103 research outputs found
The DAPT study
No full textBackground. Dopo impianto di stent è raccomandata la duplice terapia antiaggregante allo scopo di prevenire l’insorgenza di complicanze trombotiche, ma restano ancora da chiarire i benefici ed i rischi associati al prolungamento della doppia antiaggregazione oltre i 12 mesi. Metodi. Sono stati arruolati pazienti sottoposti ad angioplastica coronarica con impianto di stent medicato. Dopo 12 mesi di trattamento con tienopiridina (clopidogrel o prasugrel) e aspirina, i pazienti sono stati randomizzati a mantenimento della terapia con tienopiridina o a placebo per altri 18 mesi, in entrambi i casi con prosecuzione del trattamento con aspirina. Gli endpoint co-primari di efficacia erano rappresentati dalla trombosi di stent e dagli eventi avversi maggiori cardio- e cerebrovascolari (un composito di morte, infarto o ictus) nel periodo compreso fra 12 e 30 mesi. L’endpoint primario di sicurezza era costituito dalle emorragie moderate o severe. Risultati. Un totale di 9961 pazienti sono stati randomizzati a prosecuzione della terapia con tienopiridina o a placebo. Il mantenimento della duplice antiaggregazione rispetto al trattamento con placebo è risultato associato ad una riduzione della trombosi di stent (0.4 vs 1.4%; hazard ratio 0.29; intervallo di confidenza [IC] 95% 0.17-0.48; p<0.001) e degli eventi avversi maggiori cardio- e cerebrovascolari (4.3 vs 5.9%; hazard ratio 0.71; IC 95% 0.59-0.85; p<0.001). L’incidenza di infarto miocardico è stata inferiore nel gruppo a doppia antiaggregazione prolungata rispetto a quello trattato con placebo (2.1 vs 4.1%; hazard ratio 0.47; p<0.001). La mortalità da ogni causa è stata del 2.0% nel gruppo a doppia antiaggregazione prolungata e dell’1.5% nel gruppo placebo (hazard ratio 1.36; IC 95% 1.00-1.85; p=0.05). Il tasso di emorragie moderate o severe è risultato più elevato nel gruppo a doppia antiaggregazione prolungata (2.5 vs 1.6%; p=0.001). In entrambi i gruppi è stato osservato un rischio elevato di trombosi di stent e di infarto miocardico nei 3 mesi successivi alla sospensione della duplice terapia antiaggregante. Conclusioni. Dopo impianto di stent medicato, il prolungamento della doppia antiaggregazione oltre i 12 mesi, rispetto alla sola terapia con aspirina, ha determinato una significativa riduzione del rischio di trombosi di stent e di eventi avversi maggiori cardio- e cerebrovascolari ma è risultato associato ad un aumento del rischio emorragico. [N Engl J Med 2014;371:2155-66
Commentary: Temporarily omitting oral anticoagulants early after stenting for acute coronary syndromes patients with atrial fibrillation
No full textCovered Endovascular Reconstruction of Aortic Bifurcation Facilitated by Intravascular Lithotripsy With Shockwave Balloon: A Case Report
No full textAortoiliac occlusive disease (AIOD) is a specific form of peripheral artery disease (PAD) that affects the infrarenal aorta and iliac arteries. Patients with PAD commonly suffer from intermittent claudication (IC), a condition characterized by cramping pain during or after exercise that is relieved by rest. The first-line therapy for IC involves medical management, foot care, and structured exercise programs while revascularization therapy, which can be endovascular, surgical, or a combination of both, is generally reserved for patients with claudication who do not respond adequately to initial therapies. We present the clinical case of a 58-year-old female with hypertension, dyslipidemia, and a smoking habit who was referred to our hospital (Misericordia Hospital, Grosseto, Italy) due to bilateral IC of the buttocks and thighs. Computed tomography (CT) angiography revealed a 90% tight stenosis of the infrarenal abdominal aorta just above the iliac bifurcation with diffuse calcifications. After a careful evaluation of the patient's condition and anatomical characteristics of the atherosclerotic disease, the vascular team decided to perform covered endovascular reconstruction of aortic bifurcation (CERAB) with previous intravascular lithotripsy (IVL) with shockwave balloon using intravascular ultrasound (IVUS) as guidance, because of severe aortic luminal calcifications. We performed successful CERAB, and the patient was discharged in good clinical condition on the fifth day of hospitalization with an indication to follow optimal medical therapy. At the one-month clinical follow-up, the patient reported the disappearance of claudication with marked improvement in quality of life. This first described case of IVUS-guided IVL-facilitated CERAB demonstrates the efficacy and safety of IVL in calcific aortic disease and shows the usefulness of IVUS as guidance in peripheral calcium debulking procedures
[Management of antithrombotic therapy in patients undergoing implantation or replacement of cardiac implantable electronic devices]
