Coronary Artery Stent Placement Research Articles

Characteristics of the basal psychoautonomous indicators in patients after coronary artery stent placement at various stages of rehabilitation

Background: Clinically significant psychoautonomous syndrome, along with other modifiable factors (obesity, dyslipidemia, low physical activity, smoking, arterial hypertension, etc.) increases the risk of development and progression of coronary artery disease (CAD). In particular, patients who have undergone coronary interventions and have a higher anxiety level are prone to the development of CAD complications.
 Aim: To characterize the basal parameters of clinically significant psychoautonomous syndrome and their changes over time under combination therapy, including anxiolytics, at various stages of rehabilitation of the patients after endovascular myocardial revascularization.
 Materials and methods: This open-label randomized controlled prospective study included 60 patients aged 45 to 75 years admitted to our in-patient department for rehabilitation treatment after coronary stent placement. The patients from the intervention group (n = 30), in addition to basic treatment for CAD, were administered anxiolytic therapy (alimemazine tartrate at daily dose of 12.5 to 25 mg i. m. at the early rehabilitation step and at 5 to 10 mg during their out-patient follow-up). The in-patient study period included 3 study visits (at admittance, i. e., Day 1, at Days 5 or 6, and at discharge at Day 10 to 14). Two further study visits were performed during the out-patient rehabilitation period at Days 30 and 60. At each visit, the emotional state, sleep quality, subjective signs of autonomous dysregulation, autonomous background and suprasegmental vegetative regulation, including temporal and spectral indicators of heart rate variability, were evaluated.
 Results: After endovascular myocardial revascularization (the in-patient study period, Day 1) patients of the intervention and control groups (n = 30 in both groups) demonstrated comparable moderate levels of state anxiety (median [Q1; Q3]: 42 [40; 46] and 42 [36; 43], respectively) and trait anxiety (45 [41; 48] and 42 [40; 46], associated with insomnia (PSQI score: 8 [6; 12] and 6 [3; 9]) and autonomous imbalance (SDNN: 73 [61; 89] and 70 [44; 95]) with a shift to sympathetic hyperactivity. Addition of an anxiolytic initiated the regression of psychoautonomous abnormalities already by the end of the early in-patient rehabilitation period) (Days 10 to 14), with a subsequent decrease in state anxiety to 36 [33; 39] and trait anxiety to 33 [32; 37] (p 0.001), regression of insomnia according to PSQI to 2 [2; 4] (p 0.001), and an improvement of autonomous balance (SDNN) to 113 [81; 132] (p 0.001) at days 45 to 60 of the outpatient follow-up. The only adverse event in the patients receiving the treatment for psychoautonomous dysfunction was increased sleepiness at daytime, which was registered in most of them at initiation of the therapy for 2 to 3 days and did not require any dose modification. There were no other clinically significant adverse events, including cardiovascular.
 Conclusion: Patients with an increased level of anxiety after endovascular myocardial revascularization are characterized by an autonomous imbalance with sympathetic hyperactivity. Addition of an anxiolytic to the basic treatment for CAD allows for a reduction of both components of the psychoautonomous syndrome, which may be an additional factor for successful patient rehabilitation and as a consequence for the prevention of CAD progression.

Optimizing Stent Placement in Coronary Artery: The Role of Artificial Intelligence in Improving Patient Outcomes

Optimizing Stent Placement in Coronary Artery: The Role of Artificial Intelligence in Improving Patient Outcomes

Penetrating Atherosclerotic Ulcer with Elevated Troponin in A Patient with Old Myocardial Infarction: A Case Report

