent ischemic events and bleeding event risk scoring should guide individualized treatment.

26-Year-Old Woman With Shortness of Breath and Chest Pain

26-Year-Old Woman With Shortness of Breath and Chest Pain

From Snake Venom's Disintegrins and C-Type Lectins to Anti-Platelet Drugs.

Snake venoms are attractive natural sources for drug discovery and development, with a number of substances either in clinical use or in research and development. These drugs were developed based on RGD-containing snake venom disintegrins, which efficiently antagonize fibrinogen activation of αIIbβ3 integrin (glycoprotein GP IIb/IIIa). Typical examples of anti-platelet drugs found in clinics are Integrilin (Eptifibatide), a heptapeptide derived from Barbourin, a protein found in the venom of the American Southeastern pygmy rattlesnake and Aggrastat (Tirofiban), a small molecule based on the structure of Echistatin, and a protein found in the venom of the saw-scaled viper. Using a similar drug discovery approach, linear and cyclic peptides containing the sequence K(R)TS derived from VP12, a C-type lectin protein found in the venom of Israeli viper venom, were used as a template to synthesize Vipegitide, a novel peptidomimetic antagonist of α2β1 integrin, with anti-platelet activity. This review focus on drug discovery of these anti-platelet agents, their indications for clinical use in acute coronary syndromes and percutaneous coronary intervention based on several clinical trials, as well as their adverse effects.

Prediction of Ticagrelor and its Active Metabolite in Liver Cirrhosis Populations Using a Physiologically Based Pharmacokinetic Model Involving Pharmacodynamics

Ticagrelor, a P2Y12 receptor antagonist, has been highly recommended for use in acute coronary syndrome. The major active metabolite (AM) is similar to the parent drug, which exhibits antiplatelet activity. The inhibition of platelet aggregation (IPA) is used as an assay to demonstrate the anticoagulant efficacy of ticagrelor. In this study, we developed a physiologically based pharmacokinetic (PBPK) model to predict the pharmacokinetics of ticagrelor and its AM and combined this model with a pharmacodynamics model to reflect potential pharmacodynamic alterations in liver cirrhosis populations. The simulated results obtained using the PBPK model were validated by fold error values, which were all smaller than 2. Comparisons of exposure in different classifications of liver cirrhosis indicated that exposure to ticagrelor increased significantly with an increase in the degree of cirrhosis severity, whereas exposure to AM was decreased. The total concentration of ticagrelor and AM was related to the IPA included in the Sigmoid Emax model. The PBPK model of ticagrelor and AM could predict the pharmacokinetics of all populations, and a combination of PD models was used to extrapolate for predicting unknown scenarios. Liver cirrhosis may result in prolonged IPA, depending on the severity degree of this disease. The combined PBPK model including IPA can reveal changes in pharmacokinetics and pharmacodynamics in populations affected by liver cirrhosis and indicate the risk potential.

The safety of morphine use in acute coronary syndrome: a meta-analysis

BackgroundMorphine is widely used for pain control in patients with acute coronary syndrome (ACS). Several studies have questioned the safety of morphine in this setting with a concern of interaction...

Abstract 172: Ticagrelor Use in Acute Coronary Syndrome: A Real-World Experience

Background: Ticagrelor improves survival in patients with acute coronary syndromes (ACS) compared to clopidogrel. Patients are often urgently loaded with P2Y12 inhibitors in the setting of ACS, with little time to consider barriers for continuation in the outpatient setting. We sought to evaluate the association between socioeconomic factors (type of insurance, medication co-payment) and patient choice to switch from ticagrelor to clopidogrel prior to hospital discharge. Methods: Our medical center implemented a standardized protocol to load ACS patients with ticagrelor in 2015. During the hospitalization, pharmacists specialized in cardiovascular treatment reviewed the out-of-pocket costs with the patient and assessed their willingness to continue ticagrelor in the outpatient setting. Based on patient choice, some patients were re-loaded with clopidogrel prior to discharge. Using the ACTION Registry-GWTG, we identified all ACS patients who were loaded with ticagrelor since the start of the protocol. We examined the association between switching and socioeconomic factors using chi-squared and rank sum tests. Results: We identified a total of 162 ACS patients who were loaded with ticagrelor prior to percutaneous coronary intervention (PCI). Of these patients, 84 (51.9%) were discharged on clopidogrel. Patients who switched to clopidogrel prior to discharge were more likely to have federal outpatient or no prescription insurance (p<0.01), and were more likely to be non-white race (p=0.05; Table). Co-payment data were available for 70.4% of the 162 ticagrelor-loaded patients. For patients who were discharged on ticagrelor, the median monthly co-payment for continuing the drug in the outpatient setting was $18.00 (interquartile range, 18 to 45). The median monthly co-payment for patients who were not discharged on ticagrelor was $253.77 (IQR, 45 to 350; p<0.01). Conclusion: Co-payment, race, and prescription insurance are associated with patient choice to switch from ticagrelor to clopidogrel in the ACS setting. This finding implies that socioeconomic factors, namely drug cost, are barriers to implementation of standardized ticagrelor use in ACS patients. While clinical trials suggest a mortality benefit with ticagrelor, real-world practice may not realize this benefit.

