Higher Risk Of Stent Thrombosis Research Articles

How to decide appropriate percutaneous coronary intervention (PCI) technique for managing heavy calcified coronary lesions: serial case-report

Background: Coronary artery calcification (CAC) is still challenging for interventional cardiologists. Their contribution to major adverse cardiac events occurs from the high risk of stent thrombosis or in-stent restenosis and target lesion revascularization. Optimal preparation, such as coronary plaque modification before stenting, is required to reduce the risk of periprocedural adverse events. This case presentation aimed to describe the appropriate management of heavy calcified coronary lesions. Case Presentation: Two cases of heavy calcified coronary lesions with different baselines as Acute Coronary Syndromes (ACS) and elective PCI were presented. In our ACS patients, the Primary PCI was done by coronary angioplasty without stenting because of the complexity of the heavily calcified lesion. A referral to tertiary health care was made for further PCI procedures using a combination of calcium-ablation and balloon-based techniques. A treatable complication occurred after the orbital atherectomy was performed with good results. The second case was an elective PCI patient with heavy calcified lesions findings from coronary angiography. The balloon-based technique was performed using non-compliant and scoring balloons without complication and showed good results. Conclusion: The challenging points in managing heavy calcified coronary lesions are procedure complexity and the higher stent failure rate. Many modifying coronary calcification algorithms using advanced modalities have been proposed, which could be used to select the appropriate technique as experienced and increase the success rate. Keyword: balloon-based technique, calcium-ablation technique, heavy calcified coronary lesion, orbital atherectomy

Dual antiplatelet therapy duration and stent type in patients with high bleeding risk: A systematic review and network meta-analysis

BackgroundIt is uncertain whether the efficacy and safety of dual antiplatelet therapy (DAPT) in patients with high bleeding risk (HBR) vary according to DAPT duration and stent type (e.g., durable polymer drug-eluting stents (DP-DESs), biodegradable polymer DESs (BP-DESs), or polymer-free drug-coated stents (PF-DCSs)). We aimed to study the stent type and DAPT duration appropriate for patients with HBR. MethodsPubMed and EMBASE were searched until October 2023. Randomized controlled trials (RCTs) involving patients with HBR that compared standard DAPT (6-12 months) with DP- or BP-DES versus short DAPT (≤3 months) with DP- or BP-DES or PF-DCS or bare-metal stent (BMS) were identified. The primary efficacy outcome was major adverse cardiovascular events (MACEs), defined as cardiovascular death, myocardial infarction (MI), and stroke. The primary safety outcome was major bleeding. Secondary outcomes included MI and stent thrombosis (ST). We performed a network meta-analysis using a random effects model. ResultsThirteen RCTs with a total of 19,418 patients with HBR were included. Compared to standard DAPT with DP-DES, short DAPT with BMS was associated with a higher risk of MACE and MI. For major bleeding, short DAPT strategies were associated with a lower risk than standard DAPT strategies (e.g. short DAPT with DP-DES versus standard DAPT with DP-DES; HR[95% CI]: 0.48[0.28-0.82]). Interestingly, the use of BP-DES was associated with a higher risk of ST than DP-DES (e.g. standard DAPT with BP-DES versus short DAPT with DP-DES; HR[95% CI]: 2.65[1.03-6.79]). ConclusionsIn patients with HBR who underwent percutaneous coronary intervention, a short DAPT strategy with DP-DES should be used since it offers the best combination of efficacy and safety.

