Skip to main content

Abstract

Cardiology is a rapidly moving field that has recently seen significant medical and invasive advances. This has resulted in improved patient outcomes. While this is good, we are reminded that there are numerous areas in the management of ACS that remain somewhat controversial or unsettled. This uncertainty in the optimal management of unstable coronary patients is a fertile area for continued debate and future research. In this chapter, the first area of discussion is optimal reperfusion therapy for ST-elevation myocardial infarction, followed by optimal revascularization for non-ST-elevation myocardial infarction. The last section touches upon future approaches to the management of cardiovascular disease.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 39.99
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 54.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Keeley EC, Boura JA, Grines CL. Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomized trials. Lancet 2006; 367:579–588.

    Article  Google Scholar 

  2. FINESSE: Abciximab-only-and lytic/abciximab-facilitated PCI no better than primary PCI. Available at: www. theheart.org/article/809837.do. Last accessed December 2007.

    Google Scholar 

  3. Patel TN, Bavry AA, Kumbhani DJ, et al. A meta-analysis of randomized trials of rescue percutaneous coronary intervention after failed fibrinolysis. Am J Cardiol 2006; 97:1685–1690.

    Article  Google Scholar 

  4. Gershlick AH, Stephens-Lloyd A, Hughes S, et al. Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med 2005; 353:2758–2768.

    Article  Google Scholar 

  5. Boden WE, O’Rourke RA, Crawford MH, et al. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators. N Engl J Med 1998; 338:1785–1792. Erratum in: N Engl J Med 1998; 339:1091.

    Article  Google Scholar 

  6. Cannon CP, Weintraub WS, Demopoulos LA, et al.; TACTICS (Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy)—Thrombolysis in Myocardial Infarction 18 Investigators. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001; 344:1879–1887.

    Article  Google Scholar 

  7. de Winter RJ, Windhausen F, Cornel JH, et al. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med 2005; 353:1095–1104.

    Article  Google Scholar 

  8. Bavry AA, Kumbhani DJ, Rassi AN, et al. Benefit of early invasive therapy in acute coronary syndromes a meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol 2006; 48:1319–1325.

    Article  Google Scholar 

  9. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (writing committee to revise the 2002 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction. Circulation 2007; 116:803–877.

    Article  Google Scholar 

  10. Daemen J, Wenaweser P, Tsuchida K, et al. Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: data from a large two-institutional cohort study. Lancet 2007; 369:667–678.

    Article  Google Scholar 

  11. Shishehbor MH, Lauer MS, Singh IM, et al. In unstable angina or non-ST-segment acute coronary syndrome, should patients with multivessel coronary artery disease undergo multivessel or culprit-only stenting? J Am Coll Cardiol 2007; 49:849–854.

    Article  Google Scholar 

  12. Brener SJ, Murphy SA, Gibson CM, et al. Efficacy and safety of multivessel percutaneous revascularization and tirofiban therapy in patients with acute coronary syndromes. Am J Cardiol 2002; 90:631–633.

    Article  Google Scholar 

  13. Kandzari DE, Roe MT, Ohman EM, et al. Frequency, predictors, and outcomes of drug-eluting stent utilization in patients with high-risk non-ST-segment elevation acute coronary syndromes. Am J Cardiol 2005; 96:750–755.

    Article  Google Scholar 

  14. Babapulle MN, Joseph L, Belisle P, et al. A hierarchical Bayesian meta-analysis of randomised clinical trials of drug-eluting stents. Lancet 2004; 364:583–591.

    Article  Google Scholar 

  15. Bavry AA, Kumbhani DJ, Helton TJ, et al. Late thrombosis of drug-eluting stents: a meta-analysis of randomized clinical trials. Am J Med 2006; 119:1056–1061.

    Article  Google Scholar 

  16. Stone GW, Moses JW, Ellis SG, et al. Safety and efficacy of sirolimus-and paclitaxel-eluting coronary stents. N Engl J Med 2007; 356:998–1008.

    Article  Google Scholar 

  17. Bavry AA, Bhatt DL. Drug-eluting stents: dual anti-platelet therapy for every survivor? Circulation 2007; 116:696–699.

    Article  Google Scholar 

  18. Spertus JA, Kettelkamp R, Vance C, et al. Prevalence, predictors, and outcomes of premature discontinuation of thienopyridine therapy after drug-eluting stent placement: results from the PREMIER registry. Circulation 2006; 113:2803–2089.

    Article  Google Scholar 

  19. Bavry AA, Bhatt DL. Acute myocardial infarction and drug eluting stents: A green light for their use or time for measured restraint? Am Heart J 2007; 153:719–721.

    Article  Google Scholar 

  20. OASIS-5 Trial Group. Comparison of fondaparinux and enoxaparin in acute coronary syndromes. N Engl J Med 2006; 354:1464–1476.

    Google Scholar 

  21. Yusuf S, Mehta SR, Chrolavicius S, et al.; for the OASIS-G Trial Group. Effects of fondaparinux on mortality and reinfarction in patients with acute ST-segment elevation myocardial infarction: the OASIS-6 randomized trial. JAMA 2006; 295:1519–1530.

    Article  Google Scholar 

  22. Cohen M, Bhatt DL, Alexander JH. Randomized, double-blind, dose-ranging study of otamixaban, a novel, parenteral, short-acting direct Factor Xa inhibitor, in percutaneous coronary intervention. The SEPIA-PCI Trial. Circulation 2007; 115:2642–2651.

    Article  Google Scholar 

  23. Rajagopal V, Bhatt DL. Factor Xa inhibitors in acute coronary syndromes: moving from mythology to reality. J Thromb Haemost 2005; 3:436–438.

    Article  Google Scholar 

  24. Meadows TA, Bhatt DL. Clinical aspects of platelet inhibitors and thrombus formation. Circ Res 2007; 100:1261–1275.

    Article  Google Scholar 

  25. Canon CP, Husted S, Harrington RA, et al. Safety, tolerability, and initial efficacy of AZD6140, the first reversible oral adenosine diphosphate receptor antagonist, compared with clopidogrel, in patients with non-ST-segment elevation acute coronary syndrome: primary results of the DISPERSE-2 trial. J Am Coll Cardiol 2007; 50:1844–1851.

    Article  Google Scholar 

  26. Limkakeng AT, Halpern E, Takakuwa KM. Sixty-four slice multidetector computed tomography: the future of ED cardiac care. Am J Emerg Med 2007; 25:450–458.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

Copyright information

© 2008 Current Medicine Group, a part of Springer Science+Business Media

About this chapter

Cite this chapter

Bavry, A.A., Bhatt, D.L. (2008). Controversies and future approaches. In: Managing Acute Coronary Syndromes in Clinical Practice. Springer Healthcare, Tarporley. https://doi.org/10.1007/978-1-908517-14-2_9

Download citation

Publish with us

Policies and ethics