International Journal of Cardiology 189 (2015) 85–87
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Embracing new paradigms in managing coronary disease: Is there yet a missing link to be connected? Cheuk-Kit Wong ⁎ Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
a r t i c l e
i n f o
Article history: Received 6 April 2015 Accepted 8 April 2015 Available online 9 April 2015 Keywords: New paradigms Missing link Coronary disease
The recent 2015 ACC meeting reported multiple large-scale randomized studies ushering in a new era of coronary disease management [1–5] (Table 1). This letter while reviewing these studies takes a step back and asks where the missing link in combating coronary disease may remain. With CT coronary angiography, the PROMISE trial compared an initial CT “anatomical” strategy versus a functional ischemia testing strategy using exercise electrocardiography, nuclear stress testing, or stress echocardiography in 10,003 stable, symptomatic patients without diagnosed coronary disease [1]. The SCOT-HEART study evaluated the additional value of CT in 4162 patients who had initial clinical and ECG evaluations, plus ECG stress testing in 85% [2]. As shown in Table 1, both studies included patients with relatively high cardiovascular risks, as assessed respectively by the American and Scottish risk scores. Almost half received statins at baseline. In PROMISE, there was no difference between the 2 strategies in altering outcomes over a median follow-up of 25 months whereas in SCOT-HEART CT angiography helped clarify the diagnosis of coronary disease and was associated with a non-significant reduction of fatal and non-fatal myocardial infarction. Of note, event rates were low. At ~ 3.5 years the Kaplan–Meir rate for combined death and non-fatal myocardial infarction was 4% for PROMISE and 2% for SCOT-HEART. In the 2 PCSK9 inhibitors trials, the open-label OSLER study of 4465 patients [3] aimed to establish the safety of evolucumab, which lowered LDL by 61%. There was a minimal impact on the reported adverse events
⁎ Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ijcard.2015.04.060 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
over a median follow-up duration of 11.1 months except for higher neurocognitive events (0.9% with vs. 0.3% without evolucumab). A broad spectrum of conditions were counted: delirium (including confusion), cognitive and attention disorders/disturbances, dementia and amnestic conditions, disturbances in thinking and perception, and mental impairment disorders. In the 2341 patient placebo-controlled ODYSSEY trial [4] where everyone was already on statins, alirocumab reduced LDL by ~ 60% from week 4 through week 78. The alirocumab group also more frequently had neurocognitive events (1.2% vs. 0.5%) among other issues including injection-site reactions (5.9% vs. 4.2%), myalgia (5.4% vs. 2.9%), and ophthalmologic events (2.9% vs. 1.9%). In both trials there was clinical benefit. In OSLER evolucumab reduced prospectively adjudicated combined cardiovascular events (Kaplan–Meir rate at 1 year 0.95% vs. 2.18%). In ODYSSEY, a post-hoc analysis (ODYSSEY OUTCOMES trial) evaluated major adverse cardiovascular events including death from coronary heart disease, non-fatal myocardial infarction, fatal or non-fatal ischemic stroke, or unstable angina requiring hospitalization. This was lower with alirocumab than with placebo (Kaplan– Meir rate at 86 weeks 1.7% vs. 3.3%). In PEGASUS [5] of 21,162 patients with prior myocardial infarction 1–3 years earlier, event rates were higher but still modest (3-year Kaplan–Meir rate of combined cardiovascular death, myocardial infarction, or stroke of ~8%). Ticagrelor reduced this rate, the primary efficacy endpoint, by approximately an absolute 1.25% but increased TIMI major bleeding by a similar amount (Table 1). In contrast, the TOTAL trial of 10,732 STEMI patients undergoing primary PCI was negative [6]. Despite liberal inclusion criteria, TOTAL ended up with mostly lower risk patients (mean age 61, Kilip class ≥2 in 4.3%). The composite primary outcome (death from cardiovascular causes, recurrent myocardial infarction, cardiogenic shock, or NYHA class IV heart failure within 180 days) was similar in the thrombectomy group (6.9%) and the PCI-alone group (7.0%), but the key safety outcome (stroke within 30 days) occurred more frequently in the thrombectomy group (0.7% vs. 0.3%, P = 0.02). Bail-out aspiration thrombectomy was performed in 7.1% of patients assigned to PCI alone. In the 5 trials on stable patients, the overall low event rates attest to the benefit from prevention strategies with lipid lowering and antiplatelet therapies. Side effects from bleeding (ticagrelor) and neurocognitive disturbances (PCSK9 inhibition) with more aggressive preventive strategies might suggest that we are getting close to the best “benefit-to-risk” spot. In TOTAL routine manual thrombectomy, once considered a major advance, does not pan out. What will the next progress in combating coronary disease be?
