Prevention Of Stent Thrombosis Research Articles

Aspirin hypersensitivity: a practical guide for cardiologists.

Aspirin has been known for a long time and currently stays as a cornerstone of antithrombotic therapy in cardiovascular disease. In patients with either acute or chronic coronary syndromes undergoing percutaneous coronary intervention aspirin is mandatory in a dual antiplatelet therapy regimen for prevention of stent thrombosis and/or new ischaemic events. Aspirin is also currently a first-option antithrombotic therapy after an aortic prosthetic valve replacement and is occasionally required in addition to oral anticoagulants after implantation of a mechanical valve. Presumed or demonstrated aspirin hypersensitivity is a main clinical problem, limiting the use of a life-saving medication. In the general population, aspirin hypersensitivity has a prevalence of 0.6%-2.5% and has a plethora of clinical presentations, ranging from aspirin-exacerbated respiratory disease to anaphylaxis. Although infrequent, when encountered in clinical practice aspirin hypersensitivity poses for cardiologists a clinical dilemma, which should never be trivialized, avoiding-as much as possible-omission of the drug. We here review the epidemiology of aspirin hypersensitivity, provide an outline of pathophysiological mechanisms and clinical presentations, and review management options, starting from a characterization of true aspirin allergy-in contrast to intolerance-to suggestion of desensitization protocols.

Identifying the Incidence, Predictors, Outcomes, and Prevention of Stent Thrombosis (ST) in Post-percutaneous Coronary Revascularization Patients With Drug-Eluting Stents (DES): A Systematic Review.

Stent thrombosis (ST) is a rare but catastrophic event to happen to a stented coronary artery. The incidence of ST has greatly been reduced after the advent of modern drug-eluting stent (DES) implants, which have become the most preferred treatment option in the stenting category for coronary artery disease (CAD). Although the risk reduction by newer category implant provides substantial benefits, the possibility of thrombosis still exists mostly during the early stage of DES implantation. The development of ST after percutaneous coronary intervention (PCI) can be predicted by multiple factors, but advancements in early diagnostic techniques and modified stent types have greatly reduced the occurrence of this complication. Mortality, which is one of the complications of ST, is primarily influenced by patient-related factors such as incomplete treatment duration of dual antiplatelet therapy (DAPT). The duration of DAPT after DES implantation in patients with acute coronary syndrome (ACS) is determined based on individual characteristics, mainly considered in view of bleeding or ischemia risk. Risk evaluation systems like DAPT/precise-DAPT scores help tailor and personalize the duration of DAPT for each individual patient. This systematic review contains pertinent articles extracted from the PubMed database. We retrieved articles from various study categories, encompassing publications from the period spanning 2014 to 2022. Our analysis highlighted results from studies investigating different aspects contributing to ST development. The most favorable prevention option was the use of customized DAPT intervention based on patient-specific predictable factors. Several complications associated with ST were identified, including recurrent ST, major adverse cardiovascular events (MACE) encompassing all-cause mortality (including cardiac and non-cardiac mortality), cerebrovascular accidents (CVA) or transient ischemic attacks (TIA), hospitalization due to heart failure, and myocardial infarction requiring revascularization. Mortality was also observed as a significant outcome. The umbrella term of ST includes multiple causative factors. Although DES has improved patient survival rates vastly with its usage, careful risk factor assessment and required follow-up, in each individual being stented, further guarantee a more promising reduction in late adverse outcomes.

