thienopyridine and Coronary-Restenosis

To evaluate the impact of cilostazol on the angiographic and clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) with stents and treated with aspirin and thienopyridine.. A total of 11 randomized controlled trials including 8,525 patients comparing triple antiplatelet therapy (aspirin, thienopyridine and cilostazol) with standard dual antiplatelet therapy were included in the analysis. The primary end points were in-segment late loss and angiographic restenosis at angiographic follow-up. Secondary end points included mortality, stent thrombosis, target lesion revascularization (TLR) and major adverse cardiac events (MACE).. Triple antiplatelet therapy was associated with a significant reduction in late loss [weighted mean difference 0.14, 95% confidence interval (CI) 0.08-0.20; p < 0.001] and angiographic restenosis [odds ratio (OR) 0.58, 95% CI 0.48-0.71; p < 0.001]. Addition of cilostazol to dual antiplatelet therapy was associated with a significant reduction in TLR (OR 0.56, 95% CI 0.41-0.77; p < 0.001) and MACE (OR 0.72, 95% CI 0.60-0.86; p < 0.001) with no differences in mortality (p = 0.29), stent thrombosis (p = 0.60) or bleeding episodes (p = 0.77).. Cilostazol in addition to dual antiplatelet therapy appears to be effective in reducing the risk of restenosis and repeat revascularization after PCI without any significant benefits for mortality or stent thrombosis.

Topics: Aspirin; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Cilostazol; Clopidogrel; Combined Modality Therapy; Coronary Restenosis; Drug Therapy, Combination; Female; Graft Occlusion, Vascular; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Pyridines; Randomized Controlled Trials as Topic; Stents; Tetrazoles; Ticlopidine; Treatment Outcome

The purpose of this study is to evaluate the effect of adding cilostazol to dual antiplatelet therapy (aspirin and thienopyridine) on rates of restenosis after coronary artery stenting. A meta-analysis is conducted of randomized, controlled trials comparing 3 drug regimens (cilostazol, thienopyridine, aspirin [triple therapy]) with dual antiplatelet therapy to reduce restenosis after coronary stenting. A total of 5 studies are included for analysis. The analysis reveals that triple therapy is used in 796 patients, whereas dual therapy is used in 801 patients. Approximately 56% of patients receive a drug-eluting stent. The 6-month restenosis rates are significantly lower with triple versus dual antiplatelet therapy (12.7% vs 21.9%; odds ratio 0.5; 95% confidence interval, 0.38-0.66; P < .001). This benefit is seen regardless of whether a bare-metal or drug-eluting stent is used. Rates of major adverse cardiac events and bleeding are reported for 3 of the 5 studies (n = 1426); analysis of these outcomes shows no difference between treatment groups (P = .21 and .48, respectively). The addition of cilostazol to standard dual antiplatelet therapy reduces angiographic restenosis and increases MLD at 6 months without significantly affecting rates of major adverse cardiac events or bleeding.

Topics: Aspirin; Cilostazol; Coronary Restenosis; Coronary Vessels; Drug Therapy, Combination; Drug-Eluting Stents; Humans; Pyridines; Randomized Controlled Trials as Topic; Tetrazoles

Thrombosis of a drug-eluting stent (DES) is a catastrophic complication. The risk of stent thrombosis (ST) is increased in the perioperative setting and is strongly associated with the cessation of antiplatelet therapy. This article reviews the perioperative management of patients with DES with a clinical focus on the perioperative use of antiplatelet therapy. Cessation of dual antiplatelet therapy is the single most significant predictor of perioperative ST. Available data on perioperative management of patients with DES are limited, and recommendations are therefore limited. To avoid ST with DES, aspirin and thienopyridines should ideally be continued throughout surgery. In spite of the increased risk of bleeding, this strategy is acceptable in many types of invasive surgical procedures with no change in outcome. However, if the bleeding risk outweighs the risk of ST, other potential strategies include treatment with aspirin alone, "bridging therapy" with aspirin and a glycoprotein IIb/IIIa inhibitor and/or heparin, and "bridging therapy" without aspirin. Novel antiplatelet therapies are promising and potentially valuable in the perioperative management of patients with DES. Maintaining dual antiplatelet therapy is the mainstay of perioperative ST prevention. However, short-term discontinuation of thienopyridines might be associated with relatively low risk if aspirin therapy is maintained perioperatively.

