warfarin and Coronary-Restenosis

Topics: Angioplasty, Balloon, Coronary; Anticoagulants; Antineoplastic Agents, Phytogenic; Clinical Trials as Topic; Coronary Artery Disease; Coronary Restenosis; Drug Delivery Systems; Humans; Immunosuppressive Agents; Paclitaxel; Polymers; Sirolimus; Stents; Thrombosis; Warfarin

Topics: Anticoagulants; Aspirin; Coronary Restenosis; Drug Therapy, Combination; Fibrinolytic Agents; Heparin; Heparin, Low-Molecular-Weight; Humans; Myocardial Infarction; Myocardial Reperfusion; Platelet Aggregation Inhibitors; Thrombolytic Therapy; Ticlopidine; Tissue Plasminogen Activator; Warfarin

After successful thrombolysis, a high-grade stenosis at 24-hour angiography is strongly predictive of reocclusion and is often believed to result in high reinfarction rates. However, routine angioplasty did not reduce death or reinfarction in past trials. Systematic angiographic follow-up shows that reocclusion often occurs without clinical reinfarction. This study investigates whether the increased risk for reocclusion associated with a high-grade lesion translates into impaired clinical outcome.. In the ischemia-guided Antithrombotics in the Prevention of Reocclusion in COronary Thrombolysis (APRICOT-1) trial, 240 patients with ST-elevation MI who had an open infarct artery 24 hours after thrombolysis had 3-month repeat angiography to assess reocclusion, with clinical follow-up at 3 months and 3 years.. On the basis of the optimal discriminative stenosis severity, the reocclusion rate was 40% (47/118) in patients with a high-grade residual stenosis and 16% (20/122) in patients with a low-medium-grade lesion (risk ratio [RR], 2.43; 95% CI, 1.54-3.84; P <.01). Three-month death and reinfarction rates did not differ: 6% (7/118) versus 9% (11/122; RR, 0.66; 95% CI, 0.26-1.64; P = not significant). Systematic angiographic follow-up revealed that reocclusion of a high-grade lesion occurred in the absence of clinical reinfarction in 85% (40/47) of patients, as compared with 45% (9/20) in patients with a low-medium-grade stenosis (RR, 1.89; 95% CI, 1.15-3.12; P <.01). Despite an independent association with reocclusion, a high-grade stenosis was not predictive of either short- or long-term death and reinfarction.. After successful thrombolysis and adopting an ischemia-guided revascularization strategy, patients with a high-grade stenosis experience death/reinfarction rates similar to that of patients with a low-medium-grade lesion. This is true despite a 2- to 3-fold higher risk for reocclusion. The finding that reocclusion of a high-grade lesion often occurs without clinical reinfarction explains the absence of a relationship between a severe stenosis and death/reinfarction. Appreciation of these observations may contribute to an optimal design of a future randomized trial to re-evaluate the impact of a routine invasive strategy.

Topics: Aged; Angioplasty, Balloon, Coronary; Aspirin; Coronary Angiography; Coronary Restenosis; Coronary Stenosis; Disease-Free Survival; Female; Fibrinolytic Agents; Follow-Up Studies; Heparin; Humans; Logistic Models; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Prognosis; Recurrence; Risk Factors; Thrombolytic Therapy; Warfarin

The purpose of the present study was to determine whether postprocedural antithrombotic therapy with prolonged heparin infusion followed by 6 months of oral anticoagulation in addition to acetylsalicylic acid (ASA) reduces the incidence of angiographic restenosis after successful PTCA. One hundred ninety-one patients with uncomplicated PTCA were randomized into two groups: one group was discharged with ASA 100 mg only (G1) and the other group was additionally treated with 12-24 hr of heparin infusion and overlapping oral anticoagulation with coumadin for 6 months (G2). The two groups were comparable with respect to age, gender, coronary risk profile, clinical presentation, and angiographic lesion characteristics. Stents were implanted in 33% and 36% of the G1 and G2 patients, respectively. In-hospital myocardial infarction occurred in 4% of the G1 and 3% of the G2 patients. One patient in G1 died of subacute stent thrombosis (day 3). Six-month angiographic follow-up was obtained in 90% of G1 patients and 94% of G2 patients. Restenosis occurred in 30% and 33% of the patients and mean diameter stenoses at follow-up were 40% +/- 28% and 39% +/- 24%, respectively. Thrombin inhibition with heparin infusion followed by 6 months of oral anticoagulation did not reduce angiographic restenosis among patients undergoing PTCA with or without stent implantation. The occurrence of acute ischemic complications was also comparable in the two groups.

