Journal of the American College of Cardiology 2015

Treatment


1. J Am Coll Cardiol. 2015 Jul 7;66(1):62-73. doi: 10.1016/j.jacc.2015.05.009.

Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in
the Resuscitated Comatose Patient.

Rab T(1), Kern KB(2), Tamis-Holland JE(3), Henry TD(4), McDaniel M(5), Dickert
NW(6), Cigarroa JE(7), Keadey M(8), Ramee S(9); Interventional Council, American
College of Cardiology.

Author information: 
(1)Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
Electronic address: srab@emory.edu. (2)Sarver Heart Center, University of
Arizona, Tucson, Arizona. (3)Icahn School of Medicine, Mount Sinai Saint Luke's
Hospital, New York, New York. (4)Division of Cardiology, Department of Medicine, 
Cedars-Sinai Heart Institute, Los Angeles, California. (5)Division of Cardiology,
Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia.
(6)Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
(7)Knight Cardiovascular Institute, Oregon Health and Sciences University,
Portland, Oregon. (8)Division of Emergency Medicine, Emory University Hospital,
Emory University School of Medicine, Atlanta, Georgia. (9)Structural and Valvular
Heart Disease Program, Ochsner Medical Center, New Orleans, Louisiana.

Patients who are comatose after cardiac arrest continue to be a challenge, with
high mortality. Although there is an American College of Cardiology
Foundation/American Heart Association Class I recommendation for performing
immediate angiography and percutaneous coronary intervention (when indicated) in
patients with ST-segment elevation myocardial infarction, no guidelines exist for
patients without ST-segment elevation. Early introduction of mild therapeutic
hypothermia is an established treatment goal. However, there are no established
guidelines for risk stratification of patients for cardiac catheterization and
possible percutaneous coronary intervention, particularly in patients who have
unfavorable clinical features in whom procedures may be futile and affect public
reporting of mortality. An algorithm is presented to improve the risk
stratification of these severely ill patients with an emphasis on consultation
and evaluation of patients prior to activation of the cardiac catheterization
laboratory.

Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier
Inc. All rights reserved.

PMID: 26139060  [PubMed - indexed for MEDLINE]


2. J Am Coll Cardiol. 2015 Jan 6;65(1):27-38. doi: 10.1016/j.jacc.2014.10.029.

Bivalirudin versus heparin with or without glycoprotein IIb/IIIa inhibitors in
patients with STEMI undergoing primary percutaneous coronary intervention: pooled
patient-level analysis from the HORIZONS-AMI and EUROMAX trials.

Stone GW(1), Mehran R(2), Goldstein P(3), Witzenbichler B(4), Van't Hof A(5),
Guagliumi G(6), Hamm CW(7), Généreux P(8), Clemmensen P(9), Pocock SJ(10), Gersh
BJ(11), Bernstein D(12), Deliargyris EN(12), Steg PG(13).

Author information: 
(1)Columbia University Medical Center/New York-Presbyterian Hospital and the
Cardiovascular Research Foundation, New York, New York. Electronic address:
gs2184@columbia.edu. (2)Mount Sinai Medical Center and the Cardiovascular
Research Foundation, New York, New York. (3)Lille University Hospital, Lille,
France. (4)Helios Amperkliniken AG, Munich, Germany. (5)Isala Klinieken, Zwolle, 
the Netherlands. (6)Ospedale Papa Giovanni XXIII, Bergamo, Italy. (7)Kerckhoff
Clinic and Thoraxcenter, Bad Nauheim, Germany. (8)Hôpital du Sacré-Coeur de
Montréal, Université de Montréal, Montréal, Quebec, Canada; Cardiovascular
Research Foundation, New York, New York. (9)Rigshospitalet, Copenhagen, Denmark. 
(10)London School of Hygiene and Tropical Medicine, London, United Kingdom.
(11)Mayo Clinic College of Medicine, Rochester, Minnesota. (12)The Medicines
Company, Parsippany, New Jersey. (13)DHU FIRE, Université Paris-Diderot, Sorbonne
Paris Cité, Paris, France; Hôpital Bichat, Assistance Publique-Hôpitaux de Paris,
Paris, France; NHLI, Imperial College, Royal Brompton Hospital, London, United
Kingdom.

