A pilot study of prasugrel followed by post-procedural maintenance with clopidogrel in patients receiving percutaneous coronary intervention.

BACKGROUND: Dual anti-platelet therapy including clopidogrel or prasugrel is standard of care for patients receiving stents. Prasugrel has quicker onset so it can be loaded later than clopidogrel with greater efficacy. However, prasugrel is much more expensive than clopidogrel. OBJECTIVES: To describe the incidence of 30-day death from cardiovascular causes, myocardial infarction, unstable angina requiring intervention, and minor and major bleeding in patients loaded with 60 mg of prasugrel prior to percutaneous coronary intervention (PCI) and then continued on 75 mg of clopidogrel daily after the procedure. METHODS: We reviewed sequential medical records of 102 patients (Mean age: 67.8, male 68.6%, smokers: 22.6%, BMI: 29.5%, hypertension: 90.2%, DM: 33.3%, average ejection fraction: 49.7%) who underwent PCI (3.9% STEMI, 12.7% NSTEMI, 35.3% unstable angina and 48.1% electively) at Baylor University Medical Center between October 2009 and December 2011 who were loaded with prasugrel 60 mg prior to procedure, and then continued on 75 mg clopidogrel daily. RESULTS: None of the patients died or experienced a myocardial infarction (MI) within 30 days of the procedure. Three patients experienced unstable angina requiring intervention but none had in-stent thrombosis or restenosis on repeat angiography. None of the patients experienced a major bleeding event. One patient developed a gastrointestinal bleed which did not require blood transfusion and the bleeding it resolved on discontinuation of the clopidogrel. CONCLUSION: In this retrospective pilot study, a strategy of loading patients needing PCI with prasugrel 60 mg immediately prior to coronary intervention, then continuation of anti-platelet therapy with 75 mg clopidogrel daily was safe and effective.

Do prehospital discharge pacemaker checks provide any additional clinical benefit?

We performed a retrospective analysis of 250 records of consecutive, newly implanted, pacemaker patients from a single center to determine the rate of postimplant complications and observations discovered before and during the prehospital discharge evaluation. No observations occurred in 246 of 250 patients (98.4%) (1-sided 95% confidence interval 96.4%). Of the 250 patients, 4 had observations that were discovered at the prehospital discharge check and required reprogramming to increase the sensitivity safety margin (3 atrial and 1 ventricular). We documented only 1 complication that was discovered before the predischarge evaluation through telemetry and resulted in an atrial lead revision.

Effect of bivalirudin on length of stay in the recovery area after percutaneous coronary intervention compared with heparin alone, heparin + abciximab, or heparin + eptifibatide.

Three hundred nine patients were followed during their recovery area stay after percutaneous coronary intervention. Recovery area times for patients who received bivalirudin during percutaneous coronary intervention showed an average reduction in total recovery area length of stay of 36 minutes (p <0.0001) compared with patients who received heparin alone. This reduction was also seen when compared with the heparin + abciximab group (46-minute reduction, p = 0.0007), and the heparin + eptifibatide group (35-minute reduction, p = 0.0005). Patients who received bivalirudin took significantly less time for the activated clotting time (ACT) to normalize despite significantly higher average ACTs and significantly fewer subtherapeutic ACTs.

Validation of the i-STAT handheld activated clotting time for use with bivalirudin.

Bivalirudin is being used more frequently as an anticoagulant in the cardiac catheterization laboratory. Newer devices, used to measure activated clotting time (ACT), have not been thoroughly tested for use with bivalirudin. One such device, the i-STAT ACT, measures the generation of activated thrombin to determine the level of anticoagulation. Our study demonstrated a high level of agreement between the i-STAT ACT and the Hemochron ACT in patients anticoagulated with bivalirudin. In addition, the i-STAT was shown to have an extremely high degree of reproducibility.