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Díez-Villanueva P, Jiménez-Méndez C, Cepas-Guillén P, Arenas-Loriente A, Fernández-Herrero I, García-Pardo H, Díez-Delhoyo F. Current Management of Non-ST-Segment Elevation Acute Coronary Syndrome. Biomedicines 2024; 12:1736. [PMID: 39200201 PMCID: PMC11352006 DOI: 10.3390/biomedicines12081736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/27/2024] [Accepted: 07/30/2024] [Indexed: 09/02/2024] Open
Abstract
Cardiovascular disease constitutes the leading cause of morbimortality worldwide. Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is a common cardiovascular condition, closely related to the ageing population and significantly affecting survival and quality of life. The management of NSTE-ACS requires specific diagnosis and therapeutic strategies, thus highlighting the importance of a personalized approach, including tailored antithrombotic therapies and regimens, combined with timely invasive management. Moreover, specific and frequent populations in clinical practice, such as the elderly and those with chronic kidney disease, pose unique challenges in the management of NSTE-ACS due to their increased risk of ischemic and hemorrhagic complications. In this scenario, comprehensive management strategies and multidisciplinary care are of great importance. Cardiac rehabilitation and optimal management of cardiovascular risk factors are essential elements of secondary prevention since they significantly improve prognosis. This review highlights the need for a personalized approach in the management of NSTE-ACS, especially in vulnerable populations, and emphasizes the importance of precise antithrombotic management together with tailored revascularization strategies, as well as the role of cardiac rehabilitation in NSTE-ACS patients.
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Affiliation(s)
| | - César Jiménez-Méndez
- Cardiology Department, Hospital Universitario Puerta del Mar, 11009 Cádiz, Spain;
| | - Pedro Cepas-Guillén
- Cardiology Department, Hospital Clinic, 08036 Barcelona, Spain; (P.C.-G.); (A.A.-L.)
| | | | - Ignacio Fernández-Herrero
- Cardiology Department, Hospital Universitario Doce de Octubre, 28041 Madrid, Spain; (I.F.-H.); (F.D.-D.)
| | - Héctor García-Pardo
- Cardiology Department, Hospital Universitario Río Hortega, 47012 Valladolid, Spain;
| | - Felipe Díez-Delhoyo
- Cardiology Department, Hospital Universitario Doce de Octubre, 28041 Madrid, Spain; (I.F.-H.); (F.D.-D.)
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2
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Montalto C, Morici N, Myat A, Crimi G, De Luca G, Bossi I, de Belder A, Savonitto S, De Servi S. Multivessel vs. culprit-only percutaneous coronary intervention strategy in older adults with acute myocardial infarction. Eur J Intern Med 2022; 105:82-88. [PMID: 36109262 DOI: 10.1016/j.ejim.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 08/16/2022] [Accepted: 09/07/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The optima revascularization strategy for senior patients admitted with acute myocardial infarction (AMI) in the context of multivessel coronary artery disease (MVCAD) remains unclear. We aimed to compare a strategy of culprit-vessel (CV) vs. multi-vessel percutaneous coronary intervention (MV-PCI) in older adults (≥75 years) with AMI. METHODS We analyzed four randomized controlled trials designed to include older adults with AMI. The primary endpoint was all-cause death. The secondary endpoint was the composite of all-cause death, myocardial infarction, stroke and major bleeding (Net Adverse Clinical Events, NACE). A non-parsimonious propensity score and nearest-neighbor matching was performed to account for bias. RESULTS A total of 1,334 trial participants were included; of them, 770 (57.7%) underwent CV-PCI and 564 (42.3%) a MV-PCI strategy. After a median follow-up of 365 days, patients treated with MV-PCI experienced a lower rate of death (6.0% vs. 9.9%; p = 0.01) and of NACE (11.2% vs. 15.5%; p = 0.016). After multivariable analysis, MV-PCI was independently associated with a lower hazard of death (hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.42-0.96; p = 0.03) and NACE (NACE 0.72[0.53-0.98]; p = 0.04). These results were confirmed in a matched propensity analysis, were consistent throughout the spectrum of older age and when analyzed by subgroups and when immortal-time bias was considered. CONCLUSIONS In the setting of older adults with MVCAD who were managed invasively for AMI, a MV-PCI strategy to pursue complete revascularization was associated with better survival and lower risk of NACE compared to a CV-PCI. Adequately sized RCTs are required to confirm these findings.