Ticagrelor versus Clopidogrel, Drug of Choice for the Prevention of Stent Thrombosis after Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials

Objectives: The objective of this meta-analysis of randomized controlled trials was to compare the efficacy of ticagrelor versus Clopidogrel for preventing stent thrombosis (ST) following percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). Methodology: A comprehensive literature search was conducted using MEDLINE/PubMed, EMBASE, Web of Science, and the Cochrane Library. The inclusion criteria involved selecting randomized controlled trials that included patients with ACS undergoing PCI, comparing the use of ticagrelor and Clopidogrel, having a follow-up period of at least 30 days, and reporting data on ST. The meta-analysis was performed using the R statistical software version 4.1.1, and the "meta" package was utilized. The Mantel-Haenszel method was employed to calculate the relative risk (RR) and corresponding 95% confidence interval (CI) for comparing the risk of ST between the two treatment groups. Results: A total of seven randomized controlled trials were included in the analysis, comprising a population of 28,609 patients with ACS who were randomized to receive either ticagrelor or Clopidogrel in a ratio of 12,116:16,493. The cumulative rate of ST was found to be 2.2% (185/8,423) in the ticagrelor group and 2.7% (347/12,851) in the clopidogrel group. The meta-analysis revealed a significant decrease in the rate of ST with ticagrelor compared to Clopidogrel, demonstrating a relative risk of 0.71 (95% CI: 0.59 to 0.85). No heterogeneity was detected among the included studies, as indicated by an I2 value of 0% and a p-value of 0.463. Conclusion: In conclusion, the findings of this meta-analysis suggest that ticagrelor is a significantly more effective P2Y12 inhibitor than Clopidogrel for preventing ST following PCI in patients with ACS. These results support using ticagrelor as the preferred antiplatelet therapy in this patient population.

Role of Nursing in the Early Detection and Prevention of Stent Thrombosis in Patients Undergoing Coronary Angioplasty

Introduction: stent thrombosis is one of the serious complications after coronary angioplasty. It can present with chest pain and electrocardiographic changes or even sudden death and is characterized by angiographic or postmortem evidence of a newly formed thrombus in a previously stented segment and can occur from intraprocedurally to years after implantation. There are several risk factors, both related to the lesion and the procedure, as well as adherence to antiplatelet therapy and personal history. The objective of this case is to present a care plan to detect and prevent stent thrombosis in patients undergoing coronary angioplasty. Material and methods: an assessment is made through the model of the 14 needs of Virginia Henderson and the care plan is prepared with its respective diagnoses (NANDA), objectives (NOC) and interventions (NIC) with the indicators of results and activities. It will be evaluated using the Likert scale. Results and conclusions: the following diagnoses stand out: decreased cardiac output, ineffective peripheral tissue perfusion and deficient knowledge. Nursing intervenes in the early detection of signs and symptoms that may point us towards stent thrombosis, observing any change immediately, and in its prevention, carrying out health education after angioplasty, highlighting the importance of antithrombotic treatment and in modifying modifiable risk factors.

Evaluation of Clopidogrel Resistance and Its Role in Predicting Stent Thrombosis in Transcarotid Artery Revascularization

