心肌梗死患者抗醛固酮治疗心功能变化的临床研究

Objective:To evaluate the effect of diabetes on outcome of sirolimus-eluting stent.Methods:From December 2002 to May 2005,262 diabetes and 262 non-diabetics treated with sirolimus-eluting stents were studied.The follow-up angiography was performed in 8-month.Major adverse cardiac events(MACE)defined as death,myocardial infarction,or target lesion revascularization and follow-up angiography were analyzed.Results:Successful rate of stent implantation was 100%.There was no death during the procedure,hospitalization,and follow-up period.Acute myocardial infarction occurred in 1 diabetic at 2 days after PCI,and in 2 non-diabetics at follow-up period.Angiographic follow up at 8 months showed that absolute late lumen loss was 0.06 vs 0.04mm(P>0.05),relative late lumen loss was 2.32% vs 1.63%,and TLR rate was 12.60% vs 9.92% in diabetic group and non-diabetic group respectively.Logistic regression analysis showed that reference vessel lumen and relative late lumen loss were significantly associated with restenosis.Conclusion:Cypher stent implantation in diabetes is safe and effective,while relative late lumen loss may be related to restenosis.In a word,diabetes with small vessel may be considered to be risk factor for restenosis after Cypher stents implantation.     

Safety and Effectiveness of Firebird Sirolimus-Eluting Stent in Patients With Multi-Vessel Coronary Artery Disease

Objective:This study sought to evaluate the long-term safety and efficacy of the Firebird sirolimus-eluting stent in patients with multi-vessel coronary artery disease.The main limitation of percutaneous coronary intervention(PCI)with bare metal stents(BMS)was the increased incidence of instent restenosis.Recently,DES are frequently implanted in patients with off-label indications such as multi-vessel coronary artery disease.However,the long-term safety and effectiveness of DES among patients with multi-vessel coronary artery disease are not well understood.Methods:From January to December 2006,a total of 392 patients with multi-vessel coronary artery disease,exclusively treated with Firedird stents at 12 centers from China,were enrolled in this prospective,multicenter registry.They were followed up clinically at 6,12,18 and 24 months after the procedure.Results:A core laboratory analyzed quantitative coronary angiography data immediately after stenting and at 6-month follow-up.Acute angiographic success was 100%.Angiographic restenosis rate was 2.80% at the sixth month.The percentage of acute major adverse cardiac events(MACE)was 4.86%,4.37% and 6.91%,and the percentage of secondary cardiac events was 5.62%,5.88% and 6.39% at 12,18 and 24 months,respectively.The incidence of death,myocardial infarction,or stent thrombosis during 24 month was 3.84%(15 of 392),1.02%(4 of 392)or 2.05%(8 of 392).Conclusion:This study indicates that Firebird sirolimus-eluting stent is safe and effective for patients with multi-vessel coronary artery disease.     

Impact of prolonged dual antiplatelet therapy on patients after drug-eluting stents implantation

Background Impact of dual antiplatelet therapy beyond 12 months on patients implanted with DES remains unsolved.Methods From January 2010 to June 2011,1873 patients who have been taking DAPT and free from death,myocardial infarction,stroke,repeat coronary revascularization,stent thrombosis,and major or minor bleeding according to TIMI criteria for 12 months after implantation of DES were randomly assigned to continuous (prolonged DAPT group) or discontinuous (standard DAPT group) clopidogrel (75 mg/day).The primary outcome was major adverse cardiovascular events (MACEs) which compose of death,nonfatal myocardial infarction (MI),nonfatal stroke,target vessel revascularization (TVR) or stent thrombosis (ST) at 180 days.Results There was no significant difference in the incidence of 180-day MACEs between prolonged DAPT group and standard DAPT group (8.98 % versus 10.13 %,respectively,P=0.400).The frequency of major bleeding was 0.64 % in prolonged DAPT arm and 0.43% in standard DAPT arm (P=0.523),that of minor bleeding was 3.32 % versus 2.87 % (P=0.585),respectively.Conclusions Prolonged DAPT beyond 12 months neither improve prognosis nor increase risk of bleeding in patients implanted with DES.     

