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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThere are unique challenges of acute coronary syndrome (ACS) care in the Caribbean. When investigators examine the demographics of Caribbean patients with ACS, it is clear that patients in this region do not reflect the study populations of major ACS trials, which tend to be predominantly Caucasian.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPrevention \u0026amp; Screening\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EIn a session on acute coronary syndrome (ACS), Vladim\u00edr D\u017eav\u00edk, University of Toronto, Toronto, Ontario, Canada, described some of the unique challenges of ACS care in the Caribbean. One retrospective study showed that the annual rates of ACS hospitalization and in-hospital mortality were significantly lower in Antigua and Barbuda than in the US [Martin TC et al. \u003Cem\u003EWest Indian Med J\u003C\/em\u003E 2007]. The intensive care unit (ICU) admission rate in Antigua and Barbuda (0.19 to 0.73; per thousand men and women respectively) was approximately 20% of that in the US (4.1 to 1.8 per thousand), and the ICU mortality rate (0.07 to 0.04 per year) was only 10% of that reported in the US (1.0 to 0.5 per year per thousand aged 35 to 75 years). The study authors concluded that these findings illustrate a lack of access to hospital-based care for ACS patients in Antigua and Barbuda [Martin TC et al. \u003Cem\u003EWest Indian Med J\u003C\/em\u003E 2007].\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EWhen investigators examine the demographics of Caribbean patients with ACS, it is clear that patients in this region do not reflect the study populations of major ACS trials, which tend to be predominantly Caucasian. In one study of ACS in Trinidad and Tobago, patients were reported to primarily be of East Indian descent (62%), followed by mixed ethnicity (20%), African descent (13%), and Caucasian race (5%) [Thomas CN et al. \u003Cem\u003EWest Indian Med J\u003C\/em\u003E 2000]. Common risk factors in these patients included diabetes (53%), hypertension (49%), and smoking (30%). Female gender (p=0.04), in-hospital ventricular fibrillation (p=0.001), and left ventricular ejection fraction \u0026lt;40% (p=0.02) were independent predictors of mortality [Thomas CN et al. \u003Cem\u003EWest Indian Med J\u003C\/em\u003E 2000].\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EOther studies that have been based in the Caribbean reveal opportunities for improving several aspects of ACS care, including risk factor reduction, patient education regarding the signs and symptoms of myocardial infarction (MI), and timely use of thrombolytic therapy. For instance, in one study of ACS management in the Bahamas, the average time to presentation from the onset of symptoms of acute MI was 18 hours [Khetan et al. \u003Cem\u003EWest Indian Med J\u003C\/em\u003E 2000]. The majority of patients (56%) presented to a health care provider 12 hours after symptom onset. Patients were treated most commonly with oral nitrates (96%) and intravenous heparin (90%), followed by \u03b2-blockers (65%) and morphine (15%). Only 8% of patients were treated with thrombolytic agents. Cardiovascular risk factors, including hypertension (77%), obesity (62%), diabetes mellitus (35%), and smoking (25%), were common in Bahamian MI patients [Khetan et al. \u003Cem\u003EWest Indian Med J\u003C\/em\u003E 2000].\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EAdvances in antiplatelet therapies have improved treatment options for ACS patients, particularly those who are undergoing invasive management. Refined clopidogrel regimens that include higher loading doses have reduced the risk of stent thrombosis without a significant increase in major bleeding [Mehta SR et al. ESC 2009]. Some ACS patients do not have a strong platelet inhibition response to clopidogrel and require more potent antiplatelet therapy to prevent cardiovascular (CV) events. Newer antiplatelet therapies provide even greater protection against CV events in appropriate ACS patients. Prasugrel is an irreversible oral adenosine diphosphate receptor antagonist that reduces the risk of CV death, MI, and stroke compared with clopidogrel but with an increase in the risk of major bleeding [Wiviott SD et al. \u003Cem\u003ENew Engl J Med\u003C\/em\u003E 2007]. Ticagrelor is an investigational oral antiplatelet agent that directly and reversibly inhibits the adenosine diphosphate receptor P2Y12. Compared with clopidogrel, ticagrelor significantly reduces the risk of CV events and death without increasing major bleeding in patients with ACS (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Wallentin L et al. \u003Cem\u003ENew Engl J Med\u003C\/em\u003E 2009].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/7\/27\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Cumulative Kaplan-Meier Estimates of the Time to the First Adjudicated Occurrence of the Primary Efficacy Endpoint.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-2080018645\u0022 data-figure-caption=\u0022Cumulative Kaplan-Meier Estimates of the Time to the First Adjudicated Occurrence of the Primary Efficacy Endpoint.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/7\/27\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/7\/27\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/7\/27\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11457\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003ECumulative Kaplan-Meier Estimates of the Time to the First Adjudicated Occurrence of the Primary Efficacy Endpoint.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ECopyright \u00a9 2009 Massachusetts Medical Society. All rights reserved.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-7\u0022\u003ERisk factors for ACS are highly prevalent among patients in the Caribbean region, and access to optimal ACS care is often limited. New research supports the use of refined ACS treatment regimens, such as an increased loading dose of clopidogrel or the use of novel antiplatelet therapies in appropriate patients. When possible, physicians should seek opportunities to apply new clinical evidence to the management of patients with ACS.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2010 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/10\/7\/27.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmq7e\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmq7e\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}