While up to 70% of patients have resistance to clopidogrel (Plavix) in the coronary literature, resistance testing is not routinely performed despite its common use as an antiplatelet for prevention of stent thrombosis in transcarotid arterial revascularization (TCAR) procedures. The extent to which resistance exists in patients undergoing TCAR has not been well-described. We sought to compare the modalities for clopidogrel resistance testing and determine the prevalence of resistance and its effect on stent outcomes. Patients undergoing TCAR at our institution between 2018 and 2022 were retrospectively identified. Clopidogrel-resisting test results were recorded. Patient characteristics, perioperative details, and outcomes are described. A total of 85 patients underwent TCAR, 52 (61%) for symptomatic disease. Sixty-five patients (77%) were on dual antiplatelet therapy (DAPT) for at least 7 days prior to TCAR. 7 (8%) patients not on DAPT were on anticoagulation prior to surgery and most (6) received a loading dose of a second antiplatelet the day of their procedure. Nine patients (10.6%) developed stent thrombosis during the follow-up period. Patients not taking DAPT for at least 7 days prior to surgery were more likely to develop stent thrombosis (30% vs 4.6%; P < .001). Clopidogrel resistance testing was performed in 35 (41%) patients, with 25 patients undergoing thromboelastogram with platelet mapping, 5 undergoing VerifyNow P2Y12 inhibitor testing, and 5 undergoing testing with both modalities. Clopidogrel resistance was noted in 24 patients (69%) using all testing results. In patients that underwent both testing modalities, agreement was poor (Cohen's Kappa −0.05) (Table I). Among patients with clopidogrel resistance, 17 (72%) did not thrombose and 5 (20%) patients did thrombose. Comparatively, 1 (9.1%) patient without resistance thrombosed (P = .161). Of the five patients with thrombosed stents that underwent testing, four were clopidogrel resistant (80%) (Table II). VerifyNow correctly predicted resistance and nonresistance more accurately than thromboelastogram (7 of 9 correct, 78% vs 11 of 29 correct, 38%; P = .001). VerifyNow had a sensitivity of 60% and specificity of 100% for stent thrombosis. Our experience demonstrates that clopidogrel resistance rates are high in the TCAR patient population, with higher thrombosis rates in those that test positive for resistance. VerifyNow more reliably predicts clopidogrel resistance than thromboelastography. In addition to determining clopidogrel susceptibility, patients may also obtain benefit by initiating DAPT at least 7 days prior to surgery.Table IComparison of platelet mapping methodsThromboelastogram value (% ADP inhibition)VerifyNow value (P2y12 reaction units)Clopidogrel resistance present?Congruence in testing results?Patient 125.6182YesNoPatient 235.6172YesNoPatient 350.6187YesNoPatient 474.5163NoNoPatient 545.39YesYesAdenosine diphosphate (ADP) inhibition ≤ 50% confers platelet resistance by thromboelastography. Platelet reactivity unit (PRU) >194 confers platelet resistance by VerifyNow testing. Open table in a new tab Table IIDescription of testing among nine patients with thrombosed stentsTEG value (% ADP inhibition)Verify Now value (P2y12 reaction units)Clopidogrel resistance present?Testing result correctly predicts thrombosis?Stent 1N/AN/AN/AN/AStent 2N/AN/AN/AN/AStent 3-213YesYesStent 4-253YesYesStent 5-413YesYesStent 622.4-YesYesStent 774.5163NoNoStent 845.39Yes- TEGNo- VerifyNowYes- TEGNo- VerifyNowStent 9N/AN/AN/AN/AAdenosine diphosphate (ADP) inhibition ≤50% confers platelet resistance by thromboelastography. PRU >194 confers platelet resistance by VerifyNow testing. Open table in a new tab

Molecular Analysis of CYP2C19 Alleles and Clopidogrel Resistance Among Bangladeshi Patients with Acute Coronary Syndrome

Background: Antiplatelet therapy is a cornerstone in the management of the Acute Coronary syndrome and the prevention of stent thrombosis after PCI. After aspirin clopidogrel is the widely used antiplatelet drug in our country. Many studies showed that clopidogrel resistance is the emerging problem for managing ACS patients and after coronary intervention. But exact data about clopidogrel resistance of Bangladeshi population is still unknown.

Serial observation of PK Papyrus covered stent implantation for coronary artery perforation by optical coherence tomography and coronary angioscopy: a case report

Abstract Background Coronary artery perforation is a rare but life-threatening complication of percutaneous coronary intervention. We present a case of coronary artery perforation treated with a PK Papyrus covered stent. Neointimal coverage evaluation was performed using optical coherence tomography (OCT) and coronary angioscopy (CAS) at 3 and 9 months after stent implantation. Case summary A 63-year-old man was admitted to our hospital with worsening effort angina over 3 months. Coronary angiography revealed severe stenosis in the proximal segment of the left anterior descending artery. After stent implantation, coronary artery perforation occurred. We immediately sealed the perforation site using a PK Papyrus covered stent. The patient was discharged on postoperative day 4. OCT and CAS revealed incomplete neointimal coverage at the PK Papyrus covered stent strut 3 months after stent implantation. At 9 postoperative months, complete neointimal coverage was observed. We continued clopidogrel and edoxaban, but no clinical adverse events were encountered during the follow-up. Discussion To the best of our knowledge, this is the first report of a serial observation of PK Papyrus covered stent implantation for coronary artery perforation using OCT and CAS. In this case, OCT and CAS revealed complete neointimal coverage, without obvious thrombus, 9 months after PK Papyrus implantation. Based on the OCT and CAS findings, our report presents an appropriate follow-up strategy for the prevention of stent thrombosis when using a PK Papyrus covered stent, which will contribute to future research on the appropriate duration of dual antiplatelet therapy and evaluation of neointimal coverage.

