warfarin and Non-ST-Elevated-Myocardial-Infarction

To explore the efficiency and safety of bivalirudin in patients undergoing emergency percutaneous coronary intervention via radial access.. Bivalirudin reduces bleeding risks over heparin in patients undergoing PCI. However, bleeding advantages of bivalirudin in patients undergoing transradial intervention is uncertain.. In the BRIGHT trial, 1,723 patients underwent emergency PCI via radial access, with 576 patients in the bivalirudin arm, 576 in the heparin arm and 571 in the heparin plus tirofiban arm. The primary outcome was 30-day net adverse clinical event (NACE), defined as a composite of major cardiac and cerebral events or any bleeding.. 30-day NACE occurred in 5.7% with bivalirudin, 7.8% with heparin alone (vs. bivalirudin, P = 0.159), and 10.3% with heparin plus tifofiban (vs. bivalirudin, P = 0.004). The 30-day bleeding rate was 0.9% for bivalirudin, 2.3% for heparin (vs. bivalirudin, P = 0.057), and 5.8% for heparin plus tirofiban (vs. bivalirudin, P < 0.001). Major cardiac and cerebral events (4.9 vs. 5.7 vs. 4.6%, P = 0.899), stent thrombosis (0.5 vs. 0.5 vs. 0.7%, P = 0.899) and acquired thrombocytopenia (0.2 vs. 0.5 vs. 0.9%, P = 0.257) at 30 days were similar among three arms. The interaction test for PCI access and randomized treatment showed no significance on all bleeding (P > 0.05).. The bleeding benefit of bivalirudin was independent of artery access. Bivalirudin lead to statistical reduction on bleeding risks in comparison to heparin plus tirofiban, and only small numerical difference in comparison to heparin, with comparable risks of ischemic events and stent thrombosis in patients with acute myocardial infarction (AMI) undergoing emergency transradial PCI. © 2016 Wiley Periodicals, Inc.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Antithrombins; Cardiac Catheterization; China; Emergencies; Female; Hemorrhage; Hirudins; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Non-ST Elevated Myocardial Infarction; Peptide Fragments; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Radial Artery; Recombinant Proteins; Risk Assessment; Risk Factors; ST Elevation Myocardial Infarction; Time Factors; Tirofiban; Treatment Outcome; Tyrosine; Warfarin; Young Adult

Coronary embolism is a relatively rare but important non-atherosclerotic cause of acute coronary syndrome, mainly caused by atrial fibrillation and mechanical heart valve thrombosis due to subtherapeutic anticoagulation. There have been increasing reports of bioprosthetic valve thrombosis (BPVT), but thromboembolic events are rare and mainly affect the cerebrovascular system. Coronary embolism is an extremely rare complication of BPVT.. A 64-year-old male presented with non-ST-Elevation myocardial infarction (NSTEMI) to an Australian regional health service. Three years ago, he had undergone Bentall procedure with bioprosthetic aortic valve replacement for severe aortic regurgitation and significant aortic root dilatation. Diagnostic coronary angiography revealed embolic occlusion of first diagonal branch in the absence of underlying atherosclerosis. Prior to NSTEMI presentation, the patient was clinically asymptomatic apart from the progressive increase in transaortic mean pressure gradient on transthoracic echocardiography which was first detected seven months after surgical aortic valve replacement. Transoesophageal echocardiography showed restrictions of the aortic leaflet opening but no evidence of mass or vegetation. After eight weeks of warfarin therapy, the raised aortic valve gradient returned to normal. Lifelong warfarin was prescribed, and patient remained clinically well at 39-month follow-up.. We experienced a case of coronary embolism in a patient with probable BPVT. Reversible bioprosthetic valve hemodynamic deterioration after anticoagulation strongly supports the diagnosis in the absence of histopathology. Early moderate-to-severe hemodynamic valve deterioration warrants further investigations, including cardiac computed tomography and sequential echocardiography, to investigate for probable BPVT and consideration of timely anticoagulation initiation to prevent thromboembolic events.

