Reperfusion in Acute Myocardial Infarction: How is the Future Shaping up?

Current evidence from several clinical trials indicates that primary angioplasty in patients with acute myocardial infarction (AMI) appears superior reperfusion therapy to immediate thrombolysis, even when transfer to an angioplasty center is necessary. Thus, organization of ambulance systems and adequate angioplasty facilities appears to be the key issue in providing the most effective contemporary reperfusion therapy for AMI. Furthermore, on-site primary coronary angioplasty in high-risk AMI patients at hospitals with no cardiac surgery on-site is nowdays considered safe, effective, and faster than angioplasty after transfer to a surgical facility.    Randomized trials have demonstrated the superiority of primary angioplasty with stent implantation over balloon angioplasty alone in the treatment of AMI, including patients with diabetes. Stent use has been associated with significant decreases in length of stay, major adverse cardiovascular events, and in-hospital mortality. Finally, because of the risk of stent thrombosis, the issue of whether drug-eluting stents are safe or even more beneficial than bare-metal stents in patients with AMI, as in other non-AMI patient groups, remains uncertain, although preliminary data seem to favour the use of drug-eluting stents

Stable Coronary Artery Disease: When is Percutaneous Coronary Intervention Indicated?

In patients with chronic coronary artery disease (CAD) and good left ventricular function, percutaneous coronary intervention (PCI) does not confer any clear benefit in terms of hard long-term clinical outcomes, such as mortality, myocardial infarction or the need for subsequent revascularization, as compared with medical conservative treatment. Indeed, a meta-analysis of early data from 6 randomised controlled trials has showed convincingly that PCI improves anginal symptoms compared to conservative management, but there has been limited evidence on the effect of PCI on hard clinical outcomes. At the same time, the early fear of increased need for revascularization after PCI is probably not warranted. By comparing the benefits against cost considerations, it seems hat many percutaneous interventions that are currently performed in patients with non-acute CAD are probably not justified

Optimal Timing of Coronary Angiography and Potential Intervention in Non-ST Elevation Acute Coronary Syndromes

An invasive approach is currently considered superior to medicalmanagement for the treatment of patients with non-ST elevation acute coronary syndromes (ACS) (NSTE-ACS). However, the optimal timing of coronary angiography and subsequent intervention, if indicated, i.e. immediately after admission or after pre-treatment with optimal medical therapy including potent antiplatelet agents, has not been settled. Thrombotic material in patients with unstable angina may increasethe risk of immediate coronary intervention and there is concern that adverse events such as myocardial infarction may be increased with routine early intervention. Thus, delayed catheterization to allow plaque passivation by pre-treatment with optimal antithrombotic medication has been proposed, particularly since the effectiveness of invasive strategies has been enhanced by the widespread use of glycoprotein IIb/IIIa inhibitors... (excerpt

Stable Coronary Artery Disease: When is Percutaneous Coronary Intervention Indicated?

In patients with chronic coronary artery disease (CAD) and good left ventricular function, percutaneous coronary intervention (PCI) does not confer any clear benefit in terms of hard long-term clinical outcomes, such as mortality, myocardial infarction or the need for subsequent revascularization, as compared with medical conservative treatment. Indeed, a meta-analysis of early data from 6 randomised controlled trials has showed convincingly that PCI improves anginal symptoms compared to conservative management, but there has been limited evidence on the effect of PCI on hard clinical outcomes. At the same time, the early fear of increased need for revascularization after PCI is probably not warranted. By comparing the benefits against cost considerations, it seems that many percutaneous interventions that are currently performed in patients with non-acute CAD are probably not justified