Thrombolytics: prospects for new agents.

Thrombolytic therapy revolutionised the management of acute myocardial infarction (AMI). The ability to re-establish coronary artery patency with intravenous thrombolytic drugs has transformed our therapeutic approach, despite patency failures and re-occlusions. However, the established agents are not perfect and a number of novel thrombolytic drugs have consequently been developed and evaluated. This article reviews the currently available agents, discusses available adjunctive therapies and examines the future developments that may affect the application of this therapy.

Treatment of coronary aneurysms with covered stents: a review with illustrated case.

Coronary aneurysms are found in approximately 5% of patients undergoing coronary angiography. Most coronary artery aneurysms (CAAs) are associated with significant stenosis of the coronary lumen; however, there is no common consensus on the treatment of coronary aneurysms. A large aneurysm in the coronary artery makes the blood flow turbulent and predisposes to thrombus formation and coronary artery obstruction even without the presence of significant stenosis. Despite this important anatomical abnormality of the coronary artery, the treatment options are poorly understood and present a therapeutic challenge to the interventional cardiologist. While treating CAAs with percutaneous implantation of covered stents offers a less invasive option compared to surgical correction, the short- and long-term outcomes are unknown. In this article, we have reviewed the literature and discussed the pathophysiology, clinical importance, and treatment options for CAAs. The illustrated case demonstrates a difficult situation in the management of CAA with interesting images, including coronary angiography, intravascular ultrasound, and transesophageal echocardiography of the complication encountered in this particular case.

How should I treat severe calcific coronary artery disease?

BACKGROUND: An 80-year-old man with limiting angina pectoris. INVESTIGATION: Physical examination, laboratory tests, echocardiography, exercise ECG, coronary arteriography, pressure wire assessment. DIAGNOSIS: Single severe calcific coronary artery disease. TREATMENT: Elective percutaneous coronary intervention (PCI) for calcific mid-vessel stenosis with rotational and excimer laser atherectomy.

Use of a novel pericardial covered stent to seal an iatrogenic coronary perforation.

Iatrogenic coronary perforation complicates 0.1-0.8% of percutaneous coronary interventional (PCI) procedures. The incidence is higher if atheroablative therapy is used. When coronary perforation occurs, it may rapidly result in cardiac tamponade, myocardial infarction or death, hence prompt treatment is required. PTFE-covered stents have been used to seal coronary perforations, but these are bulky devices that lack flexibility, and rapid deployment in calcified or tortuous vessels can be difficult, particularly in emergency situations. Furthermore, difficulties in achieving adequate stent expansion and the prospect of delayed re-endothelialization have led to concern about the increased potential for stent thrombosis or restenosis. We present the first report of the successful use of a novel, highly deliverable pericardial covered stent to treat an iatrogenic coronary perforation during PCI, with angiographic follow up.

A novel strategy for managing clopidogrel-induced adverse skin reactions.

AIMS: We conducted a prospective observational study using a course of steroids and antihistamines to treat a cohort of patients who developed skin reactions to clopidogrel, to assess whether dual antiplatelet therapy could be continued in an outpatient setting. METHODS AND RESULTS: This study included 2,701 patients who underwent percutaneous coronary intervention (PCI) at our centre over a 23 month period. Patients with skin reactions to clopidogrel were identified and then commenced on five days oral prednisolone (30 mg/od) and chlorpheniramine (4 mg/tds) for seven days. A subsequent telephone survey was performed to evaluate a number of variables. The probability of the adverse reaction being secondary to clopidogrel was assessed using the Naranjo adverse drug reaction probability scale. Twenty (0.7%) patients were identified who developed adverse skin reactions to clopidogrel. There was complete resolution seen in the majority (89%) of patients within an average of 3.2 days following treatment. One patient had partial resolution, and one had no response to treatment, but both were able to continue clopidogrel. CONCLUSIONS: We propose a novel, safe and effective way of managing clopidogrel-induced skin reactions using a short course of prednisolone and chlorpheniramine, without stopping or substituting clopidogrel.

Malignancy: an unrecognized risk factor for coronary stent thrombosis?

Stent thrombosis is a potentially catastrophic complication of coronary artery stenting. There have been particular concerns about the incidence of stent thrombosis following insertion of drug-eluting stents. We report a series of cases in which stent thrombosis occurred in association with malignancy and describe the potential mechanisms behind such an association. We speculate that this association merits further investigation as it raises the possibility that known malignancy may be a risk factor for stent thrombosis and that unexplained stent thrombosis, particularly if recurrent, should stimulate a search for occult malignancy.