ABSTRACT
At the end of August 2017 the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) published new joint guidelines for the treatment of valvular heart disease. These guidelines incorporate the scientific progress since the last version of the guidelines published in 2012. This article reviews current guideline recommendations for antiplatelet and anticoagulative therapy after surgical/interventional treatment of the aortic and mitral valves and discusses the underlying scientific evidence.
Subject(s)
Anticoagulants/therapeutic use , Aortic Valve/surgery , Heart Valve Diseases/surgery , Heart Valve Prosthesis Implantation , Mitral Valve/surgery , Platelet Aggregation Inhibitors/therapeutic use , Administration, Oral , Anticoagulants/adverse effects , Dose-Response Relationship, Drug , Follow-Up Studies , Guidelines as Topic , Hemorrhage/chemically induced , Humans , Platelet Aggregation Inhibitors/adverse effects , Randomized Controlled Trials as Topic , Risk Factors , Thromboembolism/prevention & controlABSTRACT
Recent advances in percutaneous coronary intervention and antiplatelet therapy as well as faster door-to-balloon times have markedly improved the therapy of patients with acute myocardial infarction. However, impaired myocardial perfusion despite revascularization of the infarcted vessel remains an ongoing problem with high prognostic relevance. In initial clinical trials thrombus aspiration in addition to conventional percutaneous coronary intervention demonstrated benefits regarding coronary flow and myocardial perfusion and was therefore recommended in practice guidelines. These improvements in surrogate endpoints did not translate into a favorable clinical outcome in recent large-scale multicenter randomized trials investigating the routine use of thrombus aspiration in patients with acute myocardial infarction. Furthermore, an increased risk of stroke after thrombus aspiration raises safety concerns. Therefore, thrombus aspiration has been downgraded in the recent guideline updates. The current article reviews the evidence from clinical trials and the recommendations in practice guidelines regarding thrombus aspiration in acute myocardial infarction.
Subject(s)
Myocardial Infarction/mortality , Myocardial Infarction/therapy , Percutaneous Coronary Intervention/mortality , Thrombectomy/mortality , Thrombosis/mortality , Thrombosis/surgery , Combined Modality Therapy/mortality , Combined Modality Therapy/standards , Comorbidity , Evidence-Based Medicine , Humans , Myocardial Infarction/diagnosis , Percutaneous Coronary Intervention/standards , Practice Guidelines as Topic , Prevalence , Risk Factors , Suction/mortality , Suction/standards , Survival Rate , Thrombectomy/standards , Treatment OutcomeABSTRACT
While the mortality rate of acute myocardial infarction has decreased drastically in the last decades, the outcome of patients with cardiogenic shock complicating acute myocardial infarction is still devastating. The effectiveness of supportive medicinal therapy of cardiogenic shock is often limited by undesired side effects (e.g. arrhythmia and increased myocardial oxygen consumption) or inadequate hemodynamic support. Mechanical circulatory support in cardiogenic shock failed to show beneficial effects on short-term and long-term survival; however, there are hints for a survival benefit in therapy refractory cardiogenic shock. Therefore, future trials need to evaluate further medicinal treatment options and also the best type of mechanical support as well as the optimal time of initiation to improve the success of therapeutic management.
Subject(s)
Cardiotonic Agents/administration & dosage , Extracorporeal Circulation/methods , Myocardial Infarction/diagnosis , Myocardial Infarction/therapy , Shock, Cardiogenic/diagnosis , Shock, Cardiogenic/therapy , Combined Modality Therapy/methods , Evidence-Based Medicine , Humans , Treatment OutcomeABSTRACT
BACKGROUND: Growth differentiation factor-15 (GDF-15), a stress responsive cytokine, has emerged as a marker of adverse outcome in various cardiovascular diseases. Since GDF-15 has not been evaluated in patients with Takotsubo cardiomyopathy (TTC), the present study sought to investigate the diagnostic and prognostic value in this patient cohort. METHODS: A total of 22 patients presenting with TTC were matched for age and gender with 22 ST-segment elevation myocardial infarction (STEMI) patients. GDF-15 concentrations were measured at admission and 1 day thereafter. The primary clinical endpoint of the TTC cohort was the composite of death, cardiogenic shock, or new congestive heart failure within 6 months. RESULTS: TTC patients showed significantly higher GDF-15 values on admission compared to patients presenting with STEMI (median 3047 ng/l [interquartile range 2256-7572] versus median 1527 ng/l [interquartile range 1152-2677]; p=0.002). TTC patients with a biventricular ballooning pattern and patients experiencing major adverse cardiac events during the first 6 months after acute presentation showed significantly higher GDF-15 concentrations on admission (p=0.008 and p=0.005, respectively). Biventricular ballooning was identified as a predictor for elevated GDF-15 values on admission (p=0.03). High GDF-15 levels on admission were the only significant predictor for the combined clinical endpoint in multivariable regression analysis (p=0.02). CONCLUSION: TTC patients showed markedly high, but transient elevation of GDF-15 levels. Biventricular ballooning was associated with particularly high GDF-15 concentrations. Elevated GDF-15 values on admission were a strong predictor of adverse clinical outcome.
Subject(s)
Growth Differentiation Factor 15/blood , Takotsubo Cardiomyopathy/blood , Takotsubo Cardiomyopathy/diagnosis , Aged , Aged, 80 and over , Biomarkers/blood , Cohort Studies , Female , Humans , Male , Prognosis , Prospective Studies , Risk FactorsABSTRACT
ST-elevation myocardial infarction (STEMI) is a major cause of morbidity and mortality worldwide. Emergent reperfusion of the infarct related artery is the cornerstone of STEMI treatment in order to salvage myocardium and improve cardiovascular outcome. Basically, reperfusion strategies include fibrinolysis, primary percutaneous coronary intervention (PCI) or the combination of both methods. Clinical studies indicate that primary PCI is superior to fibrinolytic therapy when performed rapidly at experienced centers. However, physicians are often faced with the decision to either accept PCI-related delays due to transfer or to administer fibrinolysis immediately. A well structured regional system of STEMI care helps to select the appropriate reperfusion strategy and guarantee timely restoration of coronary blood flow. This article reviews the evidence behind the respective reperfusion therapies and summarizes current guidelines for STEMI management.
Subject(s)
Myocardial Infarction/therapy , Myocardial Reperfusion/methods , Thrombolytic Therapy/methods , Angioplasty, Balloon, Coronary/methods , Anticoagulants/therapeutic use , Clinical Trials as Topic , Combined Modality Therapy/methods , Fibrinolytic Agents/adverse effects , Fibrinolytic Agents/therapeutic use , Humans , Myocardial Infarction/diagnosis , Myocardial Revascularization/methods , Platelet Aggregation Inhibitors/therapeutic use , Practice Guidelines as Topic , Stents , Thrombolytic Therapy/adverse effects , Treatment OutcomeABSTRACT
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.