No full textIn Italy tens of thousands of patients undergo implantation or replacement of cardiac implantable electronic devices (CIEDs) annually, and up to 50% of these subjects receive antiplatelet agents or oral anticoagulants. The rate of CIED-related complications, mainly infective, has also significantly increased, so that transvenous lead extraction procedures are often required. CIED surgery is peculiar and portends specific intrinsic risks of developing life-threatening hemorrhagic complications; on the other hand periprocedural discontinuation of antithrombotic therapy in patients at high thromboembolic risk may have catastrophic consequences. Accordingly, the management of candidates to CIED surgery who receive concomitant antithrombotic therapy is of great clinical relevance, though controversial and only partially, if not at all, adequately addressed in current evidence-based guidelines. Although for many procedures the administration of aspirin alone or continuation of anticoagulant therapy seems reasonably safe, with use of bridging therapy with parenteral heparins restricted to selected cases, there are multiple variables that may make therapeutic choices challenging. The aim of the present position paper is to provide practical recommendations for the management of antithrombotic therapy in patients undergoing CIED surgery by defining indications for a systematic approach integrating general technical considerations with patient-specific elements based on a careful evaluation of the balance between hemorrhagic and thromboembolic risk. The decision-making process applied in this document relies on the stratification of the procedural hemorrhagic risk and of the risk deriving from discontinuation of antiplatelet or anticoagulant therapy combined to produce different clinical scenarios with specific indications for optimal management of periprocedural antithrombotic therapy
Management of antithrombotic therapy in patients undergoing electrophysiological device surgery
No full textThe aim of this review is to formulate practical recommendations for the management of antithrombotic therapy in patients undergoing cardiac implantable electronic device (CIED) surgery by providing indications for a systematic approach to the problem integrating general technical considerations with patient-specific elements based on a careful evaluation of the balance between haemorrhagic and thromboembolic risk. Hundreds of thousands patients undergo implantation or replacement of CIEDs annually in Europe, and up to 50% of these subjects receive antiplatelet agents or oral anticoagulants. The rate of CIED-related complications, mainly infective, has also significantly increased so that transvenous lead extraction procedures are, consequently, often required. Cardiac implantable electronic device surgery is peculiar and portends specific intrinsic risks of developing potentially fatal haemorrhagic complications; on the other hand, the periprocedural suspension of antithrombotic therapy in patients with high thromboembolic risk cardiac conditions may have catastrophic consequences. Accordingly, the management of the candidate to CIED surgery receiving concomitant antithrombotic therapy is a topic of great clinical relevance yet controversial and only partially, if at all, adequately addressed in evidence-based current guidelines. In spite of the fact that in many procedures it seems reasonably safe to proceed with aspirin only or without interruption of anticoagulants, restricting to selected cases the use of bridging therapy with parenteral heparins, there are lots of variables that may make the therapeutic choices challenging. The decision-making process applied in this document relies on the development of a stratification of the procedural haemorrhagic risk and of the risk deriving from the suspension of antiplatelet or anticoagulant therapy combined to generate different clinical scenarios with specific indications for optimal management of periprocedural antithrombotic therapy
ST segment/heart rate hysteresis improves the diagnostic accuracy of ECG stress test for coronary artery disease in patients with left ventricular hypertrophy
No full textBackground The exercise electrocardiographic stress test (ExET) is the most widely used non-invasive diagnostic method to detect coronary artery disease. However, the sole ST depression criteria (ST-max) have poor specificity for coronary artery disease in patients with left ventricular hypertrophy. We hypothesised that ST-segment depression/heart rate hysteresis, depicting the relative behaviour of ST segment depression during the exercise and recovery phase of the test might increase the diagnostic accuracy of ExET for coronary artery disease detection in such patients. Methods In three cardiology centres, we studied 113 consecutive patients (mean age 66 ± 2 years; 88% men) with hypertension-related left ventricular hypertrophy at echocardiography, referred to coronary angiography after an ExET. The following ExET criteria were analysed: ST-max, chronotropic index, heart rate recovery, Duke treadmill score, ST-segment depression/heart rate hysteresis. Results We detected significant coronary artery disease at coronary angiography in 61 patients (53%). At receiver-operating characteristic analysis, ST-segment depression/heart rate hysteresis had the highest area under the curve value (0.75, P < 0.001 when compared with the 'neutral' receiver-operating characteristic curve value of 0.5). Area under the curve values were 0.68 (P < 0.01) for the chronotropic index, 0.58 (P = NS) for heart rate recovery, 0.57 (P = NS) for ST-max and 0.52 (P = NS) for the Duke treadmill score. Conclusions Among currently available ExET diagnostic variables, ST-segment depression/heart rate hysteresis offers a substantially better diagnostic accuracy for coronary artery disease than conventional criteria in patients with hypertension-related left ventricular hypertrophy
Optimal Antithrombotic Treatment of Patients with Atrial Fibrillation Early after an Acute Coronary Syndrome-Triple Therapy, Dual Antithrombotic Therapy with an Anticoagulant... Or, Rather, Temporary Dual Antiplatelet Therapy?
