October 2008

A 45-year-old white man presented to the emergency department with a 1-week history of intermittent pain in the middle of his chest, accompanied by upper abdominal discomfort.

A 70-year-old man with a history of hypertension and hyperlipidemia was admitted to the hospital with a non–ST-segment elevation myocardial infarction (MI).

A postmenopausal woman 66 years of age presented to the emergency department with new-onset chest discomfort at rest.

We compared the rates of cardiac catheterization in 2136 non–ST-segment elevation acute coronary syndrome patients who were stratified according to their baseline thrombolysis in myocardial infarction (TIMI) risk score. Higher-risk patients were referred for catheterization at a similar rate as low-risk patients. The main reasons why physicians did not make referrals included (1) clinical trial evidence did not support an early invasive approach and (2) 68% of patients were thought not to be at high enough risk; however, 59% of these patients were found to be higher risk when their baseline TIMI risk scores were recalculated. Patients who were referred for catheterization had better in-hospital and 1-year outcomes. Our findings indicate that a significant opportunity remains to improve upon accurate risk stratification and adherence to an early invasive strategy for higher-risk patients.

Treatment of stable patients with acute coronary syndrome (ACS) is controversial. Until recently, large randomized clinical trials had indicated that an "early" invasive strategy with routine cardiac catheterization reduced the likelihood of recurrent cardiovascular events when compared with a more "selective" approach, in which stable patients were referred to cardiac catheterization based on high-risk features on noninvasive stress imaging or because of a failure in initial medical therapy.

Sudden death in young athletes is shocking because it is unexpected in these seemingly healthy individuals. We present the case of an athlete who was found to have an incidental murmur during a screening physical, which led to a diagnosis of an anomalous origin of the right coronary artery with an intramural course. This congenital anomaly has been well recognized to result in sudden death; thus, it was fortunate that the condition was identified in our patient. We provide a brief overview of the literature, discuss the challenges faced in diagnosing such coronary abnormalities, and review the various management options that are available.

A 59-year-old Indian man with a medical history significant for orally controlled diabetes presented to the emergency department after experiencing a witnessed seizure.

Despite contemporary management, patients with acute coronary syndrome (ACS) remain at risk of recurrent adverse cardiovascular events.

Rates of death and myocardial infarction were assessed for a national sample of acute coronary syndrome patients after stopping clopidogrel. In the first 90 days after stopping treatment, patients experienced a nearly twofold increased risk of adverse events compared with subsequent follow-up intervals for patients treated medically without stents and for patients treated with coronary stents. This suggests a possible clopidogrel rebound effect, but additional studies are needed to support this hypothesis and to identify strategies to reduce early events after clopidogrel cessation.

We performed a systematic review and meta-analysis of all clinical trials comparing routine invasive strategy with selective invasive strategy in patients with non–ST-segment elevation acute coronary syndrome. We did not find either strategy to offer an advantage over the other, even when we excluded trials that did not use coronary stents and glycoprotein IIb/IIIa inhibitors.