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Importance: Acute coronary syndromes (ACS) are characterized by a sudden reduction in blood supply to the heart and include ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. Each year, an estimated more than 7 million people in the world are diagnosed with ACS, including more than 1 million patients hospitalized in the US.Observations: Chest discomfort at rest is the most common presenting symptom of ACS and affects approximately 79% of men and 74% of women presenting with ACS, although approximately 40% of men and 48% of women present with nonspecific symptoms, such as dyspnea, either in isolation or, more commonly, in combination with chest pain. For patients presenting with possible ACS, electrocardiography should be performed immediately (within 10 minutes of presentation) and can distinguish between STEMI and non-ST-segment elevation ACS (NSTE-ACS). STEMI is caused by complete coronary artery occlusion and accounts for approximately 30% of ACS. ACS without significant ST-segment elevation on electrocardiography, termed NSTE-ACS, account for approximately 70% of ACS, are caused by partial or intermittent occlusion of the artery and are associated with ST-segment depressions (approximately 31%), T-wave inversions (approximately 12%), ST-segment depressions combined with T-wave inversions (16%), or neither (approximately 41%). When electrocardiography suggests STEMI, rapid reperfusion with primary percutaneous coronary intervention (PCI) within 120 minutes reduces mortality from 9% to 7%. If PCI within 120 minutes is not possible, fibrinolytic therapy with alteplase, reteplase, or tenecteplase at full dose should be administered for patients younger than 75 years without contraindications and at half dose for patients 75 years or older (or streptokinase at full dose if cost is a consideration), followed by transfer to a facility with the goal of PCI within the next 24 hours. High-sensitivity troponin measurements are the preferred test to evaluate for NSTEMI. In high-risk patients with NSTE-ACS and no contraindications, prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours are associated with a reduction in death from 6.5% to 4.9%.Conclusions and Relevance: Each year, an estimated more than 7 million people are diagnosed with ACS worldwide. For patients with STEMI, coronary catheterization and PCI within 2 hours of presentation reduces mortality, with fibrinolytic therapy reserved for patients without access to immediate PCI. For high-risk patients with NSTE-ACS without contraindications, prompt invasive coronary angiography followed by percutaneous or surgical revascularization is associated with lower rates of death. [ABSTRACT FROM AUTHOR]

Importance: Little information exists about the anatomical characteristics and clinical relevance of non-infarct-related artery (IRA) disease among patients with ST-segment elevation myocardial infarction (STEMI).Objectives: To investigate the incidence, extent, and location of obstructive non-IRA disease and compare 30-day mortality according to the presence of non-IRA disease in patients with STEMI.Design, Setting, and Participants: Retrospective study of patients pooled from a convenience sample of 8 independent, international, randomized STEMI clinical trials published between 1993 and 2007. Follow-up varied from 1 month to 1 year. Among 68,765 patients enrolled in the trials, 28,282 patients with valid angiographic information were included in this analysis. Obstructive coronary artery disease was defined as stenosis of 50% or more of the diameter of a major epicardial artery. To assess the generalizability of trial-based results, external validation was performed using observational data for patients with STEMI from the Korea Acute Myocardial Infarction Registry (KAMIR) (between November 1, 2005, and December 31, 2013; n = 18,217) and the Duke Cardiovascular Databank (between January 1, 2005, and December 31, 2012; n = 1812).Main Outcomes and Measures: Thirty-day mortality following STEMI.Results: Overall, 52.8% (14,929 patients) had obstructive non-IRA disease; 29.6% involved 1 vessel and 18.8% involved 2 vessels. There was no substantial difference in the extent and distribution of non-IRA disease according to the IRA territory. Unadjusted and adjusted rates of 30-day mortality were significantly higher in patients with non-IRA disease than in those without non-IRA disease (unadjusted, 4.3% vs 1.7%, respectively; risk difference, 2.7% [95% CI, 2.3% to 3.0%], P < .001; and adjusted, 3.3% vs 1.9%, respectively; risk difference, 1.4% [95% CI, 1.0% to 1.8%], P < .001). The overall prevalence and association of non-IRA disease with 30-day mortality was consistent with findings from the KAMIR registry (adjusted, 3.6% for patients with non-IRA disease vs 2.5% in those without it; risk difference, 1.1% [95% CI, 0.6% to 1.7%]; P < .001), but not with the Duke database (adjusted, 4.7% with non-IRA disease vs 4.3% without it; risk difference, 0.4% [95% CI, -1.4% to 2.2%], P = .65).Conclusions and Relevance: In a retrospective pooled analysis of 8 clinical trials, obstructive non-IRA disease was common among patients presenting with STEMI, and was associated with a modest statistically significant increase in 30-day mortality. These findings require confirmation in prospectively designed studies, but raise questions about the appropriateness and timing of non-IRA revascularization in patients with STEMI. [ABSTRACT FROM AUTHOR]

