thienopyridine and Coronary-Disease

In 2006, the American College of Cardiology, American Heart Association, and Society for Cardiovascular Interventions published the 2005 update of the evidence-based guidelines for the treatment of patients undergoing percutaneous coronary intervention (PCI). Together with procedural recommendations, these guidelines for percutaneous coronary intervention provide clinicians with guidance in the appropriate use of adjunctive pharmacologic therapy in patients undergoing PCI. However, there remain substantial variations in practice among clinicians and within and across institutions. Furthermore, the guidelines (being a static document) cannot incorporate additional evidence that has accumulated since their publication. Several landmark trials, notably Intracoronary Stenting and Antithrombotic Regimen-Rapid Early Action for Coronary Treatment (ISAR-REACT 2) and Acute Catheterization and Urgent Intervention Triage strategY (ACUITY), have added substantially to the knowledge base about pharmacologic therapy since publication of the guidelines. This article is therefore intended to discuss implementation into clinical practice of the revised guidelines for antiplatelet and antithrombotic pharmacologic therapy during PCI and to evaluate recent clinical evidence and make recommendations for revision of the guidelines incorporating the outcomes of recently completed trials.

Topics: American Heart Association; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Clopidogrel; Combined Modality Therapy; Coronary Disease; Drug-Eluting Stents; Hirudins; Humans; Peptide Fragments; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Practice Guidelines as Topic; Pyridines; Recombinant Proteins; Societies, Medical; Thrombolytic Therapy; Ticlopidine; United States

Great strides in interventional pharmacotherapy have been made over the past few decades, virtually all focused on optimizing peri-PCI antithrombotic therapy in order to reduce thrombotic complications. Our understanding of the role of platelets and of antiplatelet therapies in this process continues to evolve. Today, dual or even triple antiplatelet therapy has become standard of care at the time of PCI followed by dual therapy long-term in the majority of patients. However, currently available oral regimens are hampered by limitations including the need to initiate treatment at least a few hours before the procedure to achieve maximum benefit and the safety issues surrounding irreversible platelet inhibition in the uncommon, but not rare situations when a patient requires surgical revascularization. These limitations have led to the suboptimal "real-world" utilization of these proven agents and have fostered the development of a wide variety of alternative platelet inhibitors with theoretical, but still unproven clinical benefits. There are ample clinical data that strongly support the use of aspirin and clopidogrel in virtually all patients undergoing a PCI today. This review will highlight these data as well as emphasize the gaps in our understanding. (c) 2007 Wiley-Liss, Inc.

Topics: Administration, Oral; Angioplasty, Balloon, Coronary; Aspirin; Clopidogrel; Combined Modality Therapy; Coronary Disease; Coronary Thrombosis; Dose-Response Relationship, Drug; Humans; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Pyridines; Ticlopidine

Dual antiplatelet therapy with aspirin and a thienopyridine has become the standard of care for patients undergoing percutaneous intervention with stenting, regardless of indication. This article will examine the evidence for and against the use of aspirin and thienopyridines, with emphasis on platelet resistance and nonresponsiveness. Data suggest that in some patients, clopidogrel plus aspirin is not superior to aspirin alone. Resistance to aspirin and clopidogrel has been reported. Patients exhibiting aspirin resistance, as measured by an elevated platelet aggregate ratio, have a 10-fold increase in the risk of recurrent vascular events as compared to aspirin-sensitive patients. Clopidogrel nonresponsiveness has been a consistently observed phenomenon in studies utilizing various P2Y12 receptor-specific assays. Nonresponsiveness to clopidogrel treatment has been suggested as a risk factor for the occurrence of ischemic events and stent thrombosis.

