General Topics in Unstable Angina - Free PowerPoint Slides
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The access to this Website is free and unrestricted. The primary target audience is cardiologists, allied healthcare professionals (such as nurses and lab technicians), internests, family practitioners and primary care physicians. Clinical Trial Results . org is an organization of clinical trial researchers whose goal is to rapidly disseminate emerging clinical trial results to physicians & other health care professionals so that they in turn can educate their colleagues and patients with the ultimate goal of accelerating the delivery of newer treatments. PowerPoint slides can be donwloaded for free.   www.timi.org  and www.timi.tv  strives to have the most up to date and accurate data.

Free Journal
Acute Coronary Syndromes Online - Remedica
http://www.acs.remedica.com 
In ACS online, you can search for up-to-date reviews of recent papers as well as the leading articles, case studies and meeting reports. 

Website
Vulnerable Plaque
http://www.VulnerablePlaque.org  

PowerPoint Presentation
Anti-Thrombotic Therapy in PCI & ACS: 2003 Update
by Dr. James Tcheng

Mar 2002 Journal Article
New Techniques for the Evaluation of the Vulnerable Plaque
Read this review of emerging catheter-based research techniques to clinically address and treat the vulnerable plaque.

AHA 2002 Meeting Coverage

CME
Acute Coronary Syndromes: In the Interest of Time
Christopher P. Cannon, MD
http://www.medscape.com/viewarticle/446503  

ISAR-COOL: Don't wait to passivate--get to the cath lab ASAP
with slides / The ISAR-COOL study in ACS patents showed a worse outcome in patients given intensive antiplatelet "cooling-off" treatment for 3 to 5 days before PCI compared with those taken straight to the cath lab. 
American Heart Association Scientific Sessions 2002. [ Nov 20, 2002 ]

ISAR-COOL: The Intracoronary Stenting With Antithrombotic Regimen Cooling-Off Trial
Deferral of PCI for a period of "cooling off" (plaque passivation) does not improve outcomes compared with immediate intervention with intense antiplatelet coverage.

Should all ACS patients receive IIb/IIIa blockers in the emergency room?
In a lighthearted debate during 1 of the first sessions of the AHA meeting, Dr Robert Harrington had the unenviable task of debating Dr Cindy Grines on use of clopidogrel and GP IIb/IIIa blockers in ACS patients in the emergency room. They were united on giving clopidogrel to all but disagreed on the role of IIb/IIIa blockers. 
American Heart Association Scientific Sessions 2002. [ Nov 17, 2002 ]

TCT 2002 Meeting Coverage

The Role of Adjunctive Therapies in the Management of ACS
While slightly overwhelming, deciphering between the various treatments for ACS may not be as complicated as one thinks.

TCT 2002 Abstracts 

• Interventional Pharmacology and Acute Coronary Syndromes
• Imaging and Vulnerable Plaque

TCT 2002 Expert Presentations 

PCR 2002 Meeting Coverage

ACC 2002 Meeting Coverage

INTERACT: enoxaparin looks good in combination with eptifibatide
The low molecular weight heparin enoxaparin was safer and more effective than unfractionated heparin in the treatment of high-risk ACS patients when both therapies were given with the GP IIb/IIIa blocker eptifibatide in the INTERACT trial presented here today. Although many previous trials have shown benefits of using either GP IIb/IIIa blockers or low molecular weight heparin in ACS, this is the largest randomized study of the combination reported to date. 
American College of Cardiology 51st Annual Scientific Session. [ Mar 18, 2002 ]

GP IIb/IIIa blockers in stenting: abciximab best for ACS, tirofiban preferable in non-ACS
Although abciximab may be the best GP IIb/IIIa blocker for ACS patients undergoing stenting, tirofiban may be preferable for stable non-ACS patients undergoing elective stenting, a new subgroup analysis of the TARGET trial suggests. 
American College of Cardiology 51st Annual Scientific Session. [ Mar 17, 2002 ]

Summaries of important articles from major peer-reviewed journals

Fewer events, long-term cost efficacy with early invasive strategy in TACTICS-TIMI 18
Mahoney EM et al. 
JAMA 2002;288:1851-1858. [ Oct 15, 2002 ]
with slide / Details on cost-efficacy data from TACTICS-TIMI 18 suggest that initial cost differences between the early-invasive and conservative treatment arms of the trial are attenuated at 6 months. Analyzed according to years of life saved, the cost of an early invasive strategy appears to be "highly acceptable." 

