78 research outputs found
Carotid artery stenting: an update
In patients with carotid disease, the purpose of carotid artery revascularization is stroke prevention. For >50 years, carotid endarterectomy has been considered the standard treatment for severe asymptomatic and symptomatic carotid stenoses. Carotid artery stenting (CAS) has emerged in the last 15 years as minimally invasive alternative to surgery. However, the value of the endovascular approach in the management of carotid disease patients remains highly controversial. The aims of this review are to elucidate the current role of CAS, to describe the major technology advancements in the field, and to speculate about the future of this therap
Ischaemic and bleeding complications with new, compared to standard, ADP-antagonist regimens in acute coronary syndromes: a meta-analysis of randomized trials
Background: Platelets play a pivotal role in the
pathogenesis of acute coronary syndromes (ACS)
and their inhibition remains a mainstay therapy in
this setting. We aimed to perform a meta-analysis of
randomized trials to evaluate the benefits of new
oral antiplatelet regimens to block platelet ADPreceptors
compared to standard-dose clopidogrel
(300 mg loading dose followed by 75 mg/daily).
Methods: We obtained results from all randomized
trials enrolling patients with ACS. Primary endpoint
was mortality. Secondary endpoints were myocardial
infarction and definite in-stent thrombosis.
Safety endpoint was the risk of major bleeding complications.
We prespecified subanalyses according
to new antiplatelet drugs (prasugrel/ticagrelor),
high-dose clopidogrel (600 mg) and patients undergoing
percutaneous coronary intervention.
Results: A total of seven randomized trials were
finally included in the meta-analysis (n = 58 591).
We observed a significant reduction in mortality
(2.9% vs. 3.4%, OR= 0.87, 95% CI 0.79–0.95,
P = 0.002), recurrent myocardial infarction (4.2%
vs. 5.2%, OR= 0.80, 95% CI 0.74–0.87,
P < 0.0001), definite in-stent thrombosis (0.9% vs.
1.7%, OR= 0.52, 95% CI 0.43–0.63, P < 0.0001).
The benefits in mortality and reinfarction were
driven by the treatment with prasugrel or ticagrelor,
without a significant difference in terms of major
bleeding complications as compared to standarddose
clopidogrel (5% vs. 4.7%, OR= 1.06 95% CI
0.96–1.17, P = 0.25).
Conclusions: This meta-analysis showed that new
oral antiplatelet regimens are associated with a significant
reduction in mortality, reinfarction and
in-stent thrombosis in ACS patients without an overall
increase of major bleeding when treated with
new antiplatelet drugs
Ticagrelor, but not clopidogrel and prasugrel, prevents ADP-induced vascular smooth muscle cell contraction: A placebo-controlled study in rats
Introduction: Off-target effects of novel antiplatelet agents due to their potential clinical benefits are currently
an area of intensive investigation. We aimed to compare the effects of different P2Y12 antagonists on the reactivity
of vascular smooth muscle cells.
Materials and methods: Wistar rats (n=30) were pretreated with an investigated drug or placebo. Clopidogrel
(50 mg/kg, n=7), prasugrel (10 mg/kg, n=7), ticagrelor (10 mg/kg, n=7) or placebo (n=9) were administered
orally 12 and 2 hours before experiments. Constrictions of rat tail arteries induced with a stable analogue
of adenosine diphosphate (2-MeS-ADP), phenylephrine and arginine vasopressin weremeasured as an increase
in perfusion pressure. Effects of ticagrelor were assessed in the presence of ticagrelor (1 ÎĽM/L) added to the perfusion
solution as this drug reversibly inhibits the P2Y12 receptor.
Results: Pretreatmentwith clopidogrel and prasugrel did not inhibit 2-MeS-ADP-induced contraction while ticagrelor
did. Experiments employing endothelium-deprived arteries provided similar results. Clopidogrel and
prasugrel did not influence concentration-response curves in the presence of neither phenylephrine nor arginine
vasopressin. The curves obtained for both vasopressors in the presence of ticagrelor and 2-MeS-ADP
were shifted to the right with a significant reduction in the maximal response.