IMPORTANCE Little information exists about the anatomical characteristics and clinical relevance of non--infarct-related artery (IRA) disease among patients with ST-segment elevation myocardial infarction (STEMI). OBJECTIVES To investigate the incidence, extent, and location of obstructive non-IRA disease and compare 30-day mortality according to the presence of non-IRA disease in patients with STEMI. DESIGN, SETTING, AND PARTICIPANTS Retrospective study of patients pooled from a convenience sample of 8 independent, international, randomized STEMI clinical trials published between 1993 and 2007. Follow-up varied from 1 month to 1 year. Among 68 765 patients enrolled in the trials, 28 282 patients with valid angiographic information were included in this analysis. Obstructive coronary artery disease was defined as stenosis of 50% or more of the diameter of a major epicardial artery. To assess the generalizability of trial-based results, external validation was performed using observational data for patients with STEMI from the Korea Acute Myocardial Infarction Registry (KAMIR) (between November 1, 2005, and December 31, 2013; n = 18 217) and the Duke Cardiovascular Databank (between January 1, 2005, and December 31, 2012; n = 1812). MAIN OUTCOMES AND MEASURES Thirty-day mortality following STEMI. RESULTS Overall, 52.8%(14 929 patients) had obstructive non-IRA disease; 29.6%involved 1 vessel and 18.8% involved 2 vessels. There was no substantial difference in the extent and distribution of non-IRA disease according to the IRA territory. Unadjusted and adjusted rates of 30-day mortality were significantly higher in patients with non-IRA disease than in those without non-IRA disease (unadjusted, 4.3%vs 1.7%, respectively; risk difference, 2.7%[95% CI, 2.3%to 3.0%], P < .001; and adjusted, 3.3%vs 1.9%, respectively; risk difference, 1.4% [95%CI, 1.0% to 1.8%], P < .001). The overall prevalence and association of non-IRA disease with 30-day mortality was consistent with findings from the KAMIR registry (adjusted, 3.6% for patients with non-IRA disease vs 2.5%in those without it; risk difference, 1.1%[95%CI, 0.6%to 1.7%]; P < .001), but not with the Duke database (adjusted, 4.7%with non-IRA disease vs 4.3%without it; risk difference, 0.4%[95%CI, --1.4%to 2.2%], P = .65). CONCLUSIONS AND RELEVANCE In a retrospective pooled analysis of 8 clinical trials, obstructive non-IRA disease was common among patients presenting with STEMI, and was associated with a modest statistically significant increase in 30-day mortality. These findings require confirmation in prospectively designed studies, but raise questions about the appropriateness and timing of non-IRA revascularization in patients with STEMI. [ABSTRACT FROM AUTHOR]

The article presents information on the effects of the acadesine, an adenosine-regulating agent on the morbidity and mortality associated with the coronary artery bypass grafting (CABG), which could be high in the patients with poor left ventricular function. It informs that the several drugs with purported cardioprotective effects including sodium-proton exchange inhibitor, a complement activation inhibitor and a purinergic receptor antagonist failed during the randomized control trials in the patients undergoing the CABG surgery. It further informs that there is a requirement of a fully functional therapy for this.

The article discusses a study of the safety and efficacy of a single intravenous bolus of epoetin alfa in patients with ST-segment elevation myocardial infarction (STEMI) in the U.S. conducted from October 2006 to February 2010. The risk for developing infarct expansion and left ventricular (LV) remodeling are facing patients who survive STEMI. Vital signs, hemoglobin level, reticulocyte count and clinical events were some of the factors considered as safety end points. Results show a lack of association between infarct size and time from study drug administration to first cardiac magnetic resonance (CMR). Also noted is the higher incidence of adverse events in participants who received epoetin alfa.

