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J Am Coll Cardiol, 2003; 41:123-129
© 2003 by the American College of Cardiology Foundation
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A guide to therapeutic decision-making in patients with non–ST-segment elevation acute coronary syndromes

Eric J. Topol, MD, FACC*,*

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



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Figure 1 Schematic depiction in sagittal view of inflammation and embolization.

 


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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.

 


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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.

 


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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).

 


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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.

 


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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.

 





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