Biofunctionalization of cardiovascular stents to induce endothelialization: Implications for in- stent thrombosis in diabetes.

Stent thrombosis remains one of the main causes that lead to vascular stent failure in patients undergoing percutaneous coronary intervention (PCI). Type 2 diabetes mellitus is accompanied by endothelial dysfunction and platelet hyperactivity and is associated with suboptimal outcomes following PCI, and an increase in the incidence of late stent thrombosis. Evidence suggests that late stent thrombosis is caused by the delayed and impaired endothelialization of the lumen of the stent. The endothelium has a key role in modulating inflammation and thrombosis and maintaining homeostasis, thus restoring a functional endothelial cell layer is an important target for the prevention of stent thrombosis. Modifications using specific molecules to induce endothelial cell adhesion, proliferation and function can improve stents endothelialization and prevent thrombosis. Blood endothelial progenitor cells (EPCs) represent a potential cell source for the in situ-endothelialization of vascular conduits and stents. We aim in this review to summarize the main biofunctionalization strategies to induce the in-situ endothelialization of coronary artery stents using circulating endothelial stem cells.

Endovascular Treatment of an Elderly Diabetic Patient with a Circular Myocardial Infarction in Cardiogenic Shock Complicated by Stent Thrombosis

The most common cause of cardiogenic shock (CS) is acute myocardial infarction (AMI), which is diagnosed in approximately 5–8% of patients hospitalized for AMI and is more common in patients with acute ST-segment elevation myocardial infarction (STEMI). CS is caused by severe myocardial dysfunction, which leads to a decrease in cardiac output, hypoperfusion of the end organs, and hypoxia. Mortality in diabetic patients with AMI is high. Besides the fact that type 2 diabetes mellitus (DM2) contributes to the progression of coronary atherosclerosis, coronary pathology in this category of patients occurs against the background of a specific diabetic myocardial lesion – diabetic cardiomyopathy. Against the background of cardiomyopathy, acute heart failure is more often developed with a decrease in global myocardial contractility up to CS, which increases hospital-acquired mortality in MI by more than 15 times. The increased risk of death observed in patients with DM2 in the acute period of myocardial infarction (MI) persists for several years, and therefore, at present, in patients with the acute coronary syndrome (ACS) and diabetes, an early invasive strategy is preferable to a conservative strategy. The SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial demonstrated that in patients with CS complicating AMI, emergency revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) improved long-term survival when compared with initial intensive medical therapy. However, in the CULPRIT-SHOCK (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock) study, stenting of non-infarct-dependent coronary arteries in CS increases the risks of major cardiac events, as well as the number of repeated revascularizations within 30 days and 1 year. Patients with multivessel lesions, in most cases, are elderly patients (75–90 years old) who have age restrictions on taking the loading dose at the prehospital stage. Such a loading dose of clopidogrel may not be sufficient to saturate the patient in fact, despite optimal epicardial recanalization, a large proportion of patients still experience impaired reperfusion and in-stent thrombosis. A large body of evidence has been accumulated on the benefits of glycoprotein (GP) IIb-IIIa inhibitors in terms of prevention of stent thrombosis, and benefits in mortality, especially among high-risk patients, and as an upstream strategy.