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Affiliation(s)
- Claudio Montalto
- Department of Molecular Medicine, University of Pavia, Pavia, Italy; Interventional Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy.
| | - Nuccia Morici
- IRCCS S. Maria Nascente - Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Aung Myat
- Sussex Cardiac Center, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Gabriele Crimi
- Interventional Cardiology Unit, Cardio-Thoraco-Vascular Department, Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Novara, Italy
| | - Irene Bossi
- Interventional Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | - Adam de Belder
- Sussex Cardiac Center, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Stefano Savonitto
- Division of Cardiology, Manzoni Hospital, Via dell'Eremo, 9, Lecco 23900, Italy
| | - Stefano De Servi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
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Paratz ED, Nicolaides S, Layland J. Many shades of grey: seeking the optimal medical therapy of acute coronary syndrome in older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2017. [DOI: 10.1002/jppr.1365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | - Jamie Layland
- Peninsula Health Heart Service; Frankston Australia
- Peninsula Clinic School; Monash University; Frankston Australia
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4
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Fanning JP, Nyong J, Scott IA, Aroney CN, Walters DL. Routine invasive strategies versus selective invasive strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev 2016; 2016:CD004815. [PMID: 27226069 PMCID: PMC8568369 DOI: 10.1002/14651858.cd004815.pub4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People with unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI) are managed with a combination of medical therapy, invasive angiography and revascularisation. Specifically, two approaches have evolved: either a 'routine invasive' strategy whereby all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularisation; or a 'selective invasive' (also referred to as 'conservative') strategy in which medical therapy alone is used initially, with a selection of patients for angiography based upon evidence of persistent myocardial ischaemia. Uncertainty exists as to which strategy provides the best outcomes for these patients. This Cochrane review is an update of a Cochrane review originally published in 2006, to provide a robust comparison of these two strategies in the early management of patients with UA/NSTEMI. OBJECTIVES To determine the benefits and harms associated with the following.1. A routine invasive versus a conservative or 'selective invasive' strategy for the management of UA/NSTEMI in the stent era.2. A routine invasive strategy with and without glycoprotein IIb/IIIa receptor antagonists versus a conservative strategy for the management of UA/NSTEMI in the stent era. SEARCH METHODS We searched the following databases and additional resources up to 25 August 2015: the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, MEDLINE and EMBASE, with no language restrictions. SELECTION CRITERIA We included prospective randomised controlled trials (RCTs) that compared invasive with conservative or 'selective invasive' strategies in participants with acute UA/NSTEMI. DATA COLLECTION AND ANALYSIS Two review authors screened the records and extracted data in duplicate. Using intention-to-treat analysis with random-effects models, we calculated summary estimates of the risk ratio (RR) with 95% confidence intervals (CIs) for the primary endpoints of all-cause death, fatal and non-fatal myocardial infarction (MI), combined all-cause death or non-fatal MI, refractory angina and re-hospitalisation. We performed further analysis of included studies based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. We assessed the heterogeneity of included trials using Pearson χ² (Chi² test) and variance (I² statistic) analysis. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, we assessed the quality of the evidence and the GRADE profiler (GRADEPRO) was used to import data from Review Manager 5.3 (Review Manager) to create Summary of findings (SoF) tables. MAIN RESULTS Eight RCTs with a total of 8915 participants (4545 invasive strategies, 4370 conservative strategies) were eligible for inclusion. We included three new studies and 1099 additional participants in this review update. In the all-study analysis, evidence did not show appreciable risk reductions in all-cause mortality (RR 0.87, 95% CI 0.64 to 1.18; eight studies, 8915 participants; low quality evidence) and death or non-fatal MI (RR 0.93, 95% CI 0.71 to 1.2; seven studies, 7715 participants; low quality evidence) with invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. There was appreciable risk reduction in MI (RR 0.79, 95% CI 0.63 to 1.00; eight studies, 8915 participants; moderate quality evidence), refractory angina (RR 0.64, 95% CI 0.52 to 0.79; five studies, 8287 participants; moderate quality evidence) and re-hospitalisation (RR 0.77, 95% CI 0.63 to 0.94; six studies, 6921 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies also at six to 12 months follow-up.Evidence also showed increased risks in bleeding (RR 1.73, 95% CI 1.30 to 2.31; six studies, 7584 participants; moderate quality evidence) and procedure-related MI (RR 1.87, 95% CI 1.47 to 2.37; five studies, 6380 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies.The low quality evidence were as a result of serious risk of bias and imprecision in the estimate of effect while moderate quality evidence was only due to serious risk of bias. AUTHORS' CONCLUSIONS In the all-study analysis, the evidence failed to show appreciable benefit with routine invasive strategies for unstable angina and non-ST elevation MI compared to conservative strategies in all-cause mortality and death or non-fatal MI at six to 12 months. There was evidence of risk reduction in MI, refractory angina and re-hospitalisation with routine invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. However, routine invasive strategies were associated with a relatively high risk (almost double the risk) of procedure-related MI, and increased risk of bleeding complications. This systematic analysis of published RCTs supports the conclusion that, in patients with UA/NSTEMI, a selectively invasive (conservative) strategy based on clinical risk for recurrent events is the preferred management strategy.
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Affiliation(s)
- Jonathon P Fanning
- The Prince Charles HospitalSchool of Medicine, The University of QueenslandRode RoadChermsideBrisbaneAustralia4032
| | - Jonathan Nyong
- FARR Institute UCLClinical Epidemiology222 Euston RoadLondonGreater LondonUKNW1 2DA
| | - Ian A Scott
- Princess Alexandra HospitalInternal Medicine Department and Clinical Services Evaluation UnitBrisbaneAustralia
| | - Constantine N Aroney
- The Prince Charles HospitalDepartment of CardiologyRode RdChermsideBrisbaneAustralia
| | - Darren L Walters
- The Prince Charles HospitalExecutive Chair Prince Charles Heart and Lung InstituteRoad RdBrisbaneQueenslandAustralia4032
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Angeli F, Cavallini C, Verdecchia P, Morici N, Del Pinto M, Petronio AS, Antonicelli R, Murena E, Bossi I, De Servi S, Savonitto S. A risk score for predicting 1-year mortality in patients ≥75 years of age presenting with non-ST-elevation acute coronary syndrome. Am J Cardiol 2015; 116:208-13. [PMID: 25978978 DOI: 10.1016/j.amjcard.2015.04.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 04/09/2015] [Accepted: 04/09/2015] [Indexed: 11/28/2022]
Abstract
Approximately 1/3 of patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS) are ≥75 years of age. Risk stratification in these patients is generally difficult because supporting evidence is scarce. The investigators developed and validated a simple risk prediction score for 1-year mortality in patients ≥75 years of age presenting with NSTE ACS. The derivation cohort was the Italian Elderly ACS trial, which included 313 patients with NSTE ACS aged ≥75 years. A logistic regression model was developed to predict 1-year mortality. The validation cohort was a registry cohort of 332 patients with NSTE ACS meeting the same inclusion criteria as for the Italian Elderly ACS trial but excluded from the trial for any reason. The risk score included 5 statistically significant covariates: previous vascular event, hemoglobin level, estimated glomerular filtration rate, ischemic electrocardiographic changes, and elevated troponin level. The model allowed a maximum score of 6. The score demonstrated a good discriminating power (C statistic = 0.739) and calibration, even among subgroups defined by gender and age. When validated in the registry cohort, the scoring system confirmed a strong association with the risk for all-cause death. Moreover, a score ≥3 (the highest baseline risk group) identified a subset of patients with NSTE ACS most likely to benefit from an invasive approach. In conclusion, the risk for 1-year mortality in patients ≥75 years of age with NSTE ACS is substantial and can be predicted through a score that can be easily derived at the bedside at hospital presentation. The score may help in guiding treatment strategy.
