warfarin and ST-Elevation-Myocardial-Infarction

To determine the role of warfarin (WF) prophylaxis in the prevention of left ventricular thrombus (LVT) formation and subsequent embolic complications following an anterior ST elevation myocardial infarction (STEMI) complicated by reduced left ventricular ejection fraction (LVEF) and wall motion abnormalities.. The role of oral anticoagulation prophylaxis, in addition to dual antiplatelet therapy (DAPT), in the current era of percutaneous coronary intervention has not been well studied, despite being a class IIb recommendation in the AHA/ACC STEMI guidelines.. The Cochrane search strategy was used to search PubMed, Embase and the Cochrane library for relevant results. Four studies, two retrospective, one prospective registry, and a randomized feasibility control trial met criteria for inclusion. Data was pooled using a random effects model and reported as odds ratios (OR) with their 95% confidence intervals (CI). Primary outcomes of interest were rate of stroke, major bleeding and mortality.. Pooled analysis included 526 patients in the No WF group and 347 patients in the WF group. No statistical difference in rate of stroke (OR: 2.72 [95% CI: 0.47-15.88; p=0.21]) or mortality (OR: 1.50 [95% CI 0.29-7.71; p=0.63]) was observed. Major bleeding was significantly higher in the WF group (OR: 2.56 [95% CI: 1.34-4.89; p=0.004]).. The routine use of DAPT and WF for prophylaxis against LVT formation following an anterior STEMI with associated decrease in LVEF and wall motion abnormalities, appears to result in no mortality benefit or reduction in stroke rates, but may increase the frequency of major bleeding.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anterior Wall Myocardial Infarction; Anticoagulants; Chi-Square Distribution; Embolism; Female; Hemorrhage; Humans; Male; Middle Aged; Myocardial Contraction; Odds Ratio; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Risk Factors; ST Elevation Myocardial Infarction; Stroke; Stroke Volume; Thrombosis; Treatment Outcome; Ventricular Function, Left; Warfarin; Young Adult

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

To explore treatment with Direct Oral Anticoagulants (DOACs) in left ventricular thrombus (LVT) after ST-segment elevation myocardial infarction (STEMI) in patients who underwent percutaneous coronary intervention (PCI).. Contemporary data regarding using DOACs for LVT after STEMI patients who underwent PCI is limited.. To investigate the efficacy and safety of DOACs on the treatment of LVT post STEMI and PCI.. This retrospective study enrolled patients with LVT post STEMI and PCI within 1month from onset who received warfarin or DOACs at discharge. The primary endpoint was LVT resolution. Secondary endpoints were major adverse cardiovascular events (MACEs), including death, stroke, systemic embolism (SE), myocardial infarction (MI) and major or minor bleeding.. A total of 128 consecutive patients were recruited, of which 72 received warfarin and 56 DOACs [48 on rivaroxaban and 8 on dabigatran]. The rate of LVT resolution was higher within 1 month in the DOACs group than warfarin (26.8% vs. 11.1%; p = 0.022) (Kaplan-Meier estimates, p = 0.002). No significant differences were found at 3 months (p = 0.246), 6 months (p = 0.201), 9 months (p = 0.171) and 12 months (p = 0.442). No patients treated with DOACs had major bleeding, while two patients with warfarin had upper gastrointestinal bleeding (0 vs. 2 (2.8%); p = 0.209). No death or SE occurred. No significant differences on secondary endpoints were found in both the groups, including stroke, MI, minor bleeding and all bleeding events.. DOACs appear to be a suitable alternative to warfarin for the management of LVT post STEMI, especially in patients who are intolerant to warfarin.

