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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\u003EA focused update of the guidelines for the management of patients with ST-elevation myocardial infarction (STEMI) and for percutaneous coronary intervention was released in November 2009 by the American Heart Association and the American College of Cardiology [Kushner FG et al. Published online 18 November 2009 in \u003Cem\u003ECirculation\u003C\/em\u003E and \u003Cem\u003EJACC\u003C\/em\u003E].\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\u003EInterventional Techniques \u0026amp; Devices Guidelines\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EA focused update of the guidelines for the management of patients with ST-elevation myocardial infarction (STEMI) and for percutaneous coronary intervention (PCI) was released in November 2009 by the American Heart Association and the American College of Cardiology [Kushner FG et al. Published online 18 November 2009 in \u003Cem\u003ECirculation\u003C\/em\u003E and \u003Cem\u003EJACC\u003C\/em\u003E].\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe 2009 Focused Update contains both new and modified recommendations that are based on late-breaking clinical trial data from the past two years. The recommendations are organized into three classes and three levels of evidence. A Class I recommendation indicates a procedure\/treatment that \u003Cstrong\u003Eshould\u003C\/strong\u003E be performed. Class II reflects procedures\/ treatments that are \u003Cem\u003Ereasonable to perform\u003C\/em\u003E (Class IIa) or that \u003Cem\u003Emay be considered\u003C\/em\u003E (Class IIb). Procedures\/treatments that \u003Cstrong\u003Eshould not\u003C\/strong\u003E be performed are considered Class III. Levels of evidence (LOE) are based on the size of the population in which the treatment\/ procedure has been evaluated and the source of the data. Class A LOE reflects data from a large population sample and multiple randomized controlled trials. Data from limited populations and only one randomized or multiple nonrandomized trials are considered Class B. Class C recommendations are derived from very limited populations and are based on a consensus of expert opinion case studies or standard of care.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EST-Elevation Myocardial Infarction (STEMI)\u003C\/h2\u003E\n         \u003Cdiv id=\u0022sec-2\u0022 class=\u0022subsection\u0022\u003E\n            \u003Ch3 class=\u0022\u0022\u003EModified Recommendations\u003C\/h3\u003E\n            \u003Cdiv id=\u0022sec-3\u0022 class=\u0022subsection\u0022\u003E\n               \u003Ch4 class=\u0022\u0022\u003EGlycoprotein IIb\/IIIa Receptor Antagonists\u003C\/h4\u003E\n               \u003Col class=\u0022list-ord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n                     \u003Cp id=\u0022p-4\u0022\u003ETreatment with glycoprotein IIb\/IIIa receptor antagonists may be started at the time of primary PCI (with\/without stenting) in selected patients with STEMI: abciximab (Class IIa, LOE: A) OR tirofiban or eptifibatide (Class IIa, LOE: B).\u003C\/p\u003E\n                  \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n                     \u003Cp id=\u0022p-5\u0022\u003EThe usefulness of glycoprotein IIb\/IIIa receptor antagonists as part of a preparatory pharmacological strategy for patients with STEMI before their arrival in the cardiac catheterization laboratory for angiography and PCI is uncertain (Class IIb, LOE: B).\u003C\/p\u003E\n                  \u003C\/li\u003E\u003C\/ol\u003E\n            \u003C\/div\u003E\n            \u003Cdiv id=\u0022sec-4\u0022 class=\u0022subsection\u0022\u003E\n               \u003Ch4 class=\u0022\u0022\u003EThienopyridines\u003C\/h4\u003E\n               \u003Col class=\u0022list-ord \u0022 id=\u0022list-2\u0022\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n                     \u003Cp id=\u0022p-6\u0022\u003EA loading dose of thienopyridine is recommended for STEMI patients for whom PCI is planned: at least 300\u2013600 mg of clopidogrel as early as possible before or at the time of primary or nonprimary PCI [Class I, LOE: C] OR prasugrel 60 mg as soon as possible for primary PCI (Class I, LOE: B).