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Recent advances in percutaneous coronary intervention and antiplatelet therapy as well as faster door-to-balloon times have markedly improved the therapy of patients with acute myocardial infarction. However, impaired myocardial perfusion despite revascularization of the infarcted vessel remains an ongoing problem with high prognostic relevance. In initial clinical trials thrombus aspiration in addition to conventional percutaneous coronary intervention demonstrated benefits regarding coronary flow and myocardial perfusion and was therefore recommended in practice guidelines. These improvements in surrogate endpoints did not translate into a favorable clinical outcome in recent large-scale multicenter randomized trials investigating the routine use of thrombus aspiration in patients with acute myocardial infarction. Furthermore, an increased risk of stroke after thrombus aspiration raises safety concerns. Therefore, thrombus aspiration has been downgraded in the recent guideline updates. The current article reviews the evidence from clinical trials and the recommendations in practice guidelines regarding thrombus aspiration in acute myocardial infarction.

An ostial lesion is defined as a lesion near to the ostium (≤3 mm) and is characterized by a rigid fibrotic texture with pronounced sclerosis associated with a very high tendency to recoil. Under certain circumstances this may lead to a modest primary interventional result accompanied by a higher complication rate and in particular a higher rate of restenosis. Ostial lesions of the right coronary artery in particular represent a greater challenge for percutaneous interventions with a higher rate of restenosis despite the introduction of various new techniques. In contrast ostial stenosis of the left main trunk shows very good results after percutaneous interventions and implantation of drug-eluting stents. The indications for percutaneous transluminal coronary angioplasty (PTCA) of an ostial lesion correspond to the indications for treatment of all other lesions. The article gives an overview of the experiences and recommendations with respect to the diagnostics and interventional therapy of ostial lesions.

Chronic occlusion of coronary arteries also known as chronic total occlusions (CTO) are found in approximately 20 % of patients undergoing percutaneous coronary interventions (PCI) and in approximately 50 % of patients after coronary artery bypass grafts (CABG). As a result of technical advancements in retrograde recanalization techniques specialized centers can now achieve success rates of over 85 %, regardless of the CTO anatomy. Given the complexity of retrograde CTO techniques, a consensus paper issued by the Euro CTO Club requires interventional cardiologists to have sufficient experience in antegrade approaches (>300 antegrade CTO cases and >50 per year) with an additional training program (25 retrograde cases each as first and second operating surgeon) before becoming a qualified independent retrograde surgeon. The increased investment in time and technical resources can only be justified if the patient has a clear clinical benefit. This technical advancement and the progressively clearer evidence that complete revascularization can be achieved in patients with multivessel coronary artery disease have attracted growing interest in recent years from interventional cardiologists in the recanalization of CTO.

Background: Representative data on the current management of patients with acute coronary syndromes (ACS) are of high interest. The EPICOR registry aimed to prospectively collect such real-life data with particular focus on antithrombotic drug utilization and outcomes., Methods: As part of the international prospective EPICOR registry, 29 hospitals in Germany documented 296 patients with ST-elevation myocardial infarction (STEMI)-ACS and 333 with unstable angina or non-STEMI (NSTEMI)-ACS surviving the hospital phase. The statistical analysis was performed in a descriptive manner. The ClinicalTrials.gov identifier is NCT01171404., Results: The mean age of patients was 62 ± 13 years, and 77.4 % were men. Treatment with antithrombotic agents was initiated in the prehospital phase in 50.7 % of STEMI and 33.3 % of NSTEMI patients. During the hospital stay (median 7.0 days), cardiac catheterization was performed in 97.6 %, percutaneous coronary intervention in 85.6 %, thrombolysis in 4.6 %, and coronary bypass surgery in 2.7 % patients. The use of acetylic salicylic acid (ASA) was reported in 95.6 % vs. 96.1 %, clopidogrel in 60.8 % vs. 73.0 %, prasugrel in 45.6 % vs. 22.5 %, any GP IIb/IIIa inhibitor in 52.4 % vs. 18.9 % [any dual combination of ASA+(clopidogrel/prasugrel)in 94.0 vs. 91.0 %], statins in 94.6 % vs. 92.2 %, beta blockers in 96.3 % vs. 94.6 %, and ACE-I/ARB in 91.6 % vs. 87.7 % of STEMI vs. NSTEMI patients, respectively. Combined use of the five drug classes recommended in the guidelines-ASA, P2Y12 antagonists, statin, beta blocker, and ACE-I/ARB-was reported in 81.1 % vs. 69.4 % of STEMI vs. NSTEMI patients, respectively., Conclusion: In Germany a high proportion of patients with ACS are treated according to current guidelines, receiving primary revascularization as well as antithrombotic drugs and other agents for prevention of secondary events; associated bleeding complications were less frequent as compared with published registries.

One of the most important treatment principles in interventional cardiology relies on myocardial revascularization by percutaneous coronary intervention (PCI) or surgical placement of coronary artery bypass grafts (CABG). However, in order to apply these principles effectively, it is important to identify patients who require revascularization. Consequently, the appropriate method has to be selected to effectively restore blood flow. Patients will only benefit from the interventional or surgical procedures when those revascularization measures that can cause more harm than good are avoided. In the new European Society of Cardiology and European Association for Cardio-Thoracic Surgery (ESC/EACTS) guidelines on myocardial revascularization some new aspects will be addressed.