Topics: Angioplasty, Balloon, Coronary; Aspirin; Clopidogrel; Coronary Disease; Cyclooxygenase Inhibitors; Drug Resistance; Humans; Platelet Activation; Platelet Aggregation Inhibitors; Pyridines; Ticlopidine

Clinical trials have demonstrated the superior clinical efficacy of dual antiplatelet therapy with a thienopyridine (a P2Y(12) receptor blocker) and aspirin (COX-1 inhibitor) in patients undergoing stenting as well as patients with acute coronary syndromes. However, clopidogrel treatment is associated with a wide response variability and non-responsiveness in selected patients. The latter phenomenon is linked to the occurrence of recurrent ischaemic events including stent thrombosis in the recent studies. Prasugrel is a new thienopyridine derivative that produces more potent platelet inhibition and a rapid onset of action that is associated with irreversible P2Y(12) receptor blockade. The latter properties of prasugrel may provide a superior alternative to clopidogrel, with less response variability and a decreased prevalence of non-responsiveness.

Topics: Adenosine Diphosphate; Animals; Aspirin; Clinical Trials, Phase I as Topic; Clinical Trials, Phase III as Topic; Clopidogrel; Collagen; Coronary Disease; Drug Evaluation, Preclinical; Drug Resistance; Drug Synergism; Drug Therapy, Combination; Drugs, Investigational; Humans; Piperazines; Platelet Activation; Platelet Aggregation; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Prodrugs; Purinergic P2 Receptor Antagonists; Pyridines; Rats; Receptors, Purinergic P2Y12; Thiophenes; Ticlopidine

Topics: Acute Disease; Angina, Unstable; Anticoagulants; Aspirin; Clinical Trials as Topic; Coronary Disease; Heparin, Low-Molecular-Weight; Humans; Myocardial Infarction; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Pyridines; Syndrome

Topics: Angioplasty, Balloon; Anticoagulants; Clinical Trials as Topic; Coronary Disease; Europe; Heparin; Humans; Incidence; Minimally Invasive Surgical Procedures; Platelet Glycoprotein GPIIb-IIIa Complex; Postoperative Complications; Purpura, Thrombotic Thrombocytopenic; Pyridines; Risk Factors; Severity of Illness Index; Syndrome; Thrombocytopenia; Treatment Failure; United States

Platelet adhesion, activation, and aggregation are key processes in the pathogenesis of coronary disease. Inhibition of these processes forms the cornerstone of therapy for coronary artery disease and particularly of acute coronary syndromes (ACS). Aspirin was the only available antiplatelet therapy for over 100 years, and it improves clinical outcome in a wide range of clinical situations. However, aspirin only inhibits platelet activation mediated by thromboxane A2, allowing platelet activation to occur through innumerable other pathways. As a result, adverse ischemic events are common when aspirin alone is used for the treatment of coronary disease, including ACS, during coronary interventions (particularly during stent implantation), and following coronary vascular brachytherapy (VBT). In these clinical situations, the presence of either thrombus, deep injury to the vessel wall, or delayed vascular reendothelialization leads to intense and often prolonged platelet activation, overwhelming the relatively weak effects of aspirin. The development of the thienopyridines, a class of antiplatelet drugs that reduce adenosine diphosphate-(ADP) mediated platelet activation, has significantly improved clinical outcomes in many coronary conditions. Widespread use of ticlopidine, the first available thienopyridine, was limited by frequent side-effects, including life-threatening neutropenia and thrombotic thrombocytopenic purpura. Following the introduction of clopidogrel, a thienopyridine with an excellent safety profile, dual antiplatelet therapy with aspirin and clopidogrel has become standard therapy following coronary stent implantation and coronary VBT. In patients presenting with ACS, the addition of clopidogrel to aspirin has now been proven to reduce ischemic events. The most important limitation of dual antiplatelet therapy is the increased bleeding risk as compared with aspirin alone, particularly in patients undergoing coronary artery bypass grafting during the index hospitalization. However, for many patients with ACS, combination therapy is appropriate.