Topics: Anticoagulants; Aortic Valve; Australia; Bioprosthesis; Coronary Artery Disease; Embolism; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Non-ST Elevated Myocardial Infarction; Thromboembolism; Thrombosis; Warfarin

Background We sought to examine patient characteristics, peri-infarction invasive and pharmacologic management, and in-hospital major bleeding in myocardial infarction patients with atrial fibrillation or flutter, based on home anticoagulant use. Methods and Results We stratified patients by home anticoagulant: (1) no anticoagulant, (2) warfarin, and (3) direct oral anticoagulants ( DOAC s) among ST-segment-elevation myocardial infarction ( STEMI ) and non-STEMI (NSTEMI) patients with atrial fibrillation or flutter treated at 761 US hospitals in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry from January 2015 to December 2016. The primary outcome of our study was in-hospital major bleeding. Multivariable logistic regression was used to examine the independent association between home anticoagulant and in-hospital major bleeding. Among 6471 STEMI patients with atrial fibrillation or flutter, 15.7% were on warfarin and 13.0% on DOAC s; among 19 954 NSTEMI patients, 22.8% were on warfarin and 15.4% on DOAC s. In STEMI , door-to-balloon times were slightly higher in those on anticoagulant, with similar rates of angiography within 24 hours in the 3 groups. NSTEMI patients on anticoagulant were less likely to undergo angiography (49.3% no anticoagulant, 33.4% on warfarin, 36.4% on DOAC s; P<0.01) or percutaneous coronary intervention within 24 hours (21.1% no anticoagulant, 14.3% on warfarin, 15.9% on DOAC s; P<0.01). After multivariate adjustment, use of home warfarin (odds ratio: 1.00 [95% CI , 0.79-1.27] in STEMI and 1.13 [95% CI , 0.97-1.30] in NSTEMI ) or DOAC (odds ratio: 0.93 [95% CI , 0.73-1.20] in STEMI and 0.97 [95% CI , 0.81-1.16] in NSTEMI ) was not associated with increased in-hospital major bleeding compared with no anticoagulant. Conclusions In routine clinical practice, home warfarin or DOAC therapy is not associated with an increased risk of in-hospital bleeding compared with no anticoagulant.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Coronary Angiography; Factor Xa Inhibitors; Female; Hemorrhage; Humans; Male; Middle Aged; Myocardial Infarction; Non-ST Elevated Myocardial Infarction; Percutaneous Coronary Intervention; Registries; ST Elevation Myocardial Infarction; United States; Warfarin

Bleeding complications increase mortality in myocardial infarction patients. Potential gender difference in bleeding regarding prevalence and prognostic impact is still controversial.. Gender comparison regarding incidence and prognostic impact of bleeding in patients hospitalised with myocardial infarction during 2006-2008.. Observational study from the SWEDEHEART register. Outcomes were in-hospital bleedings, in-hospital mortality and one-year mortality in hospital survivors.. A total number of 50,399 myocardial infarction patients were included, 36.6% women. In-hospital bleedings were more common in women (1.9% vs. 3.1%, p<0.001) even after multivariable adjustment (odds ratio (OR) 1.17, 95% confidence interval (CI) 1.01-1.37). The increased risk for women was found in ST-elevation myocardial infarction (OR 1.46, 95% CI 1.10-1.94) and in those who underwent percutaneous coronary intervention (OR 1.80, 95% CI 1.45-2.24). In contrast the risk was lower in medically treated women (OR 0.79, 95% CI 0.62-1.00). After adjustment, in-hospital bleeding was associated with higher risk of one-year mortality in men (OR 1.35, 95% CI 1.04-1.74), whereas this was not the case in women (OR 0.97, 95% CI 0.72-1.31).. Female gender is an independent risk factor of in-hospital bleeding after myocardial infarction. A higher bleeding risk in women appeared to be restricted to invasively treated patients and ST-elevation myocardial infarction patients. Even though women have higher short- and long-term mortality, there was no difference between the genders among bleeders. After multivariable adjustment the prognostic impact of bleeding complications was higher in men.

Topics: Adrenergic beta-Antagonists; Aged; Angiotensin-Converting Enzyme Inhibitors; Female; Hemorrhage; Hospital Mortality; Hospitalization; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Incidence; Male; Non-ST Elevated Myocardial Infarction; Platelet Aggregation Inhibitors; Prognosis; Sex Distribution; Sex Factors; ST Elevation Myocardial Infarction; Sweden; Warfarin