TCT: Bivalirudin (Angiomax) Effective in Primary PCI for STEMI
WASHINGTON, Oct. 24 -- Bivalirudin (Angiomax) as monotherapy saved lives and significantly reduced major bleeding at 30 days in patients with ST-elevation myocardial infarction undergoing primary stenting, investigators reported here.The direct thrombin inhibitor was compared with a standard anti-coagulation therapy of a glycoprotein IIb/IIIa inhibitor (abciximab) plus unfractionated heparin, Gregg W. Stone, M.D., of Columbia University, told a packed house at the Transcatheter Cardiovascular Therapeutics late-breaking clinical trials plenary today.
At 30 days in the HORIZONS AMI trial, the rate of net adverse clinical events was 12.1% in the control arm versus 9.2% in the bivalirudin monotherapy arm (P=0.006), Dr. Stone said. The cardiac mortality was 1.8% in the bivalirudin arm versus 2.9% in the abciximab plus heparin arm (P=0.035), and the major bleeding rate was 4.9% versus 8.3% in the control arm (P£0.0001).
Overall mortality was 2.1% in the bivalirudin group versus 3.1% in the control arm, but overall mortality eluded statistical significance (P=0.058).
During a press conference, Dr. Stone said there was "no question of non-inferiority here -- bivalirudin was clearly superior."
Marc Cohen, M.D., of Mount Sinai Medical School and chief of interventional cardiology at Newark Beth Israel Hospital, who was not involved in the HORIZONS trial, did not agree.
In an interview, he said the data suggest that bivalirudin may be a good option for some "low risk, uncomplicated STEMI patients," but there were some disturbing signals.
For example, "the stent thrombosis rate within 24 hours of procedure was 0.3% in the GP IIb/IIIa/heparin arm versus 1.3% in the bivalirudin arm and that was significant at P=0.0009," Dr. Cohen said.
Likewise the ischemic target vessel revascularization rate of 1.9% in the control arm versus 2.6% in the bivalirudin arm "while not a statistically significant difference, was headed in the wrong way," Dr. Cohen said.
But Dr. Cohen was in the minority as Dr. Stone's presentation was greeted with enthusiastic applause and the discussant, Michael Bertrand, M.D., of the University of Lille in Lambersart, France, emphasized the positive findings of the trial in his critique.
"And I think it was surprising to see a reduction in cardiac death in a trial with these small numbers," Dr. Bertrand said during a press conference. "That is important."
Christopher Cannon, M.D., of Brigham and Women's Hospital and Harvard Medical School, was similarly impressed. "It had less bleeding and interestingly this seemed to translate into fewer cardiac deaths," he said.
Because bleeding risk is a major concern during interventions "it seems that bivalirudin would be a good choice for patients where bleeding is a concern," Dr. Cannon said in an interview. Dr. Cannon was not involved in the study.
The trial recruited 3,602 patients with symptomatic STEMI who were randomized in less than 12 hours from symptom onset. All patients were started on dual antiplatelet therapy and randomized in the emergency department to either unfractionated heparin plus abciximab (ReoPro) or eptifibatide (Integrilin) plus unfractionated heparin (n=1,800) or bivalirudin.
The 30-day follow-up data were complete on 1,778 controls and 1,777 bivalirudin patients, but analysis was based on intention to treat.
The 30-day results, Dr. Stone emphasized, are just the first installment from the HORIZONS AMI story. These pharmacologic results represent "a strategy trial," he said. After angiography, patients were referred for coronary artery bypass surgery (2.2% in the control arm and 1.3% in the bivalirudin group), medical management (5.4% in the control group and 5.2% in the bivalirudin group) or percutaneous coronary intervention (92.2% of controls and 93.2% of bivalirudin patients).
Three thousand of the patients went on to stenting and were randomized to either bare-metal stents or paclitaxel-eluting (Taxus) stents. The results of that second phase are not yet known, Dr. Stone said.
The primary 30-day endpoint was net adverse clinical events and major bleeding, which was defined as intracranial bleeding, intraocular bleeding, retroperitoneal bleeding, access site bleeding requiring surgery, hematoma ≥ 5 cm, blood product transfusion, reoperation for bleeding, Hgb↓≥3 g/dL with an overt source, and Hgb↓≥ 4 g/dL without an overt source.
