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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\u003EThis article discusses the current landscape and future prospects in the management of acute coronary syndromes (ACS) and state of the art concepts. Specific topics include the current European Society of Cardiology algorithm to rule out non-ST-elevation myocardial infarction, results from the PROMISE trial, and a review of antithrombotic therapy for ACS.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EThrombotic Disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EThrombotic Disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EThe current landscape and future prospects in the management of acute coronary syndromes (ACS) were addressed in a session encompassing state of the art concepts.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe current European Society of Cardiology (ESC) algorithm using clinical criteria and high-sensitivity cardiac troponin I (hs-cTnI) [Hamm CW et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2011] correctly rules out non-ST-elevation myocardial infarction (NSTEMI) \u0026gt;99% of the time, said Berit Moehring, MD, University Hospital Basel, Basel, Switzerland.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EFor the first time, this fast track ESC algorithm incorporates measurements of hs-cTnI. It was tested in an ongoing, observational, prospective international study of consecutive patients (n=2128) presenting to the emergency department with chest pain onset \u0026lt;12 hours and an absence of significant ST-elevations on their electrocardiogram. The final diagnosis was adjudicated by two independent cardiologists using clinical information (pain assessment, GRACE score, and exclusion of differential diagnoses) and hs-cTnI performed on blood samples.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EPatients were divided into late presenters with chest pain onset\/maximum (CPM) \u22656 hours and early presenters with CPM \u0026lt;6 hours. In the former group, rapid rule-out was based on a single measurement using hs-cTnI, and in the latter group, on hs-cTnI values at presentation and at 3 hours. The upper limit of normal for hs-cTnI, according to the ESC algorithm, is defined as 26.2 ng\/L.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EEighty-one percent (n=1729) had an hs-cTnI below the cutoff at presentation. Among the 544 late presenters, one measurement of hs-cTnI was able to rule out acute myocardial infarction (MI) in 96.0%. Twenty-two patients (1.0%) were missed by the protocol, having a final diagnosis of NSTEMI. A diagnosis of NSTEMI was ruled out in a further 19 of these 22 patients by adding clinical criteria to the hs-cTnI measurement. Therefore, with the rapid rule-out ESC protocol, 99.4% were correctly ruled out. Among the early presenters, the two hs-cTnI measurements correctly ruled out NSTEMI in 96.9%. Of the 11 patients missed using only hs-cTnI, NSTEMI was correctly ruled out in additional nine by adding the clinical criteria, meaning that a total of 99.4% were correctly ruled out.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EThe five missed patients have been followed for 24 months, at which time there were two MIs and one death. Pain assessment was the key additional criterion to help rule out NSTEMI, said Prof. Moehring.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EEARLY ADENOSINE MAY IMPROVE STEMI OUTCOMES WITH SHORT ISCHEMIC TIMES\u003C\/h2\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EIn patients with a first STEMI who undergo primary percutaneous coronary intervention (PCI), functional recovery and infarct mass were improved with a single early infusion of intracoronary adenosine in a subset of patients with short ischemic times. This was a major finding of the double-blind, placebo-controlled multicenter clinical trial Protection against myocardial injury in patients with ST-segment elevation [PROMISE; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01174550\u0026amp;atom=%2Fspmdc%2F13%2F15%2F34.atom\u0022\u003ENCT01174550\u003C\/a\u003E], the results of which were presented by David Garcia-Dorado, MD, Hospital Universitari Vall d\u0027Hebron, Barcelona, Spain.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EIn PROMISE, 201 STEMI patients within 6 hours of symptom onset with persistent TIMI flow Grade 0\/1 were randomized to receive adenosine 4.5 mg or saline given over 2 minutes distal to the lesion, immediately before PCI. Magnetic resonance imaging (MRI) was performed at 2 to 7 days and 6 months after reperfusion. The primary endpoint was infarct size by late enhancement MRI at 3 to 7 days.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThere were no differences between the placebo and adenosine groups in the rates of mortality or major adverse cardiac events at 6 months. Infarct mass was not significantly different between placebo and adenosine (20.8% vs 22.5%; p=0.396), nor was relative microvascular obstruction mass (2.75% vs 2.90%; p=0.852). At 6 months, left ventricular ejection fraction (LVEF) increased significantly from baseline in patients randomized to adenosine (3.32%; p=0.006) but not placebo-treated patients (1.49%; p=0.247).\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EIn the prespecified subgroup analysis of patients with ischemic time \u0026lt;200 minute, infarct mass was significantly smaller in the adenosine group (19.4% vs 25.7%; p=0.043), with no difference in microvascular obstruction mass (1.91% vs 2.94%; p=0.297) or LVEF recovery (3.6% vs 0.43%; p=0.199).\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EIn patients with involvement of the proximal left anterior descending artery, the difference in microvascular obstruction mass (1.80% vs 5.53%; p=0.059) and improvement in LVEF (6.8%; p=0.010 vs 0.46%; p=0.897) were favorably affected by adenosine compared with placebo.