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A guide to therapeutic decision-making in patients with non–ST-segment elevation acute coronary syndromes

^* Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

View larger version (88K): [in a new window]   Figure 1 Schematic depiction in sagittal view of inflammation and embolization.

View larger version (17K): [in a new window]   Figure 2 The survival distribution function curves represent the unadjusted fraction of survivors as a function of remaining hospitalized patients at the given time (patients at risk). ECG = electrocardiogram. With permission from Welch RD, et al. JAMA 2001;286:1977–84, ©2002, American Medical Association.

View larger version (12K): [in a new window]   Figure 3 Risk of mortality in acute coronary syndrome studies. I/T = troponin I/troponin T; OR = odds ratio. Adapted from data contained in Heidenreich PA, et al. J Am Coll Cardiol 2001;38:478–85.

View larger version (32K): [in a new window]   Figure 4 (A) Comparison of glycoprotein IIb/IIIa receptor inhibition trials in patients testing troponin-positive demonstrates marked homogeneity. p < 0.001 Breslow-Day homogeneity. (B) Clinical outcomes at 14 days for patients treated with enoxaparin versus unfractionated heparin (UFH) stratified by 0 to 24 h cardiac troponin I (cTnl) results. CI = confidence interval; CKMB Neg. Pts = creatine kinase-myocardial band-negative patients; D/MI/UR = death, MI, or urgent revascularization; GUSTO = Global Use of Strategies To Open occluded arteries in acute coronary syndromes trial; IIb/IIIa = glycoprotein IIb/IIIa receptor inhibitor; PARAGON = Platelet IIb/IIIa Antagonism for the Reduction of Acute coronary syndrome Global Organization trial; PRISM = Platelet Receptor Inhibition for Ischemic Syndrome Management trial; RR = relative risk of the outcome for patients treated with enoxaparin versus unfractionated heparin. Reprinted with permission from the American College of Cardiology (J Am Coll Cardiol 2000;36:1812–7).

View larger version (24K): [in a new window]   Figure 5 Odds ratio with 95% confidence intervals (CI) and corresponding p values for treatment effect on 30-day mortality among diabetic patients with acute coronary syndromes. Values to the left of 1.0 indicate survival benefit of platelet glycoprotein IIb/IIIa inhibition. GUSTO = Global Use of STrategies to Open occluded arteries in acute coronary syndromes trial; PARAGON = Platelet IIb/IIIa Antagonism for the Reduction of Acute coronary syndrome Global Organization Network trial; PRISM-PLUS = Platelet Receptor inhibition for Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms trial; PURSUIT = Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy trial. Roffi M, Chew DP, Mukherjee D, et al. Platelet glycoprotein IIb/IIIa inhibitors reduce mortality in diabetic patients with non–ST-segment elevation acute coronary syndromes. Circulation 2001;104:2767–71. Reproduced with permission from Lippincott, Williams and Wilkins.

View larger version (32K): [in a new window]   Figure 6 (A) (Left) Risk stratification by C-reactive protein (CRP) (mg/dl) and rapid cardiac troponin T (cTnT) assay status expressed as 14-day mortality rate by CRP and rapid cTnT result. Early positive rapid cTnT assays are those that could be read positive by 10 min. Trend evaluated by chi-squared test. (Right) Mortality rate at 14 days by CRP and rapid cTnT assay status. Early positive rapid assays for cTnT are those for which the red line appeared by 10 min, with a "negative" test in this category including both negative and late positive rapid cTnT results. C-reactive protein 1.55 mg/dl is considered a positive test. "Test Positive" in the category "CRP 1.55 mg/dl and Rapid cTnT early positive" requires both tests to be positive, with a "negative" test in this category representing all other combinations. With permission from Morrow DA et al. J Am Coll Cardiol 1998;31:1460–5. (B) Incidence of death from cardiac causes at two years in the FRagmin during InStability in Coronary artery disease trial (FRISC) according to the presence or absence of ST-segment depression on the admission electrocardiogram and the maximal troponin T (TnT) levels during the first 24 h after enrollment and to the CRP levels and the maximal TnT levels. Neg = negative; Pos = positive. With permission from Lindahl B, et al. N Engl J Med 2000;343:1139–47.