Topics: Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Coronary Restenosis; Drug Therapy, Combination; Female; Fibrinolytic Agents; Follow-Up Studies; Humans; Male; Middle Aged; Radiography; Thrombolytic Therapy; Warfarin

The type of periprocedural antithrombotic regimen that is the safest and most effective in percutaneous coronary intervention (PCI) patients on oral anticoagulant (OAC) therapy has not been fully investigated. We aimed to retrospectively investigate the in-hospital bleeding outcomes of patients receiving OAC and antiplatelet therapies during PCI using Japanese nationwide multicenter registry data. A total of 26,938 patients who underwent PCI with OAC and antiplatelet therapies between 2016 and 2017 were included. We investigated in-hospital bleeding requiring blood transfusion, mortality, and stent thrombosis according to the antithrombotic regimens used at the time of PCI: OAC + single antiplatelet therapy (double therapy) and OAC + dual antiplatelet therapy (triple therapy). The antiplatelet agents included aspirin, clopidogrel, and prasugrel. The OAC agents included warfarin and direct OACs. Adjusting the dose of OAC or intermitting OAC before PCI was at each operator's discretion. In the study population [mean age (SD), 73.5 (9.5) years; women, 21.5%], the double therapy and triple therapy groups comprised 5546 (20.6%) and 21,392 (79.4%) patients, respectively. Bleeding requiring transfusion was not significantly different between the groups [adjusted odds ratio (aOR), 0.700; 95% confidence interval (CI), 0.420-1.160; P = 0.165] (triple therapy as a reference). Mortality was not significantly different (aOR, 1.370; 95% CI, 0.790-2.360; P = 0.258). Stent thrombosis was significantly different between the groups (aOR, 3.310; 95% CI, 1.040-10.500; P = 0.042) (triple therapy as a reference). In conclusion, for patients on OAC therapy who underwent PCI, periprocedural triple therapy may be safe with respect to in-hospital bleeding risks. However, further investigations are warranted to establish the safety and efficacy of periprocedural triple therapy.

Topics: Aged; Aspirin; Clopidogrel; Coronary Artery Disease; Coronary Restenosis; Dual Anti-Platelet Therapy; Factor Xa Inhibitors; Female; Hemorrhage; Humans; Japan; Male; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Postoperative Complications; Prasugrel Hydrochloride; Registries; Retrospective Studies; Warfarin

An 84-year-old male on oral steroids, coumadin and multiple antiplatelets for stented superficial femoral artery presented to our hospital with chest oppression. His CT scan showed cardiac tamponade with periaortic hematoma. At first, sealed rupture of aortic dissection with thrombosed false lumen was suspected. However, delayed enhancement view revealed extravasation of contrast agent, which appeared to drain into the pericardium or pericardial space. Emergency thoracotomy revealed normal aorta with several small spurting vessels of pulmonary side of the pericardium. To the best of our knowledge, this is the first reported case in the literature of a parietal pleural hematoma without known cause such as malignancy or hematologic disorders.

Topics: Aged, 80 and over; Aortic Aneurysm; Aortic Dissection; Cardiac Tamponade; Coronary Restenosis; Drug Therapy, Combination; Hematoma; Humans; Male; Platelet Aggregation Inhibitors; Steroids; Tomography, X-Ray Computed; Warfarin

Approximately 6 million Americans are treated with chronic anticoagulation. Of these, 10% of patients will require temporary anticoagulation interruption for an invasive procedure each year. Anticoagulation management during this period requires a formal strategy in order to limit both bleeding and thromboembolic complications. This article will give health care providers a stepwise approach to this process. The first step is to determine whether warfarin discontinuation is necessary for the planned procedure. For procedures requiring warfarin discontinuation, the second step is to determine the appropriate timing. The third step is to identify the patient-specific thromboembolic risk in order to determine which patients require bridging therapy with parenteral anticoagulants. The fourth step is both the most complicated and most critical step in this management strategy. This decision-making step involves choosing the appropriate anticoagulant regimen, dose, and timing of reinitiation that is best tailored to a specific patient, as well as determining procedural variables, in order to limit bleeding and thrombotic complications.

