Elliott M. Antman

Bio: Elliott M. Antman is an academic researcher from Brigham and Women's Hospital. The author has contributed to research in topics: Myocardial infarction & TIMI. The author has an hindex of 161, co-authored 716 publications receiving 179462 citations. Previous affiliations of Elliott M. Antman include Duke University & Katholieke Universiteit Leuven.

Coronary care medicine: it's not your father's CCU anymore

Abstract: The management of ST-elevation MI (STEMI) has gone through four phases: 1. The "clinical observation phase"; 2. the "coronary care unit phase"; 3. the "high-technology phase"; and 4. the "evidence-based coronary care phase". A significant advance in the care of patients with acute myocardial infarction that arose as an outgrowth of the evidence-based era was introduction of a lexicon that more accurately reflected contemporary concepts of the pathophysiology underlying myocardial ischemia and infarction. Although considerable improvement has occurred in the process of care for patient with STEMI, room for improvement exists. Despite strong evidence in the literature that prompt use of reperfusion therapy improves survival of STEMI patients such treatment is underutilized and often not administered in an expeditious timeframe relative to the onset of symptom. Even in the reperfusion era, left ventricular dysfunction remains the single most important predictor of mortality following STEMI. After administration of aspirin, initiating reperfusion strategies and, where appropriate, beta blockade all STEMI patients should be considered for inhibition of the renin-angiotensin-aldosterone system. Several adjunctive pharmacotherapies have been investigated to prevent inflammatory damage in the infarct zone. Contrary to earlier beliefs that the heart is a terminally differentiated organ without the capacity to regenerate, evidence now exists that human cardiac myocytes divide after STEMI and stem cells can promote regeneration of cardiac tissue. These observations open up the possibility of myocardial replacement therapy after STEMI.

Maintaining sinus rhythm with antifibrillatory drugs in atrial fibrillation

Abstract: Management of atrial fibrillation is a common and complex clinical problem. Two major treatment strategies have emerged: suppression of recurrences versus control of ventricular rate and anticoagulation to reduce the risk of stroke. Maintaining sinus rhythm offers the hemodynamic benefits of improving ventricular performance and exercise capacity but may expose the patient to the risk of proarrhythmia/sudden death and drug-related morbidity. Controlling ventricular rate helps decrease symptomatic palpitations and improve exercise capacity but necessitates long-term anticoagulation (which may also be needed despite the use of antiarrhythmics to suppress recurrences of atrial fibrillation) with some risk of bleeding. Randomized trials are now needed to define the relative benefits of these 2 treatment strategies. Such trials should be designed to provide information on the impact of the 2 approaches on symptoms, exercise capacity, quality of life, and mortality rate in patients with atrial fibrillation.

Association of lesion complexity following fibrinolytic administration with mortality in ST-elevation myocardial infarction.

Abstract: Greater lesion complexity, according to the American College of Cardiology and American Heart Association, has been associated with decreased success rates of percutaneous coronary intervention. We hypothesized that greater lesion complexity after fibrinolytic administration for ST-segment elevation myocardial infarction would similarly be associated with increased mortality and other adverse events at 30 days. We studies 2,605 patients from the Thrombolysis In Myocardial Infarction 10B and 14, Integrilin and Tenecteplase in Acute Myocardial Infarction, ENTIRE, and FASTER studies. For all studies, angiographic outcomes were assessed immediately after fibrinolytic administration and clinical outcomes were assessed at 30 days. Greater lesion complexity was associated with poorer epicardial flow and decreased myocardial perfusion at 60 minutes and after percutaneous coronary intervention and with a higher risk of shock and mortality within 30 days. In a multivariate model, type C lesion complexity remained associated with an increased 30-day mortality rate.

Presente y futuro del tratamiento antitrombótico en el síndrome coronario agudo

Abstract: La terapia antitrombotica en el tratamiento del sindrome coronario agudo esta dirigida a inhibir tanto la cascada de coagulacion como la activacion plaquetaria, y evitar de este modo el desarrollo de las consecuencias fisiopatologicas que se derivan de estos procesos. Los principales enfoques terapeuticos que se utilizan para este fin incluyen el uso de heparina no fraccionada, heparinas de bajo peso molecular o antitrombinas directas, moleculas todas ellas que interfieren en la formacion del coagulo de trombina. Numerosos estudios clinicos han investigado las ventajas e inconvenientes de cada una de estas estrategias, asi como los beneficios y riesgos que puede tener la terapia combinada de estos farmacos o su asociacion con inhibidores plaquetarios. La dificultad para establecer los beneficios relativos de las diferentes aproximaciones terapeuticas se debe, en parte, al enorme numero de combinaciones posibles y a las distintas situaciones clinicas en las que pueden utilizarse. Ademas, la necesidad de encontrar agentes antitromboticos con una actividad inhibidora mas especifica y un rango terapeutico mas amplio esta promoviendo el desarrollo de una investigacion activa en diversos laboratorios de todo el mundo, que ha conducido al diseno de moleculas recombinantes y anticuerpos monoclonales dirigidos a interrumpir la activacion de la cascada de coagulacion en diversos puntos estrategicos. Queda por probar cual sera la relacion entre el beneficio clinico de las moleculas de nueva generacion y el coste economico anadido a los gastos de atencion sanitaria que se destine a su diseno y desarrollo.

