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An editorial discusses the potential of drug-coated balloons (DCBs) as a treatment for in-stent restenosis in coronary artery disease. It highlights the AGENT IDE study, the first U.S. trial evaluating DCBs, which showed superiority over conventional balloons in reducing adverse events. It notes that using noncoated balloons as the control may not reflect current practice.

The article focuses on the results of the TAILOR-PCI randomized study examining a clinical decision strategy that depends on CYP2C19 genotyping to guide antiplatelet drug assignment following percutaneous coronary interventions. Study subjects received clopidogrel without initial genetic testing while another group of subjects received clopidogrel versus ticagrelor or prasugel. It suggests the use of a personalized medicine approach that involved genotyping for therapeutic interventions.

The authors comment on a Japanese study that examined iterations of shorter-duration dual antiplatelet therapy (DAPT) in patients in Japan who received everolimus-eluting stents by discontinuing aspirin instead of the P2Y12 inhibitor as has commonly been the approach. They compare the findings of the study with those of a similar study in Korea that involved patients who received a current-generation drug-eluting stent. They also discuss the possible impact of the results on clinical practice.

This article focuses on a placebo-controlled phase 3 study of the effectiveness of the drug, pexelizumab, as an adjunct to percutaneous transliminal coronary intervention (PCI) in the treatment of patients with acute ST-elevation myocardial infarction. Patients received either placebo or pexelizumab prior to PCI. The main outcome measures were all-cause mortality up to the 30th day, death up to the 90th day and either death, cardiogenic shock or congestive heart failure through days 30 and 90. This study determined that mortality was low in the subjects studied and the administration of pexelizumab did not affect mortality rate.

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]

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]

Context: The secondary prevention benefit of therapy with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) has been clearly demonstrated; however, the role of early initiation of statins after acute coronary syndromes (ACSs) is unknown. Objective: To evaluate the association of early statin initiation (≤7 days) after ACS with 90-day and 1-year outcomes. Design: Observational cohort from databases of 2 randomized clinical trials, SYMPHONY and 2nd SYMPHONY. Setting: Nine hundred thirty-one clinical centers in 37 countries. Patients: A total of 12 365 ACS patients randomized from August 1997 to August 1999 who were not taking statins prior to the index ACS and who either started statin therapy early (median, 2.0 [interquartile range, 1.0-3.1] days after ACS; n = 3952) or survived more than 5 days after ACS and never received statin therapy (n = 8413). Main Outcome Measures: Ninety-day incidence of death; death or myocardial infarction (MI); and death, MI, or severe recurrent ischemia; as well as 1-year incidence of death. Results: Ninety-day and 1-year unadjusted mortality comparison suggested early statin benefit (1.2% for early statins vs 2.1% for no statins; hazard ratio [HR], 0.58; 95% confidence interval [CI], 0.42-0.81 for 90-day comparisons and 2.3% for early statins vs 4.4% for no statins; HR, 0.52; 95% CI, 0.40-0.68 for 1-year comparison). However, no benefit was evident for 90-day death or MI (6.5% vs 6.9%; HR, 0.95; 95% CI, 0.82-1.11) or death, MI, or severe recurrent ischemia (9.2% vs 8.9%; HR, 1.04; 95% CI, 0.92-1.18). After propensity and covariate adjustment, there were no 90-day or 1-year differences between the early-statin group and the no-statin group. The 90-day adjusted HR for death was 1.08 (95% CI, 0.75-1.56); for death or MI, 1.08 (95% CI, 0.91-1.29); and for death, MI, or severe recurrent ischemia, 1.15 (95% CI, 0.99-1.34). One-year mortality-adjusted HR was 0.99 (95% CI, 0.73-1.33). Among 2711 patients with core... [ABSTRACT FROM AUTHOR]

The editorial focuses on target vessel revascularization (TVR) and in-stent restenosis (ISR). The results of clinical trials, such as TAXUS V ISR whose patients had paclitaxel-eluting stents and Sirolimus-Eluting Stent with Vascular Brachytherapy for the Treatment of In-Stent Restonisis (SISR), indicate outcomes from drug-eluting stent implantation are better than those using brachytherapy. The author suggests methods for further research.

Presents an editorial regarding the treatment of ischemic heart disease for patients with acute coronary syndrome and for those undergoing percutaneous coronary intervention. Description of a study conducted by the Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis in Myocardial Infarction investigators; Trial in which patients receiving thrombolytic therapy received a dose of either clopidogrel or placebo; Reference to a study by Sabatine et al. in the September 14, 2005 issue of the journal regarding clopidogrel pretreatment.

Presents an editorial about fractionating heparins. Use of heparins in reducing ischemic events beyond that of aspirin alone in the setting of an acute coronary syndrome; Limitations of unfractionated heparins; Description of enoxaparin, a low-molecular-weight heparin; Results of clinical trials of enoxaparin; Reference to studies in this issue focusing on enoxaparin trials; Assertion that enoxaparin is an effective, noninferior alternative to unfractionated heparin for treatment of acute coronary syndrome.

This editorial comments on a study in this issue which compared two drug-eluting stents and found little difference in their efficacy. Although the study did not find much difference, the authors say a meta-analysis of 38 trials suggested that the sirolimus-eluting stents were better than the paclitaxel-eluting stents. Physicians will have to choose which stent to use based on multiple factors such as safety, availability, cost and effectiveness.

Presents a letter to the editor about fractionating heparin.

Editorial. Discusses the cardiac isoforms of troponin I (cTnI) and T (cTnT), which are markers of acute coronary syndrome (ACS). Reference to an article in the same issue by Morrow et al; Suggestion that the findings of Morrow support an early invasive strategy for troponin-positive patients with ACS; Problems with cTnI and cTnT assays, both laboratory based and point-of-care based.