Non-coronary myocardial infarction in myasthenia gravis: Case report and review of the literature

Cardiovascular adverse events in patients with myasthenia gravis (MG) are rare, but the early recognition of such events is crucial. We describe a case of a noncoronary myocardial infarction (MI) during the initial treatment period with pyridostigmine bromide in a female patient with MG. Clinicians should be cautious about the appearance of potential MI in patients with MG. A baseline electrocardiogram is advocated, when the early recognition of the MI clinical signs and the laboratory findings (myocardial markers) are vital to the immediate and appropriate management of this medical emergency, as well as to prevent future cardio-vascular events. In this case report possible causes of myocardial adverse events in the context of MG, which may occur during the ongoing treatment and the clinical course of the disease, are discussed.     

Long-term effect of stenting in unprotected left main coronary artery disease in the elderly

Objective To evaluate the feasibility, safety and efficacy of percutaneous stent implantation for treating left main coronary artery (LMCA) stenosis. Methods Consecutive patients with unprotected left main coronary artery disease treated by stent-based percutaneous intervention (PCI) at 6 medical centers in China were enrolled. Procedural data and clinical outcomes were obtained from all patients. Results From January 2001 to December 2004, 138 patients (79 males and 59 females; mean age: 69.7±5.8 years) underwent PCI for LMCA stenosis. Bare metal stents (BMS) were implanted in 51 patients with non-bifurcational lesions and in 5 patients with bifurcational lesions from January of 2001 to June of 2003 (BMS group);. drug eluting stents (DES) were used unselectively to cover both bifurcational and non-bifurcational lesions in 86 patients from July of 2003 to December of 2004 (DES group). Procedural success rate of the 138 cases was 98% (135/138). One patient (0.7%) with bifurcation lesion who was treated with DES died from severe heart failure 2 weeks after the procedure. During a mean follow up period of 21.3±5.6 months, one patient died from renal failure, one from sudden cardiac death, 4 underwent target lesion revascularization (TLR) in the BMS group, which all occurred in patients with bifurcational lesions; whereas in the DES group no deaths occurred and only one patient with bifurcational lesion had TLR. Conclusions (1) PCI is feasible and relatively safe to treat unprotected left main coronary artery disease in elderly patients at medical centers with experienced professionals. (2) BMS and DES have similar immediate and long-term efficacy in the treatment of ostium and shaft lesions of the LMCA. (3) DES are strongly suggested in the therapy of distal bifurcation lesion of unprotected LMCA.     

Effect of platelet inhibition with cangrelor during PCI on ischemic events

The intensity of antiplatelet therapy during percutaneous coronary intervention(PCI) is an important determinant of PCI-related ischemic complications.Cangrelor is a potent intravenous adenosine diphosphate(ADP)receptor antagonist that acts rapidly and has quickly reversible effects.METHODS In a double-blind,placebo-controlled trial,we randomly assigned 11,145 patients who were undergoing either urgent or elective PCI and were receiving guideline-recommended therapy to receive a bolus and infusion of cangrelor or to receive a loading dose of 600 mg or 300 mg of clopidogrel.The primary efficacy end point was a composite of death,myocardial infarction,ischemia-driven revascularization,or stent thrombosis at 48 hours after randomization;the key secondary end point was stent thrombosis at 48 hours.The primary safety end point was severe bleeding at 48 hours.RESULTS The rate of the primary efficacy end point was 4.7% in the cangrelor group and 5.9% in the clopidogrel group(adjusted odds ratio with cangrelor,0.78;95% confidence interval [CI],0.66 to 0.93;P=0.005).The rate of the primary safety end point was 0.16% in the cangrelor group and 0.11% in the clopidogrel group(odds ratio,1.50;95% CI,0.53 to 4.22;P=0.44).Stent thrombosis developed in 0.8% of the patients in the cangrelor group and in 1.4% in the clopidogrel group(odds ratio,0.62;95% CI,0.43 to 0.90;P=0.01).The rates of adverse events related to the study treatment were low in both groups,though transient dyspnea occurred significantly more frequently with cangrelor than with clopidogrel(1.2% vs.0.3%).The benefit from cangrelor with respect to the primary end point was consistent across multiple prespecified subgroups.CONCLUSIONS Cangrelor significantly reduced the rate of ischemic events,including stent thrombosis,during PCI,with no significant increase in severe bleeding.     

