Optimal duration of dual antiplatelet therapy for coronary artery disease.

The optimal duration of dual antiplatelet therapy (DAPT) for stable coronary artery disease and acute coronary syndrome is a complex decision. We review current literature on standard duration DAPT versus short duration DAPT (6 months or shorter) or extended duration DAPT (>12 months) after percutaneous coronary intervention with drug-eluting stent placement, and prolonged treatment after 12 months in acute coronary syndrome. Current guideline recommendations are summarised, including the use of risk scores for ischaemic and bleeding risk assessment. Because of the limitations of current risk scores, we propose multiple patient-related and procedure-related factors for the ischaemic and bleeding risk assessment aiding in personalised DAPT duration.

Prognostic value of post-procedural aPTT in patients with ST-elevation myocardial infarction treated with primary PCI.

Unfractionated heparin is the most commonly used anticoagulant in ST-elevation myocardial infarction (STEMI) and its effect can be monitored with activated partial thromboplastin time (aPTT). However, the optimal aPTT range during heparin therapy after primary percutaneous coronary intervention (PCI) is yet to be defined. A mean aPTT was calculated of all aPTT measurements in the first 24 hours after pPCI in a total of 1,876 STEMI patients. Mean aPTT measurements were stratified into four categories; < 1.5 times the upper limit of normal (ULN), 1.5 - 2.0 times ULN (the therapeutic group), 2.01 - 3.99 times ULN, and ≥ 4 times ULN. Compared to patients with a therapeutic aPTT, patients with aPTTs < 1.5 times ULN had no increase in recurrent ischaemic events and had similar rates of bleeding complications. Patients with a mean aPTT ≥ 4 times ULN had higher rates recurrent ischaemic and haemorrhagic complications. After multivariable analyses, aPTT ratios ≥ 4 times ULN were no longer associated with recurrent ischaemic events, but remained a strong predictor of severe and moderate bleeding (hazard ratio [HR] 4.64, p = 0.016 and HR 2.27, p = 0.052). In conclusion, in 1,876 STEMI patients treated with pPCI, low aPTTs in the first 24 hours after PCI were not associated with an increase in ischaemic events, whereas high aPTT values were associated with more frequent bleeding complications. These results indicate no clear benefit as well as a safety concern with heparin treatment after primary PCI.

Would SYNTAX have been a positive trial if XIENCE V had been used instead of TAXUS?: A meta-analysis of a first-generation vs. a second-generation drug-eluting stent system.

Treatment options for coronary revascularisation include percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). In the 'synergy between PCI with TAXUS and cardiac surgery (SYNTAX)' trial, PCI and CABG using state-of-the-art techniques (using paclitaxel-eluting stents and arterial grafts, respectively) were compared in the treatment of complex coronary artery disease. In Syntax, PCI was inferior to CABG at one year, entirely due to an increased repeat intervention rate. We hypothesised that the use of a superior drug-eluting stent system could reduce the need for repeat intervention. (Neth Heart J 2010;18:451-3.).

Guideline adherence for antithrombotic therapy in acute coronary syndrome: an overview in Dutch hospitals.

OBJECTIVE: To assess current Dutch antithrombotic treatment strategies for acute coronary syndrome (ACS) in light of the current European Society of Cardiology (ESC) guidelines. METHODS: For every Dutch hospital with a coronary care unit (CCU) (n = 93) a single cardiologist was interviewed concerning heparin, thienopyridine and GP IIb/IIIa inhibitor (GPI) treatment. In each hospital, we randomly approached one cardiologist assuming equal policy among physicians employed at the same hospital. RESULTS: The response rate was 90%. In 59% of hospitals, treatment of ST-elevation myocardial infarction (STEMI) occurred according to the 2008 ESC STEMI guideline, with unfractionated heparin. In contrast, although not recommended, low-molecular-weight heparin (LMWH) was used in 39% (enoxaparin 19%, dalteparin 12%, nadroparin 8%). In non-STEMI, low-molecular-weight-heparins (LMWHs) were used in 97% of all hospitals. Fondaparinux, agent of choice in a noninvasive strategy for the treatment of non-STEMI, was applied in only 2% of hospitals. Although recommended by the ESC, dose adjustment of LMWH therapy for patients with renal failure is not applied in 71% of hospitals. Likewise, LMWH dose adjustment is not applied for patients aged over 75 years in 92% of hospitals. CONCLUSION: To a great extent treatment of ACS in the Netherlands occurs according to ESC guidelines. Additional benefit may be achieved by routine dose adjustment of LMWH for patients with renal insufficiency and aged >75 years, since these patients are at high risk of bleeding complications secondary to antithrombotic treatment. Periodical evaluation of real-life practice may improve guideline adherence and potentially improve clinical outcome. (Neth Heart J 2010;18:291-9.).