A comparison of two invasive strategies in patients with non-st elevation acute coronary syndromes: results of the early or late intervention in unStable angina (ELISA) pilot study: 2b/3a upstream therapy and acute coronary syndromes

Hof, Arnoud W.J. van’t; Vries, Suzanna T. de; Dambrink, J-H E

doi:10.1016/j.accreview.2003.10.048

Cited by 9 publications

(15 citation statements)

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“…This result was supported by many studies which consistently reported better outcomes with upstream or early use of glycoprotein IIb/IIIa inhibitor compared with deferred treatment or other strategies (LOE 1 [452][453][454][455][456][457][458][459][460][461][462][463][464][465][466][467] ; LOE 2 468 -473 ; LOE 3 474 ; LOE 4 [475][476][477][478] ; LOE 5 479 ).…”

Section: Consensus On Sciencesupporting

confidence: 60%

Part 9: Acute Coronary Syndromes

Bossaert

O’Connor²,

Arntz³

et al. 2010

Circulation

103

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These experts reviewed 25 topics related to the acute initial management of acute coronary syndrome (ACS), which was further categorized as unstable angina, non-ST-elevation MI (UA/NSTEMI) and ST-elevation MI (STEMI). Topics were identified based on previous recommendations, emerging science, and clinical importance, using an iterative writing process involving all Task Force members. The Task Force reviewed the evidence specifically related to diagnosis and treatment of ACS in the out-ofhospital setting and the first hours of care in the in-hospital setting, typically in the emergency department (ED). The evidence review took place over several years, with ongoing refinement of recommendations being made as new evidence was published. The purpose of the review was to generate current, evidence-based treatment recommendations for healthcare providers who serve as the initial point of contact for patients with signs and symptoms suggestive of ACS.The following is a summary of the most important changes in recommendations for diagnosis and treatment of ACS since the last ILCOR review in 2005. 1,2• The history and physical examination, initial ECG, and initial serum biomarkers, even when used in combination, cannot be used to reliably exclude ACS in the prehospital and ED settings.• In contrast, chest pain observation protocols are useful in identifying patients with suspected ACS and patients who require admission or may be referred for provocative testing for coronary artery disease (CAD) to identify reversible ischemia. Such strategies also reduce cost by reducing unnecessary hospital admissions and improve patient safety through more accurate identification of NSTEMI and STEMI.• The acquisition of a prehospital 12-lead ECG is essential for identification of STEMI patients before hospital arrival and should be used in conjunction with pre-arrival hospital notification and concurrent activation of the catheter laboratory.• Nonphysicians can be trained to independently interpret 12-lead ECGs for the purpose of identifying patients with STEMI, provided that appropriate and reliable STEMI criteria are used. This skill is of particular value in the prehospital setting where paramedics may independently identify STEMI, thus mitigating over-reliance on ECG transmission.• Computer-assisted ECG interpretation can be used to increase diagnostic accuracy of STEMI diagnosis when used alone or in combination with ECG interpretation by a trained healthcare provider.• STEMI systems of care can be implemented to improve the time to treatment. The following measures have been shown to reduce the time to primary percutaneous coronary intervention (PPCI): institutional commitment, use of a team-based approach, arranging single-call activation of the catheterization laboratory by the emergency physician or prehospital provider, requiring the catheterization laboratory to be ready in 20 minutes, having an experienced cardiologist always available, and providing real-time data feedback.• Intravenous (IV) ␤-blockers should not be give...

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Section: Consensus On Sciencesupporting

confidence: 60%

Part 9: Acute Coronary Syndromes

Bossaert

O’Connor²,

Arntz³

et al. 2010

Circulation

103

View full text Add to dashboard Cite

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“…Moreover, in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) registry, 11 very early intervention was associated with a trend toward a survival benefit. Finally, in a recent multicenter trial, 12 an early (≤24 hours) invasive strategy in NSTEMI patients showed advantage over a delayed invasive 13 only 8% of the patients in the early group has been treated with GP IIb/IIIa inhibitors, and in the ABOARD trial, 14 most of the patients in the deferred intervention were treated very early (≤24 hours from admission). The benefit of a fast invasive treatment may be linked to the high prevalence of basal impaired myocardial perfusion in NSTEMI patients, even with upstream use of GP IIb/IIIa inhibitors.…”

Section: Discussionmentioning

confidence: 99%

Comparison of Immediate vs Early Invasive Strategy in Patients With First Acute Non–ST‐Elevation Myocardial Infarction

Sciahbasi

Madonna

Vita

et al. 2010

Clinical Cardiology

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Background:The best timing for coronary angiography (immediate vs early) in patients with acute non-STelevation myocardial infarction (NSTEMI) is controversial. Hypothesis: Evaluate in NSTEMI patients the effects of an immediate compared to an early invasive strategy on microvascular damage, myocardial perfusion, and infarct size. Methods: We randomized 54 consecutive patients with first episode of NSTEMI: 27 patients (22 males, age 58.8 ± 9.4 years, group A) underwent immediate (≤6 hours) percutaneous coronary intervention (PCI) with a double bolus of eptifibatide, and 27 patients (24 males, age 59.7 ± 9.8 years, P = 0.72, group B) underwent early (7-72 hours) PCI with upstream eptifibatide. Microvascular damage was evaluated at predischarge by myocardial contrast echocardiography, and the contrast defect length was calculated.Results: There were no significant differences in pre-PCI myocardial blush grade (MBG) (41% MBG 0 or 1 in group A vs 37% MBG 0 or 1 in group B, P = 0.78), in post-PCI MBG (7.4% MBG 0 or 1 in both groups, P = 1.00), and in contrast defect length (4.5% in group A vs 2.8% in group B, P = 0.56). However, group A showed a significant reduction in creatine kinase myocardial band isoenzyme peak (26 ± 26 ng/mL in group A vs 69 ± 79 ng/mL in group B, P = 0.01) and in troponin T peak (0.84 ± 1.2 ng/mL in group A vs 1.8 ± 2.1 ng/mL in group B, P = 0.048). Conclusions:In patients with NSTEMI treated with eptifibatide, immediate PCI is associated with less increase in myonecrosis markers compared with PCI within 72 hours. There were no significant differences in myocardial perfusion between the 2 strategies. IntroductionIn patients with acute non-ST-elevation myocardial infarction (NSTEMI), an early invasive strategy with coronary angiography (CA) and subsequent revascularization through percutaneous coronary intervention (PCI) is associated with reduced rates of death and myocardial infarction (MI) in comparison with a conservative strategy. 1 Guidelines for the treatment of patients with acute coronary syndromes (ACS) recommend an early (≤72 hours) invasive strategy for patients admitted with diagnosis of NSTEMI. 2 Excluding conditions requiring emergency interventions (refractory angina, shock, and life-threatening arrhythmias), controversy remains regarding the optimal timing between hospital admission and the invasive procedure, with 2 different alternatives for the invasive approach:

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“…Both trials randomized patients to routine upstream therapy with tirofiban or selective downstream therapy. The design of ELISA-1 and ELISA-2 differed only with regard to the timing of angiography and the upstream use of clopidogrel [4,5].…”

Section: Methodsmentioning

confidence: 99%

“…In-and exclusion criteria have been described and were the same for both studies [4,5]. In brief, patients with symptoms of chest pain lasting more than 30 min in the previous 24 h before admission and either or both ST segment depression (1 mm or more) or a positive cardiac biomarkers (troponin T or CKMB) were included.…”

Section: Methodsmentioning

confidence: 99%