The article focuses on a study which investigated the association between sex and 30-day mortality in acute coronary syndromes (ACS). The study included patients who participated in 11 independent and randomized ACS clinical trials between 1993 and 2006. It found that 30-day mortality was 9.6 percent in women and 5.3 percent in men. It also discovered that the relationship between sex and 30-day mortality was similar across angiographic disease severity levels. Study authors concluded that the sex-based differences in 30-day mortality can be explained by the clinical differences at presentation and severity of angiographically-documented condition.

The author discusses the need for the proper use of the criteria for coronary revascularization and for the learning health system. It mentions the principle promoted by the Institute of Medicine on the health care system and the promotion of natural outgrowth of patient care. It discusses the programs initiated by the American Heart Association (AHA) and the American College of Cardiology on the care for patients with coronary revascularization.

The article focuses on a study testing the effectiveness and safety of the naturally occurring pyridoxine metabolite and purinergic receptor antagonist MC-1 given to patients undergoing coronary artery bypass graft (CABG) surgery. The objective of the trial was to reduce morbidity and mortality rates in CABG patients due to common complications related to ischemia-reperfusion injury and myocardial infarction (MI). Researchers concluded that MC-1 did not reduce cardiovascular death or nonfatal MI among intermediate to high-risk patients undergoing CABG surgery.

Context: Cardiogenic shock complicating acute myocardial infarction (MI) remains a common and lethal disorder despite aggressive use of early revascularization. Systemic inflammation, including expression of inducible nitric oxide synthase (NOS) and generation of excess nitric oxide, is believed to contribute to the pathogenesis and inappropriate vasodilatation of persistent cardiogenic shock. Preliminary, single-center studies suggested a beneficial effect of NOS inhibition on hemodynamics, renal function, and survival in patients with cardiogenic shock.Objective: To examine the effects of an isoform-nonselective NOS inhibitor in patients with MI and refractory cardiogenic shock despite establishment of an open infarct artery.Design, Setting, and Patients: International, multicenter, randomized, double-blind, placebo-controlled trial (Tilarginine Acetate Injection in a Randomized International Study in Unstable MI Patients With Cardiogenic Shock [TRIUMPH]) with planned enrollment of 658 patients at 130 centers. Participants were enrolled between January 2005 and August 2006 when the study was terminated early.Intervention: Tilarginine (L-N(G)-monomethylarginine [L-NMMA]), 1-mg/kg bolus and 1-mg/kg per hour 5-hour infusion, vs matching placebo.Main Outcome Measures: The primary outcome was 30-day all-cause mortality among patients who received study medication. Secondary outcomes included shock resolution and duration, New York Heart Association (NYHA) functional class at 30 days, and 6-month mortality.Results: Enrollment was terminated at 398 patients based on a prespecified futility analysis. Six-month follow-up was completed in February 2007. There was no difference in 30-day all-cause mortality between patients who received tilarginine (97/201 [48%]) vs placebo (76/180 [42%]) (risk ratio, 1.14; 95% confidence interval, 0.92-1.41; P = .24). Resolution of shock (133/201 [66%] tilarginine vs 110/180 [61%] placebo; P = .31) and duration of shock (median, 156 [interquartile range, 78-759] hours tilarginine vs 190 [100-759] placebo; P = .16) were similar. At 30 days a similar percentage of patients had heart failure (48% tilarginine vs 51% placebo; P = .51) with a similar percentage of those patients in NYHA class I/II (73% tilarginine vs 75% placebo; P = .27). After 6 months mortality rates were similar in the 2 groups (58% tilarginine vs 59% placebo; hazard ratio, 1.04; 95% confidence interval, 0.79-1.36; P = .80).Conclusions: Tilarginine, 1-mg/kg bolus and 5-hour infusion, did not reduce mortality rates in patients with refractory cardiogenic shock complicating MI despite an open infarct artery. Early mortality rates in this patient group are high. Further research is needed to develop effective therapies for patients with cardiogenic shock following acute MI.Trial Registration: clinicaltrials.gov Identifier: NCT00112281 [ABSTRACT FROM AUTHOR]

The authors discuss facets and strategies of the study reported in this issue in the article, "Routine upstream initiation vs deferred selective use of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes." They feel the study provides valuable insights for clinical practice and research and suggest that, until risks linked to increases in bleeding and ischemic complications are clarified, clinical decision making should be weighed on a case-by-case basis.