International guidelines for the management of patients with ST-elevation myocardial infarction (STEMI) recommend various performance measures to monitor the quality of STEMI systems of care. Door-to-balloon (D2B) time (arrival at hospital to percutaneous coronary intervention, PCI) and overall health care system delay (first medical contact to reperfusion) are acknowledged as valuable performance measures when treating patients with primary percutaneous coronary intervention (PPCI). However, there is confusion regarding the exact definition of these performance measures, and moreover system delay and PCI-related delay (the extra delay acceptable to perform PPCI instead of fibrinolysis) are often used synonymously, which add confusion when considering reperfusion strategy. The present paper calls for a consensus regarding the use and definition of objective performance measures when treating patients with STEMI, and exemplifies why it is insufficient just to focus on D2B time.

The optimal timing of invasive diagnosis and therapy in patients with non-ST-elevation myocardial infarction (NSTEMI) is still a matter of debate. The European Society of Cardiology recommends invasive diagnosis evaluation and revascularization for practically all patients with NSTEMI within 72 h. High risk and very high risk patients should be evaluated invasively with coronary angiography within 24 h or 2 h, respectively. The risk of the individual patient should be stratified by means of the Global Registry of Acute Coronary Events (GRACE) risk score. The recommendations and guidelines are based on the results of several randomized, controlled trials and are in accordance with other retrospective studies. However, observational studies indicate that in real life many high risk patients are not evaluated invasively by coronary angiography as timely as recommended.

Is coronary revascularization required in a patient with chronic stable coronary artery disease or can optimized medical therapy (OMT) alone be a sufficient alternative? This question has been controversially discussed for non-diabetics as well as for diabetics since the COURAGE and BARI 2D trials. According to our present knowledge, a patient will benefit from coronary revascularization only when either a non-invasive test method, such as single photon emission computed tomography (SPECT) or positron emission tomography (PET) myocardial scintigraphy, stress echocardiography or stress nuclear magnetic resonance imaging, can detect relevant, objective evidence of ischemia >10% of the left ventricular myocardium or when a pathological fractional flow reserve (FFR) <0.80 can be measured in an invasive procedure for an angiographically detectable coronary stenosis. If similar relevant ischemia can be non-invasively or invasively objectified in a patient with chronic stable multivessel coronary artery disease, the often controversially discussed question arises particularly in diabetics whether a percutaneous coronary intervention (PCI) with implantation of drug-eluting stents or coronary artery bypass surgery should be favored. The FREEDOM study (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease), published in November 2012, was the first prospective randomized study to examine this issue in diabetic patients with multivessel coronary artery disease. Despite a higher rate of stroke in the surgical cohort, after an average follow-up time of 3.8 years a significant prognostic advantage in favor of bypass surgery was detected for a combined primary endpoint of all-cause mortality, nonfatal myocardial infarction and nonfatal stroke. Thus, in the new ESC guidelines on diabetes, pre-diabetes and cardiovascular diseases developed with the EASD of the European Society of Cardiology and published in 2013, coronary bypass surgery has a class I, level of evidence A recommendation for patients with diabetes mellitus, chronic stable multivessel coronary disease and a synergy between PCI with taxus and cardiac surgery (SYNTAX) score >22. The decision for or against a PCI/stent implantation or coronary bypass surgery in a diabetic patient with chronic stable multivessel coronary artery disease should therefore be made with the patient only after a detailed informed consent discussion and comprehensive explanation of both treatment options. In controversial cases, particularly with an equivocal SYNTAX score around 22, relevant comorbidities or anticipated method-specific complications, a one-stage ad hoc intervention during the diagnostic coronary angiography should be rejected in favor of a two-stage procedure with prior discussion of both treatment options in the heart team comprising noninvasive cardiologists, interventional cardiologists and cardiac surgeons.

This article gives an update on the management of ST-segment elevation myocardial infarction (STEMI) according to guidelines released in 2012 by the European Society of Cardiology. To ensure a reliable diagnosis the updated universal definition of myocardial infarction will also be covered which is defined by myocardial necrosis. Criteria for diagnosis are a rise or fall of cardiac biomarkers, preferably troponin, in conjunction with symptoms of myocardial ischemia, new repolarisation disorders or left bundle branch block, development of pathological Q-waves, new hypokinesia/akinesia or loss in viability or the detection of intracoronary thrombi during cardiac catheterization or autopsy. The current recommendations for primary diagnosis and treatment by the first medical contact will also be discussed and contains decision-making for the optimal reperfusion strategy. Primary percutaneous coronary intervention remains the preferred reperfusion strategy; however, specifications with respect to time for diagnosis and reperfusion have been introduced. Furthermore, establishing a STEMI network has been emphasized in more detail. Special attention is paid to the new antiplatelet agents and anticoagulation therapy where prasugrel and ticagrelor are currently preferred over clopidogrel.