warfarin and Coronary-Stenosis

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

A different rate and timing of subacute stent thrombosis after percutaneous coronary intervention was reported with various peri-interventional antithrombotic regimens. Next to platelet activation, coagulation triggered by tissue factor (TF) may play a key role in this process. Thirty-one consecutive patients with stable and unstable angina undergoing coronary stenting were randomly assigned to adjunct oral anticoagulation/anti-platelet therapy (coumadin, dipyridamole, aspirin and heparin; n = 16) or adjunct anti-platelet therapy with thienopyridin (ticlopidine, aspirin and heparin; n = 15). Antigen levels of plasma TF, total tissue factor pathway inhibitor (TFPI) and TFPI/ activated factor X (TFPI/FXa) complex were determined before and for up to 6 days after intervention by immunoassay. At baseline, significantly higher levels of plasma TF and TFPI/FXa were found in patients with unstable angina [TF, 161 pg/ml (126-191 pg/ml); TFPI/FXa, 7.8 ng/ml (6.1-9.6 ng/ml)] compared with stable angina [TF, 62 pg/ml (46-82 pg/ml), P < 0.0001; TFPI/FXa, 4.5 ng/ml (3-7.6 ng/ml), P= 0.003]. One hour after intervention, an increase of plasma TF and TFPI/FXa was seen in both treatment groups. In unstable angina patients, plasma levels of TF, TFPI and TFPI/FXa were more efficiently reduced by adjunct ticlopidine therapy compared with adjunct coumadin/dipyridamole. These data suggest reduced release of circulating TF by combined anti-platelet therapy with ticlopidine and aspirin after coronary artery stenting, which may-contribute to the lower incidence of subacute stent thrombosis previously observed.

Topics: Adult; Angina Pectoris; Angina, Unstable; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Coronary Angiography; Coronary Stenosis; Dipyridamole; Dose-Response Relationship, Drug; Drug Therapy, Combination; Enzyme-Linked Immunosorbent Assay; Factor Xa; Female; Follow-Up Studies; Hemorrhage; Heparin; Humans; Lipoproteins; Male; Middle Aged; Statistics as Topic; Stents; Thromboplastin; Thrombosis; Ticlopidine; Time Factors; Warfarin

Evidence-based recommendations about anticoagulation in acute type B aortic dissection (TBAD) are completely missing, but there is a diffuse conviction that it could prevent the healing process of the dissected aorta's false lumen. However, several clinical conditions may lead to the necessity to start anticoagulant therapy among patients with acute type B aortic dissection, ranging from atrial fibrillation to more complicated clinical scenarios and the correct management in this kind of patients is still an open issue.. We are presenting a 51-years-old man with multi-infarct encephalopathy referred to us for an acute TBAD and a first diagnosis of ischemic cardiomyopathy complicated by left ventricular (LV) thrombus formation. Coronary angiography revealed a critical stenosis of left anterior descending artery (LAD) treated with drug-eluting stent deployment. The patient was addressed to triple antithrombotic therapy with acetylsalicylic acid, clopidogrel and warfarin with target INR 2.0-2.5. After 6 months, computed tomography angiography revealed the stability of the dissection flap. Cardiac magnetic resonance imaging, however, confirmed the persistence of a small thrombotic formation in LV apex, thus double antithrombotic therapy with warfarin and clopidogrel was instituted. The patient remained asymptomatic during the follow-up period but was advised to suspend his job and physical activities.. Current guidelines do not discuss anticoagulant therapy in the setting of TBAD and large randomized trials are lacking. Despite it is generally considered unsafe to administer anticoagulants in patients with TBAD, we present a case in which triple antithrombotic therapy was well tolerated and did not lead to progression of the intimal flap after 6 months.

Topics: Anticoagulants; Aortic Aneurysm, Thoracic; Aortic Dissection; Aspirin; Clinical Decision-Making; Clopidogrel; Coronary Stenosis; Disease Progression; Drug-Eluting Stents; Dual Anti-Platelet Therapy; Fibrinolytic Agents; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Risk Assessment; Thrombosis; Treatment Outcome; Warfarin

Direct oral anticoagulant (DOAC) use is growing as monotherapy and combined with platelet inhibitors. The safety of such combination therapy, especially in comparison to regimens including warfarin, in real world populations remains uncertain. We investigated hemorrhage associated with DOAC and antiplatelet combination therapy in a cohort of elderly coronary artery stent recipients. We employed Medicare data 2010-2013 for a 40% random sample of beneficiaries enrolled in inpatient, outpatient and prescription benefits. We used Cox proportional hazards models to examine the association of the combination anticoagulant (DOAC or warfarin) plus antiplatelets with major hemorrhage events (upper gastrointestinal or intracranial) in the 12 months following stent placement. We identified 70,900 stent recipients. 14.4% had atrial fibrillation (AF) diagnosis preoperatively. Among the 24.5 million observation days, exposure distribution was: 73.8% antiplatelets only, 4.7% antiplatelets plus warfarin, 0.6% antiplatelets plus DOAC, 2.2% warfarin only, 0.3% DOAC only and 18.4% no observed antiplatelets or anticoagulant. Overall, 8,029 patients (11.3%) experienced major hemorrhage. Among AF patients, compared to antiplatelets only, DOAC plus antiplatelets was associated with increased hemorrhage risk (HR, 1.94; 95%CI, 1.48-2.54); warfarin plus antiplatelets conferred comparable bleed risk (HR, 1.69; 95%CI, 1.47-1.94). In the non-AF group, compared to antiplatelets alone, combination DOAC plus antiplatelets (HR, 3.09; 95%CI, 2.15-4.46), and warfarin plus antiplatelets (HR, 2.21; 95%CI, 1.97-2.48) conferred greater bleed risk. Among elderly coronary artery stent recipients with AF, the two drug combinations, DOAC plus antiplatelets and warfarin plus antiplatelets, were associated with similarly increased risk of major hemorrhage compared to antiplatelets alone.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Cohort Studies; Coronary Stenosis; Drug Therapy, Combination; Female; Hemorrhage; Humans; Platelet Aggregation Inhibitors; Proportional Hazards Models; Risk Factors; Stents; Warfarin

A 45-year-old man with heterozygous Factor V Leiden presented with his third cerebrovascular accident despite being on warfarin at a therapeutic international normalized ratio. Subsequent investigation revealed a second genetic diagnosis of Fabry disease. He then had an acute myocardial infarction whilst on aspirin and warfarin.

