Preventive stenting in acute myocardial infarction.

Current practice guidelines advocate culprit vessel intervention alone in patients with ST-segment elevation myocardial infarction (STEMI) found to have multivessel coronary disease during primary percutaneous coronary intervention (PCI). The debate on the timing of noninfarct artery intervention has recently been reinvigorated by the PRAMI (Preventive Angioplasty in Acute Myocardial Infarction) trial, in which patients undergoing preventive PCI of significant nonculprit lesions at the time primary PCI for STEMI had reduced rates of cardiac death, nonfatal myocardial infarction, and refractory angina. Given that previous literature has cautioned against multivessel PCI during STEMI, this raises the question of whether technical and pharmacological advances in PCI may have opened the door to safely revisit this issue with additional clinical rigor. The impact of STEMI pathophysiology on nonculprit vessel plaque, how treatment of nonculprit lesions alters the natural history of coronary disease after STEMI, and whether this results in a clinical benefit remain unclear, and much of the existing data are retrospective. Additionally, the PRAMI trial did not include a staged PCI, leaving questions as to how this approach might fare compared with simultaneous preventive PCI. In this review, we discuss the pathophysiology of nonculprit vessel plaque in STEMI, provide a summary of the existing literature on the topic, and discuss the PRAMI trial in the face of previous data and possible future directions for further study.

Controversies regarding the new oral anticoagulants for stroke prevention in patients with atrial fibrillation.

Increasing use of the new oral anticoagulants (NOACs) - dabigatran, rivaroxaban, and apixaban - has prompted considerable discussion in the medical community even as warfarin remains the mainstay of therapy. This article raises 10 controversial issues regarding the use of NOACs for stroke prevention in patients with atrial fibrillation, and offers a review of the latest available evidence. We provide a brief overview of the mechanism and dosing of these drugs, as well as a summary of the key clinical trials that have brought them into the spotlight. Comparative considerations relative to warfarin such as NOAC safety, efficacy, bleeding risk, reversibility, drug-transitioning and use in patients well controlled on warfarin are addressed. Use in select populations such as the elderly, those with coronary disease, renal impairment, or on multiple anti-platelet drugs is also discussed. Finally, we consider such specific issues as comparative efficacy, off-label use, cost, rebound and management during events. Ultimately, the rise of the NOACs to mainstream use will depend on further data and clinical experience amongst the medical community.