Carl J. Pepine

ACC/AHA guidelines for the management of patients with unstable angina and non–st-segment elevation myocardial infarction: A report of the american college of cardiology/ american heart association task force on practice guidelines (committee on the management of patients with unstable angina)

Preamble......971nnI.nnIntroduction ......972nnA.nnOrganization of Committee and Evidence Review......972nnB.nnPurpose of These Guidelines......973nnC.nnOverview of the Acute Coronary Syndrome......973nn1.nnDefinition of Terms......973nn2.nnPathogenesis of UA/NSTEMI ......974nn3.nnPresentations of

ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents

This document has been developed as an expert consensus document by the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA), in collaboration with the American Academy of Neurology (AAN), the American College of Physicians (ACP), the American Geriatrics Society (AGS), the American Society of Hypertension (ASH), the American Society of Nephrology (ASN), the American Society for Preventive Cardiology (ASPC), the Association of Black Cardiologists (ABC), and the European Society of Hypertension (ESH). Expert consensus documents are intended to inform practitioners, payers, and other interested parties of the opinion of ACCF and document cosponsors concerning evolving areas of clinical practice and/or technologies that are widely available or new to the practice community. Topics chosen for coverage by expert consensus documents are so designed because the evidence base, the experience with technology, and/or clinical practice are not considered sufficiently well developed to be evaluated by the formal ACCF/AHA practice guidelines process. Often the topic is the subject of considerable ongoing investigation. Thus, the reader should view the expert consensus document as the best attempt of the ACCF and document cosponsors to inform and guide clinical practice in areas where rigorous evidence may not yet be available or evidence to date is not widely applied to clinical practice. When feasible, expert consensus documents include indications or contraindications. Typically, formal recommendations are not provided in expert consensus documents as these documents do not formally grade the quality of evidence, and the provision of “Recommendations” is felt to be more appropriately within the purview of the ACCF/AHA practice guidelines. However, recommendations from ACCF/AHA practice guidelines and ACCF appropriate use criteria are presented where pertinent to the discussion. The writing committee is in agreement with these recommendations. Finally, some topics covered by expert consensus documents will be addressed subsequently by the ACCF/AHA …

ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly

Copyright

Intramyocardial, Autologous CD34+ Cell Therapy for Refractory Angina

Rationale: A growing number of patients with coronary disease have refractory angina. Preclinical and early-phase clinical data suggest that intramyocardial injection of autologous CD34+ cells can improve myocardial perfusion and function. Objective: Evaluate the safety and bioactivity of intramyocardial injections of autologous CD34+ cells in patients with refractory angina who have exhausted all other treatment options. Methods and Results: In this prospective, double-blind, randomized, phase II study (ClinicalTrials.gov identifier: NCT00300053), 167 patients with refractory angina received 1 of 2 doses (1×105 or 5×105 cells/kg) of mobilized autologous CD34+ cells or an equal volume of diluent (placebo). Treatment was distributed into 10 sites of ischemic, viable myocardium with a NOGA mapping injection catheter. The primary outcome measure was weekly angina frequency 6 months after treatment. Weekly angina frequency was significantly lower in the low-dose group than in placebo-treated patients at both 6 months (6.8±1.1 versus 10.9±1.2, P=0.020) and 12 months (6.3±1.2 versus 11.0±1.2, P=0.035); measurements in the high-dose group were also lower, but not significantly. Similarly, improvement in exercise tolerance was significantly greater in low-dose patients than in placebo-treated patients (6 months: 139±151 versus 69±122 seconds, P=0.014; 12 months: 140±171 versus 58±146 seconds, P=0.017) and greater, but not significantly, in the high-dose group. During cell mobilization and collection, 4.6% of patients had cardiac enzyme elevations consistent with non-ST segment elevation myocardial infarction. Mortality at 12 months was 5.4% in the placebo-treatment group with no deaths among cell-treated patients. Conclusions: Patients with refractory angina who received intramyocardial injections of autologous CD34+ cells (105 cells/kg) experienced significant improvements in angina frequency and exercise tolerance. The cell-mobilization and -collection procedures were associated with cardiac enzyme elevations, which will be addressed in future studies.