Factors associated with ambulance use in acute coronary syndrome in Victoria, Australia

Factors associated with ambulance use in acute coronary syndrome in Victoria, Australia

Diagnostic and Therapeutic Nanoparticles in Cardiovascular Diseases.

Cardiovascular diseases are the major cause of non-communicable illness in both developing and developed nations, representing 30% of global deaths. New therapeutic approaches are desperately needed. Nanomedicine represents one such approach, and involves using molecular entities on the scale of 10-150 nanometers, for purposes of diagnosing, treating, and preventing disease. This review provides a basic overview of nanotechnology, then reviews specific applications of nanotechnology to cardiovascular diseases. Most research has focused on diagnosing and treating atherosclerosis using nanoparticles (NPs). However, researchers are beginning to study NPs for use in acute coronary syndromes, revascularization procedures, and heart failure. Antimicrobial NPs directed at biofilms likely have applicability to identifying and treating endocarditis. Despite the large disease burden of cardiovascular diseases, there are fewer researchers and less funding being applied to this research. Additional investment in NP therapies would pay great dividends once these therapies come of age.

Implications for Ezetimibe Therapy Use Based on IMPROVE-IT Criteria

PurposeIn the IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT), simvastatin/ezetimibe combination was associated with a 6% relative risk reduction in the combined cardiovascular outcome compared with simvastatin alone in patients with acute coronary syndrome. Given strict inclusion criteria (low-density lipoprotein cholesterol 50-125 mg/dL and no use of statins more potent than simvastatin 40 mg), the implications of this important trial in routine acute coronary syndrome care are unknown. MethodsWe identified patients with acute coronary syndrome from the Veterans Affairs health care system over a 5-year period and determined what proportion would be candidates for ezetimibe on the basis of IMPROVE-IT criteria. We then evaluated what proportion could potentially see an increase in ezetimibe use if IMPROVE-IT criteria are not strictly followed. ResultsOf 219,625 patients with acute coronary syndrome, 69,508 (31.6%) would qualify for ezetimibe on the basis of strict criteria. Among those who did not meet IMPROVE-IT criteria (n = 150,117), ezetimibe could potentially be prescribed by clinicians in a further 28% of patients (n = 61,635) using statins more potent than simvastatin 40 mg, 7.1% of patients (15,527) with a documented statin intolerance, and 10.4% of patients (22,758) with low-density lipoprotein cholesterol >125 mg/dL. ConclusionsOur results provide a first look at the implications of this trial in a large health care system. Although 31.6% of patients would qualify for ezetimibe, there is a large potential for an increase in ezetimibe use in acute coronary syndrome outside of the strict trial inclusions. These findings call for a discussion on ezetimibe's role in patients with acute coronary syndrome already taking high-intensity statins or those with statin intolerance.

The new oral anticoagulants: clinical use and reversal agent development

Warfarin has been the centre of oral anticoagulant therapy for over 60 years. Recent development of new oral anticoagulants (NOACs) has provided a safe and effective alternative for stroke prevention in patients with atrial fibrillation and for prevention of venous thromboembolism. Determination of their use in acute coronary syndrome has been hampered by increases in bleeding events in most large trials, especially when used with antiplatelet therapy. NOACs have equal or superior efficacy and safety profiles compared to warfarin, fewer drug interactions; no dietary restrictions; predictable responses that eliminates monitoring; a rapid onset eliminates bridging with parenteral anticoagulants; and a potential reduction in mortality in patients with atrial fibrillation. There are reports of bleeding events and deaths associated with NOACs. Haemorrhage associated with dabigatran and warfarin were the most common safety issues for anticoagulants reported to the United States Food and Drug Administration in 2012. The lack of a NOAC reversal agent is a significant clinical concern for many physicians. Current reversal agents for unfractionated heparin, low molecular weight heparins and warfarin are less than optimal, and there are no effective reversal agents for NOACs. Development programs for anticoagulant reversal of the NOACs have three approaches: multiple coagulation factor replacement, large molecules (recombinant antibodies or altered coagulation factors) that either bind to or substitute for the coagulation factor while the anticoagulant itself is either being excreted or metabolized, and a small molecule specifically designed to bind to the NOACs and heparins and prevent them from binding to the coagulation factor targets.