The HORIZONS AMI trial was funded by the Medicines Company and Boston Scientific via unrestricted educational grants to the Cardiovascular Research Foundation, which Dr. Stone said maintained complete control over the study design and data. Dr. Stone disclosed research support from The Medicines Company and Boston Scientific and honoraria from Pfizer. Dr. Cohen disclosed support from Sanofi-Aventis, Schering-Plough, Bristol-Myers Squibb, and "some funding from The Medicines Company". Dr. Cannon disclosed support from Merck, Schering-Plough, AstraZeneca, GlaxoSmithKline, and Bristol-Myers Squibb.Primary source: Transcatheter Cardiovascular TherapeuticsSource reference: Stone, GW et al "HORIZONS AMI A Prospective, Randomized Comparison of Bivalirudin vs. Heparin Plus Glycoprotein IIb/IIIa Inhibitors During Primary Angioplasty in Acute Myocardial Infarction 30 Day Results" Late Breaking Clinical Trials
Showing posts with label unstable angina. Show all posts
Showing posts with label unstable angina. Show all posts
Thursday, October 25, 2007
Wednesday, August 15, 2007
ACC/AHA Update Guidelines for Unstable Angina, NSTEMI
August 14, 2007 — The American College of Cardiology (ACC) and the American Heart Association (AHA) have updated their 2002 Guidelines for the Management of Patients with Unstable Angina (UA)/Non-ST-Elevation Myocardial Infarction (NSTEMI), introducing a number of recommendations for initial diagnostic tests, choice and duration of antiplatelet therapy, and new anticoagulants.[1] The new document also highlights strategies and agents that are no longer considered valuable in the treatment or diagnosis of patients with unstable coronary artery disease (CAD).
The guidelines are published online August 6, 2007 in the Journal of the American College of Cardiology and Circulation.
In an interview with heartwire, writing group chair Dr Jeffrey Anderson (University of Utah Hospital, Salt Lake City) highlighted some of the key changes in the updated guidelines.
"There have been a lot of new trials, new drugs, new anticoagulants, and new issues, so there are a moderate number of changes," he said. "I don't think there are a lot of things that are completely reversed, but there's certainly been an evolution and fine-tuning of the 2002 guidelines."
One of the overarching themes, according to Anderson, is a slight pullback in terms of the emphasis on an initial invasive strategy for all UA/NSTEMI patients. "In these guidelines we've sort of swung the pendulum back a little bit from the initial invasive strategy from 2002," he said. Instead, the 2007 update urges physicians to first establish whether patients are high or low risk and then apply the guidelines according to that initial risk assessment. "In low-risk patients, particularly low-risk women, an initially conservative strategy is more appropriate.... Low-risk patients should first be noninvasively risk-stratified and treated medically, but not all sent to the lab." Based on the Invasive Versus Conservative Treatment in Unstable Coronary Syndome (ICTUS) trial, the guidelines also state that an initially conservative strategy can also be considered in stabilized patients, he said.
But Dr Eric Peterson (Duke University, Durham, NC), another member of the writing group, sees this slightly differently. "I take it almost the other way around," he told heartwire. "The guidelines give a 1a recommendation for use of an early invasive strategy in patients who match any of these risk factors, including those who have positive markers, but there is some latitude that's given to physicians — a 2b recommendation — that they can consider a conservative strategy if they initially stabilize the patient."
Peterson acknowledged there was "tension inside the guideline committee" about how to balance some of the conflicting trials in this area — for example, ICTUS vs [Intracoronary Stenting with Antithrombotic Regimen Cooling Off] ISAR-COOL or [Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction] TACTICS-TIMI 18. "When it comes to the issue of invasive vs conservative strategies, there is evidence that goes both ways, depending on which study you choose to look at.... Following that evidence, there are differences in clinician opinion as to what the right strategy would be, and I think in part the guidelines reflect that."
What the guidelines do urge, says Peterson, is for physicians to first make the decision as to what treatment strategy they're going to take, then follow the recommended pathways according to what they've decided. "These guidelines give clinicians the mandate to make that decision up front and then to tailor the therapy that would go along with that, depending on what strategy you choose."