Topics: Clopidogrel; Coronary Disease; Humans; Platelet Aggregation Inhibitors; Pyridines; Ticlopidine

We determined if high on-treatment platelet reactivity (HTPR) can be overcome on the day of percutaneous coronary intervention (PCI) in patients with or without previous maintenance thienopyridine therapy. Patients with HTPR, as defined as P2Y12 reaction units (PRU) >230, were switched to an alternate thienopyridine. Patients with HTPR undergoing PCI are at increased risk for ischemic complications. A total of 429 patients undergoing PCI with drug-eluting stents were enrolled. Patients on maintenance thienopyridine (n = 249) with PRU >230 were loaded with the alternative thienopyridine. Patients who were thienopyridine naïve (n = 180) were randomized to clopidogrel 600 (n = 90) or prasugrel 60 mg (n = 90). Patients with HTPR were loaded with the alternative agent. Patients on maintenance clopidogrel (n = 192) had a higher prevalence of HTPR compared with prasugrel (n = 57; 51% vs 4%, p <0.001). Patients on maintenance clopidogrel with HTPR (n = 98) who were loaded with prasugrel achieved PRU ≤230 in 97%. Thienopyridine-naïve patients loaded with clopidogrel had a higher prevalence of HTPR compared with prasugrel (37% vs 3%, p <0.001). Clopidogrel-loaded patients with HTPR (n = 33) who were reloaded with prasugrel achieved PRU ≤230 in 94%. All 3 prasugrel-loaded patients with HTPR treated with clopidogrel achieved PRU ≤230. Two patients experienced 30-day major adverse clinical events. One patient experienced Thrombolysis In Myocardial Infarction major bleeding. In conclusion, HTPR can be overcome in patients with and without previous maintenance thienopyridine therapy by identifying patients with HTPR and switching to an alternate thienopyridine.

Topics: Clopidogrel; Coronary Disease; Drug-Eluting Stents; Female; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Platelet Function Tests; Prasugrel Hydrochloride; Pyridines; Risk Factors; Ticlopidine; Treatment Outcome

The TAXUS Liberté Post Approval Study (TL-PAS) contributed patients treated with TAXUS Liberté paclitaxel-eluting stent and prasugrel to the Dual Antiplatelet Therapy Study (DAPT) that compared 12 and 30 months thienopyridine plus aspirin therapy after drug-eluting stents.. Outcomes for 2191 TL-PAS patients enrolled into DAPT were assessed. The DAPT coprimary composite end point (death, myocardial infarction [MI], or stroke) was lower with 30 compared with 12 months prasugrel treatment (3.7% versus 8.8%; hazard ratio [HR], 0.407; P<0.001). Rates of death and stroke were similar between groups, but MI was significantly reduced with prolonged prasugrel treatment (1.9% versus 7.1%; HR, 0.255; P<0.001). The DAPT coprimary end point, stent thrombosis, was also lower with longer therapy (0.2% versus 2.9%; HR, 0.063; P<0.001). MI related to stent thrombosis (0% versus 2.6%; P<0.001) and occurring spontaneously (1.9% versus 4.5%; HR, 0.407; P=0.007) were both reduced with prolonged prasugrel. MI rates increased within 90 days of prasugrel cessation after both 12 and 30 months treatment. Composite Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) moderate or severe bleeds were modestly increased (2.4% versus 1.7%; HR, 1.438; P=0.234) but severe bleeds were not more frequent (0.3% versus 0.5%; HR, 0.549; P=0.471) in the prolonged treatment group.. Prasugrel and aspirin continued for 30 months reduced ischemic events for the TAXUS Liberté paclitaxel-eluting stent patient subset from DAPT through reductions in MI and stent thrombosis. Withdrawal of prasugrel was followed by an increase in MI after both 12 and 30 months therapy. The optimal duration of dual antiplatelet therapy with prasugrel after TAXUS Liberté paclitaxel-eluting stent remains unknown, but appears to be >30 months.. http://www.clinicaltrials.gov. Unique identifier: NCT00997503.