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Affiliation(s)
- Fabio Angeli
- Dipartimento di Cardiologia, Ospedale S. M. Della Misericordia, Perugia, Italy.
| | - Claudio Cavallini
- Dipartimento di Cardiologia, Ospedale S. M. Della Misericordia, Perugia, Italy
| | - Paolo Verdecchia
- Dipartimento di Medicina Interna, Ospedale di Assisi, Assisi, Italy
| | - Nuccia Morici
- Dipartimento cardiotoracovascolare, Ospedale Niguarda Cà Granda, Milano, Italy
| | - Maurizio Del Pinto
- Dipartimento di Cardiologia, Ospedale S. M. Della Misericordia, Perugia, Italy
| | - Anna Sonia Petronio
- Dipartimento cardiotoracovascolare, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | | | - Ernesto Murena
- Dipartimento di Cardiologia, Ospedale S. Maria Delle Grazie, Naples, Italy
| | - Irene Bossi
- Dipartimento cardiotoracovascolare, Ospedale Niguarda Cà Granda, Milano, Italy
| | - Stefano De Servi
- Dipartimento cardiotoracovascolare, IRCCS Policlinico S. Matteo, Pavia, Italy
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Galasso G, De Servi S, Savonitto S, Strisciuglio T, Piccolo R, Morici N, Murena E, Cavallini C, Petronio AS, Piscione F. Effect of an invasive strategy on outcome in patients ≥75 years of age with non-ST-elevation acute coronary syndrome. Am J Cardiol 2015; 115:576-80. [PMID: 25595527 DOI: 10.1016/j.amjcard.2014.12.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 12/05/2014] [Accepted: 12/05/2014] [Indexed: 10/24/2022]
Abstract
The Italian Elderly ACS study was the first randomized controlled trial comparing an early aggressive with an initially conservative strategy in patients with non-ST-segment elevation acute coronary syndromes aged ≥75 years, with the results showing no significant benefit of early aggressive therapy. The aim of this study was to evaluate the outcomes of trial patients, according to the treatment actually received during hospitalization. The trial enrolled 313 patients. The primary end point was the composite of death, myocardial infarction (MI), disabling stroke, and repeat hospital stay for cardiovascular causes or bleeding within 1 year. All patients in whom coronary angiography was performed during initial hospitalization were defined as having undergone invasive treatment (182 patients), whereas all patients who did not undergo coronary angiography were classified as medically managed (conservative treatment [CT] group, 131 patients). The primary end point occurred in 53 patients (40.5%) in the CT group and 45 patients (24.7%) in the invasive treatment group (hazard ratio 0.56, 95% confidence interval 0.37 to 0.83, p = 0.003). The invasive treatment group showed significantly lower rates of MI (6% vs 13% in the CT group; hazard ratio 0.43, 95% confidence interval 0.20 to 0.92, p = 0.034) and the aggregate of death and MI (14.3% vs 27.5% CT group; hazard ratio 0.48, 95% confidence interval 0.29 to 0.81, p = 0.004). In conclusion, elderly patients with non-ST-segment elevation acute coronary syndromes treated invasively experienced significantly better survival free from the composite of all-cause mortality, nonfatal MI, disabling stroke, and repeat hospitalization for cardiovascular causes or bleeding.
