Major noncardiac surgery following coronary stenting: When is it safe to operate?

The optimal timing for elective noncardiac surgery (NCS) after coronary stenting is uncertain. We identified 47 patients who underwent elective NCS within 90 days of coronary stent placement between January 1995 and December 2000. Twenty-seven patients had NCS within 3 weeks of coronary stenting. Six of the seven in whom thienopyridine antiplatelet therapy was discontinued died postoperatively in a manner suggestive of stent thrombosis. In contrast, only 1 of the 20 patients in whom the thienopyridine was continued through the NCS died. The frequency of perioperative hemorrhage was similar whether or not the antiplatelet agent was continued. Only 1 perioperative death occurred in the 20 patients with NCS more than 3 weeks following stenting.     

Overcoming Aspirin Resistance with Loading Clopidogrel Earlier in Elective Percutaneous Coronary Intervention

We aimed to analyze the clinical effect of clopidogrel loading time on adverse cardiovascular events among patients with aspirin resistance. Recurrent adverse events may still occur despite dual antiplatelet therapy after coronary stenting. Aspirin resistance is one of the possible reasons of this trouble. Optimal antiplatelet strategy for coronary stenting is unknown among patients with aspirin resistance. A total of 980 patients scheduled for elective coronary stenting were enrolled and allocated into two groups according to the loading time of clopidogrel more or less than 6 hours before coronary intervention (early- or late-loaded groups, respectively). Aspirin resistance was determined according to the urinary levels of 11-dehydrothromboxane B2. Overall 240 patients who were allocated to early- and late-loaded groups were identified as aspirin resistant according to the urinary levels of 11-dehydrothromboxane B2. After a follow-up period of 12 months major adverse cardiac events were observed among 16 patients (13.9%) in the early-loaded group and 30 patients (25.8%) in the late-loaded group (p = 0.02). Early loading of clopidogrel was an independent predictor of lower rate of cardiac events (hazard ratio = 0.46 [0.32–0.76, 95% confidence interval], p = 0.001). The rates of bleeding events and periprocedural myocardial infarction were similar in early- and late-loaded groups. The current study demonstrated that loading of clopidogrel earlier than 6 hours before elective coronary stenting among aspirin-resistant patients was associated with increased benefits for ischemic events with similar bleeding rates.     

Efficacy and safety of individually tailored antiplatelet therapy in patients with acute coronary syndrome after coronary stenting: a single center, randomized, feasibility study

Background Low responsiveness to clopidogrel (LRC) is associated with increased risk of ischemic events. This study was aimed to explore the feasibility of tailored antiplatelet therapy according to the responsiveness to clopidogrel. Methods A total of 305 clopidogrel naive patients with acute coronary syndromes (ACS) undergoing coronary stenting were randomly assigned to receive standard (n = 151) or tailored (n = 154) antiplatelet therapy. The ADP-induced platelet aggregation tests by light transmission aggregometry were performed to identify LRC patients assigned to the tailored group. The standard antiplatelet regimen was dual antiplatelet therapy with aspirin and clopidogrel. The tailored antiplatelet therapy was standard regimen for non-LRC patients and an additional 6-month cilostazol treatment for LRC patients. The primary efficacy outcome was the composite of cardiovascular death, myocardial infarction or stroke at one year. Results LCR was present in 26.6% (41/154) of patients in the tailored group. The percentage platelet aggregation for LCR patients was significantly decreased at three days after adjunctive cilostazol treatment (77.5% ± 12.1% vs. 64.5% ± 12.1%, P < 0.001). At one year follow-up, a non-significant 37% relative risk reduction of primary events were observed in the tailored group as compared to the standard group (5.8% vs. 9.3%, P = 0.257). There were no differences in the rates of stent thrombosis and hemorrhagic events between the two groups. Conclusions Tailored antiplatelet therapy for ACS patients after coronary stenting according to responsiveness to clopidogrel is feasible. However, its efficacy and safety need further confirmation by clinical trials with larger sample sizes.     

