coronary disease, acute coronary syndrome
DISEASE INTERVENTION COMPARISON RESULTS
Am J Cardiol. 2013 Jun 15;111(12):1701-7 Diagnostic
IN coronary disease, acute coronary syndrome, myocardial infarction, older patients The Use of
high-sensitive cardiac troponin, increased cutoff at 40-50 ng/L in older patients and renal failure
As Diagnostic Tool
Is better Than
standard cutoff at 14 ng/L
To better diagnose acute coronary syndrome: sensitivity 87% and specificity 87% at 50 ng/Lfor older patients
Am Heart J. 1999;137(6):1137-1144 Diagnostic
IN coronary disease, acute coronary syndrome The Use of
troponin T
As Diagnostic Tool
Is better Than
creatine kinase-MB (CK-MB)
To equally diagnosing acute myocardial infeartion in the first 24 h, but much better predicting death or major cardiac complications
Circulation. 2003 Feb 25;107(7):966-72 Randomized Controlled Trial
IN coronary disease, acute coronary syndrome The Use of
adenosine diphosphate (ADP) receptor inhibitors, clopidogrel, added to aspirin, combined anti-platelet therapy
As Treatment, Acute
Is better Than
aspirin alone
To reduce ischemic events (cardiovascular death, myocardial infarction, or stroke) at 30 days (4.3% in intv. VS 5.4% in ctrl.) and at 12 months (5.2% in intv. VS 6.3% in ctrl.) No significant excess in life-threatening bleeds (but yes for total bleeds)
N Engl J Med. 2007 Nov 15;vol(issue):pag [Epub ahead of print Nov 4] Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome The Use of
adenosine diphosphate (ADP) receptor inhibitors, prasugrel, added to aspirin, combined anti-platelet drugs
As Treatment, Acute
Is better Than
clopidogrel, added to aspirin, combined anti-platelet therapy
To reduce recurrence of myocardial infarction (7.4% for prasugrel VS 9.7% for clopidogrel) and a derived combined end-point of cardiovascular death and major events.
N Engl J Med. 2009 Sep 10;361(11):1045-57 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome The Use of
adenosine diphosphate (ADP) receptor inhibitors, ticagrelor, added to aspirin, combined anti-platelet therapy
As Treatment, Acute
Is better Than
clopidogrel, added to aspirin, combined anti-platelet drugs
To reduce at 12 months cardiovascular events (death from vascular causes, myocardial infarction, or stroke): 10% ticagrelor VS 12% clopidogrel. Ticagrelor increased minor bleedings but not major haemorrhages.
N Engl J Med. 2011 Aug 25;365(8):699-708. [Epub 2011 Jul 24] Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome The Use of
anticoagulants, oral factor Xa inhibitors, apixaban, 5 mg twice daily
As Treatment, Chronic
Is worse Than
placebo
To improve results at 8 months: it increase in major bleeding events (1.3% apixaban VS 0.5% placebo) and did not reduced cardiovascular events (7.5% apixaban VS 7.9% placebo)
N Engl J Med. 2012 Jan 5;366(1):9-19. Epub 2011 Nov 13 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome The Use of
anticoagulants, oral factor Xa inhibitors, rivaroxaban, 2.5 or 5 mg twice daily, in addition to double antiplatelet treatment
As Treatment, Chronic
Is better Than
placebo
To reduce at 13 months cardiovascular events (cardiovascular death, myocardial infartion , stroke): 8.9% rivaroxaban VS 10.7% placebo. However, it increases major bleedings: 2.1% rivaroxaban VS 0.6% placebo
N Engl J Med. 2014 Dec 4;371(23):2155-66 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, after percutaneous coronary intervention, drug eluting stents The Use of
dual antiplatelet therapy (aspirin + P2Y12 inhibitor (clopidogrel or prasugrel)) for 30 months
As Treatment, Chronic
Is worse Than
dual antiplatelet therapy (aspirin + thienopyridine) for 12 months only
To improve all-cause mortality (2.0% 30 months VS 1.5% 12 months), even if it reduced cardiovascular events (4.3% 30 months VS 5.9% 12 months). Extended treatment increased major bleedings (2.5% vs 1.6%) but that did not explain the mortality difference
