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Objectives This study sought to assess whether the use of eptifibatide instead of abciximab is associated with a difference in outcomes of patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). Background Pooled data from randomized controlled trials suggest that the use of abciximab may be associated with a survival advantage in patients undergoing primary PCI for acute STEMI. However, a large proportion of patients in the community are treated with eptifibatide, an agent that shares some but not all pharmacological properties with abciximab. Methods We evaluated the outcomes of 3,541 patients who underwent primary PCI for STEMI from October 2002 to July 2006 in a large regional consortium and who were treated with abciximab (n = 729) or with eptifibatide (n = 2,812). Results There was no difference in the incidence of in-hospital death (4.1% with abciximab vs. 3.5% with eptifibatide, p = 0.39), recurrent myocardial infarction (0.8% vs. 1.2%, p = 0.42), or stroke/transient ischemic attack (0.7% vs. 0.6%, p = 0.80). There was no difference in the need for blood transfusion (12.4% vs. 11.7%, p = 0.61), whereas there was a greater incidence of gastrointestinal bleeding with abciximab (4.8% vs. 2.8%, p = 0.01). In parsimonious risk-adjusted models, no significant difference between abciximab and eptifibatide was observed with respect to any of the outcomes measures. Conclusions Currently, eptifibatide is used as the adjunct antiplatelet agent in the majority of patients undergoing primary PCI. There is no apparent difference in early outcomes of patients treated with eptifibatide compared with patients treated with abciximab.

Background— Neoatherosclerosis is an emerging phenomenon in which lipid-rich plaques (LRPs) develop within pre-existing stents. This study was undertaken to describe near-infrared spectroscopy (NIRS) and intravascular ultrasound findings in pre-existing stents and to compare NIRS findings in pre-existing stents, in which an increased lipid signal has been speculated to indicate neoatherosclerosis, and NIRS findings in a control group of freshly implanted stents, in which any lipid signal originates from fibroatheroma under the stent. Methods and Results— At the site of LRP detected by NIRS in a cohort of pre-existing stents, intravascular ultrasound was used to determine the presence of neointimal tissue. The lipid-core burden index and maximum lipid-core burden index in 4 mm were measured within stented segments. Findings were compared between pre-existing stents and a control group of freshly implanted stents. Among 60 pre-existing stents implanted 5.5±4.0 years earlier, NIRS detected LRP in 33%. At the site of LRP, intravascular ultrasound found no neointimal tissue in 35% of cases. NIRS findings in pre-existing stents were indistinguishable from those of freshly implanted stents (lipid-core burden index: 50±72 versus 42±58; P =0.40 and maximum lipid-core burden index in 4 mm: 156±184 versus 155±203; P =0.69). Conclusions— The detection of LRP in a pre-existing stent by NIRS alone is not reliable evidence of neoatherosclerosis, as the lipid signal may originate from fibroatheroma underlying the stent. By identifying the presence or absence of neointimal tissue at the site of LRP detected by NIRS, intravascular ultrasound may provide some insight into the potential source of the lipid signal in pre-existing stents. Registration Information— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01694368.

Aims A recent study demonstrated that intracoronary near-infrared spectroscopy (NIRS) findings in non-target vessels are associated with major adverse cardiovascular and cerebrovascular events (MACCE). It is unknown whether NIRS findings at non-stented sites in target vessels are similarly associated with future MACCE. This study evaluated the association between large lipid-rich plaques (LRP) detected by NIRS at non-stented sites in a target artery and subsequent MACCE. Methods and results This study evaluated 121 consecutive registry patients undergoing NIRS imaging in a target artery. After excluding stented segments, target arteries were evaluated for a large LRP, defined as a maximum lipid core burden index in 4 mm (maxLCBI4 mm) ≥400. Excluding events in stented segments, Cox regression analysis was performed to evaluate for an association between a maxLCBI4 mm ≥400 and future MACCE, defined as all-cause mortality, non-fatal acute coronary syndrome, and cerebrovascular events. NIRS detected a maxLCBI4 mm ≥400 in a non-stented segment of the target artery in 17.4% of patients. The only baseline clinical variable marginally associated with MACCE was ejection fraction (HR 0.96, 95% CI 0.93–1.00, P = 0.054). A maxLCBI4 mm ≥400 in a non-stented segment at baseline was significantly associated with MACCE during follow-up (HR 10.2, 95% CI 3.4–30.6, P < 0.001). Conclusion Detection of large LRP by NIRS at non-stented sites in a target artery was associated with an increased risk of future MACCE. These findings support ongoing prospective studies to further evaluate the ability of NIRS to identify vulnerable patients. [10.1093/ehjci/jew016][1] [1]: /lookup/doi/10.1093/ehjci/jew016

