Outcome of patients with prior percutaneous revascularization undergoing repeat coronary intervention (from the PRESTO Trial).

Patients with previous percutaneous coronary intervention (PCI) are often excluded from clinical trials. As a result, limited data are available on the long-term outcome of such patients undergoing repeat PCI. In this study, we assessed the impact of previous PCI on outcomes in patients undergoing repeat PCI. We compared the baseline features and outcomes of 7,056 patients without previous PCI (group I) with those of 1,281 patients with previous PCI of the original target lesion (group II) and 1,408 patients with previous PCI of a nontarget lesion (group III) undergoing PCI in the Prevention of Restenosis with Tranilast and its Outcomes (PRESTO) trial. Compared with patients in group I, patients in groups II and III were more likely to have diabetes (25% and 24% vs 21%, p <0.02), previous myocardial infarction (51% and 56% vs 29%, p <0.001), and ostial lesions (10% and 7% vs 5%, p <0.001), and less likely to have, as their indication for PCI, myocardial infarction (2% and 7% vs 17%, p <0.001). At 1 month, major adverse cardiac events, including death, myocardial infarction, and repeat revascularization, were low and similar in all 3 groups. Compared with patients in group I, the risk of major adverse cardiac events at 9 months was significantly increased for patients in groups II (34.1% vs 18.6%, relative risk [RR] 2.03, adjusted RR 1.78, 95% confidence interval 1.58 to 2.01) and III (23.9% vs 18.6%, RR 1.30, adjusted RR 1.16, 95% confidence interval 1.02 to 1.33). The increased risk of major adverse cardiac events was entirely due to higher rates of repeat revascularization. In conclusion, despite similar short-term outcomes, patients with previous PCI undergoing PCI of either target or nontarget lesions had lower event-free survival at 9 months of follow-up.

Percutaneous coronary intervention: historical perspectives, current status, and future directions.

In the twenty-six years since Gruntzig introduced a simple balloon angioplasty technique, percutaneous coronary intervention has undergone extraordinary growth and has now surpassed bypass surgery in frequency of performance. Several critical breakthrough technologies account for this remarkable progress: intracoronary stents have increased success rates and reduced restenosis, adjunctive antiplatelet therapy has reduced periprocedural complications, and restenosis after stent placement has been effectively treated with local radiation. Most recently, drug-eluting stents coated with cell-cycle inhibitors have shown great promise for further reducing restenosis, possibly to negligible levels.

Right ventricular hemangioma causing right ventricular inflow obstruction and right heart failure.

We report a patient who presented with symptoms of right heart failure. Transesophageal echocardiography revealed a right ventricular mass, causing right ventricular inflow obstruction. Coronary angiography revealed a characteristic tumor blush. After successful surgical resection, histologic findings were consistent with a right ventricular hemangioma.

Acute myocardial infarction in a patient with von Willebrand disease: pathogenetic dilemmas and therapeutic challenges.

Acute myocardial infarction occurs very rarely in patients with von Willebrand disease, a hereditary bleeding disorder characterized by deficiency of von Willebrand factor. We report a 45-year-old woman with von Willebrand disease who presented with acute anterior myocardial infarction. Percutaneous coronary intervention with adjuvant antiplatelet and antithrombotic therapy was performed without significant bleeding complications.

Combination antithrombotic therapy with antiplatelet agents and anticoagulants for patients with atherosclerotic heart disease.

We reviewed the efficacy and safety of combination antithrombotic therapy with aspirin plus warfarin versus aspirin alone in patients with atherosclerotic heart disease. We performed a comprehensive MEDLINE search of English-language reports published between 1966 and 2002 and search of references and relevant papers. Only clinical research studies on primary or secondary prevention of cardiovascular events in patients at high risk for coronary artery disease or patients experiencing unstable angina or myocardial infarction were included. Despite daily aspirin treatment, many patients break through aspirin treatment and experience cardiovascular events. Individuals at high risk for coronary disease or with established disease benefit from combination therapy with aspirin plus warfarin, if compliance with warfarin is greater than 70% and the target international normalized ratio (INR) of 2.0-2.5 is achieved. Combination therapy within these parameters leads to a 29-45% reduction in the risk of death, reinfarction and/or ischemic stroke. There is a significant increase in the rate of minor and a slight increase in the rate of major bleeding with combination therapy. Other potential indications for combination therapy include myocardial infarction associated with acute left ventricular aneurysm or significant left ventricular systolic dysfunction. In spite of reluctance to use oral anticoagulants, several large, randomized clinical trials support combination therapy with aspirin plus warfarin (INR, 2.0-2.5) in high-risk patients with atherosclerotic heart disease. Combination therapy increases the risk of minor and major bleeding, but not intracranial bleeding.

Platelets and antiplatelet therapy in patients with diabetes mellitus.

Atherosclerotic heart disease is the leading cause of death in patients with diabetes mellitus. Platelets play a major role in the clinical manifestations of ischemic heart disease. Diabetic patients have hyperreactive platelets with exaggerated adhesion, aggregation and thrombin generation. Antiplatelet agents, including aspirin, clopidogrel, and glycoprotein IIb/IIIa inhibitors, have shown significant efficacy in reducing recurrent ischemic events in patients with diabetes. Treatment with glycoprotein IIb/IIIa inhibitors during percutaneous coronary intervention reduces mortality in diabetic patients.

Right ventricular foreign body: percutaneous transvenous retrieval of a Greenfield filter from the right ventricle--a case report.

A 55-year-old man suffered head injury during a motor vehicle accident. He underwent a prophylactic inferior vena cava Greenfield filter placement. The filter migrated and lodged in the right ventricle at the level of the tricuspid valve. Successful percutaneous, transvenous retrieval of the Greenfield filter from the right ventricle was carried out.

Unfractionated versus fractionated heparin for percutaneous coronary intervention.

Since the advent of percutaneous coronary intervention (PCI), intravenous unfractionated heparin has been the primary antithrombotic therapy to prevent periprocedural ischemic complications. As compared with unfractionated heparin, low molecular weight heparins (LMWHs) have a greater bioavailability and a more predictable therapeutic response. In several recent studies of patients undergoing PCI, LMWHs have been shown to be as safe and effective as unfractionated heparin; given their better pharmacokinetic profile and the lack of need for coagulation monitoring, they have the potential to replace unfractionated heparin during coronary interventions. This article reviews the current status of anticoagulation therapy with unfractionated heparin and LMWHs in the cardiac catheterization laboratory.

The evolution of thrombolytic therapy and adjunctive antithrombotic regimens in acute ST-segment elevation myocardial infarction.

Acute ST-segment elevation myocardial infarction continues to be associated with substantial mortality rates. Despite much advancement in care, current treatments have also failed to eliminate the significant risk of morbidity, including reinfarction, reocclusion of the infarct-related artery, and thromboembolic stroke. The potential benefit of early thrombolytic therapy in reducing mortality was first established in 1986. Further benefits of conjunctive therapy with aspirin were demonstrated soon thereafter. This review examines the most significant trends in the pharmacologic therapy of ST-segment elevation myocardial infarction since the publication of these early studies: the development of fibrinolytic drugs with improved clot selectivity and improved pharmacokinetic profiles that simplify administration, making ED or even prehospital thrombolysis more practical. More recent data can be interpreted as showing that regimens that are simpler and easier to administer are also clinically superior. This article reviews pharmacologic advances and evaluates the evidence for their use in EDs.