The Journal of invasive cardiology
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This paper provides a comprehensive up-to-date review of the medical and invasive management of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), and ST-elevation myocardial infarction (STEMI), as supported by recent updates to the ACC/AHA Guidelines. The authors have summarized findings from key clinical trials published in recent years that contribute to clinician's understanding of how best to optimize therapy. The goals for the management of NSTE-ACS and STEMI are rapid and accurate risk stratification, appropriate and institution-specific triage to interventional versus medical strategies and optimal pharmacologic therapy - all of which provide for a smooth and seamless transition of care between the emergency department and the cardiology service. ⋯ Dosing recommendations for enoxaparin use in the setting of PCI have been issued by the CATH Panel and have been summarized in this consensus report. Similar recommendations have been presented for the use of oral antiplatelet agents and GP IIb/IIIa antagonists. The addition of statins, angiotensin-converting enzyme (ACE) inhibitors and beta-blockers is also stressed as part of a comprehensive secondary cardioprotective strategy for patients with coronary heart disease.
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Review Case Reports
Mitral annuloplasty causing left circumflex injury and infarction: novel use of intravascular ultrasound to diagnose suture injury.
Suture injury of the left circumflex coronary artery and infarction may be an under-recognized complication of mitral valve annuloplasty. Our cases illustrate a potential role for early coronary angiography in patients who have persistent hemodynamic instability or ventricular irritability, which may be related to left circumflex artery injury. This potentially devastating complication of mitral annuloplasty can be diagnosed by use of intravascular ultrasound to distinguish suture injury from an atherosclerotic lesion.
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Review Case Reports
Percutaneous balloon pericardiotomy for the treatment of infected pericardial effusion with tamponade.
Percutaneous balloon pericardiotomy has been used as an alternative for surgically created pericardial window mainly for the management of malignant pericardial effusions in critically ill patients. We describe a patient with purulent pericardial effusion and cardiac tamponade who was treated successfully and without complications with percutaneous balloon pericardiotomy.
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Review Case Reports
Very late bare-metal stent thrombosis. A case report and review of the literature.
Stent thrombosis is a catastrophic event characterized by the acute thrombotic occlusion of a previously-stented segment of a coronary artery. It usually presents as an ST-segment elevation myocardial infarction and/or death, and most commonly occurs within the first several weeks after stent placement. ⋯ While very late stent thrombosis (VLST), occurring beyond 1 year, is not uncommon with the use of drug-eluting stents, it is distinctly unusual with the use of bare-metal stents. We report a case of very late thrombosis of a bare-metal stent occurring 717 days after implantation.
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Primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) achieves brisk coronary flow in > 90% of patients, but myocardial reperfusion (reperfusion at the tissue level) is often suboptimal, as evidenced by persistent ST-segment elevation and abnormal myocardial blush. Patients with suboptimal myocardial reperfusion have limited myocardial salvage and increased mortality. Distal micro-embolization may contribute to poor myocardial reperfusion, and this has stimulated great interest in the use of adjunctive thrombectomy with primary PCI in an attempt to prevent distal micro-embolization and improve outcomes. ⋯ The results of these trials have been conflicting and the totality of evidence does not support the routine use of thrombectomy for removal of thrombus in patients with STEMI treated with primary PCI. In patients with large thrombus burden, distal macroembolization is common and is associated with poor outcomes. Adjunctive thrombectomy can effectively remove thrombus, and it seems appropriate to perform adjunctive thrombectomy prior to primary PCI in patients with large thrombus burden.