Effectiveness of therapeutic barium enema for diverticular hemorrhage

AIM:To evaluate the effectiveness of barium impaction therapy for patients with colonic diverticular bleeding.METHODS:We reviewed the clinical charts of patients in whom therapeutic barium enema was performed for the control of diverticular bleeding between August2010 and March 2012 at Yokohama Rosai Hospital.Twenty patients were included in the review,consisting of 14 men and 6 women.The median age of the patients was 73.5 years.The duration of the followup period ranged from 1 to 19 mo(median:9.8 mo).Among the 20 patients were 11 patients who required the procedure for re-bleeding during hospitalization,6patients who required it for re-bleeding that developed after the patient left the hospital,and 3 patients who required the procedure for the prevention of rebleeding.Barium(concentration:150 w%/v%)was administered per the rectum,and the leading edge of the contrast medium was followed up to the cecum by fluoroscopy.After confirmation that the ascending colon and cecum were filled with barium,the enema tube was withdrawn,and the patient’s position was changed every 20 min for 3 h.RESULTS:Twelve patients remained free of rebleeding during the follow-up period(range:1-19mo)after the therapeutic barium enema,including 9men and 3 women with a median age of 72.0 years.Re-bleeding occurred in 8 patients including 5 men and 3 women with a median age of 68.5 years:4developed early re-bleeding,defined as re-bleeding that occurs within one week after the procedure,and the remaining 4 developed late re-bleeding.The DFI(disease-free interval)decreased 0.4 for 12 mo.Only one patient developed a complication from therapeutic barium enema(colonic perforation).CONCLUSION:Therapeutic barium enema is effective for the control of diverticular hemorrhage in cases where the active bleeding site cannot be identified by colonoscopy.     

Splenic artery ligature associated with endoscopic banding for schistosomal portal hypertension

AIM:To propose a less invasive surgical treatment for schistosomal portal hypertension.METHODS:Ten consecutive patients with hepatosplenic schistosomiasis and portal hypertension with a history of upper gastrointestinal hemorrhage from esophageal varices rupture were evaluated in this study.Patients were subjected to a small supraumbilical laparotomy with the ligature of the splenic artery and left gastric vein.During the procedure,direct portal vein pressure before and after the ligatures was measured.Upper gastrointestinal endoscopy was performed at the 30th postoperative day,when esophageal varices diameter were measured and band ligature performed.During follow-up,other endoscopic procedures were performed according to endoscopy findings.RESULTS:There was no intra-operative mortality and all patients had confirmed histologic diagnoses ofschistosomal portal hypertension.During the immediate postoperative period,two of the ten patients had complications,one characterized by a splenic infarction,and the other by an incision hematoma.Mean hospitalization time was 4.1 d(range:2-7 d).Pre-and post-operative liver function tests did not show any significant changes.During endoscopy thirty days after surgery,a decrease in variceal diameters was observed in seven patients.During the follow-up period(57-72mo),endoscopic therapy was performed and seven patients had their varices eradicated.Considering the late postoperative evaluation,nine patients had a decrease in variceal diameters.A mean of 3.9 endoscopic banding sessions were performed per patient.Two patients presented bleeding recurrence at the late postoperative period,which was controlled with endoscopic banding in one patient due to variceal rupture and presented as secondary to congestive gastropathy in the other patient.Both bleeding episodes were of minor degree with no hemodynamic consequences or need for blood transfusion.CONCLUSION:Ligature of the splenic artery and left gastric vein with supraumbilical laparotomy is a promising and less invasive method for treating presinusoidal schistosomiasis portal hypertension.     

