<International Circulation>: STEMI/PCI guidelines were updated in this meeting， what is new and what are the reasons for this update? What’s new in the reperfusion therapies for acute myocardial infarction and the medical management of unstable angina pectoris?

    Prof. Smith: This update was triggered by eighteen new randomized clinical trials which were deemed to be very important with regard to STEMI and PCI. The update was done very quickly as we feel that the writing of total guidelines may frequently take up to two years yet the cardiovascular community really needs and benefits from information regarding important current trials. So this is why we have done a focused update. One of the major recommendations to come out of this update was that every community in the United States set up a very well coordinated network to care for patients with heart attacks. It is remarkable， even astounding， that that has not occurred earlier with competition between hospitals for patients and so forth. A strong Class I recommendation is that the EMS (emergency response system) and the local hospitals (those that do PCI and those that do not)， really begin to look at how they coordinate the care of patients. The preferred approach to acute myocardial infarction at this point is still reperfusion with PCI. However， many patients can get into an emergency room with the capability for fibrinolysis much quicker than they can get in for PCI. Some of the trials that were very important， CARESS and TRANSFER-AMI， looked at patients with high risk who came in with evidence of heart failure and a prominent degree of ST-elevation anteriorly and other markers of high risk that were given fibrinolysis and then asked the question， should they be transferred immediately for PCI， or could they wait and undergo PCI electively and having it emergently only if they had a recurrence of symptoms? Both studies showed that there was a better outcome if high risk patients undergoing fibrinolysis were transferred immediately for PCI. The endpoints were multiple endpoints， multiple adverse cardiac events (MACE) and if we look closer at the data and separate out these endpoints， which of course is not a driving factor but always interesting to do， neither study suggested a difference in mortality and in both studies the major difference seemed to be in elimination of recurrent refractory ischemia. We made the recommendation about transfer largely on those studies. Those are important findings. We also have some recommendations about the use of IIb/IIIa receptor antagonists. Previously， we felt the data favoring large molecule abciximab given at the time of catheterization was much greater than for the s