BIFURCATION: A CLINICAL CASE IN ACUTE CORONARY SYNDROME

Abstract Bifurcation A clinical case in acute coronary syndrome. Coronary bifurcation lesions are considered one of challenging entities in the field of coronary intervention due to the risk of side branch loss and higher risk of stent thrombosis. There are limited data on the preferred treatment strategy in ST–segment elevation myocardial infarction (STEMI) patients with bifurcation lesions as most dedicated study excluded patients with acute coronary syndrome. In all comers population a 10–20% of STEMI patients had bifurcation culprit lesion. In 2018 guideline suggested a provisional approach by stenting the main vessel and implanting a second stent only if necessary as a bailout strategy. This reccomandation was supported by a large series of study that uniquely documented the superiority of one versus two stent technique. The same message could also be exported in the context of acute patients, as our clinical case, thanks to registry like COBIS 2 including ST–segment elevation patient. But this precious advice cannot be applied in all clinical subsets. Especially when we manage with a relevant side–branch and when the risk of loosing the side branch is very high. In this subgroup of patient, bifurcation lesion may benefit from a 2 stent approach. Different technical option are available. Among these, DK–crush and inverted Main Branch stenting across Side Branch (Invertend Culotte or inverted T technique) could be the best choice. Our patient was a young lady presenting with a lateral STEMI (D1 and aVL). The culprit lesion was a Medina 1.1.1 bifurcation lesion involving left anterior descending and first–diagonal. Since our side branch had thrombus inside, the vessel was relevant by definition. Other anatomical characteristique to take into account: relevant size and covering a large myocardial territory. Planning the strategy to treat our LAD–D1 bifurcation we consider the angle and the difference in size between main and side branch. We decided to proceed with DK–crush and its recent evolution DK–nano crush. In conclusion “do it provisional” guideline message is not always possible, 2 stent technique seems to be the best choice in presence of a relevant side–branch / high risk to loose it. Our take home message is, if the clinical scenario allow it, don’t hesitate to perform a multistep two vessel strategy technique and to try to reconstruct perfect anatomical carina even in STEMI context.

Impact of intracoronary imaging-guided percutaneous coronary intervention on procedural outcomes among patients with cardiogenic shock

Abstract Background Intracoronary imaging (ICI), including intravascular ultrasound (IVUS) or optical coherence tomography (OCT), is known to correlate with a reduction in rates of cardiac death after percutaneous coronary intervention (PCI), driven by lower rates of reinfarction and stent thrombosis. [1,2] However, there are limited data around its utility amongst patients with acute coronary syndrome (ACS) and cardiogenic shock, who are inherently at a high risk of stent thrombosis. Aims To examine the frequency of utilisation of ICI among ACS patients with cardiogenic shock, and their subsequent outcomes, in a national cohort of PCI procedures over a six-year period. Methods All PCI procedures for ACS patients with cardiogenic shock in England and Wales between 2014 and 2020 were retrospectively analysed, stratified into two groups: ICI and non-ICI groups. Multivariable logistic regression analyses were performed to examine the odds of in-hospital major adverse cardiovascular and cerebrovascular events (MACCE; composite of all-cause mortality, acute stroke/transient ischaemic attack (TIA), and reinfarction) and major bleeding (BARC 3-5) in the ICI-guided group, compared with the non-ICI group, as well as predictors of receipt of ICI-guided PCI. Results Of 15,738 PCI procedures performed between 2014 and 2020, 1,240 procedures (7.9%) were ICI-guided. Overall, the rate of ICI use amongst those with cardiogenic shock has more than doubled from 2014 (5.7%) to 2020 (13.3%). The ICI-guided group were predominantly younger, males, with a higher proportion of non-ST elevation ACS and stent thrombosis. The rate of MACCE was significantly lower in the ICI-guided group compared with the non-ICI group (29.8% vs. 38.2%, p<0.001), driven by lower rate of all-cause mortality (28.6% vs. 37.0%, p<0.001). (Figure 1) There were no differences for other secondary outcomes between groups. In multivariable analysis, the odds of MACCE and all-cause mortality in those undergoing ICI-guided PCI remained significantly lower than in the non-ICI group (OR 0.65 95% CI 0.56, 0.76 and OR 0.65 95% CI 0.55, 0.75, respectively, p<0.001 for both). (Figure 2). Advanced age (OR 0.98) and STEMI presentation (OR 0.54) negatively correlated with ICI use while stent thrombosis presentation (OR 2.66), previous PCI (OR 2.02), intervention on LMS (OR 4.19) and proximal LAD lesions (OR 1.62) and need for calcium modification (OR 2.13) positively correlated with increased ICI use. Conclusion The utilisation of ICI among patients with cardiogenic shock has more than doubled over a 6-year period on a national level but remains significantly under-utilised, with less than 1-in-6 patients in receipt of ICI-guided PCI in 2020. ICI use is associated with a prognostic benefit in terms of reduction of in-hospital MACCE and all-cause mortality in this high-risk patient group and should be more frequently utilised to increase their long-term survival.Figure 1.In-hospital crude outcomesFigure 1B.Adjusted odds ratios (OR)

Intracoronary imaging guided percutaneous coronary intervention outcomes among individuals with cardiogenic shock.

