Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Home Print this page Email this page
Users Online:527

 Table of Contents  
Year : 2013  |  Volume : 1  |  Issue : 1  |  Page : 22-28

Management of Coronary Artery Disease in 2013: Recent Insights

Interventional Cardiologist, Shekhar Heart and Lung Centre, Indira Nagar, Lucknow, Uttar Pradesh, India

Date of Web Publication17-Jun-2013

Correspondence Address:
Akshyaya Kumar Pradhan
Interventional Cardiologist, Shekhar Heart and Lung Centre, Indria Nagar, Lucknow 226 016, Uttar Pradesh
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-449x.113602

Rights and Permissions

How to cite this article:
Pradhan AK. Management of Coronary Artery Disease in 2013: Recent Insights. Heart India 2013;1:22-8

How to cite this URL:
Pradhan AK. Management of Coronary Artery Disease in 2013: Recent Insights. Heart India [serial online] 2013 [cited 2023 May 31];1:22-8. Available from: https://www.heartindia.net/text.asp?2013/1/1/22/113602

  Defining Myocardial Infarction Top

The recently updated European Society of Cardiology (ESC) consensus statement on "third universal definition of myocardial infarction" released in 2012 has emphasized the central role of cardiac biomarker 6 in diagnosis of acute coronary syndromes. [1] The term acute MI should be used when there is evidence of myocardial necrosis in a clinical setting consistent with acute myocardial ischemia. Hence detection of an rise and/or fall of cardiac biomarker values preferably cardiac troponin with at least one value above the 99th percentile upper reference limit needed along with at least one of the following:

  1. Symptoms of ischemia.
  2. New or presumed new significant ST-segment-T wave (ST-T) changes or new left bundle branch block.
  3. Development of pathological Q waves in the electrocardiogram (ECG).
  4. Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.
  5. Identification of an intracoronary thrombus by angiography or autopsy.

High sensitive troponins

Recently, high-sensitivity or ultrasensitive assays have been introduced that have a 10 to 100-fold lower limit of detection and fulfill the requirements of analytical precision. Therefore, MI can now be detected more frequently and earlier in patients presenting with chest pain. The superiority of these new assays, particularly in the early phase of pain onset, was prospectively demonstrated. [2],[3] The negative predictive value for MI with a single test on admission is 95% and by including a second sample within 3 h of presentation the sensitivity for MI approaches 100%. The waiting time in Emergency Department can be reduced with a rapid rule put protocol. The new ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation, 2011 now recommend a rapid rule-out protocol (0 and 3 h) when highly sensitive troponin tests are available. [4] The guidelines also emphasize the role for prompt withdrawl of blood for troponins and recommend point-of-care tests for troponins should be implemented when a central laboratory cannot consistently provide test results within 60 min.

Coronary computed tomography (CT) angiography

Multidetector computed tomography (CT) is a promising technique for direct visualization of the coronary arteries. Owing to its high negative predictive value reported in various studies [5],[6],[7] CT angiography, can be useful to exclude ACS or other causes of chest pain. The ESC 2011 guidelines for non ST segment elevation myocardial infarction (NSTEMI) recommend Coronary CT angiography as an alternative to invasive angiography to exclude ACS when there is a low to intermediate likelihood of CAD and when troponins and ECG are inconclusive (Class IIa).

In the CT-STAT trial, Goldstein et al. [8] randomly assigned patients with acute chest pain in the Emergency Department to Coronary computed tomography angiography (CCTA) and to single-positron emission computed tomography myocardial perfusion imaging (MPI). The CCTA strategy resulted in a 54% reduction in time to diagnosis compared with MPI (2.9 h vs. 6.3 h), and costs of care were 38% lower for the CCTA group. The two strategies showed no difference in freedom from major adverse cardiac events (MACE) at 6 months of follow-up.

Antiplatelet therapy

Platelet activation and subsequent aggregation play a dominant role in the propagation of arterial thrombosis and consequently are the key therapeutic targets in the management of ACS. New adenosine diphosphate (ADP) receptor blockers prasugrel and ticagrelor have a more rapid onset of action and greater potency and have been proven superior to clopidogrel in large outcome trials.

In the TRITON-TIMI 38 trial, [9] prasugrel (60 mg loading dose followed by 10 mg) was compared to clopidogrel (300 mg loading dose and then 75 mg daily) in clopidogrel naive patients undergoing percutaneous coronary angioplasty (PCI). The composite primary endpoint (cardiovascular death, non-fatal MI, or stroke) occurred in 11.2% of clopidogrel-treated patients and in 9.3% of prasugrel treated patients (hazard ratio (HR) 0.82; 95% confidence interval (CI) 0.73-0.93; P = 0.002), mostly driven by a significant risk reduction for MI. In the whole cohort, the rate of definite or probable stent thrombosis (as defined by the academic research consortium (ARC)) was significantly reduced in the prasugrel group compared to the clopidogrel group (1.1% vs. 2.4%, respectively; HR 0.48; 95% CI 0.36-0.64; P = 0.001). Prasugrel is contraindicated in patients with prior stroke/transient ischaemic attack. Its use is generally not recommended in patients aged ≥75 years or in patients with lower body weight (<60 kg) as it was not associated with net clinical benefit in these subsets.