Topics: Aspirin; Coronary Restenosis; Drug Therapy, Combination; Drug-Eluting Stents; Perioperative Care; Platelet Aggregation Inhibitors; Pyridines; Risk Factors

Topics: Abciximab; Angioplasty, Balloon, Coronary; Antibodies, Monoclonal; Aspirin; Coronary Restenosis; Dipyridamole; Drug Combinations; Fibrinolytic Agents; Heparin, Low-Molecular-Weight; Humans; Immunoglobulin Fab Fragments; Platelet Aggregation Inhibitors; Pyridines; Randomized Controlled Trials as Topic; Thrombolytic Therapy

Cilostazol has been associated with reduction in restenosis in patients undergoing coronary and peripheral arterial angioplasty. Our objective was to evaluate the impact of cilostazol on restenosis in patients undergoing contemporary PCI with bare metal (BMS) or drug eluting stents (DES) and treated with aspirin and thienopyridine.. Ten randomised trials (n=2,809 patients) comparing triple antiplatelet therapy (aspirin, thienopyridine and cilostazol) with standard dual antiplatelet therapy were included. Summary risk ratios for restenosis, late loss, target lesion revascularisation (TLR) and target vessel revascularisation (TVR) were calculated using fixed-effects models. Cilostazol was associated with a significant reduction in late loss in BMS (mean difference 0.24 mm, 95% CI 0.15-0.33, p<0.001) and DES groups (mean difference 0.12 mm, 95% CI 0.07-0.18, p<0.001). Cilostazol therapy was associated with a significant reduction in angiographic restenosis (Odds ratio [OR] 0.52, 95% CI 0.41- 0.66, p<0.001) with consistent benefits in patients treated with BMS (OR 0.49, 95% CI 0.35-0.70, p<0.001) or DES (OR 0.54, 95% CI 0.38-0.76, p=0.001). Addition of cilostazol to dual antiplatelet therapy was associated with a significant reduction in TLR (OR 0.38, 95% CI 0.25-0.58, p<0.001), with no difference in subacute stent thrombosis (OR 1.91, 95% CI 0.33-11.08, p=0.47), or major bleeding (OR 0.87, 95% CI 0.44-1.74, P=0.69) but with an increased risk of skin rash (OR 3.67, 95% CI 1.86-7.24, p<0.001).. Cilostazol in addition to dual antiplatelet therapy is associated with a reduction in angiographic restenosis in patients undergoing stent based PCI. This inexpensive drug may be particularly beneficial in patients who are at high risk of restenosis and it should undergo further evaluation in large, definitive randomised controlled trials.

Topics: Aged; Angioplasty, Balloon, Coronary; Aspirin; Cilostazol; Coronary Angiography; Coronary Restenosis; Coronary Stenosis; Drug Therapy, Combination; Drug-Eluting Stents; Exanthema; Female; Hemorrhage; Humans; Male; Metals; Middle Aged; Odds Ratio; Platelet Aggregation Inhibitors; Prosthesis Design; Publication Bias; Pyridines; Randomized Controlled Trials as Topic; Risk Assessment; Stents; Tetrazoles; Thrombosis; Treatment Outcome