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C.-K. Wong / International Journal of Cardiology 189 (2015) 85–87
Table 1 Summary of the outcome in the 5 recent trials reported in 2015 ACC meeting (including data from supplementary materials). Trials
Description of patients at baseline
PROMISE [1]
10,003 symptomatic patients; 67.6% with CT angio vs. Death, MI, hospitalization for unstable 10-year cardiac risk of ≥7.5% based on functional tests for angina, or major procedural complication: 2013 atherosclerotic CV disease risk ischemia 3.3% vs. 3.0% (P = 0.75) score from ACC–AHA guidelines; 46% on statins
Comparators
SCOT-HEART [2]
4146 symptomatic patients; predicted 10-year CHD risk of 17% based on the ASSIGN scorea; 43% on statins
CT angio vs. standard care alone
Certainty of the diagnosis of angina secondary to CHD at 6 weeks. Reclassification 27% vs. 1%; P b 0.0001
OSLER [3]
4465 patients, 20% with known coronary disease; 70% on statins; baseline LDL 120 mg/dl
Evolocumab vs. standard care alone
Incidence of adverse effects: overall similar in both groups but neurocognitive events more frequent in the evolocumab group (0.9% vs. 0.3%)
ODYSSEY [4]
2341 patients; ~100% on statins; baseline Alirocumab vs. LDL 122 mg/dl; placebo 70% with clinical coronary heart disease
PEGASUS [5]
Double-blind 1:1:1 fashion, 21,162 patients who had had a MI 1 to 3 years earlier
Ticagrelor 90 mg twice daily vs. 60 mg twice daily vs. placebo
Primary (efficacy) outcome
Other findings More patients in the CT angio group underwent catheterization within 90 days after randomization (12.2% vs. 8.1%). K–M rate for death or MI was 3.9% vs. 4.1% at 42 months, respectively After 1 · 7 years, CT angio was associated with a 38% reduction in fatal and nonfatal MI (26 pts vs. 42 pts, p = 0 · 0527). K–M rate for death or MI was 1.8% vs. 2.4% at 40
months respectively As compared with standard therapy alone, evolocumab reduced the level of LDL cholesterol by 61% (P b 0.001), and reduced cardiovascular events from 2.18% to 0.95% at 1 year (P = 0.003). Percentage change in LDL level from baseline Post-hoc analysis showed a lower K–M rate to week 24: −61% vs. 0.8%; P b 0.001 of major adverse cardiovascular events (ODYSSEY OUTCOME) with alirocumab at 86 weeks (1.7% vs. 3.3%; P = 0.02) The primary efficacy end point (composite of The primary safety end point (TIMI major cardiovascular death, MI, or stroke): 7.85% bleeding) was 2.6% vs. 2.3% vs. 1.06% vs. 7.77% vs. 9.04% at 3 years (K–M rates) (intracranial or fatal bleed 0.63%, 0.71% and 0.60%) at 3 years (K–M rates)
CHD: Coronary Heart Disease; K–M: Kaplan–Meir; MI: Myocardial infarction. a ASSIGN score is validated Scottish cardiovascular risk score that also incorporates social deprivation and family history of cardiovascular disease (http://assign-score.com).