RITA 3: Routine intervention strategy halves angina for NSTEMI and UA patients at moderate risk
Fox KAA, et al. 
Lancet 2002; published online September 1, 2002 [ Sep 01, 2002 ]
with slide / A randomized trial comparing invasive versus conservative management of patients with non-ST-elevation MI and unstable angina judged to be at moderate risk for death has shown that the invasive strategy cuts the incidence of refractory angina by almost 50%, without any increase in death or MI. 

Multiple ruptured plaques, in addition to the culprit lesion, are present in patients with ACS
Rioufol G et al. 
Circulation 2002;106:published online before print. [ Jul 22, 2002 ]
with slide / Using IVUS, French researchers have found multiple atherosclerotic plaque ruptures lurking in all 3 major coronary arteries, in addition to the culprit lesion, in patients with acute coronary syndrome. 

Safety of clopidogrel pre-bypass debated
Hongo et al, Khot et al. 
J Am Coll Cardiol 2002; 40: 231-237, 218-219. [ Jul 19, 2002 ]
Two articles question the routine administration of clopidogrel in ACS patients (recommended post-CURE) or before anticipated stent implantation, mainly due to increased bleeding risk in patients who go on to early CABG. However, their arguments are refuted by CURE investigators and another leading cardiologist. 

ASPECT-2: coumadin more effective than aspirin in ACS
van Es RF et al. 
Lancet 2002; 360: 109-13. [ Jul 12, 2002 ]
In the treatment of ACS, high-intensity oral anticoagulants or aspirin plus medium-intensity oral anticoagulants were more effective than aspirin alone in the reduction of cardiovascular events and death in the ASPECT-2 trial. However, several experts say that clopidogrel probably represents a better option than oral anticoagulants for combination with aspirin in these patients. 

Women with ACS benefit from early aggressive PCI
Mueller C et al. 
J Am Coll Cardiol 2002;40:245-50. [ Jul 11, 2002 ]
The findings from a prospective cohort study appear to contradict previous studies that have suggested that men, but not women, have reduced MI and deaths following early PCI. The difference may be due to lower rates of CABG in this latest study, researchers say. 

Version 3.0 of TIMI risk calculator now available
The TIMI Study Group has just released a new version of its TIMI risk calculator, which incorporates the 2002 updated ACC/AHA unstable angina (UA) and non-ST-segment elevation MI (NSTEMI) guidelines. The calculator also has the TIMI Risk score for ST-segment elevation MI (STEMI), as well as the Early TIMI risk score based on just 3 variables. [ Jun 17, 2002 ]

Cut-and-vacuum thrombectomy device shows promise as pretreatment for PTCA in patients with ACS
Beran G et al. 
Circulation 2002; 105: published online before print May 6, 2002. [ May 06, 2002 ]
A novel device used to cut through thrombi, then remove fragments using an external vacuum, has shown promise as a pretreatment for patients with acute coronary syndromes (ACS) prior to undergoing PTCA. 

Near-infrared spectroscopy may pinpoint plaques ready to rupture
Wang J et al. 
J Am Coll Cardiol 2002; 39: 1305-13. [ Apr 16, 2002 ]
with slide / Texas researchers are using near-infrared (NIR) spectroscopy to characterize the tissue in atherosclerotic plaques; they report results of an ex vivo study showing the technique may flag lesions vulnerable to rupture. This same technology might also be used in the future as a noninvasive clinical tool to pinpoint vulnerable plaques, and evaluation in that application is already underway, they say. 

GP IIb/IIIa inhibitors benefit ACS patients not scheduled for early revascularization
Boersma E et al. 
Lancet 2002; 359: 189-98. [ Jan 17, 2002 ]
with slide / GP IIb/IIIa inhibitors are beneficial in patients with acute coronary syndromes not routinely scheduled for early revascularization, particularly in patients at high risk of thrombotic complications, according to a new meta-analysis. Treatment with a GP IIb/IIIa inhibitor should therefore be considered, especially in high-risk patients, early after admission, and continued until a decision about early coronary revascularization has been made, the authors recommend. 

Elevated C-reactive protein, thin plaque caps found in patients with sudden cardiac death
Burke AP et al. 
Circulation 2002; 105:DOI 10.1161/01.CIR.00000:SS07.29953.38 [ Apr 15, 2002 ]
with slide / A post-mortem study of 300 patients dying suddenly of coronary artery disease has shown the inflammatory marker C-reactive protein was significantly elevated in serum from these patients, and correlated both with levels of CRP found within the plaques and the number of plaques with thin caps vulnerable to rupture. 