Topics: Activated Protein C Resistance; alpha-Galactosidase; Aspirin; Atorvastatin; Coronary Stenosis; Defibrillators, Implantable; Drug Therapy, Combination; Enzyme Replacement Therapy; Fabry Disease; Factor V; Heptanoic Acids; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hypercholesterolemia; Male; Metoprolol; Middle Aged; Perindopril; Pyrroles; Quality of Life; Recurrence; Sequence Deletion; Stents; Stroke; Stroke Rehabilitation; Thrombophilia; Warfarin

Instrumentation of the aorta during cardiac catheterization, resulting in peripheral embolization, is an underdiagnosed clinical entity. Such an atheromatous embolization can present in a subtle way or could be catastrophic. Isolated splenic infarction as a complication of the procedure is extreme rare. We report a 59-year-old man with risk factors for atherosclerotic vascular disease who underwent percutaneous coronary intervention and presented 3 days later with isolated splenic infarction. He was managed conservatively with heparin. Further evaluation revealed a concomitant mural thrombus in an abdominal aortic aneurysm, which could be a contributing factor along with atheroembolization from advanced atherosclerosis. Our case highlights the importance of using a right brachial or radial approach in an individual with significant atherosclerotic vascular disease and with an abdominal aortic aneurysm.

Topics: Angioplasty, Balloon, Coronary; Anticoagulants; Aortic Aneurysm, Abdominal; Aspirin; Atherosclerosis; Cardiac Catheterization; Clopidogrel; Coronary Stenosis; Embolism, Cholesterol; Heparin; Humans; Infarction; Male; Middle Aged; Platelet Aggregation Inhibitors; Risk Factors; Spleen; Thrombosis; Ticlopidine; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

There is a lack of published evidence on what is the optimal management strategy in anticoagulated patients with nonvalvular atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI) and, hence, need antiplatelet therapy.. Review of cases of patients with nonvalvular AF undergoing PCI in our hospital, either as an elective case or following acute coronary syndrome (ACS).. By means of our local West Midlands Regional Health Authority computerized Hospital Activity Analysis register, we obtained a list of all patients seen at our hospital with a diagnosis of AF in association with ACS or PCI between 2000 and 2005. Patient clinical details and antithrombotic therapy management during PCI were recorded.. Of the drugs prescribed on discharge, aspirin and clopidogrel were prescribed to 25 patients (71.4%), while 6 patients (17.1%) were discharged receiving triple therapy, 2 patients (5.7%) receiving clopidogrel alone, and 2 patients (5.7%) receiving warfarin plus one antiplatelet drug (either aspirin or clopidogrel). There was wide variability in the antithrombotic regime and duration of treatment used by the four interventionists in our unit.. This case series reveals the lack of any coordinated strategy in the prevention of thrombotic or thromboembolic events in patients with AF and a recent PCI. Further large studies are required to assess the bleeding and thrombotic risk with various post-PCI strategies in order to facilitate the development of guidelines. Suggested management guidelines are made in this article.

Topics: Aged; Aged, 80 and over; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Atrial Fibrillation; Clopidogrel; Cohort Studies; Combined Modality Therapy; Consensus Development Conferences as Topic; Coronary Stenosis; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Therapy, Combination; Female; Follow-Up Studies; Heparin, Low-Molecular-Weight; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Risk Factors; Stents; Stroke; Ticlopidine; Warfarin

There are few studies of the therapeutic regimens for the prevention of stenotic transformation of aneurysms in Kawasaki disease (KD). The aim of this study was to assess the prophylactic effect of combined therapy in the acute stage and convalescent- to chronic-stage against the formation of stenotic lesions.. In 85 patients, 103 giant aneurysms (ANl), 46 medium-sized aneurysms (ANm), and 13 small aneurysms (ANs) were analyzed. With respect to therapy in the acute stage, no localized stenosis of ANl in the left coronary artery was noted in patients who received high-dose gamma globulin therapy (G). For ANm, the group (G) showed a significantly higher regression rate than the aspirin group and steroids group. Furthermore, no coronary artery occlusion/recanalization of ANl occurred with the prophylactic regimen of aspirin and warfarin {aw}. Prophylaxis {aw} and the prophylactic regimen of aspirin alone {a} significantly lowered the incidence compared with either the prophylactic regimen of warfarin {w} or no prophylaxis {n}. However, no significant differences were noted between prophylaxis {w} and {n}.. High-dose gamma globulin therapy in the acute stage of KD is the first choice for the prevention of stenotic transformation. Prophylaxis {aw} is recommended for ANl.

Topics: Acute Disease; Aspirin; Coronary Aneurysm; Coronary Stenosis; gamma-Globulins; Humans; Longitudinal Studies; Mucocutaneous Lymph Node Syndrome; Prednisolone; Retrospective Studies; Warfarin