This chapter about antithrombotic therapy during percutaneous coronary intervention (PCI) is part of the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading, see Guyatt et al, CHEST 2004;126:179S-187S). Among the key recommendations in this chapter are the following: For patients undergoing PCI, we recommend pretreatment with aspirin, 75 to 325 mg (Grade 1A). For long-term treatment after PCI, we recommend aspirin, 75 to 162 mg/d (Grade 1A). For long-term treatment after PCI in patients who receive antithrombotic agents such as clopidogrel or warfarin, we recommend lower-dose aspirin, 75 to 100 mg/d (Grade 1C+). For patients who undergo stent placement, we recommend the combination of aspirin and a thienopyridine derivative (ticlopidine or clopidogrel) over systemic anticoagulation therapy (Grade 1A). We recommend clopidogrel over ticlopidine (Grade 1A). For all patients undergoing PCI, particularly those undergoing primary PCI, or those with refractory unstable angina or other high-risk features, we recommend use of a glycoprotein (GP) IIb-IIIa antagonist (abciximab or eptifibatide) [Grade 1A]. In patients undergoing PCI for ST-segment elevation MI, we recommend abciximab over eptifibatide (Grade 1B). In patients undergoing PCI, we recommend against the use of tirofiban as an alternative to abciximab (Grade 1A). In patients after uncomplicated PCI, we recommend against routine postprocedural infusion of heparin (Grade 1A). For patients undergoing PCI who are not treated with a GP IIb-IIIa antagonist, we recommend bivalirudin over heparin during PCI (Grade 1A). In PCI patients who are at low risk for complications, we recommend bivalirudin as an alternative to heparin as an adjunct to GP IIb-IIIa antagonists (Grade 1B). In PCI patients who are at high risk for bleeding, we recommend that bivalirudin over heparin as an adjunct to GP IIb-IIIa antagonists (Grade 1B). In patients who undergo PCI with no other indication for systemic anticoagulation therapy, we recommend against routine use of vitamin K antagonists after PCI (Grade 1A).

Topics: Abciximab; Angioplasty, Balloon, Coronary; Antibodies, Monoclonal; Aspirin; Clopidogrel; Contraindications; Coronary Restenosis; Coronary Stenosis; Drug Therapy, Combination; Evidence-Based Medicine; Fibrinolytic Agents; Heparin; Hirudins; Humans; Immunoglobulin Fab Fragments; Peptide Fragments; Practice Guidelines as Topic; Pyridines; Recombinant Proteins; Risk Assessment; Stents; Ticlopidine

Despite antirestenotic efficacy of coronary drug-eluting stents (DES) compared with bare metal stents (BMS), the relative risk of stent thrombosis and adverse cardiovascular events is unclear. Although dual antiplatelet therapy (DAPT) beyond 1 year provides ischemic event protection after DES, ischemic event risk is perceived to be less after BMS, and the appropriate duration of DAPT after BMS is unknown.. To compare (1) rates of stent thrombosis and major adverse cardiac and cerebrovascular events (MACCE; composite of death, myocardial infarction, or stroke) after 30 vs 12 months of thienopyridine in patients treated with BMS taking aspirin and (2) treatment duration effect within the combined cohorts of randomized patients treated with DES or BMS as prespecified secondary analyses.. International, multicenter, randomized, double-blinded, placebo-controlled trial comparing extended (30-months) thienopyridine vs placebo in patients taking aspirin who completed 12 months of DAPT without bleeding or ischemic events after receiving stents. The study was initiated in August 2009 with the last follow-up visit in May 2014.. Continued thienopyridine or placebo at months 12 through 30 after stent placement, in 11,648 randomized patients treated with aspirin, of whom 1687 received BMS and 9961 DES.. Stent thrombosis, MACCE, and moderate or severe bleeding.. Among 1687 patients treated with BMS who were randomized to continued thienopyridine vs placebo, rates of stent thrombosis were 0.5% vs 1.11% (n = 4 vs 9; hazard ratio [HR], 0.49; 95% CI, 0.15-1.64; P = .24), rates of MACCE were 4.04% vs 4.69% (n = 33 vs 38; HR, 0.92; 95% CI, 0.57-1.47; P = .72), and rates of moderate/severe bleeding were 2.03% vs 0.90% (n = 16 vs 7; P = .07), respectively. Among all 11,648 randomized patients (both BMS and DES), stent thrombosis rates were 0.41% vs 1.32% (n = 23 vs 74; HR, 0.31; 95% CI, 0.19-0.50; P < .001), rates of MACCE were 4.29% vs 5.74% (n = 244 vs 323; HR, 0.73; 95% CI, 0.62-0.87; P < .001), and rates of moderate/severe bleeding were 2.45% vs 1.47% (n = 135 vs 80; P < .001).. Among patients undergoing coronary stent placement with BMS and who tolerated 12 months of thienopyridine, continuing thienopyridine for an additional 18 months compared with placebo did not result in statistically significant differences in rates of stent thrombosis, MACCE, or moderate or severe bleeding. However, the BMS subset may have been underpowered to identify such differences, and further trials are suggested.. clinicaltrials.gov Identifier: NCT00977938.