择期冠状动脉介入治疗患者氯吡格雷抵抗现象的观察

目的:利用流式细胞术观察择期冠状动脉介入治疗患者所服用药物氯吡格雷的作用特点及氯吡格雷抵抗现象。方法:选取60例择期冠状动脉介入治疗患者,在服用氯吡格雷前、术前(服药后5天)、术后2小时及术后5天分别采血,利用流式细胞术测定其二磷酸腺苷诱导的血小板聚集率及血小板表面活化的糖蛋白Ⅱb/Ⅲa复合物(PAC-1)的表达情况。结果:60例患者在服用氯吡格雷前及术后5天的血小板聚集率和PAC-1的表达基本符合正态分布曲线。氯吡格雷抵抗的发生率在术前为25%,术后2h为30%,术后5天为13%。不同基础血小板聚集率组中,术后2h氯吡格雷抵抗发生率无明显差别(P>0.05)。结论:在择期冠状动脉介入治疗患者中,氯吡格雷的抗血小板作用存在个体差异,部分患者存在氯吡格雷抵抗现象。氯吡格雷抵抗可能不受基础血小板聚集率高低的影响。     

Combining warfarin and antiplatelet therapy after coronary stenting in the Global Registry of Acute Coronary Events: is it safe and effective to use just one antiplatelet agent?

AIMS: To identify factors associated with the use of single or dual antiplatelet therapy in patients prescribed warfarin following coronary stenting and to investigate whether single (aspirin or thienopyridine) vs. dual antiplatelet therapy plus warfarin leads to an excess of adverse outcomes. METHODS AND RESULTS: We analysed data from 800 patients with an acute coronary syndrome who underwent coronary stenting (130 patients received a drug-eluting stent) and were discharged on warfarin and either dual (n = 580) or single (n = 220) antiplatelet therapy. The use of single antiplatelet therapy was more common in Europe than in the USA (34 vs. 17%, P < 0.001). There was no difference in major bleeding in hospital or in 6-month mortality or myocardial infarction. In the single antiplatelet group, the use of either aspirin or thienopyridine (clopidogrel or ticlopidine) in combination with warfarin resulted in similar outcomes. CONCLUSION: Use of single vs. dual antiplatelet therapy and warfarin following stenting is common. In this observational study, there was no difference in mortality or myocardial infarction at 6 months; however, larger trials are needed to assert any firm recommendations.     

Triple versus dual antiplatelet therapy after coronary stenting: impact on stent thrombosis.

OBJECTIVES: We evaluated safety and efficacy of triple antiplatelet therapy with aspirin, clopidogrel, or ticlopidine and cilostazol after coronary stenting. BACKGROUND: Triple antiplatelet therapy might have beneficial effect to prevent thrombotic complications in patients undergoing coronary stenting. METHODS: Patients undergoing successful coronary stenting were divided into dual antiplatelet therapy (aspirin plus clopidogrel or ticlopidine, group I, n = 1,597) and triple antiplatelet therapy (aspirin plus clopidogrel or ticlopidine plus cilostazol, group II, n = 1,415) groups. The primary end point included death, myocardial infarction, target lesion revascularization, or stent thrombosis within 30 days. The secondary end point was side effects of study drugs, including major bleeding, vascular complication, hepatic dysfunction, and hematological complications. RESULTS: Multi-vessel stenting and the use of long stents were more prevalent in group II than in group I. The primary end point was 0.8% in group I and 0.3% in group II (p = 0.085). Stent thrombosis within 30 days was significantly lower in group II (n = 1, 0.1%) than in group I (n = 9, 0.5%; p = 0.024). The independent predictors of stent thrombosis were primary stenting (odds ratio [OR] 7.9, 95% confidence interval [CI] 2.0 to 30.8, p = 0.003) and triple therapy (OR 0.12, 95% CI 0.015 to 0.98, p = 0.048). The overall adverse drug effects, including major bleeding, neutropenia, and thrombocytopenia, were no different between two groups (1.8% vs. 2.6%, p = 0.104). CONCLUSIONS: Compared with the dual antiplatelet regimen, triple antiplatelet therapy seemed to be more effective in preventing thrombotic complications after stenting without an increased risk of side effects. Triple antiplatelet therapy might be safely applied in patients or lesions with a high risk of stent thrombosis.     

