ABSTRACT
Even 10 years after the first appearance in the literature of articles reporting on the management of patients on oral anticoagulation (OAC) undergoing percutaneous coronary intervention with stent (PCI-S), this issue is still controversial. Nonetheless, some guidance for the everyday management of this patient subset, accounting for about 5-8 % of all patients referred for PCI-S, has been developed. In general, a period of triple therapy (TT) of OAC, with either vitamin K-antagonists (VKA) or non-vitamin K-antagonist oral anticoagulants (NOAC), aspirin, and clopidogrel is warranted, followed by the combination of OAC, and a single antiplatelet agent for up to 12 months, and then OAC alone. The duration of the initial period of TT is dependent on the individual risk of thromboembolism, and bleeding, as well as the clinical context in which PCI-S is performed (elective vs acute coronary syndrome), and the type of stent implanted (bare-metal vs drug-eluting). In this article, we aim to provide a comprehensive, at-a-glance, overview of the management strategies, which are currently suggested for the peri-procedural, medium-term, and long-term periods following PCI-S in OAC patients. While acknowledging that most of the evidence has been obtained from patients on OAC because of atrial fibrillation, and with warfarin being the most frequently used VKA, we refer in this overview to the whole population of OAC patients undergoing PCI-S. We refer to the whole population of patients on OAC undergoing PCI-S also when OAC is carried out with NOAC rather than VKA, pointing out, when appropriate, the particular management issues.
Subject(s)
Acute Coronary Syndrome/therapy , Anticoagulants/administration & dosage , Coronary Artery Disease/therapy , Percutaneous Coronary Intervention/instrumentation , Stents , Acute Coronary Syndrome/blood , Acute Coronary Syndrome/diagnosis , Administration, Oral , Anticoagulants/adverse effects , Blood Coagulation/drug effects , Coronary Artery Disease/blood , Coronary Artery Disease/diagnosis , Coronary Thrombosis/etiology , Coronary Thrombosis/prevention & control , Drug Administration Schedule , Hemorrhage/chemically induced , Humans , Patient Selection , Percutaneous Coronary Intervention/adverse effects , Platelet Aggregation Inhibitors/administration & dosage , Risk Assessment , Risk Factors , Time Factors , Treatment OutcomeABSTRACT
OBJECTIVES: We sought to compare survival after coronary artery bypass graft (CABG) and percutaneous transluminal coronary angioplasty (PTCA) in high-risk anatomic subsets. BACKGROUND: Compared with medical therapy, CABG decreases mortality in patients with three-vessel disease and two-vessel disease involving the proximal left anterior descending artery (LAD), particularly if left ventricular (LV) dysfunction is present. How survival after PTCA and CABG compares in these high-risk anatomic subsets is unknown. METHODS: In the Bypass Angioplasty Revascularization Investigation (BARI), 1,829 patients with multivessel disease were randomized to an initial strategy of PTCA or CABG between 1988 and 1991. Stents and IIb/IIIa inhibitors were not utilized. Since patients in BARI with diabetes mellitus had greater survival with CABG, separate analyses of patients without diabetes were performed. RESULTS: Seven-year survival among patients with three-vessel disease undergoing PTCA and CABG (n = 754) was 79% versus 84% (p = 0.06), respectively, and 85% versus 87% (p = 0.36) when only non-diabetics (n = 592) were analyzed. In patients with three-vessel disease and reduced LV function (ejection fraction <50%), seven-year survival was 70% versus 74% (p = 0.6) in all PTCA and CABG patients (n = 176), and 82% versus 73% (p = 0.29) among non-diabetic patients (n = 124). Seven-year survival was 87% versus 84% (p = 0.9) in all PTCA and CABG patients (including diabetics) with two-vessel disease involving the proximal LAD (n = 352), and 78% versus 71% (p = 0.7) in patients with two-vessel disease involving the proximal LAD with reduced LV function (n = 72). CONCLUSION: In high-risk anatomic subsets in which survival is prolonged by CABG versus medical therapy, revascularization by PTCA and CABG yielded equivalent survival over seven years.