In contrast to most other medical conditions, cardiovascular disease can and often kills suddenly. This “sudden death” path has led to the growth of bystander CPR training, development of “paramedics”, and widespread use of automatic defibrillators. This is getting people involved before the doctors in the field. STEMI with ongoing myocyte necrosis is diagnosed on a 12-lead ECG which can be done easily provided machine availability. Early STEMI diagnosis and therapy has been advocated for decades but there are less recognized issues as shown in Table 2. Intra-cardiac ST-segment monitoring through an implanted device has been tested for diagnosing STEMI/ischemia [7] using a conventional endocardial pacemaker lead in the right ventricular apex. This device detected endocardial ST shifts, emitting distinct vibratory alarms and providing notification though telemetry with an external device. Over ~1.52 years of follow-up in 37 high-risk patients, 4 patients had significant ST-segment changes. They were hospitalized with the short alarmto-door times of 6, 18, 21, and 60 min, and had genuine acute coronary syndrome with thrombotic coronary occlusion or ruptured plaques. Apart from being invasive, this endocardial ST monitoring deviates from surface ECG recording where infarction was classified (STEMI vs. non-STEMI) and localized (anterior vs. non-anterior).
With surface ECG recent advances in body surface multi-lead recordings using the ECVue vest has allowed non-invasive mapping of cardiac arrhythmia which complements invasive mapping [8]. Single lead ECG recording through a FDA approved system on smart phones is now often used to capture transient arrhythmia. For STEMI, it was thought [9] that multiple leads surface ECG recording with smart phone transmission for centralized analysis might follow allowing earlier STEMI diagnosis and therapy using antiplatelet drugs kept in the first aid box. This has not eventuated. Has the time come to connect the missing link? Smaller portable ECG machines have been available, and skills of ECG recording are easier to acquire than those of CPR. Should every household now keep a machine (so that emergency recorded tracing can be immediately sent to their doctors) and tablets of aspirin and ticagrelor? Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References
Table 2 Less recognized advantages and disadvantages related to timing of STEMI diagnosis and therapy. Early diagnosis and therapy
Late diagnosis and therapy
Some STEMI may be aborted with very early pre-hospital fibrinolysis [9].
Sudden death may precede diagnosis — this has contributed to the development of training for bystander CPR and use of automatic defibrillators. Reperfusion is not only associated with less myocardial salvage but also more reperfusion damage including myocardial hemorrhage [11,12].
Pre-hospital as compared to cath lab administration of 180 mg loading dose of ticagrelor reduced stent thrombosis rate (0% vs. 0.8% in the first 24 h, and 0.2% vs. 1.2% at 30 days) in the 1862 STEMI patients ATLANTIC trial [10]. At least theoretically very early therapy of potent antiplatelet drugs alone may abort some STEMIs [9].
Possibility of treating both culprit and non-culprit vessels in the same setting of primary PCI exists with both pathways and may confer additional benefit [10]. Reperfusion strategy should tailor to the stage of STEMI [12].
[1] P.S. Douglas, U. Hoffmann, M.R. Patel, et al., Outcomes of anatomical versus functional testing for coronary artery disease, N. Engl. J. Med. (2015)http://dx.doi.org/10. 