Antithrombotic therapy in unstable angina/non-ST elevation myocardial infarction: the evolving role of low-molecular-weight heparin.

Abstract: Acute coronary syndromes (ACS) represent a spectrum of diseases resulting from a disturbance in myocardial blood flow. The etiology of this disturbance stems from either partial or complete thrombotic occlusion of the culprit vessel. Appropriate antithrombotic therapy is crucial in limiting the progression of ACS. Conventional antithrombotic therapy in ACS has typically utilized unfractionated heparin (UFH). However, UFH has several limitations that may restrict its clinical usefulness. Direct antithrombin agents are currently not indicated for ACS and have the potential for problems including a narrow therapeutic window and bleeding. The low-molecular-weight heparins offer a convenient and attractive alternative, which, in the case of enoxaparin, have demonstrated superiority over UFH in two large randomized trials. Low-molecular-weight heparins (LMWH) represent an important therapeutic advance in the management of ACS and additional information is forthcoming that will better define the role of LMWH in ACS.

Measuring inconsistency in meta-analyses

Abstract: Cochrane Reviews have recently started including the quantity I 2 to help readers assess the consistency of the results of studies in meta-analyses. What does this new quantity mean, and why is assessment of heterogeneity so important to clinical practice? Systematic reviews and meta-analyses can provide convincing and reliable evidence relevant to many aspects of medicine and health care.1 Their value is especially clear when the results of the studies they include show clinically important effects of similar magnitude. However, the conclusions are less clear when the included studies have differing results. In an attempt to establish whether studies are consistent, reports of meta-analyses commonly present a statistical test of heterogeneity. The test seeks to determine whether there are genuine differences underlying the results of the studies (heterogeneity), or whether the variation in findings is compatible with chance alone (homogeneity). However, the test is susceptible to the number of trials included in the meta-analysis. We have developed a new quantity, I 2, which we believe gives a better measure of the consistency between trials in a meta-analysis. Assessment of the consistency of effects across studies is an essential part of meta-analysis. Unless we know how consistent the results of studies are, we cannot determine the generalisability of the findings of the meta-analysis. Indeed, several hierarchical systems for grading evidence state that the results of studies must be consistent or homogeneous to obtain the highest grading.2–4 Tests for heterogeneity are commonly used to decide on methods for combining studies and for concluding consistency or inconsistency of findings.5 6 But what does the test achieve in practice, and how should the resulting P values be interpreted? A test for heterogeneity examines the null hypothesis that all studies are evaluating the same effect. The usual test statistic …

The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration

Abstract: Systematic reviews and meta-analyses are essential to summarize evidence relating to efficacy and safety of health care interventions accurately and reliably. The clarity and transparency of these reports, however, is not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users. Since the development of the QUOROM (QUality Of Reporting Of Meta-analysis) Statement—a reporting guideline published in 1999—there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realizing these issues, an international group that included experienced authors and methodologists developed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions. The PRISMA Statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this Explanation and Elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA Statement, this document, and the associated Web site (http://www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

Abstract: "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure" provides a new guideline for hypertension prevention and management. The following are the key messages(1) In persons older than 50 years, systolic blood pressure (BP) of more than 140 mm Hg is a much more important cardiovascular disease (CVD) risk factor than diastolic BP; (2) The risk of CVD, beginning at 115/75 mm Hg, doubles with each increment of 20/10 mm Hg; individuals who are normotensive at 55 years of age have a 90% lifetime risk for developing hypertension; (3) Individuals with a systolic BP of 120 to 139 mm Hg or a diastolic BP of 80 to 89 mm Hg should be considered as prehypertensive and require health-promoting lifestyle modifications to prevent CVD; (4) Thiazide-type diuretics should be used in drug treatment for most patients with uncomplicated hypertension, either alone or combined with drugs from other classes. Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, β-blockers, calcium channel blockers); (5) Most patients with hypertension will require 2 or more antihypertensive medications to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg for patients with diabetes or chronic kidney disease); (6) If BP is more than 20/10 mm Hg above goal BP, consideration should be given to initiating therapy with 2 agents, 1 of which usually should be a thiazide-type diuretic; and (7) The most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated. Motivation improves when patients have positive experiences with and trust in the clinician. Empathy builds trust and is a potent motivator. Finally, in presenting these guidelines, the committee recognizes that the responsible physician's judgment remains paramount.

Cochrane Handbook for Systematic Reviews of Interventions

Abstract: The Cochrane Handbook for Systematic Reviews of Interventions is the official document that describes in detail the process of preparing and maintaining Cochrane systematic reviews on the effects of healthcare interventions.