N Engl J Med. 2015 May 07;372(19):1791-800 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, after percutaneous coronary intervention, drug eluting stents The Use of
mantaining dual antiplatelet after 1 year with ticagrelor (90 mg twice daily or 60 mg twice daily) plus low-dose aspirin
As Treatment, Chronic
Is better Than
placebo plus low-dose aspirin
To reduce cardiovascular events (8% both doses ticagrelor VS 9% aspirin alone) but increasing major bleeding (2.5% ticagrelor VS 1% aspirin alone)
J Am Coll Cardiol. 2015 Mar 24;65(11):1092-102 Meta-Analysis
IN coronary disease, acute coronary syndrome, after percutaneous coronary intervention, drug eluting stents The Use of
short- (≤6 months) dual antiplatelet therapy
As Treatment, Chronic
Is better Than
long-term (1 year) dual antiplatelet therapy
To reduce bleeding (HR 0.66) while achieving similar rates of cardiac events (cardiac death, myocardial infarction, or definite/probable stent thrombosis: HR 1.11)
BMJ. 2015 Apr 16;350:h1618 Meta-Analysis
IN coronary disease, acute coronary syndrome, after percutaneous coronary intervention, drug eluting stents The Use of
short term course of dual antiplatelet therapy
As Treatment, Chronic
Is better Than
12 month dual antiplatelet therapy
To reduce major bleeding (OR 0.58) with no significant differences in ischaemic or thrombotic outcomes. Extended VS 12 month Tt yielded a reduction of ischemic events (OR 0.33 to 0.53) but more major bleeding (OR 1.66) and more all-cause deaths (OR 1.30)
N Engl J Med. 2017 Oct 19;377(16):1513-1524 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, after percutaneous coronary intervention, drug eluting stents, atrial fibrillation The Use of
dual treatment with dabigatran 110 mg twice daily plus an a P2Y12inhibitor (clopidogrel or ticagrelor) antiplatelet
As Treatment, Chronic
Is better Than
triple therapy with dose-adjusted vitamin K antagonist plus dual antiplatelet
To reduce at 14 months major or clinically relevant bleeding events (15% dabigatran 110mg VS 27% triple therapy) with no increase of cardiovascular events (13.7% dual-therapy VS 13.4% triple-therapy)
Lancet. 2013 Mar 30;381(9872):1107-15 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, after percutaneous coronary intervention, drug eluting stents, atrial fibrillation The Use of
dual treatment with INR adjusted warfarin plus clopidogrel
As Treatment, Chronic
Is better Than
triple therapy with dose-adjusted vitamin K antagonist plus dual antiplatelet (aspirin + clopidogrel)
To reduce at 1 year any bleeding event (19% dual Tt VS 44% triple Tt) with no increase in the rate of thrombotic events
N Engl J Med. 2016 Dec 22;375(25):2423-2434 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, after percutaneous coronary intervention, drug eluting stents, atrial fibrillation The Use of
low-dose rivaroxaban (15 mg /d) plus an P2Y12 inhibitor antiplatelet for 12 months OR very-low-dose rivaroxaban (2.5 mg twice daily) plus dual antiplatelet for 1, 6, or 12 months
As Treatment, Chronic
Is better Than
dose-adjusted vitamin K antagonist plus dual antiplatelet for 1, 6, or 12 months
To reduce clinically significant bleeding (17% rivaroxaban 15 + 1 antiplatelet, 18% rivaroxaban 2.5 + 2 antiplatelets, and 26.7% antivitamin K + 2 antiplatelets) while having similar rates of cardiovascular events (6.5%, 5.6% and 6% respectively)
N Engl J Med. 2004 Apr 8;350(15):1495-504 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, high or normal cholesterol The Use of
high dose statins, atorvastatin 80 mg/d
As Treatment, Chronic
Is better Than
standard dose statins, standard lipid lowering, pravastatin 40 mg/d
To reduce cardiovascular events (composite of death from any cause, myocardial infarction, hospitalization for unstable angina, revascularization and stroke): 22,4% at 2 years in intv. VS 26,3% in ctrl.