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EAlthough the results of the PROMISE trial do not support the routine use of intracoronary adenosine in STEMI patients receiving primary PCI, when considered together with previous studies [Grygier M et al. \u003Cem\u003EAm J Cardiol\u003C\/em\u003E 2011; Niccoli G et al. \u003Cem\u003EJACC Cardiovasc Interv\u003C\/em\u003E 2013], it does suggest that the use of adenosine in patients receiving PCI with TIMI grade flow \u0026lt;2 within 3 hours of symptom onset may be beneficial if confirmed, concluded Prof. Garcia-Dorado.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EANTITHROMBOTICS: THE PRESENT AND THE FUTURE\u003C\/h2\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EPhilippe Gabriel Steg, MD, H\u00f4pital Bichat-Claude Bernard, Paris, France, reviewed antithrombotic therapy for ACS, saying that it remains complex despite the increased flexibility allowed by new agents. \u003Cem\u003EIn vivo\u003C\/em\u003E, arterial thrombosis involves a confluence of platelet activation and aggregation, tissue factor generation, and fibrin formation after vascular injury [Falati S et al. \u003Cem\u003ENat Med\u003C\/em\u003E 2002]. To target this process, antiplatelet agents and anticoagulants must be combined in sequence and with overlap but the optimal cocktail of agents is not known [Hamm W et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EThe future of the management of ACS will include more effective and more flexible anticoagulation, Prof. Steg predicted. Bivalirudin was associated with a reduction in 30-day mortality and non-CABG-related major bleeding when given in the hospital compared with heparin plus a glycoprotein IIb\/IIIa inhibitor [EUROMAX; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01087723\u0026amp;atom=%2Fspmdc%2F13%2F15%2F34.atom\u0022\u003ENCT01087723\u003C\/a\u003E]. Drugs that work on the REG1 anticoagulation system (ie, pegnivacogin) can achieve rapid anticoagulation with injection [Dyke CK et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2008], but are reversible with an oligonucleotide antidote (ie, anivamersen) [Chan MY et al. \u003Cem\u003EJ Thromb Haemost\u003C\/em\u003E 2008]. Pegnivacogin is being compared with bivalirudin in a Phase 3 study with a planned enrollment of \u0026gt;13,000 patients undergoing PCI [REGULATE-PCI; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01848106\u0026amp;atom=%2Fspmdc%2F13%2F15%2F34.atom\u0022\u003ENCT01848106\u003C\/a\u003E].\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EOral antiplatelet therapies have issues with long onset and long offset, which may be overcome by injectable agents, including the novel ADP-P2Y12 receptor antagonist cangrelor (plasma half-life of 5 to 9 minutes) [Bhatt DL et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003ELong-term death rates post-ACS remain high [Fox KA et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2010]. Potential therapies after discharge to improve post-acute outcomes include continuing dual antiplatelet therapy (DAPT) [Valgimigli M et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2012] and long-term DAPT using a more potent agent such as ticagrelor [Wallentin L et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009], triple therapy with an additional antiplatelet agent [Morrow DA et al. \u003Cem\u003EN Engl J Med 2012\u003C\/em\u003E]; or a novel oral anticoagulant (eg, rivaroxaban) [Mega JL et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2012]. Although the addition of rivaroxaban to aspirin and reduced the rates of cardiovascular and all-cause death, it did so at the expense of increased bleeding. Eliminating aspirin from the post-acute regimen has also been proposed on the concept that aspirin is a relatively weak antiplatelet agent and increases the risk of gastrointestinal bleeding. Aspirin added to an oral anticoagulant and clopidogrel (so called \u201ctriple therapy\u201d) has been associated with an increase in all-cause mortality (p=0.027) and bleeding (p\u0026lt;0.001) compared with clopidogrel plus oral anticoagulant (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) in a large (n=496) randomized clinical trial of patients undergoing PCI [Dewilde W et al. \u003Cem\u003ELancet\u003C\/em\u003E 2013]. Reducing the intensity of antithrombotic therapy over time is another potential option [Wallentin L et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009].\u003C\/p\u003E\n         \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\/13\/15\/34\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Double Versus Triple Antithrombotic Therapy in Patients Undergoing PCI\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-994735922\u0022 data-figure-caption=\u0022Double Versus Triple Antithrombotic Therapy in Patients Undergoing PCI\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\/13\/15\/34\/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\/13\/15\/34\/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\/13\/15\/34\/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\/13600\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-18\u0022 class=\u0022first-child\u0022\u003EDouble Versus Triple Antithrombotic Therapy in Patients Undergoing PCI\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EMI=myocardial infarction; ST=stent thrombosis; TVR=target vessel revasculariztion.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Dewilde W et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. \u003Cem\u003ELancet\u003C\/em\u003E 2013;381(9872):1107\u20131115. With permission from Elsevier.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\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\/13\/15\/34.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?nznnb1\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?nznnb1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}