Topics: Aged; Aspirin; Cardiovascular Diseases; Coronary Restenosis; Double-Blind Method; Drug Therapy, Combination; Drug-Eluting Stents; Female; Hemorrhage; Humans; Intention to Treat Analysis; Male; Middle Aged; Platelet Aggregation Inhibitors; Pyridines; Risk; Stents

We assessed the impact of smoking on outcomes in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention using alternative antithrombotic regimens and stent types. In the HORIZONS-AMI trial 3,602 patients were randomly assigned to unfractionated heparin (UFH) plus a glycoprotein IIb/IIIa inhibitor (GPI) or bivalirudin alone and paclitaxel-eluting stents or bare-metal stents. Compared to nonsmokers, smokers had significantly lower rates of mortality and major bleeding at 30 days and at 1 year; however, the differences were no longer significant after covariate adjustment. Smoking was associated with increased rates of definite/probable stent thrombosis (ST) at 1 year (adjusted RR 1.99, 95% confidence interval 1.28 to 3.10) mainly because of a higher rate of late ST after paclitaxel-eluting stent implantation (1.9% vs 0.4%, p = 0.0006). In smokers bivalirudin monotherapy compared to UFH plus a GPI was associated with lower mortality at 30 days (0.5% vs 2.2%, p = 0.002) and at 1 year (1.8% vs 4.0%, p = 0.008). No decrease in mortality was seen with bivalirudin in nonsmokers. Major bleeding was significantly decreased with bivalirudin regardless of smoking status (smokers 3.7% vs 8.9%, p <0.0001; nonsmokers 6.5% vs 9.6%, p = 0.01). In conclusion, in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention, smoking is an independent predictor of definite/probable ST at 1 year. Bivalirudin monotherapy compared to UFH plus a GPI decreased major bleeding regardless of smoking status but may have different effects on individual components of ischemic events.

Topics: Aged; Angioplasty, Balloon, Coronary; Antithrombins; Coronary Angiography; Coronary Restenosis; Coronary Thrombosis; Drug Therapy, Combination; Drug Utilization; Female; Hemorrhage; Heparin; Hirudins; Humans; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Paclitaxel; Peptide Fragments; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Pyridines; Recombinant Proteins; Smoking; Stents