Subject(s)
Angioplasty, Balloon, Coronary/standards , Coronary Artery Bypass/standards , Coronary Disease/mortality , Coronary Disease/therapy , Aged , Coronary Angiography , Coronary Disease/complications , Coronary Disease/diagnosis , Coronary Disease/physiopathology , Female , Follow-Up Studies , Humans , Male , Middle Aged , Multivariate Analysis , Patient Selection , Proportional Hazards Models , Registries , Regression Analysis , Risk Factors , Severity of Illness Index , Stroke Volume , Survival Analysis , Time Factors , Treatment Outcome , Ventricular Dysfunction, Left/etiologySubject(s)
Atrial Fibrillation/diagnosis , Atrial Fibrillation/therapy , Aged , Aged, 80 and over , Algorithms , Anti-Arrhythmia Agents/therapeutic use , Atrial Fibrillation/classification , Atrial Fibrillation/epidemiology , Atrial Flutter/diagnosis , Comorbidity , Diagnosis, Differential , Disease Management , Electric Countershock , Electrocardiography , Female , Fibrinolytic Agents/therapeutic use , Humans , Male , Middle Aged , Prevalence , Prognosis , Racial Groups , Risk Assessment , Tachycardia/diagnosis , Thromboembolism/etiology , Thromboembolism/prevention & controlSubject(s)
Atrial Fibrillation/therapy , Wolff-Parkinson-White Syndrome/therapy , Algorithms , Anti-Arrhythmia Agents/pharmacology , Anti-Arrhythmia Agents/therapeutic use , Anticoagulants/therapeutic use , Atrial Fibrillation/diagnosis , Atrial Fibrillation/physiopathology , Cardiac Catheterization , Catheter Ablation , Electric Countershock , Heart Rate/drug effects , Hemodynamics , Humans , International Normalized Ratio , Quality of Life , Risk Assessment , Thromboembolism/complications , Thromboembolism/physiopathology , Warfarin/therapeutic use , Wolff-Parkinson-White Syndrome/diagnosis , Wolff-Parkinson-White Syndrome/physiopathologySubject(s)
Angioplasty, Balloon, Coronary/standards , Coronary Artery Disease/therapy , Age Factors , Angina Pectoris/therapy , Angioplasty, Balloon, Coronary/adverse effects , Angioplasty, Balloon, Coronary/trends , Cardiology Service, Hospital/standards , Comorbidity , Contraindications , Coronary Artery Bypass/standards , Coronary Artery Disease/classification , Coronary Artery Disease/complications , Diabetes Complications , Graft Occlusion, Vascular/prevention & control , Hemodynamics , Intraoperative Complications/etiology , Myocardial Infarction/therapy , Platelet Aggregation Inhibitors/therapeutic use , Platelet Glycoprotein GPIIb-IIIa Complex/antagonists & inhibitors , Postoperative Complications/etiology , Professional Competence/standards , Quality Assurance, Health Care/standards , Randomized Controlled Trials as Topic , Risk Assessment , Risk Factors , Sex Factors , Survival Rate , Thrombolytic Therapy , Treatment OutcomeSubject(s)
Angioplasty, Balloon, Coronary , Angina, Unstable/therapy , Angioplasty, Balloon, Coronary/standards , Cardiac Catheterization , Coronary Artery Bypass , Coronary Disease/therapy , Diabetic Angiopathies/therapy , Humans , Myocardial Infarction/therapy , Platelet Aggregation Inhibitors/therapeutic use , Quality Assurance, Health Care , Risk Assessment , Thrombolytic TherapyABSTRACT
Arterial stiffness, as evidenced by increased pulse pressure (PP), is associated with adverse cardiovascular events. However, the prognostic importance of PP in patients who have undergone revascularization is unknown. We examined the prognostic importance of PP and predictors of increased PP in patients entered into the Balloon Angioplasty Revascularization Investigation (BARI). Estimated correlation and standardized regression coefficients were reported, indicating the relative magnitude of independent effects of baseline characteristics on PP. The independent association of PP and outcome over 5 years was determined. Baseline characteristics independently associated with PP were higher mean arterial pressure, older age, female sex, noncoronary vascular disease, history of diabetes mellitus, and history of hypertension (p <0.001 for all). Cox regression covariates significantly associated with time to death were age, smoking, male gender, diabetes history, congestive heart failure, and baseline use of angiotensin-converting enzyme inhibitors, diuretic, or digitalis. When PP was added to the model, it was found to be an independent predictor of time to death (p = 0.008). When PP and mean arterial pressure were added to the model, PP remained significantly associated with time to death (p = 0.033). When renal disease and noncoronary vascular disease were added to the model, the relative risk declined from 1.07 to 1.04 and the association was no longer statistically significant. Thus, increased PP is directly and independently associated with mean arterial pressure, hypertension, age > or =65 years, diabetes mellitus, and the presence of noncoronary vascular disease, and inversely associated with a history of myocardial infarction. After coronary revascularization, PP, reflecting arterial stiffness, is independently associated with total mortality.