Clopidogrel as adjunctive antiplatelet therapy during coronary stenting

OBJECTIVES

We examined the procedural and 30-day clinical outcomes among patients receiving aspirin and either ticlopidine or clopidogrel during coronary stenting.

BACKGROUND

Ticlopidine-plus-aspirin has become standard antiplatelet therapy for the prevention of thrombotic complications after coronary stenting. Clopidogrel has a similar mechanism of action as ticlopidine, but both its efficacy and its safety as a pharmacologic adjunct to coronary stenting have not been well described.

METHODS

This single-center, prospective analysis examined the in-hospital procedural and 30-day clinical outcomes among 875 consecutive patients undergoing coronary stenting who received adjunctive aspirin and either clopidogrel (n = 514; 58.7%) or ticlopidine (n = 361; 41.3%) therapy.

RESULTS

Procedural success rates were similar among the clopidogrel- (99.6%) and ticlopidine-treated patients (99.4%). Subacute stent thrombosis (i.e., >24 h ≤30 days) occurred in one clopidogrel-treated (0.2%) and in one ticlopidine-treated (0.3%) patient (p = 0.99). By 30 days following the index procedure, the combined rates of death, nonfatal myocardial infarction and need for target vessel revascularization were similar among patients who received either clopidogrel (2.1%) or ticlopidine (1.4%; p = 0.57) therapy.

CONCLUSIONS

In this analysis the antiplatelet combination therapy of aspirin-plus-clopidogrel was an effective regimen for preventing thrombotic complications and major adverse cardiovascular events among a broad spectrum of patients undergoing coronary artery stenting.     

Elective percutaneous coronary intervention using broad-spectrum antiplatelet therapy (eptifibatide, clopidogrel, and aspirin) alone, without scheduled unfractionated heparin or other antithrombin therapy

Background

Adjunctive pharmacotherapy during percutaneous coronary intervention (PCI) has historically consisted of a regimen of antiplatelet agents accompanied by an antithrombin agent, typically unfractionated heparin. Paradoxically, unfractionated heparin may activate platelets, induce other pro-thrombotic activities, increase bleeding complications, and cause thrombocytopenia. To optimize patient care and avoid the potential risks of unfractionated heparin in patients undergoing elective PCI, one of the authors began to use adjunctive pharmacotherapy consisting of broad-spectrum antiplatelet therapy alone, without scheduled unfractionated heparin or other antithrombin therapy.

Methods

Five hundred consecutive patients undergoing scheduled, elective PCI (stent deployment, cutting balloon atherotomy, conventional balloon angioplasty, or high-speed rotational atherectomy) received adjunctive pharmacotherapy consisting of eptifibatide, clopidogrel, and aspirin.

Results

The technical success rate was 100%. During the first 24 hours, there were no major adverse clinical events. Non-Q-wave myocardial infarction occurred in 1.6% of patients, major and minor bleeding complications in 0.2% and 0.6%, respectively, and thrombocytopenia in 0.6%. During the first 30 days, there was 1 (0.2%) major adverse clinical event.

Conclusions

For elective PCI, adjunctive pharmacotherapy consisting of broad-spectrum antiplatelet therapy alone, without scheduled unfractionated heparin or other antithrombin therapy, appears to be safe and may prove to be efficacious.     

The elective use of the seven-cell NIR stent in coronary arteries < 2.75 mm in diameter: clinical and angiographic results at 6-month follow-up.