The article discusses a clinical study that was conducted to examine the association between the use of the drug clopidogrel after patients received either a drug-eluting stent or a bare-metal stent for the treatment of coronary artery disease. Clopidogrel is a drug used in thienopyridine antiplatelet therapy to prevent late stent thrombosis. The authors were interested in the long-term outcomes of patients and found that the use of clopidogrel in patients with drug-eluting stents may be associated with a lower risk of death or myocardial infarction.

ontext Selected care processes are increasingly being used to measure hospital quality; however, data regarding the association between hospital process performance and outcomes are limited. Objectives To evaluate contemporary care practices consistent with the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations, to examine how hospital performance varied among centers, to identify characteristics predictive of higher guideline adherence, and to assess whether hospitals' overall composite guideline adherence was associated with observed and risk-adjusted in-hospital mortality rates. Design, Setting, and Participants An observational analysis of hospital care in 350 academic and nonacademic US centers of 64 775 patients enrolled in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) National Quality Improvement Initiative between January 1, 2001, and September 30, 2003, presenting with chest pain and positive electrocardiographic changes or cardiac biomarkers consistent with non-ST-segment elevation acute coronary syndrome (ACS). Main Outcome Measures Use of 9 ACC/AHA class I guideline-recommended treatments and the correlation among hospitals' use of individual care processes as well as overall composite adherence rates. Results Overall, the 9 ACC/AHA guideline-recommended treatments were adhered to in 74% of eligible instances. There was modest correlation in hospital performance among the individual ACS process metrics. However, composite adherence performance varied widely (median [interquartile range] composite adherence scores from lowest to highest hospital quartiles, 63% [59%-66%] vs 82% [80%-84%]). Composite guideline adherence rate was significantly associated with in-hospital mortality, with observed mortality rates decreasing from 6.31% for the lowest adherence quartile to 4.15% for the highest adherence quartile (P<.001). After risk adjustment, every 10% increase in composite adherence at a hospital was associated with an analogous 10% decrease in its patients' likelihood of in-hospital mortality (adjusted odds ratio, 0.90; 95% confidence interval, 0.84-0.97; P<.001). Conclusion A significant association between care process and outcomes was found, supporting the use of broad, guideline-based performance metrics as a means of assessing and helping improve hospital quality. [ABSTRACT FROM AUTHOR]

Context: Coronary artery bypass graft (CABG) surgery with autologous vein grafting is commonly performed. Progressive neointimal hyperplasia, however, contributes to considerable vein graft failure. Edifoligide is an oligonucleotide decoy that binds to and inhibits E2F transcription factors and thus may prevent neointimal hyperplasia and vein graft failure.Objective: To assess the efficacy and safety of pretreating vein grafts with edifoligide for patients undergoing CABG surgery.Design, Setting, and Participants: A phase 3 randomized, double-blind, placebo-controlled trial of 3014 patients undergoing primary CABG surgery with at least 2 planned saphenous vein grafts and without concomitant valve surgery, who were enrolled between August 2002 and October 2003 at 107 US sites.Intervention: Vein grafts were treated ex vivo with either edifoligide or placebo in a pressure-mediated delivery system. The first 2400 patients enrolled were scheduled for 12- to 18-month follow-up angiography.Main Outcome Measures: The primary efficacy end point was angiographic vein graft failure (> or =75% vein graft stenosis) occurring 12 to 18 months after CABG surgery. Other end points included other angiographic variables, adverse events through 30 days, and major adverse cardiac events.Results: A total of 1920 patients (80%) either died (n = 91) or underwent follow-up angiography (n = 1829). Edifoligide had no effect on the primary end point of per patient vein graft failure (436 [45.2%] of 965 patients in the edifoligide group vs 442 [46.3%] of 955 patients in the placebo group; odds ratio, 0.96 [95% confidence interval {CI}, 0.80-1.14]; P = .66), on any secondary angiographic end point, or on the incidence of major adverse cardiac events at 1 year (101 [6.7%] of 1508 patients in the edifoligide group vs 121 [8.1%] of 1506 patients in the placebo group; hazard ratio, 0.83 [95% CI, 0.64-1.08]; P = .16).Conclusions: Failure of at least 1 vein graft is quite common within 12 to 18 months after CABG surgery. Edifoligide is no more effective than placebo in preventing these events. Longer-term follow-up and additional research are needed to determine whether edifoligide has delayed beneficial effects, to understand the mechanisms and clinical consequences of vein graft failure, and to improve the durability of CABG surgery. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT00042081. [ABSTRACT FROM AUTHOR]