1056/NEJMoa1415516. [2] SCOT-HEART Investigators, CT angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicenter trial, Lancet (2015). http://dx.doi.org/10.1016/S0140-6736(15)60291-4. [3] M.S. Sabatine, R.P. Guigliano, S.D. Wiviott, et al., Efficacy and safety of evolocumab in reducing lipids and cardiovascular events, N. Engl. J. Med. (2015)http://dx.doi.org/ 10.1056/NEJMoa1500858. [4] J.G. Robinson, M. Farnier, M. Krempf, et al., Efficacy and safety of alirocumab in reducing lipids and cardiovascular events, N. Engl. J. Med. (2015)http://dx.doi.org/10.1056/ NEJMoa501031. [5] M.P. Bonaca, D.L. Bhatt, M. Cohen, et al., Long-term use of ticagrelor in patients with prior myocardial infarction, N. Engl. J. Med. (2015). http://dx.doi.org/10.1056/ NEJMoa1500857. [6] S.S. Jolly, J.A. Cairns, S. Yusuf, et al., Randomized trial of primary PCI with or without routine manual thrombectomy, N. Engl. J. Med. (2015). http://dx.doi.org/10.1056/ NEJMoa1415098. [7] T.A. Fischell, D.R. Fischell, A. Avezum, et al., Initial clinical results using intracardiac electrogram monitoring to detect and alert patients during coronary plaque rupture and ischemia, J. Am. Coll. Cardiol. 56 (2010) 1089–1098. [8] D. Erkapic, H. Greiss, D. Pajitnev, S. Zaltsberg, N. Deubner, A. Berkowitsch, S. Möllman, J. Sperzel, A. Rolf, J. Schmitt, C.W. Hamm, M. Kuniss, T. Neumann, Clinical
C.-K. Wong / International Journal of Cardiology 189 (2015) 85–87 impact of a novel three-dimensional electrocardiographic imaging for non-invasive mapping of ventricular arrhythmias-a prospective randomized trial, Europace (Oct 27 2014)http://dx.doi.org/10.1093/europace/euu282 (Epub ahead of print). [9] C.K. Wong, Aborting STEMI: what treatment opportunities may Smart-Phone ECGs give us prior to first medical contact to facilitate primary PCI? Int. J. Cardiol. 168 (2013) 5453–5455. [10] C.K. Wong, From culprit artery reperfusion to non-culprit revascularization: Will ECG play a bigger role in the evolving STEMI care? Int. J. Cardiol. 182 (2015) 124–125.
87
[11] C.K. Wong, C. Bucciarelli-Ducci, Q waves and failed ST resolution: Will intramyocardial haemorrhage be a concern in reperfusing “late presenting” STEMIs? Int. J. Cardiol. 182 (2015) 203–210. [12] C.K. Wong, Intra-myocardial hemorrhage in STEMI reperfusion: an alternative explanation for failures from “augmented” fibrinolysis regime and fibrinolysis facilitated PCI, Int. J. Cardiol. 184 (2015) 766–768, http://dx.doi.org/10.1016/j.ijcard.2015. 03.016.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Embracing new paradigms in managing coronary disease: Is there yet a missing link to be connected? Cheuk-Kit Wong ⁎ Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
a r t i c l e
i n f o
Article history: Received 6 April 2015 Accepted 8 April 2015 Available online 9 April 2015 Keywords: New paradigms Missing link Coronary disease
The recent 2015 ACC meeting reported multiple large-scale randomized studies ushering in a new era of coronary disease management [1–5] (Table 1). This letter while reviewing these studies takes a step back and asks where the missing link in combating coronary disease may remain. With CT coronary angiography, the PROMISE trial compared an initial CT “anatomical” strategy versus a functional ischemia testing strategy using exercise electrocardiography, nuclear stress testing, or stress echocardiography in 10,003 stable, symptomatic patients without diagnosed coronary disease [1]. The SCOT-HEART study evaluated the additional value of CT in 4162 patients who had initial clinical and ECG evaluations, plus ECG stress testing in 85% [2]. As shown in Table 1, both studies included patients with relatively high cardiovascular risks, as assessed respectively by the American and Scottish risk scores. Almost half received statins at baseline. In PROMISE, there was no difference between the 2 strategies in altering outcomes over a median follow-up of 25 months whereas in SCOT-HEART CT angiography helped clarify the diagnosis of coronary disease and was associated with a non-significant reduction of fatal and non-fatal myocardial infarction. Of note, event rates were low. At ~ 3.5 years the Kaplan–Meir rate for combined death and non-fatal myocardial infarction was 4% for PROMISE and 2% for SCOT-HEART. In the 2 PCSK9 inhibitors trials, the open-label OSLER study of 4465 patients [3] aimed to establish the safety of evolucumab, which lowered LDL by 61%. There was a minimal impact on the reported adverse events
⁎ Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ijcard.2015.04.060 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
