Background: A substantial proportion of patients receiving fibrinolytic therapy for myocardial infarction with ST-segment elevation have inadequate reperfusion or reocclusion of the infarct-related artery, leading to an increased risk of complications and death. Methods: We enrolled 3491 patients, 18 to 75 years of age, who presented within 12 hours after the onset of an ST-elevation myocardial infarction and randomly assigned them to receive clopidogrel 8300-mg loading dose, followed by 75 mg once daily) or placebo. Patients received a fibrinolytic agent, aspirin, and when appropriate, heparin (dispensed according to body weight) and were echeduled to undergo angiography 48 to 192 hours after the start of study medication. The primary efficacy end point was a composite of an ocluded infarct-related artery (defined by a Thrombolysus in Myocardial Infarction flow grade of 0 or 1) on angiography or death or recurrent myocardial infarction before angiography. Results: The rates of the primary efficacy end point were 21.7 percent in the placebo group and 15.0 percent in the clopidogrel group, representing an absolute reduction of 6.7 percentage points in the rate and a 36 percent reduction in the odds of the end point with clopidogrel therapy (95 percent confidence interval, 24 to 47 percent; P<0.001). By 30 days, clopidogrel therapy reduced the odds ol the composite end point of death from cardiovascular causes, recurrent myocardial infarction, or recurrent ischemia leading to the need for urgent revascularization by 20 percent (from 14.1 to 11.6 percent, P=0.03). The rates of major bleeding and intracranial hemorrhage were similar in the two groups. Conclusions: In patients 75 years of age or younger who have myocardial infarction with ST-segment elevation and who receive aspirin and a standard fibrinolytic regimen, the addition of clopidogrel improves the patency rate of the infarct-related artery and reduces ischemic complications.

Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation

Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Patient-initiated research has spurred increased awareness of SCAD, and improved diagnostic capabilities and findings from large case series have led to changes in approaches to initial and long-term management and increasing evidence that SCAD not only is more common than previously believed but also must be evaluated and treated differently from atherosclerotic myocardial infarction. High rates of recurrent SCAD; its association with female sex, pregnancy, and physical and emotional stress triggers; and concurrent systemic arteriopathies, particularly fibromuscular dysplasia, highlight the differences in clinical characteristics of SCAD compared with atherosclerotic disease. Recent insights into the causes of, clinical course of, treatment options for, outcomes of, and associated conditions of SCAD and the many persistent knowledge gaps are presented.

/pdf/spontaneous-coronary-artery-dissection-current-state-of-the-2tmhkoj05i.pdf

Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association.

Spontaneous coronary artery dissection (SCAD) has long been recognized as a cause of acute coronary syndromes (ACS). Initially considered very rare and associated primarily with pregnancy and the peripartum period, the use of higher sensitivity Troponin assays and early angiography in ACS, coupled with greater awareness of the condition, has led to increased diagnosis, and it is now understood that SCAD represents a significant cause of ACS in predominantly young to middle-aged women, with most cases occurring outside the context of recent pregnancy.1,2 Although there are no randomized controlled trials in SCAD, knowledge has further advanced in the last 5-years as a result of an international research effort primarily focused on building and studying national SCAD registries.3–19 These studies have demonstrated, not only that SCAD is a distinct pathophysiological entity, but that there are key differences in management and outcomes compared to ACS of atherosclerotic aetiology. This position paper aims to set-out current knowledge on SCAD for the benefit of practicing clinicians caring for patients with this condition. It presents the consensus on contemporary management and areas of controversy and uncertainty, which remain a focus of ongoing research. The information is provided to support clinical care providers but is not intended to replace individualized decision-making by clinicians and other health care professionals.

European Society of Cardiology, acute cardiovascular care association, SCAD study group: a position paper on spontaneous coronary artery dissection.

Spontaneous Coronary Artery Dissection: Clinical Outcomes and Risk of Recurrence

Contemporary Review on Spontaneous Coronary Artery Dissection.

Coronary stent implantation, particularly drug eluting stents, is now the major method of coronary revascularisation. Following drug-eluting stent implantation dual antiplatelet therapy with aspirin and thienopyridine is recommended for at least 12 months. Premature discontinuation, often at the time of noncardiac surgery, has been associated with stent thrombosis which has a significant risk of death and myocardial infarction. Late (>30 days) and very late (>365 days) stent thrombosis appears to more common with DES and poses the questions of when is it safe to stop antiplatelet therapy post coronary stenting and how to manage patients who need non-cardiac surgery. This article reviews the evidence for stent thrombosis and the peri-operative management of patients with coronary stents and provides an algorithm for patient management based on multidisciplinary assessment of bleeding risk, perioperative cardiac event and stent thrombosis risk.

Focused Clinical Review: Periprocedural Management of Antiplatelet Therapy in Patients with Coronary Stents

surgery. 2 Surgical AVR is the definitive treatment for aortic valve disease. It is a proven treatment, with extremely good long-term follow-up data, that relieves symptoms and improves prognosis in successfully treated patients. 3 However, older patients, with their increasing prevalence of comorbidities, are often overlooked for AVR because of a perceived increased risk. 4 Analysis of data on over 5000 patients from the Euro Heart Survey on valvular heart disease found that a third of elderly patients with severe, symptomatic aortic stenosis were denied valve surgery. 5 There is a lack of suitable treatment alternatives for such patients. Percutaneous treatment, which avoids the need for cardiopulmonary bypass, is an attractive potential treatment option for this group. Here, we review balloon aortic valvuloplasty (BAV) and the more recently developed percutaneous aortic valve replacement (PAVR), and examine their relative merits as therapies for high-risk symptomatic older patients.

/pdf/percutaneous-management-of-aortic-stenosis-in-high-risk-1vqd5t2d5u.pdf

Percutaneous management of aortic stenosis in high-risk patients.

Rarely aneurysmal dilatation of saphenous vein grafts following coronary artery bypass surgery may be complicated by fistulae which communicate with cardiac chambers. We describe our attempt to close a fistula which entered the right atrium by deploying covered stents within the graft.

Fistula From Aneurysmal Saphenous Vein Graft to Right Atrium Treated with Covered Stents

The recently described complication of late and very late stent thrombosis with coronary stents has raised the question of when is it safe to stop antiplatelet therapy in the era of drug eluting stents? With several million patients having already had coronary stents implanted worldwide, the importance of an appreciation of stent thrombosis is not only critical to the cardiologist but also surgeon, physician, dentist and other specialists that perform procedures on patients which require with-holding antiplatelet agents. Currently there is great concern amongst medical professionals on how to manage this group of patients in the absence of clear guidelines. This article reviews the current data on coronary stents, in-stent restenosis and stent thrombosis and role of antiplatelet medication post percutaneous coronary intervention (PCI) to provide a concise and clear algorithm for managing perioperative antiplatelet therapy in patients having undergone recent PCI. The algorithm encourages a multidisciplinary approach and is based on the surgical bleeding risk, operative risk of adverse cardiac events and stent thrombosis risk to guide safe practice. Challenging areas including aspirin and clopidogrel hypersensitivity, clopidogrel resistance and concomitant vitamin K antagonist therapy are also addressed.

Deciphering dual antiplatelet therapy in the era of drug-eluting coronary stents.

Anterior ECG changes following iatrogenic dissection of the right coronary artery into the aortic root: exclusion of left coronary obstruction with transoesophageal echocardiography.

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