Topics: Adult; Aged; Aged, 80 and over; Aspirin; Coronary Disease; Double-Blind Method; Drug Therapy, Combination; Drug-Eluting Stents; Female; Humans; Incidence; Internationality; Male; Middle Aged; Myocardial Infarction; Paclitaxel; Piperazines; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Purinergic P2Y Receptor Antagonists; Pyridines; Thiophenes; Time Factors; Treatment Outcome

Patients' responses to oral antiplatelet therapy are subject to variation. Bedside monitoring offers the opportunity to improve outcomes after coronary stenting by individualizing therapy.. We randomly assigned 2440 patients scheduled for coronary stenting at 38 centers to a strategy of platelet-function monitoring, with drug adjustment in patients who had a poor response to antiplatelet therapy, or to a conventional strategy without monitoring and drug adjustment. The primary end point was the composite of death, myocardial infarction, stent thrombosis, stroke, or urgent revascularization 1 year after stent implantation. For patients in the monitoring group, the VerifyNow P2Y12 and aspirin point-of-care assays were used in the catheterization laboratory before stent implantation and in the outpatient clinic 2 to 4 weeks later.. In the monitoring group, high platelet reactivity in patients taking clopidogrel (34.5% of patients) or aspirin (7.6%) led to the administration of an additional bolus of clopidogrel, prasugrel, or aspirin along with glycoprotein IIb/IIIa inhibitors during the procedure. The primary end point occurred in 34.6% of the patients in the monitoring group, as compared with 31.1% of those in the conventional-treatment group (hazard ratio, 1.13; 95% confidence interval [CI], 0.98 to 1.29; P=0.10). The main secondary end point, stent thrombosis or any urgent revascularization, occurred in 4.9% of the patients in the monitoring group and 4.6% of those in the conventional-treatment group (hazard ratio, 1.06; 95% CI, 0.74 to 1.52; P=0.77). The rate of major bleeding events did not differ significantly between groups.. This study showed no significant improvements in clinical outcomes with platelet-function monitoring and treatment adjustment for coronary stenting, as compared with standard antiplatelet therapy without monitoring. (Funded by Allies in Cardiovascular Trials Initiatives and Organized Networks and others; ARCTIC ClinicalTrials.gov number, NCT00827411.).

Topics: Aged; Aspirin; Clopidogrel; Coronary Disease; Coronary Thrombosis; Drug Monitoring; Female; Humans; Male; Middle Aged; Myocardial Infarction; Piperazines; Platelet Aggregation Inhibitors; Point-of-Care Systems; Prasugrel Hydrochloride; Pyridines; Retreatment; Stents; Thiophenes; Ticlopidine

Although clopidogrel and aspirin (dual therapy, DT) are used for acute coronary syndrome (ACS), sometimes treatment with warfarin (triple therapy, TT) is required.. To determine the incidence, complications, and outcomes of TT.. We analyzed Israeli surveys of ACS from 2000 to 2004.. In these surveys, 5,706 (96%) were discharged alive from hospital. Post-ACS TT and DT were 76 patients (1.3%) and 2,661 patients (46.7%), respectively. The TT group was older with more prior cardiac disease. During hospitalization, the TT patients received more intravenous anticoagulant and antithrombotic agents, and had more heart failure, arrhythmias, ischemia, and major bleeding (2.6 vs. 0.6%, p=0.03). There were no differences in adjusted 30-day and 6-month mortality between the 2 groups.. TT is feasible among ACS patients who require concomitant warfarin treatment.

Topics: Aspirin; Clopidogrel; Coronary Disease; Drug Therapy, Combination; Female; Hematologic Agents; Humans; Male; Pyridines; Risk Factors; Syndrome; Ticlopidine; Ventricular Function; Warfarin

Topics: Aspirin; Coronary Disease; Humans; Platelet Aggregation Inhibitors; Pyridines