over a median follow-up duration of 11.1 months except for higher neurocognitive events (0.9% with vs. 0.3% without evolucumab). A broad spectrum of conditions were counted: delirium (including confusion), cognitive and attention disorders/disturbances, dementia and amnestic conditions, disturbances in thinking and perception, and mental impairment disorders. In the 2341 patient placebo-controlled ODYSSEY trial [4] where everyone was already on statins, alirocumab reduced LDL by ~ 60% from week 4 through week 78. The alirocumab group also more frequently had neurocognitive events (1.2% vs. 0.5%) among other issues including injection-site reactions (5.9% vs. 4.2%), myalgia (5.4% vs. 2.9%), and ophthalmologic events (2.9% vs. 1.9%). In both trials there was clinical benefit. In OSLER evolucumab reduced prospectively adjudicated combined cardiovascular events (Kaplan–Meir rate at 1 year 0.95% vs. 2.18%). In ODYSSEY, a post-hoc analysis (ODYSSEY OUTCOMES trial) evaluated major adverse cardiovascular events including death from coronary heart disease, non-fatal myocardial infarction, fatal or non-fatal ischemic stroke, or unstable angina requiring hospitalization. This was lower with alirocumab than with placebo (Kaplan– Meir rate at 86 weeks 1.7% vs. 3.3%). In PEGASUS [5] of 21,162 patients with prior myocardial infarction 1–3 years earlier, event rates were higher but still modest (3-year Kaplan–Meir rate of combined cardiovascular death, myocardial infarction, or stroke of ~8%). Ticagrelor reduced this rate, the primary efficacy endpoint, by approximately an absolute 1.25% but increased TIMI major bleeding by a similar amount (Table 1). In contrast, the TOTAL trial of 10,732 STEMI patients undergoing primary PCI was negative [6]. Despite liberal inclusion criteria, TOTAL ended up with mostly lower risk patients (mean age 61, Kilip class ≥2 in 4.3%). The composite primary outcome (death from cardiovascular causes, recurrent myocardial infarction, cardiogenic shock, or NYHA class IV heart failure within 180 days) was similar in the thrombectomy group (6.9%) and the PCI-alone group (7.0%), but the key safety outcome (stroke within 30 days) occurred more frequently in the thrombectomy group (0.7% vs. 0.3%, P = 0.02). Bail-out aspiration thrombectomy was performed in 7.1% of patients assigned to PCI alone. In the 5 trials on stable patients, the overall low event rates attest to the benefit from prevention strategies with lipid lowering and antiplatelet therapies. Side effects from bleeding (ticagrelor) and neurocognitive disturbances (PCSK9 inhibition) with more aggressive preventive strategies might suggest that we are getting close to the best “benefit-to-risk” spot. In TOTAL routine manual thrombectomy, once considered a major advance, does not pan out. What will the next progress in combating coronary disease be?
86
C.-K. Wong / International Journal of Cardiology 189 (2015) 85–87
Table 1 Summary of the outcome in the 5 recent trials reported in 2015 ACC meeting (including data from supplementary materials). Trials
Description of patients at baseline
PROMISE [1]
10,003 symptomatic patients; 67.6% with CT angio vs. Death, MI, hospitalization for unstable 10-year cardiac risk of ≥7.5% based on functional tests for angina, or major procedural complication: 2013 atherosclerotic CV disease risk ischemia 3.3% vs. 3.0% (P = 0.75) score from ACC–AHA guidelines; 46% on statins
Comparators
SCOT-HEART [2]
4146 symptomatic patients; predicted 10-year CHD risk of 17% based on the ASSIGN scorea; 43% on statins
CT angio vs. standard care alone
Certainty of the diagnosis of angina secondary to CHD at 6 weeks. Reclassification 27% vs. 1%; P b 0.0001
OSLER [3]
4465 patients, 20% with known coronary disease; 70% on statins; baseline LDL 120 mg/dl
Evolocumab vs. standard care alone
Incidence of adverse effects: overall similar in both groups but neurocognitive events more frequent in the evolocumab group (0.9% vs. 0.3%)
ODYSSEY [4]
2341 patients; ~100% on statins; baseline Alirocumab vs. LDL 122 mg/dl; placebo 70% with clinical coronary heart disease
