Volume 9 Issue 7, July 2012

Infusion of glucose–insulin–potassium (GIK) before hospital admission in patients with signs and symptoms of acute coronary syndrome has been shown to reduce the incidence of cardiac arrest or in-hospital mortality. Whether out-of-hospital GIK in combination with strict glycemic control can prevent progression to MI requires further study.

The EINSTEIN-PE trial showed that rivaroxaban has equal efficacy and a lower rate of bleeding than coumarins in the treatment of acute pulmonary embolism. We anticipate regulatory and consumer acceptance for rivaroxaban, representing the first new anticoagulant treatment for venous thromboembolism since the introduction of warfarin compounds 50 years ago.

Randomized studies and evaluations of large registries have repeatedly shown that epinephrine used as a standard vasopressor for cardiopulmonary resuscitation increases the rate of return of spontaneous circulation. By contrast, epinephrine might decrease long-term survival and impair neurological outcome.

The BRIDGE-ACS study showed benefits of a quality improvement initiative in adherence to evidence-based therapy for acute coronary syndromes at public hospitals in Brazil. No mortality benefit was observed, but this finding might have been different if all effective therapies for in-hospital treatment of myocardial infarction were included.

Oral direct factor Xa inhibitors, particularly apixaban and rivaroxaban, are novel and promising alternatives to warfarin for stroke prevention in patients with atrial fibrillation. Drs Cabral and Ansell review the data from clinical trials of these drugs, and also discuss the challenges of reversing their anticoagulant effects, interactions with other medications, patient compliance, and therapeutic monitoring.

Novel, oral, direct inhibitors of factor Xa are valuable additions to anticoagulation therapy in patients with various thrombotic disorders, but have shown mixed results in trials for secondary prevention in patients with an acute coronary syndrome. Drs Wisler and Becker review the available data, with particular emphasis on the phase III APPRAISE 2 and ATLAS ACS 2–TIMI 51 trials of apixaban and rivaroxaban.

Direct inhibitors of thrombin are a novel class of anticoagulant. The authors critically review the data from clinical trials on the use of the parenteral and oral forms of these drugs for primary or secondary prevention or treatment in patients with acute coronary syndrome, atrial fibrillation, or venous thromboembolism, or those undergoing percutaneous coronary intervention or orthopedic surgery.

Oral anticoagulation therapy is the most effective strategy for preventing thromboembolic complications in pregnant women with prosthetic heart valves. However, this therapy is associated with increased fetal morbidity and mortality. The authors discuss the controversies surrounding the choice of prosthetic heart valve in women of childbearing age and the advantages and disadvantages of various anticoagulation strategies during pregnancy.

Many barriers exist to the translation and implementation of European and US guidelines for cardiovascular disease into clinical practice in China, but also to the development of Chinese-specific guidelines. Professors Zhao and Hu give their expert perspectives on the multifaceted reasons for these barriers, and how future guidelines for Chinese clinical practice should be developed and applied.

Important advances in anticoagulation therapy have been made in the past few years. Many novel agents, including oral factor Xa inhibitors and direct thrombin inhibitors, are currently under investigation as alternatives to vitamin K antagonists in various clinical settings. This focus issue features four Review articles, written by leading experts, in which new clinical trial data and controversies in the field are discussed and put into context.