Acute myocardial infarction during pregnancy has been reported and has been shown to be associated with poor maternal and fetal outcomes. However, the vast majority of these patients do not have previously recognized ischemic heart disease. Pregnancy and delivery pose significant cardiac stress and risk to the mother and fetus. However, it is unknown how available therapies can be utilized in the pregnant patient with identified ischemic heart disease to minimize these risks. Case Report: We present a 39-year-old asymptomatic diabetic female with a positive stress echocardiogram at 16 weeks of pregnancy who remained asymptomatic throughout pregnancy with medical management and went on to have a normal vaginal delivery in the process suffering a small non-ST elevation myocardial infarction with pulmonary edema following delivery due to volume overload. She ultimately underwent cardiac catheterization and successful four-vessel CABG 1 months after her delivery. Conclusion: We present this patient to suggest a successful strategy of managing a patient with non-revascularized asymptomatic coronary artery disease during pregnancy. In addition to reviewing the appropriate medical therapy during pregnancy, we discuss the data on revascularization procedures as well as recommendations for delivery and stress testing for such patients.

RESENTATION fter 3 hours of increasingly intense chest pain, our patient, 50-year-old female smoker, called an ambulance. She had xperienced 2 hours of intermittent, substernal low-intenity, dull aching chest pain, followed by 1 hour of severe nd continuous pain with radiation to the left shoulder and rm. Prehospital electrocardiogram revealed normal sinus hythm and ST elevation in leads II, III, aVF, and V2-V6, ndicating inferior-lateral acute ST-elevation myocardial inarction (STEMI). (Figure 1) Emergency medical personnel ave her 4 aspirin tablets of 81 mg each, to be chewed and wallowed, and sublingual nitroglycerine 0.4 mg on the way o the hospital. Upon arrival at the emergency room, the patient contined to complain of substernal chest pain and rated the pain s an 8 on a 110 scale, with 10 being the highest. Further valuation revealed that the patient had had a previous yocardial infarction in 1990. Given her 60-pack-year moking habit and medical history, including type 2 diabees mellitus, obesity, hypertension, chronic obstructive airay disease, and hyperlipidemia, she was at high risk for nother. Her home medications include fluticasone/salmetrol inhaler, insulin, clopidogrel, potassium supplement, itamins, lovastatin, lisinopril, omeprazole, metoprolol, asirin, and furosemide. The patient was allergic to sulfa edications. Additional presenting features included: no xcessive caffeine intake; no history of substance abuse; no istory of premature coronary artery disease in first-degree elatives; and an intentional 15-pound weight loss over the revious 5 months due to very restrictive dieting. The patient’s vital signs were stable with temperature of 7° F, heart rate of 70 bpm, blood pressure of 117/63 mm

Despite many recent advancements in the treatment of coronary heart disease, it continues to be an important source of patient morbidity and mortality as well as a significant source of healthcare-related expenditures. Clopidogrel has become an integral part of the management of acute coronary syndromes (ACS) and, consequently, has become one of the world's best selling drugs. Numerous trials have demonstrated the clinical efficacy of clopidogrel in revascularized and nonrevascularized ACS including unstable angina as well as non-ST elevation and ST-elevation myocardial infarction. As a result of these trials, the use of clopidogrel has been incorporated into the American College of Cardiology/American Heart Association guidelines. Additionally, numerous analyses have proven clopidogrel to be highly cost effective. However, clopidogrel remains underutilized and guideline adherence remains inadequate despite the robust clinical data and guidelines. Institution of disease-management programs and quality-improvement initiatives appear to be an excellent strategy to promote guideline adherence and appropriate use of clopidogrel.