\u003C\/p\u003E\n                  \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n                     \u003Cp id=\u0022p-7\u0022\u003EPatients who receive a bare metal (BMS) or drug-eluting (DES) stent during PCI for acute coronary syndrome should be given clopidogrel 75 mg daily (Class I, LOE: B) or prasugrel 10 mg daily (Class I, LOE: B) for at least 12 months. If the risk of morbidity due to bleeding outweighs the anticipated benefit that is afforded by thienopyridine therapy, earlier discontinuation should be considered (Class I, LOE: C).\u003C\/p\u003E\n                  \u003C\/li\u003E\u003C\/ol\u003E\n            \u003C\/div\u003E\n         \u003C\/div\u003E\n         \u003Cdiv id=\u0022sec-5\u0022 class=\u0022subsection\u0022\u003E\n            \u003Ch3 class=\u0022\u0022\u003ENew Recommendations\u003C\/h3\u003E\n            \u003Cdiv id=\u0022sec-6\u0022 class=\u0022subsection\u0022\u003E\n               \u003Ch4 class=\u0022\u0022\u003EThienopyridines\u003C\/h4\u003E\n               \u003Col class=\u0022list-ord \u0022 id=\u0022list-3\u0022\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n                     \u003Cp id=\u0022p-8\u0022\u003EPrasugrel is not recommended as part of a dual antiplatelet therapy regimen in STEMI patients with a prior history of stroke and transient ischemic attack for whom primary PCI is planned (Class III, LOE: C).\u003C\/p\u003E\n                  \u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n                     \u003Cp id=\u0022p-9\u0022\u003EIntensive glucose control.\u003C\/p\u003E\n                  \u003C\/li\u003E\u003Cli id=\u0022list-item-7\u0022\u003E\n                     \u003Cp id=\u0022p-10\u0022\u003EIt is reasonable to use an insulin-based regimen to achieve and maintain glucose levels \u0026lt;180 mg\/dL while avoiding hypoglycemia for patients with STEMI with either a complicated or uncomplicated course (Class I, LOE: B).\u003C\/p\u003E\n                  \u003C\/li\u003E\u003Cli id=\u0022list-item-8\u0022\u003E\n                     \u003Cp id=\u0022p-11\u0022\u003EStents.\u003C\/p\u003E\n                  \u003C\/li\u003E\u003Cli id=\u0022list-item-9\u0022\u003E\n                     \u003Cp id=\u0022p-12\u0022\u003EA DES may be used as an alternative to a BMS for primary PCI in STEMI (Class IIa, LOE: B).\u003C\/p\u003E\n                  \u003C\/li\u003E\u003Cli id=\u0022list-item-10\u0022\u003E\n                     \u003Cp id=\u0022p-13\u0022\u003EA DES may be considered for clinical and anatomical settings in which the efficacy\/safety profile appears favorable (Class IIb, LOE: B).\u003C\/p\u003E\n                  \u003C\/li\u003E\u003C\/ol\u003E\n            \u003C\/div\u003E\n         \u003C\/div\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-7\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPercutaneous Coronary Intervention\u003C\/h2\u003E\n         \u003Cdiv id=\u0022sec-8\u0022 class=\u0022subsection\u0022\u003E\n            \u003Ch3 class=\u0022\u0022\u003EModified Recommendations\u003C\/h3\u003E\n            \u003Cdiv id=\u0022sec-9\u0022 class=\u0022subsection\u0022\u003E\n               \u003Ch4 class=\u0022\u0022\u003EAngiography in Patients with Chronic Kidney Disease (CKD)\u003C\/h4\u003E\n               \u003Col class=\u0022list-ord \u0022 id=\u0022list-4\u0022\u003E\u003Cli id=\u0022list-item-11\u0022\u003E\n                     \u003Cp id=\u0022p-14\u0022\u003EAppropriate contrast agents during angiography or PCI in patients with CKD now include both isosmolar (Class I, LOE: A) and a low-molecular-weight contrast medium other than ioxaglate or iohexol (Class I, LOE: B).\u003C\/p\u003E\n                  \u003C\/li\u003E\u003Cli id=\u0022list-item-12\u0022\u003E\n                     \u003Cp id=\u0022p-15\u0022\u003EFractional flow reserve (FFR).\u003C\/p\u003E\n                  \u003C\/li\u003E\u003Cli id=\u0022list-item-13\u0022\u003E\n                     \u003Cp id=\u0022p-16\u0022\u003EIt is reasonable to use FFR (Class IIa, LOE: A) or Doppler velocimetry (Class IIa, LOE: C) to assess the effects of intermediate coronary stenoses (30% to 70% luminal narrowing) in patients with anginal symptoms.