Penetrating atherosclerotic ulcer (PAU), an uncommon etiology of acute aortic syndrome (AAS), is a potential cause of chest pain seen in emergency departments. As PAU may lead to electrocardiogram (ECG) changes or rarely, elevated troponin levels, it is most likely misdiagnosed as acute coronary syndrome (ACS). Hence, individuals with PAU may be offered potentially life-threatening treatment. This paper reports a case of a 81-year-old male who presented with intermittent chest pain with a history of old inferior myocardial infarction and stent placement in the left circumflex coronary artery (LCX) three years ago. Initially, he was diagnosed with non-ST-elevation myocardial infarction (NSTEMI) based on abnormal ECG changes and raised troponin I. However, emergency coronary angiography (CAG) showed no restenosis in the left circumflex coronary artery (LCX) but with mild stenosis in the left anterior descending artery (LAD) and right coronary artery (RCA). Computed tomographic angiography (CTA) of the whole aorta showed multiple atherosclerotic plaques with penetrating atherosclerotic ulcer in the aortic arch and descending aorta. Endovascular aortic repair with Ankura II covered stent was performed. This case study reminds us that it is clinically difficult to distinguish PAU from ACS. Upon excluding ACS from the diagnosis, we should take into consideration of PAU, especially in elderly patients with positive cTnI.

736 Hazy spots: through the eye of optical coherence tomography

Abstract Aims Acute stent thrombosis after coronary artery stent placement is a rare but serious complication in percutaneous coronary intervention (PCI). Stenting culprit lesions in acute coronary syndrome (ACS) has higher risk of acute stent thrombosis than stable coronary artery disease, and many local and systemic factors may contribute to increase this risk. Tissue protrusion (TP), and in particular, plaque prolapse after PCI can play a role in acute stent thrombosis, and intra-vessel imaging is the principal instrument to identify such underlying lumen alteration after stent implantation, and guide intervention. Methods and results We report the case of a 54-year-old man with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, obesity and no other relevant comorbidities in remote history, who underwent a coronary angiography for an unstable angina. A long, calcific sub-occlusion of the left anterior descending artery (LAD), which involved LAD-first diagonal branch (D1) bifurcation (Medina 1.1.1) and LAD-D2 bifurcation (Medina 1.1.0) was found. After deployment of two overlapping drug-eluting stents (DES), (ULTIMASTER TANSEI 3.0 × 38 mm and 3.0 × 21 mm) and struts apposition optimization with sequence of proximal optimization technique (POT) on D1 and D2, and a kissing balloon technique (KS) on LAD-D2 bifurcation, a ‘hazy’ in-stent image was detected right after the LAD-D2 bifurcation, suggesting an acute in-stent thrombosis, in absence of flow alteration (TIMI 3), symptoms or ECG modifications. Multiple thrombus-aspiration were made and resulted in abundant thrombus removal and improvement in the angiographic image, with persistent valid flow on every three vessels (TIMI 3). After 5 days of triple anticoagulant therapy with ticagrelor, cardioaspirin and UFH infusion, he underwent a new coronary angiography control. A similar ‘hazy’ image was detected right after LAD-D2 bifurcation within the LAD. An optical coherence tomography (OCT) pullback was made to assess the nature of the angiographic finding. OCT showed good struts apposition in almost every cross-sectional images, but an evident TP was detected right on the angiographic hazy spot. OCT allowed to evaluate the lipid-richness of the stented plaque and the nature of the TP, which was mixed with evident both white and red thrombus apposition (minimum luminal area measured 4.5 mm2). OCT guided a new PCI, with a stent-in-stent implantation on LAD. TP was absent on the post-PCI OCT run. Conclusions In this report, we showed the usefulness of OCT in revealing a potential high risk thrombogenic source. OCT not only characterized something that angiography alone couldn’t, but suggested the etiology of the amount of thrombus removed by the vessel during the first PCI. Indeed, despite an optimized cycle of anticoagulant therapy, OCT still revealed several mixed thrombus apposition on the TP, and this suggested its role in the acute stent thrombosis. OCT guided the choice to appose a new stent-in-stent to solve a potential thrombogenic source.