Context The American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of non–ST-segment elevation acute coronary syndromes (NSTE ACS) recommend early invasive management for high-risk patients, given the benefits with this approach demonstrated in randomized clinical trials. Objectives To determine the use and predictors of early invasive management strategies (cardiac catheterization <48 hours following presentation) in high-risk patients with NSTE ACS and to examine the association of early invasive management with mortality. Design, Setting, and Patients The CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Quality Improvement Initiative evaluated care patterns and outcomes for 17 926 high-risk NSTE ACS patients (positive cardiac markers and/or ischemic electrocardiographic changes) based on ACC/AHA guidelines recommendations at 248 US hospitals with catheterization and revascularization facilities between March 2000 and September 2002. Main Outcome Measures Use of early invasive management within 48 hours of presentation, predictors of early invasive management, and in-hospital mortality. Results Of the 17 926 patients analyzed, 8037 (44.8%) underwent early cardiac catheterization less than 48 hours following presentation. Predictors of early invasive management included cardiology care, younger age, lack of prior or current congestive heart failure, lack of renal insufficiency, ischemic electrocardiographic changes, positive cardiac markers, white race, and male sex. Patients treated with early invasive management were more likely to be treated with medications and interventions recommended by the ACC/AHA guidelines and had a lower risk of in-hospital mortality after adjusting for differences in clinical characteristics and after comparing propensity-matched pairs (2.5% vs 3.7%, P<.001). Conclusions An early invasive ... [ABSTRACT FROM AUTHOR]

Context It is unclear if blood transfusion in anemic patients with acute coronary syndromes is associated with improved survival. Objective To determine the association between blood transfusion and mortality among patients with acute coronary syndromes who develop bleeding, anemia, or both during their hospital course. Design, Setting, and Patients We analyzed 24,112 enrollees in 3 large international trials of patients with acute coronary syndromes (the GUSTO IIb, PURSUIT, and PARAGON B trials). Patients were grouped according to whether they received a blood transfusion during the hospitalization. The association between transfusion and outcome was assessed using Cox proportional hazards modeling that incorporated transfusion as a time-dependent covariate and the propensity to receive blood, and a landmark analysis. Main Outcome Measure Thirty-day mortality. Results Of the patients included, 2401 (10.0%) underwent at least 1 blood transfusion during their hospitalization. Patients who underwent transfusion were older and had more comorbid illness at presentation and also had a significantly higher unadjusted rate of 30-day death (8.00% vs 3.08%; P<.001), myocardial infarction (MI) (25.16% vs 8.16%; P<.001), and death/MI (29.24% vs 10.02%; P<.001) compared with patients who did not undergo transfusion. Using Cox proportional hazards modeling that incorporated transfusion as a time-dependent covariate, transfusion was associated with an increased hazard for 30-day death (adjusted hazard ratio [HR], 3.94; 95% confidence interval [CI], 3.26-4.75) and 30-day death/MI (HR, 2.92; 95% CI, 2.55-3.35). In the landmark analysis that included procedures and bleeding events, transfusion was associated with a trend toward increased mortality. The predicted probability of 30-day death was higher with transfusion at nadir hematocrit values above 25%. Conclusions Blood transfusion in the setting of acute coronary syndromes is associated with higher mortality, and th... [ABSTRACT FROM AUTHOR]

Presents a study to systematically evaluate the end points of all-cause death and nonfatal myocardial infarction, transfusion, and major bleeding observed in the 6 randomized controlled trials comparing enoxaparin and unfractionated heparin in treatment of acute coronary syndromes. Description of the study and its results; Conclusion.