PEGASUS [5]
Double-blind 1:1:1 fashion, 21,162 patients who had had a MI 1 to 3 years earlier
Ticagrelor 90 mg twice daily vs. 60 mg twice daily vs. placebo
Primary (efficacy) outcome
Other findings More patients in the CT angio group underwent catheterization within 90 days after randomization (12.2% vs. 8.1%). K–M rate for death or MI was 3.9% vs. 4.1% at 42 months, respectively After 1 · 7 years, CT angio was associated with a 38% reduction in fatal and nonfatal MI (26 pts vs. 42 pts, p = 0 · 0527). K–M rate for death or MI was 1.8% vs. 2.4% at 40
months respectively As compared with standard therapy alone, evolocumab reduced the level of LDL cholesterol by 61% (P b 0.001), and reduced cardiovascular events from 2.18% to 0.95% at 1 year (P = 0.003). Percentage change in LDL level from baseline Post-hoc analysis showed a lower K–M rate to week 24: −61% vs. 0.8%; P b 0.001 of major adverse cardiovascular events (ODYSSEY OUTCOME) with alirocumab at 86 weeks (1.7% vs. 3.3%; P = 0.02) The primary efficacy end point (composite of The primary safety end point (TIMI major cardiovascular death, MI, or stroke): 7.85% bleeding) was 2.6% vs. 2.3% vs. 1.06% vs. 7.77% vs. 9.04% at 3 years (K–M rates) (intracranial or fatal bleed 0.63%, 0.71% and 0.60%) at 3 years (K–M rates)
CHD: Coronary Heart Disease; K–M: Kaplan–Meir; MI: Myocardial infarction. a ASSIGN score is validated Scottish cardiovascular risk score that also incorporates social deprivation and family history of cardiovascular disease (http://assign-score.com).
In contrast to most other medical conditions, cardiovascular disease can and often kills suddenly. This “sudden death” path has led to the growth of bystander CPR training, development of “paramedics”, and widespread use of automatic defibrillators. This is getting people involved before the doctors in the field. STEMI with ongoing myocyte necrosis is diagnosed on a 12-lead ECG which can be done easily provided machine availability. Early STEMI diagnosis and therapy has been advocated for decades but there are less recognized issues as shown in Table 2. Intra-cardiac ST-segment monitoring through an implanted device has been tested for diagnosing STEMI/ischemia [7] using a conventional endocardial pacemaker lead in the right ventricular apex. This device detected endocardial ST shifts, emitting distinct vibratory alarms and providing notification though telemetry with an external device. Over ~1.52 years of follow-up in 37 high-risk patients, 4 patients had significant ST-segment changes. They were hospitalized with the short alarmto-door times of 6, 18, 21, and 60 min, and had genuine acute coronary syndrome with thrombotic coronary occlusion or ruptured plaques. Apart from being invasive, this endocardial ST monitoring deviates from surface ECG recording where infarction was classified (STEMI vs. non-STEMI) and localized (anterior vs. non-anterior).
With surface ECG recent advances in body surface multi-lead recordings using the ECVue vest has allowed non-invasive mapping of cardiac arrhythmia which complements invasive mapping [8]. Single lead ECG recording through a FDA approved system on smart phones is now often used to capture transient arrhythmia. For STEMI, it was thought [9] that multiple leads surface ECG recording with smart phone transmission for centralized analysis might follow allowing earlier STEMI diagnosis and therapy using antiplatelet drugs kept in the first aid box. This has not eventuated. Has the time come to connect the missing link? Smaller portable ECG machines have been available, and skills of ECG recording are easier to acquire than those of CPR. Should every household now keep a machine (so that emergency recorded tracing can be immediately sent to their doctors) and tablets of aspirin and ticagrelor? Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References
Table 2 Less recognized advantages and disadvantages related to timing of STEMI diagnosis and therapy. Early diagnosis and therapy
Late diagnosis and therapy
Some STEMI may be aborted with very early pre-hospital fibrinolysis [9].
