ISCHAEMIC HEART DISEASE

There is no need to “cool-off” the ACS before intervention ▸ Once the benefits of percutaneous coronary intervention (PCI) in acute coronary syndromes had been accepted, the next decision was on whether to do it very early, or after a cooling-off period of 2–3 days. This period would allow some settling of inflammatory and thrombotic tendency with appropriate medical treatment, making PCI safer. Not so it seems. Patients were randomly allocated to antithrombotic pretreatment for 3–5 days or to early intervention after pretreatment for less than six hours. In both groups, antithrombotic pretreatment consisted of intravenous unfractionated heparin, aspirin, clopidogrel (600 mg loading dose followed by 75 mg twice daily dose), and intravenous tirofiban. The primary end point was reached in 11.6% (three deaths, 21 infarctions) of the group receiving prolonged antithrombotic pretreatment and in 5.9% (no deaths, 12 infarctions) of the group receiving early intervention (relative risk (RR) 1.96, 95% confidence interval (CI) 1.01 to 3.82; p  =  0.04). This outcome was attributable to events occurring before catheterisation; after catheterisation, both groups incurred 11 events each (p  =  0.92).

Cypher stents reduce restenosis rates to 5.9% even in small arteries ▸ Small arteries restenose aggressively after stenting. Drug eluting stents offer a possible solution. The mean diameter of treated coronary arteries was 2.55 mm and mean lesion length was 15.0 mm. Multiple stents were implanted in 170 (48%) patients. At eight months, minimum lumen diameter was significantly higher with sirolimus eluting stents than with control stents (2.22 mm v 1.33 mm, p < 0.0001). The rate of binary restenosis was significantly reduced with sirolimus eluting stents compared with control stents (5.9% v 42.3%, p  =  0.0001). These stents were implanted in a “real world” fashion, with no routine predilatation or intravascular ultrasound, making the data all the more startling. …