Comment in
    J Am Coll Cardiol. 2015 Jan 6;65(1):39-42.

BACKGROUND: In the HORIZONS-AMI (Harmonizing Outcomes with RevasculariZatiON and
Stents in Acute Myocardial Infarction) trial, 3,602 patients undergoing primary
percutaneous coronary intervention (PCI) for ST-segment elevation myocardial
infarction (STEMI) treated with bivalirudin had lower bleeding and mortality
rates, but higher acute stent thrombosis rates compared with heparin + a
glycoprotein IIb/IIIa inhibitor (GPI). Subsequent changes in primary PCI,
including the use of potent P2Y12 inhibitors, frequent radial intervention, and
pre-hospital medication administration, were incorporated into the EUROMAX
(European Ambulance Acute Coronary Syndrome Angiography) trial, which assigned
2,218 patients to bivalirudin versus heparin ± GPI before primary PCI.
OBJECTIVES: The goal of this study was to examine the outcomes of procedural
anticoagulation with bivalirudin versus heparin ± GPI for primary PCI, given the
evolution in primary PCI.
METHODS: Databases from HORIZONS-AMI and EUROMAX were pooled for patient-level
analysis. The Breslow-Day test evaluated heterogeneity between trials.
RESULTS: A total of 5,800 patients were randomized to bivalirudin (n = 2,889) or
heparin ± GPI (n = 2,911). The radial approach was used in 21.3% of patients,
prasugrel/ticagrelor was used in 18.1% of patients, and GPI was used in 84.8% of
the control group. Bivalirudin compared with heparin ± GPI resulted in reduced
30-day rates of major bleeding (4.2% vs. 7.8%; relative risk [RR]: 0.53; 95%
confidence interval [CI]: 0.43 to 0.66; p < 0.0001), thrombocytopenia (1.4% vs.
2.9%, RR: 0.48; 95% CI: 0.33 to 0.71; p = 0.0002), and cardiac mortality (2.0%
vs. 2.9%; RR: 0.70; 95% CI: 0.50 to 0.97; p = 0.03), with nonsignificantly
different rates of reinfarction, ischemia-driven revascularization, stroke, and
all-cause mortality. Bivalirudin resulted in increased acute (<24 h) stent
thrombosis rates (1.2% vs. 0.2%; RR: 6.04; 95% CI: 2.55 to 14.31; p < 0.0001),
with nonsignificantly different rates of subacute stent thrombosis. Composite net
adverse clinical events were lower with bivalirudin (8.8% vs. 11.9%; RR: 0.74;
95% CI: 0.63 to 0.86; p < 0.0001). There was no significant heterogeneity between
the 2 trials for these outcomes, and results were consistent across major
subgroups.
CONCLUSIONS: Despite increased acute stent thrombosis, primary PCI with
bivalirudin improved 30-day net clinical outcomes, with significant reductions in
major bleeding, thrombocytopenia, and transfusions compared with heparin ± GPI,
results that were consistent with evolution in PCI technique and pharmacotherapy.
(Harmonizing Outcomes with RevasculariZatiON and Stents in Acute Myocardial
Infarction [HORIZONS-AMI]; NCT00433966) (European Ambulance Acute Coronary
Syndrome Angiography [EUROMAX]; NCT01087723).

Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier
Inc. All rights reserved.

PMID: 25572507  [PubMed - indexed for MEDLINE]


3. J Am Coll Cardiol. 2014 Dec 2;64(21):e1-76. doi: 10.1016/j.jacc.2014.03.022. Epub
2014 Mar 28.

2014 AHA/ACC/HRS guideline for the management of patients with atrial
fibrillation: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines and the Heart Rhythm Society.

January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, Conti
JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou
PJ, Tracy CM, Yancy CW; American College of Cardiology/American Heart Association
Task Force on Practice Guidelines.

Erratum in
    J Am Coll Cardiol. 2014 Dec 2;64(21):2305-7.

PMID: 24685669  [PubMed - indexed for MEDLINE]

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