Therapeutic Plasma Exchange for Treatment of Heparin Induced Thrombocytopenia in a Patient Undergoing Left Ventricular Assist Device Implantation

Introduction Heparin-induced thrombocytopenia (HIT) is an autoimmune reaction to heparin exposure that is associated with a high morbidity and mortality. HIT occurs when platelet factor 4 (PF4) antibodies are released and bind to exogenous heparin. This creates complexes that may induce a life-threatening systemic coagulopathy. Standard treatment for HIT includes discontinuation of heparin and administration an alternative thrombin inhibitor. We report a case of a man who developed HIT prior to left ventricular assist device (LVAD) implantation, a procedure which requires a large dose of intraoperative heparin. The patient was treated with therapeutic plasma exchange (TPE) and was able to safely undergo LVAD implantation. Case Report A 52-year-old Caucasian man was initially admitted for a delayed presentation ST elevation myocardial infarction. He underwent left anterior descending coronary artery (LAD) stent placement and was discharged home on appropriate medical therapy but with significant residual left ventricular dysfunction. The patient returned three weeks later in cardiogenic shock requiring emergent extracorporeal membrane oxygenation (ECMO) placement with a heparin drip per protocol. He was weaned off ECMO and transitioned to Impella support. Labs for thrombocytopenia revealed HIT which was confirmed with a positive serotonin release assay (SRA). For refractory shock and an echocardiogram which showed an ejection fraction of 10-15%, the patient was approved for durable LVAD implantation. TPE was initiated to remove the PF4 antibodies. Using optical density as a guide, the patient underwent five rounds of TPE until he was SRA negative. He then uneventfully received heparin during LVAD implantation. Post procedure, the patient was started on argatroban with warfarin until his INR was therapeutic. The patient was discharged one-month post procedure. He has completed a course of rehab and is now functionally class I with plans for a transplant evaluation. Summary To our knowledge this is the first case report of the use of optical density guided TPE for HIT in a patient undergoing LVAD implantation. The treatment required a multidisciplinary approach and led to an excellent outcome in a critically ill patient.

Abstract 15121: Mortality in Cancer Patients Undergoing Percutaneous Coronary Intervention: Insights From a Hospital-based Cross-sectional Study

Introduction: Comorbid risk factors between cancer and coronary artery diseases (CAD) and underlying pathogenesis of inflammation and oxidative stress led to an increase in the number of cancer patients developing CAD. Hypothesis: The prime purpose of our hospital-based study is to evaluate the risk of mortality due to cancer and chronic comorbidities in post-percutaneous coronary intervention (PCI) patients. Methods: We conducted a cross-sectional study using the nationwide inpatient sample (NIS, 2012 to 2014) including 1,131,415 adult patients undergoing PCI with placement of non-drug and/or drug-eluting coronary artery stents. The logistic regression model was used to assess the odds ratio (OR) of the association between comorbid cancer and mortality in post-PCI hospitalized patients. Results: Most of the post-PCI patients with cancer were older adults (mean age 70.6 years), males (71.8%), and Caucasians (80.6%). Females (OR 1.28, 95% CI 1.24-1.34) had higher odds of post-PCI mortality risk compared to males. Among all comorbidities, coagulopathy and deficiency anemia were associated with increased risk of mortality by three times (95% CI 2.837-3.250) and 1.6 times (95% CI 1.534-1.692), respectively in post-PCI hospitalized patients. Comorbid cancer was associated with an increased risk of mortality in post-PCI hospitalized patients (OR 1.88, 95% CI 1.69-2.09) after controlling for potential confounders. Conclusions: Cancer is a significant risk factor increasing the risk of mortality by 88% in post-PCI hospitalized patients. An integrated care model requiring more vigilance and aggressive management for the complex patient population with cancer and other comorbidities are needed.

Management of Antiplatelet Therapy During Continuous-Flow Left Ventricular Assist Device Support After Thrombotic Hemorrhagic Events.

