Management of non ST-segment elevation acute coronary syndromes—continuing the search for the bad guys

Thambyrajah, Jeet; Belder, Mark de

doi:10.1016/s0195-668x(02)00697-8

Cited by 5 publications

(1 citation statement)

References 19 publications

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“…[4][5][6]19,20 23 the invasive procedure should be performed within 48 h of the onset of symptoms (so-called early PCI: recommendation I-A). The ISAR-COOL (Intracoronary Stenting with Antithrombotic Regimen Cooling-Off) trial showed that an immediate PCI (within ,2.5 h) could improve the outcome of death from any cause and large non-fatal MI at 30 days when compared with a primary 'cooling down' strategy in patients with high-risk ACS.…”

Section: Acs Without St-segment Elevationmentioning

confidence: 99%

Percutaneous coronary intervention guidelines: new aspects for the interventional treatment of acute coronary syndromes

Elsässer

Hamm

2005

European Heart Journal Supplements

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In March 2005, the European Society of Cardiology (ESC) guidelines on percutaneous coronary intervention (PCI) were published, in which the management of patients with acute coronary syndromes (ACSs) was presented in detail for the interventional cardiologist. These guidelines supplement previous guidelines from the ESC on ACS with and without ST-elevation. Patients presenting with non-ST-segment elevation ACS should be treated according to the risk of progressing to myocardial infarction (MI) or death. Immediate (,2.5 h) or early (,48 h) coronary angiography and PCI are advised, particularly in patients with elevated troponin levels or diabetes mellitus. Coronary intervention in high-risk patients should be performed with triple antiplatelet therapy (aspirin, clopidogrel, and glycoprotein IIb/IIIa inhibitors). In patients with ST-segment elevation MI, primary PCI is the preferred treatment option, particularly .3 h after onset of clinical symptoms. Adjunctive therapy should include abciximab. Patients treated with thrombolysis should undergo invasive evaluation within 24 h. If this cannot be achieved, ischaemia-driven angiography is recommended.

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Section: Acs Without St-segment Elevationmentioning

confidence: 99%

Percutaneous coronary intervention guidelines: new aspects for the interventional treatment of acute coronary syndromes

Elsässer

Hamm

2005

European Heart Journal Supplements

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Guidelines for Percutaneous Coronary Interventions

Silber¹,

Albertsson²,

Fernández-Avilés³

et al. 2005

European Heart Journal

1,202

130

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In patients with stable CAD, PCI can be considered a valuable initial mode of revascularization in all patients with objective large ischaemia in the presence of almost every lesion subset, with only one exception: chronic total occlusions that cannot be crossed. In early studies, there was a small survival advantage with CABG surgery compared with PCI without stenting. The addition of stents and newer adjunctive medications improved the outcome for PCI. The decision to recommend PCI or CABG surgery will be guided by technical improvements in cardiology or surgery, local expertise, and patients' preference. However, until proved otherwise, PCI should be used only with reservation in diabetics with multi-vessel disease and in patients with unprotected left main stenosis. The use of drug-eluting stents might change this situation. Patients presenting with NSTE-ACS (UA or NSTEMI) have to be stratified first for their risk of acute thrombotic complications. A clear benefit from early angiography (<48 h) and, when needed, PCI or CABG surgery has been reported only in the high-risk groups. Deferral of intervention does not improve outcome. Routine stenting is recommended on the basis of the predictability of the result and its immediate safety. In patients with STEMI, primary PCI should be the treatment of choice in patients presenting in a hospital with PCI facility and an experienced team. Patients with contra-indications to thrombolysis should be immediately transferred for primary PCI, because this might be their only chance for quickly opening the coronary artery. In cardiogenic shock, emergency PCI for complete revascularization may be life-saving and should be considered at an early stage. Compared with thrombolysis, randomized trials that transferred the patients for primary PCI to a 'heart attack centre' observed a better clinical outcome, despite transport times leading to a significantly longer delay between randomization and start of the treatment. The superiority of primary PCI over thrombolysis seems to be especially clinically relevant for the time interval between 3 and 12 h after onset of chest pain or other symptoms on the basis of its superior preservation of myocardium. Furthermore, with increasing time to presentation, major-adverse-cardiac-event rates increase after thrombolysis, but appear to remain relatively stable after primary PCI. Within the first 3 h after onset of chest pain or other symptoms, both reperfusion strategies seem equally effective in reducing infarct size and mortality. Therefore, thrombolysis is still a viable alternative to primary PCI, if it can be delivered within 3 h after onset of chest pain or other symptoms. Primary PCI compared with thrombolysis significantly reduced stroke. Overall, we prefer primary PCI over thrombolysis in the first 3 h of chest pain to prevent stroke, and in patients presenting 3-12 h after the onset of chest pain, to salvage myocardium and also to prevent stroke. At the moment, there is no evidence to recommend facilitated PCI. Rescue PCI is reco...

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