The outcome of interventional procedures has been improved by the use of coronary stents in vessels > 3.0 mm in diameter. We report a single-center prospective study of elective coronary stenting in 39 consecutive patients with de novo lesions and reference diameters < 2.75 mm. Seven-cell NIR stents were deployed with standard antiplatelet therapy, but without routine use of IIb/IIIa inhibitors or intravascular ultrasound. There was one case of acute stent thrombosis, but no cases of subacute thrombosis. The binary restenosis rate was 27.8% (10/36 lesions) and the target lesion revascularization rate was 19.4%. Symptoms improved markedly as judged by Canadian Cardiovascular Society and questionnaire scores and the use of antianginal therapy. This pilot study suggests that the elective use of coronary stents in vessels < 2.75 mm in diameter is safe with acceptable long-term results. A randomized trial comparing outcomes after stents and balloon angioplasty in small vessels is required.     

冠状动脉支架术后三联抗血小板药物治疗对血小板功能的影响

目的探讨三联抗血小板药物治疗对冠状动脉(冠脉)支架术后患者血小板活化和聚集功能的影响。方法120例冠心病行冠脉支架植入术患者,随机分为三联组(阿司匹林、氯吡格雷和西洛他唑)和两联组(阿司匹林和氯吡格雷),三联组于术后第1天起加服西洛他唑。两组分别于术后第1天服用西洛他唑前及第5天测定血小板活化复合物(PAC-1)和CD_(62)p,同时测定5μmol/L及20μmol/L ADP诱导的血小板最大聚集率(MPAR)。结果两组临床基线资料及CD_(62)p、PAC-1和MPAR基线值差异均无统计学意义。分别计算各指标第二次测定值与基线值的差值,两组ΔMPAR差异无统计学意义,但三联组和两联组ΔCD_(62)p和ΔPAC-1分别为[(5.12±11.25)%比(1.08±4.97)%,P＜0.05]和[(12.12±12.30)%比(2.22±15.15)%,P＜0.01]。对急性冠脉综合征(ACS)患者亚组分析结果表明三联组ΔMPAR(5μmol/L)[(8.68±10.35)％比(2.92±13.06)%,P=0.018]、ΔMPAR(20μmol/L)[(11.05±11.14)%比(5.16±13.27)%,P=0.019]、ΔCD_(62)p[(5.57±12.08)％比(1.35±4.42)%,P=0.028】和ΔPAC-1[(11.62±12.73)%比(1.29±15.73)%,P= 0.001]均显著高于两联组。3个月临床随访显示三联组与两联组主要不良心、脑血管事件发生率分别为0和3.3%(2/60),出血发生率分别为5%(3/60)和3.3%(2/60),均无统计学意义。结论三联抗血小板药物治疗与常规两联治疗相比能更有效地抑制冠脉支架术后血小板活化和聚集,但其疗效和安全性还需大规模临床试验证实。     

特发性血小板减少性紫癜合并抗磷脂抗体综合征患者ACS后成功PCI术1例

1 病例资料 患者,女,71岁,因"胸闷1d,突发晕厥1次"入院.患者本次入院为1d前(上午10时许)活动时出现压迫性胸骨中段胸闷,伴左侧手臂痛,出冷汗,伴头晕恶心,家属急送至我院急诊(约14:00时),患者于急诊门口突发晕厥,心电监护提示心室颤动,立即予心肺复苏、电除颤,10余分钟后好转,急查肌钙蛋白7.52 ng/...     

Reduced Anticoagulation with Antiplatelet Therapy Alone is Safe and Effective after "Bail-Out" Stenting for Failed Angioplasty

