James P. Zidar

2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/ Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline) A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Jeffrey L. Anderson, MD, FACC, FAHA, Chair; Cynthia D. Adams, RN, PhD, FAHA; Elliott M. Antman, MD, FACC, FAHA; Charles R. Bridges, MD, ScD, FACC, FAHA[‡][1]; Robert M. Califf, MD, MACC; Donald E. Casey, Jr, MD, MPH, MBA, FACP[§][2]; William E. Chavey II, MD, MS[#][3]; Francis M. Fesmire, MD,

2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/ Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline)

Jeffrey L. Anderson, MD, FACC, FAHA, Chair; Cynthia D. Adams, RN, PhD, FAHA; Elliott M. Antman, MD, FACC, FAHA; Charles R. Bridges, MD, ScD, FACC, FAHA[‡][1]; Robert M. Califf, MD, MACC; Donald E. Casey, Jr, MD, MPH, MBA, FACP[§][2]; William E. Chavey II, MD, MS[#][3]; Francis M. Fesmire, MD,

Cost-Effectiveness of Sirolimus-Eluting Stents for Treatment of Complex Coronary Stenoses Results From the Sirolimus-Eluting Balloon Expandable Stent in the Treatment of Patients With De Novo Native Coronary Artery Lesions (SIRIUS) Trial

Background—Recently, sirolimus-eluting stents (SESs) have been shown to dramatically reduce the risk of angiographic and clinical restenosis compared with bare metal stent (BMS) implantation. However, the overall cost-effectiveness of this strategy is unknown. Methods and Results—Between February and August 2001, 1058 patients with complex coronary stenoses were enrolled in the SIRIUS trial and randomized to percutaneous coronary revascularization with either a SES or BMS. Clinical outcomes, resource use, and costs were assessed prospectively for all patients over a 1-year follow-up period. Initial hospital costs were increased by

Randomized COMparison of Platelet Inhibition With Abciximab, TiRofiban and Eptifibatide During Percutaneous Coronary Intervention in Acute Coronary Syndromes The COMPARE Trial

2881 per patient with SESs. Over the 1-year follow-up period, use of SESs led to substantial reductions in the need for repeat revascularization, including repeat percutaneous coronary intervention and bypass surgery. Although follow-up costs were reduced by

Randomized Comparison of GR-II Stent and Palmaz-Schatz Stent for Elective Treatment of Coronary Stenoses

2571 per patient with SESs, aggregate 1-year costs remained

Acute and long-term cost implications of coronary stenting

309 per patient higher. The incremental cost-effectiveness ratio for SES was

Outcome after prolonged balloon inflations of >20 minutes for initially unsuccessful percutaneous transluminal coronary angioplasty

1650 per repeat revascularization event avoided or

Internal mammary artery graft angioplasty: Acute and long-term outcome

27 540 per quality-adjusted year of life gained, values that compare reasonably with other accepted medical interventions. Under updated treatment assumptions regarding available stent lengths and duration of antiplatelet therapy, use of SESs was projected to reduce total 1-year costs compared with BMSs. Conclusions—Although use of SESs was not cost-saving compared with BMS implantation, for patients undergoing percutaneous coronary intervention of complex coronary stenoses, their use appears to be reasonably cost-effective within the context of the US healthcare system.

A randomized, placebo-controlled trial of enoxaparin after high-risk coronary stenting: the ATLAST trial

Background—The relative anti-aggregatory effects of currently prescribed platelet glycoprotein IIb/IIIa receptor antagonists during and after percutaneous coronary intervention for acute coronary syndromes have not been established. Methods and Results—We randomized 70 acute coronary syndrome patients undergoing percutaneous coronary intervention to receive abciximab, eptifibatide, or tirofiban at doses used in the Evaluation of Platelet IIb/IIIa Inhibitor for STENTing (EPISTENT), Platelet glycoprotein IIb/IIIa in Unstable angina Receptor Suppression Using Integrilin Therapy (PURSUIT), and Platelet Receptor Inhibition in ischemic Syndrome Management in Patients Limited by Unstable Signs and symptoms (PRISM-PLUS)/Randomized Efficacy Study of Tirofiban for Outcomes and Restenosis (RESTORE) trials, respectively. Platelet aggregation (PA) in response to 20 &mgr;mol/L of adenosine diphosphate was measured with turbidimetric aggregometry in both D-phenylalanyl-l-prolyl-l-arginine chloromethylketone and citrate-anticoagulated blood early (15 and 30 minutes) and late (4, 12, and 18 to 24 hours) after drug initiation. At 15 and 30 minutes, PA was significantly less inhibited by the tirofiban-RESTORE regimen compared with abciximab (P =0.028) and eptifibatide regimens (P =0.0001). The abciximab regimen, however, showed increasingly varied anti-aggregatory effects during continued infusion for ≥4 hours. Citrate exaggerated ex vivo platelet inhibition after eptifibatide and tirofiban, but had the opposite effect on abciximab. Of all regimens evaluated, the eptifibatide regimen inhibited PA most consistently throughout both the early and late periods. Conclusions—Currently recommended drug regimens to inhibit the platelet glycoprotein IIb/IIIa receptor have distinct pharmacodynamic profiles that might affect their relative efficacy in acute coronary syndromes and percutaneous coronary intervention.

Treatment of long coronary artery narrowings with long angioplasty balloon catheters

BackgroundThis prospective multicenter randomized clinical trial was designed to evaluate the long-term angiographic and clinical outcomes of elective treatment with the GR-II stent compared with the Palmaz-Schatz (PS) stent in patients with coronary stenoses. Methods and ResultsSeven hundred fifty-five patients with myocardial ischemia and de novo native coronary stenoses in 3- to 4-mm vessels were randomly assigned to the PS (375 patients) or the GR-II stent (380 patients). The primary end point was 12-month target lesion revascularization (TLR)-free survival. Angiography was performed at baseline and at follow-up in the first 300 consecutive patients to assess the frequency of angiographic restenosis. Procedure success was 98.5% for the GR-II stent and 99.4% for the PS stent (P =0.19). At 30 days, patients assigned to the GR-II stent had a higher stent thrombosis rate (3.9% versus 0.3% for PS stent, P <0.001) and TLR rate (3.9% versus 0.5% for PS stent, P <0.001). The GR-II group had a higher follow-up restenosis frequency (47.3% versus 20.6% for the PS group, P <0.001) and a lower 12-month TLR-free survival rate (71.7% versus 83.9% for the PS group, P <0.001). Multivariate logistic regression analysis identified a smaller final stent minimal lumen diameter (odds ratio [OR] 2.49, 95% CI 1.56 to 3.98;P <0.001), diabetes mellitus (OR 2.14, 95% CI 1.42 to 3.22;P <0.001), and use of the GR-II stent (OR 1.78, 95% CI 1.20 to 2.64;P <0.01) as independent determinants of 12-month TLR. ConclusionsOn the basis of these long-term follow-up data, we conclude that use of the GR-II stent should be limited to the acute treatment of abrupt or threatened closure after failed conventional balloon angioplasty procedures.