refludan and Coronary-Thrombosis

Acute coronary syndromes encompass a spectrum of conditions, including myocardial infarction and unstable angina. These syndromes are related to the formation and disruption of atherosclerotic plaque. Rupture of plaque leads to thrombin generation, fibrin deposition, and platelet aggregation, ultimately resulting in restriction of blood flow and ischemia of cardiac tissue. Percutaneous coronary intervention (PCI), including angioplasty and coronary stent placement, has been developed to open occluded arteries. The frequency with which these procedures are performed speaks to their largely successful outcomes. However, the mechanical manipulations of PCI result in additional plaque rupture and damage to the vessel wall, exposing subendothelial components to blood and resulting in the initiation of the clotting cascade and in platelet activation. Left unchecked, these intertwined processes lead to formation of arterial thrombi at the site of endothelial damage, and potentially to abrupt vessel closure or embolization of thrombi into the distal microcirculation. Thrombin plays a central role in thrombus formation and platelet activation, and its inhibition significantly reduces thrombus-related sequelae. Current antithrombotic strategies during PCI are based on the traditional indirect thrombin inhibitor heparin. Heparin has several limitations in efficacy and safety, due in part to its indirect mechanism of action. Bivalirudin, a direct thrombin inhibitor, offers significant improvement over heparin in the clinical outcomes and risks associated with PCI.

Topics: Angioplasty, Balloon, Coronary; Arginine; Clinical Trials as Topic; Coronary Disease; Coronary Thrombosis; Fibrinolytic Agents; Fondaparinux; Heparin; Hirudins; Humans; Peptide Fragments; Pipecolic Acids; Polysaccharides; Recombinant Proteins; Sulfonamides; Thrombin

Topics: Aged; Antithrombins; Aortic Valve Stenosis; Coronary Angiography; Coronary Thrombosis; Echocardiography; Enzyme-Linked Immunosorbent Assay; Female; Heart Valve Prosthesis Implantation; Heparin; Hirudins; Humans; Intra-Aortic Balloon Pumping; Recombinant Proteins; Thrombocytopenia

A 49-year-old man was admitted with high-risk left ventricular thrombosis and systemic embolization. Prompt and complete resolution of the thrombus was achieved under intravenous lepirudin administration but not under full-dose heparin treatment. Medical physicians, including emergency medicine physicians, cardiologists, cardiac surgeons, and hematologists, should become more aware of these alternative anticoagulant treatments, especially in cases when other therapeutic options (such as thrombolysis or cardiac surgery) may be associated with high morbidity or mortality.

Topics: Coronary Thrombosis; Echocardiography; Fibrinolytic Agents; Heart Ventricles; Heparin; Hirudins; Humans; Male; Middle Aged; Recombinant Proteins; Treatment Failure; Treatment Outcome

An 81-year-old woman with a history of prior coronary artery bypass surgery, heparin-induced thrombocytopenia with "white clot" syndrome, and renal insufficiency presented with unstable angina. She was referred for cardiac catheterization. Complex percutaneous revascularization of the native circumflex coronary artery was performed using stents. A combination of tirofiban and lepirudin was used with dosing adjusted for renal insufficiency. The hospital course was uncomplicated and the patient was discharged on the fourth hospital day. This is only the second report of the combination use of direct thrombin inhibitor and glycoprotein IIb/IIIa receptor inhibitor.

Topics: Aged; Aged, 80 and over; Anticoagulants; Combined Modality Therapy; Coronary Artery Disease; Coronary Thrombosis; Drug Therapy, Combination; Female; Fibrinolytic Agents; Heparin; Hirudin Therapy; Hirudins; Humans; Platelet Aggregation Inhibitors; Recombinant Proteins; Renal Insufficiency; Stents; Thrombocytopenia; Tirofiban; Tyrosine