A combined anti-thrombotic therapy for thrombosis of mitral prosthetic valves

Background For patients with prosthetic heart valves, thrombosis of the valves is dangerous. A second surgery for re-replacing the thrombosed valve is quite traumatic. There have been some researches on noninvasive therapies for thrombosis of prosthetic heart valves. But the combined anti-thrombotic therapy including anti-coagulants and anti-platelet agents was seldom studied. Methods Fourteen patients suffered from thrombosis of the mitral prosthetic valve with stable hemodynamics were studied retrospectively. Thrombosis of the valves was demonstrated by transesophageal echocardiography. All the patients were given a combined antithrombotic therapy with clopidogrel and warfarin during the whole treatment with close monitoring. Low molecular weight heparin (LMWH) was given twice a day during the first 5 days of further treatment in four inpatients. Transthoracic echocardiography was performed repeatedly to observe the function of the mitral prosthetic valves and changes of the thrombus. Results This study included 4 males and 10 females. In these patients, 13 suffered from thrombosis of the mechanical mitral valves, and one patient had thrombosis of the bioprosthetic mitral valve. After an average of 32.0 ± 20.4 days’ treatment, eleven (78.6%) patients’ thrombi disappeared thoroughly with normalized valvular function, only three (21.4%) patients’ thrombi still existed, but no deterioration of valvular functions. For the patients with successful treatment , sizes of the left atriums decreased after treatment (P = 0.01). No significant changes of other chambers and left ventricular ejection fraction were observed (P > 0.05). None experienced major bleeding except for two cases of mild subcutaneous hemorrhage. Conclusions The combined anti-thrombotic therapy based on clopidogrel and warfarin (plus LMWH) is a feasible treatment of thrombosis of prosthetic heart valves under a close monitoring , for both inpatients and outpatients.     

Rectal arterio-portal fistula: An unusual cause of persistent bleeding per rectum following a proximal spleno-renal shunt

Gastrointestinal arterio-venous malformations are a known cause of gastrointestinal bleeding. We present a rare case of persistent rectal bleeding due to a rectal arterio-portal venous fistula in the setting of portal hypertension secondary to portal vein thrombosis. The portal hypertension was initially surgically treated with splenectomy and a proximal splenorenal shunt. However, rectal bleeding persisted even after surgery, presenting us with a diagnostic dilemma. The patient was re-evaluated with a computed tomography mesenteric angiogram which revealed a rectal arterio-portal fistula. Arterio-portal fistulas are a known but rare cause of portal hypertension, and possibly the underlying cause of continued rectal bleeding in this case. This was successfully treated using angiographic localizationand super-selective embolization of the rectal arterioportal venous fistula via the right internal iliac artery. The patient subsequently went on to have a full term pregnancy. Through this case report, we hope to high-light awareness of this unusual condition, discuss the diagnostic workup and our management approach.     

Long-term clinical outcomes of drug-eluting stents vs. bare-metal stents in Chinese geriatric patients

Background & Objective Little is known about the relative efficacies of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and bare-metal stents (BMS) in elderly patients. The objective of this study was to evaluate the clinical outcome for geriatric patients who received either DES or BMS. Methods From January 2002 to October 2005, 199 consecutive Chinese geriatric patients (≥ 75 years old) underwent PCI with coronary DES or BMS implantation at our institution. We analyzed the major clinical end points that included all-cause mortality, cardiovascular death, myocardial infarction, target lesion revascularization (TLR), stent thrombosis, and bleeding complications. Results The three-year cumulative rates of all-cause mortality, cardiovascular death, and myocardial infarction were significantly lower in the DES group (6.3%, 3.6%, 5.4%) compared with the BMS group (16.2%, 11.5%, 14.9%; P < 0.05). No significant differences were found in the three-year cumulative rate for target lesion revascularization (6.3% vs. 4.6%, P = 0.61) or stent thrombosis (3.6% vs. 2.3%, P = 0.70). Likewise, there were no statistically significant differences in the cumulative rate for intracranial hemorrhage, or major and minor hemorrhage at three years. Conclusions DES-based PCI was associated with a significant reduction in the three-year cumulative rate of all-cause mortality, cardiovascular death, and myocardial infarction compared with BMS, without increased risk of TLR, stent thrombosis, or bleeding complications at three years in this group of Chinese geriatric patients.     