Although combination therapy for various cardiac conditions with dual antiplatelet therapy (aspirin and thienopyridine derivatives) and warfarin sodium has become increasingly popular, the safety and effectiveness of this aggressive treatment regimen remain unknown.. We retrospectively enrolled and analyzed 575 consecutive patients who had been implanted with drug-eluting coronary stents. The primary and secondary endpoints were major bleeding complications and major adverse cardiovascular events (MACE), respectively. At the time of discharge, 525 patients (91.3%) were prescribed with dual antiplatelet therapy, and 50 (8.7%) of them received dual antiplatelet plus anticoagulant therapy (triple therapy). The patients treated with triple therapy had a greater prevalence of comorbid conditions, including left ventricular systolic dysfunction and multi-vessel coronary disease compared to those on the dual antiplatelet regimen. During a median follow-up of 459 days, 14 (2.7%) patients receiving dual, and 9 (18.0%) receiving triple therapy reached the primary endpoint (p<0.001). These results show that warfarin use was associated with an increased risk of subsequent major bleeding. On the other hand, the incidence of MACE did not differ between the two groups (p=0.108 by the log-rank test). Multivariate analysis showed that renal impairment was an independent predictor of the risk of subsequent major bleeding in the triple therapy group.. Triple therapy increased the hemorrhagic complications in patients after percutaneous coronary intervention with drug-eluting stents, especially in patients with impaired renal function. Great caution should be taken with patients who necessitate the addition of anticoagulation therapy with warfarin to dual antiplatelet therapy.

Topics: Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Cardiovascular Diseases; Coronary Disease; Drug-Eluting Stents; Female; Hemorrhage; Humans; Kidney Diseases; Male; Platelet Aggregation Inhibitors; Prognosis; Pyridines; Retrospective Studies; Ventricular Dysfunction; Warfarin

Antithrombotic and antiplatelet therapies have been proposed to treat non-ST elevation acute coronary syndrome (NSTEACS), yet limited information is available about their applications from a multicenter "real-world" clinical procedure, especially in China. This study was undertaken to characterize the use of antithrombotic and antiplatelet agents in relation to the risk levels of the NSTEACS patients who were enrolled in Sino-Global Registry of Acute Coronary Events (GRACEs) registry study.. We analyzed the data from 618 Chinese NSTEACS patients stratified into low-(n = 151), intermediate-(n = 233), and high-risk groups (n = 234) based on GRACE risk scores. The baseline characteristics, clinical presentations, antithrombotic and antiplatelet agents were recorded and compared among the three groups.. The administration rates of low-molecular-weight heparins (LMWHs) (86.08%) and thienopyridines (85.92%) were higher whereas the administration rate of glycoprotein IIb/IIIa inhibitor (1.78%) was much lower than those reported previously. Meanwhile, within the first 24 hours of admission, the use of heparin/LMWHs in the high-risk group was more than that in the intermediate- and low-risk groups (73.50% vs 63.09% vs 55.63%, P = 0.001). Furthermore, the combination of antithrombotic and antiplatelet medications showed no significant differences in all groups.. In the "real world" practice of China, the antithrombotic and antiplatelet therapies on NSTEACS are well adherent to the current guidelines except for several gaps, such as the very low use of glycoprotein IIb/IIIa inhibitor. Moreover, these antithrombotic and antiplatelet treatments usually tend to be underused for the high-risk ones.

Topics: Acute Coronary Syndrome; Aged; Coronary Disease; Female; Fibrinolytic Agents; Heparin, Low-Molecular-Weight; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Pyridines; Registries; Risk Assessment

To investigate how thienopyridine treatment, with or without associated fibrinolysis, affects the rates of major bleeding and inhospital death in patients with ST-elevation myocardial infarction (STEMI).. The rates of major bleeding and in-hospital death were studied in 14,259 consecutive patients with STEMI. During hospitalization, 5340 (38%) received thienopyridines, 3007 (21%) received fibrinolytic drugs, and 2044 (14%) received both.. Major bleeding occurred more frequently in patients who received thienopyridines with or without fibrinolytics, in 4.6% and 4.1%, respectively, compared with 2.3% in those who received fibrinolytics alone and 2.8% in those who received neither (P< .001). Multivariate analysis, which included adjustments for risk factors for bleeding, percutaneous coronary intervention and cardiac catheterization, showed that thienopyridine treatment was an independent risk factor for bleeding (odds ratio=1.68; 95% confidence interval, 1.23-2.31). In-hospital mortality was lower in patients who received a thienopyridine, and such treatment was an independent predictor of lower mortality (odds ratio=0.50; 95% confidence interval, 0.39-0.60).. Thienopyridine treatment was associated with an increased risk of major bleeding but also with a better in-hospital prognosis. These findings in unselected patients with STEMI, who are representative of those seen in daily clinical practice, complement, but do not replace, the data obtained in randomized clinical trails of selected patients.