Hemorrhagic or thrombotic events are common complications in heart failure patients with continuous-flow left ventricular assist device (CF-LVAD) support. Aim of this study is to investigate the effect of change in antiplatelet therapy after thrombotic or hemorrhagic events in patients with CF-LVAD support. A total of 231 CF-LVAD patients were included in this study. Patients with CF-LVAD were categorized into three groups: (1) high antiplatelet regimen as control group (aspirin [ASA] 325 mg; n = 115), (2) low antiplatelet regimen (ASA 81 mg; n = 82), started after hemorrhagic complications, and (3) double antiplatelet therapy (ASA/clopidogrel; n = 34) started after thrombotic complications. In our analysis, indications for low antiplatelet therapy were gastrointestinal (GI) bleeding (36%), hemorrhagic stroke (8%), and epistaxis (9%). Freedom from major bleeding events after changing therapy was comparable at 1 year for all three groups respectively 96%, 97%, and 91% (log rank = 0.421). Major indications for double antiplatelet therapy were pump thrombosis (15%) and coronary artery stent placement (2.5%). Freedom from thrombotic events after changing therapy was comparable at 1 year for groups 1, 2, and 3, respectively, 97%, 98%, and 91% (log rank = 0.317). Logistic regression shows that Heartmate II patients required more antiplatelet therapy changes compared with HeartWare (odds ratio [OR]: 3.611, 95% confidence interval [CI]: 1.8-6.9; p = 0.0001). HeartMate II required more adjustment of antiplatelet therapy during follow-up. Reducing or increasing antithrombotic therapies in response to major thrombotic hemorrhagic events in CF-LVAD patients is a safe strategy to avoid recurrences.

Left main coronary artery stent placement in a 7.0 kg infant with Williams Syndrome.

We report the case of a 9-month-old male with Williams syndrome who underwent patch augmentation of supravalvar aortic stenosis and pulmonary artery stenosis, and required emergent drug-eluting left coronary artery stenting on post-operative day 1 for severe left ventricular dysfunction related to myocardial ischemia.

Utilization of Anticoagulation and Antiplatelet Therapies in Patients with Atrial Fibrillation and Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Utilization of Anticoagulation and Antiplatelet Therapies in Patients with Atrial Fibrillation and Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Association of time from arrest to percutaneous coronary intervention with survival outcomes after out-of-hospital cardiac arrest

BackgroundTimely post-resuscitation coronary reperfusion therapy is recommended; however, the timing of immediate coronary reperfusion for out-of-hospital cardiac arrest (OHCA) has not been established. We studied the effect of the time interval from arrest to percutaneous coronary intervention (PCI) on resuscitated OHCA patients. MethodsAll witnessed OHCA patients with a presumed cardiac etiology received successful PCI at hospitals between 2013 and 2015, excluding cases with unknown information regarding the time from arrest to PCI and survival outcomes. The main exposure of interest was the time interval from arrest to ballooning or stent placement in coronary arteries, and cases were categorized into five groups of 0–90, 90–120, 120–150, and 150–180min and 3–6h. The endpoint was survival with good neurological recovery. Multivariable logistic regression analysis was performed, adjusting for patient-community, prehospital, and hospital factors. ResultsA total of 765 patients (24.1% received PCI within 90min; 31.0% in 90–120min; 17.8% in 120–150min; 12.3% in 150–180min; 14.9% in 3–6h after arrest) were included. Good neurological recovery was more frequent in the early PCI groups than the delayed PCI group (63.6%, 55.3%, 47.8%, 33.0%, and 42.1%, respectively). The adjusted OR (95% CI) for good neurological recovery compared with the most early PCI group was 0.86 (0.53–1.39) in the PCI group between 90 and 120min; 0.76 (0.45–1.31) in the PCI group between 120 and 150min; 0.42 (0.22–0.79) in the PCI group between 150 and 180min; and 0.53 (0.30–0.93) in PCI group after 3h. ConclusionsAmong resuscitated OHCA patients with a presumed cardiac etiology and successful PCI, patients who received a delayed coronary intervention after 150min from arrest were less likely to have neurologically intact survival compared to those who received an early intervention.