Tratamiento farmacológico del síndrome coronario crónico

The primary objectives of the pharmacological strategy in patients with stable angina and chronic coronary syndrome are to control symptoms and prevent cardiovascular events. In the long-term prevention of angina, it is often necessary to combine first- and second-line anti-ischaemic drugs and the choice of treatment should be tailored to the patient, taking comorbidities into account and the underlying mechanism of the ischaemia. Anti-thrombotic therapy is the mainstay to prevent events, and dual anti-platelet therapy is necessary in certain clinical scenarios, especially in the prevention of stent thrombosis after percutaneous revascularisation. Lipid-lowering therapy and other drugs associated with cardiovascular morbidity and mortality benefit also form part of the therapeutic strategy in these patients. Finally, percutaneous, or surgical revascularisation should be considered when significant symptoms persist, despite medical treatment, and when considered of prognostic benefit.

Effects of clopidogrel, prasugrel and ticagrelor on prevention of stent thrombosis in patients underwent percutaneous coronary intervention: A network meta-analysis.

BackgroundClopidogrel, prasugrel and ticagrelor, acting on platelet P2Y12 receptor, are commonly used for prevention of stent thrombosis (ST) among patients who underwent percutaneous coronary intervention (PCI). This study aimed to compare the effects of these drugs by a systematic review and network meta‐analysis.HypothesisEfficacies of clopidogrel, prasugrel and ticagrelor on preventing ST are not the same.MethodsPubMed, Embase and Cochrane Library were searched for randomized controlled trials (RCTs) that investigated the effect of clopidogrel, prasugrel, or ticagrelor on prevention of ST in patients who underwent PCI. The efficacies between groups were compared by a Bayesian network meta‐analysis, by which the pooled odds ratios (ORs) and 95% confidence intervals (CIs) was calculated.ResultsFourteen studies and 46 983 participants were included in this study. The pooled results illustrated that clopidogrel, prasugrel and ticagrelor were effective on prevention of ST. Patients treated with prasugrel (OR = 0.30, 95% CI = 0.052 ~ 0.73, P < 0.05) and ticagrelor (OR = 0.25, 95% CI = 0.035 ~ 0.65, P < 0.05) had lower incidence of ST compared to those treated with clopidogrel. Patients treated with ticagrelor showed similar frequency with those in prasugrel group (OR = 0.86, 95% CI = 0.22 ~ 2.3, P > 0.05). No significant heterogeneity was observed across included studies.ConclusionsOur findings suggest that prasugrel and ticagrelor are more effective than clopidogrel on prevention of ST among patients underwent PCI. Simultaneously, there is no significant difference in the prevention of ST between prasugrel and ticagrelor.

Bivalirudin and sirolimus co-eluting coronary stent: Potential strategy for the prevention of stent thrombosis and restenosis

Localized drug delivery with sustained elution characteristics from nanocarrier coated stents represents a viable therapeutic approach to circumvent concerns related to coronary stent therapy. We fabricated a Sirolimus (SRL) and Bivalirudin (BIV) releasing nanoparticles (NPs) coated stent for concurrent mitigation of vascular restenosis and acute stent thrombosis. SRL NPs were prepared by nanoprecipitation method whereas the BIV vesicles were generated using hydrophobic ion pair approach followed by micellization phenomenon. MTT assay and confocal microscopic analysis indicated superior anti-proliferative activity and higher cellular uptake of SRL NPs into human coronary artery smooth muscle cells, respectively. DSC and ATR-FTIR techniques confirmed the formation of complex between BIV and phosphatidylglycerol via some weak physical interactions. More than 2 fold rise in log P value was obtained for DSPG-BIV at 3:1 M ratio compared with native BIV solution. The SAXS analysis indicated formation of oligolamellar vesicles of DSPG-BIV complex which was preferentially entrapped into lipophilic lamellae of vesicles. APTT, PT, and TT tests revealed that the BIV vesicles caused significant prolongation of clotting time compared to native BIV solution. The SEM analysis showed uniform and defect free stent coating. In vitro release study demonstrated that SRL and BIV were eluted in a sustained manner from coated stents.

