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Mansour K, Taher AT, Musallam KM, Alam S. Aspirin resistance. Adv Hematol 2009; 2009:937352. [PMID: 19960045 PMCID: PMC2778169 DOI: 10.1155/2009/937352] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Revised: 02/09/2009] [Accepted: 02/15/2009] [Indexed: 12/19/2022] Open
Abstract
The development of adverse cardiovascular events despite aspirin use has established an interest in a possible resistance to the drug. Several definitions have been set and various laboratory testing modalities are available. This has led to a wide range of prevalence reports in different clinical entities. The etiologic mechanism has been related to clinical, genetic, and other miscellaneous factors. The clinical implications of this phenomenon are significant and warrant concern. Management strategies are currently limited to dosing alteration and introduction of other anitplatelet agents. However, these measures have not met the expected efficacy or safety.
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Affiliation(s)
- Khaled Mansour
- Division of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon
| | - Ali T. Taher
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon
| | - Khaled M. Musallam
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon
| | - Samir Alam
- Division of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon
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Collyer T, Gray D, Sandhu R, Berridge J, Lyons G. Assessment of platelet inhibition secondary to clopidogrel and aspirin therapy in preoperative acute surgical patients measured by Thrombelastography® Platelet Mapping™. Br J Anaesth 2009; 102:492-8. [DOI: 10.1093/bja/aep039] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Faxon DP, Freedman JE. Facts and controversies of aspirin and clopidogrel therapy. Am Heart J 2009; 157:412-22. [PMID: 19249409 DOI: 10.1016/j.ahj.2008.11.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 11/25/2008] [Indexed: 11/28/2022]
Abstract
Because of the central role of platelets in mediating ischemic events, antiplatelet agents are critical components of atherothrombosis prevention. Given their robust safety and efficacy profiles, aspirin and clopidogrel are consistently recommended by evidence-based treatment guidelines. Despite these recommendations, controversies surrounding the appropriate application of aspirin and clopidogrel remain. Questions of appropriate dosing, length of therapy, and use of combination therapy are most pressing, and considerable debate exists regarding the variability of response to antiplatelet therapy, including the definition, measurement, and clinical relevance of responsiveness. This review discusses the facts and controversies surrounding the use of aspirin and clopidogrel. Overall, despite the existing controversies, antiplatelet therapy with aspirin and/or clopidogrel remains a proven and essential therapeutic tool for safe and effective management of atherothrombotic risk in specific clinical settings.
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Affiliation(s)
- David P Faxon
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02120, USA.
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Failure of therapy or resistance to antiplatelet drugs? COR ET VASA 2009. [DOI: 10.33678/cor.2009.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Lee SW, Park SW, Kim YH, Yun SC, Park DW, Lee CW, Hong MK, Rhee KS, Chae JK, Ko JK, Park JH, Lee JH, Choi SW, Jeong JO, Seong IW, Cho YH, Lee NH, Kim JH, Chun KJ, Kim HS, Park SJ. A randomized comparison of sirolimus- versus Paclitaxel-eluting stent implantation in patients with diabetes mellitus. J Am Coll Cardiol 2008; 52:727-33. [PMID: 18718419 DOI: 10.1016/j.jacc.2008.04.056] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Revised: 04/14/2008] [Accepted: 04/15/2008] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The aim of this study was to compare the effectiveness of sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) in patients with diabetes mellitus (DM). BACKGROUND Drug-eluting stent implantation significantly improved the angiographic and clinical outcomes compared with bare-metal stent implantation in diabetic patients. However, comparison of SES with PES in diabetic patients has not been sufficiently evaluated. METHODS This prospective, multicenter, randomized study compared SES (n = 200) and PES implantation (n = 200) for diabetic patients (n = 400). The primary end point was in-segment restenosis at 6 months according to intention-to-treat principle. RESULTS The 2 groups had similar baseline clinical and angiographic characteristics. Six-month in-stent (3.4% vs. 18.2%, p < 0.001) and in-segment restenosis (4.0% vs. 20.8%, p < 0.001) and 9-month target lesion revascularization (2.0% vs. 7.5%, p = 0.017) were significantly lower in the SES versus the PES group. The incidence of death (0% in SES vs. 0.5% in PES, p = 0.999) or myocardial infarction (0.5% in SES vs. 0.5% in PES, p = 0.999) at 9-month follow-up was not statistically different between the 2 groups. Major adverse cardiac events including death, myocardial infarction, and target lesion revascularization at 9 months (2.0% vs. 8.0%, p = 0.010) were lower in the SES versus the PES group. CONCLUSIONS Sirolimus-eluting stent implantation is superior in reducing angiographic restenosis and improving 9-month clinical outcomes in patients with DM and coronary artery disease compared with PES implantation.