Topics: Anticoagulants; Antithrombins; Benzimidazoles; beta-Alanine; Coronary Restenosis; Dabigatran; Heart Valve Prosthesis; Hemorrhage; Humans; Morpholines; Neoplasms; Perioperative Care; Risk Assessment; Rivaroxaban; Stents; Thiophenes; Venous Thromboembolism; Warfarin

The optimal combination of anticoagulant and antiplatelet therapy following percutaneous coronary intervention with stenting (PCI-S) among patients requiring oral anticoagulation (OAC) is unknown.. We sought to compare the efficacy of a modified dual-antiplatelet regimen (daily aspirin and every other day clopidogrel) to conventional treatment (daily aspirin and daily clopidogrel) following percutaneous coronary intervention (PCI) with drug-eluting stents (DES) among patients who are also discharged on warfarin.. We performed a single-center, retrospective analysis of consecutive patients (n = 454) who underwent PCI-S with DES and were discharged on warfarin and either a conventional (n = 170) or modified (n = 284) antiplatelet regimen between March 2003 and May 2007. In-hospital and 1-year events were compared between the two groups.. There were no differences in 1-year rates of death, myocardial infarction, stent thrombosis or target lesion revascularization between patients receiving a conventional compared to a modified antiplatelet regimen. In-hospital bleeding rates were also similar between the two groups.. An antiplatelet regimen of aspirin with every-other-day clopidogrel may be as efficacious as daily aspirin and clopidogrel among patients receiving warfarin following PCI-S with DES.

Topics: Aged; Aged, 80 and over; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Clopidogrel; Combined Modality Therapy; Coronary Artery Disease; Coronary Restenosis; Coronary Thrombosis; Drug Therapy, Combination; Drug-Eluting Stents; Female; Humans; Male; Middle Aged; Myocardial Infarction; Platelet Aggregation Inhibitors; Retrospective Studies; Ticlopidine; Treatment Outcome; Warfarin

Topics: Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Clopidogrel; Coronary Restenosis; Coronary Thrombosis; Drug-Eluting Stents; Humans; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Stroke; Ticlopidine; Warfarin

In-stent restenosis (ISR) remains the major limitation of coronary stent implantation. Controversies exist regarding optional treatment for ISR. Recently, we developed aggressive surgical options, coronary endarterectomy and stent removal, in this complex setting.. Between April 2001 and March 2004, 11 consecutive patients who presented with angina and angiographically severe ISR were treated with coronary endarterectomy and stent removal with concomitant multivessel coronary bypass grafting. There were 10 men and 1 woman. The age ranged from 43 to 75 years old (mean 64.1 +/- 9.6 years). The mean number of target vessel interventions was 1.6 +/- 0.7. Data were analyzed retrospectively.. The target vessel was the left anterior descending artery (LAD) in all patients. The mean interval from the last intervention was 4.8 +/- 1.9 months. The mean number of target vessel interventions was 1.6 +/- 0.7. The mean LAD incision length was 57.3 +/- 11.0 mm. The left internal mammary artery (LIMA) was grafted in situ, as an on-lay patch. Procedural success without in-hospital complications was achieved in all cases, except one patient with low output syndrome. Postprocedure angiography demonstrated that all LIMA patches and LAD arteries were patent and left ventricular functions were preserved.. Coronary endarterectomy and stent removal with on-lay LIMA patch is a safe and effective technique used in patients with ISR involving diffuse target vessel disease.

Topics: Adult; Aged; Angioplasty, Balloon, Coronary; Aspirin; Coronary Artery Bypass; Coronary Restenosis; Device Removal; Endarterectomy; Female; Follow-Up Studies; Heparin, Low-Molecular-Weight; Humans; Male; Middle Aged; Postoperative Care; Retrospective Studies; Stents; Warfarin