Journal of the American College of Cardiology
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J. Am. Coll. Cardiol. · Feb 2003
Review"Routine invasive" versus "selective invasive" approaches to non-ST-segment elevation acute coronary syndromes management in the post-stent/platelet inhibition era.
Is a "routine invasive" or "selective invasive" strategy the best approach for patients with non-ST-segment elevation acute coronary syndrome (ACS)? A "selective invasive" strategy incorporates ischemia-guided use of aggressive medical therapy followed by angiography and revascularization for angina or stress-induced myocardial ischemia. The "routine invasive" strategy (cardiac catheterization followed by percutaneous coronary intervention within 24 to 48 h of symptom-onset) is frequently employed, but no randomized, controlled trials have demonstrated improved clinical outcomes. Recently, the second Fragmin and fast Revascularization during InStability in Coronary artery disease (FRISC-II) and the Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction (TACTICS TIMI-18) trials found significant reductions in death, recurrent myocardial infarction, or hospitalization for biomarker-positive ACS. ⋯ The FRISC-II, TACTICS TIMI-18, and RITA-3 studies indicate that higher-risk patients benefit from early revascularization, but that aggressive antiplatelet, antithrombin, and anti-ischemic therapy are also important. While all three trials support an "early invasive" approach in intermediate- and high-risk patients, other trials support a more "conservative" approach in those without electrocardiographic changes or enzyme elevations. Optimal management should incorporate both strategies.
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J. Am. Coll. Cardiol. · Feb 2003
ReviewShort- and long-term oral antiplatelet therapy in acute coronary syndromes and percutaneous coronary intervention.
Platelets play a central role in both the short- and long-term manifestations of atherothrombosis. In acute coronary syndrome (ACS), there is a steep rise in cardiovascular events early, followed by an incremental rise in cardiovascular events over the long term. This long-term event rate is related to persistent platelet activation and thrombin generation. ⋯ For the large number of patients undergoing percutaneous coronary intervention in the CURE trial, there was a substantial risk reduction with clopidogrel pretreatment followed by long-term therapy (p < 0.002). This benefit was present, regardless of whether intervention was performed early or late. The significant benefits of aspirin and clopidogrel persist for the combined efficacy-safety end point of cardiovascular death, MI, stroke, or life-threatening bleeding when clopidogrel is started early, combined with aspirin and other standard therapies, and continued for up to one year.
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J. Am. Coll. Cardiol. · Jan 2003
Analysis and results of prolonged resuscitation in cardiac arrest patients rescued by extracorporeal membrane oxygenation.
We conducted this study to determine the result of prolonged cardiopulmonary resuscitation (CPR) with extracorporeal membrane oxygenation (ECMO) and the predictive factors for hospital discharge and ECMO weaning. ⋯ Prolonged CPR rescue by ECMO provides an acceptable survival rate and outcome in survivors. Our results of the selected cases encourage further investigations of the wider application of ECMO in CPR.
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J. Am. Coll. Cardiol. · Jan 2003
Randomized Controlled Trial Multicenter Study Clinical TrialRITZ-5: randomized intravenous TeZosentan (an endothelin-A/B antagonist) for the treatment of pulmonary edema: a prospective, multicenter, double-blind, placebo-controlled study.
The objective of this study was to evaluate the addition of intravenous (IV) tezosentan to standard therapy for patients with pulmonary edema. ⋯ In the present study, tezosentan (an ET-1 antagonist) did not affect the outcome of pulmonary edema, possibly because of the high dose used.