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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\u003EIn recent decades, the landscape for management of patients with acute coronary syndrome (ACS) has changed dramatically. This article discusses how some of these changes have significantly improved outcomes in the Swedish patient population.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EIn recent decades, the landscape for management of patients with acute coronary syndrome (ACS) has changed dramatically. In a State of the Art Lecture, Stefan James, MD, PhD, Uppsala University Hospital, Uppsala, Sweden, discussed how some of these changes have significantly improved outcomes in the Swedish patient population.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EIMPLEMENTATION OF RESEARCH FINDINGS AND GUIDELINES\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EProf James highlighted the importance of following guideline recommendations in patients with ACS, discussing results from an observational study demonstrating that every 10% increase in adherence to guideline recommendations of the American College of Cardiology and the American Heart Association results in a 10% decrease in mortality (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Peterson ED et al. \u003Cem\u003EJAMA.\u003C\/em\u003E 2006].\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\/14\/27\/5\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Association Between Adherence to ACC and AHA Guidelines and Patient Mortality\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1702225020\u0022 data-figure-caption=\u0022Association Between Adherence to ACC and AHA Guidelines and Patient Mortality\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\/14\/27\/5\/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\/14\/27\/5\/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\/14\/27\/5\/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\/14998\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-4\u0022 class=\u0022first-child\u0022\u003EAssociation Between Adherence to ACC and AHA Guidelines and Patient Mortality\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EACC, American College of Cardiology; AHA, American Heart Association.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EEvery 10% increase in guidelines adherence \u2192 11% decrease in mortality.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EReproduced from Peterson, ED. Association Between Hospital Process Performance and Outcomes Among Patients With Acute Coronary Syndromes. \u003Cem\u003EJAMA\u003C\/em\u003E. 2006;295:1912\u20131920. Copyright \u00a9 2006 American Medical Association. All rights reserved.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EHe also presented data from the SWEDEHEART registry [SWEDEHEART. \u003Cem\u003EEur Heart J\u003C\/em\u003E. 2009], Sweden\u0027s new online national cardiac registry of all patients hospitalized with ACS or undergoing coronary or valvular intervention. Following implementation of this registry, from 2005 to 2011, there was a dramatic improvement in how Swedish hospitals met guideline recommendations for the management of these patients. Prof James also noted that the rate of uptake of adherence to guidelines also markedly improved when hospitals\u0027 outcomes data were made transparent to both practitioners and the public (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Larsson S et al. \u003Cem\u003EHealth Affairs\u003C\/em\u003E. 2012]. From 1996 to 2007, increased adherence to evidence-based treatments in STEMI patients was also associated with a sharp decline in mortality from 21% to 12% [Jernberg T et al. \u003Cem\u003EJAMA.\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\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\/14\/27\/5\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Change in Adherence to Guidelines Following Public Reporting of Hospital Outcomes Data\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1702225020\u0022 data-figure-caption=\u0022Change in Adherence to Guidelines Following Public Reporting of Hospital Outcomes Data\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/27\/5\/F2.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\/14\/27\/5\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\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\/14\/27\/5\/F2.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\/14999\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 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003EChange in Adherence to Guidelines Following Public Reporting of Hospital Outcomes Data\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003ECopyrighted and published by Project HOPE\/Health Affairs as Larsson S et al. Use of 13 Disease Registries in 5 Countries Demonstrates the Potential to Use Outcome Data to Improve Health Care\u0027s Value. \u003Cem\u003EHealth Aff.\u003C\/em\u003E (Millwood). 2012;31:1, 220\u2013227. The published article is archived and available online at \u003Ca href=\u0022http:\/\/healthaffairs.org\u0022\u003Ehttp:\/\/healthaffairs.org\u003C\/a\u003E.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EINNOVATIVE REPERFUSION AND INTERVENTIONAL STRATEGIES\u003C\/h2\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EPrimary percutaneous coronary intervention (PCI) was another important innovation for patients with ACS and STEMI. Prof James discussed the marked shift in the past decade from the use of fibrinolysis to PCI, and how this has been associated with a lower risk of bleeding complications and has almost completely eliminated the occurrence of fatal bleeds. This transition has also improved the delay to reperfusion and dramatically reduced the incidence of cardiogenic shock. He noted that most patients aged \u0026gt; 65 years are now receiving primary angiography for STEMI and primary PCI.