This study sought to assess whether the use of eptifibatide instead of abciximab is associated with a difference in outcomes of patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).Pooled data from randomized controlled trials suggest that the use of abciximab may be associated with a survival advantage in patients undergoing primary PCI for acute STEMI. However, a large proportion of patients in the community are treated with eptifibatide, an agent that shares some but not all pharmacological properties with abciximab.We evaluated the outcomes of 3,541 patients who underwent primary PCI for STEMI from October 2002 to July 2006 in a large regional consortium and who were treated with abciximab (n = 729) or with eptifibatide (n = 2,812).There was no difference in the incidence of in-hospital death (4.1% with abciximab vs. 3.5% with eptifibatide, p = 0.39), recurrent myocardial infarction (0.8% vs. 1.2%, p = 0.42), or stroke/transient ischemic attack (0.7% vs. 0.6%, p = 0.80). There was no difference in the need for blood transfusion (12.4% vs. 11.7%, p = 0.61), whereas there was a greater incidence of gastrointestinal bleeding with abciximab (4.8% vs. 2.8%, p = 0.01). In parsimonious risk-adjusted models, no significant difference between abciximab and eptifibatide was observed with respect to any of the outcomes measures.Currently, eptifibatide is used as the adjunct antiplatelet agent in the majority of patients undergoing primary PCI. There is no apparent difference in early outcomes of patients treated with eptifibatide compared with patients treated with abciximab.

Background— There are less data on the clinical and diagnostic imaging characteristics, management, and outcomes of patients with previous cardiac surgery (PCS) presenting with acute type A aortic dissection (AAD). Methods and Results— In 617 patients with AAD, we evaluated the differences in the clinical characteristics, management, and in-hospital outcomes of the cohorts with and without PCS. A history of PCS was present in 100 of 617 patients. Patients with PCS were more likely to be males ( P =0.02), older ( P =0.014), and to have a history of previous aortic dissection ( P P P P =0.007). Fewer AAD patients with PCS underwent surgical repair ( P =0.001). Hospital mortality was not adversely influenced by PCS (odds ratio [OR], 1.46; 95% confidence interval [CI], 0.81 to 2.63), but a trend for increased death was seen in patients with previous aortic valve replacement (AVR) (OR, 2.31; 95% CI, 0.98 to 5.43). Age70 years or older, previous AVR, shock, and renal failure identified PCS patients at risk for death. Conclusions— Our study highlights differences in clinical characteristics, management, and outcomes of AAD patients with PCS. Importantly, PCS, with the exception of previous AVR, does not adversely influence early outcomes of AAD patients, including those undergoing surgical repair. However, because of otherwise dismal outcomes with medical management of AAD, our data indicate that a history of PCS (even that of previous AVR) should not preclude physicians from recommending surgical correction of type A aortic dissection in appropriate patients.

Acute myocardial infarction during pregnancy has been reported and has been shown to be associated with poor maternal and fetal outcomes. However, the vast majority of these patients do not have previously recognized ischemic heart disease. Pregnancy and delivery pose significant cardiac stress and risk to the mother and fetus. However, it is unknown how available therapies can be utilized in the pregnant patient with identified ischemic heart disease to minimize these risks.We present a 39-year-old asymptomatic diabetic female with a positive stress echocardiogram at 16 weeks of pregnancy who remained asymptomatic throughout pregnancy with medical management and went on to have a normal vaginal delivery in the process suffering a small non-ST elevation myocardial infarction with pulmonary edema following delivery due to volume overload. She ultimately underwent cardiac catheterization and successful four-vessel CABG 1 months after her delivery.We present this patient to suggest a successful strategy of managing a patient with non-revascularized asymptomatic coronary artery disease during pregnancy. In addition to reviewing the appropriate medical therapy during pregnancy, we discuss the data on revascularization procedures as well as recommendations for delivery and stress testing for such patients.