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[Short dual antiplatelet therapy: how, when and why].
Ditali, V, Carrozzi, C, Leonardi, S
Giornale italiano di cardiologia (2006). 2020;(2 Suppl 1):14S-25S
Abstract
Dual antiplatelet therapy (DAPT) is a cornerstone of antithrombotic treatment in patients undergoing percutaneous coronary intervention. The optimal duration of DAPT, i.e. the minimal period needed to ensure the best safety and efficacy, to prevent ischemic complications, including stent thrombosis, has been extensively explored in multiple randomized controlled trials over the last years. Accumulating evidence is supporting a clinical approach where there is a prevailing role of the risk of bleeding: in patients at high bleeding risk (HBR) it is generally advisable to reduce the duration of DAPT irrespective of their risk of thrombosis. In addition, among HBR patients, (i) new recommendations prefer direct oral anticoagulants (DOAC) over vitamin K antagonists in DOAC-eligible patients with atrial fibrillation and coronary artery disease; (ii) measures to minimize bleedings while on DAPT should be pursued, including de-escalation of P2Y12 receptor inhibitor therapy; and (iii) new studies are testing reversal strategies for short DAPT regimens, with early discontinuation of aspirin. In the present review, we discuss the rationale and decision-making considerations to reduce safely DAPT duration in HBR patients.
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2.
Device Based Approaches to the Prevention of Contrast-Induced Acute Kidney Injury.
Nanayakkara, S, Kaye, DM
Interventional cardiology clinics. 2020;(3):395-401
Abstract
Contrast-induced acute kidney injury is not uncommon after percutaneous coronary intervention, particularly in high-risk patients. Pharmacologic approaches have not demonstrated significant benefit, and numerous device-based approaches exist targeting a variety of pathways. In this review, we summarize the most recent interventions and the evidence behind them.
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3.
Weighing Coronary Revascularization Options in Patients With Type 2 Diabetes Mellitus.
Godoy, LC, Tavares, CAM, Farkouh, ME
Canadian journal of diabetes. 2020;(1):78-85
Abstract
Patients with diabetes mellitus (DM) are at increased risk for developing coronary artery disease. Choosing the optimal revascularization strategy, such as coronary artery bypass grafting or percutaneous coronary intervention (PCI), may be difficult in this population. A large body of evidence suggests that, for patients with DM and stable multivessel ischemic heart disease, coronary artery bypass grafting is usually superior to PCI, leading to lower rates of all-cause mortality, myocardial infarction and repeat revascularization in the long term. In patients with less complex coronary anatomy (2- or single-vessel disease, especially without involvement of the proximal left anterior descendent artery), PCI may be a viable option. Because these anatomic patterns are less frequent in patients with DM, there is less evidence to guide revascularization in these cases. Patients with DM and left main disease and those in the acute coronary syndrome setting are also underrepresented in randomized trials, and the best revascularization strategy for these patients is not clear. Once the revascularization procedure is performed, patients should be kept engaged in controlling the risk factors for progression of cardiovascular disease. Avoidance of smoking, control of cholesterol, blood pressure and glycemic levels; regular practice of physical activity of at least moderate intensity; and a balanced diet are of key importance in the post-revascularization period. In this study, we review the current literature in the management of patients with DM and coronary artery disease undergoing a revascularization procedure.
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4.
Implications of Kidney Disease in the Cardiac Patient.
Nicolas, J, Claessen, B, Mehran, R
Interventional cardiology clinics. 2020;(3):265-278
Abstract
Cardiovascular and renal diseases share common pathophysiological grounds, risk factors, and therapies. The 2 entities are closely interlinked and often coexist. The prevalence of kidney disease among cardiac patients is increasing. Patients have an atypical clinical presentation and variable disease manifestation versus the general population. Renal impairment limits therapeutic options and worsens prognosis. Meticulous treatment and close monitoring are required to ensure safety and avoid deterioration of kidney and heart functions. This review highlights recent advances in the diagnosis and treatment of cardiac pathologies, including coronary artery disease, arrhythmia, and heart failure, in patients with decreased renal function.