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EAnother important shift is in the transition from using femoral to using radial access for primary PCI. According to Prof James, from 2003 to 2013, the number of patients receiving radial procedures increased from approximately 15% to almost 80%. Compared with femoral access, radial access is also associated with a reduction in complications during hospitalization, most notably a 50% decrease in all bleeding risk.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EINTERVENTIONAL DEVICES\u003C\/h2\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EThere has also been a significant evolution throughout time in drug-eluting stent (DES) design with regard to the drugs, polymers, stent platforms, and delivery systems involved. Old-generation DES (o-DES), despite being safe, has been associated with an increased risk of late stent thrombosis (LST) [Sarno G et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2014]. Recent data from the SWEDEHEART study have shown that the LST risk associated with newer-generation DES (n-DES) is similar to that associated with bare-metal stents (BMS) and lower than that of o-DES.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EProf James described the introduction of bioresorbable vascular scaffolds (BVSs) as the fourth revolution in interventional cardiology. He noted, however, that observational data thus far have shown a markedly increased stent thrombosis (ST) risk using BVS technology compared with n-DES. In one study, the cumulative incidence of definite or probable scaffold thrombosis was 1.5% at 30 days and 2.1% at 6 months, with 16 of 23 cases occurring within 30 days [Capodanno D et al. \u003Cem\u003EEurointervention\u003C\/em\u003E. 2014]. So, although this new technology holds promise, Prof James emphasized the importance of optimizing the implantation technique and using intracoronary imaging to reduce the thrombosis risk throughout time.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPHARMACOLOGICAL AGENTS AND STRATEGIES\u003C\/h2\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EPharmacological agents and strategies have revolutionized PCI and treatment of patients with PCI. In Sweden, secondary prevention with statin treatment has greatly increased throughout time since 1994, and now most patients receive statin treatment post ACS.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EProf James believes that potent statin therapy is one of the most important contributors to the low patient mortality post myocardial infarction (MI).\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003ENew platelet inhibitors have also emerged, including the novel P2Y12 antagonist ticagrelor, which inhibits adenosine diphosphate\u2014induced platelet aggregation more potently than clopidogrel and reduces the incidence of MI and death in patients with ACS [Damman P et al. \u003Cem\u003EJ Thromb Thrombolysis\u003C\/em\u003E. 2012]. According to Prof James, since its launch in 2011, ticagrelor has now taken \u0026gt; 80% of the market in Sweden, with a simultaneous reduction in the use of clopidogrel down to approximately 15% of the patient population.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-5\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ESECONDARY PREVENTION AND ASSESSMENT OF PATIENT-REPORTED OUTCOMES\u003C\/h2\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EPatients now report reductions in sick leave following MI. According to Prof James, registry data for the SWEDEHEART registry have shown that from 2006 to 2012, the number of patients working full-time 6 to 10 weeks post MI has increased from about 40% to 65% in 2012, and only 20% are now at full sick leave [Hambraeus et al. \u003Cem\u003EScand Cardiovasc J\u003C\/em\u003E. 2014].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-6\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPRIMARY AND SECONDARY PREVENTION STRATEGIES\u003C\/h2\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EProf James also discussed the large, prospective, registry-based randomized TASTE trial [Lagerqvist B et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E. 2014], which was conducted to determine the effect of intracoronary thrombus aspiration on distal embolization and perfusion. Patients with STEMI were randomized to receive thrombus aspiration or to not receive thrombus aspiration prior to PCI. At 1 year, the results demonstrated no significant difference between the groups in mortality (\u003Cem\u003EP\u003C\/em\u003E = .57), rehospitalization for MI (\u003Cem\u003EP\u003C\/em\u003E = .81), or ST (\u003Cem\u003EP\u003C\/em\u003E = .48).\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EHe remarked that another important area of study currently underway in the SWEDEHEART registry (VALIDATE) is a randomized comparison of heparin vs bivalirudin in STEMI or NSTEMI patients treated with ticagrelor or prasugrel pre-PCI. The primary outcomes are death, MI, and major bleeding events.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EThanks to innovations in pharmaceutical agents, devices, strategies, and trial design and implementation, there have been significant decreases in the morbidity and mortality of cardiovascular disease in Europe and large parts of the world [Nabel EG, Braunwald E. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2012]. About half of the reduction is explained by evidence-based medical therapies in the acute phase, and about half is attributable to risk factor modification [Ford ES et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E. 2007]. In his concluding remarks, however, Prof James emphasized the need for continued innovation, because ischemic heart diseases and cerebrovascular diseases are predicted to remain the 2 leading causes of death worldwide for some time to come.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 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\/14\/27\/5.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?nzotwd\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?nzotwd\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}