Cilostazol has been associated with reduction in restenosis in patients undergoing coronary and peripheral arterial angioplasty. Our objective was to evaluate the impact of cilostazol on restenosis in patients undergoing contemporary PCI with bare metal (BMS) or drug eluting stents (DES) and treated with aspirin and thienopyridine.. Ten randomised trials (n=2,809 patients) comparing triple antiplatelet therapy (aspirin, thienopyridine and cilostazol) with standard dual antiplatelet therapy were included. Summary risk ratios for restenosis, late loss, target lesion revascularisation (TLR) and target vessel revascularisation (TVR) were calculated using fixed-effects models. Cilostazol was associated with a significant reduction in late loss in BMS (mean difference 0.24 mm, 95% CI 0.15-0.33, p<0.001) and DES groups (mean difference 0.12 mm, 95% CI 0.07-0.18, p<0.001). Cilostazol therapy was associated with a significant reduction in angiographic restenosis (Odds ratio [OR] 0.52, 95% CI 0.41- 0.66, p<0.001) with consistent benefits in patients treated with BMS (OR 0.49, 95% CI 0.35-0.70, p<0.001) or DES (OR 0.54, 95% CI 0.38-0.76, p=0.001). Addition of cilostazol to dual antiplatelet therapy was associated with a significant reduction in TLR (OR 0.38, 95% CI 0.25-0.58, p<0.001), with no difference in subacute stent thrombosis (OR 1.91, 95% CI 0.33-11.08, p=0.47), or major bleeding (OR 0.87, 95% CI 0.44-1.74, P=0.69) but with an increased risk of skin rash (OR 3.67, 95% CI 1.86-7.24, p<0.001).. Cilostazol in addition to dual antiplatelet therapy is associated with a reduction in angiographic restenosis in patients undergoing stent based PCI. This inexpensive drug may be particularly beneficial in patients who are at high risk of restenosis and it should undergo further evaluation in large, definitive randomised controlled trials.

Topics: Aged; Angioplasty, Balloon, Coronary; Aspirin; Cilostazol; Coronary Angiography; Coronary Restenosis; Coronary Stenosis; Drug Therapy, Combination; Drug-Eluting Stents; Exanthema; Female; Hemorrhage; Humans; Male; Metals; Middle Aged; Odds Ratio; Platelet Aggregation Inhibitors; Prosthesis Design; Publication Bias; Pyridines; Randomized Controlled Trials as Topic; Risk Assessment; Stents; Tetrazoles; Thrombosis; Treatment Outcome

Biological age is a strong determinant of prognosis in patients with acute myocardial infarction (AMI). We sought to examine the impact of age after primary percutaneous coronary intervention in AMI and to determine whether routine coronary stent implantation and/or platelet glycoprotein IIb/IIIa inhibitors improve clinical outcomes in elderly patients after primary angioplasty.. In the CADILLAC trial, 2082 patients with AMI were randomized to balloon angioplasty, angioplasty plus abciximab, stenting alone, or stenting plus abciximab. No patient was excluded on the basis of advanced age; patients ranging from 21 to 95 years of age were enrolled. One-year mortality increased for each decile of age, exponentially after 65 years of age (1.6% for patients <55 years, 2.1% for 55 to 65 years, 7.1% for 65 to 75 years, 11.1% for patients >75 years; P<0.0001). Elderly patients also had increased rates of stroke and major bleeding compared with their younger counterparts. Among elderly patients (> or =65 years), 1-year rates of ischemic target revascularization (7.0% versus 17.6%; P<0.0001) and subacute or late thrombosis (0% versus 2.2%; P=0.005) were reduced with stenting compared with balloon angioplasty. Routine abciximab administration, although safe, was not of definite benefit in elderly patients. Rates of mortality, reinfarction, disabling stroke, and major bleeding in the elderly were independent of reperfusion modality.. Despite contemporary mechanical reperfusion strategies, mortality, major bleeding, and stroke rates remain high in elderly patients undergoing primary percutaneous coronary intervention, outcomes that are not affected by stents or glycoprotein IIb/IIIa inhibitors. By reducing restenosis, however, stent implantation improves clinical outcomes in elderly patients with AMI.

Topics: Abciximab; Adrenergic beta-Antagonists; Adult; Age Factors; Aged; Aged, 80 and over; Angioplasty, Balloon, Coronary; Antibodies, Monoclonal; Aspirin; Cohort Studies; Combined Modality Therapy; Coronary Angiography; Coronary Restenosis; Female; Hemorrhage; Humans; Immunoglobulin Fab Fragments; Life Tables; Male; Middle Aged; Myocardial Infarction; Platelet Aggregation Inhibitors; Proportional Hazards Models; Pyridines; Stents; Stroke; Treatment Outcome