Prasugrel plus aspirin beyond 12 months Is associated with improved outcomes after Taxus Liberté Paclitaxel-eluting coronary stent placement

Background—The TAXUS Liberté Post Approval Study(TL-PAS) contributed patients treated with TAXUS Liberté paclitaxel-eluting stent and prasugrel to the Dual Antiplatelet Therapy Study(DAPT) that compared 12 and 30 months thienopyridine plus aspirin therapy after drug-eluting stents.Methods and Results Outcomes for 2191 TL-PAS patients enrolled into DAPT were assessed. The DAPT coprimary composite end point(death, myocardial infarction [MI], or stroke) was lower with 30 compared with 12 months prasugrel treatment(3.7% versus 8.8%; hazard ratio [HR], 0.407; P 0.001). Rates of death and stroke were similar between groups, but MI was significantly reduced with prolonged prasugrel treatment(1.9% versus7.1%; HR, 0.255; P 0.001). The DAPT coprimary end point, stent thrombosis, was also lower with longertherapy(0.2% versus 2.9%; HR, 0.063; P 0.001). MI related to stent thrombosis(0% versus 2.6%; P 0.001) and occurring spontaneously(1.9% versus 4.5%; HR, 0.407; P = 0.007) were both reduced with prolonged prasugrel. MI rates increased within 90 days of prasugrel cessation after both 12 and 30 months treatment. Composite Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries(GUSTO) moderate or severe bleeds were modestly increased(2.4% versus 1.7%; HR, 1.438; P =0.234) but severe bleeds were not more frequent(0.3% versus 0.5%; HR, 0.549; P = 0.471) in the prolonged treatment group.Conclusions Prasugrel and aspirin continued for 30 months reduced ischemic events for the TAXUS Liberté paclitaxel-eluting stent patient subset from DAPT through reductions in MI and stent thrombosis. Withdrawal of prasugrel was followed by an increase in MI after both 12 and 30 months therapy. The optimal duration of dual antiplatelet therapy with prasugrel after TAXUS Liberté paclitaxel-eluting stent remains unknown, but appears to be 30 months.     

Low-dose aspirin for preventing recurrent venous thromboembolism

Background Patients who have had a first episode of unprovoked venous thromboembolism have a high risk of recurrence after anticoagulants are discontinued.Aspirin may be effective in preventing a recurrence of venous thromboembolism.Methods We randomly assigned 822 patients who had completed initial anticoagulant therapy after a first episode of unprovoked venous thromboembolism to receive aspirin,at a dose of 100 mg daily,or placebo for up to 4 years.The primary outcome was a recurrence of venous thromboembolism.Results During a median follow-up period of 37.2 months,venous thromboembolism recurred in 73 of 411 patients assigned to placebo and in 57 of 411 assigned to aspirin(a rate of 6.5% per year vs.4.8% per year;hazard ratio with aspirin,0.74;95% confidence interval [CI],0.52 to 1.05;P = 0.09).Aspirin reduced the rate of the two prespecified secondary composite outcomes:the rate of venous thromboembolism,myocardial infarction,stroke,or cardiovascular death was reduced by 34%(a rate of 8.0% per year with placebo vs.5.2% per year with aspirin;hazard ratio with aspirin,0.66;95% CI,0.48 to 0.92;P = 0.01),and the rate of venous thromboembolism,myocardial infarction,stroke,major bleeding,or death from any cause was reduced by 33%(hazard ratio,0.67;95% CI,0.49 to 0.91;P = 0.01).There was no significant between-group difference in the rates of major or clinically relevant nonmajor bleeding episodes(rate of 0.6% per year with placebo vs.1.1% per year with aspirin,P = 0.22) or serious adverse events.Conclusions In this study,aspirin,as compared with placebo,did not significantly reduce the rate of recurrence of venous thromboembolism but resulted in a significant reduction in the rate of major vascular events,with improved net clinical benefit.These results substantiate earlier evidence of a therapeutic benefit of aspirin when it is given to patients after initial anticoagulant therapy for a first episode of unprovoked venous thromboembolism.     

