Very Late Stent Thrombosis in a Drug-Eluting Stent due to Interruption of Anti-Platelet Agents in Patients With Acute Myocardial Infarction and Thrombocytosis

Stent thrombosis is a fatal complication in patients who have undergone percutaneous coronary intervention, and discontinuation of anti-platelet agent is a major risk factor of stent thrombosis. We report a rare case of very late stent thrombosis (VLST) following discontinuation of anti-platelet agents in a patient who experienced acute myocardial infarction and essential thrombocytosis. She had undergone implantation of a drug eluting stent (DES) and a bare metal stent (BMS) two and half years prior to her presentation. VLST developed in DES, not in BMS, following interruption of anti-platelet therapy

Head-to-head comparison of bivalirudin versus heparin without glycoprotein IIb/IIIa inhibitors in patients with acute myocardial infarction undergoing primary angioplasty

BACKGROUND: In patients receiving primary percutaneous coronary intervention for ST elevation myocardial infarction (STEMI), bivalirudin with provisional glycoprotein (GP) IIb/IIIa inhibitors has been demonstrated to be noninferior to heparin plus systematic GP IIb/IIIa inhibitors in preventing recurrent ischemic events with improved safety in terms of bleeding. However, no study has been performed comparing head-to-head bivalirudin with heparin without GP IIb/IIIa inhibitor infusion in STEMI patients. METHODS: We retrospectively studied 899 consecutive patients who presented with STEMI treated by primary angioplasty within 12 h after symptoms. Among them, 566 received bivalirudin and 333 received unfractionated heparin. Their in-hospital outcome in terms of efficacy and safety was assessed using rates of major adverse cardiac events (MACE) and major bleeding, respectively. Clinical, angiographic and procedural characteristics were well matched between the two groups. RESULTS: Patients in the heparin group more frequently required intra-aortic balloon pumping (6.6% vs. 3.6%, P=.037). Regarding the safety end point, the MACE rate, including death, ischemic stroke and urgent repeated revascularization, was low and similar in both groups (2.7% bivalirudin vs. 1.2% heparin, P=.15). The rate of major bleeding, including major hematoma, gastrointestinal bleeding and hematocrit drop >15% during hospitalization, was high and identical in the two groups (4.1% bivalirudin vs. 4.2% heparin, P=.92). CONCLUSION: This study suggests that bivalirudin and heparin present similar safety and efficacy profiles when used without GP IIb/IIIa inhibitor infusion during primary angioplasty.6 page(s

Angiographic and procedural correlates of stent thrombosis after intracoronary implantation of drug-eluting stents

BACKGROUND: Stent thrombosis (ST) following the implantation of drug-eluting stents (DES) remains the major limitation of this new technology. The identification of modifiable correlates of ST may help reduce this catastrophic event. METHODS: This was a retrospective, single-center, lesion-based study. A cohort of 45 consecutive lesions (35 patients) initially treated with successful DES implantation from May 2003 to February 2005 that re-presented with ST within 12 months was identified. This cohort was compared to a control group of 1,620 unselected lesions (1,187 patients) that were successfully treated with DES implantation and which remained free of ST. Comparison of angiographic and procedural features was made between the ST and no-ST groups, and logistic regression analysis was then performed to identify independent correlates of ST. For the purposes of the study only definite ST events (angiographically or autopsy proven) were considered. RESULTS: Independent angiographic predictors of cumulative ST at 12 months were left anterior descending (LAD) artery (OR: 1.91, CI: 1.01-3.59, P = 0.045), bifurcation (OR: 2.43, CI: 1.06-5.56, P = 0.035), and in-stent restenotic (OR: 2.64, CI: 1.12-6.25, P = 0.027) lesions. Procedural predictors were number of stents per lesion (OR: 2.30, CI: 1.29-4.11, P = 0.005) and intravascular ultrasound (IVUS) guidance (OR: 0.45, CI: 0.24-0.84, P = 0.013). Correlates of subacute events were LAD artery, proximal segment, and lack of IVUS guidance. Correlates of late ST were bifurcation and in-stent restenotic lesions. CONCLUSIONS: Angiographic and procedural correlates of subacute and late ST after DES implantation differ. Lack of IVUS guidance was the only modifiable predictor identified. Treatment of bifurcation and restenotic lesions was predictive of late events.7 page(s

Prognostic value of the Syntax score in patients undergoing coronary artery bypass grafting for three-vessel coronary artery disease

BACKGROUND: The Syntax score prognostic value has recently been highlighted in patients undergoing percutaneous coronary intervention (PCI) for multivessel coronary artery disease (CAD), however its prognostic value in patients undergoing coronary artery bypass grafting (CABG) for multivessel CAD is still unknown. The aim of this study was to evaluate the prognostic value of the Syntax score in patients undergoing CABG for 3-vessel CAD. METHODS: A cohort of 320 consecutive patients with multivessel (3-vessel) CAD who were subjected for CABG were included in this study and divided into tertiles according to the Syntax score (34). During the 1-year follow-up, cardiovascular events including death, myocardial infarction (MI), and stroke were systematically indexed. The primary end point was the composite criteria death/MI/stroke. RESULTS: The Syntax score ranged from 11-74 with a mean of 31.2 +/- 12.6 and a median of 28.5 [22-38]. Baseline clinical characteristics were similar among the tertiles. No statistical difference was found for the composite criteria death/MI/stroke: 9.4% versus 7.5% versus 10.4% in the groups with a Syntax score 34, respectively (P = 0.754). CONCLUSION: Unlike for PCI, the Syntax score has a poor prognostic value for severe cardiovascular events in patients undergoing CABG for 3-vessel CAD. Other risk scores should be used to predict the outcome of this population.6 page(s