Coronary stenting in patients on dialysis has increased by nearly 50% over the past decade, despite heightened risks of associated stent thrombosis and bleeding relative to the general population. We examined clopidogrel, prasugrel or ticlopidine use after percutaneous coronary intervention (PCI) with stenting in patients on dialysis. We conducted 3-, 6-, and 12-month landmark analyses to test the hypothesis that thienopyridine discontinuation prior to those time points would be associated with higher risks of death, myocardial infarction, or repeat revascularization, and a lower risk of major bleeding episodes compared with continued thienopyridine use.. Using the US Renal Data System, we identified 8458 patients on dialysis with Medicare Parts A+B+D undergoing PCI with stenting between July 2007 and December 2010. Ninety-nine percent of all thienopyridine prescriptions were for clopidogrel. At 3 months, 82% of patients who received drug-eluting stents (DES) had evidence of thienopyridine use. These proportions fell to 62% and 40% at 6 and 12 months, respectively. In patients who received a bare-metal stent (BMS), 70%, 34%, and 26% of patients had evidence of thienopyridine use at 3, 6, and 12 months, respectively. In patients who received a DES, there was a suggestion of higher risks of death or myocardial infarction associated with thienopyridine discontinuation in the 3-, 6-, and 12-months landmark analyses, but no higher risk of major bleeding episodes. In patients who received a BMS, there were no differences in death or cardiovascular events, and possibly lower risk of major bleeding with thienopyridine discontinuation in the 3- and 6-month landmark analyses.. The majority of patients on dialysis who undergo PCI discontinue thienopyridines before 1 year regardless of stent type. While not definitive, these data suggest that longer-term thienopyridine use may be of benefit to patients on dialysis who undergo PCI with DES.

Topics: Aged; Angioplasty, Balloon, Coronary; Cohort Studies; Confidence Intervals; Coronary Restenosis; Coronary Stenosis; Databases, Factual; Dose-Response Relationship, Drug; Drug Administration Schedule; Female; Follow-Up Studies; Humans; Kidney Failure, Chronic; Male; Medicare Part D; Middle Aged; Poverty; Proportional Hazards Models; Pyridines; Radiography; Retrospective Studies; Risk Assessment; Stents; Survival Analysis; Time Factors; Treatment Outcome; United States

Diabetes mellitus (DM) accounts for >25% of all percutaneous coronary interventions. In patients with DM, drug-eluting stent implantation is associated with a reduced risk of restenosis and target lesion revascularization. However, concern has been raised about the incidence of late and very late stent thrombosis and the increased mortality rate, mostly after thienopyridine withdrawal. We evaluated the long-term prognostic effect of thienopyridine discontinuation after drug-eluting stent implantation on the subsequent occurrence of stent thrombosis and all-cause death among a cohort of high-risk "de novo" diabetic patients. From May 2002 to December 2005, 542 consecutive patients with DM underwent drug-eluting stent implantation at 2 hospitals in Milan, Italy. For study purposes, only the 217 patients who had not previously undergone percutaneous or surgical revascularization were considered in the final analysis. The follow-up time was curtailed at 3.5 years. Detailed information about dual antiplatelet therapy (DAT) were collected for all patients included. Of the 217 patients, 15 died (6.9%); in 9 cases, the cause of death was cardiac (4.1%). The incidence of cumulative stent thrombosis was 4.6% (10 patients); 3 stent thromboses were early (1.38%), 5 late (2.3%), and only 2 were very late (0.9%). Of the 10 cases of stent thrombosis, 5 were definite and 5 were probable. Most (80%) of the stent thromboses occurred within the first 6 months during DAT. The median duration of DAT was 420 days (interquartile range 350 to 859). DAT discontinuation was the only independent predictor of the follow-up events (hazard ratio 20.42, 95% confidence interval 4.99 to 83.62). In conclusion, DM remains an independent adverse factor on clinical outcome. In this setting, prolonged DAT, even beyond that recommended in the guidelines, might be beneficial.