Selection and evaluation of three interventional procedures for achalasia based on long-term follow-up

AIM: To determine the best method out of the three types of interventional procedure for achalasia based on a longterm follow-up.METHODS: The study cohort was comprised of 133 patients of achalasia. Among them, 60 patients were treated under fluoroscopy with pneumatic dilation (group A), 8 patients with permanent uncovered or antireflux covered metal stent dilation (group B), and 65 patients with temporary partially covered metal stent dilation (group C).RESULTS: One hundred and thirty dilations were performed on the 60 patients of group A (mean 2.2 times per case).The mean diameter of the strictured cardia was 3.3±2.1 mm before dilation and 10.6±3.8 mm after dilation. The mean dysphagia score was 2.7±1.4 before dilation and 0.9±0.3after dilation. Complications in group A were chest pain (n=30), reflux (n=16), and bleeding (n=6). Thirty-six patients (60 %) in group A exhibited dysphagia relapse during a 12-month follow-up, and 45 patients (90 %) out of 50 exhibited dysphagia relapse during a 36-month followup. Five uncovered and 3 antireflux covered expandable metal stents were permanently placed in the 8 patients of group B. The mean diameter of the strictured cardia was 3.4±1.9 mm before dilation and 19.5±1.1 mm after dilation.The mean dysphagia score was 2.6±1.3 before dilation and 0.4±0.1 after dilation. Complications in group B were chest pain (n=6), reflux (n＝5), bleeding (n=3), and hyperplasia of granulation tissue (n=3). Four patients (50 %) in group B exhibited dysphagia relapse during a 12-month followup, and 2 case (66.7 %) out of 3 patients exhibited dysphagia relapse during a 36-month follow-up. Sixty-five partially covered expandable metal stents were temporarily placed in the 65 patients of group C and withdrawn after 3-7 days via gastroscopy. The mean diameter of the strictured cardia was 3.3±2.3 mm before dilation and 18.9±3.5 mm after dilation. The mean dysphagia score was 2.4±1.3 before dilation and 0.5±0.2 after dilation. Complications in group C were chest pain (n=26), reflux (n=13), and bleeding (n=8).6 patients (9.2 %) out of 65 exhibited dysphagia relapse during a 12-month follow-up, and 8 patients (14.5 %) out of 55 exhibited dysphagia relapse during a 36-month followup. All the stents were inserted and withdrawn successfully.The follow-up in groups A-C lasted 12-96 months.CONCLUSION: Temporary partially covered metal stent dilation is one of the best methods with interventional procedure for achalasia in terms of long-term follow-up.     

Acute extensive portal and mesenteric venous thrombosis after splenectomy： Treated by interventional thrombolysis with transjugular approach

AIM： To present a series of cases with symptomatic acute extensive portal vein （PV） and superior mesenteric vein （SMV） thrombosis after splenectomy treated by transjugular intrahepatic approach catheter-directed thrombolysis.
METHODS： A total of 6 patients with acute extensive PV-SMV thrombosis after splenectomy were treated by transjugular approach catheter-directed thrombolysis. The mean age of the patients was 41.2 years. After access to the portal system via the transjugular approach, pigtail catheter fragmentation of clots, local urokinase injection, and manual aspiration thrombectomy were used for the initial treatment of PV-SMV thrombosis, followed by continuous thrombolytic therapy via an indwelling infusion catheter in the SMV, which was performed for three to six days. Adequate anticoagulation was given during treatment, throughout hospitalization, and after discharge.
RESULTS： Technical success was achieved in all 6 patients. Clinical improvement was seen in these patients within 12-24 h of the procedure. No complications were observed. The 6 patients were discharged 6-14 d （8 ± 2.5 d） after admission. The mean duration of follow-up after hospital discharge was 40 ± 16.5 mo. Ultrasound and contrast-enhanced computed tomography confirmed patency of the PV and SMV, and no recurrent episodes of PV-SMV thrombosis developed during the follow-up period.
CONCLUSION： Catheter-directed thrombolysis via transjugular intrahepatic access is a safe and effective therapy for the management of patients with symptomatic acute extensive PV-SMV thrombosis.     