In the PLATelet inhibition and patient Outcomes (PLATO) trial, [10] ticagrelor reduced the composite primary endpoint (cardiovascular death, non-fatal MI, or stroke) and also reduced cardiovascular mortality in clopidogrel naive or pretreated patients with either ST segment elevation myocardial infarction

(STEMI) -(planned for primary PCI) or moderate-to-high risk NSTEMI (planned for either conservative or invasive management). Although there was no significant difference in overall PLATO defined major bleeding rates between the clopidogrel and ticagrelor groups, PLATO-defined and TIMI-defined major bleeding that was unrelated to coronary artery bypass grafting (CABG) surgery was increased with Ticagrelor. The new ESC 2012 guidelines for STEMI recommend prasugrel and ticagrelor as first line ADP receptor blockers. [11] Clopidogrel should be used preferably when prasugrel or ticagrelor are either not available or contraindicated.

Antithrombotics for PCI

Intravenous unfractionated heparin (UFH) titrated to an appropriate activated clotting remains the mainstay and time tested strategy for anticoagulant therapy at the time of PCI. Enoxaparin and fondaparinux have been studied less extensively in this setting. The ATOLL (acute STEMI treated with Primary PCI and IV enoxaparin or UFH to lower ischemic and bleeding events at short- and long-term follow-up) trial comparing intravenous enoxaparin with UFH for primary PCI failed to meet its primary, composite endpoint. [12]

Fondaparinux, the only selective activated factor X (factor Xa) inhibitor available for clinical use is inhibits coagulation factor Xa by binding reversibly and non-covalently to antithrombin, with a high affinity. In the OASIS-5 (the fifth organization to assess strategies in acute ischemic syndromes investigators) study, fondaparinux was non inferior to enoxaparin with respect to primary efficacy outcome of death, MI, or refractory ischemia in patients of NSTEMI. [13] At the same point, major bleeds were halved with fondaparinux (2.2% vs 4.1%). At 6 months the composite endpoint of death, MI, or stroke was significantly lower with fondaparinux vs. enoxaparin (11.3% vs. 12.5%). In the population submitted to PCI, catheter thrombus was observed more frequently with fondaparinux (0.9%) than with enoxaparin (0.4%), but was abolished by injection of an empirically determined bolus of UFH at the time of PCI.

The FUTURA/OASIS-8 trial [ 14] compared a low dose i.v. bolus of UFH (50 IU/kg) and a standard dose UFH, namely 85 IU/kg (reduced to 60 U/kg in the case of the use of GP IIb/IIIa receptor inhibitors), in patients pretreated with fondaparinux, submitted to PCI within 72 h following initiation of therapy. There was no significant difference between the two groups in terms of the primary composite endpoint (major bleeding, minor bleeding, or major vascular access site complications) at 48 h after PCI (4.7% vs. 5.8%, low vs. standard dose group; OR 0.80; 95% CI 0.54-1.19; P = 0.27).

The practical implications of these data are that a standard UFH bolus should be recommended at the time of PCI in patients pre-treated with fondaparinux on the basis of a more favorable net clinical benefit and lower risk of catheter thrombosis compared to low dose UFH. The new ESC guidelines of NSTEMI 2011 list Fondaparinux (2.5 mg subcutaneously daily) as having the most favorable efficacy-safety profile with respect to anticoagulation (Class I recommendation). [15],[16] If the initial anticoagulant is fondaparinux, a single bolus of UFH (85 IU/kg adapted to ACT, or 60 IU in the case of concomitant use of GP IIb/IIIa receptor inhibitors) should be added at the time of PCI. However it is not recommended in setting of primary PCI for STEMI.