In with the new, out with the old
As expected, bivalirudin and fondaparinux have made it into the 2007 update. Both agents have a class 1 indication for use on top of antiplatelet therapy for patients in whom an invasive strategy is selected. Unfractionated heparin (UFH) and enoxaparin are given class 1 indications in patients undergoing an invasive strategy or a conservative strategy, but fondaparinux is preferred over these other agents in patients at an increased risk of bleeding for whom a conservative strategy is selected. In UA/NSTEMI patients for whom an initial conservative strategy is selected (with the possibility of converting to an invasive strategy other than coronary artery bypass grafting [CABG]), enoxaparin or fondaparinux are recommended over UFH.
Also new to the guidelines are recommendations for the use of multislice computed tomographic (CT) angiography and cardiac MRI, reflecting other recent appropriateness criteria and scientific statements dealing with imaging. Brain-type natriuretic peptide (BNP) makes its debut in the updated guidelines as a biomarker test that can be considered to supplement global risk assessment in ACS patients. Otherwise, a cardiac-specific troponin is now recommended as the "preferred marker."
"Troponin has continued to rise and really everything else has fallen way behind," Anderson explained. "In 2002, there was more attention paid to alternative markers; now we've sort of pushed those down the list."
Other notable changes or tweaks in the 2007 update include a fresh emphasis on reducing delays to initial evaluation and facilitated emergency-department (ED) diagnosis and triage, including the use of a 12-lead ECG ideally within 10 minutes of ED arrival. For patients treated invasively, recommended duration of clopidogrel therapy has been extended. "The guidelines now recommend that clopidogrel therapy be continued for at least one year after drug-eluting stent placement and ideally up to one year with a bare-metal stent or even with medical therapy, because we think the additional antiplatelet therapy seems to be beneficial," Anderson commented.
The new guidelines also give the option of using a higher loading dose of clopidogrel. "A lot of the more recent studies use 600 mg, and even though we need more studies in terms of larger numbers and hard outcomes, those studies look very promising. So we offer that as an option," Anderson said.
According to Anderson, recommendations for glycoprotein (GP) IIb/IIIa inhibitors are largely unchanged from the 2002 guidelines. "The only thing that's come along is whether, with high-risk ACS patients, you can just give clopidogrel alone without adding a GP IIb/IIIa inhibitor," Anderson explained. "There's one study that has showed that adding on a GP IIb/IIIa inhibitor did seem to benefit patients, so in higher-risk patients we're still suggesting you use a GP IIb/IIIa inhibitor if you're doing an invasive strategy, even if you're using clopidogrel. In the lower-risk patients, you can use either one or the other; at least one and possibly both."
Finally, the guidelines also drive the final nail into the coffin for strategies that have proved nonbeneficial or harmful over the past five years, including the use of supplements such as beta-carotene, vitamins E and C, and folic acid. Also singled out as harmful in the new guidelines are hormone replacement therapy in postmenopausal women and the use of nonsteroidal anti-inflammatory drugs (NSAIDs), except for aspirin, for UA/NSTEMI patients during hospitalization.
"If one looks at what has happened over the past five to 10 years, adverse outcomes in NSTEMI have really fallen dramatically," Anderson said. "The bottom line is, the guidelines seem to be working. In the past 10 years we've pushed the envelope in terms of evidence-based medicine for diagnostics and treatment, and we do seem to be having an impact on the risks associated with ACS. With that in mind, the message would be to push ahead and fine-tune what we do and hopefully get even better outcomes."
In the paper, Anderson disclosed receiving research grants from AstraZeneca and Bristol-Myers Squibb; being on the speakers' bureau for Merck; and acting as a consultant/advisor for Bristol-Myers Squibb, Merck, Sanofi, and ThromboVision. Peterson disclosed receiving research grants from Bristol-Myers Squibb/Sanofi, Millennium, and Schering-Plough and being on the speakers' bureau for Millennium and Schering-Plough.
Reference
Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2007; DOI:10.1016/j.jacc.2007.02.028. Available at: http://content.onlinejacc.org/cgi/content/full/50/7/e1. Circulation. 2007; DOI:10.1161/CIRCULATIONAHA.107.185752. Available at: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.185752.
August 14, 2007 — The American College of Cardiology (ACC) and the American Heart Association (AHA) have updated their 2002 Guidelines for the Management of Patients with Unstable Angina (UA)/Non-ST-Elevation Myocardial Infarction (NSTEMI), introducing a number of recommendations for initial diagnostic tests, choice and duration of antiplatelet therapy, and new anticoagulants.[1] The new document also highlights strategies and agents that are no longer considered valuable in the treatment or diagnosis of patients with unstable coronary artery disease (CAD).
