Key Points
Patients with leukemia are often denied percutaneous coronary intervention (PCI), and those who do undergo PCI are older and sicker.
There is a minor increase in vascular complications and ...no increase in retroperitoneal bleeds, suggesting transfusions may be given for reasons unrelated to the PCI.
Since cardiac complications are not increased in leukemia patients, the increased mortality observed in after PCI in acute leukemia may be related more to underlying malignancy.
Directional coronary atherectomy revisited Grines, Cindy L.; Marshall, J. Jeffrey
Catheterization and cardiovascular interventions,
July 1, 2022, 2022-07-00, 20220701, Volume:
100, Issue:
1
Journal Article
Peer reviewed
Key Points
Historically, DCA was able to achieve large lumen diameter and reduction in restenosis but at a cost of higher peri‐procedural MI.
Use of a new DCA device in a Japanese registry ...demonstrated superior acute success and similar in‐hospital complications to PCI without DCA.
DCA may be useful as a niche application in some coronary lesions, but the exact role will need to be defined by additional studies.
Combining Antiplatelet and Anticoagulant Therapies Holmes, David R., MD; Kereiakes, Dean J., MD; Kleiman, Neal S., MD ...
Journal of the American College of Cardiology,
07/2009, Volume:
54, Issue:
2
Journal Article
Peer reviewed
Open access
Antiplatelet therapy is the cornerstone for both primary and secondary prevention therapies for ischemic events resulting from coronary atherosclerotic disease. Dual antiplatelet therapy (aspirin ...plus a thienopyridine, usually clopidogrel) has assumed a central role in the treatment of acute coronary syndromes and after coronary stent deployment. In addition to antiplatelet therapy, anticoagulant therapy might be indicated for stroke prevention in a variety of conditions that include atrial fibrillation, profound left ventricular dysfunction, and after mechanical prosthetic heart valve replacement. For this reason, the use of triple antithrombotic therapy (a dual antiplatelet regimen plus warfarin) is expected to become more prominent, given an aging patient population. But although triple therapy can prevent both thromboembolism and stent thrombosis, it is also associated with significant bleeding hazards. Furthermore, when bleeding events do occur, the challenge of balancing the risk of stent thrombosis or stroke and the need for hemostasis requires considerable expertise. It is both prudent and timely to review treatment strategies that employ combinations of antiplatelet and anticoagulant therapies as well as strategies aimed at reducing bleeding risk in patients treated with these therapies.
Key Points
Anatomy and physiology do not correlate well for the borderline stenosis.
FFR (and NHPR) identify patients who will benefit more than those undergoing percutaneous coronary intervention ...(PCI) based on anatomy alone.
For the borderline lesion in the SIHD patient, apply physiology for when to treat, and anatomy (imaging) for how to treat.
Gender disparities in ST-segment elevation myocardial infarction (STEMI) outcomes continue to be reported worldwide; however, the magnitude of this gap remains unknown. To evaluate gender-based ...discrepancies in clinical outcomes and identify the primary driving factors a global meta-analysis was performed. Studies were selected if they included all comers with STEMI, reported gender specific patient characteristics, treatments, and outcomes, according to the registered PROSPERO protocol: CRD42020161469. A total of 56 studies (705,098 patients, 31% females) were included. Females were older, had more comorbidities and received less antiplatelet therapy and primary percutaneous coronary intervention (PCI). Females experienced significantly longer delays to first medical contact (mean difference 42.5 min) and door-to-balloon time (mean difference 4.9 min). In-hospital, females had increased rates of mortality (odds ratio OR 1.91, 95% confidence interval CI 1.84 to 1.99, p <0.00001), repeat myocardial infarction (MI) (OR 1.25, 95% CI 1.00 to 1.56, p=0.05), stroke (OR 1.67, 95% CI 1.27 to 2.20, p <0.001), and major bleeding (OR 1.82, 95% CI 1.56 to 2.12, p <0.00001) compared with males. Older age at presentation was the primary driver of excess mortality in females, although other factors including lower rates of primary PCI and aspirin usage, and longer door-to-balloon times contributed. In contrast, excess rates of repeat MI and stroke in females appeared to be driven, at least in part, by lower use of primary PCI and P2Y12 inhibitors, respectively. In conclusion, despite improvements in STEMI care, women continue to have in-hospital rates of mortality, repeat MI, stroke, and major bleeding up to 2-fold higher than men. Gender disparities in in-hospital outcomes can largely be explained by age differences at presentation but comorbidities, delays to care and suboptimal treatment experienced by women may contribute to the gender gap.
Key Points
Multivessel disease patients who are incompletely revascularized with PCI have have worse clinical outcomes including death and need for subsequent revascularization
The mechanism of ...increased mortality with incomplete revascularization is uncertain, and is confounded by higher atherosclerotic burden and more comorbidities
Although we recommend complete revascularization, there are no randomized trials except in the STEMI population.
Many trials have been done to compare primary percutaneous transluminal coronary angioplasty (PTCA) with thrombolytic therapy for acute ST-segment elevation myocardial infarction (AMI). Our aim was ...to look at the combined results of these trials and to ascertain which reperfusion therapy is most effective.
We did a search of published work and identified 23 trials, which together randomly assigned 7739 thrombolytic-eligible patients with ST-segment elevation AMI to primary PTCA (n=3872) or thrombolytic therapy (n=3867). Streptokinase was used in eight trials (n=1837), and fibrin-specific agents in 15 (n=5902). Most patients who received thrombolytic therapy (76%, n=2939) received a fibrin-specific agent. Stents were used in 12 trials, and platelet glycoprotein IIb/IIIa inhibitors were used in eight. We identified short-term and long-term clinical outcomes of death, non-fatal reinfarction, and stroke, and did subgroup analyses to assess the effect of type of thrombolytic agent used and the strategy of emergent hospital transfer for primary PTCA. All analyses were done with and without inclusion of the SHOCK trial data.
Primary PTCA was better than thrombolytic therapy at reducing overall short-term death (7% n=270
vs 9% 360; p=0·0002), death excluding the SHOCK trial data (5% 199
vs 7% 276; p=0·0003), non-fatal reinfarction (3% 80
vs 7% 222; p<0·0001), stroke (1% 30
vs 2% 64; p=0·0004), and the combined endpoint of death, non-fatal reinfarction, and stroke (8% 253
vs 14% 442; p<0·0001). The results seen with primary PTCA remained better than those seen with thrombolytic therapy during long-term follow-up, and were independent of both the type of thrombolytic agent used, and whether or not the patient was transferred for primary PTCA.
Primary PTCA is more effective than thrombolytic therapy for the treatment of ST-segment elevation AMI.
Key Points
Despite performing more complex percutaneous coronary interventions, the risk of perforation remains stable.
Newer covered stents are lower profile, easier to deliver, and have high ...initial success rates but similar to older covered stents, the risk of thrombosis and restenosis remains.
We propose routine intravascular imaging to optimize covered stents, avoid reversal of anticoagulation until hardware is removed from the coronary and vigilant follow‐up for thrombosis and/or restenosis.
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