Subject(s)
Angioplasty, Balloon, Coronary , Blood Pressure , Coronary Disease/therapy , Pulse , Aged , Coronary Artery Bypass , Coronary Disease/mortality , Coronary Disease/physiopathology , Coronary Vessels/physiopathology , Elasticity , Female , Humans , Male , Middle Aged , Multicenter Studies as Topic , Prognosis , Proportional Hazards Models , Randomized Controlled Trials as Topic , Risk Factors , Survival RateSubject(s)
Angioplasty, Balloon, Coronary/methods , Brachytherapy , Coronary Disease/therapy , Graft Occlusion, Vascular/radiotherapy , Angioplasty, Balloon, Coronary/mortality , Animals , Coronary Disease/diagnosis , Coronary Disease/mortality , Dogs , Graft Occlusion, Vascular/prevention & control , Humans , Prognosis , Randomized Controlled Trials as Topic , Survival Rate , Treatment OutcomeSubject(s)
Angioplasty, Balloon, Coronary , Coronary Disease/therapy , Forecasting , Humans , RecurrenceABSTRACT
Coronary artery disease remains the leading cause of morbidity and mortality in the Western world. The initial approach to treatment involves risk factor modification in an attempt to halt or slow the progression of disease. Treatment of symptomatic disease aims at reducing myocardial oxygen demand with medical therapy. When this fails, revascularization to restore blood supply by percutaneous coronary intervention or coronary artery bypass grafting is often necessary. Advances in medical technology have both increased the success rate and lowered the morbidity and mortality of these 2 procedures. However, a significant number of patients have diffuse coronary artery disease, absent conduits after previous bypass surgery, small distal vessels, and comorbidities that may preclude either procedure. In a recent analysis of 500 consecutive patients at a tertiary referral center, approximately 12% of these patients fell into this category (1). With the widespread use of revascularization, it is likely that the number of patients who will not be suitable for revascularization in the future will increase significantly. Therapeutic angiogenesis is an exciting new method of improving blood supply to an ischemic segment of the myocardium to provide symptomatic relief to a large and growing population of patients.
Subject(s)
Coronary Disease/therapy , Endothelial Growth Factors/therapeutic use , Fibroblast Growth Factors/therapeutic use , Lymphokines/therapeutic use , Neovascularization, Physiologic , Animals , Coronary Disease/surgery , Humans , Randomized Controlled Trials as Topic , Vascular Endothelial Growth Factor A , Vascular Endothelial Growth FactorsABSTRACT
Great strides have been made in the understanding of unstable angina and its relationship to the acute coronary syndromes and myocardial infarction during the last decade of the 20th century, Detailed information about ECG changes and serum cardiac markers, as well as the conclusions drawn from numerous large, randomized interventional trials can now be integrated into the traditional clinical picture. Clinicians can now classify patients into diagnostic and prognostic categories and can perform risk stratification with unprecedented precision. With this information, the decision to hospitalize patients and the selection of noninvasive or invasive evaluation and management strategies can be individualized for optimal outcomes.