Topics: Acute Disease; Aged; Aged, 80 and over; Coronary Disease; Electrocardiography; Endpoint Determination; Female; Fibrinolytic Agents; Hemorrhage; Hospital Mortality; Humans; Male; Middle Aged; Myocardial Infarction; Prospective Studies; Pyridines; Registries

Currently available clinical database was mostly developed in North America and Europe (Western Countries). Clinical database of Asian patients are still not large enough to develop Asian region specific clinical guidelines, although the population of patients in the majority of Asia countries are increasing rapidly. Marked ethnic and life-style heterogeneity within Asian region also makes it difficult to develop Asian region specific Evidence-based clinical practice guidelines. In general, there are certain differences in the background epidemiology of the atherosclerotic and thrombotic diseases in Asia countries and Western ones such as Asian patients are more prone to cerebrovascular disease (CVD) than coronary artery disease (CAD). Accordingly, there also are marked differences in the use of antiplatelet agents in Asian patients underwent coronary intervention (such as frequent use of cilostazol) as compared to those living in the Western countries. Currently available database also suggests the difference in side effects of antiplatelet agents in Asian patients as compared to Western ones such as relatively high incidence of hepatic dysfunction with the use of thienopiridine. In the future, it would be important to clarify the detailed difference of Asian patients and Western ones in regards to the effects and side effects of antiplatelet therapy by the multi-national prospective observation registry and clinical trials including equal number of Asian and Western patients. It would also be important for Asian physician to develop scientifically valid methods to import the results of "Global Evidence" with appropriate modification for the clinical practice in patients living in the specific region of Asia.

Topics: Asia; Cerebral Hemorrhage; Cerebrovascular Disorders; Cilostazol; Clopidogrel; Coronary Disease; Europe; Humans; Liver; North America; Platelet Aggregation Inhibitors; Pyridines; Tetrazoles; Ticlopidine

and Overview. Dual antiplatelet therapy with aspirin and a thienopyridine has been shown to reduce cardiac events after coronary stenting. However, many patients and health care providers prematurely discontinue dual antiplatelet therapy, which greatly increases the risk of stent thrombosis, myocardial infarction and death.. This advisory stresses the importance of 12 months of dual antiplatelet therapy after placement of a drug-eluting stent and educating patients and health care providers about hazards of premature discontinuation. It also recommends postponing elective surgery for one year, and if surgery cannot be deferred, considering the continuation of aspirin during the perioperative period in high-risk patients with drug-eluting stents.

Topics: Aspirin; Coronary Disease; Coronary Thrombosis; Drug Administration Schedule; Education, Professional; Elective Surgical Procedures; Humans; Myocardial Infarction; Patient Education as Topic; Perioperative Care; Platelet Aggregation Inhibitors; Postoperative Complications; Pyridines; Risk Factors; Stents; Time Factors