The guidelines are published online August 6, 2007 in the Journal of the American College of Cardiology and Circulation.
In an interview with heartwire, writing group chair Dr Jeffrey Anderson (University of Utah Hospital, Salt Lake City) highlighted some of the key changes in the updated guidelines.
"There have been a lot of new trials, new drugs, new anticoagulants, and new issues, so there are a moderate number of changes," he said. "I don't think there are a lot of things that are completely reversed, but there's certainly been an evolution and fine-tuning of the 2002 guidelines."
One of the overarching themes, according to Anderson, is a slight pullback in terms of the emphasis on an initial invasive strategy for all UA/NSTEMI patients. "In these guidelines we've sort of swung the pendulum back a little bit from the initial invasive strategy from 2002," he said. Instead, the 2007 update urges physicians to first establish whether patients are high or low risk and then apply the guidelines according to that initial risk assessment. "In low-risk patients, particularly low-risk women, an initially conservative strategy is more appropriate.... Low-risk patients should first be noninvasively risk-stratified and treated medically, but not all sent to the lab." Based on the Invasive Versus Conservative Treatment in Unstable Coronary Syndome (ICTUS) trial, the guidelines also state that an initially conservative strategy can also be considered in stabilized patients, he said.
But Dr Eric Peterson (Duke University, Durham, NC), another member of the writing group, sees this slightly differently. "I take it almost the other way around," he told heartwire. "The guidelines give a 1a recommendation for use of an early invasive strategy in patients who match any of these risk factors, including those who have positive markers, but there is some latitude that's given to physicians — a 2b recommendation — that they can consider a conservative strategy if they initially stabilize the patient."
Peterson acknowledged there was "tension inside the guideline committee" about how to balance some of the conflicting trials in this area — for example, ICTUS vs [Intracoronary Stenting with Antithrombotic Regimen Cooling Off] ISAR-COOL or [Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction] TACTICS-TIMI 18. "When it comes to the issue of invasive vs conservative strategies, there is evidence that goes both ways, depending on which study you choose to look at.... Following that evidence, there are differences in clinician opinion as to what the right strategy would be, and I think in part the guidelines reflect that."
What the guidelines do urge, says Peterson, is for physicians to first make the decision as to what treatment strategy they're going to take, then follow the recommended pathways according to what they've decided. "These guidelines give clinicians the mandate to make that decision up front and then to tailor the therapy that would go along with that, depending on what strategy you choose."
In with the new, out with the old
As expected, bivalirudin and fondaparinux have made it into the 2007 update. Both agents have a class 1 indication for use on top of antiplatelet therapy for patients in whom an invasive strategy is selected. Unfractionated heparin (UFH) and enoxaparin are given class 1 indications in patients undergoing an invasive strategy or a conservative strategy, but fondaparinux is preferred over these other agents in patients at an increased risk of bleeding for whom a conservative strategy is selected. In UA/NSTEMI patients for whom an initial conservative strategy is selected (with the possibility of converting to an invasive strategy other than coronary artery bypass grafting [CABG]), enoxaparin or fondaparinux are recommended over UFH.
Also new to the guidelines are recommendations for the use of multislice computed tomographic (CT) angiography and cardiac MRI, reflecting other recent appropriateness criteria and scientific statements dealing with imaging. Brain-type natriuretic peptide (BNP) makes its debut in the updated guidelines as a biomarker test that can be considered to supplement global risk assessment in ACS patients. Otherwise, a cardiac-specific troponin is now recommended as the "preferred marker."
"Troponin has continued to rise and really everything else has fallen way behind," Anderson explained. "In 2002, there was more attention paid to alternative markers; now we've sort of pushed those down the list."
Other notable changes or tweaks in the 2007 update include a fresh emphasis on reducing delays to initial evaluation and facilitated emergency-department (ED) diagnosis and triage, including the use of a 12-lead ECG ideally within 10 minutes of ED arrival. For patients treated invasively, recommended duration of clopidogrel therapy has been extended. "The guidelines now recommend that clopidogrel therapy be continued for at least one year after drug-eluting stent placement and ideally up to one year with a bare-metal stent or even with medical therapy, because we think the additional antiplatelet therapy seems to be beneficial," Anderson commented.