Topics: Anterior Wall Myocardial Infarction; Anticoagulants; Hemorrhage; Humans; Myocardial Infarction; Percutaneous Coronary Intervention; Retrospective Studies; ST Elevation Myocardial Infarction; Stroke; Thrombosis; Treatment Outcome; Warfarin

Left ventricular thrombus (LVT) can complicate ST-Elevation myocardial infarction (STEMI) and is associated with poor outcomes. Conventional triple anticoagulation [Vitamin K Antagonists (VKA) plus dual-antiplatelet therapy (DAPT)] is the first-line therapy for LVT after STEMI. In patients with LVT following STEMI, contemporary data of triple therapy with rivaroxaban are lacking.. We conducted a retrospective cohort study involving 1335 STEMI patients who underwent primary percutaneous coronary intervention (PCI). Among patients who developed LVT after STEMI, we observed differences in efficacy between rivaroxaban plus DAPT therapy and VKA plus DAPT. The time of LVT resolution was also evaluated, as well as net clinical adverse events, and rates of bleeding events.. In 1335 patients with STEMI, a total of 77 (5.7%) developed LVT over the follow-up period (median 25.0 months). Of the patients diagnosed with LVT, 31 patients were started on triple therapy with VKA, 33 patients on triple therapy with rivaroxaban. There was a consistent similarity in LVT resolution with rivaroxaban application compared to VKA application during the follow-up period [HR (log-rank test) 1.57(95% CI 0.89-2.77), p = 0.096; Adjusted HR 1.70(95% CI 0.90-3.22), p = 0.104]. Triple therapy with rivaroxaban showed quicker resolution than with VKA (6 months: p = 0.049; 12 months: p = 0.044; 18 months: p = 0.045). Similar risks of ISTH bleeding were not significantly different between the 2 groups [VKA 9.7% vs Rivaroxaban 6.1%, Adjusted HR 0.48 (95% CI 0.73-3.20); p = 0.444)]. Fewer net adverse clinical events (NACE) were observed in the rivaroxaban group [VKA 58.1% vs Rivaroxaban 24.2%; HR (log-rank test) 0.31(95% CI 0.14-0.68), p = 0.003; Adjusted HR 0.23(95% CI 0.09-0.57), p = 0.001].. In the observational study, triple therapy with rivaroxaban has similar and quicker LVT resolution in patients with LVT after STEMI, compared with triple therapy with VKA, and perhaps was associated with a better clinical benefit. Larger sample sizes and randomized controlled trials are needed to confirm this observation.

Topics: Anticoagulants; Humans; Percutaneous Coronary Intervention; Retrospective Studies; Rivaroxaban; ST Elevation Myocardial Infarction; Thrombosis; Treatment Outcome; Vitamin K; Warfarin

Topics: Antigens, Human Platelet; Arginine; Aspirin; Autoantibodies; Combined Modality Therapy; Coronary Thrombosis; Drug Substitution; Drug Therapy, Combination; Eptifibatide; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Pipecolic Acids; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Platelet Transfusion; Purpura, Thrombocytopenic, Idiopathic; Shock, Cardiogenic; ST Elevation Myocardial Infarction; Stents; Sulfonamides; Thrombectomy; Thrombolytic Therapy; Thrombosis; Ticagrelor; Warfarin

We sought to describe the safety and efficacy outcomes of patients on warfarin presenting with ST-elevation myocardial infarction (STEMI).. Limited data exist on the outcomes and optimal management of STEMI patients on warfarin undergoing primary percutaneous coronary intervention (PCI).. Baseline characteristics and outcomes were prospectively collected for 2,390 consecutive STEMI patients referred for primary PCI. Patients were stratified based on warfarin use at baseline. The primary safety endpoint was the rate of in-hospital bleeding (a composite of major bleeding or minor bleeding) according to the thrombolysis in myocardial infarction (TIMI) classification. Efficacy endpoints included major adverse cardiovascular events (MACE), defined as death, myocardial infarction, or stroke, as well as intracranial bleeding, cardiogenic shock, and length of stay. Multiple logistic regression was used to determine if warfarin was independently associated with bleeding and MACE.. Warfarin patients (n = 59 vs. n = 2,331) were significantly older (73.2 years vs. 61.7 years; P < 0.01), and more likely to present as Killip Class IV (13.6% vs. 2.7%; P < 0.01). TIMI major/minor bleeding occurred in 30.4% of the warfarin patients and 14.2% of the control patients (P < 0.01). After adjustment warfarin was independently associated with an increased risk of bleeding (OR 2.08; P = 0.04). Warfarin patients also had an increased frequency of MACE (20.3% vs. 5.9%; P < 0.01), though this was not significant after adjustment (OR 2.00; P = 0.10).. STEMI patients on warfarin referred for primary PCI are more likely to experience bleeding. New strategies are needed to optimize the management and minimize bleeding in this high-risk population.