New ACC/AHA guidelines hone management of unstable angina, NSTEMI
The American College of Cardiology and the American Heart Association have updated guidelines for the management of unstable angina and non-ST-segment elevation MI (NSTEMI). The 95-page document appears on the Web sites of the ACC and the AHA.
[ Mar 17, 2002 ]

Full text journal article Aug 2002
Coronary Vasospasm as a Possible Cause of Elevated Cardiac Troponin 1 in Patients With Acute Coronary Syndrome and Insignificant Coronary Artery Disease
How much do you know about coronary vasospasm?

Full text journal article Mar 2002
Is There a Benefit to Early Angiography in Patients With ST-Segment Depression Myocardial Infarction? An Observational Study
ST-Segment Depression Myocardial Infarction

Full text journal article Jun 2002
Direct Stent Implantation in Acute Coronary Syndrome
Direct stenting is equivalent to single-vessel conventional stenting with respect to MACE in selected ACS patients.

Acute coronary syndromes: direct stent for all?
Loubeyre C, et al.
J Invasive Cardiol 2002;14:313-4.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12042622  
Full text 
There should be unrestricted use of direct stenting in ACS, but enhancements in stenting strategy are still necessary.

Critical pathways for management of patients with acute coronary syndromes: an assessment by the National Heart Attack Alert Program
Cannon CP, et al.
Am Heart J 2002;143:777-89.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12040337
http://www.mosby.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=abs&id=a120260&target= 
Critical pathways offer the potential to improve the care of patients with ACS while reducing the cost of care. Their use should improve the process and cost-effectiveness of care, but further research in this field is needed to determine whether these changes in the process of care will translate into improved clinical outcomes

Prognostic significance of elevated troponin I after percutaneous coronary intervention
Cantor WJ, et al.
J Am Coll Cardiol 2002;39:1738-44.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12039485
Elevated cTnI, often observed after PCI in patients with ACS, is associated with worse 90-day clinical outcomes. This marker, therefore, is a useful prognostic indicator in such patients.

Intravascular ultrasound findings in patients with acute coronary syndromes with and without elevated troponin I level
Fuchs S, et al.
Am J Cardiol 2002;89:1111-3.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11988203

Use of clopidogrel loading, enoxaparin, and double-bolus eptifibatide in the setting of early percutaneous coronary intervention for acute coronary syndromes
Miller L, et al.
J Invasive Cardiol 2002;14:247-50.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11983945
This pilot study demonstrates the feasibility of administering aspirin, clopidogrel, enoxaparin, and eptifibatide in the setting of percutaneous coronary intervention for acute coronary syndromes. These agents can be administered moments before the coronary intervention with no apparent compromise in patient safety.

Pathology of the unstable plaque
Virmani R, et al.
Prog Cardiovasc Dis 2002;44:349-56.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12024333
http://www.us.elsevierhealth.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=abs&id=apcad0440349&target=
This review provides a focused discussion of the thin-cap fibroatheroma as a specific cause of acute coronary syndromes. The pathology of the unstable plaque is presented in reference to unstable angina, acute myocardial infarction, and sudden coronary death. The influence of risk factors for coronary artery disease on culprit lesion morphology is also discussed. Finally, the value of coronary calcification, as a predictor of unstable plaques in the clinical setting, is explored.

Impact of clinical syndrome acuity on the differential response to 2 glycoprotein IIb/IIIa inhibitors in patients undergoing coronary stenting: the TARGET Trial
Stone GW, et al.
Circulation 2002;105:2347-54.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12021219
http://www.circulationaha.org/cgi/content/full/105/20/2347
http://www.circulationaha.org/cgi/content/abstract/105/20/2347
In patients with ACS undergoing stent implantation, abciximab use compared with tirofiban results in greater suppression of periprocedural myonecrosis, although a survival benefit has not been demonstrated. Patients with stable coronary syndromes may have equivalent or better outcomes with tirofiban relative to abciximab, with fewer adverse hematologic and hemorrhagic events. These data raise important issues regarding the relative pharmacodynamic inhibition of platelet function required in varying clinical scenarios and have important implications for the cost- effective utilization of glycoprotein IIb/IIIa inhibitors.