J Am Coll Cardiol. 2010 May 11;55(19):2096-106 Cohorts
IN coronary disease, acute coronary syndrome, myocardial infarction The Use of
copeptin, added to troponin
As Diagnostic Tool
Is better Than
troponin
To more accurately diagnose an acute coronary syndrome (c-statistics 0.93 copeptin + troponin VS 0.84 troponin alone) and to rule out coronary syndrome in the first 3 hours: 92% negative predictive value with copeptin + troponin
Cochrane Database Syst Rev. 2011;1:CD007038 Systematic Review, Cochrane Review
IN coronary disease, acute coronary syndrome, myocardial infarction The Use of
pentasacharide analogues, fondaparinux
As Treatment, Acute
Is better Than
low molecular weight heparins (LMWH), enoxaparin
To reduce the risk of all-cause mortality at 90 to 180 days (RR 0.89) while reducing minor bleeding
Ann Intern Med. 2005 Aug 16;143(4):241-50 Meta-Analysis
IN coronary disease, acute coronary syndrome, myocardial infarction The Use of
vitamin K antagonists, warfarin, added to aspirin
As Treatment, Chronic
Is better Than
aspirin alone, NOT compared to aspirin plus clopidrogel
To decrease the annual rate of myocardial infarction (0.022 vs. 0.041) and ischemic stroke (0.004 vs. 0.008) but not to reduce mortality. Major bleeding increased (0.015 vs. 0.006)
Eur Heart J. 2011 Jun;32(11):1379-89 Diagnostic
IN coronary disease, acute coronary syndrome, myocardial infarction, older patients The Use of
high-sensitive cardiac troponin assays
As Diagnostic Tool
Is better Than
standard cardiac troponin assay
To diagnose acute myocardial infarction: AUC 0.95 sensitive troponine VS 0.90 standard troponine. Best cut-offs in elderly patients differed clearly from younguer patients. Mild elevations are commont in non-infarctus elderly (20% patients)
Eur Heart J. 2013 Sep 11. [Epub ahead of print] Meta-Analysis
IN coronary disease, acute coronary syndrome, myocardial infarction, ST-segment elevation The Use of
intracoronary bone marrow cell therapy
As Treatment, Acute
Is better Than
placebo or no cell therapy
To improve (at a time not well defined) left ventricle ejection fraction (LVEF) : 2.5% mean increase, 5.3% when LVEF was < 40%
N Engl J Med. 1998 Nov 5;339(19):1349-57 Randomized Controlled Trial
IN coronary disease, acute coronary syndrome, myocardial infarction, unstable angina, normal cholesterol The Use of
statins, pravastatin 40 mg/d
As Prevention, Secondary
Is better Than
placebo
To reduce - at 6 years - overall mortality (11.0% in pravastatin vs 14.1% in placebo) and cardiovascular mortality (7.3% in pravastatin vs 9.6% in placebo)
JAMA. 2006 Apr 5;295(13):1519-30. Epub 2006 Mar 14 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, ST-segment elevation The Use of
pentasacharide analogues, fondaparinux (2.5 mg/d) for 8 days
As Treatment, Acute
Is better Than
unfractionated heparin for 2 days, or placebo
To reduce at 30 days bad outcome (death or reinfarction): 9.7% fondaparinux VS 11.2% controls. No difference in bleeding.
Lancet. 2000 Jul 1;356(9223):9-16 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, unstable angina The Use of
routine invasive strategy (angiography and revascularization), first 10 days
As Treatment, Acute
Is better Than
non invasive startegy
To reduce, 1 year later, death (2.2% invasive VS 3.2% conservative) and reinfarction (9% invasive VS 12% conservative)
N Engl J Med. 2001 Aug 16;345(7):494-502 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, without ST elevation The Use of
adenosine diphosphate (ADP) receptor inhibitors, clopidogrel, added to aspirin, combined anti-platelet therapy
As Treatment, Acute
Is better Than
aspirin alone
To reduce, at 1 year, ischemic events (cardiovascular death, myocardial infarction or stroke): 9.3% in intv VS 11.4% in ctrl. Increase major bleeds (3.7% in intv. VS 2.7% in ctrl.)
J Am Coll Cardiol. 2010 Mar 2;55(9):858-64 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, without ST elevation The Use of
early invasive strategy of coronary angiography and revascularization when feasible
As Treatment, Acute
Is equal Than
conservative strategy: coronary angiography and revascularization only if recurrent ischemia or on provocative testing
To modify at 5 years cumulative death or MI rates (22.3% early VS 18.1% conservative), or mortality.
JAMA. 2001 Nov 21; 286 (19):2405-12 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, without ST elevation The Use of
early invasive strategy of coronary angiography between 4 and 48 hours and revascularization when feasible
As Treatment, Acute
Is better Than
Conservative strategy: coronary angiography and revascularization only if recurrent ischemia at rest or on provocative testing
To reduce composite end point of death, MI, or rehospitalization for acute coronary syndrome at 6 months: 15.3% in intv. VS 25% in ctrl.