Context: In acute myocardial infarction, the presence and severity of heart failure at the time of initial presentation have been formally categorized by the Killip classification. Although well studied in ST-elevation myocardial infarction, the prognostic importance of Killip classification in non-ST-elevation acute coronary syndromes is not well established.Objectives: To determine the prognostic importance of physical examination for heart failure analyzed according to Killip classification in non-ST-elevation acute coronary syndromes and to understand its predictive value relative to other variables.Design, Setting, and Patients: From April 2001 to September 2003, We analyzed information from 26 090 patients with non-ST-elevation acute coronary syndromes enrolled in the GUSTO IIb, PURSUIT, PARAGON A, and PARAGON B trials. Demographic information was categorized by Killip class. Killip classes III and IV were combined into 1 category. Multivariate Cox proportional hazard models were developed to determine the prognostic importance of Killip classification in comparison with other variables.Main Outcome Measure: Association between Killip classification and all-cause mortality at 30 days and 6 months.Results: Patients in Killip class II (n = 2513) and III/IV (n = 390) were older than those in Killip class I (n = 23 187), with higher rates of diabetes, prior myocardial infarction, ST depression, and elevated cardiac enzymes (all P<.001). Higher Killip class was associated with higher mortality at 30 days (2.8% in Killip class I vs 8.8% in class II vs 14.4% in class III/IV; P<.001) and 6 months (5.0% vs 14.7% vs 23.0%, respectively; P<.001). Patients with Killip class II, III, or IV constituted 11% of the overall population but accounted for approximately 30% of the deaths at both time points. In multivariate analysis, Killip class III/IV was the most powerful predictor of mortality at 30 days (hazard ratio [HR], 2.35; 95% confidence interval [CI], 1.69-3.26; P<.001) and 6 months (HR, 2.12; 95% CI, 1.63-2.75; P<.001). Killip class II was predictive of mortality at 30 days (HR, 1.73; 95% CI, 1.44-2.09; P<.001) and 6 months (HR, 1.52; 95% CI, 1.31-1.76; P<.001). Five factors-age, Killip classification, heart rate, systolic blood pressure, and ST depression-provided more than 70% of the prognostic information for 30-day and 6-month mortality.Conclusions: Killip classification is a powerful independent predictor of all-cause mortality in patients with non-ST-elevation acute coronary syndromes. Age, Killip classification, heart rate, systolic blood pressure, and ST depression should receive particular attention in the initial assessment of these patients. [ABSTRACT FROM AUTHOR]

The direct thrombin inhibitor bivalirudin has been associated with better efficacy and less bleeding than heparin during coronary balloon angioplasty but has not been widely tested during contemporary percutaneous coronary intervention (PCI). The purpose of this study was to determine the efficacy of bivalirudin, with glycoprotein IIb/IIIa (Gp IIb/IIIa) inhibition on a provisional basis for complications during PCI, compared with heparin plus planned Gp IIb/IIIa blockade with regard to protection from periprocedural ischemic and hemorrhagic complications. The Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE)–2 trial, a randomized, double-blind, active-controlled trial conducted among 6010 patients undergoing urgent or elective PCI at 233 community or referral hospitals in 9 countries from October 2001 through August 2002. Patients were randomly assigned to receive intravenous bivalirudin (0.75-mg/kg bolus plus 1.75 mg/kg per hour for the duration of PCI), with provisional Gp IIb/IIIa inhibition (n = 2999), or heparin (65-U/kg bolus) with planned Gp IIb/IIIa inhibition (abciximab or eptifibatide) (n = 3011). Both groups received daily aspirin and a thienopyridine for at least 30 days after PCI. The primary composite end point was 30-day incidence of death, myocardial infarction, urgent repeat revascularization, or in-hospital major bleeding; the secondary composite end point was 30-day incidence of death, myocardial infarction, or urgent repeat revascularization. Provisional Gp IIb/IIIa blockade was administered to 7.2% of patients in the bivalirudin group. By 30 days, the primary composite end point had occurred among 9.2% of patients in the bivalirudin group vs 10.0% of patients in the heparin-plus-Gp IIb/IIIa group (odds ratio, 0.92; 95% confidence interval, 0.77-1.09; P = .32). The secondary composite end point occurred in 7.6% of patients in the... [ABSTRACT FROM AUTHOR]

