Current cardiology reports
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Recent advances in low-density lipoprotein cholesterol (LDL-C) lowering therapy have now enabled reducing LDL-C safely to very low levels. This review summarizes evidence from recent randomized clinical trials of intensive LDL-C lowering in patients with acute coronary syndrome (ACS) and provides a practical approach for LDL-C lowering to reduce the risk of recurrent ischemic events in this population. ⋯ The risk of atherothrombotic events falls linearly with LDL-C level extending to very low achieved LDL-C levels (< 10 mg/dL) without apparent safety concerns. The addition of ezetimibe or proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (i.e., evolocumab or alirocumab) to statin therapy lowers LDL-C to very low levels (≤ 30-50 mg/dL) with safety under the conditions studied and reduces the risk of recurrent cardiovascular events in patients with atherosclerotic cardiovascular disease. Current data support LDL-C lowering to levels below 70 mg/dL in patients post-ACS. Combination of high-intensity statins, ezetimibe, and if needed PCSK9 inhibitors merits consideration in such patients with ACS to optimize outcomes.
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Review Comparative Study
Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis.
This article reviews the latest data on unprotected left main (ULM) percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery, with a focus on the NOBLE and EXCEL trials. ⋯ In EXCEL trial, the primary endpoint at 3 years was 15.4% in the PCI group and 14.7% in the CABG group (p = 0.02 for non-inferiority of PCI versus CABG). In NOBLE, the primary endpoint at 5 years was 28% and 18% for PCI and CABG, respectively (HR 1.51, CI 1.13-2.0, which did not meet the criteria for non-inferiority of PCI to CABG; p for superiority of CABG was 0.0044). Higher repeat revascularization and non-procedural myocardial infarction were noted in PCI group but there was no difference in all-cause or cardiac mortality between the two groups. A heart team approach with appropriate patient selection, careful assessment of LM lesions, and meticulous procedural technique makes PCI a valid alternative to CABG for ULM stenosis.
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This review aims to discuss the use of fluorodeoxyglucose (FDG) positron emission tomography (PET/CT) for diagnosis and management of patients with large-vessel vasculitis (LVV). ⋯ Incidence of LVV is likely underestimated, in part due to its non-specific symptoms. Nevertheless, early diagnosis of LVV is essential to initiate timely therapy in order to prevent vascular complications, such as stenoses and aneurysms. FDG PET/CT imaging has the ability to detect LVV during the acute phase, prior to edema and other vascular structural changes, with its high sensitivity for inflammatory activity. FDG PET/CT was shown to be a powerful prognostic marker by allowing identification of patients at risk of vascular complications. Additionally, preliminary data support the use of FDG PET/CT to follow therapy efficacy. FDG PET/CT allows early detection of inflammation, before morphological and irreversible vascular changes can be observed, allowing prompt diagnosis and treatment of LVV.
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We provide a concise update on the contemporary management of cardiogenic shock in the setting of acute coronary syndrome (ACS). Early shock recognition, optimal selection and initiation of mechanical circulatory support (MCS), early coronary revascularization, and a team-based, protocol-driven approach are the current pillars of management. ⋯ Cardiogenic shock complicates approximately 5-10% of ACS cases and continues to have high mortality. Early use of mechanical circulatory may prevent the downward spiral of shock and has significantly increased over time, supported mainly by registry data. In the CULPRIT-SHOCK trial, culprit-only revascularization was associated with a lower 30-day incidence of all-cause death or severe renal failure, compared with immediate multivessel PCI. Routine revascularization of non-infarct related artery lesion(s) during primary PCI for cardiogenic shock is, therefore, not recommended. The routine use of an intra-aortic balloon pump (IABP) was not associated with improved outcomes in the IABP-SHOCK II trial. A team-based and protocol-driven approach may further improve outcomes. Recent advances in coronary revascularization and use of MCS, implementation of shock teams and standardized protocols may improve outcomes of cardiogenic shock in ACS patients.
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The treatment of patients requiring anticoagulation who develop acute coronary syndrome (ACS) and/or require percutaneous coronary intervention (PCI) must balance the reduction in major adverse cardiovascular events, stroke, and major bleeding. The development of direct oral anticoagulants (DOACs) for the treatment of atrial fibrillation has ushered in an era of potential treatment options for these complex patients. PURPOSE OF REVIEW: To review the clinical evidence underlying the use of DOACs for the treatment of patients with atrial fibrillation and ACS or PCI. ⋯ Recent evidence shows that DOACs plus one antiplatelet agent can decrease bleeding in patients with atrial fibrillation undergoing PCI for ACS. Although not powered to detect non-inferiority or superiority, large studies suggest rivaroxaban 10-15 mg plus P2Y12 inhibitor for 12 months or dabigatran 150 mg twice daily plus P2y12 inhibitor for 12 months will have similar rates of MACE and stent thrombosis as triple therapy. In patients who have contraindications to DOACs, the strategy of INR-adjusted warfarin plus clopidogrel appears to be safer than warfarin plus dual antiplatelet therapy.