Limited data exist around the utility of intracoronary imaging (ICI) during percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) and cardiogenic shock (CS), who are inherently at a high risk of stent thrombosis (ST). All PCI procedures for ACS patients with CS in England and Wales between 2014 and 2020 were retrospectively analysed, stratified into two groups: ICI and angiography-guided groups. Multivariable logistic regression analyses were performed to examine odds ratios (OR) of in-hospital outcomes, including major adverse cardiovascular and cerebrovascular events (MACCE; composite of all-cause mortality, acute stroke/transient ischaemic attack (TIA), and reinfarction) and major bleeding, in the ICI-guided group compared with angiography-guided PCI. Of 15,738 PCI procedures, 1240(7.9%) were ICI-guided. The rate of ICI use amongst those with CS more than doubled from 2014 (5.7%) to 2020 (13.3%). The ICI-guided group were predominantly younger, males, with a higher proportion of non-ST-elevation ACS and ST. MACCE was significantly lower in the ICI-guided group compared with the angiography-guided group (crude: 29.8% vs. 38.2%, adjusted odds ratio (OR) 0.65 95% confidence interval [CI] 0.56-0.76), driven by lower all-cause mortality (28.6% vs. 37.0%, OR 0.65 95%CI 0.55-0.75). There were no differences in other secondary outcomes between groups. ICI use among CS patients has more than doubled over 6 years but remains significantly under-utilized, with less than 1-in-6patients in receipt of ICI-guided PCI by 2020. ICI-guided PCI is associated with prognostic benefits in CS patients and should be more frequently utilized to increase their long-term survival.

Drug-coated balloon therapy is more effective in treating late drug-eluting stent in-stent restenosis than the early occurring one-a systematic review and meta-analysis.

Drug-eluting stent in-stent restenosis (DES-ISR) remains one of the important assignments to be resolved in interventional cardiology, as it is present in 5%-10% of total percutaneous coronary intervention cases. Drug-coated balloon (DCB) utilization is promising, as it comes with long-term protection from recurrent restenosis in optimal conditions without the hazard of higher risk for stent thrombosis and in-stent restenosis. We aim to reduce the need for recurrent revascularization in DES-ISR, specifying the population in which the DCB therapy should be used. In this meta-analysis, the results of studies containing data on the time frame between drug-eluting stent implantation and the clinical presentation of in-stent restenosis and concomitant drug-coated balloon treatment were summarized. A systematic search was performed in Medline, Central, Web of Science, Scopus and Embase databases on November 11th, 2021. The QUIPS tool was used to assess the risk of bias in the included studies. The occurrence of a major cardiac adverse events (MACE) composite endpoint, containing target lesion revascularization (TLR), myocardial infarction, and cardiac death, and each of these separately, was assessed at 12 months after the balloon treatment. Random effects meta-analysis models were used for statistical analysis. Data of 882 patients from four studies were analyzed. Across the included studies, a 1.68 OR (CI 1.57-1.80, p < 0.01) for MACE and a 1.69 OR (CI 1.18-2.42 p < 0.01) for TLR were observed, both in favor of late DES-ISR. The main limitation of the study is the relatively low patient number. Nevertheless, this analysis shows the first statistically significant results for the effect of DCB treatment in the early or late presentation of DES-ISR. As to date, intravascular imaging (IVI) remains limitedly accessible, other landmarks as the time frame of in-stent restenosis development are to be pursued to advance therapeutic outcomes. In consideration of other biological, technical and mechanical factors, time frame of occurrence as a prognostic factor could reduce the burden of recurrent revascularization in patients at an already high risk. Systematic Review Registration: identifier [CRD42021286262].

Management of Bifurcation Culprit Lesion in the Setting of Anterior ST Elevation Myocardial Infarction