The aim of this retrospective study was to compare the safety and efficacy of antiplatelet therapy alone with conventional anticoagulation with warfarin after òbail-outó coronary stenting for failed balloon angioplasty at a tertiary referral centre. Eighty-two consecutive patients undergoing òbail-outó stenting over a 22-month-period were studied. Forty patients received antiplatelet therapy alone with aspirin and ticlopidine and 42 patients received anticoagulation with warfarin for 30 days. The main outcome measures examined were death, myocardial infarction, coronary artery bypass surgery, repeat angioplasty, and significant vascular complications. The angiographic procedural success rate was 100% in both groups. At six weeks there were no deaths and no patient required emergency coronary artery bypass surgery in either group. There were three (7.1%, p = NS) stent thromboses and two (4.8%, p = NS) Q-wave myocardial infarctions in the warfarin group as compared to none in the antiplatelet group. There was a significantly higher incidence of vascular complications in the warfarin group (21.4% vs. 0%, p = 0.004). The length of hospital stay was significantly shorter in the antiplatelet group [3.4 (2.0) vs. 7.8 (2.6) days, p < 0.001]. This study suggests that reduced anticoagulation with antiplatelet therapy alone after òbail-outó stenting is an effective and safe strategy which reduces vascular complications and hospital stay without increasing the rate of stent thrombosis.     

Idiopathic thrombocytopenic purpura and percutaneous coronary stenting: a dangerous duo?

Dual antiplatelet therapy is a mainstay in the management of patients undergoing coronary stenting. Whether this is also appropriate in patients with a diagnosis of idiopathic thrombocytopenic purpura (ITP) is unclear. We report the case of a 66-year-old man with ITP admitted for an acute coronary syndrome. On admission platelets were 110 × 10⁹/L without petechiae or purpura, and coronary angiography revealed multivessel disease with significant left main involvement. Given the unfeasibility of surgical revascularization with cardiopulmonary bypass because of ITP, a staged percutaneous revascularization strategy was chosen. Both left circumflex and right coronary arteries were treated with bare-metal stenting during the index admission. After 4 weeks of strict clinical monitoring and evidence of a stable total platelet count on oral prednisone, percutaneous coronary intervention with drug-eluting stenting was performed in the left main and left anterior descending arteries. He was then discharged on lifelong aspirin and a 6-month clopidogrel regimen without thrombotic or bleeding complications. Given the paucity of data on ITP and stenting, no strict recommendations can be proposed and treatment should be individualized to minimize both bleeding and thrombosis risks. Nonetheless, this case suggests the feasibility of percutaneous revascularization in selected patients with multivessel coronary disease and ITP.     

冠状动脉介入治疗术后局部缺血防治进展

经皮冠状动脉成形术(PTCA)术后局部缺血并发症包括:急性冠状动脉闭塞,发生率2%~10%,病人的死亡率随之增加。由于侧支闭塞或血栓形成,围手术期心肌梗塞发生率5%~20%。急性冠脉综合症、老年病人、复合病变患者、围手术期并发症大大增加,直接支架植入有效防治急性冠脉闭塞,但仍然存在血栓形成等并发症,合用阿司匹林和抗血小板因子(抵克力得、氯吡格雷、阿昔单抗、依替巴肽、替罗非班)能降低局部缺血的发生率,已成为PTCA病人标准的辅助治疗     

Safety of dental extractions in coronary drug-eluting stenting patients without stopping multiple antiplatelet agents

Background:

The risk of excessive bleeding prompts physicians to stop multiple antiplatelet agents before minor surgery, which puts coronary stenting patients at risk for adverse thrombotic events.

Hypothesis:

We hypothesized that most dental extractions can be carried out safely without stopping multiple antiplatelet agents.

Methods:

All dental extraction patients who had undergone coronary stenting and who were also on oral multiple antiplatelet agents therapy were enrolled. One hundred patients underwent dental procedures without stopping antiplatelet agents. All wounds were sutured and followed up at 24 hours, 1 week, and 1 month after the procedure. There were 2233 patients who had not taken oral antiplatelet agents from a health promotion center and had teeth extracted by the same method. After performing propensity‐score matching for the entire population, a total of 100 matched pairs of patients were created. The primary outcome was a composite of excessive intraextraction blood loss, transfusion, and rehospitalization for bleeding, and the secondary outcome was a composite of death, nonfatal myocardial infarction, target lesion revascularization, and stent thrombosis within 1 month after the procedure.