Topics: Aged; Anticoagulants; Databases, Factual; Female; Hemorrhage; Hospital Mortality; Humans; Length of Stay; Male; Middle Aged; Percutaneous Coronary Intervention; Retrospective Studies; Risk Assessment; Risk Factors; ST Elevation Myocardial Infarction; Time Factors; Treatment Outcome; Warfarin

Therapeutic anticoagulation may be a surrogate marker for increased MACE in the setting of a STEMI. Consideration should be given to transradial access for patients on anticoagulation. Triple therapy (DAPT plus anticoagulant) should be minimized.

Topics: Anticoagulants; Humans; Myocardial Infarction; Percutaneous Coronary Intervention; ST Elevation Myocardial Infarction; 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

The contemporary role of prophylactic anticoagulation following extensive anterior wall ST-segment myocardial infarction (STEMI) is unclear.. We evaluated anterior STEMI patients with left ventricle dysfunction (left ventricular ejection fraction ≤40%) ("high risk"), categorized by prophylactic warfarin use, within a regional STEMI. Patients with pre-existing atrial fibrillation were excluded. The primary outcome was an adjusted (for Global Registry of Acute Coronary Events risk score) 1-year composite of recurrent ischemia, stroke/transient ischemic attack/systemic embolism, or all-cause death. Of the 2032 STEMI admissions, 436 (21.5%) were high risk. After excluding 19 (4.4%) patients with definite left ventricle thrombus and 21 (4.8%) in-hospital deaths (2 had left ventricle thrombus), prophylactic warfarin was utilized in 236/398 (59.3%) high-risk survivors. Prescriptions were comparable across sex, but recipients were on average younger (58.5 years versus 64.0 years,. A high utilization of prophylactic warfarin occurs in anterior STEMI patients with left ventricle dysfunction, yet appears to provide no additional benefit on the ischemic composite. The association with lower all-cause mortality, but higher bleeding, calls for an improved understanding of its role in high-risk STEMI.

Topics: Administration, Oral; Aged; Alberta; Anterior Wall Myocardial Infarction; Anticoagulants; Chi-Square Distribution; Female; Hemorrhage; Humans; Logistic Models; Male; Middle Aged; Odds Ratio; Propensity Score; Registries; Risk Factors; ST Elevation Myocardial Infarction; Stroke; Stroke Volume; Thromboembolism; Time Factors; Treatment Outcome; Ventricular Dysfunction, Left; Ventricular Function, Left; Warfarin

Topics: Adult; Anticoagulants; Cardiomyopathies; Chest Pain; Coronary Angiography; Coronary Occlusion; Drug-Eluting Stents; Dyspnea; Echocardiography; Electrocardiography; Heart Diseases; Heart Transplantation; Humans; Male; Myocardial Ischemia; ST Elevation Myocardial Infarction; Thrombosis; Ventricular Dysfunction, Left; 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

Left ventricular non-compaction cardiomyopathy is a rare congenital cardiomyopathy, which usually presents early in life but may also manifest into adulthood. We present the case of an elderly woman with left ventricular non-compaction cardiomyopathy, which was discovered incidentally following an ST-elevation myocardial infarction.

Topics: Aged; Angioplasty, Balloon, Coronary; Aspirin; Cardiomyopathy, Hypertrophic, Familial; Clopidogrel; Coronary Angiography; Drug-Eluting Stents; Echocardiography, Doppler, Color; Electrocardiography; Female; Hematologic Agents; Humans; Incidental Findings; ST Elevation Myocardial Infarction; Thrombosis; Ticlopidine; Treatment Outcome; Warfarin