Novel oral anticoagulants

In ATLAS ACS 2-TIMI 51 study, [17] rivaroxaban in patients with a recent ACS, reduced the risk of the composite end point of death from cardiovascular causes, myocardial infarction, or stroke compared to placebo (hazard ratio in the rivaroxaban group, 0.84; 95% CI, 0.74 to 0.96; P = 0.008). The twice-daily 2.5-mg dose of rivaroxaban reduced the rates of death from cardiovascular causes (2.7% vs. 4.1%, P = 0.002) and from any cause (2.9% vs. 4.5%, P = 0.002), a survival benefit that was not seen with the twice-daily 5-mg dose. Interestingly, stent thrombosis was reduced by one third. This was associated with 3 fold increase in non-CABG-related major bleeding, and intracranial haemorrhage. However, apixaban in APPRAISE-2, [18] darexaban in RUBY-1 [19] and dabigatran in REDEEM [ 20] trial, caused dose-dependent increases in major bleeding but no signal of added efficacy when adding anticoagulant therapy to antiplatelet therapy in this setting of ACS. Hence the verdict on novel oral anticoagulants in ACS is still not out, but low dose rivaroxaban reducing mortality in ACS as an add on therapy on aspirin and clopidogrel is interesting.

Glycoprotein IIb/IIIa antagonists

INFUSE-AMI trial showed that local delivery of abciximab reduced the 30-day infarct size, evaluated by magnetic resonance imaging, but did not improve abnormal wall motion score, ST-segment resolution, post-PCI coronary flow or myocardial perfusion. [21]

The large abciximab intracoronary vs. intravenously drug application 4 (AIDA-STEMI) randomized trial, found no clinical benefit (but also no harm) in this route of administration in terms of the composite of death, reinfarction and heart failure, and found a borderline reduction in the secondary endpoint of heart failure. [22] Therefore, the intracoronary route may be considered but the i.v. route should remain the standard of care for administration of GP IIb/IIIa inhibitor.

PCI without on site CABG

The Atlantic CPORT investigators randomized, [23] in a non-inferiority design, nearly 19,000 patients undergoing PCI to a hospital with or without on-site surgery in a ratio of. Six-week mortality was virtually identical (1.0 vs. 0.9%) and 9-month MACE were also similar (11.2 vs. 12.1%); however, target vessel revascularization (TVR) was higher without on-site surgery (6.5 vs. 5.4%, P ¼ 0.01). This difference was seen regardless of the definition of TVR and regardless of stent type and may reflect a more conservative approach or a lower initial success rate without on-site surgery.

Multi vessel disease

The FREEDOM trial randomized 1900 diabetic patients with multi-vessel disease to PCI using drug-eluting stents (DESs) vs. CABG. At 5 years, the primary outcome of death, MI, or cerebrovascular accident occurred more commonly in the PCI group (26.6 vs. 18.7%,P = 0.005). The benefit of CABG was driven by differences in rates of both MI (P < 0.001) and death from any cause (P = 0.049). However, stroke was more frequent in the CABG group (5-year rates of 2.4% in PCI Vs 5.2% with CABG). Hence, patients with diabetes and advanced coronary artery disease, CABG should definitely offered to as a first line therapy. [24]

In the SYNTAX trial, investigators compared PCI to CABG in patients with left main or three-vessel CAD. The previously reported 1-year results showed similar rates of death and MI with both procedures, more strokes with CABG, and more repeat revascularization procedures with PCI. [25] The recently presented 5 year results of SYNTAX study demonstrate that outcomes were similar with coronary artery bypass grafting and percutaneous coronary intervention in the lowest tertile of SYNTAX score, whereas CABG outcomes were superior in the highest tertile. Longer follow-up now suggests that CABG beats PCI in the intermediate-risk group as well. [26]

However, a meta-analysis of 19 randomized trials of over 10,000 patients found a 30-day rate of stroke of 1.2% after CABG and 0.34% after PCI (P = 0.0001). This equates to an excess of seven strokes for every 1000 patients treated with CABG rather than PCI. Similar results were observed after a median follow-up of 1 year and in an analysis of nearly 34,000 patients from 27 observational studies. [27]


In primary PCI, drug-eluting stents (DES) reduce the risk of repeated TVR, compared with bare-metal stents (BMS). [28] There have been concerns about increased risks of very late stent thrombosis and reinfarction with DES, compared to BMS. However, HORIZONS AMI a randomized study of DES versus. BMS in STEMI patients, did not reveal any safety concerns, whereas a consistent reduction of restenosis and unplanned repeat revascularization was found after DES implantation even on long-term follow up. [29] An issue with the routine use of DES in this setting is that it is often difficult to determine reliably the ability of patients to comply with or tolerate the protracted use of dual antiplatelet therapy (DAPT).