Abstract P072: Association of Occupational Exposures with Cardiovascular Disease among Hispanics/Latinos: Results from the Hispanic Community Health Study/Study of Latinos

Background: Cardiovascular disease (CVD) is a leading cause of mortality and morbidity in the US. Acute, high-dose exposures to some solvents, metals, and pesticides can be cardiotoxic, but little is known about the cardiovascular effects of chronic, low-level exposures. Thus, we evaluated cross-sectional associations of self-reported occupational exposures to solvents, metals, and pesticides with CVD prevalence among diverse Hispanics/Latinos in the US. Methods: The analyses included baseline data from 7,404 currently employed participants, ages 18-74 years, from the HCHS/SOL. CVD was defined as the presence of one or more of the following: coronary heart disease (self-reported angina, myocardial infarction, coronary bypass surgery, balloon angioplasty, or stent placement in coronary arteries, or electrocardiogram [ECG] evidence of major Q wave abnormalities or minor Q, QS waves with ST, T abnormalities); atrial fibrillation (self-reported or ECG evidence of atrial fibrillation or flutter); heart failure (self-reported); or cerebrovascular disease (self-reported stroke or transient ischemic attack). Survey-weighted Poisson regression models were used to estimate prevalence ratios (PR) and 95% confidence intervals (CIs) for each occupational exposure, adjusted for sociodemographic (age, gender, field center, Hispanic/Latino background, health insurance), acculturation (language, years of duration in the US), lifestyle (smoking, alcohol, physical activity, diet), and occupational (full- or part-time employment) characteristics. Results: Overall, 6.1% of participants had any prevalent CVD; coronary heart disease (4.3%) was most common, followed by cerebrovascular disease (1.0%), heart failure (0.8%), and atrial fibrillation (0.7%). Current occupational exposures to solvents, metals, and pesticides were reported by 6.5%, 8.5%, and 4.7% of participants, respectively. The prevalence of any CVD (PR: 2.18, 95% CI: 1.34-3.55), coronary heart disease (PR: 2.20, 95% CI: 1.31-3.71), and atrial fibrillation (PR: 5.92, 95% CI: 1.89-18.61) were significantly elevated for participants who reported current occupational pesticide exposure compared to no exposure. Current occupational metal exposure was associated with a greater prevalence of atrial fibrillation (PR: 3.78, 95% CI: 1.24-11.46). Further adjustment for hypertension, hypercholesterolemia, diabetes, or body mass index did not appreciably change the results. Current occupational solvent exposure was not associated with CVD prevalence. Conclusions: Occupational exposure to pesticides and metals is associated with higher CVD prevalence at baseline. These cross-sectional associations do not appear to be attenuated by hypertension, hypercholesterolemia, diabetes, or obesity. Further research is needed to examine other biologic mechanisms that may underlie these associations.

Major thoracic surgery in patients under antiplatelet therapy

Advances in anticoagulant and antiplatelet regimes are associated with a significant risk reduction in the occurrence of thrombotic events. However, this thrombotic protection may carry an increased risk of bleeding during and after surgery. Aspirin is the main antiplatelet medication used in patients with coronary artery disease, nevertheless there is a growing evidence demonstrating that the use of the most potent antiplatelet medication, clopidogrel, on its own or in combination with aspirin, is more effective in both chronic and acute settings (1). The most recent recommendation for patients who have undergone to drug—eluting coronary artery stent placement advises toreceive the dual antiplatelet therapy for at least 12 months. Dual antiplatelet therapy has become the mainstay treatment strategy for the prevention of stent thrombosis. Premature discontinuation of antiplatelet therapy markedly increases the risk of stent thrombosis, a catastrophic event that frequently leads to myocardial infarction and/or death (2).

Coronary in-stent restenosis: predisposing clinical and stent-related factors, diagnostic performance and analyses of inaccuracies in 320-row computed tomography angiography.