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5.
Management of Angina Post Percutaneous Coronary Intervention.
Cruz Rodriguez, JB, Kar, S
Current cardiology reports. 2020;(2):7
Abstract
PURPOSE OF REVIEW Our review discusses the management of post percutaneous coronary intervention angina (PPCIA) which negatively impacts 20-40% of patients and imposes a high burden on the healthcare system. RECENT FINDINGS Mechanisms of PPCIA include microvascular dysfunction, distal coronary vasospasm or disease, microembolization, myocardial bridge, coronary artery disease (CAD) progression, and rarely stent thrombosis or in-stent restenosis. Nitrates, beta blockers (BB), calcium channel blockers, and ranolazine are the common medical management options. Only BB showed 1-year mortality benefit following myocardial infarction. Stress echocardiography and cardiac magnetic resonance are the best to detect CAD vs. microvascular dysfunction. Invasively, vasoprovocative testing and fractional flow reserve provide useful prognostic information. If the ischemia burden is ≤10%, conservative management should be considered based upon the individual patient scenario. The optimal management of PPCIA remains unclear and further research is necessary. Multiple treatment options exist, which should be implemented in an individualized fashion.
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6.
Intracoronary Lithotripsy for the Treatment of Calcified Plaque.
Yeoh, J, Hill, J
Interventional cardiology clinics. 2019;(4):411-424
Abstract
Intravascular lithotripsy facilitates percutaneous coronary intervention of lesions with severe calcification by using high-pressure ultrasonic energy. It is the newest adjunctive tool for calcium modification and is showing promise as its users gather more experience and it becomes readily available worldwide. This article reviews intravascular lithotripsy technology, the evidence in the literature, and the advantages and disadvantages compared with other forms of calcium modification, and discusses its role in specific subsets of coronary lesions. It concludes with a discussion about the future direction of research involving this new technology as its role within percutaneous cardiac procedures becomes more defined.
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7.
Effect of Alprostadil on the Prevention of Contrast-Induced Nephropathy: A Meta-Analysis of 36 Randomized Controlled Trials.
Xie, J, Jiang, M, Lin, Y, Deng, H, Li, L
Angiology. 2019;(7):594-612
Abstract
Contrast-induced nephropathy (CIN) is the third leading cause of acquired acute renal injury in hospitalized patients. Alprostadil plays a role in the maintenance and redistribution of intrarenal blood flow and the excretion of electrolytes and water. However, the effectiveness of alprostadil in preventing CIN remains controversial. Thirty-six articles with a total of 5495 patients were included in this study. Both groups (experimental group and control group) received standard hydration therapy. In the experimental group, patients received different doses of alprostadil. Serum creatinine (SCr), blood urea nitrogen (BUN), estimated glomerular filtration rate (eGFR), cystatin C, creatinine clearance rate (CCr), and β2-microglobulin (β2-MG) were measured at 24, 48, and 72 hours after contrast media injection. The incidence of CIN in the experimental group was significantly lower than that in the control group (6.56% vs 16.74%). The level of SCr, cystatin C, BUN, and β2-MG in the experimental group was lower than those in the control group; CCr and eGFR in the experimental group were higher than those in the control group. This study demonstrated that alprostadil may reduce the incidence of CIN in patients undergoing coronary angiogram and/or percutaneous coronary intervention.
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8.
Chronic Total Occlusion Wiring: A State-of-the-Art Guide From The Asia Pacific Chronic Total Occlusion Club.