Introduction: Coronary bifurcation lesions are considered one of the challenging entities in the field of coronary intervention due to the risk of side branch loss and higher risk of stent thrombosis. However, there is limited data about the proper management of such lesions in the setting of myocardial infarction as most bifurcation lesion studies excluded patients with acute coronary syndromes (ACS). The aim of this study was to compare in-hospital and mid-term outcomes of single-stent and two-stents strategy in the management of bifurcation culprit lesions in patients presenting with anterior STEMI.&#x0D; Methods: This retrospective multi-center study included all patients presented with anterior STEMI who underwent primary PCI between January 2017 and December 2019, coronary angiography showed true bifurcation lesion with sizable side branch that can be managed by stenting. Patients with left main bifurcation, those indicated for urgent CABG, and patients in cardiogenic shock were excluded. Included patients were divided into two groups according to the stenting strategy either single or two stents. Six months follow up data were collected by telephone calls and by examination of medical records.&#x0D; Results: Out of 1355 anterior STEMI patients presented between January 2017 and December 2019, 158 patients (11.6%) were identified to have bifurcation culprit lesions with a sizable diagonal branch. 93 patients (59%) were treated by single stent while 65 patients (41%) were managed by two-stents strategy. The baseline characteristics and angiographic findings were similar in both groups except for higher side branch involvement in the two stents group (83.31%±11.20 vs 71.88%±15.05, t= -5.39, p &lt;0.001). Mean fluoroscopy time (23.96±8.90 vs 17.81±5.72 mins) and contrast volume (259.23± 59.45 vs 232.58± 96.18 ml) were significantly higher in two stents group than single stent group (p=0.049). However, the angiographic success rates (residual stenosis ≤30% and restoration of TIMI flow grade II or III) were comparable (96.8% vs 99%, MCp=0.151). There is no significant difference in the overall incidence rate of MACE in both groups 6 months following the index procedure (13.9 % vs 16.9%, FEp=0.698), with no difference between different bifurcation stenting techniques in patients managed with two stents.&#x0D; Conclusion: Although two stents strategy in the setting of STEMI is much complex with more fluoroscopy time and contrast volume, the procedural success rate and the incidence of MACE were comparable to one stent strategy, on medium-term follow up.

Descriptive and prognostic study at 5 years of percutaneous coronary intervention by long active stents ≥ 40 mm

The treatment of long coronary lesions often requires long stents, which carries a higher risk of stent thrombosis, restenosis and major adverse cardiac events. Our objective is to evaluate the clinical and angiographic results, immediate, in the medium and in the long-term of the coronary angioplasties with very long active stents ≥ 40 mm. We carried out a retrospective, multicenter, descriptive and prognostic study, during a period of 5 years between January 2015 and January 2020 in four Tunisian centers, including all patients who underwent coronary angioplasty with an active stent ≥ 40 mm in length. Four hundred and eighty patients were included. Our population was at high cardiovascular risk: the mean age was 62.45 years with a sex ratio of 3.40. The most frequent cardiovascular risk factors were as follows: arterial hypertension: 61.1%, diabetes: 56.6% and tobacco: 60.5%. The most common clinical presentation was acute coronary syndromes in 69.70%. The artery most frequently stented with a very long stent was the anterior interventricular artery in 49.4%. The treated lesions were complex: 23.5% were calcified, 8.7% were total chronic occlusions and 25% had bifurcations. The average length of the implanted stents was 47.72 mm. The long coronary lesion required an overlap by a 2nd stent in 16.45% of the interventions. Angiographic and clinical success was observed in 96% and 95% of cases respectively. Seventeen cases of per-procedural complications were recorded during the procedure (3.55%). Angiographic control was only performed during the follow-up in 21.7% of patients. The stent thrombosis rate was 0.83%. The incidence of MACE, TVR and TLR and was 16.3%, 9.2% and 7.9%, respectively. Diabetes appeared to be predictive factors of TLR (survival without TLR at 12 months = 99% vs. 93.7%; P = 0.01). The study of the characteristics lesion showed that ostial lesions and bifurcation lesions are predictive factors for increased TLR (ostial lesion: survival without TLR at 5 years = 78.2% vs. 87.4%; P = 0.001/bifurcation lesion: survival without TLR at 5 years = 84% vs. 92.7%; P = 0.03). Coronary stenoses requiring treatment with long stents are generally associated with high cardiovascular risk and complex atheromatous disease. They can be revascularized with a long active stent (≥ 40 mm) with an acceptable MACE, TLR, TVR and thrombosis rate.

Network meta-analysis and trial sequential analysis for atrial fibrillation patients receiving PCI or with ACS.

In patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI), choosing the most appropriate antithrombotic treatment remains a dilemma. We aimed to compare the relative efficacy and safety outcomes of antithrombotic drugs in patients with AF after undergoing PCI or ACS. Randomized controlled trials were systematically searched on PubMed, EMBASE, and the Cochrane Library. Five studies (11,532 patients) were included in the network meta-analysis. Trial sequential analysis (TSA) was performed to assess the reliability and conclusiveness of the meta-analysis comparing the dual antithrombotic therapy strategies with the triple antithrombotic therapy strategy. Compared with vitamin K antagonist + dual antiplatelet therapy, novel oral anticoagulant (NOAC) + P2Y12 inhibitor was associated with a significantly better trial-defined primary safety outcome (odds ratio: 0.53; 95% CI, 0.31-0.90) and the lowest probability of thrombolysis in myocardial infarction major bleeding and intracranial hemorrhage using the cumulative ranking technique. In patients omitting aspirin, TSA demonstrated conclusive evidence with significant decreases in all safety outcomes and inconclusive evidence with a nonsignificant increase in in-stent thrombosis (risk ratio: 1.32; TSA-adjusted 95% CI, 0.54-3.24) and myocardial infarction (risk ratio: 1.19; TSA-adjusted 95% CI, 0.84-1.68). In patients with AF receiving PCI or with ACS, NOAC + P2Y12 inhibitor was associated with the lowest bleeding risk but resulted in a statistically nonsignificant, numerically greater risk for stent thrombosis and myocardial infarction, suggesting that triple antithrombotic therapy should still be an option for certain patients at a high risk of stent thrombosis or myocardial infarction.