Early experience with a helical coronary thrombectomy device in patients with acute coronary thrombosis
Constantinides S, et al.
Heart 2002;87:455-60.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11997421
http://heart.bmjjournals.com/cgi/content/full/87/5/455
http://heart.bmjjournals.com/cgi/content/abstract/87/5/455
Thrombectomy with the X-SIZER catheter system appears promising in percutaneous coronary intervention where thrombus extraction is considered necessary before stent implantation.

Guidelines for acute coronary syndrome without ST elevation
Ward DJ, et al.
Lancet 2002;359:1349; discussion 1350.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11965312

Heparin dosing and outcome in acute coronary syndromes: The GUSTO-IIb experience
Gilchrist IC, et al.
Am Heart J 2002;144:73-80.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12094191
http://www.mosby.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=abs&id=a123112&target=
The lowest mortality rate appeared with a heparin dose of approximately 14 U/kg/h. There is a defined, dose-associated benefit of unfractionated heparin in acute coronary syndromes similar to that seen previously in thrombolytic-treated infarctions. Heparin therapy is complicated by its complex biologic interactions and relatively crude measures of its effect. Better measures of heparin effectiveness and strategies need to be developed with either better antithrombin agents or adjunctive therapies such as antiplatelet regimens to treat patients who require benefits beyond that supplied by unfractionated heparin.

First national survey on management strategies in non ST-elevation acute ischaemic syndromes in Argentina. Results of the STRATEG-SIA study
Ferreiros ER, et al.
Eur Heart J 2002;23:1021-9.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12093054
A routine, unselected invasive approach in non-ST elevation acute ischaemic syndromes in Argentina is associated with no apparent improvement of patients' outcome.

Editorial
Coronary angiography and revascularization for acute coronary syndromes without ST elevation: the next challenge
de Arenaza DP, et al.
Eur Heart J 2002;23:997-9.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12093048

Early angioplasty in acute coronary syndromes without persistent st- segment elevation improves outcome but increases the need for six-month repeat revascularization. An analysis of the pursuit trial
Ronner E, et al.
J Am Coll Cardiol 2002;39:1924-9.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12084589
Percutaneous coronary intervention within 24 is associated with improved outcome (other analysis) but more repeat revascularization. Prospective analyses are needed to test the hypothesis that rapid PCI in ACS with a platelet glycoprotein IIb/IIIa receptor antagonist reduces myocardial infarction (and possibly death) and is therefore most suited for patients at highest risk of infarction, despite a higher need for repeat revascularization.

Direct Use of the X-SIZER Catheter System in the Treatment of Acute Thrombotic Coronary Occlusion
Palmer ND, et al.
J Invasive Cardiol 2002;14:420-2.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12082198
This case report suggests that the X-SIZER device has potential as an adjunct to PTCA and stenting in reducing the risk associated with thrombotic occlusion. In addition, its limited ability to cross severe stenoses or reduce lesion severity suggests that the X-SIZER should not be regarded as an atherectomy device. 

Platelet Glycoprotein IIb/IIIa Inhibitor Use During Percutaneous Coronary Intervention: IIb or Not IIb, What is the Question?
Young JJ, et al.
J Invasive Cardiol 2002;14:404-10.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12082194
Currently, the small molecule GP IIb/IIIa inhibitor, tirofiban (Aggrastat, Merck & Company), which (similar to eptifibatide) is approved for the medical therapy of patients with non-ST segment elevation acute coronary syndromes (ACS), has not received indication for use in the PCI setting. Although the clinical benefits of both abciximab and eptifibatide administered at the time of PCI have been proven in randomized clinical trials, only abciximab has demonstrated a late survival advantage in patients following PCI. Evidence in support of the presence, magnitude and possible mechanisms for abciximab survival advantage is herein reviewed.

Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials
Boersma E, et al.
Lancet 2002;359:189-98.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11812552
Glycoprotein IIb/IIIa inhibitors reduce the occurrence of death or myocardial infarction in patients with acute coronary syndromes not routinely scheduled for early revascularisation. The event reduction is greatest in patients at high risk of thrombotic complications. Treatment with a glycoprotein IIb/IIIa inhibitor might therefore be considered especially in such patients early after admission, and continued until a decision about early coronary revascularisation has been made

Revisiting the culprit lesion in non-Q-wave myocardial infarction. Results from the VANQWISH trial angiographic core laboratory
Kerensky RA, et al.
J Am Coll Cardiol 2002;39:1456-63.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11985907
Coronary angiography early after NQWMI frequently identifies severe obstructive CAD, but a single identifiable culprit lesion was identified in <50% of patients. Multiple culprit lesions were seen in 14% of patients. An angiographic culprit lesion could not be identified in more than one- third of patients undergoing coronary angiography as part of an invasive strategy.