The aim of this study was to identify predisposing factors for coronary in-stent restenosis (ISR) and assess its detection by 320-row computed tomography angiography (CTA) using invasive coronary angiography (ICA) as a gold standard. A total of 189 patients (aged 35-79, mean age 56.6, 169 males) with 318 stents underwent ICA within 4 days after CTA. ISR was found in 19 (10.0 %) patients and 25 (7.9 %) stents. At the patient level, the presence of ISR was significantly related to the number of deployed stents (P = 0.026) and body mass index (P = 0.030). At the stent level, stents with diameter <3mm were more likely to have ISR than those with diameter ≥3mm (53.8 % vs. 28.9 %, P = 0.016). Bare metal stents were significantly more likely to have ISR than drug-eluting stents (15.2 % vs. 6 %, P = 0.022). ISR was not significantly related to stent length (P = 0.097) and stent placement in coronary arteries at the vessel level (P = 0.059). False-positive or false-negative results of CTA were not related to stent location, diameter, length, and strut thickness (P > 0.05). At the patient level, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of CTA for detecting ISR were 90, 96, 74, 99, and 96 %, respectively. At the stent level, the corresponding figures were 92, 96, 67, 99, and 96 %. The high negative predictive value of 99 % suggests that 320-row CTA is helpful for excluding ISR.

A Cross-Sectional Analysis of Cardiovascular Disease in the Hemophilia Population

A Cross-Sectional Analysis of Cardiovascular Disease in the Hemophilia Population

A New Insight Into Sudden Cardiac Death in Young People: A Systematic Review of Cases of Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TTC) causes sudden cardiac death and has garnered increased attention worldwide in recent years. However, few studies have clearly classified the risk factors for this disease, including gender, race and morbidity, as well as the physical and mental stressors that can exacerbate the disease, particularly in young patients. To better analyze the characteristics of young TTC patients, we performed a systematic review of reported cases involving young patients.A computer-assisted search was performed using prominent electronic medical information sources to identify literature published between January 1965 and December 2013. Relevant studies containing clinical data of young TTC patients were included.Ninety-six records that included information about 104 cases were ultimately selected for our review. Several of the following results were noted: First, physical stress was more likely to exacerbate TTC than was mental stress in young patients. Second, more female than male TTC patients were noted among both young patients and the general population. Third, ethnicity appears to play no role in the disease, as no significant differences were noted among individuals of different races with respect to clinical characteristics, morbidity or stressors. Fourth, the clinical manifestations of TTC were similar to those of other cardiac diseases, including coronary heart disease. However, TTC may be detected using the combination of echocardiography and ventriculography.Clinicians should consider TTC if young patients present with symptoms similar to those of coronary heart disease so that harmful treatments such as coronary artery stent placement may be avoided. Moreover, the answers to questions regarding the clinical diagnostic criteria, etiology, pathophysiology, and the management of this syndrome in youth remain unclear; therefore, further research is needed.

Abstract 364: Comparison Between Frequency Domain Optical Coherence Tomography and Intravascular Ultrasound in Detecting Mechanical Complications of Coronary Stent Implantation: A Meta-analysis.

Background: Frequency Domain Optical Coherence Tomography (FD-OCT) is a novel method for evaluation of complications related to stent. Current literature has paucity of data with limited sample size comparing FD-OCT to Intravascular ultrasound (IVUS). The objective of this meta-analysis is to compare FD-OCT to IVUS in evaluation of mechanical complications after stent implantation. Methods: PubMed was searched through January 2015. Four studies (n=95 vessels) comparing FD-OCT to IVUS procedures to determine mechanical complications of coronary artery stent placement were included. End points were detection of intraluminal thrombus, edge dissection, malapposition, and malapposition area. The mean difference (MD) or odds ratio (OR) with 95% confidence interval (CI) was computed as appropriate and p&lt;0.05 was considered as a level of significance. Results: FD-OCT detected significantly more complications including intraluminal thrombus (OR: 5.15, CI: 1.06-24.89, p=0.04), edge dissections (OR: 6.10, CI: 2.11-17.68, p=0.0009) (figure A) and malapposition (OR: 4.83, CI: 2.21-10.99, p&lt;0.0002) (figure B) compared to IVUS. Malapposition area measurement was not different between two modalities (p=0.27). Conclusion: The results of our meta-analysis suggest that FD-OCT is a better intravascular imaging modality compared to IVUS in detecting mechanical complications after coronary artery stent implantation. Additionally, this study suggests that FD-OCT and IVUS are comparable in detecting malapposition area.