The new guidelines also give the option of using a higher loading dose of clopidogrel. "A lot of the more recent studies use 600 mg, and even though we need more studies in terms of larger numbers and hard outcomes, those studies look very promising. So we offer that as an option," Anderson said.
According to Anderson, recommendations for glycoprotein (GP) IIb/IIIa inhibitors are largely unchanged from the 2002 guidelines. "The only thing that's come along is whether, with high-risk ACS patients, you can just give clopidogrel alone without adding a GP IIb/IIIa inhibitor," Anderson explained. "There's one study that has showed that adding on a GP IIb/IIIa inhibitor did seem to benefit patients, so in higher-risk patients we're still suggesting you use a GP IIb/IIIa inhibitor if you're doing an invasive strategy, even if you're using clopidogrel. In the lower-risk patients, you can use either one or the other; at least one and possibly both."
Finally, the guidelines also drive the final nail into the coffin for strategies that have proved nonbeneficial or harmful over the past five years, including the use of supplements such as beta-carotene, vitamins E and C, and folic acid. Also singled out as harmful in the new guidelines are hormone replacement therapy in postmenopausal women and the use of nonsteroidal anti-inflammatory drugs (NSAIDs), except for aspirin, for UA/NSTEMI patients during hospitalization.
"If one looks at what has happened over the past five to 10 years, adverse outcomes in NSTEMI have really fallen dramatically," Anderson said. "The bottom line is, the guidelines seem to be working. In the past 10 years we've pushed the envelope in terms of evidence-based medicine for diagnostics and treatment, and we do seem to be having an impact on the risks associated with ACS. With that in mind, the message would be to push ahead and fine-tune what we do and hopefully get even better outcomes."
In the paper, Anderson disclosed receiving research grants from AstraZeneca and Bristol-Myers Squibb; being on the speakers' bureau for Merck; and acting as a consultant/advisor for Bristol-Myers Squibb, Merck, Sanofi, and ThromboVision. Peterson disclosed receiving research grants from Bristol-Myers Squibb/Sanofi, Millennium, and Schering-Plough and being on the speakers' bureau for Millennium and Schering-Plough.
Reference
Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2007; DOI:10.1016/j.jacc.2007.02.028. Available at: http://content.onlinejacc.org/cgi/content/full/50/7/e1. Circulation. 2007; DOI:10.1161/CIRCULATIONAHA.107.185752. Available at: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.185752.
Thursday, August 09, 2007
Guidelines for Unstable Angina or Non-STEMI Add Conservative Option
DALLAS, Aug. 8 -- Patients with non-ST elevation segment myocardial infarction or less severe unstable angina can begin with a conservative noninvasive treatment strategy, according to updated guidelines from two major heart groups.
An early echocardiogram should be considered to identify left ventricular dysfunction, according to the updated guidelines, posted online by the American Heart Association and American College of Cardiology ahead of publication in Circulation and the Journal of the American College of Cardiology.
The AHA/ACC guideline panel, chaired by Jeffrey L. Anderson, M.D., of the University of Utah, recommended an exercise or pharmacologic stress test before or soon after discharge to identify patients with latent ischemia that might benefit from revascularization.
The recommendations represent a substantive departure from the 2002 version of the guidelines, which emphasized an early, invasive strategy for most patients with non-STEMI or unstable angina. Five years later, a conservative approach is a reasonable option for more patients because "use of aggressive anticoagulant and antiplatelet agents has reduced the incidence of adverse outcomes inpatients managed conservatively," the authors said.
The choice between an early invasive or conservative noninvasive strategy hinges on a physician's ability to make an accurate estimate of a patient's risk. The guidelines set forth two criteria for establishing low risk:
A low-risk score on a recognized scale, such as TIMI or GRACE
The patient or physician prefers an invasive strategy in the absence of high-risk features
The guidelines panel pointed out that the "primary objective in selecting a treatment strategy is to yield the best long-term clinical outcome." General patient characteristics, such as those outlined in the guidelines, can help physicians in the decision-making process but ultimately "individual judgment is required."