Topics: Aged; Analysis of Variance; Angioplasty, Balloon, Coronary; Cause of Death; Cohort Studies; Combined Modality Therapy; Confidence Intervals; Coronary Angiography; Coronary Restenosis; Coronary Stenosis; Diabetes Mellitus; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug-Eluting Stents; Female; Graft Occlusion, Vascular; Hospital Mortality; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Probability; Proportional Hazards Models; Prospective Studies; Pyridines; Risk Assessment; Severity of Illness Index; Survival Analysis

Significant advances in interventional cardiology have occurred over the past 30 years, leading to substantial increases in the number and anatomic complexity of treated patients, the long-term success of these procedures, and a reduction in the need for coronary bypass surgery. While the risk ofrestenosis has been dramatically reduced by drug-eluting stents, delayed neo-intimal healing has led to a small, but significant occurrence of "late" stent thrombosis. This thrombotic risk is substantially reduced by continuation of dual-anti-platelet therapy for one or more years following DES placement. Current guidelines for patient selection for DES, for duration of DAT following DES, and for facing surgical and invasive procedures after DES were discussed, and the avoidance of early discontinuation of anti-platelet therapy following DES was emphasized.

Topics: Angioplasty, Balloon, Coronary; Antineoplastic Agents, Phytogenic; Aspirin; Consensus; Coronary Artery Disease; Coronary Restenosis; Drug-Eluting Stents; Humans; Immunosuppressive Agents; Paclitaxel; Platelet Aggregation Inhibitors; Pyridines; Sirolimus

Oral treatment with prednisone has demonstrated efficacy in reducing restenosis after percutaneous coronary interventions (PCI). However, administration of steroids at high dose may raise concerns in terms of applicability and tolerability. Monitoring the occurrence of possible side-effects is therefore mandatory.. Secondary effects of oral prednisone in this setting is analyzed. The "expected" secondary effects of the steroid treatment are described, together with the "unexpected" occurrence of likely drug-induced neutropenia observed in patients prescribed prednisone and thienopyridines simultaneously after PCI.. Two-hundred and twenty patients were monitored for the occurrence of side-effects of the prednisone therapy. Twenty-eight patients (14%) had side-effects likely related to the prednisone treatment: gastric pain (4%), increment of arterial pressure needing upgrading of antihypertensive treatment (4%), edema (1.8%), and concomitant infections (1.4%). In three patients (1.4%), agranulocytosis was detected at the time of the routine blood cell count scheduled 4 weeks after PCI in otherwise asymptomatic patients. Neutropenia subsided completely after withdrawal of prednisone and thienopyridine in all cases and the blood cell formula normalized within 3 weeks.. Side-effects of oral prednisone given after PCI to reduce restenosis occur in less than 15% of patients. Complaints are mild and reversible and can be easily managed with adjunctive diuretic and antacid drugs. The occurrence of agranulocytosis after prednisone had never been reported before, but was observed in 1.4% of our patients receiving simultaneously a thienopyridine. To explain such an unusual event we propose the hypothesis of a possible metabolic interaction between prednisone and thienopyridines.

Topics: Aged; Angioplasty, Balloon, Coronary; Anti-Infective Agents; Coronary Restenosis; Drug-Related Side Effects and Adverse Reactions; Humans; Male; Middle Aged; Neutropenia; Prednisone; Prospective Studies; Pyridines; Risk Factors