N Engl J Med. 2005 Sep 15;353(11):1095-104 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, without ST elevation The Use of
early invasive strategy of coronary angiography revascularization when feasible
As Treatment, Acute
Is equal Than
conservative strategy: coronary angiography and revascularization only if recurrent ischemia or on provocative testing
To reduce at 1 year a composite enpoint of death, nonfatal myocardial infarction, or rehospitalization for anginal symptoms: 22.7% in early invasive VS 21.2% with conservative strategy. Early invasive strategy associated more AMI but less rehospitalisations
Lancet. 2002 Jan 19;359(9302):189-98 Meta-Analysis
IN coronary disease, acute coronary syndrome, without ST elevation The Use of
glycoprotein IIb/IIIa inhibitors, anti-platelet
As Treatment, Acute
Is better Than
placebo
To reduce at 30 days death or myocardial infarction (10.8% in intv. VS 11.8% in ctrl.). Increase major bleeds (2,4% in intv. VS 1,4% in ctrl)
N Engl J Med. 2006 Apr 6;354(14):1464-76. Epub 2006 Mar 14 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, without ST elevation The Use of
pentasacharide analogues, fondaparinux (2.5 mg/d SC) for 6 days
As Treatment, Acute
Is equal Than
low molecular weight heparin (LMWH), enoxaparin 1 mg/Kg/12h
To reduce at 30 days bad outcome (death, reinfarction, or refractory ischemia): 8.0% fondaparinux VS 8.6% enoxaparin. Fondaparinux had fewer major haemorrhages: 3.1% VS 5.0% enoxaparin
JAMA. 2008 Jul 2;300(1):71-80 Meta-Analysis
IN coronary disease, acute coronary syndrome, without ST elevation, biomarkers positive The Use of
early invasive strategy of coronary angiography revascularization when feasible
As Treatment, Acute
Is better Than
conservative strategy
To reduce death, myocardial infarction or readmission: 21% early invasive strategy VS 25.5% conservative.
Lancet. 2006 Sep 16;368(9540):998-1004 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, without ST-segment elevation The Use of
early invasive strategy with coronary angiography and, if appropriate, revascularisation within 7 days
As Treatment, Acute
Is better Than
conservative strategy: non-invasive primarily medical strategy
To reduce at 5 years death or myocardial infarction: 19.9% invasive strategy VS 24.5% conservative strategy.
Ann Intern Med. 2008 Feb 5;148(3):186-96 Systematic Review
IN coronary disease, acute coronary syndrome, without ST-segment elevation The Use of
routine invasive strategy (angiography and revascularization)
As Treatment, Acute
Is equal Than
conservative strategy (ischaemia- or symptom-driven angiography)
To reduce mortality (RR 0.90, 0.80 to 1.14) or re-infarction (RR 0.86, 0.68 to 1.08)
Eur Heart J. 2012 Jan;33(1):51-60 Randomized Controlled Trial
IN coronary disease, acute coronary syndrome, without ST-segment elevation, women The Use of
routine invasive strategy (angiography and revascularization)
As Treatment, Acute
Is worse Than
conservative strategy (ischaemia- or symptom-driven angiography)
To routine invasive strategy increased death at 1 year in women (8.8% VS 1.1% in the RCT and OR 1.51 in the meta-analysis) and did NOT modify MI and stroke rates. Results in men are not always extapolable to women
Eur Heart J. 2013 Jun 4. [Epub ahead of print] Cohorts
IN dementia, alzheimer, coronary disease, acute coronary syndrome, myocardial infarction, older patients The Use of
cholinesterase inhibitors
As Treatment, Chronic
Is better Than
no cholinesterase inhibitors
To reduce the risk of myocardial infarction (HR 0.62) and death (HR 0.64). Patients taking the highest doses recommended had the lowest risk of MI or death
Arch Intern Med. 1999 Oct 25;159(19):2273-8 Randomized Controlled Trial
IN mind-body relations, coronary disease, acute coronary syndrome The Use of
remote intercessory prayer, praying for others
As Treatment, Acute
Is better Than
no praying, usual care group
To reduce a particular score of the hospital course of patients. No influence observed in mortality or length of stay in ICU or in hospital.