\u003C\/p\u003E\n                  \u003C\/li\u003E\u003Cli id=\u0022list-item-14\u0022\u003E\n                     \u003Cp id=\u0022p-17\u0022\u003ERoutine assessment with FFR or Doppler ultrasonography to assess angiographic disease severity in concordant vascular distribution in patients with angina and a positive, unequivocal noninvasive functional study is not recommended (Class III, LOE: C).\u003C\/p\u003E\n                  \u003C\/li\u003E\u003C\/ol\u003E\n            \u003C\/div\u003E\n         \u003C\/div\u003E\n         \u003Cdiv id=\u0022sec-10\u0022 class=\u0022subsection\u0022\u003E\n            \u003Ch3 class=\u0022\u0022\u003ENew Recommendations\u003C\/h3\u003E\n            \u003Cdiv id=\u0022sec-11\u0022 class=\u0022subsection\u0022\u003E\n               \u003Ch4 class=\u0022\u0022\u003EPCI for Unprotected Left Main Coronary Artery Disease\u003C\/h4\u003E\n               \u003Col class=\u0022list-ord \u0022 id=\u0022list-5\u0022\u003E\u003Cli id=\u0022list-item-15\u0022\u003E\n                     \u003Cp id=\u0022p-18\u0022\u003EPCI of the left main coronary artery using stents as an alternative to coronary artery bypass graft (CABG) may be considered in patients with anatomical conditions that are associated with low risk of PCI procedural complications and clinical conditions that predict an increased risk of adverse surgical outcomes (Class IIb, LOE: B).\u003C\/p\u003E\n                  \u003C\/li\u003E\u003Cli id=\u0022list-item-16\u0022\u003E\n                     \u003Cp id=\u0022p-19\u0022\u003ETiming of angiography and antiplatelet therapy in UA\/ NSTEMI.\u003C\/p\u003E\n                  \u003C\/li\u003E\u003Cli id=\u0022list-item-17\u0022\u003E\n                     \u003Cp id=\u0022p-20\u0022\u003EPatients with definite or likely unstable angina\/non-ST-elevation myocardial infarction (UA\/NSTEMI) who are selected for an invasive approach should receive dual antiplatelet therapy (Class I, LOE: A). Aspirin should be initiated on presentation (Class I, LOE: A). Either clopidogrel (before or at the time of PCI) (Class I, LOE: A) OR prasugrel (at the time of PCI) (Class I, LOE: B) is recommended as a second antiplatelet agent.\u003C\/p\u003E\n                  \u003C\/li\u003E\u003C\/ol\u003E\n               \u003Cp id=\u0022p-21\u0022\u003EIt is reasonable for initially stabilized high-risk patients with UA\/NSTEMI Global Registry of Acute Coronary Events (GRACE) score \u0026gt;140 to undergo an early invasive strategy within 12 to 24 hours of admission. For patients who are not at high risk, an early invasive approach is also reasonable (Class IIa, LOE: B).\u003C\/p\u003E\n            \u003C\/div\u003E\n         \u003C\/div\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2009 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section ref-list\u0022 id=\u0022ref-list-1\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EAdditional Reading\u003C\/h2\u003E\u003Col class=\u0022cit-list ref-use-labels\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022ref-label ref-label-empty\u0022\u003E\u003C\/span\u003E\n            \u003Cdiv class=\u0022cit ref-cit ref-journal no-rev-xref\u0022 id=\u0022cit-9.5.35.1\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EKushner\u003C\/span\u003E  \u003Cspan class=\u0022cit-name-given-names\u0022\u003EFG\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-etal\u0022\u003Eet al\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cspan class=\u0022cit-article-title\u0022\u003EPublished online 18 November 2009\u003C\/span\u003E in \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003ECirculation\u003C\/abbr\u003E and \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EJACC\u003C\/abbr\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003C\/li\u003E\u003C\/ol\u003E\u003C\/div\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\/9\/5\/35.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_openurl.js?nzmike\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}