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Commencing Volume 19, Issue 1, MedReviews has ceased the publication of this journal. Reviews in Cardiovascular Medicine will continue to be published by IMRPress, Ltd. (www.imrpress.org)

Volume 7, Supplement 4, 2006

Volume 7, Supplement 4, 2006

Table of Contents

Effects of GP IIb/IIIa Inhibitors on Vascular Inflammation, Coronary Microcirculation, and Platelet Function Contemporary Issues in the Cath Lab
The platelet glycoprotein (GP) IIb/IIIa inhibitors differ markedly in their pharmacokinetics, pharmacodynamics, and differential receptor affinities. Abciximab and the small-molecule GP IIb/IIIa inhibitors (eptifibatide, tirofiban) have separate, distinct binding sites on the GP IIb/IIIa receptor complex. The affinity of abciximab for the platelet GP IIb/IIIa integrin receptor, together with non-platelet-receptor mediated effects achieved through its affinity for the aVß3 and CD11b/18 receptors, most likely contribute to the clinical benefit associated with the use of abciximab as adjunctive pharmacotherapy during primary percutaneous coronary intervention for the treatment of ST-elevation acute myocardial infarction. [Rev Cardiovasc Med. 2006;7(suppl 4):S3-S11]
Optimizing Antiplatelet Therapy for the ACS Patient: Reacting to Clinical Trial Data from the ISAR-REACT-2 Studies Contemporary Issues in the Cath Lab
Antiplatelet therapy is the cornerstone of treatment for patients with an acute coronary syndrome (ACS). However, patients presenting with possible ACS are a heterogeneous population, and there is a choice of many potential combination antiplatelet therapies, with aspirin, thienopyridines (eg, clopidogrel), and glycoprotein (GP) IIb/IIIa antagonists. The ISAR-REACT-2 trial investigated the optimal application of triple (aspirin + thienopyridine + GP IIb/IIIa inhibitor) versus dual (aspirin + thienopyridine) antiplatelet therapy for patients with ACS undergoing percutaneous coronary intervention. Abciximab was associated with a significant 25% relative reduction in risk for the 30-day combined endpoint of death, myocardial infarction, or urgent target vessel revascularization. All of this benefit was confined to the patients with elevated troponin levels. The data indicate that troponin can be used as a biomarker to identify patients most likely to benefit from the addition of a GP IIb/IIIa antagonist. [Rev Cardiovasc Med. 2006;7(suppl 4):S12-S19]
The Relationship of Platelet Reactivity to the Occurrence of Post-Stenting Ischemic Events: Emergence of a New Cardiovascular Risk Factor Contemporary Issues in the Cath Lab
The reactivity of platelets to agonists plays a central role in the genesis of thrombosis following percutaneous coronary intervention (PCI) and spontaneous plaque rupture. Antiplatelet therapy has reduced the occurrence of thrombotic events following PCI, including myocardial infarction and stent thrombosis. Because the platelet is a fundamental component in the generation of an arterial thrombus and the stimulus for thrombosis is marked in PCI, it is logical to predict that patients with superior platelet inhibition would have the best outcomes with respect to ischemic events post PCI. However, until recently there was little information linking measurements of high ex vivo platelet reactivity to the occurrence of ischemic events. An emerging body of data, mostly from small studies, supports the pivotal link between periprocedural platelet physiology and increased risk of adverse thrombotic events. This review explores the available information linking platelet reactivity during and after PCI to the occurrence of adverse events, including myocardial infarction, recurrent ischemia within 6 months, and stent thrombosis. [Rev Cardiovasc Med. 2006;7(suppl 4):S20-S28]
Evolving Antithrombotic Treatment Strategies for Acute ST-Elevation Myocardial Infarction Contemporary Issues in the Cath Lab
The importance of the dissolution and prevention of thrombosis in treating patients with ST-segment elevation myocardial infarction (STEMI) has motivated the development of novel therapies targeting platelet aggregation and thrombus formation. In contemporary practice, the current challenge is the integration of these therapies into reperfusion strategies that may include fibrinolytic therapy or percutaneous coronary revascularization (PCI). Evidence from clinical trials shows that addition of glycoprotein IIb/IIIa inhibition to PCI for treatment of STEMI has substantially lowered the incidence of recurrent ischemic events and improved early survival. In contrast, current trials evaluating a strategy termed facilitated PCI, or planned early PCI after pharmacologic reperfusion therapy, have presently demonstrated an increased risk of bleeding events and mortality. Additional trials have extended the role of antithrombotic agents to STEMI that previously were reserved for patients undergoing elective revascularization or among those treated with non-ST-segment elevation acute coronary syndromes. For example, the recent studies have demonstrated the benefit of clopidogrel treatment among STEMI patients treated with fibrinolysis in reducing the incidence of infarct artery reocclusion and improving early survival. Other anticoagulants under investigation in the management of STEMI include enoxaparin, bivalirudin, and fondaparinux. This review summarizes the current status of pharmacologic and invasive strategies for the treatment of STEMI and describes recent and ongoing directions for clinical investigation. [Rev Cardiovasc Med. 2006;7(suppl 4):S29-S37]
Impact of Chronic Kidney Disease and Diabetes on Percutaneous Coronary Intervention Outcomes Contemporary Issues in the Cath Lab
Abnormalities of glucose metabolism and chronic kidney disease (CKD) complicate treatment and outcomes for patients undergoing percutaneous coronary intervention (PCI). Likely causes of the complicating effects of diabetes include hyperglycemia, abnormalities of microvascular perfusion, and a prothrombotic and proinflammatory state. CKD predisposes to atherosclerosis, adds to the mortality and morbidity risk of cardiovascular disease (CVD), and increases risks for patients undergoing PCI. The complexity of the renal dysmetabolic syndrome and its close association with CVD must be taken into account when developing a therapeutic plan for these patients. Clinical data support the use of abciximab for patients with disturbances of glucose metabolism or with CKD who are undergoing PCI. The use of drug-eluting stents reduces the rate of target vessel revascularization and restenosis. [Rev Cardiovasc Med. 2006;7(suppl 4):S38-S48]
Accelerating Time to Reperfusion in Acute Myocardial Infarction: Prehospital and Emergency Department Strategies, Systems of Care, and Pharmacologic Interventions Contemporary Issues in the Cath Lab
Although primary percutaneous coronary intervention has emerged as the preferred reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI), it is available only in a minority of US hospitals. The fundamental problem is that there is presently no organized, uniform, national STEMI triage and treatment system that is comparable to the well-developed, highly successful system in the United States that directs major trauma victims to verified trauma centers. This article reviews prehospital and emergency department triage strategies, systems, and pharmacologic interventions for patients with STEMI that can help shorten the time to reperfusion in these patients. [Rev Cardiovasc Med. 2006;7(suppl 4):S49-S60]