Clinical relevance of clopidogrel-proton pump inhibitors interaction

Clopidogrel is a widely used antiplatelet agent for the secondary prevention of cardiovascular events in patients with stable coronary heart disease, acute coronary syndromes and ischemic stroke. Even though clopidogrel is safer than aspirin in terms of risk for gastrointestinal(GI) bleeding, the elderly, and patients with a history of prior GI bleeding, with Helicobacter pylori infection or those who are also treated with aspirin, anticoagulants, corticosteroids or nonsteroidal antiinflammatory drugs are at high risk for GI complications when treated with clopidogrel. Accordingly, proton pump inhibitors are frequently administered in combination with clopidogrel to reduce the risk for GI bleeding. Nevertheless, pharmacodynamic studies suggest that omeprazole might attenuate the antiplatelet effect of clopidogrel. However, in observational studies, this interaction does not appear to translate into increased cardiovascular risk in patients treated with this combination. Moreover, in the only randomized, double-blind study that assessed the cardiovascular implications of combining clopidogrel and omeprazole, patients treated with clopidogrel/omeprazole combination had reduced risk for GI events and similar risk for cardiovascular events than patients treated with clopidogrel and placebo. However, the premature interruption of the study and the lack of power analysis in terms of the cardiovascular endpoint do not allow definite conclusions regarding the cardiovascular safety of clopidogrel/omeprazole combination. Other proton pump inhibitors do not appear to interact with clopidogrel. Nevertheless, given the limitations of existing observational and interventional studies, the decision to administer proton pump inhibitors to patients treated with clopidogrel should be individualized based on the patient’s bleeding and cardiovascular risk.     

Clinical evidence of interaction between clopidogrel and proton pump inhibitors

Clopidogrel is approved for reduction of atherothrombotic events in patients with cardiovascular(CV)and cerebrovascular disease.Dual antiplatelet therapy with aspirin and clopidogrel decreases the risk of major adverse cardiac events after acute coronary syndrome or percutaneous coronary intervention,compared with aspirin alone.Due to concern about gastrointestinal bleeding in patients who are receiving clopidogrel and aspirin therapy,current guidelines recommend combined use of a proton pump inhibitor(PPI)to decrease the risk of bleeding.Data from previous pharmacological studies have shown that PPIs,which are extensively metabolized by the cytochrome system,may decrease the ADP-induced platelet aggregation of clopidogrel. Results from retrospective cohort studies have shown a higher incidence of major CV events in patients re-ceiving both clopidogrel and PPIs than in those without PPIs.However,other retrospective analyses of randomized clinical trials have not shown that the concomitant PPI administration is associated with increased CV events among clopidogrel users.These controversial results suggest that large specific studies are needed. This article reviews the metabolism of clopidogrel and PPIs,existing clinical data regarding the interaction between clopidogrel and PPIs,and tries to provide recommendations for health care professionals.     

Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction

It is not known whether prehospital fibrinolysis,coupled with timely coronary angiography,provides a clinical outcome similar to that with primary percutaneous coronary intervention(PCI) early after acute STsegment elevation myocardial infarction(STEMI).METHODS Among 1892 patients with STEMI who presented within 3 hours after symptom onset and who were unable to undergo primary PCI within 1 hour,patients were randomly assigned to undergo either primary PCI or fibrinolytic therapy with bolus tenecteplase(amended to half dose in patients ≥75 years of age),clopidogrel,and enoxaparin before transport to a PCI-capable hospital.Emergency coronary angiography was performed if fibrinolysis failed;otherwise,angiography was performed 6 to 24 hours after randomization.The primary end point was a composite of death,shock,congestive heart failure,or reinfarction up to 30 days.RESULTS The primary end point occurred in 116 of 939 patients(12.4%) in the fibrinolysis group and in 135 of 943 patients(14.3%) in the primary PCI group(relative risk in the fibrinolysis group,0.86;95% confidence interval,0.68 to 1.09;P = 0.21).Emergency angiography was required in 36.3% of patients in the fibrinolysis group,whereas the remainder of patients underwent angiography at a median of 17 hours after randomization.More intracranial hemorrhages occurred in the fibrinolysis group than in the primary PCI group(1.0% vs.0.2%,P = 0.04;after protocol amendment,0.5% vs.0.3%,P = 0.45).The rates of nonintracranial bleeding were similar in the two groups.CONCLUSION Prehospital fibrinolysis with timely coronary angiography resulted in effective reperfusion in patients with early STEMI who could not undergo primary PCI within 1 hour after the first medical contact.However,fibrinolysis was associated with a slightly increased risk of intracranial bleeding.     