To assess bleeding complications among patients undergoing percutaneous coronary intervention (PCI) and receiving triple therapy of warfarin, aspirin, and a thienopyridine.. Triple therapy of warfarin, aspirin, and a thienopyridine is strongly discouraged, given the potential risk of bleeding complications.. Post-PCI patients receiving triple therapy thereafter underwent assessment for bleeding complications. Continuous variables are presented as median (25th-75th percentiles). The study group included 180 patients (80% males; age 65 (52, 75.5)). PCI was on an urgent/emergent basis in 86.6%. The main indications for warfarin use were left ventricular mural thrombus and atrial fibrillation (46.9 and 36.9% respectively). Glycoprotein IIb/IIIa receptor antagonists were used in 47.7%. Post-PCI triple therapy duration was 30 days (30, 30). During the post-triple therapy, 104 patients (57.8%) continued treatment with warfarin and aspirin for 376 days (150, 775). During the triple therapy period, 20 patients developed bleeding complications, (mean INR 2.1 +/- 0.7 at 7 (6, 8.5) days post-PCI): 2 major groin hematoma (initial phase of warfarin treatment during overlap with heparin) and 18 minor. During post-triple therapy, primarily under warfarin and aspirin, 19 patients developed bleeding complications: 1 major and 18 minor.. Short-term triple therapy after PCI was not associated with prohibitively high bleeding complication rates, and thus should be favorably considered in patients with a clear indication for warfarin use.

Topics: Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Blood Coagulation Tests; Coronary Angiography; Coronary Disease; Drug Administration Schedule; Drug Therapy, Combination; Echocardiography, Doppler; Female; Hemorrhage; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Prognosis; Pyridines; Research Design; Retrospective Studies; Survival Analysis; Warfarin

The authors describe a case of a 74-year-old man with advanced coronary heart disease in whom pulmonary hemorrhagic complications during therapy with ticlopidine and subsequently with clopidogrel and amiodarone were observed. Fever and massive hemoptysis following five days of ticlopidine treatment, before elective coronary angiography, were noticed. Transient interstitial X-ray changes of the right lung were visible. Three months later a new episode on the third day of clopidogrel administration was manifested. He was after PCI, performed because of ACS complicated with ventricular fibrillation. Two days following clopidogrel discontinuation hemoptysis remitted but after ten days occurred again (this time with bilateral X-ray changes). Amiodarone, given after VF, was stopped. Spectacular improvement with steroid treatment was observed. Indobufen (reversible COX- 1 inhibitor) as an antiplatelet therapy was availed. The authors discuss therapeutic dilemma concerning the patient with coexisting different diseases.

Topics: Aged; Amiodarone; Cardiovascular Agents; Clopidogrel; Coronary Disease; Drug Interactions; Drug Therapy, Combination; Hemoptysis; Humans; Male; Platelet Aggregation Inhibitors; Pyridines; Recurrence; Ticlopidine

We sought to determine the frequency and timing of complications at our institution when surgery was performed within two months of coronary stent placement.. The optimal delay following coronary stent placement prior to non-cardiac surgery is unknown.. We analyzed the Mayo Clinic Percutaneous Coronary Intervention and Surgical databases between 1990 and 2000 and identified 207 patients who underwent surgery in the two months following successful coronary stent placement.. Eight patients (4.0%) died or suffered a myocardial infarction or stent thrombosis. All 8 patients were among the 168 patients (4.8%, 95% confidence interval [CI] 2.1 to 9.2) undergoing surgery six weeks after stent placement; the frequency of these events ranged from 3.8% to 7.1% per week during each of the six weeks. No events occurred in the 39 patients undergoing surgery seven to nine weeks after stent placement (0%, 95% CI 0.0 to 9.0).. These data suggest that, whenever possible, non-cardiac surgery should be delayed six weeks after stent placement, by which time stents are generally endothelialized, and a course of antiplatelet therapy to prevent stent thrombosis has been completed.

Topics: Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Blood Transfusion; Coronary Angiography; Coronary Disease; Coronary Thrombosis; Female; Humans; Male; Middle Aged; Minnesota; Myocardial Infarction; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Pyridines; Retrospective Studies; Stents; Surgical Procedures, Operative; Time Factors; Treatment Outcome; Warfarin

Topics: Angioplasty, Balloon, Coronary; Clopidogrel; Combined Modality Therapy; Coronary Disease; Double-Blind Method; Humans; Platelet Aggregation Inhibitors; Premedication; Pyridines; Research Design; Stents; Survival Analysis; Ticlopidine; Treatment Outcome