Conclusions: Oral administration of ticagrelor, in contrast to clopidogrel and prasugrel, prevents adenosine
diphosphate-induced contraction of vascular smooth muscle cells in a rat model. Both the clinical significance
and detailed mechanism of our findings warrant further investigation
Low-molecular-weight heparins vs. unfractionated heparin in the setting of percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis
Summary. Background: The aim of the current study was to
perform two separate meta-analyses of available studies
comparing low-molecular-weight heparins (LMWHs) vs.
unfractionated heparin (UFH) in ST-elevation myocardial
infarction (STEMI) patients treated (i) with primary percutaneous
coronary intervention (pPCI) or (ii) with PCI after
thrombolysis. Methods: All-cause mortality was the prespecified
primary endpoint and major bleeding complications
were recorded as the secondary endpoints. Relative risk (RR)
with a 95%confidence interval (CI) and absolute risk reduction
(ARR) were chosen as the effect measure. Results: Ten studies
comprising 16 286 patients were included. The median followup
was 2 months for the primary endpoint. Among LMWHs,
enoxaparin was the compound most frequently used. In the
pPCI group, LMWHs were associated with a reduction in
mortality [RR (95% CI) = 0.51 (0.41–0.64), P < 0.001,
ARR = 3%] and major bleeding [RR (95% CI) = 0.68
(0.49–0.94), P = 0.02, ARR = 2.0%] as compared with
UFH. Conversely, no clear evidence of benefits with LWMHs
was observed in the PCI group after thrombolysis. Metaregression
showed that patients with a higher baseline risk had
greater benefits from LMWHs (r = 0.72, P = 0.02). Conclusions:
LMWHs were associated with greater efficacy and safety
than UFH in STEMI patients treated with pPCI, with a
significant relationship between risk profile and clinical benefits.
Based on this meta-analysis, LMWHs may be considered as a
preferred anticoagulant among STEMI patients undergoing
pPCI
Impact on outcome of different types of carotid stent: Results from the European Registry of Carotid Artery Stenting
AIMS:
Conflicting data exist on the impact on outcome of the use of different stent types during carotid artery stenting (CAS). The aim of this study was to evaluate clinical outcomes according to different carotid stent design among the population of the European Registry of Carotid Artery Stenting (ERCAS).
METHODS AND RESULTS:
The present study was conducted in 1,604 patients who underwent neuroprotected CAS in ERCAS. All types of commercially available carotid stent were used. Open-cell design stents were classified according to free cell area into 7.5 mm2. A total of 713 closed-cell, 456 hybrid-cell, 238 7.5 mm2 open-cell stents were implanted. Overall, the 30-day stroke and death rate was 1.37%. At 30 days, 19 strokes occurred (1.18%): eight in the group of patients treated with a closed-cell (1.12%), two in those with a hybrid-cell (0.44%), three in those with a 7.5 mm2 open-cell stent (3.05%) (p=0.045).
CONCLUSIONS:
Data of the present study suggest that, in the setting of neuroprotected CAS performed in high-volume centres by properly trained operators, the use of an open-cell design stent with a free cell area >7.5 mm2 may be associated with an increased 30-day stroke risk
Significant Drop in Right Atrial Pressure Does Not Influence Fractional Flow Reserve Coronary Assessment
The effect of a highly elevated level of right atrial filling pressure on fractional flow reserve (FFR) measurement remains unclear. Transcatheter tricuspid valve intervention, a recently introduced option for inoperable or high-risk patients, represents a unique model of in-vivo physiology to investigate the eventual influence of central venous pressure on coronary FFR measurements. The case is reported of a patient with a degenerated tricuspid surgical bioprosthesis who underwent transcatheter tricuspid valve-in-valve replacement and concomitant coronary functional assessment with FFR. In an experimental model, the significant fall in right atrial pressure did not influence FFR measurements in the presence of angiographically proven mild coronary artery disease
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