The EXAMINATION trial presented at ESC Congress 2012, randomized 1500 patients with STEMI to everolimus DESs and BMSs. [30] The primary endpoint of death, recurrent MI, or revascularization was similar in the two groups. However, TVR rates were lower with the everolimus stent (3.7 vs. 6.8%), as was sub acute stent thrombosis (SAT) (0.9 vs. 2.5%). Biolimus eluting biodegradable polymer stents were compared the BMS in a 1100-patient randomized COMFORTABLE -AMI trial. [31] 1-year MACE was lower with the biolimus stent, a difference driven mainly by a reduction in re-infarction and TLR. The ESC 2011 guidelines for NSTEMI recommend that owing to the lack of randomized trials in NSTE-ACS, the choice between the use of a BMS or a DES should be based on an individual assessment of benefit versus risk. The new American College of Cardiology/American Heart Association STEMI 2013 guidelines say that lowest rates of stent thrombosis have been reported with cobalt-chromium everolimus-eluting stents. [32],[33]

In the setting of stable angina, a meta-analysis of 72 randomized trials (>117, 000 patients) looked at comparative outcomes of different DESs compared with BMSs. Everolimus DESs seemed to have the lowest TVR. Reassuringly, there was no increased risk of any long-term safety outcomes with DESs compared with BMSs; in fact, DESs were associated with reduced MI and SAT rates. [34]

The RESET trial found that everolimus DES was non inferior sirolimus DES at 1 year for the primary endpoint of TLR (4.3 vs. 5.0%). [35] The TWENTE trial randomized 1391 patients to zotarolimus (Resolute) versus everolimus (Xience) stents in a non-inferiority design. The primary endpoint of target vessel failure (TVF) was similar in the two groups (8.2 vs. 8.1%), and stent thrombosis rates were low and similar. [36] SORT OUT IV also compared these two different DESs (sirolimus and everolimus) in a non-inferiority design but with a composite primary endpoint of safety and efficacy. The composite endpoint was similar in the two groups at 9 and 18 months, but definite stent thrombosis was higher at 18 months with the sirolimus stent (0.9 vs. 0.2%). [37] Even in the subset of left main reduced 1-year MACE, TVF, and restenosis was shown with everolimus DESs. [38]

Stent thrombosis

In Bern Rotterdam Cohort study, Raber et al. reported that everolimus eluting stent (EES) use is associated with a lower risk of very late stent thrombosis compared to early-generation DESs. [39] The overall incidence rate of definite stent thrombosis with EES was (1.4 per 100 person-years) compared to SES (2.9; HR, 0.41; P < 0.0001) and PES (4.4; HR, 0.33; P < 0.0001). The incidence rate per 100 person-years of early (0-30 days), late (31 days-1 year), and very late stent thrombosis was significantly lower among everolimus DES-treated patients when compared to sirolimus and paclitaxel eluting DESs. Differences in favor of EES were most pronounced beyond 1 year, with a HR of 0.33 (EES versus SES; P = 0.006) and 0.34 (EES versus PES; P < 0.0001).

In a pooled analysis of ISAR-TEST 3 and 4 and LEADERS trials, the risk of SAT at 4 years with biodegradable polymer DESs was compared with that with a cypher stent (a durable polymer); biodegradable polymer was associated with lower TLR and SAT (HR: 0.56), driven mainly by a reduction in very late SAT. [40] In a meta-analysis of 50, 000 patients, 1-year SAT was the lowest with everolimus DESs compared with BMSs, zotarolimus, paclitaxel, or sirolimus DESs. [32]

Duration of dual antiplatelet therapy after PCI

The PRODIGY trial compared a 6 month versus 24-month dual Antiplatelet (DAPT) strategy following a variety of BMSs or DESs implantation. [41] The study failed to show that prolonging DAPT for 24 months is superior to 6 month duration of therapy in reducing composite primary endpoint of death, MI or stroke in patients receiving 1 st or 2 nd generation DES.

The PROTECT trial compared zotarolimus with sirolimus (cypher) stents in nearly 9,000 patients with duration of DAPT left to the discretion of the operator and showed no difference between the two stents in the primary endpoint of stent thrombosis at 3 years. [42]

In the EXCELLENT non-inferiority randomized study of 6 months versus 12-month DAPT after DESs, 1-year TVF occurred in 4.8 vs. 4.3%, respectively. A further study of 2000 patients compared 3-12-month DAPT following zotarolimus DESs and found no difference in SAT (0.2 vs. 0.3%) at 1 year. [43]

Physiological lesion assessment guidance for PCI

The FAME 2 trial assessed fractional flow reserve (FFR) in stable patients and those who had at least one significant lesion (FFR < 0.8) were randomized to FFR-guided PCI or optimal medical therapy (OMT). [44] The primary endpoint of death, MI, or urgent revascularization was 4.3% in the PCI group and 12.7% in the OMT group (P < 0.001); this difference was due to higher urgent revascularization in the OMT group. The 2011 ACC/AHA Guidelines for PCI recommend FFR to assess angiographic intermediate coronary lesions (50% to 70% diameter stenosis) and to guide revascularization in patients with Stable Ischemic Heart Disease (class IIa). [45]

