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Acute Coronary Syndromes

Virtual_Cardiology@ESC.journals: Issue 2

 To celebrate the ESC's 2016 Acute Cardiovascular Care meeting in Lisbon, this issue of the ESC Virtual Journal highlights some of the must read articles on Acute Coronary Syndromes from across the ESC Journal Family. We have made these free to view in their full text formats, so that you can fully benefit from the science we publish.


Biolimus-A9 polymer-free coated stent in high bleeding risk patients with acute coronary syndrome: a Leaders Free ACS sub-study.
Naber CK, Urban P, Ong PJ, Valdes-Chavarri M, Abizaid AA, Pocock SJ, Fabbiocchi F, Dubois C, Copt S, Greene S, Morice MC; LEADERS FREE Investigators. Eur Heart J. 2016 May 17.

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Effective anti-thrombotic therapy without stenting: intravascular optical coherence tomography-based management in plaque erosion (the EROSION study).
Jia H, Dai J, Hou J, Xing L, Ma L, Liu H, Xu M, Yao Y, Hu S, Yamamoto E, Lee H, Zhang S, Yu B, Jang IK. Eur Heart J. 2016 Aug 30.

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STENTYS Self-Apposing sirolimus-eluting stent in ST-segment elevation myocardial infarction: results from the randomised APPOSITION IV trial.
van Geuns RJ, Yetgin T, La Manna A, Tamburino C, Souteyrand G, Motreff P, Koch KT, Vrolix M, IJsselmuiden A, Amoroso G, Berland J, Montalescot G, Teiger E, Christiansen EH, Spaargaren R, Wijns W. EuroIntervention. 2016 Feb;11(11):e1267-74.

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Long-term clinical outcomes after percutaneous coronary intervention versus coronary artery bypass grafting for acute coronary syndrome from the DELTA registry: a multicentre registry evaluating percutaneous coronary intervention versus coronary artery bypass grafting for left main treatment.
Pyxaras SA, Hunziker L, Chieffo A, Meliga E, Latib A, Park SJ, Onuma Y, Capranzano P, Valgimigli M, Narbute I, Makkar RR, Palacios IF, Kim YH, Buszman PP, Chakravarty T, Sheiban I, Mehran R, Margey R, Agnihotri A, Marra S, Capodanno D, Leon MB, Moses JW, Fajadet J, Lefevre T, Morice MC, Erglis A, Tamburino C, Alfieri O, Serruys PW, Colombo A, Naber CK. EuroIntervention. 2016 Aug 5;12(5):e623-31.

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The benefit of adding ezetimibe to statin therapy in patients with prior coronary artery bypass graft surgery and acute coronary syndrome in the IMPROVE-IT trial.
Eisen A, Cannon CP, Blazing MA, Bohula EA, Park JG, Murphy SA, White JA, Giugliano RP, Braunwald E; IMPROVE-IT (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial) Investigators. Eur Heart J. 2016 Aug 28.

Biodegradable polymer sirolimus-eluting stents versus durable polymer everolimus-eluting stents for primary percutaneous coronary revascularisation of acute myocardial infarction.
Pilgrim T, Piccolo R, Heg D, Roffi M, Tüller D, Vuilliomenet A, Muller O, Cook S, Weilenmann D, Kaiser C, Jamshidi P, Khattab AA, Taniwaki M, Rigamonti F, Nietlispach F, Blöchlinger S, Wenaweser P, Jüni P, Windecker S. EuroIntervention. 2015 Dec 23;11(8).

Effect of a single dose of the interleukin-6 receptor antagonist tocilizumab on inflammation and troponin T release in patients with non-ST-elevation myocardial infarction: a double-blind, randomized, placebo-controlled phase 2 trial.
Kleveland O, Kunszt G, Bratlie M, Ueland T, Broch K, Holte E, Michelsen AE, Bendz B, Amundsen BH, Espevik T, Aakhus S, Damås JK, Aukrust P, Wiseth R, Gullestad L. Eur Heart J. 2016 Aug 7;37(30):2406-13.

Impact of high-sensitivity cardiac troponin on use of coronary angiography, cardiac stress testing, and time to discharge in suspected acute myocardial infarction.
Twerenbold R, Jaeger C, Rubini Gimenez M, Wildi K, Reichlin T, Nestelberger T, Boeddinghaus J, Grimm K, Puelacher C, Moehring B, Pretre G, Schaerli N, Campodarve I, Rentsch K, Steuer S, Osswald S, Mueller C. Eur Heart J. 2016 Jun 29.

