Drug-eluting versus bare metal stenting in acute myocardial infarction. A clinical review.

Coronary heart disease is a leading cause of death around the world. The treatment of acute myocardial infarction has evolved with the advent of novel thrombolytic agents, anticoagulants, antiplatelets, and innovative percutaneous techniques. The development of drug-eluting stents has dramatically lowered the risk of in-stent restenosis compared to bare metal stents. Clinicians in the United States and Europe have begun utilizing DES in the setting of AMI despite the fact that no practice guidelines exist to support their use. Lingering concerns exist about the reported increased risk of early and late stent thrombosis after DES implantation. In this review, we will highlight the >7,500 patients studied in randomized controlled trials and >30,000 registry patients comparing drug-eluting and bare metal stent implantation during acute myocardial infarction. In the selected patient populations of the 13 randomized controlled trials comparing drug-eluting and bare metal stent implantation, death/re-infarction/stent thrombosis were not different between groups while target vessel revascularization was significantly lower in the drug-eluting stent patients. In the "real world" registry studies, mortality/target vessel revascularization/stent thrombosis were less frequent in the first year after drug-eluting stent implantation while re-infarction was not different between the groups. While multiple questions remain regarding long-term follow up and especially late stent thrombosis, it appears that drug-eluting stents are effective at decreasing target vessel revascularization while not being associated with an elevated risk of death/re-infarction/stent thrombosis in the first year post myocardial infarction.

Therapeutic range of digoxin's efficacy in heart failure: what is the evidence?

Clinical studies have solidified the utility of digoxin in patients with left ventricular dysfunction and normal sinus rhythm. No definitive data have been published to clarify the range of serum digoxin concentrations associated with clinical benefit. The traditional therapeutic range of 0.8-2.0 ng/ml was developed originally to classify digoxin toxicity, not efficacy. In addition, this reference range was used before publication of the Digitalis Investigators Group trial. Clinical and neurohormonal studies have attempted to characterize serum concentrations that are associated with clinical efficacy.