Results:

There were 2 excessive intraextraction bleeding cases that continued at the extraction site for 4 and 5 hours, respectively, in the coronary stenting patients, and 1 excessive intraextraction bleeding case that continued for 3 hours in the control patients. There were no cases of transfusion, rehospitalization for bleeding, or major cardiovascular events for the 2 propensity‐matched groups.

Conclusions:

We found that most dental extractions in coronary stenting patients can be carried out safely without stopping multiple antiplatelet agents. The authors have no conflicts of interest to disclose. This study was supported in part by a grant from Yuhan Corporation, Ltd., Seoul, The Republic of Korea.     

Antiplatelet therapy for elective coronary stenting: a moving target

The recognition of the major contribution of platelet-mediated mechanisms to the pathogenesis of thrombotic complications after coronary stenting has led to the development and evaluation of different antiplatelet regimens. The combination of aspirin and adenosine diphosphate antagonists such as ticlopidine and clopidogrel has solved the issue of acute stent thrombosis. The timing and dose of dual oral antiplatelet therapy have, however, changed over time with a shift from postintervention treatment to preintervention treatment with a high loading dose of clopidogrel. Pretreatment with aspirin and clopidogrel has been associated with a further 30% reduction in ischemic complications after coronary intervention. Recent data have even shown that in case of optimal pretreatment with such a dual oral antiplatelet therapy, glycoprotein IIb/IIIa antagonists are no longer mandatory for elective coronary stenting and should be reserved only for high-risk procedures or for acute coronary interventions.     

Optimal management of platelet function after coronary stenting

Opinion statement Coronary stenting elicits vessel wall damage, and subsequent activation of platelets is implicated as a major component of complications such as acute, subacute, and late stent thrombosis. As such, dual antiplatelet therapy using aspirin and clopidogrel has become a routine adjunct to coronary stenting. Use of aspirin and clopidogrel with or without glycoprotein IIb/IIIa inhibitors after coronary stenting reduces the complication rate and improves long-term outcomes. Dual antiplatelet therapy using aspirin and clopidogrel is recommended for at least 4 weeks with bare metal stents, and for 3 to 6 months with drug-eluting stents for prevention of major adverse cardiac events. After coronary stenting, 1 year of dual antiplatelet therapy is recommended for prevention of future cardiac events. However, despite the use of antiplatelet agents, stent thrombosis occurs in approximately 1% of patients, with an increased likelihood of occurrence in high-risk patients or a lesion subset of patients. Although the incidence of stent thrombosis is low, stent thrombosis usually presents as acute coronary syndrome and the mortality rate is up to 45%. Thus, considering the widespread use of stents, a considerable number of people are inadequately protected from thrombotic events despite current standard antiplatelet therapy using aspirin and clopidogrel. A concern with clopidogrel is the loading time and loading dose required to achieve and maintain optimal inhibition of platelet aggregation. The current recommendation for ensuring maximum antiplatelet activity is administration of a 300-mg loading dose of clopidogrel initiated at least 6 hours prior to percutaneous coronary intervention (PCI), and ideally the day before. If this is not possible, a loading dose of 600 mg of clopidogrel should be administered at least 2 hours before PCI. Recently, new combinations of antiplatelet agents (ie, triple therapy using aspirin, clopidogrel, and cilostazol) and new drugs with potent antiplatelet effects (ie, Prasugrel [currently being developed by Sankyo Pharmaceuticals and Ube Pharmaceuticals in Japan and by Eli Lilly and Co. (Indianapolis, IN) in the United States], Cangrelor [currently being developed by AstraZeneca Pharmaceuticals, Wilmington, DE], and AZD6140) have been evaluated in clinical trials; such treatments may help reduce the number of cardiac events after coronary stenting.     