M9. Five–year Outcome of Bioresorbable Vascular Scaffold versus Drug-Eluting Stent for Coronary Artery Disease: A Meta-Analysis of Randomized Control Trial

Abstract Introduction Late stent thrombosis and restenosis remain major drawbacks of Drug-Eluting Stent (DES). Therefore, Bioresorbable Vascular Scaffolds (BVS) were created to combat these disadvantages. However, the long-term outcome of BVS versus DES for treating coronary artery disease remains inconclusive. Method We performed an orderly literature search from several electronic databases. We used the keyword “bioresorbable vascular scaffold” and “drug-eluting stent”. The inclusion criteria were comparing BVS and DES, Randomized Control Trial (RCT), and reported 5-year follow-up. The primary endpoints were cardiac death and stent thrombosis. Secondary endpoints were ischemic-driven target lesion revascularization (ID–TLR) and target lesion failure (TLF) as a composite of cardiac death, target vessel myocardial infarction (TVMI), or ID–TLR. Risk ratio (RR) with 95% confidence intervals (CIs) were used to report all outcomes. Results A total of 3 RCT were selected (ABSORB II, ABSORB III, and ABSORB JAPAN) with 2.890 patients were pooled in our analysis. At five years, compared to DES, BVS had no significant difference in cardiac death (RR = 0.81 [95% CI, 0.50-1.32], p = 0.40). However, BVS had higher risk of stent thrombosis (RR = 2.74 [95% CI, 1.38-5.46], p = 0.004), ID–TLR (RR = 1.38 [95% CI, 1.04-1.84], p = 0.03) and TLF (RR = 1.26 [95% CI, 1.03-1.54], p = 0.02). Conclusions Comparing to DES, BVS has a significantly greater risk of stent thrombosis, ID–TLR, and TLF after five years of follow-up.

Management of bifurcation culprit lesion in the setting of anterior ST elevation myocardial infarction

Abstract Introduction Coronary bifurcation lesions are considered one of the challenging entities in the field of coronary intervention due to the risk of side branch loss and higher risk of stent thrombosis. However, there is limited data about the proper management of such lesions in the setting of myocardial infarction as most bifurcation lesion studies excluded patients with acute coronary syndrome (ACS). Aim To compare in-hospital and mid-term outcomes of single-stent and two-stents strategy in the management of bifurcation culprit lesions in patients presenting with anterior STEMI Methods This retrospective multi-center study included all consecutive patients presented with anterior STEMI who underwent primary PCI between January 2017 and December 2019, coronary angiography showed true bifurcation lesion with sizable side branch that can be managed by stenting. Patients with left main bifurcation lesion, patients indicated for urgent CABG, or patients in cardiogenic shock were excluded. Included patients were divided into two main groups according to the stenting strategy either single or two stents strategy. Six months of follow up data were collected by telephone calls and the examination of medical records Results Out of 1355 anterior STEMI patients presented between January 2017 and December 2019, 158 patients (11.6%) were identified to have bifurcation culprit lesions with a sizable diagonal branch. The baseline characteristics and angiographic findings were similar in both groups except for higher side branch involvement in the two stents group (83.31%± 11.20 and 71.88%±15.05, t=−5.39, p&amp;lt;0.001). Mean fluoroscopy time (23.96±8.90 vs 17.81±5.72 min) and contrast volume (259.23±59.45 vs 232.58±96.18 ml) were significantly higher in two stents group than single stent group (p=0.049). However the angiographic success rates (residual stenosis ≤30% and restoration of TIMI flow grade II or III) were comparable (96.8% vs 99%, MC p=0.151). There is no significant difference regarding the overall incidence rate of MACCE in both groups 6 months following the index procedure (13.9% vs 16.9%, FEp=0.698), with no difference between different bifurcation stenting techniques in patients managed with two stents Conclusion Although two stents strategy in the setting of STEMI is much complex with more fluoroscopy time and contrast volume, the procedural success rate and the incidence of complications between two groups were comparable on the medium-term follow up Funding Acknowledgement Type of funding sources: None.