Hemodynamic support

The counter-pulsation to reduce infarct size pre-PCI-acute myocardial infarction (CRISP AMI) trial showed no benefit from a routine intra-aortic balloon pump (IABP) in anterior myocardial infarction without shock, and did show increased bleeding, which is consistent with data available regarding the role of IABPs in patients with acute myocardial infarction without cardiogenic shock. [46]

The IABP-SHOCK II trial showed that the 30 -day mortality was very similar in the two groups (39.7 vs. 41.3%, respectively). [47] However, in the IABP group, only 13% were inserted pre-PCI. However the 5-year follow data of BCIS-1 trial reported a significant mortality advantage favoring upfront IABP insertion (HR: 0.66, 95% CI: 0.44-0.98, P = 0.039), although the potential mechanisms of this remain unclear. [48]

Access site for PCI

The STEMI-RADIAL presented at transcatheter therapeutics (TCT) randomized 700 patients to either a radial or femoral approach. [49] The primary endpoint of bleeding or access-site complications was dramatically lower with the radial approach and MACE was equivalent. Also the radial approach was associated with less contrast use and shorter ICU stay. In the radial versus femoral (RIVAL) access for coronary intervention trial, using radial rather than femoral access actually reduced mortality in the subset of STEMI patients. [50] Similar findings were also observed in the RIFLE STEACS trial. [51] In RIVAL there was, however, an interaction between benefit of the radial access route and operator experience, suggesting that the benefit of radial access over femoral depends upon the radial expertise of operators.

High dose statins

Current guidelines suggest early and aggressive low-density lipoprotein (LDL) cholesterol lowering therapy with high dose statins in patients with acute coronary syndrome. ESC guidelines for STEMI 2012 state that, the strongest trial data available so far favors atorvastatin at a dose of 80 mg daily. [11]

The LUNAR study compared the efficacy of high dose rosuvastatin with that of atorvastatin in decreasing LDL cholesterol in patients with ACS. Results from the LUNAR study show that rosuvastatin 40mg more effectively decreased LDL cholesterol, increased high density lipoproteins (HDL) cholesterol, and improved other blood lipid parameters than atorvastatin 80 mg. [52] It would not be long before rosuvastatin makes inroads into major guidelines for secondary prevention in ACS.

Biodegradable stents

Bioabsorbable stent promise important theoretical advantages over conventional DES including shorter antiplatelet duration, restored vasomotion and abolished late stent thrombosis risk. The ABSORB B Cohort tested revision 1.1 version of the everolimus-eluting bioabsorbable vascular scaffold (BVS, Abbott vascular) in patients, with up to 2 de novo native coronary artery. [53] In the first 45 patients of ABSORB Cohort B, in-stent late loss was 0.19 mm at 6-month angiographic follow-up. The 6-month major adverse cardiac event rate (defined as cardiac death, MI, or ischemia-driven TLR) was 4.4%. Furthermore, no stent thrombosis had occurred at 6 months. The everolimus BVS (Absorb) demonstrated a similar neointimal response as the everolimus DES (xience). [54]

  Conclusion Top

The management of coronary artery disease is evolving rapidly. The use of high sensitive troponin assays and coronary CT angiography in emergency department promises to be a boon for early and accurate diagnosis of acute MI. With the addition of more powerful ADP receptor antagonists and novel anticoagulant, the medical management of ACS has been revamped. Everolimus DES have been promising with low rates of stent thrombosis and TVR. Biodegradable vascular scaffolds are also now being implanted with ease. In addition a shorter duration of DAPT following PCI is on the anvil. FFR and the Radial route have been positive developments in reducing mortality associated with PCI. Future holds bright for biodegradable vascular scaffolds and gene therapy