西洛他唑改善冠心病患者支架置入术后长期预后的研究

目的探讨西洛他唑对冠心病患者支架置入术后5年临床预后的影响。方法选择择期行经皮冠状动脉介入治疗的冠心病患者200例,随机分为西洛他唑组(100例)和对照组(100例),西洛他唑组在常规抗血小板药物的同时加服西洛他唑200 mg/d。对照组常规服用抗血小板药物,2组持续用药6个月。随访5年,比较主要不良心脑血管事件发生率和其他不良反应发生率。结果西洛他唑组患者主要不良心脑血管事件发生率明显低于对照组,差异有统计学意义(17% vs 42%,P0.01)。西洛他唑组患者心悸发生率明显高于对照组,差异有统计学意义(13% vs 3%,P0.05)。西洛他唑组患者1年无事件生存率明显高于对照组(P0.05),5年时差异更明显(P0.01)。结论支架置入术后应用西洛他唑,可以减少冠心病患者主要不良心脏事件的发生率,而不增加出血并发症,临床应用安全有效。     

Clopidogrel and Coronary Stenting: What is the Next Question?

Today, following coronary stenting, clopidogrel has largely replaced ticlopidine as part of combination antiplatelet therapy following coronary stenting primarily due to its better tolerability. While there is no randomized, blinded, efficacy trial of ticlopidine versus clopidogrel, there are ample data from a number of observational studies, randomized non-blinded trials, and a randomized blinded safety trial to prove that clopidogrel is not only safer than ticlopidine, but also at least as efficacious following stenting. With over 10,000 treated patients, pooled data suggest similar rates of stent thrombosis (clopidogrel 0.98% vs. ticlopidine 0.98%) and lower rates of major adverse cardiac events with clopidogrel (clopidogrel 1.63% vs. ticlopidine 4.52%, p<0.001), with a clear advantage for clopidogrel regarding adverse events (clopidogrel 5.91% vs. ticlopidine 9.75%, p<0.001). With clopidogrel's superior safety and at least equivalent efficacy, the question of “which thienopyridine?” post-stenting has been answered. Now the questions “how much?”, “how soon?” and “how long?” must be addressed. The Clopidogrel for the Reduction of Events During Observation (CREDO) trial is a multi-center, double-blind, randomized trial designed to answer these remaining questions. CREDO will evaluate the efficacy and safety of clopidogrel pretreatment versus no pretreatment, and prolonged (1 year), versus short-term (1 month) dual antiplatelet therapy in 2,000 patients undergoing planned or highly probable coronary intervention with a stent.     

Early versus late coronary stenting following acute myocardial infarction: Results of the STENTIM I Study (French Registry of Stenting in Acute Myocardial Infarction)

This study was undertaken to determine the feasibility and safety of coronary stenting in acute myocardial infarction (AMI). In AMI, primary percutaneous transluminal coronary angioplasty (PTCA) is accepted as the preferred method of reperfusion for patients presenting at highly experienced centres. Until recently, however, stenting has been avoided during AMI because of a potential high risk of thrombosis. This prospective observational study carried out in 20 centres and included 648 consecutive patients who underwent PTCA with stent implantation for AMI. Of these 648 patients, 269 (41.5%, Group 1) were dilated early (<24 hr) after the onset of the symptoms (75% treated by direct PTCA) and 379 (58.5%, Group 2) were dilated between 24 hr and 14 days after AMI. Combined therapy with ticlopidin and aspirin was used after the procedure. Bailout stenting occurred more often in Group 1 than in Group 2 (17% vs. 9.5%)(P < 0.05). Angiographic successful stenting was similar in both groups of patients (96% vs. 97%). During the hospital follow-up period, stent thrombosis occurred in eight patients (3%) in Group 1 and in six patients (1.6%) in Group 2 (NS). There was 14 deaths (5.2%) in Group 1 and 11 deaths (3.9%) in Group 2 (NS). After multivariate analysis bailout stenting was identified as the sole predictor of stent thrombosis (P < 0.0001). Vascular access-site complications occurred in six patients (1%) with no difference between the two groups. This study indicates that patients who receive a coronary stent in AMI can be managed safely with antiplatelet therapy. Randomized studies are needed to determine the precise indication for coronary stenting as an adjunct to primary PTCA. Cathet. Cardiovasc. Diagn. 42:243–248, 1997. © 1997 Wiley-Liss, Inc.