Triple therapy in the elderly patients and women – results from the MUNICH triple cohort in patients with AF undergoing PCI

Abstract Introduction Approximately 20% of patients with atrial fibrillation (AF) are suffering from coronary artery disease (CAD), requiring percutaneous coronary intervention (PCI) and stenting over time. These patients are in need of a so-called “triple therapy” (TT) for prevention of stent thrombosis and stroke. Prospective and randomized trials examined risk for bleeding in TT and compared it to a dual regimen, but in majority excluded elderly patients. Moreover, in all to date presented triple therapy trials women represent a minority of included patients (mostly &amp;lt;30%). This raises the question, why female and elderly patients are underrepresented and these groups have a different outcome then younger and male patients, when treated with a guideline recommended TT. Methods The objective of our retrospective cohort study was to determine the number of women and elderly patients with the indication for TT and to evaluate the differences in medical treatment. Furthermore, we evaluated safety, represented by bleeding (BARC ≥2 bleedings) and efficacy endpoints (composite clinical endpoint: all-cause-death, myocardial infarction, stent thrombosis, stroke and other systemic thromboembolism) in women vs. men, and elderly vs. younger patients. Moreover, we investigated the influence of NOAC (new oral anticoagulant) vs. VKA (vitamin K antagonist) treatment. Follow-ups were performed via phone-calls or in-hospital visits. Results In total, we included 928 patients with AF, that underwent PCI and stenting. Mean follow-up was 464 days. 627 patients were &amp;lt;80 years old (mean age: 72±7 years), 301 were ≥80 years old (mean age: 84±4 years). Only 27.9% of all patients were female. The number of men and women receiving TT was comparable (83.0% vs. 82.2%, p=0.78), while in the younger group significantly more patients received TT (537 (85.6%) vs. 228 (74.7%) (p&amp;lt;0.001). The incidence of BARC ≥2 bleedings in patients with TT was not significantly different in younger vs. older patients and in men vs. women. Also, the incidence of the composite clinical endpoint did not differ significantly in both comparisons. Conclusion In our real-life cohort female sex represents around a quarter of TT patients in line with large RCTs. But, unlike the large RCTs, 1/3 of our included patients were older then 80 years and seem to be underrepresented in randomized TT trials. TT seems to be safe in elderly as well as in female patients. As they both represent an important group, future trials should focus more on including a well balanced patient cohort to improve the applicability of the results. Funding Acknowledgement Type of funding source: None

Clopidogrel versus Prasugrel towards Prevention of Stent Thrombosis of Intracranial Aneurysm – A metanalysis and literature review (5221)

Clopidogrel versus Prasugrel towards Prevention of Stent Thrombosis of Intracranial Aneurysm – A metanalysis and literature review (5221)

Allele and Genotype Frequencies of CYP2C19 in Patients with Drug-Eluting Stents Following Percutaneous Coronary Intervention in Southwest of Iran

Background: Clopidogrel is a platelet inhibitor drug widely used in patients undergoing percutaneous coronary intervention (PCI) for the prevention of stent thrombosis. Genetic variation within CYP2C19 gene causes variable clopidogrel response. The FDA has recommended CYP2C19 genotyping in the patients taking clopidogrel, especially in the population with high prevalence rates of CYP2C19 *2 and *3 alleles. Objectives: The aim of this study was to determine the prevalence of CYP2C19 gene polymorphisms in the population received Drug-Eluting Stents following PCI in the southwest of Iran. Methods: This cross-sectional study was conducted on 102 patients undergoing PCI. Demographic characteristics and risk factors of patients were collected using a questionnaire and CYP2C19 genotyping was carried out by PCR-RFLP. Then CYP2C19 allele and genotype frequencies were determined and analyzed using χ2 test. Results: Data analysis showed that the frequencies of CYP2C19*1, CYP2C19*2, and CYP2C19*3 allele were 79.4%, 15.2%, and 5.4%, respectively. The frequency of CYP2C19*1/*1 genotype was 60.8%. Moreover, CYP2C19*1/*2, CYP2C19*1/*3, CYP2C19*2/*3 heterozygote genotypes were shown in 28.4%, 8.8%, and 2.0% of the subjects, respectively. None of the patients had CYP2C19*2/*2 or CYP2C19*3/*3 genotypes. Conclusions: The results of this study showed a high prevalence of CYP2C19*2 polymorphism in the population lived in the southwest of Iran. The frequency of CYP2C19*1/*2 genotype is compatible with the majority of the Iranian population and more similar to Caucasian populations.