Context: Controversy surrounds the diagnostic and prognostic importance of slightly elevated cardiac markers in patients with acute coronary syndromes without ST-segment elevation.Objectives: To investigate the relationship between peak creatine kinase (CK)-MB level and outcome and to determine whether a threshold CK-MB level exists below which risk is not increased.Design and Setting: Retrospective observational analysis of data from the international Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial, conducted from November 1995 to January 1997.Patients: A total of 8250 patients with acute coronary syndromes without ST-segment elevation who had at least 1 CK-MB sample collected during their index hospitalization.Main Outcome Measure: Mortality at 30 days and 6 months, was assessed by category of index-hospitalization peak CK-MB level (0-1, >1-2, >2-3, >3-5, >5-10, or >10 times the upper limit of normal). Multivariable logistic regression was used to determine the independent prognostic significance of peak CK-MB level after adjustment for baseline predictors of 30-day and 6-month mortality.Results: Mortality at 30 days and 6 months increased from 1.8% and 4.0%, respectively, in patients with normal peak CK-MB levels, to 3.3% and 6.2 % at peak CK-MB levels 1 to 2 times normal, to 5.1% and 7.5% at peak CK-MB levels 3 to 5 times normal, and to 8.3% and 11.0% at peak CK-MB levels greater than 10 times normal. Log-transformed peak CK-MB levels were predictive of adjusted 30-day and 6-month mortality (P<.001 for both).Conclusions: Our data show that elevation of CK-MB level is strongly related to mortality in patients with acute coronary syndromes without ST-segment elevation, and that the increased risk begins with CK-MB levels just above normal. In the appropriate clinical context, even minor CK-MB elevations should be considered indicative of myocardial infarction. [ABSTRACT FROM AUTHOR]

Several letters to the editor are presented in response to the article "Are medical conferences useful? and for whom?," by J. P. Ioannidis in a 2012 issue of the periodical, and a response by J. P. loannidis to letters to the editor about his article is also presented.

This editorial examines drug-eluting stents. The rapid approval of stents and short term trials did little to prepare physicians and patients for the long-term issues that have been arising. The author maintains that drug-eluting stenting is clearly a breakthrough in the prevention of restenosis. The author calls for working towards common data standards and efficient methods of data aggregation that can be integrated into clinical practice.

Questions the use of risk stratification in making therapeutic decisions in the management of acute coronary syndromes. Question as to the reliability of risk stratification; Discussion of an article in this issue of the 'Journal of the American Medical Association' which presents a scoring system to predict all-cause mortality, nonfatal MI, and severe recurrent ischemia among patients without ST-segment elevation; Implications of the study.

The authors discuss a study about the mHealth Screening to Prevent Strokes (mSToPS) pragmatic trial published within the issue. The authors state that the results of the study demonstrate the potential and the challenges inherent in a pragmatic trial for the use of information technology (IT) in health and medicine. They discuss the limitations of the study, particularly in relation to the subjects' use of their wearable electrocardiography (ECG) patch.

In this Viewpoint, Verghese and colleagues discuss the promise and challenges of integrating artificial intelligence (AI) into clinical care and argue that AI will always need guidance by physicians if it is to improve the care of patients. [ABSTRACT FROM AUTHOR]

The authors comment on cholesterol, cardiovascular risk, statins, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors and low-density lipoprotein cholesterol (LDL-C) lowering. Topics discussed include link between LDL-C and coronary heart disease (CHD) risk, information on the 2013 American College of Cardiology/American Heart Association cholesterol guidelines, and role of discovery science in developing more precise risk-prediction models.

The author focuses on the importance and development on the use of randomized controlled trials (RCTs) on research and control of the cardiovascular disease (CVD). He highlights the importance of RCT as the critical tool for the clinical investigation, and mentions the adaptation to RCT at several steps including enrollment characteristics, study of treatments, and investigation of primary endpoints during the clinical trials.

Two letters to the editor are presented in response to the article "Intravenous Erythropoietin in Patients With ST-Segment Elevation Myocardial Infarction: REVEAL: A Randomized Controlled Trial," by Samer S. Najjar and colleagues, which appeared in a previous issue.

A letter to the editor is presented written by Dr. Robert A. Harrington in response to a previous letter to the editor regarding his work with creatinine and renal function.

A response to several letters to the editor concerning the article "Efficacy and Safety of Edifoligide, an E2F Transcription Factor Decoy, for Prevention of Vein Graft Failure Following Coronary Artery Bypass Graft Surgery: PREVENT IV: A Randomized Controlled Trial," published in 2005 is presented.

Presents a reply by Sunil Rao and colleagues to a letter to the editor in response to their article "Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes."