Literature Review
Table of Contents
Etiology and Pathogenesis of STEMI/UA/NSTEMI
Angina at 1 year after myocardial infarction: prevalence and associated findings.
Maddox TM et al., Arch Intern Med 2008 Jun 23; 168:1310 PMID: 18574088
Reduction in acute myocardial infarction mortality in the United States: risk-standardized mortality rates from 1995-2006.
Krumholz HM et al., JAMA 2009 Aug 19; 302:767. PMID: 19690309
Unstable angina: an etiologic approach to management.
Braunwald E. Circulation 1998;98:2219-22 PMID: 9826306
Unstable Angina: Diagnosis and Management.
Braunwald E, Mark DB, Jones RH, et al. 1994; AHCPR Publication No. 94-0602;1-154
Coronary angiographic findings soon after non-Q-wave myocardial infarction.
DeWood MA, Stifter WF, Simpson CS, et al. N Engl J Med 1986;315:417-23 PMID: 3736619
Acute coronary syndromes: unstable angina and non-Q-wave myocardial infarction.
Theroux P, Fuster V. Circulation 1998;97:1195-206 PMID: 9537346
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Risk Stratification
Diagnostic mishaps in the ER
Redefinition of myocardial infarction: prospective evaluation in the community.
Roger VL, Killian JM, Weston SA, et al. Circulation 2006;114:790-7. PMID: 16908764
Prognositic influence of elevated values of cardiac troponin I in acute chest pain by means of rapid testing for cardiac troponin T or troponin I.
Galvani M, Ottani F, Ferrini D, et al. N Engl J Med 1997;337:1648-53. PMID: 9133515
Missed diagnoses of acute myocardial infarction in the emergency department: results from a multicenter study
McCarthy BD, Beshansky JR, D'Agostino RB, Selker HP. Ann Emerg Med. 1993;22:579-82. PMID: 8442548
Missed diagnoses of acute cardiac ischemia in the emergency department
Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, et al. N Engl J Med. 2000;342:1163-70. PMID: 10770981
Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room
Lee TH, Rouan GW, Weisberg MC, Brand DA, Acampora D, Stasiulewicz C, et al. Am J Cardiol. 1987;60:219-24. PMID: 3618483
Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin.
Hamm CW, Goldmann BU, Heeschen C, Kreymann G, Berger J, Meinertz T. N Engl J Med 1997;337:1648-53. PMID: 9385123
Prognostic influence of elevated values of cardiac troponin I in patients with unstable angina.
Galvani M, Ottani F, Ferrini D, et al. Circulation 1997;95:2053-9. PMID: 9133515
Cardiac Biomarkers
Novel and conventional biomarkers for prediction of incident cardiovascular events in the community.
Melander O et al., JAMA 2009 Jul 1; 302:49. PMID: 19567439
Standardization of creatinine kinase-MB CK-MB) mass assays: the use of recombinant CK-MB as a reference material.
Christenson RH, Vaidya H, Landt Y, et al. Clin Chem 1999;45:1414-23. PMID: 10471643
Biomarkers in acute cardiac disease: the present and the future.
Jaffe AS, Babuin L, Apple FS. J Am Coll Cardiol 2006;48:1-11. PMID: 16814641
ACC/AHA guidelines for management of Patients with Unstable angina on non-ST- Segment elevation MI, a Report for the Am Coll of Cardiol/ Am Heart Association Task Force on Practice Guidelines
Braumwald E, Antman EM, Beasley JW et al J Am Coll Cardiol 2000;36:970 -1062. PMID: 10987629
Until approximately nine years ago, CPK-MB was the best cardiac marker available. In retrospect they were not as sensitive as believed. It is estimated that one third of patients presenting without an ST-elevation and without elevations in the CPK-MB who were mistakenly diagnosed with unstable angina are now being recognized as having a Non-ST elevation MI based on positive troponin levels.
Prognostic Usefulness of Marginal Troponin T Elevation.
Henrikson, CA, Howell EE, Bush DE, et al. Am J Cardiol 93:275-79. PMID: 14759374
Essentially, a Troponin is “positive” anytime it is not completely negative. Even very small elevations of troponin correlate with the worse clinical outcomes in the ACS patient.
Elevated Cardiac Troponins: Their Significance in Actue Coronary Syndrome and Noncardiac Conditions.
Clark, M, Payne, J., J Okla St Med Assoc. 2006;99:6
PMID: 16821493
Troponin T binds to tropomysin, remains elevated for 8-21 days and is less specific than Troponin I. Trononin I binds to actin, is more specific in renal failure and remains elevated for 5-10 days. Most institutions now use TnI.
The Year in Non-ST-Segment Elevation Acute Coronary Syndromes
Giugliano, R, Braunwald, E, J Am Coll Cardiol 2005;46:906-919 PMID: 17903640
The absolute value of the troponin correlates with the intracoronary thrombus identified angiographically.
Diagnosis of Acute Coronary Syndrome.
Achar, S, Kundu S., Norcross W., Am Fam Physic. 2005;72:119-26. PMID: 16035692
Changes in myoglobin concentration can be useful where the presence of myocardial injury is already established and there’s a concern reinfarction may have occurred. The plasma myoglobin will rise within an hour and fall precipitously in the next 3-4 hours, indicating a new myocyte injury.
ECG findings
Use of the initial electrocardiogram to predict in-hospital complications of acute myocardial infarction.
Brush JE Jr, Brand DA, Acampora D, Chalmer B, Wackers FJ., N Engl J Med 1985;312:1137-41. PMID: 4022062
Risk stratification according to the initial electrocardiogram in patients with suspected acute myocardial infarction.
Fesmire FM, Percy RF, Wears RL, MacMath TL., Arch Inern Med 1989;849:1294-7. PMID: 2730248
Diagnostic and prognostic importance of comparing the initial to the previous electrocardiogram in patients admitted for suspected acute myocardial infarction.
Fesmire FM, Percy RF, Wears RL. South Med J 1991;84:841-63. PMID: 2068623
Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery.
de Zwaan C, Bar FW, Janssen JH, et al. Am Heart J 1989;117:657-65. PMID: 2784024
Marked T wave inversions (2 mm or greater) in anterior precordial leads strongly suggests acute ischemia, particularly that due to a critical stenosis of the LAD.
Reversal of segmental hypokinesis by coronary angioplasty in patients with unstable angina, persistent T wave inversion, and left anterior descending coronary artery stenosis. Additional evidence for myocardial stunning in humans.
Patients with T inversions in anterior precordial leads T inversions and hypokinesis of the anterior wall are at high risk if given medical treatment alone.
ST segment elevation and the prediction of hospital life-threatening complications: the role of right ventricular and posterior leads.
Zalenski RJ, Rydman RJ, Sloan EP, et al. J Electrocardiol 1998;3 Suppl:164-71. PMID: 9988023
Approximately 4% of acute MI patients will demonstrate an ST-segment elevation isolated to the posterior chest leads V7 thru V9. The presence of ST-segment elevation in right ventricular leads (V4R thru V6R) or posterior leads (V7 thru V9) adds additional prognostic information to a patient presenting with inferior ST-segment elevation.
Significance of ST segment elevations in posterior chest leads (V7 to V9) in patients with acute inferior myocardial infarction: application for thrombolytic therapy.
Matetzky S, Freimark D, Chouraqui P, et al. J Am Coll Cardiol 1998;31:506-11. PMID: 9502627
ST-segment elevation in V7 thro V9 is diagnostically important since it qualifies the patient for consideration of acute reperfusion therapy.
Sensitivity of routine clinical criteria for diagnosing myocardial infarction within 24 hours of hospitalization.
Lee, TH, Rouan GW, Weisberg, MC, et al. Ann Intern Med 1987; 106:181-6 PMID: 3800180
Ruling out Acute Myocardial Infarction A prospective Multicenter Validation of a 12-hour Strategy for Patients at Low Risk.
Lee, TH, Juarez GJ, Cook EF, Weisberg MC, Rouan GW, Brand DA, Goldman L. N Engl J Med. 1991;324:1239-46. PMID: 2014037
TIMI Risk Score
The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making.
Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, et al. JAMA 2000;284:835-42. PMID: 10938172
Mulitple clinical factors other than the results of cardiac biomarkers should be included in determining whether a patient will undergo a revascularization.
Actual tool is in:
ACC/AHA 2007 guidelines for the management of patients with unstable angina//non-ST segment elevation MI.
Anderson JL, Adams CD, Antman EM, et al.Circulation 2007;116:903-877 PMID: 17679616
GRACE Prediction Score
A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry.
Eagle KA, Lim MJ, Dabbous OH, et al. JAMA 2004;291:2727-33. (GRACE Prediction Model) PMID: 15187054
Predictors of hospital mortality in the global registry of acute coronary events.
Granger CB, Goldberg RJ, Dabbous O, et al. Arch Intern Med 2003;163:2345-53. PMID: 14581255
PURSUIT Risk Model
Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The Pursuit Investigators.
Boersma E, Pieper KS, Stayerberg EW, et al. Circulation 2000;101:2557-67. PMID: 10840005
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Early Invasive vs Early Conservative Management of UA/NSTEMI
Effect of PCI on quality of life in patients with stable coronary disease.
Weintraub WS et al. for the COURAGE Trial Research Group., N Engl J Med 2008 Aug 14; 359:677. PMID: 18703470
Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q myocardial infarction: results of the TIMI IIIB trial.
TIMI IIIB Trial Investigators. Circulation 89:1545, 1994. PMID: 8149520
The study showed the initial hospitalization was longer and the need for rehospitalization more frequent in the group receiving conservative treatment.
Outcomes in patients assigned 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.
Boden WE, O’Rourke RA, Crawford MH, et al. N Engl J Med 338:1785, 1998. PMID: 9632444
A prospective randomized trial of triage angiography in acute coronary syndromes ineligible for thrombylysis therapy: results of Medicine versus Angiography in Thrombolyitic exclusion (MATE).
McCullough PA, O’Neill WW, Graham M, et al. J Am Coll Card 32:596, 1998 PMID: 9741499
Invasive compared with non-invasive treatment in unstable coronary artery disease: FRISC II prospective randomized multicenter study. Fragmin and Fast Revascularization during Instability in Coronary Artery Disease Investigators.
Lancet 354:708, 1999. PMID: 10475181
An early invasive strategy was shown to reduce both mortality and myocardial infarction at one year.
Ability of minor elevations of troponins I and T to predict benefit from an early invasive strategy in patients with unstable angina and non-ST elevation myocardial infarction. Results from an randomized trial.
Morrow DA, Cannon CP, Rifai N, et al, for the TACTICS – TIMI 18 Investigators. JAMA. 2001. Nov 21;286:2405-12. PMID: 11712935
Patients at the greatest risk, such as those with positive troponin values and with ST segement depression at the study level, had the highest event rate and derived the greatest benefit from an invasive strategy.
Quantitative analysis of the admission electrocardiogram identifies patients with unstable coronary artery disease who benefit the most from early invasive treatment.
Holmvang L, Clemmensen P, Lindahl B, et al. J Am Coll Card 41:905, 2003. 12651033
How should patients with unstable angina and non-ST-segment elevation myocardial infarction be managed: A meta-analysis of randomized trials.
Choudhry NK, Singh JM, Barolet A, Tomlinson GA, Detsky AS. Am J Med. 2005;118:465-74. PMID: 15866246
Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials. Mehta SR, Cannon CP, Fox KA, et al.JAMA. 2005;293:2908-17. PMID: 15956636
Value of first day angiography/angioplasty in evolving non-ST segment elevation myocardial infarction: an open multicenter randomized trial.
Spacek R, Widimsky P, Straka Z, et al. The Vino Study. Eur Heart J 2002;23:230-8. PMID: 11792138
Early invasive versus selectively invasive management for acute coronary syndromes.
deWinter RJ, Windhausen F, Cornel JH, et al. N Engl J Med 2005;353:1095-104. PMID: 16162880
5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomized trial.
Fox KA, Poole-Wilson P, Clayton TC, et al. Lancet 2005;366:914-20. PMID: 16154018
PRAGUE Trial.
Widimsky P, Groch L, Zelizko M, et al. Eur Heart J. 2000;21:823-31.PMID: 10781354
The PRAGUE trial supports transfer of STEMI patient for PCI without administering thrombolytics beforehand if PCI will be available in less than 90 minutes.
Cannon CP, Gibson CM, McCabe CH, et al. Circulation 1998;98:2805-14. PMID: 9860780
Although thrombolysis reduces mortality more than placebo, normal blood flow is restored in only 60% of patients.
Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction.
Gershlick AH, Stephens-Lloyd A, Hughes S, et al. N Engl J Med. 2005;353:2758-68. REACT Trial PMID: 16382062
Treatment of STEMI with PCI is well-established. However, due to limited resources in some facilities for PCI, first-line therapy in 30-70% of patients is thrombolytic therapy. The REACT trial shows the superiority of rescue PCI over conservative treatment or repeated thrombolysis in patients without clinical reperfusion at 90 minutes after initial thrombolysis.
For STEMI patients who undergo thrombolytic therapy, immediate transfer to a PCI center should be facilitated so there’s no delay in undergoing angiography if thrombolytic reperfusion is incomplete.
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Medications/Therapy
Anti-platelet agents
Aspirin
Collaborative overview of randomized trials of antiplatelet therapy—I: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy invarious categories of patients.
Antiplatelet Trialists’ Collaboration. BMJ 1994;308:81–106. PMID: 8298418
Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients.
Antithrombotics Trialists’ Collaboration. BMJ 2002; 324:71– 86. PMID: 11786451
Protective effects of aspirin against acute myocardial infarction and death in men with unstable angina: results of a Veterans Administration Cooperative Study.
Lewis HDJ, Davis JW, Archibald DG, et al. N Engl J Med 1983;309:396–403. PMID: 6135989
Aspirin, heparin, or both to treat acute unstable angina.
Théroux P, Ouimet H, McCans J, et al. N Engl J Med 1988;319:1105–11. PMID: 3050522
Unfractionated and low-molecular-weight heparin as adjuncts to thrombolysis in aspirin-treated patients with ST-elevation acute myocardial infarction: a meta-analysis of the randomized trials.
Eikelboom JW, Quinlan DJ, Mehta SR, et al. Circulation. 2005;112:3855-67. PMID: 16344381
Enoxaparin is superior to UFH in reducing reinfarction and death but increased minor and major bleeding
Thienopyridines
A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE).
CAPRIE Steering Committee. Lancet 1996;348:1329 –39. PMID: 8918275
Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation.
Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK. N Engl J Med 2001;345:494 –502. PMID: 11519503
Effects of pretreatment with clopidogrel and aspirin followed by long- term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study.
Mehta SR, Yusuf S, Peters RJ, et al. Lancet 2001;358:527–33. PMID: 11520521
Anticoagulants
Heparin
Aspirin versus heparin to prevent myocardial infarction during the acute phase of unstable angina.
Theroux P, Waters D, Qiu S, McCans J, de Guise P, Juneau M. Circulation 1993;88:2045– 8. PMID: 8222097
Comparison of the effect of heparin and aspirin versus aspirin alone on transient myocardial ischemia and in-hospital prognosis in patients with unstable angina.
Holdright D, Patel D, Cunningham D, et al. J Am Coll Cardiol 1994;24:39–45. PMID: 8006281
Adding heparin to aspirin reduces the incidence of myocardial infarction and death in patients with unstable angina. A meta-analysis. Oler A, Whooley MA, Oler J, Grady D.JAMA 1996;276:811–5. PMID: 8769591
Combination antithrombotic therapy in unstable rest angina and non-Q-wave infarction in nonprior aspirin users: primary end points analysis from the ATACS trial. Antithrombotic Therapy in Acute Coronary Syndromes Research Group.
Cohen M, Adams PC, Parry G, et al. Circulation 1994;89:81– 8. PMID: 8281698
LMWH
A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group.
Cohen M, Demers C, Gurfinkel EP, et al. N Engl J Med 1997;337:447–52. PMID: 9250846
Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Qwave myocardial infarction: results of the Thrombolysis In Myocardial Infarction (TIMI) 11B trial.
Antman EM, McCabe CH, Gurfinkel EP, et al. Circulation 1999;100:1593– 601. PMID: 10517729
Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial.
Ferguson JJ, Califf RM, Antman EM, et al. JAMA 2004;292:45–54. PMID: 15238590
Percutaneous coronary intervention after subcutaneous enoxaparin pretreatment in patients with unstable angina pectoris.
Collet JP, Montalescot G, Lison L, et al. Circulation 2001;103:658–63. PMID: 11156876
Study reporting ability to use LMWH even in setting of PCI
Bivalrudin
Bivalirudin during primary PCI in acute myocardial infarction.
Stone GW et al., N Engl J Med 2008 May 22; 358:2218. PMID: 18499566
Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial.
Ferguson JJ, Califf RM, Antman EM, et al. JAMA 2004;292:45–54. PMID: 15238590
Bivalirudin for patients with acute coronary syndromes.
Stone GW, McLaurin BT, Cox DA, et al. N Engl J Med 2006;355:2203–16. PMID: 17124018
Fondaparinux
Comparison of fondaparinux and enoxaparin in acute coronary syndromes.
Yusuf S, Mehta SR, Chrolavicius S, et al. N Engl J Med 2006;354:1464 –76. PMID: 16537663
Effects of fondaparinux on mortality and reinfarction in patients with acute ST-segment elevation myocardial infarction: the OASIS-6 randomized trial.
Yusuf S, Mehta SR, Chrolavicius S, et al. JAMA 2006;295:1519 –30. PMID: 16537725
Platelet GP IIb/IIIa Receptor Antagonists
Abciximab in patients with acute ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention after clopidogrel loading: a randomized double-blind trial.
Mehilli J et al., Circulation 2009 Apr 14; 119:1933. PMID: 19332467
Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta analysis of all major randomized clinical trials.
Boersma E, Harrington RA, Moliterno DJ, et al. Lancet 2002;359:189–98. PMID: 11812552
GP IIb/IIIa inhibitors are of substantial benefit in patients with UA/NSTEMI who undergo PCI, of modest benefit in patients who are not routinely scheduled to undergo revascularizaition (but may do so) and are of questionable benefit in patients who do not undergo revascularization.
Potential non-glycoprotein IIb/IIIa effects of abciximab.
Coller BS. Am Heart J. 1999;138:S1-S5.PMID: 10385784
Platelet aggregation gradually returns to normal 24-48 hours after discontinuation of the drug.
Effect of glycoprotein IIb/IIIa receptor blockade abciximab on outcome in patients with acute coronary syndromes without early coronary revascularization: the GUSTO IV-ACS randomized trial.
Simoons ML, Lancet 2001;357:1915-24. PMID: 11425411
GUSTO IV-ACS enrolled patients in whom early (less than 48 hours) revascularization was not intended. Results suggest that abciximab in the dose regimens used in GUSTO IV-ACS is not indicated in the management of patients with UA or NSTEMI when early invasive management is not intended.
Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty.
The EPIC Investigation. N Engl J Med 1994;330:956–61 PMID: 8121459
Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization.
The EPILOG Investigators. N Engl J Med 1997;336:1689 –96 PMID: 9182212
Randomised placebo-controlled and balloon-angioplasty-controlled trial to assess safety of coronary stenting with use of platelet glycoprotein- IIb/IIIa blockade. Evaluation of Platelet IIb/IIIa Inhibitor for Stenting.
The EPISTENT Investigators. Lancet 1998;352:87–92 PMID: 9672272
Abciximab
Randomised placebo-controlled trial of abciximab before and during coronary intervention in refractory unstable angina: the CAPTURE study.
The CAPTURE Investigators. Lancet 1997;349:1429 –35. PMID: 9164316
Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty.
The EPIC Investigation. N Engl J Med 1994;330:956–61. PMID: 8121459
Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization.
The EPILOG Investigators. N Engl J Med 1997;336:1689 –96. PMID: 9182212
Randomised placebo-controlled and balloon-angioplasty-controlled trial to assess safety of coronary stenting with use of platelet glycoprotein- IIb/IIIa blockade. Evaluation of Platelet IIb/IIIa Inhibitor for Stenting.
The EPISTENT Investigators. Lancet 1998;352:87–92. PMID: 9672272
Effect of glycoprotein IIb/IIIa receptor blocker abciximab on outcome in patients with acute coronary syndromes without early coronary revascularisation: the GUSTO IV-ACS randomized trial.
Simoons ML. Lancet 2001;357:1915–24. PMID: 11425411
Evidence that Abciximab should not be used unless PCI is planned
Abciximab in patients with acute coronary syndromes undergoing percutaneous coronary intervention after clopidogrel pretreatment: the ISAR-REACT 2 randomized trial.
Kastrati A, Mehilli J, Neumann FJ, et al. JAMA. 2006;295:1531-8. PMID: 16533938
Abciximab showed clinical benefit over placebo following clopidogrel therapy by reducing the composite endpoint of death, MI or urgent revascularization. GP IIa/IIIb treatment effect was enhanced and statistically significant only in the higher-risk, troponin-positive patients. The results also corroborate previous analysis that showed GP IIb/IIIa inhibitors were not required in troponin-negative patients with ACS or low-risk patients having elective PCI who were pretreated with clopidogrel.
Tirofiban
A comparison of aspirin plus tirofiban with aspirin plus heparin for unstable angina.
Platelet Receptor Inhibition in Ischemic Syndrome Management (PRISM) Study Investigators. N Engl J Med 1998;338:1498 –505. PMID: 9599104
Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction.
Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) Study Investigators. N Engl J Med 1998;338:1488 –97. PMID: 9599103
Effects of platelet glycoprotein IIb/IIIa blockade with tirofiban on adverse cardiac events in patients with unstable angina or acute myocardial infarction undergoing coronary angioplasty. Randomized Efficacy Study of Tirofiban for Outcomes and REstenosis.
The RESTORE Investigators. Circulation 1997;96:1445–53. PMID: 9315530
Eptifibatide
The efficacy and safety of prasugrel with and without a glycoprotein IIb/IIIa inhibitor in patients with acute coronary syndromes undergoing percutaneous intervention: a TRITON-TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel-Thrombolysis In Myocardial Infarction 38) analysis.
O'Donoghue M et al., J Am Coll Cardiol 2009 Aug 18; 54:678. PMID: 19679245
Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial.
Montalescot G et al., Lancet 2009 Feb 28; 373:723. PMID: 19249633
Ischaemia versus bleeding: the art of clinical decision-making.
Stone GW., Lancet 2009 Feb 28; 373:695. PMID: 19249613
Inhibition of platelet glycoproteinIIb/IIIa with eptifibatide in patients with acute coronary syndromes. Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy.
The PURSUIT Trial Investigators. N Engl J Med 1998; 339:436–43. PMID: 9705684
Clinical pharmacology of eptifibatide.
Phillips DR, Scarborough RM. Am J Cardiol 1997;80:11B-20B. PMID: 9291241
Eptifibatide has a half-life of 2-3 hours. Platelet aggregation returns to normal 4- hours after discontinuation of the drug.
Beta-Blockers
Mortality benefit of beta blockade in patients with acute coronary syndromes undergoing coronary intervention: pooled results from the Epic, Epilog, Epistent, Capture and Rapport trials.
Ellis K, Tcheng JE, Sapp S, Topol EJ, Lincoff AM. J Interv Cardiol 2003;16:299–305. PMID: 14562669
Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial.
Chen ZM, Pan HC, Chen YP, et al. Lancet 2005;366:1622–32. PMID: 16271643
Raised question of worse outcomes with early IV Beta Blocker usage
Ace Inhibitors
Indications for ACE inhibitors in the early treatment of acute myocardial infarction: sytemic overview of individual data from 100,000 patients in randomized trials.
ACE Inhibitor Myocardial Infarction Collaborative Group. Circulation 1998;97:2202-12. PMID: 9631869
ACE Inhibitors reduce mortality rates in patients with MI or who recently had an MI and have LV dysfuncition.
The long term impact of the angiotensin converting enzyme inhibitor trandolapril on mortality and hospital admissions in patients with left ventricular dysfunction after a myocardial infarction: follow-up to 12 years.
Buch P, Rasmussen S, Abildstrom SZ, Kober L, Carlsen J, TorpPedersen C. Eur Heart J 2005;26:145-52. PMID: 15618070
Follow-up of patients with LV dysfunction after MI in the TRACE trial regarding mortality and hospitalization rate was maintained for upwards of 10-12 years.
ARBs
Valsartan, captopril or both in myocardial infarction complicated by heart failure, left ventricular dysfunction or both.
Pfeffer MA, McMurray JJ, Velazquez EJ, et al. N Engl J Med 2003;360:1037-433. PMID: 14610160
The ARB valsartan was as effective as captorpil in patients at high risk for cardiovascular events after MI. However, the combination of valsartan and captopril increased adverse events and did not improve survival.
Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction.
Pitt B, Remme W, Zannad F, et al. N Engl J Med 2003;348:1309-21. PMID: 12668699
Eplerenone given to MI patients with either heart failure or diabetes mellitus had a reduced morbidity and mortality in the EPHESUS study.
Statins
Intensive Lipid-Lowering With Atorvastatin for Secondary Prevention in Patients After Coronary Artery Bypass Surgery
Shah SJ, Waters DD, Barter P,. Kastelein JJ, et al. J Am Coll Cardiol. 2008 May 20;51(20):1938-43. PMID: 18482661
Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) Study Investigators. Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial.
Schwartz GG, Olsson AG, Ezekowitz MD, et al. JAMA. 2001 Apr 4;285(13):1711-8. PMID: 11277825
Effects of Early Treatment With Statins on Short-term Clinical Outcomes in Acute Coronary Syndromes: A Meta-analysis of Randomized Controlled Trials.
Briel M, Schwartz GG, Thompson PL, et al. JAMA. 2006;295:2046-2056. PMID: 16670413
Effect of statin use within the first 24 hours of admission for acute myocardial infarction on early morbidity and mortality.
Fonarow GC, Wright RS, Spencer FA, et al. Am J Cardiol. 2005;96:611-616. PMID: 16125480
Intensive versus moderate lipid lowering with statins after acute coronary syndromes.
Cannon CP, Braunwald E, McCabe CH, et al. N Engl J Med. 2004;350:1495-1504. PMID: 15007110
Calcium Channel Blockers
Calcium channel blockers in acute myocardial infarction and unstable angina: an overview.
Held PH, Yusuf S, Furberg CD. BMJ 1989; 299:1187–92. PMID: 2513047
Diltiazem and reinfarction in patients with non-Q-wave myocardial infarction. Results of a double-blind, randomized, multicenter trial.
Gibson RS, Boden WE, Theroux P, et al. N Engl J Med 1986; 315:423–9. PMID: 3526151
Nitrates
Effect of intravenous nitrates on mortality in acute myocardial infarction: an overview of the randomised trials.
Yusuf S, Collins R, MacMahon S, Peto R. Lancet 1988;1:1088 –92. PMID: 2896919
Morphine
Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative.
Meine TJ, Roe MT, Chen AY, et al. Am Heart J 2005;149:1043–9. PMID: 15976786
Prompted downgrading of morphine usage from Class 1 to 2a
Clopidogrel
Role of clopidogrel loading dose in patients with ST-segment elevation myocardial infarction undergoing primary angioplasty: results from the HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trial.
Dangas G et al. for the HORIZONS-AMI Trial Investigators., J Am Coll Cardiol 2009 Oct 6; 54:1438. Simon DI and Parikh SA., PMID: 19796737
Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial
Wiviott SD, Braunwald E, McCabe CH, Horvath I, et al. Lancet. 2008 Apr 19;371(9621):1353-63. Epub 2008 Apr 2. PMID: 18377975
Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation.
Sabatine MS, Cannon CP, Gibson CM, et al. N Engl J Med. 2005;352:1179-89. PMID: 15758000
Combining aspirin with clopidogrel shows significant benefit in patients with acute coronary syndromes and those undergoing percutaneous revascularization.
Clopidogrel and aspirin versus aspirin alone for the prevention of atherothromboitc events.
Bhatt DL, Fox KA, Hacke W, et al. N Engl J Med. 2006;354:1706-17. PMID: 16531616
The Charisma trial took 15,603 patients with multiple atherothrombotic risk factors and placed in aspirin alone vs clopidogrel plus aspirin group. Groups did not differ for all-cause mortality, CV death or nonfatal MI.
Plavix
Prasugrel versus clopidogrel in patients with acute coronary syndromes.
Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, et al. NEJM. 2007 Nov 15;357(20):2001-15. PMID: 17982182
Long-term clopidogrel therapy after percutaneous coronary intervention in PCI-CURE and CREDO: the "Emperor's New Clothes" revisited.
Eriksson P. Eur. Heart J. 2004;25:720–722. PMID: 15120880
Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) Trial.
Fox, KA, Mehta, SR, Peters, R, et al. Circulation 2004; 110:1202. PMID: 15313956
Transfusions
Impact of Red Blood Cell Transfusion on Clinical Outcomes in Patients With Acute Myocardial Infarction.
Aronson D, Dann E, Bonstein L, et al. Am J Cardiol. 2008 Jul 15;102(2):115-9. Epub 2008 May 9. PMID: 18602505
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Procedures
Electrocardiogram at presentation
A new terminology for left ventricular walls and location of myocardial infarcts that present Q wave based on the standard of cardiac magnetic resonance imaging: a statement for healthcare professionals from a committee appointed by the International Society for Holter and Noninvasive Electrocardiography.
Bayes de Luna A, Wagner G, Birnbaum Y, et al. Circulation 2006;114:1755-60. PMID: 17043179
Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain Study).
Rouan GW, Lee TH, Cook EF, Brand DA, Weisberg MC, Goldman L., Am J Cardiol 1989;64:1087-92. PMID: 2683709
Prognostic value of the admission electrocardiogram in acute coronary syndromes.
Savonitto S, Ardissino D, Granger CB, et al. JAMA 1999;281:707-13. PMID: 10052440
An evaluation of technologies for identifying acute cardiac ischemia in the emergency department: a report from a National Heart Attack Alert Program Working Group.
Selker HP, Zalenski RJ, Antman EM, et al. Ann Emerg Med 1997;29:13-87. PMID: 8998086
History and physical examination
Development and validation of a clinical score to estimate the probability of coronary artery disease in men and women presenting with suspected coronary disease.
Morise AP, Haddad WJ, Beckner D. Am J Med 1997;102:350-6. PMID: 9217616
Value of the history and physical in identifying patients at increased risk for coronary artery disease.
Pryor DB, Shaw L, McCants CB, et al. Ann Intern Med 1993;118:81-90. PMID: 8416322
Should we emergently revascularize Occluded Coronaries for Cardiogenic Shock: An International Randomized Trial of Emergency PTCA/CABG-trial design. The SHOCK Trial Study Group.
Hochman JS, Sleeper LA, Godfrey E, et al. Am Heart J 1999;137:313-21. PMID: 9924166
Assessment for cadiogenic shock on physical exam
Laboratory testing for cardiac biomarkers of necrosis
Biomarkers in acute cardiac disease: the present and the future.
Jaffe AS, Babuin L, Apple FS., J Am Coll Cardiol 2006;48:1-11. PMID: 16814641
Early diagnosis and exclusion of acute myocardial infarction using biochemical monitoring. The BIOMACS Study Group. Biochemical Markers of Acute Coronary Syndromes.
Lindahl B, Venge P, Wallentin L. Coron Artery Dis 1995;6:321-8. PMID: 7655716
Non-invasive radiologic evaluation of acute chest pain
Assessment of left ventricular wall motion in angina pectoris by two-dimensional echocardiography and myocardial perfusion by technetium-99m sestamibi tomography during adenosine-induced coronary vasodilatation and comparison with coronary angiography.
American College of Radiology. Cardiac Imaging Guidelines. Acute Chest Pain – Suspect Myocardial Ischemia. 2005.
Amanullah AM, Bevegard S, Lindvall K, Aasa M., Am J Cardiol 1993;72:983-89. PMID: 8213598
Utility of stress echocardiography in the triage of patients with atypical chest pain from the emergency department.
Colon PJ, Guarisco JS, Murgo J, Cheirif J., Am J Cardiol 1998;82:1282-4, A10. PMID: 9832109
Accuracy of imaging technologies in the diagnosis of acute cardiac ischemia in the emergency department: a meta-analysis.
Ioannidis JP, Salem D, Chew PW, Lau J., Ann Emerg Med 2001;37:471-7. PMID: 11326183
2-D echocardiography prediction of adverse events in ED patients with chest pain.
Lim SH, Sayre MR, Gibler WB., Am J Emerg Med 2003;21:106-10. PMID: 12671809
Chest in the accident and emergency department: is chest radiography worthwhile?
Templeton PA, McCallion WA, McKinney LA, Wilson HK. Arch Emerg Med 1991;8:97-101. PMID: 1888421
Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia: a randomized controlled trial. Udelson JE, Beshansky JR, Ballin DS, Feldman JA, Griffith JA, Griffith JL, Hander J, et al. JAMA 2002;288:2693-700. PMID: 12460092
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Discharge and Transition
Association of early follow-up after acute myocardial infarction with higher rates of medication use.
Daugherty SL et al., Arch Intern Med 2008 Mar 10; 168:485. PMID: 18332293
Smoking cessation initiated during hospital stay for patients with coronary artery disease: a randomized controlled trial.
Smith PM and Burgess E., CMAJ 2009 Jun 23; 180:1297. PMID: 19546455
Dissociation Between Hospital Performance of the Smoking Cessation Counseling Quality Metric and Cessation Outcomes After Myocardial Infarction.
Reeves GR, Wang TY, Reid KJ, et al. Arch Intern Med. 2008;168(19):2111-2117. PMID: 18955640
Association of Early Follow-up After Acute Myocardial Infarction With Higher Rates of Medication Use.
Daugherty SL., Ho PM, Spertus JA, Jones PG, et al. Arch Intern Med. 2008 Mar 10;168(5):485-91; discussion 492. PMID: 18332293
The course of patients with suspected myocardial infarction: the identification of low-risk patients for early transfer from intensive care. Mulley AG, Thibault GE, Hughes RA, Barnett GO, Reder VA, Sherman EL. N Engl J Med 1980; 302:943-8. PMID: 7360201
The effects of supporting discharge from hospital to home in older people.
Hyde CJ, Robert IE, Sinclair AJ. Age Ageing 2000; 29:271-279. PMID: 10855913
Discharge planning from hospital to home.
Shepperd S, Parkes J, McClaran J, Phillips C. Cochrane Database Systematic Rev 2003; The Cochrane Library (ISSN 1464-780X). PMID: 14973952
A systematic review of discharge arrangements for older people.
Parker SG, Peet SM, McPherson A, Cannaby AM, Abrams K, Baker R, Wilson A, Lindesay J, Parker G, Jones DR. Health Technology Assessment 2002; 6:1-183. PMID: 12065067
Comprehensive discharge planning with post-discharge support for older patients with congestive heart failure: a meta-analysis.
Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. JAMA 2004; 291:1358-1367. PMID: 15026403
The care transitions intervention: results of a randomized controlled trial.
Coleman EA, Parry C, Chalmers S, Min SJ. Arch Int Med 2006; 166:1822-8. PMID: 17000937
Assessing the quality of preparation for posthospital care from the patient's perspective: the care transitions measure.
Coleman EA, Mahoney E, Parry C. Med Care. 43:246-55, 2005. PMID: 15725981
Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention.
Coleman EA, Smith JD, Frank JC, Min S-J, Parry C, Kramer AM. J Am Geriatr Soc. 2004; 52:1817-1825. PMID: 15507057
A new tool for identifying discrepancies in postacute medications for community-dwelling older adults.
Smith JD, Coleman EA, Min SJ. Amer J Geriatr Pharmacotherapy. 2:141-7, 2004. PMID: 15555490
A Patient-Centered Approach to Facilitating Effective Transfers Between Sites of Geriatric Care.
The Care Transitions Intervention. Home Health Services Quarterly, 2003; 22:1-18.
Lost in transition: challenges and opportunities for improving the quality of transitional care.
Coleman EA, Berenson RA. Ann Intern Med. 2004 Oct 5;141(7):533-6. PMID: 15466770 [PubMed - indexed for MEDLINE]
Posthospital care transitions: patterns, complications, and risk identification.
Coleman EA, Min SJ, Chomiak A, Kramer AM. Health Serv Res. 2004 Oct;39(5):1449-65. PMID: 15333117 [PubMed - indexed for MEDLINE]
Improving the quality of transitional care for persons with complex care needs.
Coleman EA, Boult C; American Geriatrics Society Health Care Systems Committee. J Am Geriatr Soc. 2003 Apr;51(4):556-7. No abstract available. PMID: 12657079 [PubMed - indexed for MEDLINE]
Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs.
Coleman EA. J Am Geriatr Soc. 2003 Apr;51(4):549-55. Review. PMID: 12657078 [PubMed - indexed for MEDLINE]
Usefulness of in-hospital prescription of statin agents after angiographic diagnosis of coronary artery disease in improving continued compliance and reduced mortality.
Muhlestein JB, Horne BD, Bair TL, Li Q, Madsen TE, Pearson RR, Anderson JL Am J Cardiol 2001;87(3):257-61. PMID: 11165956
Despite well-documented clinical benefit of the use of statins in patients with coronary artery disease (CAD) and even mild lipid elevations, studies have documented the presence of a significant "treatment gap" between those patients in whom treatment is indicated and those patients who actually receive it. It has been proposed that a prescription for statin therapy given to indicated patients at the time of initial angiographic diagnosis of CAD has the potential to improve long-term medication compliance.
Transfer for primary angioplasty versus immediate thrombolysis in acute myocardial infarction: a meta-analysis Circulation. Dalby M, Bouzamondo A, Lechat P, Montalescot G.2003;108:1809-14. PMID: 14530206
This meta-analysis provided supportive data that transfer to another facility providing an invasive procedure is superior to immediate thrombolysis as long as it adds no more than 2 hours to the time it would otherwise take for the patient to receive thrombolytic therapy. Moreover, the advantage of transferring the patient was probably under estimated in view of the additional benefits of glycoprotein IIIb/IIa inhibitors that were not commonly employed in prior randomized controlled studies.
Impact of medication therapy discontinuation on mortality after myocardial infarction.
Ho PM, Spertus JA, Masoudi FA, et al. Arch Intern Med. 2006;166:1842-7. PMID: 17000940
This study showed that discontinuation of three proven therapies (statins, beta-blockers and aspirin) one month after discharge was associated with increased risk for death in patients hospitalized for MI. Discontinuance was common, with 1 in 3 patients stopping a drug within a month after discharge. Patients who discontinued all medications were older, had more comorbid conditions, were less likely married, white, completed high school or have undergone coronary revascularization during the index hospitalization.
Inpatient and follow-up cardiology care and mortality for acute coronary syndrome patients in the Veterans Health Administration.
Ho PM, Luther, SA, et al. Am Heart J. 2007 Sep;154(3):489-94. PMID: 17719295 [PubMed - indexed for MEDLINE]
Application of current guidelines to the management of unstable angina and non-ST-elevation myocardial infarction.
Braunwald, E. Circulation. 2003 Oct 21;108(16 Suppl 1):III28-37. PMID: 14605017 [PubMed - indexed for MEDLINE]
Recent trends in the care of patients with non-ST-segment elevation acute coronary syndromes: insights from the CRUSADE initiative. Mehta RH, Roe MT, Chen AY, et al.Arch Intern Med. 2006 Oct 9;166(18):2027-34. PMID: 17030838 [PubMed - indexed for MEDLINE]
Stats for discharge meds included
Guidelines for the management of acute coronary syndromes.
Acute Coronary Syndrome Guidelines Working Group.2006.Med J Aust. 2006 Apr 17;184(8 Suppl):S9-29. No abstract available. PMID: 16618231
Supplement with guidelines but has long term management of ACS with specific outline for discharge meds and other considerations.
Improving the management of patients after myocardial infarction, from admission to discharge.
Amin, A., Clin Ther. 2006 Oct;28(10):1509-39. PMID: 17157110 [PubMed - indexed for MEDLINE]
Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.
Arora V, Johnson J, et al. Qual Saf Health Care. 2005 Dec;14(6):401-7. PMID: 16326783
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Differential Diagnosis and Co-existing Conditions
Women
Symptoms in acute coronary syndromes: does sex make a difference?
Patel H, Rosengren A, Ekman I., Am Heart J 2004;148:27-33. PMID: 15215788
Women’s early warning symptoms of acute myocardial infarction.
McSweeney JC, Cody M, O’Sullivan P, Elberson K, Moser DK, Garvin BJ. Circulation 2003;108:2619-23. PMID: 14597589
Diabetes Mellitus
Relationship between spontaneous and iatrogenic hypoglycemia and mortality in patients hospitalized with acute myocardial infarction.
Kosiborod M et al., JAMA 2009 Apr 15; 301:1556. PMID: 19366775
Glucose normalization and outcomes in patients with acute myocardial infarction.
Kosiborod M et al., Arch Intern Med 2009 Mar 9; 169:438. PMID: 19273773
Multivessel Coronary Revascularization in Patients With and Without Diabetes Mellitus: 3-Year Follow-Up of the ARTS-II (Arterial Revascularization Therapies Study–Part II) Trial
Daemen J, Kuck KH, Macaya C, LeGrand V, et al and ARTS-II Investigators. J Am Coll Cardiol. 2008 Dec 9;52(24):1957-67. PMID: 19055986
Drug-Eluting or Bare-Metal Stenting in Patients With Diabetes Mellitus: Results From the Massachusetts Data Analysis Center Registry.
Garg P, Normand SL, Silbaugh TS, Wolf RE, Zelevinsky K, Lovett A, Varma MR, Zhou Z, Mauri L. Circulation. 2008 Nov 25;118(22):2277-85, 7p following 2285. Epub 2008 Nov 10. PMID: 19001019
Glucose Control and Vascular Complications in Veterans with Type 2 Diabetes
Duckworth W, Abraira C, Moritz T, Reda D, Emanuele N, Reaven PD, Zieve FJ, Marks J, Davis SN, Hayward R, Warren SR, Goldman S, McCarren M, Vitek ME, Henderson WG, Huang GD; VADT Investigators. N Engl J Med. 2009 Jan 8;360(2):129-39. Epub 2008 Dec 17. PMID: 19092145
Comparison of Cardiovascular Outcomes in Elderly Patients With Diabetes Who Initiated Rosiglitazone vs Pioglitazone Therapy
Winkelmayer WC, Setoguchi S, Levin R, Solomon D.H. Arch Intern Med. 2008;168(21):2368-2375. PMID: 19029503
Influence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease: the Bypass Angioplasty Revascularization Investigation (BARI).
Circulation 1997;96:1761-9. PMID: 9323059
A randomized trial of PCI vs CABG in 1,829 patients with multivessel disease, 19% of which had diabetes. Five years after randomization patients who required diabetes treatment had a lower survival rate than patients without diabetes (73.1% vs 91.3%).
Eight year mortality in the Emory Angioplasty vs Surgery Trial (EAST).
King SB, III, Kosinki A, Guyton RA, Lembo NJ, Weintraub WS. J Am Coll Cardiol 2000;35:1116-21. PMID: 10758949
Stents may improve the outcome of patients with diabetes who undergo PCI. The outcome after stenting was superior to that of PTCA in diabetics and the restenosis rate was reduced from 63% to 25%. For the non-diabetic the restenosis rate using Stent vs PTCA was reduced from 36% to 27%.
Diabetes mellitus, glycoprotein IIb/IIIa blockade and heparin: evidence for a comlex interaction in a multicenter trial.
Kleiman NS, Lincoff AM, Kereiakes DJ, et al. EPILOG Investigators. Circulation 1998;97:1912-20. PMID: 9609084
Abciximab resulted in a greater decline in death/MI over six months after PCI in patients with diabetes.
Post-CABG Patients
Does prior percutaneous coronary intervention adversely affect early and mid-term survival after coronary artery surgery?
Yap C-H et al., JACC Cardiovasc Interv 2009 Aug; 2:758. PMID: 19695544
Care of the Patient with Previous Coronary Bypass Surgery.
Theroux P, Waters D. Unstable angina: special considerations in the post-bypass patient. In:Waters D, Bourassa MG, Brest AN, editors. Philadelphia, PA:FA Davis, 1991:169-91. PMID: 2044088
Up to 20% of patients presenting with UA/NSTEMI have previously undergone CABG.
Preoperative and operative predictive variables of late clinical events following saphenous vein coronary artery bypass graft surgery.
Lambert M, Kouz S, Campeau L. Can J Cardiolog 1989;5:87-92. PMID: 2784996
Approximately 20% of post-CABG patients develop UA/NSTEMI during an interval of 7.5 years. Post-CABG patients with UA/NSTEMI are at higher risk, with more extensive CAD and LV dysfunction in comparison to patients who haven’t undergone a prior CABG procedure.
Prevention of distal embolization during saphenous vein graft lesion angioplasty. Experience with a new temporary occlusion and aspiration system.
Carlino M, De Gregorio J, di Mario C, et al. Circulation 1999;99:3221-3. PMID: 10385493
The outcomes of UA/NSTEMI in post-CABG patients are less favorable than those in patients who have not undergone CABG. There is a higher rate of embolization of atherosclerotic material from friable grafts at the time of intervention, associated with higher rates of complications.
Older Patients
Factors associated with longer time from symptom onset to hospital presentation for patients with ST-elevation myocardial infarction.
Ting HH et al., Arch Intern Med 2008 May 12; 168:959. PMID: 18474760
Factors associated with racial differences in myocardial infarction outcomes.
Spertus JA et al., Ann Intern Med 2009 Mar 3; 150:314. PMID: 19258559
The effect of routine, early invasive management on outcome for elderly patients with non-ST-segment elevation acute coronary syndromes.
Bach RG, Cannon CP, Weintraub WS, et al. Ann Intern Med. 2004;141:186-95. PMID: 15289215
Patients older than 65 yrs of age had a higher risk for death or MI at six months and these risks were substantially lowered with an invasive strategy (8.8% vs 13.6%). Despite grater therapeutic benefit and cost-effectiveness in the elderly, a clinical paradox is that invasive procedures are less likely employed as patients get older.
Chronic Kidney Disease
Cardiac troponins in renal insufficiency: review and clinical implications.
Freda BJ, Tang WH, Van Lente F, Peacock WF, Francis GS., J Am Coll Cardiol 2002;40:2065-71. PMID: 12505215
Among patients with end-stage renal disease but no acute MI, 15-53% demonstrated increased CTnT compared to only 10% who showed an increased CTnI. Dialysis typically increases CTnT but decreases CTnI.
Prevalance of Elevated Troponin I in End Stage Renal Disease Patients Receiving Hemodialysis.
Gupta A, Nguyen HB, Jacobsen G. Acadamie of Emergency Medicine 2004;11:979-981. PMID: 15347551
Troponin I values can be as high as 0.8 in patients with chronic renal failure. If the Troponin I is greater than 0.8 there’s a much better reason to suspect myocardial injury.
Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction.
Anavekar NS, McMurray JJ, Velasquez EJ, et al. N Engl J Med 2004;351:1296-305. PMID: 15385655
Chronic kidney disease constitutes a risk factor for adverse outcomes after MI.
A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry.
Eagle KA, Lim MJ, Dabbous OH, et al. JAMA 2004;291:2727-33. the GRACE Risk Model PMID: 15187054
In the highly validated GRACE predictive model, serum creatinine was one of eight variables that predicted death in the first six months after discharge, adding 1-20 points based on the level of the serum creatinine during hospitalization for acute coronary syndrome.
Cocaine and Methamphetamine
Cocaine and chest pain: clinical features and outcome of patients hospitalized to rule out myocardial infarction.
Gitter MJ, Goldsmith SR, Dunbar DN, Sharkey SW. Ann Intern Med 1991;115:277-82. PMID: 1854111
Most patients who present to the ED with cocaine-associated chest pain do not develop an MI.
Cocaine-induced myocardial ischemia and infarction: pathophysiology, recognition and management.
Pitts WR, Lange RA, Cigarroa JE, Hillis LD. Prog Cardiovasc Dis 1997;40:65-76. PMID: 9247556
Myocardial infarction occurs in 6% of patients who present to the ED with cocaine-induced chest pain.
Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade.
Lange RA, Cigarroa RG, Flores ED, et al. Ann Intern Med 1990;112:897-903. PMID: 1971166
Beta-blockade augments cocaine-induced coronary artery vasoconstriction.
Influence of labetalol on cocaine-induced coronary vasoconstriction in humans.
Boehrer JD, Moliterno DJ, Willard JE, Hillis LD, Lange RA. Am J Med 1993;94:608-10. PMID: 8506886
Labetolol, an alpha and beta-blocker, has been advocated because it has been not shown to induce coronary artery vasoconstriction, though beta-adrenergic blocking action predominates over its alpha-adrenergic-blocking activity in commonly used doses.
Prinzmetal’s (Variant) Angina
Angina pectoris II.
Prinzmetal M, Goldman A, Shubin H, et al. Am Heart J 1959;57:530-43. PMID: 13626816
Prinzmetal’s angina can be an unstable angina that is manifested as transient ST- elevation that spontaneously resolves with NTG use and not progress onward to myocardial infarction.
Role of coronary vasospasm in the pathogenesis of myocardial infarction: study in patients with no significant coronary stenosis.
Fukai T, Koyanagi S, Takeshita A. Am Heart J 1993;125:1011-7. PMID: 8249786
Prolonged vasospasm due to Prinzmetal’s angina may result in MI, high degree AV block, ventricular tachycardia or sudden death.
Pulmonary Embolism
Prevalence of Increased Cardiac Troponin I Levels in Patients with and without Acute Pulmonary Embolism and Relationship of Increased Cardiac Troponin Levels with In-Hospital Mortality in Patients with Acute Pulmonary Embolism.
Yalamachi K, Sukhij R, Aronow WS, et al. Am J of Cardiol 2004;93:263-264. PMID: 14715366
Troponins can be frequently elevated in patients with pulmonary embolism, indicating a worse prognosis.
Elevated Cardiac Troponins: Their Significance in Acute Coronary Syndrome and Noncardiac Conditions.
Clark, M, Payne, J. J Okla St Med Assoc. 2006;99:6. PMID: 16821493
Troponins can be a better marker of the significance and mortality of a pulmonary embolism than right ventricular dysfunction.
Sepsis
Myocardial Cell Injury In septic Shock.
Turner, Tsiatros M, Belloma R. Critical Care Medicine 1999;27:1775-80. PMID: 10507597
Troponins are frequently elevated in sepsis, particularly septic shock. Elevated Troponins may indicate a worsening left ventricular function and be irreversible, those this is not always the outcome and LV function may return to normal.
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Textbook References
American College of Physicians Textbook “ACP Medicine” 2007 edition.
UA/NSTEMI patients with high risk indicators were identified which increase their likelihood toward morbidity and death. These high risk indicators with a Class I and Level A confidence were outlined which warranted added consideration for an early invasive strategy.
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Quality Improvement
Implementing patient safety interventions in your hospital: what to try and what to avoid.
Ranji SR, Shojania KG. Med Clin North Am. 2008 Mar;92(2):275-93, vii-viii. PMID: 18298979
Evidence-based quality improvement: the state of the science.
Shojania KG, Grimshaw JM. Health Aff (Millwood). 2005 Jan-Feb;24(1):138-50. PMID: 15647225
The Ethics of Using Quality Improvement Methods in Health Care.
Lynn, J, Baily, M, Botrell, M, et al. Ann Intern Med. 2007;146:666-673. PMID: 17438310
Why Don’t Physicians Follow Clinical Practice Guidelines? A Framework for Improvement.
Cabana, M, Rand, C, Powe, N, et al. JAMA. 1999;282:1458-1465. PMID: 10535437
Implementing Practice guidelines through Clinical Quality Improvement.
James, B. Frontiers of Health Service Management, Volume 10:1: 3-37. PMID: 10127902
Quality Improvement Opportunities in Health Care—Making It Easy to Do It Right.
James, B. JMCP September/October 2002 Vol. 8, No. 5 392-399. PMID: 14613407
Connections Between Quality Measurement and Improvement.
Berwick, D, James, B, Coye, M. MEDICAL CARE Volume 41, Number 1, Supplement, pp I–30–I–38. PMID: 12544814
Bridging the Gap between Theory+ Practice. Exploring Continuous Quality Improvement.
James, B. 1992. National Quality Forum. Chicago: Hospital Research and Educational Trust: 27p
To Err is Human: Building a Safer Health System.
Kohn, L, Corrigan, J, Donaldson, M, Editors.1999. Committee on Quality of Health Care in America, Institute of Medicine. Washington, D.C.: National Academy Press. 312p.
Crossing the Quality Chasm: A New Health System for the 21st Century.
Committee on Quality of Health Care in America, Institute of Medicine. 2001
Washington, D.C.: National Academy Press.360p.
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