No full textThe combination of atrial fibrillation (AF) and acute coronary syndrome (ACS) is a complex situation in which a three-dimensional risk-cardioembolic, coronary, and hemorrhagic-has to be carefully managed. Triple antithrombotic therapy (TAT) is burdened with a high risk of serious bleeding, while dual antithrombotic therapy with an anticoagulant (DAT) likely provides only suboptimal coronary protection early after stent implantation. Moreover, TAT precludes the advantages provided by the use of the latest and more potent P2Y(12)inhibitors in ACS patients. Here, we aimed to simulate and compare the expected coronary, cardioembolic, and hemorrhagic outcomes offered by DAT, TAT, or modern dual antiplatelet therapy (DAPT) with aspirin plus one of the latest P2Y(12)inhibitors in AF patients early after an ACS. The comparison of numbers needed to treat to prevent major adverse events with the various antithrombotic regimens suggests that AF-ACS patients at high ischemic and hemorrhagic risk and at moderately low embolic risk (CHA(2)DS(2)VASc score 2-4) might safely withhold anticoagulation after revascularization for one month taking advantage of a modern DAPT, with a favorable risk-to-benefit ratio. In conclusion, this strategy, not sufficiently addressed in recent European and North American guidelines or consensus documents, adds to the spectrum of treatment options in these difficult patients; it might be the best choice in a substantial number of patients; and should be prospectively tested in a randomized controlled trial
Long-Term Outcomes of Patients With Acute Coronary Syndrome and Nonobstructive Coronary Artery Disease
No full textPatients with acute coronary syndrome (ACS) and nonobstructive coronary artery disease (CAD) have a substantial risk of subsequent coronary events within 1 year. The aim of the present study was to evaluate the prevalence, long-term outcomes, and adherence to oral antiplatelet therapy in patients with ACS and nonobstructive CAD compared with patients with ACS and obstructive CAD who had undergone percutaneous coronary intervention. Nonobstructive CAD was defined as an angiographic finding of <50% diameter stenosis in any major epicardial artery. These patients were further stratified into 2 groups: those with normal coronary arteries (0% angiographic stenosis) and those with mild CAD (0% to 50% angiographic stenosis). Major adverse cardiac events, defined as death, myocardial infarction, ACS leading to hospitalization, and nonfatal stroke, were recorded and compared with a historical control group of patients with ACS and obstructive CAD who had undergone percutaneous coronary intervention. Of 2,438 consecutive patients with ACS undergoing coronary angiography, 318 (13%) had nonobstructive CAD. Of the 318 with nonobstructive CAD, 160 had normal coronary arteries and 158 had mild CAD. Patients with obstructive CAD had experienced greater rates of major adverse cardiac events at 26 ± 16 months (16.6% vs 9.1%, p = 0.001), driven by a greater rate of myocardial infarction compared with those without (5.3% vs 0%, p <0.001). However, the rate of death, ACS leading to hospitalization, and stroke was similar. After adjusting for baseline characteristics, no difference was found in the risk of major adverse cardiac events across the groups. Only 50% of patients with nonobstructive CAD were prescribed dual antiplatelet therapy. In conclusion, patients with ACS and nonobstructive CAD remain at high risk of long-term recurrent ischemic events
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