Wu, EB, Tsuchikane, E, Lo, S, Lim, ST, Ge, L, Chen, JY, Qian, J, Lee, SW, Kao, HL, Harding, SA
Heart, lung & circulation. 2019;(10):1490-1500
Abstract
OBJECTIVE Despite the advances in wire technology and development of algorithm-driven methodology for chronic total occlusion (CTO) intervention, there is a void in the literature about the technical aspects of CTO wiring. The Asia Pacific CTO Club, a group of 10 experienced operators in the Asia Pacific region, has tried to fill this void with this state-of-the-art review on CTO wiring. METHODS This review explains, for proximal cap puncture: choices of wires, shaping of the wire, use of dual lumen catheter, and method of step-down of wire penetration force for successful wiring. In wiring the CTO body, the techniques of loose tissue tracking, intentional intimal plaque tracking, and intentional subintimal wiring are described in detail. For distal lumen wiring, a blunt distal cap, presence of a distal cap side branch, calcium, and sharp tapered distal stump predict cap toughness, and wire penetration force should be stepped-up in these cases. The importance of choosing between redirection, parallel wiring, and Stingray (Boston Scientific, Marlborough, MA, USA) for angiographic guidance is discussed along with which will be more successful. On the retrograde side, the problems encountered with distal cap puncture and methods to overcome these problems are explained. The method of wiring the CTO body through a retrograde approach depending on the morphology of the CTO is described. Different reverse controlled antegrade and retrograde tracking (CART) wiring methods - including end balloon wiring, side balloon entry, and conventional reverse CART - are explained in detail. CONCLUSION This is a systematic CTO wiring review, which is believed to be beneficial for CTO operators worldwide.
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9.
Antithrombotic treatment in atrial fibrillation patients undergoing PCI: Is dual therapy the winner?
Mantis, C, Alexopoulos, D
Thrombosis research. 2019;:133-139
Abstract
Approximately 7% of patients undergoing percutaneous coronary intervention (PCI) with stent implantation have atrial fibrillation. The optimal antithrombotic treatment in such of patients remains one of the most challenging and difficult scenarios in Cardiology. Triple antithrombotic therapy (TAT), consisting of dual antiplatelet therapy plus an oral anticoagulant, has been used for decades in order to reduce ischemic and thromboembolic events, while significantly increasing the risk for severe bleeding. Recently, results of several clinical trials suggest that the use of dual antithrombotic therapy (DAT), consisting of single antiplatelet therapy plus an oral anticoagulant, reduces the risk of bleeding, while maintaining the same level of efficacy as compared to TAT. These data have been interpreted in a variety of ways, often giving conflicting recommendations and leaving many unanswered questions on the optimal antithrombotic treatments of patients with atrial fibrillation who undergo PCI. DAT consisting of a non-vitamin K antagonist oral anticoagulant and clopidogrel, while omitting aspirin from the immediate post discharge period, appears as an attractive, simplified strategy for most patients and supported by many experts in the field. In this review we aim to better define the role of DAT versus TAT in atrial fibrillation patients undergoing PCI and analyze remaining controversial issues and future expectations.
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10.
Bivalirudin during percutaneous coronary intervention in acute coronary syndromes.
Laine, M, Lemesle, G, Dabry, T, Panagides, V, Peyrol, M, Paganelli, F, Bonello, L
Expert opinion on pharmacotherapy. 2019;(3):295-304
Abstract
INTRODUCTION Anticoagulant therapy is critical to prevent ischemic recurrences and complications in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). Unfractionated heparin (UFH), an injectable anticoagulant has several limitations: lack of predictability of its biological efficacy, platelets activation, heparin-induced thrombopenia and bleedings. Bivalirudin, a synthetic direct thrombin inhibitor has biological properties that promised better clinical outcome in ACS patients undergoing PCI. AREAS COVERED The present review aimed to summarize two decades of randomized clinical trials that compared bivalirudin to UFH in ACS patients treated with PCI. Early trials highlighted a reduction of bleedings with bivalirudin compared to UFH in combination with glycoprotein inhibitors (GPI). Recent studies questioned this reduction given that GPI are less and less used during PCI. Further, trials raised concerns about the risk of stent thrombosis in patients treated with bivalirudin. In light of this data, bivalirudin has been downgraded in international guidelines and appears as a second line anticoagulant agent after UFH. EXPERT OPINION The highly questioned reduction of bleedings under bivalirudin and the potential risk of stent thrombosis are unwarranted. Based on clinical trials, UFH has no equivalent in terms of anticoagulation in ACS patients undergoing PCI.