Although drug-eluting stents (DES) significantly reduce restenosis, they require 3 to 6 months of thienopyridine therapy to prevent stent thrombosis. The rate and consequences of prematurely discontinuing thienopyridine therapy after DES placement for acute myocardial infarction (MI) are unknown.. We used prospectively collected data from a 19-center study of MI patients to examine the prevalence and predictors of thienopyridine discontinuation 30 days after DES treatment. We then compared the mortality and cardiac hospitalization rates for the next 11 months between those who stopped and those who continued thienopyridine therapy. Among 500 DES-treated MI patients who were discharged on thienopyridine therapy, 68 (13.6%) stopped therapy within 30 days. Those who stopped were older, less likely to have completed high school or be married, more likely to avoid health care because of cost, and more likely to have had preexisting cardiovascular disease or anemia at presentation. They were also less likely to have received discharge instructions about their medications or a cardiac rehabilitation referral. Patients who stopped thienopyridine therapy by 30 days were more likely to die during the next 11 months (7.5% versus 0.7%, P<0.0001; adjusted hazard ratio=9.0; 95% confidence interval=1.3 to 60.6) and to be rehospitalized (23% versus 14%, P=0.08; adjusted hazard ratio=1.5; 95% confidence interval=0.78 to 3.0).. Almost 1 in 7 MI patients who received a DES were no longer taking thienopyridines by 30 days. Prematurely stopping thienopyridine therapy was strongly associated with subsequent mortality. Strategies to improve the use of thienopyridines are needed to optimize the outcomes of MI patients treated with DES.

Topics: Aged; Aged, 80 and over; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Cause of Death; Clopidogrel; Combined Modality Therapy; Coronary Restenosis; Drug Administration Schedule; Drug Implants; Female; Follow-Up Studies; Hospitalization; Humans; Life Tables; Male; Middle Aged; Mortality; Myocardial Infarction; Patient Education as Topic; Platelet Aggregation Inhibitors; Prevalence; Proportional Hazards Models; Prospective Studies; Pyridines; Registries; Sirolimus; Stents; Survival Analysis; Thrombosis; Ticlopidine; Treatment Outcome; Treatment Refusal

The plasmin activation system is involved in the development of restenosis after percutaneous coronary interventions (PCI). Conflicting data exist concerning the role of plasminogen activator inhibitor-1 (PAI-1) and its predictive value for restenosis.. To evaluate the fibrinolytic response to injury after PCI with or without stent implantation on different antithrombotic medications and its relation to late restenosis.. Eighty consecutive patients with successful PCI without (balloon only; n = 37) or with stent implantation (stent; n = 43) on different antithrombotic regimes (balloon only, aspirin; stent, aspirin/coumadin/dipyridamole vs. aspirin/ticlopidine). Blood samples were taken at baseline and up to 7 days after PCI and PAI-1 active antigen and tissue plasminogen activator (t-PA) antigen were determined. Restenosis was angiographically determined after 6 months.. PCI increased both t-PA and PAI-1 levels (P < 0.001), with a significant prolonged and pronounced increase in stent vs. balloon-only patients (P < 0.05). Restenosis (stent 26%; balloon 38%) was significantly correlated to an attenuated PAI-1 increase after 24 h in the ticlopidine group (P = 0.007; restenosis, relative Delta PAI-1 + 50 +/- 28%; non-restenosis, + 139 +/- 50%), but not in the coumadin group. In the balloon-only group late restenosis (ISR) was associated with a trend for an augmented PAI-1 increase after 24 h.. Coronary stent implantation significantly increases t-PA and PAI-1 plasma levels up to 1 week compared with balloon angioplasty alone. ISR in ticlopidine-treated patients was associated with an attenuated early PAI-1 active antigen increase. A less than 50% increase 24 h after stent implantation under ticlopidine treatment may identify patients at risk for the development of ISR.

Topics: Aged; Angioplasty, Balloon, Coronary; Aspirin; Combined Modality Therapy; Coronary Restenosis; Female; Fibrinolysis; Fibrinolytic Agents; Humans; Male; Middle Aged; Plasminogen Activator Inhibitor 1; Predictive Value of Tests; Pyridines; Retrospective Studies; Stents; Ticlopidine; Tissue Plasminogen Activator

Topics: Angioplasty, Balloon, Coronary; Clopidogrel; Coronary Restenosis; Coronary Stenosis; Humans; Paclitaxel; Platelet Aggregation Inhibitors; Pyridines; Stents; Thrombosis; Ticlopidine

Topics: Angioplasty, Balloon, Coronary; Brachytherapy; Coronary Restenosis; Coronary Thrombosis; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Pyridines; Stents; Time Factors