2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Predicting the no-reflow phenomenon following successful percutaneous coronary intervention

In the setting of acute myocardial infarction, early and adequate reopening of an infarct-related artery is not necessarily followed by a complete restoration of myocardial perfusion. This condition is usually defined as ‘no-reflow’. The pathophysiology of no-reflow is multifactorial since extravascular compression, microvascular vasoconstriction, embolization during percutaneous coronary intervention, and platelet and neutrophil aggregates are involved. In the clinical arena, angiographic findings and easily available clinical parameters can predict the risk of no-reflow. More recently, several studies have demonstrated that biomarkers, especially those related to the pathogenetic components of no-reflow, could also have a prognostic role in the prediction and in the full understanding of the multiple mechanisms of this phenomenon. Thus, in this article, we investigate the role of several biomarkers on admission in predicting the occurrence of no-reflow following successful percutaneous coronary intervention.

Practical strategies for the management of anticoagulation therapy: unsolved issues in the cardiac catheterization laboratory

PURPOSE

Percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in the management of patients with ST-elevation myocardial infarction (STEMI) and higher-risk patients with unstable angina/non-STEMI (UA/NSTEMI). Recent updates have been issued for guidelines from the American College of Cardiology and American Heart Association delineating the appropriate use of anticoagulants as ancillary therapies to PCI. This manuscript reviews the recent clinical trial data supporting the updated guidelines and highlights remaining areas of uncertainty.

METHODS

SCOPUS and Pubmed were searched for relevant English-language reports of clinical trials, registries, articles and case reports. Search terms included but were not limited to: PCI, anticoagulation, ancillary, STEMI, NSTEMI, angina, acute coronary syndrome. The reference lists of identified articles were searched for additional relevant publications.

RESULTS

Unfractionated heparin (UFH), the historical standard of care for anticoagulation in STEMI and NSTEMI patients undergoing PCI, is sub-optimal and the list of anticoagulants recommended for alternatives in the current guidelines has expanded to include superior anticoagulants, including the low-molecular-weight heparin enoxaparin and the direct thrombin inhibitor bivalirudin. Additionally, fondaparinux is recommended if supplemented during PCI by an additional agent with anti-IIa activity. However, uncertainties in the guidelines remain. Clinical discretion is still required when deciding which anticoagulant to use, ensuring seamless transitions throughout the care pathway, and how to correctly identify the risk status of a patient and modify anticoagulant regimens accordingly, such as in special patient populations.

CONCLUSIONS

The published evidence supports the updates to the guidelines. Updated guidelines still have knowledge gaps which require the application of clinical discretion by the cardiologist.

Timing of angiography after fibrinolysis for ST-elevation acute myocardial infarction

PURPOSE OF REVIEW

Despite its limited efficacy in opening occluded coronary arteries in ST-elevation myocardial infarction, fibrinolysis remains the major reperfusion strategy used worldwide. Apart from bleeding, early reocclusion of the culprit artery is a common complication of the therapy and usually leads to a worse prognosis.

RECENT FINDINGS

During the last 7 years routine percutaneous coronary intervention after fibrinolysis has been shown to improve early and long-term outcome in six large randomized trials.

SUMMARY

The optimal time window to perform percutaneous coronary intervention is between 3 and 24 h after fibrinolysis.

A fatal complication of tirofiban in an octogenarian: Diffuse alveolar hemorrhage

An 84-year-old female patient with a past medical history significant for hypertension and diabetes mellitus, was admitted to the Emergency Department with acute coronary syndrome and complete atrioventricular block. She underwent a successful primary percutaneous coronary intervention. Ten minutes following tirofiban administration, the patient complained of hemoptysis and severe dyspnea. After chest X-ray and diagnostic bronchoscopy, she was diagnosed with diffuse alveolar hemorrhage. She died because of respiratory insufficiency on the third day of hospitalization. We present the first tirofiban-related diffuse alveolar hemorrhage case caused with half of the recommended dose of tirofiban used in the setting of non-ST-elevation myocardial infarction.