CORONARY ARTERY STENTS

THE INTRODUCTION AND WIDEspread use of coronary stents have been the most important advancement in the percutaneous treatment of coronary artery disease (CAD) since the initial introduction of balloon angioplasty. There have been several phases in the evolution of stent practice, some of which occurred simultaneously: (1) initial use limited by the need for multiple medications to prevent subacute thrombosis; (2) recognition that these antithrombotic regimens prolonged hospitalization, increased bleeding complications, and failed toprevent acuteor subacuteartery closure; (3) recognition of the importance of stent implantation for treatment of acute or threatened artery closure after balloon angioplasty; (4) documentation of decreased restenosis in narrowly defined populations; (5) a shift from anticoagulant to antiplatelet therapies; and (6) widespread use of stents for many clinical presentations and lesion types. Throughout these phases, stent technology has improved with more flexible and deliverable stents, allowing an increasing number of angiographic lesion subsets to be treated. Scientific knowledge about stents has expanded rapidly. In 1996, the American College of Cardiology (ACC) published an evidence-based expert consensus document that included the initial 2 randomized trials using the prototype Palmaz-Schatz stent and registry experiences that led to US Food and Drug Administration approval of the first 2 stents for the treatment of discrete, de novo lesions to prevent restenosis and for treatment of acute or impending artery closure with angioplasty. By the time the ACC document was published, stents were being used in more than 50% of all percutaneous coronary artery procedures. Subsequently, stent technology and research continued to advance and by the time the second ACC consensus document was published just 2 years later, neither of the 2 stents on which the first document was based were used, having been replaced by improved stents. Since 1996, the number of randomized clinical trials and other studies evaluating stents has increased rapidly, and stents are now used in the

Mild Renal Insufficiency Is Associated With Angiographic Coronary Artery Disease in Women

Background—Mild renal insufficiency is associated with an increased risk for cardiovascular events in women with coronary artery disease (CAD). However, the relationship between mild renal insufficiency and atherosclerotic CAD in women is not known. Methods and Results—Women with chest pain who were referred for coronary angiography in the NHLBI Women’s Ischemia Syndrome Evaluation (WISE) study underwent quantitative coronary angiography, blood measurements of creatinine, lipids, and homocysteine, and assessment of CAD risk factors. Fifty-six women had mild renal insufficiency (serum creatinine 1.2 to 1.9 mg/dL), and 728 had normal renal function (creatinine <1.2 mg/dL). Creatinine correlated with angiographic CAD severity score (r =0.11, P <0.004) and maximum coronary artery stenosis (r =0.11, P <0.003). Compared with women with normal renal function, those with mild renal insufficiency were more likely to have significant angiographic CAD (≥50% diameter stenosis in ≥1 coronary artery) (61% versus 37%;P <0.001) and CAD in multiple vessels (P <0.001 for association) and had greater maximum percent diameter coronary stenosis (59±35% versus 38±36%;P <0.001). Mild renal insufficiency was associated with significant angiographic CAD independent of age and risk factors (OR=1.9, 95%CI=1.1 to 3.5). After controlling for homocysteine in 509 women, mild renal insufficiency remained predictive of CAD (OR=3.2, 95%CI=1.4 to 7.2). Conclusions—In women with chest pain, mild renal insufficiency is an independent predictor of significant angiographic CAD. Mildly increased serum creatinine is probably a marker for unmeasured proatherogenic factors.

ACC/AHA guidelines for the management of patients with unstable angina and non-ST segment elevation myocardial infarction: Executive summary and recommendations: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients with Unstable Angina)

Eugene Braunwald, MD, FACC, Chair; Elliott M. Antman, MD, FACC; John W. Beasley, MD, FAAFP; Robert M. Califf, MD, FACC; Melvin D. Cheitlin, MD, FACC; Judith S. Hochman, MD, FACC; Robert H. Jones, MD, FACC; Dean Kereiakes, MD, FACC; Joel Kupersmith, MD, FACC; Thomas N. Levin, MD, FSCAI, FACC; Carl J. Pepine, MD, FACC; John W. Schaeffer, MD, FACC; Earl E. Smith III, MD, FACEP; David E. Steward, MD, FACP; Pierre Theroux, MD, FACC

EARLY-ONSET MENOPAUSAL VASOMOTOR SYMPTOMS ARE ASSOCIATED WITH ENDOTHELIAL DYSFUNCTION: THE NATIONAL HEART LUNG AND BLOOD INSTITUTE-SPONSORED WOMEN’S ISCHEMIA SYNDROME EVALUATION (WISE) STUDY

Vasomotor symptoms (VMS) have been linked to endothelial dysfunction. Relations may depend on the timing of VMS. We tested relations between early onset VMS and brachial artery flow mediated dilation (FMD) in the Women’s Ischemia Syndrome Evaluation (WISE).nn104 women undergoing coronary