Bivalirudin with a post-procedure infusion versus heparin monotherapy for the prevention of stent thrombosis.

To evaluate the efficacy of post-primary percutaneous coronary intervention (PCI) bivalirudin infusion (at full PCI dose) to prevent stent thrombosis (ST) compared with heparin monotherapy. Early randomized controlled trials (RCTs) have shown that compared with heparin use, bivalirudin use during primary PCI is associated with an increased risk of ST. However, bivalirudin was stopped in those trials at the end of the procedure and glycoprotein IIb/IIIa inhibitors (GPIs) were routinely used with heparin. The increased risk of ST may be eliminated by continuing bivalirudin infusion post-procedure for few hours. Indeed, in most recent trials, a trend of lower ST risk has been observed with a post-procedure infusion of bivalirudin compared with heparin monotherapy (without the routine use of GPI). Relevant RCTs were included and risk ratios (RRs) were calculated using random effect models. The primary outcome of interest was the risk of early definite ST. Four RCTs involving 13,505 patients were included in this meta-analysis. Compared with heparin monotherapy, bivalirudin (with a post-procedure infusion) was associated with a 55% decrease in the risk of early definite ST (RR: 0.45, 95% confidence interval: 0.23-0.85; P = 0.015). There was no difference in the risk of early ST between bivalirudin (with a post-procedure infusion) and heparin with GPI. For primary PCI, a bivalirudin-based anticoagulant strategy (with post procedure infusion) is associated with a lower risk of early definite ST compared with treatment with heparin monotherapy (without GPI).

Mussel-inspired dopamine-CuII coatings for sustained in situ generation of nitric oxide for prevention of stent thrombosis and restenosis

Nitric oxide (NO) is a highly potent, yet short-lived bioactive molecule with a broad spectrum of physiological functions. Continuous and controllable in situ generation of NO from vascular stent surface can effectively prevent restenosis and thrombosis after its implantation. In this study, inspired by the adhesion and protein cross-linking in the mussel byssus, through immersing the stents into an aqueous solution with dopamine (DA) and copper ions (CuII), we developed a one-step metal-catecholamine assembled strategy to prepare a durable in situ NO-generating biomimetic coating (DA-CuII). Due to the high NO catalytic efficacy and robust chelation of CuII into the DA-CuII network, the coated stents exhibited excellent hemocompatibility. The coating also catalytically decomposed endogenous S-nitrosothiols (RSNOs) from fresh blood, and locally generated NO for over 30 days with a flux comparable to its physiological range (0.5–4 × 10−10 mol × cm−2 × min−1). Moreover, the optimized biomimetic coatings displayed specific cell selectivity to significantly enhance endothelial cell (EC) growth while substantially inhibit smooth muscle cell (SMC) growth and migration. This feature impressively promoted regeneration of a new endothelial cell layer after stent implantation, hence improved the anti-thrombogenic and anti-restenosis qualities of vascular stents in vivo. We envision that our long-term in situ NO-generating coatings could serve as biosurfaces for long-term prevention of stent thrombosis and restenosis.

Prevention of Stent Thrombosis in Rats by a Direct Oral Factor Xa Inhibitor Edoxaban

