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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\u003EInitial therapy for AMI aims at restoration of perfusion achieved through either medical or mechanical (PCTA, CABG) means.\u003C\/p\u003E\n            \u003Cp id=\u0022p-2\u0022\u003EACC\/AHA STEMI guidelines were updated and expanded in 2004, and are now generally regarded as the \u201cfinal word.\u201d The new guidelines emphasize primary PCI as the initial reperfusion therapy of choice if promptly available. Timing of therapies prompted a presentation focusing on STEMI management in the first 24 hours.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Emyocardial infarction\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EEarly Reperfusion\u2014If Possible\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EInitial therapy for AMI aims at restoration of perfusion achieved through either medical or mechanical (PCTA, CABG) means.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EACC\/AHA STEMI guidelines were updated and expanded in 2004, and are now generally regarded as the \u201cfinal word.\u201d The new guidelines emphasize primary PCI as the initial reperfusion therapy of choice if promptly available. Timing of therapies prompted a presentation focusing on STEMI management in the first 24 hours.\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\/6\/1\/16\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1515402881\u0022 data-figure-caption=\u0022\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure1\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/6\/1\/16\/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\/6\/1\/16\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure1\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\/6\/1\/16\/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\/16087\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\u003C\/div\u003E\n         \u003Cp id=\u0022p-5\u0022\u003ETiming was a pivotal issue in the Treatment with Enoxaparin and Tirofiban in Acute Myocardial Infarction (TETAMI) trial. AMI patients presenting \u0026gt;\/=12 hours after symptom onset are generally considered to be ineligible for reperfusion therapy\u2014and there are no current specific treatment recommendations for this subgroup, according to TETAMI investigator Marc Cohen, MD, Newark Beth Israel Medical Center. \u201cTETAMI was established to get a better understanding of the characteristics and outcomes of STEMI patients who are deemed ineligible for standard reperfusion.\u201d\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EAll patients with STEMI who were \u0026lt;24 hours from onset were included in either the TETAMI randomized trial or registry. Those patients ineligible for acute reperfusion (presented too late), had no cardiogenic shock, and were not scheduled for catheterization and revascularization within 48 hours \u201cwere randomized to 1 of 4 antithrombotic regimens involving enoxaparin or unfractionated heparin, in combination with tirofiban or placebo for 2 to 8 days,\u201d Dr. Cohen said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003E\u201cA concurrent registry tracked STEMI patients presenting \u0026lt;12 hours after onset, and who underwent reperfusion.\u201d This registry also tracked the remaining STEMI patients who neither received reperfusion nor were enrolled in the TETAMI randomized trial.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003E\u201cWe found that patients in the TETAMI registry who received early reperfusion had lower clinical event rates at 30 days, compared with patients who did not receive reperfusion therapy. In particular, 30-day mortality was only 4.4% in patients who received reperfusion therapy, compared with 12% in non-TETAMI patients who did not receive reperfusion therapy.\u201d\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EEarly access to treatment and early reperfusion therapy in STEMI will save lives and reduce mortality. However, in their published results, Dr. Cohen and colleagues noted a substantial fraction of patients with STEMI (40%) present too late for reperfusion therapy. In the large-scale 18-month Rapid Early Action for Coronary Treatment (REACT) program, it was observed that investigators were unable to shorten the time from onset of symptoms to hospital arrival in study communities.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003E\u201cThe overall picture points to the need for further studies to identify the optimal treatment of patients with STEMI who are ineligible for reperfusion, particularly those who present more than 12 hours after symptom onset,\u201d Dr. Cohen noted. Further research and initiatives in education and outreach are also needed to encourage earlier presentation for care.\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\/6\/1\/16\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1515402881\u0022 data-figure-caption=\u0022\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure2\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/6\/1\/16\/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\/6\/1\/16\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure2\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\/6\/1\/16\/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\/16088\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\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EImproving Outcomes: Beyond Reperfusion\u003C\/h2\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EWhat about medical management in STEMI? Christopher Granger, MD, Duke University Clinical Research Institute, noted that timing is of the essence in this strategy as well.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EFive lives were saved per 1,000 patients if ACEIs were started in the first 24 hours after symptom onset, according to data from the ACEI Collaborative Group. Although ACEIs tended to be better if the MI is anterior, the benefit was still evident for infarctions in other locations. Additionally, ACEIs conferred benefits in several subgroups, including younger patients, diabetics, and those with higher heart rates (e.g., \u0026gt;\/= 80\u2013100 bpm).\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EAnother area of controversy is use of insulin to control blood glucose in diabetics with AMI. ACC\/AHA guidelines (2004) say yes, but Dr. Cohen presented more recent data (2005, 2006) that failed to support that indication. The DIGAMI-2 trial found no benefit in acute glycemic control, and other studies failed to demonstrate improved survival if glucose is tightly controlled in AMI. In addition, data does not support routine use of GIK (glucose-insulin-potassium) infusion.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EAn additional challenge is initiation and adherence to effective drug regimens. We know that patients not discharged on medication tend not to be on medication 90 days later, and the literature supports the widespread lack of compliance with medical regimens. Dr. Granger characterized adherence as a pivotal challenge in improving STEMI management.\u003C\/p\u003E\n         \u003Cp\u003EDr. Granger\u0027s presentation pointed to clear benefits of improved outcomes with medical management concurrent with and after PCI, organized around 6 key points:\n\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n                  \u003Cp id=\u0022p-16\u0022\u003EACEIs should be started early, especially in high-risk patients\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n                  \u003Cp id=\u0022p-17\u0022\u003EAldosterone blockade confers added benefit in patients with reduced EF and\/or HF\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n                  \u003Cp id=\u0022p-18\u0022\u003EBeta-blockers\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n                  \u003Cp id=\u0022p-19\u0022\u003ENo to routine acute blood glucose control\u2014await further trials\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n                  \u003Cp id=\u0022p-20\u0022\u003EStatin benefit begins early\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n                  \u003Cp id=\u0022p-21\u0022\u003EImproving adherence to complex regimens\u2014a critical factor in treatment success\u003C\/p\u003E\n               \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n         \u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2006 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\/6\/1\/16.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?nzly71\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?nzly71\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}