  References Top

1.Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al. Third universal definition of myocardial infarction. Eur Heart J 2012;33:2551-67.  Back to cited text no. 1
2.Keller T, Zeller T, Peetz D, Tzikas S, Roth A, Czyz E, et al. Sensitive troponin I assay in early diagnosis of acute myocardial infarction. N Engl J Med 2009;361:868-77.  Back to cited text no. 2
3.Reichlin T, Hochholzer W, Bassetti S, Steuer S, Stelzig C, Hartwiger S, et al. Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med 2009;361:858-67.  Back to cited text no. 3
4.Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The task force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST segment elevation of the European society of cardiology (ESC). Eur Heart J 2011;32:2999-3054.  Back to cited text no. 4
5.Rubinshtein R, Halon DA, Gaspar T, Jaffe R, Karkabi B, Flugelman MY, et al. Usefulness of 64 slice cardiac computed tomographic angiography for diagnosing acute coronary syndromes and predicting clinical outcome in the emergency department patients with chest pain of uncertain origin. Circulation 2007;115:1762-8.  Back to cited text no. 5
6.Meijboom WB, Mollet NR, Van Mieghem CA, Weustink AC, Pugliese F, van Pelt N, et al. 64-Slice CT coronary angiography in patients with non ST elevation acute coronary syndrome. Heart 2007;93:1386-92.  Back to cited text no. 6
7.Hollander JE, Chang AM, Shofer FS, Collin MJ, Walsh KM, McCusker CM, et al. One-year outcomes following coronary computerized tomographic angiography for evaluation of emergency department patients with potential acute coronary syndrome. Acad Emerg Med 2009;16:693-8.  Back to cited text no. 7
8.Goldstein JA, Chinnaiyan KM, Abidov A, Achenbach S, Berman DS, Hayes SW, et al. The CT-STAT (Coronary computed tomographic angiography for systematic triage of acute chest pain patients to treatment) trial. J Am Coll Cardiol 2011;58:1414-22.  Back to cited text no. 8
9.Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2007;357:2001-15.  Back to cited text no. 9
10.Steg PG, James S, Harrington RA, Ardissino D, Becker RC, Cannon CP, et al. Ticagrelor versus clopidogrel in patients with ST-elevation acute coronary syndromes intended for reperfusion with primary percutaneous coronary intervention: A platelet inhibition and patient outcomes (PLATO) trial subgroup analysis. Circulation 2010;122:2131-41.  Back to cited text no. 10
11.Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC), Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012;33:2569-619.  Back to cited text no. 11
12.Montalescot G, Zeymer U, Silvain J, Boulanger B, Cohen M, Goldstein P, et al. Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: The international randomized open label ATOLL trial. Lancet 2011;378:693-703.  Back to cited text no. 12
13.Fifth Organization to Assess Strategies in Acute Ischemic Syndromes Investigators, Yusuf S, Mehta SR, Chrolavicius S, Afzal R, Pogue J, et al. Comparison of fondaparinux and enoxaparin in acute coronary syndromes. N Engl J Med 2006;354:1464-76.  Back to cited text no. 13
14.FUTURA/OASIS-8 Trial Group, Steg PG, Jolly SS, Mehta SR, Afzal R, Xavier D, et al. Low-dose vs. standard dose unfractionated heparin for percutaneous coronary intervention in acute coronary syndromes treated with fondaparinux: The FUTURA/OASIS-8 randomized trial. JAMA 2010;304:1339-49.  Back to cited text no. 14
15.Simoons ML, Bobbink IW, Boland J, Gardien M, Klootwijk P, Lensing AW, et al. A dose-finding study of fondaparinux in patients with non-ST-segment elevation acute coronary syndromes: The pentasaccharide in unstable angina (PENTUA) study. J Am Coll Cardiol 2004;43:2183-90.  Back to cited text no. 15
16.Mehta SR, Steg PG, Granger CB, Bassand JP, Faxon DP, Weitz JI, et al. Randomized, blinded trial comparing fondaparinux with unfractionated heparin in patients undergoing contemporary percutaneous coronary intervention: Arixtra study in percutaneous coronary intervention: A randomized evaluation (ASPIRE) pilot trial. Circulation 2005;111:1390-7.  Back to cited text no. 16
17.Mega JL, Braunwald E, Wiviott SD, Bassand JP, Bhatt DL, Bode C, et al. Rivaroxaban in patients with a recent acute coronary syndrome. N Engl J Med 2012;366:9-19.  Back to cited text no. 17
18.Alexander JH, Lopes RD, James S, Kilaru R, He Y, Mohan P, et al. Apixaban with antiplatelet therapy after acute coronary syndrome. N Engl J Med 2011;365:699-708.  Back to cited text no. 18
19.Steg PG, Mehta SR, Jukema JW, Lip GY, Gibson CM, Kovar F, et al. RUBY-1: A randomized, double-blind, placebo controlled trial of the safety and tolerability of the novel oral factor Xa inhibitor darexaban (YM150) following acute coronary syndrome. Eur Heart J 2011;32:2541-54.  Back to cited text no. 19