Background/Aims: Stent thrombosis is a serious complication after percutaneous coronary intervention and femoropopliteal endovascular intervention. The aim of this study was to determine the antithrombotic effects of a direct factor Xa inhibitor edoxaban alone or in combination with antiplatelet agents in a rat model of stent thrombosis. Methods: Stainless steel stents (4 stents per rat) were placed in an extracorporeal arteriovenous shunt. The shunt was inserted into the carotid artery and the jugular vein in each rat to circulate blood. Stent thrombosis was induced by exposing the stents to arterial blood for 30 min. Protein content of the thrombus was measured. Edoxaban and antiplatelet agents (aspirin, clopidogrel, and ticagrelor) were orally administered before the thrombus induction. Results: Edoxaban (0.3–3 mg/kg), clopidogrel (1–10 mg/kg), aspirin (10–100 mg/kg), and ticagrelor (0.3–3 mg/kg) exerted significant and dose-dependent antithrombotic effects in a rat stent thrombosis model. The effect of edoxaban was comparable to that of antiplatelet agents. The combination of submaximal doses of edoxaban and clopidogrel or aspirin significantly potentiated the antithrombotic effects compared with antiplatelet agents alone. Conclusion: These results suggest that edoxaban alone and in combination with clopidogrel or aspirin are promising antithrombotic therapies for the prevention of stent thrombosis.

Safety and efficacy of ultrathin strut biodegradable polymer sirolimus-eluting stent versus durable polymer drug-eluting stents: a meta-analysis of randomized trials

BackgroundThe Orsiro biodegradable polymer sirolimus-eluting stent (O-SES) is a new-generation biodegradable polymer drug-eluting stent with the thinnest strut thickness to date developed to improve the percutaneous treatment of patients with coronary artery disease. We perform a meta-analysis of randomized clinical trials (RCTs) comparing the efficacy and safety of an ultra-thin, Orsiro biodegradable polymer sirolimus-eluting stent (O-SES) compared with durable polymer drug-eluting stents (DP-DESs).MethodsMedline, Embase, and CENTRAL databases were searched for randomized controlled trials comparing the safety and efficacy of O-SES versus DP-DES. Paired reviewers independently screened citations, assessed risk of bias of included studies, and extracted data. We used the Mantel-Haenszel method to calculate risk ratio (RR) by means of a random-effects model.ResultsSix RCTs with a total of 6949 patients were selected. All included trials were rated as low risk of bias. The O-SES significantly reduced the risk of myocardial infarction (RR 0.78, 95% confidence interval [CI] 0.62–0.98; I2 = 0%; 10 fewer per 1000 [from 1 fewer to 18 fewer]; high quality) compared with the DP-DES. There was no significant difference between O-SES and DP-DES in the prevention of stent thrombosis (RR: 0.75; 95% CI: 0.52–1.08), cardiac death (RR: 0.93; 95% CI: 0.63–1.36), target lesion revascularization (RR 1.10, 95% CI 0.86–1.42) and target vessel revascularization (RR 0.97, 95% CI 0.78–1.21).ConclusionAmong patients undergoing percutaneous coronary intervention, O-SES resulted in significantly lower rates of myocardial infarction than DP-DES and had a trend toward reduction in stent thrombosis.

Assessment of the Risk of Rhabdomyolysis and Myopathy During Concomitant Treatment with Ticagrelor and Statins.

The introduction of ticagrelor, one of the first directly-acting oral antiplatelet drugs, provided new possibilities in the prevention of thrombotic events in patients with acute coronary syndromes (ACS). Current guidelines recommend ticagrelor in dual antiplatelet therapy with aspirin over clopidogrel for prevention of stent thrombosis in patients with ACS. Moreover, in the management of ACS, lipid-lowering treatment with high-intensity statin therapy is advised for secondary prevention of cardiovascular events over the long term. Despite the apparent advantages of combined antiplatelet and lipid-lowering treatments, a possible interaction between statins and ticagrelor may lead to myopathy and rhabdomyolysis. In this review, relevant information was gathered on the ticagrelor-statin interaction that might lead to this life-threatening condition. This review focuses on the most widely used statins—simvastatin, atorvastatin, and rosuvastatin. Possible mechanisms of this interaction are discussed, including CYP3A4 isoenzymes, organic anion transporter polypeptide (OATPs), P-glycoprotein and glucuronidation. PubMed database was searched for relevant case reports and all data gathered from the introduction of ticagrelor to March 2018 are presented and discussed. In summary, co-administration of statins and ticagrelor was found to be relatively safe in routinely prescribed doses. However, caution should be exercised, especially in elder populations.