Transjugular intrahepatic portosystemic shunt in liver transplant recipients

AIM： To evaluate the efficacy of transjugular intrahepatic portosystemic shunts （TIPSs） after liver transplantation （LT）. METHODS： Between November 1996 and December 2005, 10 patients with severe recurrent hepatitis C virus infection （n = 4）, ductopenic rejection （n = 5） or portal vein thrombosis （n = 1） were included in this analysis. Eleven TIPSs （one patient underwent two TIPS procedures） were placed for management of therapy-refractory ascites （n = 7）, hydrothorax （n = 2） or bleeding from colonic varices （n = 1）. The median time interval between LT and TIPS placement was 15 （4-158） mo. RESULTS： TIPS placement was successful in all patients. The mean portosystemic pressure gradient was reduced from 12.5 to 8.7 mmHg. Complete and partial remission could be achieved in 43% and 29% of patients with ascites. Both patients with hydrothorax did not respond to TIPS. No recurrent bleeding was seen in the patient with colonic varices. Nine of 10 patients died during the study period. Only one of two patients, who underwent retransplantation after the TIPS procedure, survived. The median survival period after TIPS placement was 3.3 （range 0.4-20） too. The majority of patients died from sepsis with multiorgan failure. CONCLUSION： Indications for TIPS and technical performance in LT patients correspond to those in non-transplanted patients. At least partial control of therapy-refractory ascites and variceal bleeding could be achieved in most patients. Nevertheless, survival rates were disappointing, most probably because of the advanced stages of liver disease at the time of TIPS placement and the high risk of sepsis as a consequence of immunosuppression.     

Carcinoid tumor of the duodenum and accessory papilla associated with polycythemia vera

Carcinoid tumors have been reported in a wide range of organs but most frequently involve the gastrointestinal tract; however, duodenal carcinoid tumors are rare. We report a 50-year-old male patient complaining of multiple melenas for 3 wk. The panendoscopy and endoscopic retrograde cholangiopancreaticography revealed swelling accessory papilla with an ulcer. The biopsy taken showed a carcinoid tumor. The lesion was removed by wide resection. Patient was found to have an abnormal blood cell count during the follow-up period with elevated levels of hemoglobin and hematocrit of 21.2 g/dL and 63.5%, respectively, thrombocytosis of 501 000/μL, and leukocytosis of 20 410/μL. He was diagnosed as a polycythemia vera by a hematologist after further evaluation. He received periodic phlebotomy and hydroxyurea treatment. The response was good and his hematocrit was stabilized by periodic phlebotomy in the range of 44-49% during the last 2 years. The possible origin of UGI bleeding by a duodenal carcinoid tumor, although rare, should be considered. There has been one case report of a duodenal carcinoid tumor that involved accessory papilla of the pancreas divisum and one case report of metastatic carcinoid tumor associated with polycythemia vera. It is different in our patient as compared with the latter report, which mentioned a polycythemia vera patient who was found to have a metastatic carcinoid in the 17 years follow-up period. Chemotherapy had been given before the carcinoid tumor was revealed. Our patient had no previous chemotherapy for polycythemia vera before he was found to have duodenal carcinoid tumor; this excludes the possibility of chemotherapy induced carcinoid tumor, although it had been suspected in the previous report. In our patient, the existence of both diseases may be by predisposition of each other since both diseases have an increased incidence of other neoplasm, or they may be coexistent incidentally.