Angioplasty versus Stenting in Acute Myocardial Infarction

Primary coronary angioplasty has become the preferred method of reperfusion in patients with acute myocardial infarction. Still, the procedure is limited by the substantial rates of restenosis and reocclusion. This trial compared angioplasty with stenting, with or without treatment with the glycoprotein IIb/IIIa inhibitor abciximab. Stenting (alone or with abciximab) was superior to standard balloon angioplasty (alone or with abciximab) in reducing the need for repeated revascularization.

This study will set a new standard for reperfusion therapy in patients with acute myocardial infarction. At experienced centers, coronary stenting, with or without abciximab, should be the preferred approach to reperfusion.

Related Perspective

Estrogen-Receptor Polymorphisms and Effects of Estrogen Replacement on High-Density Lipoprotein Cholesterol

Sequence variants in the estrogen receptor (ER-) gene may be important in individual responses to hormone-replacement therapy. ER- polymorphisms were characterized in 309 women enrolled in the Estrogen Replacement and Atherosclerosis trial, and the association between these polymorphisms and the response of high-density lipoprotein (HDL) cholesterol to hormone-replacement therapy was examined. Women with DNA sequence variants in intron 1 had a heightened response of HDL cholesterol during hormone-replacement therapy, as compared with women with other genotypes.

Although the specific effects of these genotypes on estrogen-receptor function is unknown, the data point to the possibility of using genetic screening to individualize decision making about hormone-replacement therapy.

Related Editorial

Duration of Enoxaparin Thromboprophylaxis after Surgery for Cancer

How long should patients who undergo abdominal surgery for cancer receive thromboprophylaxis? To investigate this question, 332 patients received enoxaparin for about eight days postoperatively and were then randomly assigned to receive either placebo or enoxaparin for another three weeks. Venography was performed in all patients at the end of treatment. Venous thromboembolism occurred in 12.0 percent of the placebo group and 4.8 percent of the enoxaparin group.

Cancer is a leading cause of thrombophilia, and surgery for cancer further increases the risk of venous thrombosis. The evidence from this well-designed study supports the use of thromboprophylaxis for at least four weeks after abdominal or pelvic surgery for cancer.

Special Article: Psychological Sequelae of the September 11 Terrorist Attacks

This telephone survey of Manhattan residents was performed five to nine weeks after the terrorist attacks on the World Trade Center. The prevalence of acute post-traumatic stress disorder (PTSD) was 7.5 percent, and the prevalence of depression was 9.7 percent. Among residents living close to the World Trade Center, the prevalence of PTSD was 20.0 percent.

The prevalences reported in this survey are approximately twice as high as the expected values for PTSD and depression in the general population. The burden of these psychological sequelae was substantial in the early aftermath of the World Trade Center attacks.

Clinical Practice: Acute Exacerbations of Chronic Obstructive Pulmonary Disease

A 68-year-old former heavy smoker with a history of chronic obstructive pulmonary disease presents to the emergency room with a two-day history of worsened dyspnea and increased purulence and volume of phlegm. Chest radiography shows hyperinflation and no acute infiltrates. Measurement of arterial blood gases while the patient is breathing ambient air shows acute respiratory acidosis. How should this patient be treated?

This article reviews the short-term management of exacerbations of chronic obstructive pulmonary disease.

Medical Progress: Immune Thrombocytopenic Purpura

Immune thrombocytopenic purpura, which may lead to bleeding, is typically caused by antibodies directed against the platelet glycoprotein IIb/IIIa complex. Since the management of the disorder is different for children and adults, the authors of this up-to-date review provide separate sections on the two age groups. Along with advances in management, they also discuss the current understanding of pathophysiology and, in particular, the way in which autoantibodies against platelets are generated.

Sounding Board: Should Family Members Be Present during Cardiopulmonary Resuscitation?

The author acknowledges that the presence of family members during resuscitation procedures is not always desirable or possible. However, she endorses programs at hospitals that would allow family members to be present according to their wishes. She notes that the attitudes of physicians and nurses are the greatest barriers to establishing such programs.

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