Ambulance use in acute coronary syndrome in Ireland: A cross-sectional study.

As myocardial salvage is time dependent, prompt emergency department attendance is imperative in the presence of unresolved acute coronary syndrome symptoms. Although ambulance use is the recommended mode of transport during an acute coronary syndrome event, people regularly have misperceptions about its role. Consequently, many fail to use this service when warranted. To evaluate factors associated with ambulance usage among patients admitted to emergency departments with acute coronary syndrome symptoms in Ireland. Patients (N=1947) diagnosed with acute coronary syndrome were recruited across five hospitals. The ACS Response Index was used to identify mode of transport to access the emergency department, symptom context and experience and the rationale for non-ambulance use. Using logistic regression, predictors of ambulance use were identified. Only 40.1% of the sample used an ambulance. The primary reason for non-ambulance use was the perception that it was unwarranted (31%). A further 23.8% thought another mode of transportation would be faster. Independent predictors of ambulance usage differed among the three sub-diagnoses of acute coronary syndrome. For each group, visiting the general practitioner with symptoms was associated with a greater likelihood of not using an ambulance. The use of ambulance services is not positively embraced by the public. Furthermore, it appears that general practitioners may not always promote its use, particularly in the early stages of acute coronary syndrome symptom onset. The findings from our study suggest that a public education drive is necessary to promote ambulance usage during an acute coronary syndrome event.

CRT-102 Everolimus-Eluting Bioresorbable Vascular Scaffold Use in Acute Coronary Syndromes: Initial Clinical Experience from South Western Canada

Contemporary studies have established encouraging clinical outcomes for the everolimus-eluting bioresorbable vascular scaffold (BVS) ABSORB™ in patients with stable coronary artery disease (CAD). There is limited data on its use in patients presenting with acute coronary syndromes (ACS). We aimed

Bivalirudin Use in the Elderly for Acute Coronary Syndrome

ABSTRACT Introduction: Bivalirudin has been approved for use in acute coronary syndromes as part of the anticoagulation regimen. Elderly patients are at a higher risk for bleeding because of their co morbidities, decreased body mass and their age. Hence, this article reviews the landmark published papers on bivalirudin therapy in this patient population with the goal of understanding the particular benefits and risks. Discussion: Several review articles suggest that the use of bivalirudin alone is associated with lower rates of major bleeding when compared with unfractionated heparin plus glycoprotein IIb/IIIa inhibitor in patients with acute coronary syndrome with invasive strategy planned. These beneficial effects span through the age ranges. Therefore, it is a good option for elderly patients. Decreased bleeding complications lead to better clinical outcomes in the elderly after percutaneous coronary intervention. It also leads to decreased length of stay in the hospital. Keywords: Anticoagulants; elderly; acute coronary syndrome; ST elevation myocardial infarction.

Rivaroxaban: A Review of Its Use in Acute Coronary Syndromes

Rivaroxaban (Xarelto(®)) is an orally administered highly selective direct inhibitor of factor Xa that has been approved in many countries to reduce the risk of stroke in patients with atrial fibrillation and for the treatment and prevention of venous thromboembolism. More recently, rivaroxaban at a low dosage of 2.5mg twice daily, co-administered with aspirin alone or aspirin plus either clopidogrel or ticlopidine, was approved for use in the EU for patients with a recent acute coronary syndrome (ACS). The approval of rivaroxaban in ACS was primarily based on findings of the phase III ATLAS ACS 2-TIMI 51 trial, which showed that after a median of 13.1months of treatment with rivaroxaban 2.5mg twice daily (combined with aspirin or aspirin plus either clopidogrel or ticlopidine) there was a statistically significant reduction in the rate of the primary composite endpoint, which was death from cardiovascular causes, myocardial infarction or stroke, compared with placebo. Rivaroxaban 2.5mg twice daily was also associated with a reduction in all-cause and cardiovascular mortality. There was an increase in the risk of major bleeding and intracranial haemorrhage with rivaroxaban 2.5mg twice daily compared with placebo; however, there was no increase in the risk of fatal bleeding. Aspirin plus either ticagrelor or prasugrel was not evaluated as background dual antiplatelet therapy in ATLAS ACS 2-TIMI 51 and the safety implications of rivaroxaban used in combination with such therapy are unknown. In conclusion, results of the ATLAS ACS 2-TIMI 51 trial suggest a potentially important role for rivaroxaban 2.5mg twice daily co-administered with aspirin alone or aspirin plus either clopidogrel or ticlopidine in patients with a recent ACS.