20.Oldgren J, Budaj A, Granger CB, Khder Y, Roberts J, Siegbahn A, et al. Dabigatran vs. placebo in patients with acute coronary syndromes on dual antiplatelet therapy: A randomized, double-blind, phase II trial. Eur Heart J 2011;32:2781-9.  Back to cited text no. 20
21.Stone GW, Maehara A, Witzenbichler B, Godlewski J, Parise H, Dambrink JH, et al. Intracoronary abciximab and aspiration thrombectomy in patients with large anterior myocardial infarction: The INFUSE-AMI randomized trial. JAMA 2012;307:1817-26.  Back to cited text no. 21
22.Thiele H, Wöhrle J, Hambrecht R, Rittger H, Birkemeyer R, Lauer B, et al. Intracoronary versus intravenous bolus abciximab during primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction: A randomized trial. Lancet 2012;379:923-31.  Back to cited text no. 22
23.Aversano T, Lemmon CC, Liu L, Atlantic CPORT Investigators. Outcomes of PCI at hospitals with or without on-site cardiac surgery. N Engl J Med 2012;366:1792-802.  Back to cited text no. 23
24.Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med 2012;367:2375-84.  Back to cited text no. 24
25.Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al. Percutaneous coronary intervention versus coronary artery bypass grafting for severe coronary artery disease. N Engl J Med 2009;360:961-72.  Back to cited text no. 25
26.Mohr FW, Morice MC, Kappetein AP, Feldman TE, Ståhle E, Colombo A, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5 year follow up of the randomised, clinical SYNTAX trial. Lancet 2013;381:629-38.  Back to cited text no. 26
27.Palmerini T, BiondiZoccai G, Reggiani LB, Sangiorgi D, Alessi L, DeServi S, et al. Risk of stroke with coronary artery bypass graft surgery compared with percutaneous coronary intervention. J Am Coll Cardiol 2012;60:798-805.  Back to cited text no. 27
28.Kastrati A, Dibra A, Spaulding C, Laarman GJ, Menichelli M, Valgimigli M, et al. Meta-analysis of randomized trials on drug-eluting stents vs. bare-metal stents in patients with acute myocardial infarction. Eur Heart J 2007;28:2706-13.  Back to cited text no. 28
29.Stone GW, Witzenbichler B, Guagliumi G, Peruga JZ, Brodie BR, Dudek D, et al. Heparin plus a glycoprotein IIb/IIIa inhibitor versus bivalirudin monotherapy and paclitaxel-eluting stents versus bare-metal stents in acute myocardial infarction (HORIZONS-AMI): Final 3-year results from a multicentre, randomized controlled trial. Lancet 2011;377:2193-204.  Back to cited text no. 29
30.Sabate M, Cequier A, Iñiguez A, Serra A, Hernandez-Antolin R, Mainar V, et al. Everolimus-eluting stent versus bare-metal stent in ST-segment elevation myocardial infarction (EXAMINATION): 1 year results of a randomized controlled trial. Lancet 2012;380:1482-90.  Back to cited text no. 30
31.Räber L, Kelbæk H, Ostojic M, Baumbach A, Heg D, Tüller D, et al. Effect of biolimus-eluting stents with biodegradable polymer vs. bare-metal stents on cardiovascular events among patients with acute myocardial infarction: The COMFORTABLE AMI randomized trial. JAMA 2012;308:777-87.  Back to cited text no. 31
32.Palmerini T, Biondi-Zoccai G, Della Riva D, Stettler C, Sangiorgi D, D'Ascenzo F, et al. Stent thrombosis with drug eluting and bare-metal stents: Evidence from a comprehensive network meta-analysis. Lancet 2012;379:1393-402.  Back to cited text no. 32
33.O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American college of cardiology foundation/American heart association task force on practice guidelines. Circulation 2013;127:e362-425.  Back to cited text no. 33
34.Bangalore S, Kumar S, Fusaro M, Amoroso N, Attubato MJ, Feit F, et al. Short- and long-term outcomes with drug-eluting and bare-metal coronary stents: A mixed-treatment comparison analysis of 117 762 patient-years of follow-up from randomized trials. Circulation 2012;125:2873-91.  Back to cited text no. 34
35.Kimura T, Morimoto T, Natsuaki M, Shiomi H, Igarashi K, Kadota K, et al. Comparison of everolimus-eluting and sirolimus-eluting coronary stents: 1-year outcomes from the randomized evaluation of sirolimus-eluting versus everolimus-eluting stent trial (RESET). Circulation 2012;126:1225-36.  Back to cited text no. 35
36.von Birgelen C, Basalus MW, Tandjung K, van Houwelingen KG, Stoel MG, Louwerenburg JH, et al. A randomized controlled trial in second-generation zotarolimus-eluting resolute stents versus everolimus-eluting xience V stents in real-world patients: The TWENTE trial. J Am Coll Cardiol 2012;59:1350-61.  Back to cited text no. 36
37.Jensen LO, Thayssen P, Hansen HS, Christiansen EH, Tilsted HH, Krusell LR, et al. Randomized comparison of everolimus-eluting and sirolimus-eluting stents in patients treated with percutaneous coronary intervention: The Scandinavian organization for randomized trials with clinical outcome IV (SORT OUT IV). Circulation 2012;125:1246-55.  Back to cited text no. 37