Rebound thrombin generation after heparin therapy in unstable angina. A randomized comparison between unfractionated and low-molecular-weight heparin
Bijsterveld NR, et al.
J Am Coll Cardiol 2002;39:811-7.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11869846
Rebound coagulation activation occurs within hours after discontinuation of both UFH and dalteparin. With both drugs, thrombin generation is significantly greater after treatment than before or during treatment. A longer duration or weaning of treatment, or continuation with another anticoagulant treatment, may reduce rebound coagulation activation and ischemic events.

Patients with acute coronary syndromes without persistent ST elevation undergoing percutaneous coronary intervention benefit most from early intervention with protection by a glycoprotein IIb/IIIa receptor blocker
Ronner E, et al.
Eur Heart J 2002;23:239-46.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11792139
Patients treated with a platelet glycoprotein IIb/IIIa receptor blocker, and early percutaneous coronary intervention (within 24 h) had the lowest event rate in this post hoc analysis. Thus 'watchful waiting' may not be the optimal strategy. Rather an early invasive strategy with percutaneous coronary intervention under protection of a platelet glycoprotein IIb/IIIa receptor blocker should be considered in selected patients. Randomized trials are warranted to verify this issue.

Value of first day angiography/angioplasty in evolving Non-ST segment elevation myocardial infarction: an open multicenter randomized trial. The VINO Study
Spacek R, et al.
Eur Heart J 2002;23:230-8.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11792138
First day coronary angiography followed by angioplasty whenever possible reduces mortality and reinfarction in evolving myocardial infarction without persistent ST-elevation, in comparison with an early conservative treatment strategy.

ST depression in ECG at entry indicates severe coronary lesions and large benefits of an early invasive treatment strategy in unstable coronary artery disease; the FRISC II ECG substudy. The Fast Revascularisation during InStability in Coronary artery disease
Diderholm E, et al.
Eur Heart J 2002;23:41-9.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11741361
In unstable coronary artery disease, ST-segment depression is associated with a 100% increase in the occurrence of three-vessel/left main disease and to an increased risk of subsequent cardiac events. In these patients an early invasive strategy substantially decreases death/myocardial infarction.

Outcomes of patients with acute coronary syndromes and prior coronary artery bypass grafting: results from the platelet glycoprotein IIb/IIIa in unstable angina: receptor suppression using integrilin therapy (PURSUIT) trial
Labinaz M, et al.
Circulation 2002;105:322-7.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11804987
http://www.circulationaha.org/cgi/content/full/105/3/322
http://www.circulationaha.org/cgi/content/abstract/105/3/322
Patients with prior CABG with non-ST-segment elevation ACS have a significantly worse prognosis than do patients without a history of CABG. The treatment effect of eptifibatide in the prior CABG group was similar to the effect seen in patients without prior CABG

Inflammation and long-term mortality after non-ST elevation acute coronary syndrome treated with a very early invasive strategy in 1042 consecutive patients
Mueller C, et al.
Circulation 2002;105:1412-5.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11914246
http://www.circulationaha.org/cgi/content/full/105/12/1412
http://www.circulationaha.org/cgi/content/abstract/105/12/1412
CRP is a strong independent predictor of short and long-term mortality after NSTACS that are treated with very early revascularization.

Coronary angiographic morphology in unstable angina: comparative observations of culprit lesions in saphenous vein grafts versus native coronary arteries
Preston LM, et al.
J Invasive Cardiol 2002;14:81-6.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11818643
In UA, culprit lesions of SVGs assessed angiographically demonstrate morphology consistent with ulcerated plaque and thrombus more frequently than lesions in NCAs, but total occlusions are more common in NCAs. Angiographically-evident active thrombotic and ulcerated lesions underlie acute ischemic syndromes more frequently in SVGs than in native vessels.

Acute coronary syndrome is a common clinical presentation of in-stent restenosis
Walters DL, et al.
Am J Cardiol 2002;89:491-4.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11867029
Acute coronary syndromes are a common clinical presentation of restenosis among patients whose follow-up angiogram is obtained for clinical reasons, and occur more frequently in patients with in-stent restenosis than in those with restenosis without stenting.