Other revisions to the guidelines focused on more aggressive treatment of cardiac risk factors. The AHA and ACC recommended a target LDL level of less than 100 mg/dL for all patients and cited 70 mg/dL as the ideal level. Blood pressure should be treated to less than 140/90 mm Hg, and patients with diabetes or chronic kidney disease should have a blood pressure of less than 130/80 mm Hg.
Secondary prevention strategies should emphasize aggressive use of ACE inhibitors. Patients with heart failure should receive an aldosterone receptor antagonist, a class of medication that was not available when the guidelines were revised in 2002.
Other recommendations incorporated into the update include:
12 months of treatment with the antiplatelet agent clopidogrel after placement of a drug-eluting coronary stent and six months of treatment for patients who receive bare-metal stents.
Discontinuation of hormone replacement therapy in postmenopausal women.
Use of assays for cardiac troponin and B-type natriuretic peptide in the evaluation and monitoring of patients
Discontinuation of NSAIDs during hospitalization for unstable angina or non-STEMI.
Dr. Anderson reported grants from AstraZenica and Bristol-Myers Squibb, and that he is on the speaker's bureau of Merck. He also reported relationships with Sanofi and ThromboVision. Other members of the writing committee also reported relationships with various pharmaceutical firms. Additional source: Journal of the American College of CardiologySource reference: Anderson JL et al. "http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185752v1" 20target="">ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction-executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial infarction).">
ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction-executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial infarction
DALLAS, Aug. 8 -- Patients with non-ST elevation segment myocardial infarction or less severe unstable angina can begin with a conservative noninvasive treatment strategy, according to updated guidelines from two major heart groups.
An early echocardiogram should be considered to identify left ventricular dysfunction, according to the updated guidelines, posted online by the American Heart Association and American College of Cardiology ahead of publication in Circulation and the Journal of the American College of Cardiology.
The AHA/ACC guideline panel, chaired by Jeffrey L. Anderson, M.D., of the University of Utah, recommended an exercise or pharmacologic stress test before or soon after discharge to identify patients with latent ischemia that might benefit from revascularization.
The recommendations represent a substantive departure from the 2002 version of the guidelines, which emphasized an early, invasive strategy for most patients with non-STEMI or unstable angina. Five years later, a conservative approach is a reasonable option for more patients because "use of aggressive anticoagulant and antiplatelet agents has reduced the incidence of adverse outcomes inpatients managed conservatively," the authors said.
The choice between an early invasive or conservative noninvasive strategy hinges on a physician's ability to make an accurate estimate of a patient's risk. The guidelines set forth two criteria for establishing low risk:
A low-risk score on a recognized scale, such as TIMI or GRACE
The patient or physician prefers an invasive strategy in the absence of high-risk features
The guidelines panel pointed out that the "primary objective in selecting a treatment strategy is to yield the best long-term clinical outcome." General patient characteristics, such as those outlined in the guidelines, can help physicians in the decision-making process but ultimately "individual judgment is required."
Other revisions to the guidelines focused on more aggressive treatment of cardiac risk factors. The AHA and ACC recommended a target LDL level of less than 100 mg/dL for all patients and cited 70 mg/dL as the ideal level. Blood pressure should be treated to less than 140/90 mm Hg, and patients with diabetes or chronic kidney disease should have a blood pressure of less than 130/80 mm Hg.
Secondary prevention strategies should emphasize aggressive use of ACE inhibitors. Patients with heart failure should receive an aldosterone receptor antagonist, a class of medication that was not available when the guidelines were revised in 2002.
Other recommendations incorporated into the update include:
12 months of treatment with the antiplatelet agent clopidogrel after placement of a drug-eluting coronary stent and six months of treatment for patients who receive bare-metal stents.
Discontinuation of hormone replacement therapy in postmenopausal women.
Use of assays for cardiac troponin and B-type natriuretic peptide in the evaluation and monitoring of patients
Discontinuation of NSAIDs during hospitalization for unstable angina or non-STEMI.
Dr. Anderson reported grants from AstraZenica and Bristol-Myers Squibb, and that he is on the speaker's bureau of Merck. He also reported relationships with Sanofi and ThromboVision. Other members of the writing committee also reported relationships with various pharmaceutical firms. Additional source: Journal of the American College of CardiologySource reference: Anderson JL et al. "http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185752v1" 20target="">ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction-executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial infarction).">
ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction-executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial infarction
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