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A structured review supports long-term low-dose aspirin plus a P2Y12-receptor inhibitor for 1 year. |
| More than 90% of percutaneous coronary interventions also involve stent placement. Stent thrombosis is a major complication of stent placement, and preventing it is the main goal of post-stent management. To determine the optimal approach to post-stent management, researchers conducted a structured literature review of 91 randomized trials, systematic reviews, and meta-analyses.
Dual antiplatelet therapy with long-term, low-dose aspirin (75–100 mg daily) plus a P2Y12-receptor inhibitor (usually clopidogrel) for 1 year after stent placement is the standard recommendation. Although this recommendation applies to both drug-eluting and bare-metal stents, a shorter duration of clopidogrel therapy (minimum of 1 month) is considered to be permissible for patients who have received bare-metal stents for nonacute coronary syndrome indications. Higher doses of aspirin (>200 mg daily) are associated with a twofold higher risk for bleeding, with no additional benefit. Risk for stent thrombosis continues beyond 1 year; however, studies of P2Y12-receptor inhibitor use beyond 1 year show no benefit in the face of elevated bleeding risk. Large clinical trials of shorter and longer durations of P2Y12-receptor inhibition are under way. COMMENTThree P2Y12-receptor inhibitors are available. However, adverse events have limited use of prasugrel (Effient) and ticagrelor (Brilinta). Studies of optimal clopidogrel dosing suggest that bleeding risk rises with higher doses; thus, the current recommendation is for a 300-mg loading dose followed by 75 mg daily. Because adding warfarin (i.e., for patients with atrial fibrillation or mechanical heart valves) is associated with two- to threefold higher risk for major bleeding complications, aspirin should be discontinued while patients receive warfarin. If at all possible, noncardiac elective surgery should be delayed until 1 full year of dual antiplatelet therapy with aspirin and clopidogrel is completed. Patients at high risk for bleeding should take proton-pump inhibitors while receiving dual antiplatelet therapy. Based on anticipated studies, clinicians soon might have more guidance for tailoring dual antiplatelet therapy duration to a patient’s specific clinical profile and type of stent. |
percutaneous coronary intervention
High incidence of acute coronary occlusion in patients without protocol positive ST segment elevation referred to an open access primary angioplasty programme.
Abstract
Background Primary percutaneous coronary intervention (PPCI) programmes vary in admission criteria from open referral to acceptance of electrocardiogram (ECG) protocol positive patients only. Rigid criteria may result in some patients with acutely occluded coronary arteries not receiving timely reperfusion therapy.
Objective To compare the prevalence of acute coronary occlusion and, in these cases, single time point biomarker estimates of myocardial infarct size between patients presenting with protocol positive ECG changes and those presenting with less diagnostic changes in the primary angioplasty cohort of an open access PPCI programme.
Methods We retrospectively performed a single centre cross sectional analysis of consecutive patients receiving PPCI between January and August 2008. Cases were categorised according to presenting ECG—group A: protocol positive (ST segment elevation/left bundle branch block/posterior ST elevation myocardial infarction), group B: ST segment depression or T-wave inversion, or group C: minor ECG changes. Clinical characteristics, coronary flow grades and 12 h postprocedure troponin-I levels were reviewed.
Results During the study period there were 513 activations of the PPCI service, of which 390 underwent immediate angiography and 308 underwent PPCI. Of those undergoing PPCI, 221 (72%) were in group A, 41 (13%) in group B and 46 (15%) in group C. Prevalence of coronary occlusion was 75% in group A compared with 73% in group B and 63% in group C. Median 12 h postintervention troponin-I (25th–75th percentile) for those with coronary occlusion was significantly higher in group A patients; 28.9 μg/l (13.2–58.5) versus 18.1 μg/l (6.7–32.4) for group B (p=0.03); and 15.5 μg/l (3.8–22.0) for group C (p<0.001), suggesting greater infarct size in group A.
Conclusions A number of patients referred to an open access PPCI programme have protocol negative ECGs but myocardial infarction and acute coronary artery occlusion amenable to angioplasty.
Source: PMJ. BMJ
If Possible, STEMI Patients Should Go Straight to a Cath Lab.
Within a system designed to reduce time to reperfusion, mortality was lower in patients transported directly to a PCI-capable center than in those transferred from a non–PCI-capable center.
In the city of Ottawa, emergency medical system providers trained in electrocardiogram interpretation can triage patients with ST-segment-elevation myocardial infarction (STEMI) directly to a center with percutaneous coronary intervention (PCI) capability. In a registry study, investigators compared outcomes in 822 patients transported directly to a PCI-capable hospital with those in 567 patients transported initially to a non–PCI-capable hospital, then transferred for primary PCI.
The median door-to-balloon time was significantly shorter in patients transported directly for PCI (66 minutes) than in those transferred for PCI (117 minutes). At 180 days, all-cause mortality was lower in directly transported patients than in those first taken to a non–PCI-capable hospital (5.0% vs. 11.5%; P<0.001). After multivariable adjustment, direct transfer was associated with about a 50% reduction in mortality risk (odds ratio, 0.52; P=0.01).
Comment: This study strengthens evidence that standardized geographic protocols designed to reduce time to reperfusion for ST-segment-elevation myocardial infarction reduce mortality. The importance of prehospital STEMI diagnosis and systems for rapid transport and treatment are now reflected in guideline recommendations (JW Cardiol Jan 6 2010), and implementation of these practices should be a public-health priority.
Source: Journal Watch Cardiology
Does Appropriateness of PCI Influence Procedural Outcomes?
An analysis of registry data reveals no such association, suggesting that patient selection and procedural performance should be assessed separately.
Appropriate use criteria (AUC) for percutaneous coronary intervention (PCI) have become a major quality metric for patient selection and resource utilization. In this analysis, investigators made use of the National Cardiovascular Data Registry to determine whether an association exists between adherence to AUC and in-hospital outcomes of PCI.
Included were 203,561 patients undergoing PCI for nonacute indications at 779 hospitals during 2009–2011. A total of 12.1% of the procedures were classified as inappropriate (range, 0%–56.6%). Compared with the hospital tertile with the lowest median rate of inappropriate PCI (5.3%), the tertile with the highest rate (20.0%) had similar risk-adjusted in-hospital mortality (0.3%; odds ratio, 1.12; P=0.35) and periprocedural bleeding rate (1.7%; OR, 1.02; P=0.07), as well as a similar rate of guideline-recommended medications provision at discharge (85.2%; P=0.58).
Comment: These investigators failed to find an association between inappropriate percutaneous coronary intervention and in-hospital outcomes, suggesting that patient selection for PCI by appropriate use criteria represents an aspect of PCI quality that differs from processes of care assessed by other metrics, including postprocedure outcomes. The wide range of variation in PCI appropriateness among hospitals is cause for concern, but these findings indicate that AUC adherence alone is an insufficient measure of the quality of PCI at any given hospital.
Source: Journal Watch Cardiology
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