Invasive strategies and outcomes for non-ST-segment elevation acute coronary syndromes: a twelve-year experience from SWEDEHEART.
Damman P, Jernberg T, Lindahl B, de Winter RJ, Jeppsson A, Johanson P, Held C, James SK. EuroIntervention. 2015 Nov 18;11(7).

Long-term follow-up after bioresorbable vascular scaffold implantation in STEMI patients: PRAGUE-19 study update.
Toušek P, Kočka V, Malý M, Kozel M, Petr R, Hajsl M, Jarkovský J, Lisa L, Buděšínský T, Widimský P. EuroIntervention. 2016 May 17;12(1):23-9.

Interventional post-myocardial infarction ventricular septal defect closure: a systematic review of current evidence.
Schlotter F, de Waha S, Eitel I, Desch S, Fuernau G, Thiele H. EuroIntervention. 2016 May 17;12(1):94-102.

Outcomes in patients treated with ticagrelor or clopidogrel after acute myocardial infarction: experiences from SWEDEHEART registry.
Sahlén A, Varenhorst C, Lagerqvist B, Renlund H, Omerovic E, Erlinge D, Wallentin L, James SK, Jernberg T. Eur Heart J. 2016 Jul 19.

Morphine delays and attenuates ticagrelor exposure and action in patients with myocardial infarction: the randomized, double-blind, placebo-controlled IMPRESSION trial
Jacek Kubica, Piotr Adamski, Małgorzata Ostrowska, Joanna Sikora, Julia Maria Kubica, Wiktor Dariusz Sroka, Katarzyna Stankowska, Katarzyna Buszko, Eliano Pio Navarese, Bernd Jilma, Jolanta Maria Siller-Matula, Michał Piotr Marszałł, Danuta Rość, Marek Koziński.

The effect of cangrelor and access site on ischaemic and bleeding events: insights from CHAMPION PHOENIX
J. Antonio Gutierrez, Robert A. Harrington, James C. Blankenship, Gregg W. Stone, Ph. Gabriel Steg, C. Michael Gibson, Christian W. Hamm, Matthew J. Price, Philippe Généreux, Jayne Prats, Efthymios N. Deliargyris, Kenneth W. Mahaffey, Harvey D. White, Deepak L. Bhatt on behalf of on Behalf of the CHAMPION PHOENIX Investigators. First published online: 23 September 2015

Temporal trends in the treatment and outcomes of elderly patients with acute coronary syndrome.
Andreas W. Schoenenberger, Dragana Radovanovic, Stephan Windecker, Juan F. Iglesias, Giovanni Pedrazzini, Andreas E. Stuck, Paul Erne on behalf of the AMIS Plus Investigators. First published online: 12 January 2016

Relationship between diabetes, platelet reactivity, and the SYNTAX score to one-year clinical outcome in patients with non-ST-segment elevation acute coronary syndrome undergoing percutaneous coronary intervention.
De Servi S, Crimi G, Calabrò P, Piscione F, Cattaneo M, Maffeo D, Toso A, Bartorelli A, Palmieri C, De Carlo M, Capodanno D, Barozzi C, Tomasi L, Della Riva D, Angiolillo DJ, Palmerini T. EuroIntervention. 2016 Jun 20;12(3):312-8. 

Medically managed patients with non–ST-elevation acute myocardial infarction have heterogeneous outcomes, based on performance of angiography and extent of coronary artery disease.
Laurent Feldman, Philippe G Steg, Myriam Amsallem, Etienne Puymirat, Emmanuel Sorbets, Meyer Elbaz, Bernard Ritz, Arnaud Hueber, Simon Cattan, Christophe Piot, Jean Ferrières, Tabassome Simon, Nicolas Danchin, and on behalf of the FAST-MI investigators. European Heart Journal: Acute Cardiovascular Care, 2048872615626354, first published on January 12, 2016

Excess mortality and guideline-indicated care following non-ST-elevation myocardial infarction. Tatendashe B Dondo, Marlous Hall, Adam D Timmis, Mark S Gilthorpe, Oras A Alabas, Phillip D Batin, John E Deanfield, Harry Hemingway, and Chris P Gale. European Heart Journal: Acute Cardiovascular Care, 2048872616647705, first published on May 3, 2016