38.Valenti R, Migliorini A, Parodi G, Carrabba N, Vergara R, Dovellini EV, et al. Clinical and angiographic outcomes of patients treated with everolimus-eluting stents or first-generation paclitaxel-eluting stents for unprotected left main disease. J Am Coll Cardiol 2012;60:1217-22.  Back to cited text no. 38
39.Räber L, Magro M, Stefanini GG, Kalesan B, van Domburg RT, Onuma Y, et al. Very late coronary stent thrombosis of a newer-generation everolimus-eluting stent compared with early-generation drug-eluting stents: A prospective cohort study. Circulation 2012;125:1110-21.  Back to cited text no. 39
40.Stefanini GG, Byrne RA, Serruys PW, deWaha A, Meier B, Massberg S, et al. Biodegradable polymer drug-eluting stents reduce the risk of stent thrombosis at 4 years in patients undergoing percutaneous coronary intervention: A pooled analysis of individual patient data from the ISAR-TEST3, ISAR-TEST4, and LEADERS randomized trials. Eur Heart J 2012;33:1214-22.  Back to cited text no. 40
41.Valgimigli M, Campo G, Monti M, Vranckx P, Percoco G, Tumscitz C, et al. Short-versus long-term duration of dual-antiplatelet therapy after coronary stenting: A randomized multicenter trial. Circulation 2012;125:2015-26.  Back to cited text no. 41
42.Camenzind E, Wijns W, Mauri L, Kurowski V, Parikh K, Gao R, et al. Stent thrombosis and major clinical events at 3 years after zotarolimus-eluting or sirolimus-eluting coronary stent implantation: A randomised, multicentre, open-label, controlled trial. Lancet 2012;380:1396-405.  Back to cited text no. 42
43.Gwon HC, Hahn JY, Park KW, Song YB, Chae IH, Lim DS, et al. Six-month versus 12-month dual antiplatelet therapy after implantation of drug-eluting stents: The efficacy of xience/promus versus cypher to reduce late loss after stenting (EXCELLENT) randomized, multicenter study. Circulation 2012;125:505-13.  Back to cited text no. 43
44.De Bruyne B, Pijls NH, Kalesan B, Barbato E, Tonino PA, Piroth Z, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med 2012;367:991-1001.  Back to cited text no. 44
45.Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: A report of the American college of cardiology foundation/American heart association task force on practice guidelines and the society for cardiovascular angiography and interventions. Circulation 2011;124:e574-651.  Back to cited text no. 45
46.Patel MR, Smalling RW, Thiele H, Barnhart HX, Zhou Y, Chandra P, et al. Intra-aortic balloon counterpulsation and infarct size in patients with acute anterior myocardial infarction without shock: The CRISP AMI randomized trial. JAMA 2011;306:1329-37.  Back to cited text no. 46
47.Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012;367:1287-96.  Back to cited text no. 47
48.Perera D, Stables R, Clayton T, DeSilva K, Lumley M, Clack L, et al. Long-term mortality data from the balloon pump-assisted coronary intervention study (BCIS1): A randomized, controlled trial of elective balloon counterpulsation during high-risk percutaneous coronary intervention. Circulation 2013;127:207-12.  Back to cited text no. 48
49.Bernat I. STEMI RADIAL: A prospective randomized trial of radial vs. femoral access in patients with ST segment elevation MI. TCT October 26, Miami, Florida; 2012.  Back to cited text no. 49
50.Jolly SS, Yusuf S, Cairns J, Niemelä K, Xavier D, Widimsky P, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): A randomised, parallel group, multicenter trial. Lancet 2011;377:1409-20.  Back to cited text no. 50
51.Romagnoli E, Biondi-Zoccai G, Sciahbasi A, Politi L, Rigattieri S, Pendenza G, et al. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: The RIFLE-STEACS (radial versus femoral randomized investigation in ST-elevation acute coronary syndrome) study. J Am Coll Cardiol 2012;60:2481-9.  Back to cited text no. 51
52.Pitt B, Loscalzo J, Monyak J, Miller E, Raichlen J. Comparison of lipid-modifying efficacy of rosuvastatin versus atorvastatin in patients with acute coronary syndrome (from the LUNAR study). Am J Cardiol 2012;109:1239-46.  Back to cited text no. 52
53.Serruys PW, Ormiston JA, Onuma Y, Regar E, Gonzalo N, Garcia-Garcia HM, et al. A bioabsorbable everolimus-eluting coronary stent system (ABSORB): 2-year outcomes and results from multiple imaging methods. Lancet 2009;373:897-910.  Back to cited text no. 53
54.Gomez-Lara J, Brugaletta S, Farooq V, Onuma Y, Diletti R, Windecker S, et al. Head-to-head comparison of the neointimal response between metallic and bioresorbable everolimus-eluting scaffolds using optical coherence tomography. JACC Cardiovasc Interv 2011;4:1271-80.  Back to cited text no. 54


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Defining Myocard...

 Article Access Statistics
    PDF Downloaded419    
    Comments [Add]    

Recommend this journal