Sudden death may precede diagnosis — this has contributed to the development of training for bystander CPR and use of automatic defibrillators. Reperfusion is not only associated with less myocardial salvage but also more reperfusion damage including myocardial hemorrhage [11,12].
Pre-hospital as compared to cath lab administration of 180 mg loading dose of ticagrelor reduced stent thrombosis rate (0% vs. 0.8% in the first 24 h, and 0.2% vs. 1.2% at 30 days) in the 1862 STEMI patients ATLANTIC trial [10]. At least theoretically very early therapy of potent antiplatelet drugs alone may abort some STEMIs [9].
Possibility of treating both culprit and non-culprit vessels in the same setting of primary PCI exists with both pathways and may confer additional benefit [10]. Reperfusion strategy should tailor to the stage of STEMI [12].
[1] P.S. Douglas, U. Hoffmann, M.R. Patel, et al., Outcomes of anatomical versus functional testing for coronary artery disease, N. Engl. J. Med. (2015)http://dx.doi.org/10. 1056/NEJMoa1415516. [2] SCOT-HEART Investigators, CT angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicenter trial, Lancet (2015). http://dx.doi.org/10.1016/S0140-6736(15)60291-4. [3] M.S. Sabatine, R.P. Guigliano, S.D. Wiviott, et al., Efficacy and safety of evolocumab in reducing lipids and cardiovascular events, N. Engl. J. Med. (2015)http://dx.doi.org/ 10.1056/NEJMoa1500858. [4] J.G. Robinson, M. Farnier, M. Krempf, et al., Efficacy and safety of alirocumab in reducing lipids and cardiovascular events, N. Engl. J. Med. (2015)http://dx.doi.org/10.1056/ NEJMoa501031. [5] M.P. Bonaca, D.L. Bhatt, M. Cohen, et al., Long-term use of ticagrelor in patients with prior myocardial infarction, N. Engl. J. Med. (2015). http://dx.doi.org/10.1056/ NEJMoa1500857. [6] S.S. Jolly, J.A. Cairns, S. Yusuf, et al., Randomized trial of primary PCI with or without routine manual thrombectomy, N. Engl. J. Med. (2015). http://dx.doi.org/10.1056/ NEJMoa1415098. [7] T.A. Fischell, D.R. Fischell, A. Avezum, et al., Initial clinical results using intracardiac electrogram monitoring to detect and alert patients during coronary plaque rupture and ischemia, J. Am. Coll. Cardiol. 56 (2010) 1089–1098. [8] D. Erkapic, H. Greiss, D. Pajitnev, S. Zaltsberg, N. Deubner, A. Berkowitsch, S. Möllman, J. Sperzel, A. Rolf, J. Schmitt, C.W. Hamm, M. Kuniss, T. Neumann, Clinical
C.-K. Wong / International Journal of Cardiology 189 (2015) 85–87 impact of a novel three-dimensional electrocardiographic imaging for non-invasive mapping of ventricular arrhythmias-a prospective randomized trial, Europace (Oct 27 2014)http://dx.doi.org/10.1093/europace/euu282 (Epub ahead of print). [9] C.K. Wong, Aborting STEMI: what treatment opportunities may Smart-Phone ECGs give us prior to first medical contact to facilitate primary PCI? Int. J. Cardiol. 168 (2013) 5453–5455. [10] C.K. Wong, From culprit artery reperfusion to non-culprit revascularization: Will ECG play a bigger role in the evolving STEMI care? Int. J. Cardiol. 182 (2015) 124–125.
87
[11] C.K. Wong, C. Bucciarelli-Ducci, Q waves and failed ST resolution: Will intramyocardial haemorrhage be a concern in reperfusing “late presenting” STEMIs? Int. J. Cardiol. 182 (2015) 203–210. [12] C.K. Wong, Intra-myocardial hemorrhage in STEMI reperfusion: an alternative explanation for failures from “augmented” fibrinolysis regime and fibrinolysis facilitated PCI, Int. J. Cardiol. 184 (2015) 766–768, http://dx.doi.org/10.1016/j.ijcard.2015. 03.016.
