Antiplatelet therapy for treatment of coronary artery disease in older patients.

Coronary artery disease in older patients is more frequently diffuse and complex, and is often treated by percutaneous coronary intervention on top of medical therapy. There are currently no specific recommendations for antiplatelet therapy in patients aged≥75 years. Aspirin remains pivotal, and is still indicated as a long-term treatment after percutaneous coronary intervention. In addition, a P2Y12 inhibitor is administered for 6-12 months according to clinical presentation. Age is a minor bleeding risk factor, but because older patients often have several co-morbidities, they are considered as having a high bleeding risk according to different scoring systems. This increased bleeding risk has resulted in different therapeutic strategies for antithrombotic treatment after percutaneous coronary intervention; these include short dual antiplatelet therapy, a switch from potent to less potent antiplatelet therapy or single antiplatelet therapy with a P2Y12 inhibitor instead of aspirin, among others. A patient-centred approach, taking into account health status, functional ability, frailty, cognitive skills, bleeding and ischaemic risks and patient preference, is essential when caring for older adults with coronary artery disease. The present review focuses on the knowledge base, specificities of antiplatelet therapies, a balance between haemorrhagic and ischaemic risk, strategies for antiplatelet therapy and directions for future investigation pertaining to coronary artery disease in older patients.

Clinical and angiographic characteristics of out-of-hospital cardiac arrest among patients with ST-segment elevation myocardial infarction.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is the most severe complication of ST-segment elevation myocardial infarction (STEMI). Nevertheless, clinical and angiographic characteristics associated with OHCA among patients with STEMI have not been studied extensively. AIM: To evaluate the clinical and angiographic characteristics of consecutive patients who presented with STEMI associated or not with OHCA. METHODS: This was an observational study including consecutive patients treated for STEMI associated or not with OHCA. Baseline clinical and angiographic characteristics, biological characteristics and mortality were compared between patients with STEMI who experienced OHCA and patients with STEMI who did not. RESULTS: Among the 686 included patients with STEMI, 148 (21.6%) presented with concomitant OHCA. Multivariable analysis revealed that culprit lesion localized on the left system (odds ratio [OR] 1.94, 95% confidence interval [CI] 1.24-3.13; P<0.01), culprit lesion at the level of a bifurcation lesion (OR 1.87, 95% CI 1.21-2.88; P<0.01) and the presence of chronic total occlusion on another artery (OR 3.39, 95% CI 1.93-5.99; P<0.001) were associated with the occurrence of OHCA, whereas dyslipidaemia, familial history of coronary artery disease and hypertension were found to be negatively associated with the occurrence of OHCA in patients with STEMI: OR 0.47, 95% CI 0.29-0.75 (P<0.01); OR 0.09, 95% CI 0.02-0.25 (P<0.001); and OR 0.60, 95% CI 0.38-0.93 (P=0.02), respectively. CONCLUSION: In this study of consecutive patients with STEMI, culprit lesion localized on the left system, culprit lesion at the level of a bifurcation lesion and the presence of chronic total occlusion on a non-culprit artery were associated with OHCA.

Percutaneous Coronary Intervention in Out-of-Hospital Cardiac Arrest Related to Acute Coronary Syndrome: A Literature Review.

Out-of-hospital cardiac arrest (OHCA) continues to be a major global cause of death, affecting approximately 67 to 170 per 100,000 inhabitants annually in Europe, with a persisting high rate of mortality of up to 90% in most countries. Acute coronary syndrome (ACS) represents one of the most significant cause of cardiac arrest, and therefore invasive coronary angiography (CAG) with subsequent percutaneous coronary intervention (PCI) has emerged as a fundamental component in the management of OHCA patients. Recent evidence from large randomized controlled trials (RCTs) challenges the routine use of early CAG in the larger subgroup of patients with non-ST segment elevation myocardial infarction (NSTEMI). Additionally, emerging data suggest that individuals resuscitated from OHCA related to ACS face an elevated risk of thrombotic and bleeding events. Thus, specific invasive coronary strategies and anti-thrombotic therapies tailored to this unique setting of OHCA need to be considered for optimal in-hospital management. We sought to provide an overview of the prevalence and complexity of coronary artery disease observed in this specific population, discuss the rationale and timing for CAG after return of spontaneous circulation (ROSC), summarize invasive coronary strategies, and examine recent findings on antithrombotic therapies in the setting of ACS complicated by OHCA. By synthesizing the existing knowledge, this review aims to contribute to the understanding and optimization of care for OHCA patients to improve outcomes in this challenging clinical scenario.

Evolution of Coronary Stent Platforms: A Brief Overview of Currently Used Drug-Eluting Stents.

Cardiovascular disease, including ischemic heart disease, is the leading cause of death worldwide, and percutaneous coronary interventions (PCIs) have been demonstrated to improve the prognosis of these patients on top of optimal medical therapy. PCIs have evolved from plain old balloon angioplasty to coronary stent implantation at the end of the last century. There has been a constant technical and scientific improvement in stent technology from bare metal stents to the era of drug-eluting stents (DESs) to overcome clinical challenges such as target lesion failure related to in-stent restenosis or stent thrombosis. A better understanding of the underlying mechanisms of these adverse events has led DESs to evolve from first-generation DESs to thinner and ultrathin third-generation DESs with improved polymer biocompatibility that seems to have reached a peak in efficiency. This review aims to provide a brief historical overview of the evolution of coronary DES platforms and an update on clinical studies and major characteristics of the most currently used DESs.

Intracoronary imaging in addition to coronary angiography for patients with out-of-hospital cardiac arrest: More information for better care?

About 70% of out-of-hospital cardiac arrests are related to an ischaemic heart disease in Western countries. Percutaneous coronary intervention has been shown to improve the prognosis of survivors when an unstable coronary lesion is identified as the potential cause of the cardiac arrest. Acute complete coronary occlusion is often demonstrated among patients with ST-segment elevation on electrocardiogram after the return of spontaneous circulation. In patients without ST-segment elevation, routine coronary angiography has been shown to be not superior to conservative management. However, an electrocardiogram-based decision to perform immediate coronary angiography could be insufficient to identify unstable coronary lesions, which are frequently associated with intermediate coronary stenosis. Intracoronary imaging can be helpful to detect plaque rupture or erosion and intracoronary thrombus, but could also lead to better stent implantation, and help to reduce the risk of stent thrombosis. In patients with coronary lesions without the instability characteristic, conservative management should be the default strategy, and a search for another cause of the cardiac arrest should be systematic. In the present review, we sought to describe the potential benefit of intracoronary imaging in patients with out-of-hospital cardiac arrest.