Update in Cardiology

Update in Cardiology

Peter H. Stone, MD

From Brigham and Women's Hospital, Boston, Massachusetts.

2002-2003 Series: Update Sessions from ACP-ASIM's 2002 Annual Session

David A. Cramer, MD, and Paul T. Kefalides, MD, Co-Editors

This Update looks back at a most exciting year in cardiology and anticipates novel therapeutic approaches. Topics discussed are unstable coronary artery disease; treatments of chronic coronary artery disease; risk factors for atherosclerotic cardiovascular disease, notably C-reactive protein; management of heart failure; and a potpourri of cardiovascular issues, including valvular disease, peripheral vascular disease, and arrhythmia.

Unstable Coronary Artery Syndromes

Roughly 1.5 million hospital admissions each year in the United States result from unstable angina or non–ST-segment elevation myocardial infarction. A reliable way of stratifying risk among these patients would permit those more likely to develop adverse cardiac events to receive costly invasive treatments in a timely manner. Those at lower risk could safely be managed more conservatively—and less expensively. The cardiac troponins I and T, which have prognostic value in patients with unstable angina or non–ST-segment elevation myocardial infarction, might serve this purpose.

Minor Elevations in Troponin Levels Predicted Clinical Benefit from Early Revascularization in Patients with Acute Coronary Syndromes

Morrow DA, Cannon CP, Rifai N, et al. Ability of minor elevations of troponins I and T to predict benefit from an early invasive strategy in patients with unstable angina and non-ST elevation myocardial infarction: results from a randomized trial. JAMA. 2001; 286:2405-12. [PMID: 11712935]

The TACTICS-TIMI 18 (Treat Angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy–Thrombolysis in Myocardial Infarction 18) trial is a prospective international study that enrolled 2220 patients with unstable angina or non–ST-segment elevation myocardial infarction. The 1780 patients completing 6 months of follow-up had been randomly assigned to invasive management (coronary angiography within 48 hours and revascularization if feasible) or conservative medical management, which could include intravenous unfractionated heparin and tirofiban, a platelet glycoprotein IIb/IIIa inhibitor.

Risk stratification markedly affected the benefit of treatment. Patients whose troponin I level was 0.1 µg/L or higher had a significantly lower risk for death, myocardial infarction, or rehospitalization after 6 months when treated invasively rather than conservatively (15.3% vs. 25.0%; odds ratio, 0.54 [95% CI, 0.40 to 0.73]). Elevations in troponin I level no greater than 0.4 µg/L had …

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