[Differentiated antiplatelet therapy for acute coronary syndromes]. / Differenzierte antithrombozytäre Therapie bei akutem Koronarsyndrom.

Dual antiplatelet therapy is the cornerstone of maintenance medication following invasive treatment of patients with acute coronary syndromes (ST elevation myocardial infarction, non-ST elevation myocardial infarction, unstable angina). Over the last decade, P2Y12 inhibition in addition to low-dose acetylsalicylic acid has been intensively debated. The debate was enriched by the results of the large phase III clinical trials for prasugrel (TRITON) and ticagrelor (PLATO) compared to clopidogrel in patients with acute coronary syndromes. This article summarizes the critical details und subanalyses of both study programmes and highlights on clinical decision making when using the three P2Y12 blockers in acute coronary syndromes. A special focus is on higher risk patients such as those with ST elevation myocardial infarction and those with coexisting diabetes, but also on minimizing relevant bleedings, which are common during more intense platelet inhibition.

Is percutaneous coronary intervention as effective as bypass surgery in left main stem coronary artery stenosis?

Recent advances in percutaneous coronary intervention (PCI) have rekindled interest in this treatment modality also in the setting of unprotected left main stenosis. Randomized trials reported a similar risk of death or myocardial infarction between PCI and coronary artery bypass grafting (CABG). However, rates of stroke were higher after CABG, whereas patients undergoing PCI had a higher risk of repeat revascularization. Although CABG remains the standard of care for left main stenosis in current guideline recommendations, PCI is considered a reasonable alternative in patients with low to intermediate anatomical complexity and at increased surgical risk. An interdisciplinary assessment is indispensable in order to choose the best treatment option for each individual patient.

Bypass surgery versus percutaneous coronary intervention for the treatment of unprotected left main disease. A meta-analysis of randomized controlled trials.

OBJECTIVE: We performed a meta-analysis of randomized controlled trials to compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for the treatment of de novo unprotected left main disease. BACKGROUND: Although CABG is accepted to be standard of care for revascularization of unprotected left main stenosis, PCI is increasingly being used as an alternative primary approach. METHODS: We searched for randomized, controlled trials comparing CABG and PCI for the treatment of unprotected left main disease. Major adverse cardiac and cerebrovascular events (all-cause death, myocardial infarction, stroke, and repeat revascularization) were analyzed. RESULTS: The search strategy identified 4 randomized controlled trials enrolling a total of 1,611 patients. Follow-up ranged between 1 and 2 years. There were no significant differences in the risk of death or myocardial infarction between the two treatment modalities. While the risk of stroke was significantly lower in patients undergoing PCI (risk ratio (RR) 0.26, 95% confidence interval (CI) 0.10-0.69, p = 0.007), the risk of repeat revascularization was higher among patients undergoing PCI (RR 1.94, 95% CI 1.43-2.61, p < 0.001). No relevant statistical heterogeneity across studies could be found. CONCLUSION: In this largest series of randomized patients with unprotected left main stenosis to date, the risk of death and myocardial infarction was comparable between CABG and PCI. However, patients undergoing CABG had a higher risk of stroke, whereas patients undergoing PCI were at a higher risk for repeat revascularization.

[Left main intervention: options and limitations in interventional cardiology]. / Hauptstamminterventionen : Möglichkeiten und Grenzen der interventionellen Kardiologie.

Revascularisation is indicated in patients with left main stenosis (LMS) because of its known positive effect on long-term survival. Coronary artery bypass graft (CABG) surgery has been the traditional procedure of choice for LMS patients, with percutaneous coronary intervention (PCI) being reserved for high-risk surgical patients or for those who have one or more functioning distal bypass grafts (i.e. "protected" left main PCI). Recent studies have re-examined the role of PCI in LMS, however, leading to a recent Class II recommendation for its use in selected patients. The SYNTAX Trial demonstrated that PCI can be performed with good results in the following patient subgroups: patients with isolated LMS, particularly if confined to the ostium; patients with concomitant LMS and isolated single vessel disease; patients with a SYNTAX score of <33; and patients who are at high risk for conventional CABG surgery. Patients with complex coronary anatomy (SYNTAX score >33) or those with concomitant double- or triple-vessel disease are more suited to CABG surgery. Patients who undergo PCI for LMS should be treated in specialized centers with surgical back-up, preferably with patient management decisions being made by a "heart team" consisting of at least one cardiologist and one cardiac surgeon. Ongoing studies are being performed using the hard clinical endpoints of death, myocardial infarction, and stroke in order to further compare the results of PCI vs CABG in LMS patients.

Reversal of cardiogenic shock by percutaneous left atrial-to-femoral arterial bypass assistance.

BACKGROUND: Recovery of myocardial function after revascularization of acutely occluded coronary arteries may require several days. During this critical time, patients in cardiogenic shock may have low output. A newly developed percutaneous left ventricular assist device (VAD) may offer effective treatment for these patients by providing active circulatory support. METHODS AND RESULTS: Between May 2000 and May 2001, VADs were implanted in 18 consecutive patients who had cardiogenic shock after myocardial infarction. The device was connected to the patient's circulation by insertion of a 21F venous cannula into the left atrium by transseptal puncture; blood was returned to the iliac artery through an arterial cannula. Mean duration of cardiac assistance was 4+/-3 days. Mean flow of the VAD was 3.2+/-0.6 L/min. Before support, cardiac index was 1.7+/-0.3 L/min per m(2) and improved to 2.4+/-0.6 L/min per m(2) (P<0.001). Mean blood pressure increased from 63+/-8 mm Hg to 80+/-9 mm Hg (P<0.001). Pulmonary capillary wedge pressure, central venous pressure, and pulmonary artery pressure were reduced from 21+/-4, 13+/-4, and 31+/-8 mm Hg to 14+/-4, 9+/-3, and 23+/-6 mm Hg (all P<0.001), respectively. Overall 30-day mortality rate was 44%. CONCLUSIONS: A newly developed VAD can be rapidly deployed in the catheterization laboratory setting. This device provides up to 4.0 L/min of assisted cardiac output, which may aid to revert cardiogenic shock. The left ventricle is unloaded by diverting blood from the left atrium to the systemic circulation, making recovery more likely after an ischemic event. The influence of this device on long-term prognosis warrants further investigation.