A Cross-Sectional Analysis of Cardiovascular Disease in the Hemophilia Population

A Cross-Sectional Analysis of Cardiovascular Disease in the Hemophilia Population

TCT-399 The Impact Of STENTYS® (STENTYS SA, Paris, France) Self-Apposing Coronary Artery Stent Placement On The Lipid Core Plaque Burden, As Assessed With Near-Infrared Spectroscopy; How Does The Lipid Rich Plaque Modify After Stent Deployment And After Balloon Post-Dilatation?

TCT-399 The Impact Of STENTYS® (STENTYS SA, Paris, France) Self-Apposing Coronary Artery Stent Placement On The Lipid Core Plaque Burden, As Assessed With Near-Infrared Spectroscopy; How Does The Lipid Rich Plaque Modify After Stent Deployment And After Balloon Post-Dilatation?

Preoperative management of antiplatelet drugs for a coronary artery stent: how can we hit a moving target?

BackgroundWith the advent of percutaneous coronary intervention, specifically the bare metal stent and subsequently, the drug-eluting stent, the scope of interventional cardiology has greatly increased. Aspirin, in combination with a thienopyridine is the present-day cornerstone of oral antiplatelet therapy after coronary artery stent placement. Continuing this chronic antiplatelet therapy, to mitigate a perioperative major adverse cardiac event, can be challenging and remains controversial in patients with a coronary artery stent undergoing non-cardiac surgery. We describe here the rationale for and successful use of an alternate approach to formulating local institutional management protocols for patients with a coronary artery stent, undergoing an elective surgical procedure.DiscussionA recent systematic review identified 11 clinical practice guidelines for the perioperative management of antiplatelet therapy in patients with a coronary stent who need non-cardiac surgery. However, there is significant variance and inadequacy with these current applicable professional society guidelines. Moreover, persistently variable success has been experienced in translating even well-grounded national clinical guidelines into local practice, including in the perioperative setting. Under the auspices of a broadly multidisciplinary institutional task force and applying the Consensus-Oriented Decision-Making model, we created two evidence-informed and local expert opinion-supported standardized clinical assessment and management plans for the preoperative management of antiplatelet therapy in patients with a coronary artery stent.SummaryPatient care can be optimized via evidence-based, yet locally developed and reiterative standardized clinical assessment and management plans for patients with coronary artery stents undergoing surgical procedures. Such standardized clinical assessment and management plans can result in greater consistency in care, providing a positive feedback loop in which the care plan itself can be continuously reevaluated, improved, and brought up to date with the most recent available data and knowledge.

Trojna antitrombotička terapija kod bolesnika sa atrijalnom fibrilacijom i koronarnom bolešću

According to current guidelines, all patients with a recent coronary artery stent placement should receive double antiplatelet therapy with a combination of aspirin plus clopidogrel to reduce the likelihood of acute and subacute stent thrombosis. The length of treatment depends on the type of the stent, with bare metal stents requiring at least 1 month and drug-eluting stents requiring 6 months of both antiplatelet drugs. The length of treatment of patients with acute coronary syndrome is 12 months of dual antithrombocite drugs. Atrial fibrillation carries a high risk for thromboembolic events and any patient with at least two moderate risk factors should be on oral anticoagulation with a vitamin K antagonist. Since atrial fibrillation and coronary artery disease with stent placement are common, it is not infrequent to treat patients with both these conditions, where triple antithrombotic therapy with aspirin, clopidogrel and oral antagonist of vitamin K would be needed. However, concerns about increased bleeding risk do exist and clinicians are uncertain about how to manage this diffi cult clinical situation-especially since there are no large randomised trials to guide clinical practice regarding this particular issue.