Rapid rule out of acute myocardial infarction: novel biomarker-based strategies.
Christian Mueller, Evangelos Giannitsis, Martin Möckel, Kurt Huber, Johannes Mair, Mario Plebani, Kristian Thygesen, Allan S Jaffe, Bertil Lindahl, and the Biomarker Study Group of the ESC Acute Cardiovascular Care Association. European Heart Journal: Acute Cardiovascular Care, 2048872616653229, first published on July 1, 2016

Rule-in of acute myocardial infarction: Focus on troponin
Bertil Lindahl. Original scientific paper 6 Jun 2016

Double or triple antithrombotic combination therapy in patients who need anticoagulation and antiplatelet therapy in parallel.
Rohla M, Weiss TW, Wojta J, Niessner A, Huber K. Eur Heart J Cardiovasc Pharmacother. 2015 Jul;1(3):191-7.

A nationwide registry study to compare bleeding rates in patients with atrial fibrillation being prescribed oral anticoagulants.
Halvorsen S, Ghanima W, Tvete IF, Hoxmark C, Falck P, Solli O, Jonasson C. Eur Heart J Cardiovasc Pharmacother. 2016 Sep 27. pii: pvw031. [Epub ahead of print]

Editor Summaries

1)Acute coronary syndrome (ACS) patients at high bleeding risk, may benefit from stents, that do not require prolonged antiplatelet regimens. The Leaders Free ACS sub-study investigated the efficacy and safety of a combination of 1-month dual anti-platelet therapy (DAPT) with implantation of either a polymer-free Biolimus-A9-coated stent (BA9-DCS) or a bare-metal stent (BMS) in ACS patients at high bleeding risk. At one year follow-up, treatment with the BA9-DCS was more effective and safer driven by significantly lower rates of cardiac mortality (3.4 vs. 6.9%,P = 0.049) and myocardial infarction (6.9 vs. 13.8%, P = 0.005) than the BMS. Given the better safety and efficacy profile of the DCS despite one month DAPT, it seems no longer justified to implant BMS. Back to top

2)Whether acute coronary syndromes (ACS) caused by plaque erosion without flow limiting stenosis should rather be treated by percutaneous coronary intervention (PCI) or conservatively by medical management is uncertain. In the EROSION trial patients diagnosed with plaque erosion by optical coherence tomography (OCT) and residual diameter stenosis <70% on coronary angiogram were treated with anti-thrombotic therapy without stenting. Forty-seven patients (47/60, 78.3%; 95% confidence interval: 65.8–87.9%) met the primary endpoint, which was >50% reduction of thrombus volume at 1 month compared with baseline. This single center, proof of concept study suggests that selected ACS patients with plaque erosion may be managed conservatively. Whether conservative treatment of plaque erosion is preferable to PCI needs to be investigated in randomized trials. Back to top

3)Thrombus burden and altered vaso-reactivity in patients with ST-segment elevation myocardial infarction (STEMI) may hamper size selection and apposition of balloon-expandable stents. The APPOSITION IV trial investigated the apposition and strut coverage of the self-apposing, sirolimus-eluting STENTYS stent compared with a zotarolimus-eluting balloon-expandable stent in STEMI patients. At four months, a lower percentage of malapposed stent struts was observed in the STENTYS group (N=21; Nstruts=501) compared with controls (N=26; Nstruts=326; 0.07% vs. 1.16%; p=0.002) with significantly more covered struts, using a 20 μm cut-off (94.32% vs. 89.09%; p=0.003). However, at nine months this endpoint was no longer different between groups. The study suggests, that despite a better stent strut apposition and coverage at four months in the STENTYS group, this device is equivalent to a conventional balloon-expandable stent with respect to late stent strut apposition and coverage at nine months. Back to top

4)If the culprit lesion of an acute coronary syndrome (ACS) is located in an unprotected left main coronary artery (ULMCA) the optimal revascularization strategy is a matter of debate. In the DELTA all-comer, multinational registry the long-term outcomes of ACS patients with ULMCA treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) was investigated. In 379 ACS patients, PCI in ULMCA was associated with comparable clinical outcomes to those observed with CABG at long-term follow-up. As patients in this study received first-generation drug eluting stents better outcomes with newer-generation stents may be postulated. Back to top