Duration of dual antiplatelet therapy and stability of coronary heart disease: a 60 000-patient meta-analysis of randomised controlled trials

BackgroundDual antiplatelet therapy (DAPT) has important implications for clinical outcomes in coronary disease. However, the optimal DAPT duration remains uncertain.Methods and resultsWe searched four major databases for randomised controlled trials...

Outcomes of Drug-Eluting Stent Thrombosis After Treatment for Acute Versus Chronic Coronary Syndrome

The primary objective of the current analysis was to assess the association between the clinical presentation at index procedure and mortality in patients with second-generation drug-eluting stent thrombosis (G2-ST). Patients with acute coronary syndrome (ACS) have a higher risk for stent thrombosis (ST) as compared with those with chronic coronary syndrome (CCS). However, clinical outcomes of patients with G2-ST after treatment for ACS and CCS remain poorly understood. From the REAL-ST (Retrospective Multicenter Registry of ST After First- and Second-Generation Drug-Eluting Stent Implantation) registry, this study evaluated 313 patients with G2-ST. According to baseline clinical presentation, patients were divided into the 2 groups: the ACS and CCS groups (n = 147 and n = 166, respectively). The primary endpoint was the cumulative 3-year incidence of all-cause death after the index ST events. Timing of ST, target lesion revascularization, and recurrent ST were also assessed. Early ST was more frequently observed in the ACS group (71.4% vs. 44.6%), while very late ST was less likely to occur in the ACS group than in the CCS group (11.6% vs. 30.7%). Cumulative 3-year incidence of all-cause death after the index ST events was comparable between the ACS and CCS groups (28.6% vs. 28.3%; hazard ratio: 1.14; 95% confidence interval: 0.75 to 1.73; p = 0.55). Compared with the CCS group, the ACS group showed higher incidences of target lesion revascularization and recurrent ST (23.8% vs. 17.2%; p = 0.06; and 9.9% vs. 1.4%; p = 0.001, respectively). Patients with G2-ST were associated with higher mortality irrespective of baseline clinical presentation.

Role and Timing of Aspirin Therapy Following PCI in Patients With Atrial Fibrillation

In patients with atrial fibrillation who undergo percutaneous coronary intervention (PCI), both anticoagulation and dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) are indicated. However, this "triple" antithrombotic therapy is associated with high rates of bleeding. Finding the right balance of reducing ischemic risk and protecting coronary stents from restenosis while not increasing bleeding risk is difficult. In the past 5 years, 6 randomized clinical trials have shown the benefit of dropping aspirin from the triple therapy regimen to create "dual" therapy (oral anticoagulants and P2Y12 inhibitors alone) with reductions in bleeding without a significant increase in ischemic events. Because of small trends toward higher risk of stent thrombosis, especially in higher risk patients with acute coronary syndromes, current recommendations call for dual therapy as the "default" regimen, but that risk stratification be used to help inform the decision on potentially using a brief period of triple therapy in selected high ischemic risk patients. For long-term therapy (after one year post-PCI), recent studies have found oral anticoagulation alone without any antiplatelet therapy has a favorable benefit risk ratio. Thus, while dropping aspirin at varying times post-PCI has become an attractive strategy in many patient groups, careful patient selection and individualized assessment of the risk:benefit balance is warranted.

Antithrombotic therapy in patients with atrial fibrillation and percutaneous coronary intervention: what has changed in the guidelines in 2020?