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7
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Savonitto S, Morici N, Cavallini C, Antonicelli R, Petronio AS, Murena E, Olivari Z, Steffenino G, Bonechi F, Mafrici A, Toso A, Piscione F, Bolognese L, De Servi S. One-Year Mortality in Elderly Adults with Non-ST-Elevation Acute Coronary Syndrome: Effect of Diabetic Status and Admission Hyperglycemia. J Am Geriatr Soc 2014; 62:1297-303. [DOI: 10.1111/jgs.12900] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
| | - Nuccia Morici
- Division of Cardiology; Ospedale S. Carlo; Milano Italy
| | - Claudio Cavallini
- Department of Cardiology; Ospedale Santa Maria della Misericordia; Perugia Italy
| | | | - Anna Sonia Petronio
- Institute of Cardiology Azienda Ospedaliera Universitaria Pisana; Pisa Italy
| | - Ernesto Murena
- Division of Cardiology; Ospedale S Maria delle Grazie; Pozzuoli Italy
| | - Zoran Olivari
- Division of Cardiology; Ospedale Ca' Foncello; Treviso Italy
| | | | - Francesco Bonechi
- Division of Cardiology; Ospedale San Giuseppe; Empoli-Fucecchio Italy
| | | | - Anna Toso
- Division of Cardiology; Ospedale Misericordia e Dolce; Prato Italy
| | - Federico Piscione
- Department of Medicine and Surgery; University of Salerno; Salerno Italy
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Angeli F, Verdecchia P, Savonitto S, Morici N, De Servi S, Cavallini C. Early invasive versus selectively invasive strategy in patients with non-ST-segment elevation acute coronary syndrome: Impact of age. Catheter Cardiovasc Interv 2014; 83:686-701. [DOI: 10.1002/ccd.25307] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 10/31/2013] [Accepted: 11/22/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Fabio Angeli
- Division of Cardiology and Cardiovascular Pathophysiology; Teaching Hospital “S.M. della Misericordia,”; Perugia Italy
| | - Paolo Verdecchia
- Department of Internal Medicine; Hospital of Assisi; Assisi Italy
| | - Stefano Savonitto
- Division of Cardiology; IRCCS “Arcispedale S. Maria Nuova,”; Reggio Emilia Italy
| | - Nuccia Morici
- Department of Cardiology; Hospital “Niguarda Ca' Granda,”; Milano Italy
| | | | - Claudio Cavallini
- Department of Cardiology; Teaching Hospital “S.M. della Misericordia,”; Perugia Italy
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9
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Savonitto S, Cavallini C, Petronio AS, Murena E, Antonicelli R, Sacco A, Steffenino G, Bonechi F, Mossuti E, Manari A, Tolaro S, Toso A, Daniotti A, Piscione F, Morici N, Cesana BM, Jori MC, De Servi S. Early Aggressive Versus Initially Conservative Treatment in Elderly Patients With Non–ST-Segment Elevation Acute Coronary Syndrome. JACC Cardiovasc Interv 2012; 5:906-16. [DOI: 10.1016/j.jcin.2012.06.008] [Citation(s) in RCA: 137] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 05/29/2012] [Accepted: 06/07/2012] [Indexed: 01/12/2023]
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Savonitto S, Morici N, Sacco A, Klugmann S. Target populations and relevant therapeutic end points to further improve outcomes in NSTEACS patients. Future Cardiol 2009; 5:27-41. [DOI: 10.2217/14796678.5.1.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
An aggressive pharmaco-interventional approach has been shown to improve long-term outcome among high-risk patients with acute coronary syndromes without ST-segment elevation (NSTEACS). However, these patients continue to represent a minority among those enrolled in clinical trials, thus precluding the possibility to further improve therapeutic efficacy. Target populations that are not adequately addressed by the majority of therapeutic trials are mainly the elderly and those with reduced renal function, who all show unfavorable outcome after an episode of NSTEACS. In order to allow comparison among different studies, a prerequisite for the planning of meaningful trials should be a uniform definition of the study end points besides mortality, particularly with reference to recurrent myocardial infarction, and rehospitalization owing to cardiovascular instability or severe bleeding. In addition to trial design issues, improvements in the regulatory rules for drug development and in hospital networking conceal significant opportunities to improve treatment of NSTEACS.
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Affiliation(s)
- Stefano Savonitto
- Dipartimento Cardiologico ‘Angelo De Gasperis’, Ospedale Niguarda Ca’ Granda, Piazza Ospedale Maggiore 3, 20162 Milano, Italy
| | - Nuccia Morici
- ‘Angelo De Gasperis’ Department of Cardiology, Ospedale Niguarda Ca’ Granda, Milan, Italy
| | - Alice Sacco
- ‘Angelo De Gasperis’ Department of Cardiology, Ospedale Niguarda Ca’ Granda, Milan, Italy
| | - Silvio Klugmann
- ‘Angelo De Gasperis’ Department of Cardiology, Ospedale Niguarda Ca’ Granda, Milan, Italy
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Current World Literature. Curr Opin Support Palliat Care 2008; 2:288-91. [DOI: 10.1097/spc.0b013e32831d29c1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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