The article presents an analytical review of the studies aimed at determining the optimal antithrombotic therapy in patients with atrial fibrillation undergoing elective or emergency percutaneous coronary intervention (PCI) due to the development of acute coronary syndrome (ACS). The results of the WOEST study are analysed. This study was the first to demonstrate an opportunity to safely discontinue administration of aspirin as part of the multicomponent antithrombotic therapy that included warfarin as an anticoagulant. Three studies were analysed - PIONEER AF-PCI, RE-DUAL-PCI and AUGUSTUS, where direct oral anticoagulants (DOACs) - rivaroxaban, dabigatran and apixaban were used as anticoagulants as part of the multicomponent therapy. The results of these studies formed the backbone of the updated European guidelines for the diagnosis and treatment of atrial fibrillation, 2020. The guidelines offer to divide patients with AF and ACS, who require multicomponent antithrombotic therapy, into two categories. The first group includes AF patients with uncomplicated PCI without a high risk of stent thrombosis, as well as patients with a risk of bleeding that prevails over the risk of stent thrombosis. The second category of patients, in contrast, is characterized by a high risk of stent thrombosis, which prevails over the risk of bleeding. In the absence of contraindications, the patients of both categories should choose DOAC as an anticoagulant and be prescribed clopidogrel as a P2Y12 inhibitor for 12 months. In AF patients with uncomplicated PCI without a high risk of stent thrombosis, as well as in patients with a risk of bleeding, which prevails over the risk of stent thrombosis, the period of treatment with the second antiplatelet drug (aspirin) should belimited to the hospital stay. Patients at increased risk of stent thrombosis and reduced risk of bleeding can extend the aspirin therapy for 1 month. The approaches to the choice of the duration and composition of the multicomponent antithrombotic therapy in AF patients taking oral anticoagulants after elective PCI are similar to those in ACS patients, except for the duration of clopidogrel therapy, which is reduced to 6 months in all patients.

Benefit of dual antithrombotic therapy with direct oral anticoagulants in patients with atrial fibrillation undergoing percutaneous coronary intervention: a systematic review and metaanalysis of randomized clinical trials.

Antithrombotic treatment in patients with atrial fibrillation undergoing percutaneous coronary intervention is still debated. We conducted a meta-analysis of recent randomized controlled trials to evaluate the benefit of different antithrombotic strategies. Data were analyzed between May and September 2019. Efficacy outcomes were trial-defined major adverse cardiovascular events (MACE); its individual components; stent thrombosis. Safety outcomes were trial-defined primary bleeding outcome; TIMI and ISTH major bleeding; clinically relevant non-major bleeding; intracranial hemorrhage. Differences in outcomes among groups were expressed as pooled odds ratio (OR) and corresponding 95% confidence interval (CI). Four randomized studies were included (10,969 patients). The mean age ranged from 69 to 72years, prevalence of acute coronary syndrome (ACS) varied from 48 to 62%. Comparing dual antithrombotic therapy (DAT) with a direct oral anticoagulant (DOAC) versus triple antithrombotic therapy (TAT) with vitamin K antagonist (VKA), OR for trial-defined MACE and primary bleeding outcome were 1.03 (95% CI, 0.86-1.24) and 0.59 (95% CI, 0.41-0.86), respectively. There was a 68% lower risk of intracranial hemorrhage and a non-statistically significant higher risk of stent thrombosis with DAT. DAT wasas effective and safer than TAT in patients with stable coronary artery disease, while a trend towards increased ischemic events was seen in ACS patients. DAT with a DOAC showed similar efficacy and less bleeding than TAT with a VKA. However, increased stent thrombosis with DAT may be present, and TAT should be considered in patients at high ischemic risk, such as ACS patients.

Higher risk of stent thrombosis with double therapy with direct oral anticoagulants: cherry picking the populations of interest does not help.

Higher risk of stent thrombosis with double therapy with direct oral anticoagulants: cherry picking the populations of interest does not help.

Balloon coronary angioplasty and parenteral antiplatelet therapy for intraoperative myocardial infarction during general surgery: An attempt to balance benefits and risks - a case report

Introduction. Cardiovascular complications remain one of the major risk factors for perioperative morbidity and bad outcome in non-cardiac surgery patients. Here we report a case of the patient suffering intraoperative ST-segment elevation acute myocardial infarction (STEMI) promptly treated with percutaneous balloon angioplasty and intravenous antiplatelet agents. Case report. A 62-year-old man, without previous history of cardiovascular morbidity, developed STEMI during abdominal surgery. Due to profound hypotension with mean arterial pressure of less than 40 mmHg, surgery was promptly ended and patient transferred to intensive care unit. Within one hour after the end of the surgery, coronary angiography and successful balloon angioplasty of occluded right coronary artery were performed. Tirofiban infusion was started in recommended dose. Developed hemodynamic instability was related to hypovolemia and excessive drainage, reaching 1,500 mL of blood in the following 15 hours. The following morning, drainage persisted (additional 600 mL of blood) which resulted in profound hypotension (65/40 mmHg). Overall, the patient received 1,970 mL of blood, 6 doses of thrombocytes and 840 mL of fresh frozen plasma. All together, the patient had a favorable outcome, despite the occurrence of bleeding complications and hemodynamic instability. Conclusion. The choice of treatment strategy for patients suffering perioperative STEMI during major non-cardiac surgery is challenging. After major non-cardiac surgery, characterized by both high bleeding risk and high risk of stent thrombosis, balloon angioplasty instead of stenting along with parenteral antiplatelet treatment may be a fair therapeutic choice. Clinical choices have to be made individually, according to the weighted risks and benefits.

The balance of thrombosis and hemorrhage in STEMI patients with or without associated cardiac arrest: An observational study

BackgroundData is scarce on hemorrhagic and thrombotic complications in patients with ST-elevation myocardial infarction (STEMI) associated with out-of-hospital cardiac arrest (OHCA). MethodsThis is a monocentric, retrospective study conducted from January 2012 to December 2017 in a tertiary university hospital, which serves as a cardiac arrest center for a large urban area. Over the study period, all consecutive patients who were treated with stent implantation for STEMI with or without OHCA were included. Baseline characteristics, treatments, hemorrhagic and thrombotic events were compared between STEMI patients with and without OHCA. Univariate and multivariate analysis were performed in order to identify predictors of 30-day mortality, occurrence of major bleeding (MB), and early stent thrombosis (ST). ResultsA total of 549 patients treated for STEMI without OHCA and 146 patients for STEMI with OHCA were included. The incidence of definite ST and MB after coronary angioplasty was significantly higher in patients with OHCA (2.6% vs. 7.5%, p = 0.004 and 3.3% vs. 19.2%, p < 0.001, respectively). Independent predictors of MB in OHCA patients were anticoagulation therapy (HR = 3.11, 95%CI [1.22–7.98], p = 0.02) and the use of glycoprotein IIb/IIIa inhibitors (HR = 4.16, 95%CI [1.61–10.79], p = 0.003). Independent predictors of mortality in OHCA patients were age (HR = 1.05, 95%CI [1.02–1.09], p = 0.004) and ST (HR = 5.62, 95%CI [1.61–19.65], p = 0.007, with a protective effect of new anti-P2Y12 treatments (HR = 0.20, 95%CI [0.08-0.46], p < 0.001). ConclusionPatients treated for STEMI associated with OHCA are at higher-risk of ST and MB than those who did not experience cardiac arrest. In this subset of patients, prospective studies are needed to better evaluate the balance of thrombosis and hemorrhage.

Revisiting the effects of omitting aspirin in combined antithrombotic therapies for atrial fibrillation and acute coronary syndromes or percutaneous coronary interventions: meta-analysis of pooled data from the PIONEER AF-PCI, RE-DUAL PCI, and AUGUSTUS trials

Recently, three randomized trials reported that dual antithrombotic treatments (DATs) including non-vitamin K antagonist oral anticoagulants (NOACs) and a P2Y12 inhibitor without aspirin were associated with significantly less bleeding than vitamin K antagonist (VKA)-based triple antithrombotic therapy (TAT) in atrial fibrillation (AF) patients with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). We conducted an analysis of pooled data from these trials. A meta-analysis of the PIONEER AF-PCI, RE-DUAL PCI, and AUGUSTUS trials considering major bleeding [International Society on Thrombosis and Haemostasis (ISTH) and Thrombolysis in Myocardial Infarction], clinically relevant non-major bleeding, all-cause/cardiovascular death, stroke, myocardial infarction (MI), and stent thrombosis. Treatment effect is reported as odds ratio (OR) and 95% confidence interval. Among 9463 patients (53% with ACS), DAT regimens were associated with significantly less bleeding than TAT (OR 0.598, 0.491 -0.727; P < 0.001 for ISTH major bleeding), as were NOAC-based vs. VKA-based regimens (OR 0.577, 0.477 -0.698; P < 0.001). Stroke and mortality rates were similar, but there was statistically non-significant trend towards greater risk of MI (OR 1.211, 0.955 -1.535; P = 0.115) and significantly higher risk for stent thrombosis (OR 1.672, 1.022 -2.733, P = 0.041) with DAT vs. TAT (but not NOAC- vs. VKA-based regimens). This was mainly driven by Dabigatran 110 mg; the trends were lower with full-dose NOAC or Rivaroxaban 15 mg-based DATs. Our findings support the use of full-dose NOAC (Apixaban 5 mg, Dabigatran 150 mg) or Rivaroxaban 15 mg-based treatments in most AF patients with ACS or undergoing PCI. Notwithstanding the better safety of DAT, an initial course of NOAC-based TAT may be desirable in most AF patients.