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Affiliation(s)
- Seung-Whan Lee
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Abstract
Adverse drug reactions (ADRs) occur frequently in modern medical practice, increasing morbidity and mortality and inflating the cost of care. Patients with cardiovascular disease are particularly vulnerable to ADRs due to their advanced age, polypharmacy, and the influence of heart disease on drug metabolism. The ADR potential for a particular cardiovascular drug varies with the individual, the disease being treated, and the extent of exposure to other drugs. Knowledge of this complex interplay between patient, drug, and disease is a critical component of safe and effective cardiovascular disease management. The majority of significant ADRs involving cardiovascular drugs are predictable and therefore preventable. Better patient education, avoidance of polypharmacy, and clear communication between physicians, pharmacists, and patients, particularly during the transition between the inpatient to outpatient settings, can substantially reduce ADR risk.
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57
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Gasparyan AY, Watson T, Lip GYH. The role of aspirin in cardiovascular prevention: implications of aspirin resistance. J Am Coll Cardiol 2008; 51:1829-43. [PMID: 18466797 DOI: 10.1016/j.jacc.2007.11.080] [Citation(s) in RCA: 198] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Revised: 10/19/2007] [Accepted: 11/10/2007] [Indexed: 02/08/2023]
Abstract
Aspirin is well recognized as an effective antiplatelet drug for secondary prevention in subjects at high risk of cardiovascular events. However, most patients receiving long-term aspirin therapy still remain at substantial risk of thrombotic events due to insufficient inhibition of platelets, specifically via the thromboxane A2 pathway. Although the exact prevalence is unknown, estimates suggest that between 5.5% and 60% of patients using this drug may exhibit a degree of "aspirin resistance," depending upon the definition used and parameters measured. To date, only a limited number of clinical studies have convincingly investigated the importance of aspirin resistance. Of these, few are of a sufficient scale, well designed, and prospective, with aspirin used at standard doses. Also, most studies do not sufficiently address the issue of noncompliance to aspirin as a frequent, yet easily preventable cause of resistance to this antiplatelet drug. This review article provides a comprehensive overview of aspirin resistance, discussing its definition, prevalence, diagnosis, and therapeutic approaches. Moreover, the clinical implications of aspirin resistance are explored in various cardiovascular disease states, including diabetes mellitus, hypertension, heart failure, and other similar disorders where platelet reactivity is enhanced.
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Affiliation(s)
- Armen Yuri Gasparyan
- Haemostasis Thrombosis and Vascular Biology Unit, University Department of Medicine, City Hospital, Birmingham, United Kingdom
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Kitoga M, Pasquet A, Preumont V, Kefer J, Hermans MP, Vanoverschelde JL, Buysschaert M. Coronary in-stent restenosis in diabetic patients after implantation of sirolimus or paclitaxel drug-eluting coronary stents. DIABETES & METABOLISM 2008; 34:62-7. [PMID: 18069029 DOI: 10.1016/j.diabet.2007.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2007] [Revised: 09/21/2007] [Accepted: 09/25/2007] [Indexed: 11/17/2022]
Abstract
It is now emerging that, in patients who are at high risk for cardiovascular complications and, in particular, those with diabetes, the occurrence of late restenosis and thrombosis after treatment of coronary artery disease with drug-eluting stents is higher than earlier reports have suggested. Therefore, the aim of this study was to assess the prevalence of in-stent restenosis in a cohort of consecutive patients with diabetes treated for coronary disease in 2005 with drug-eluting stents [either sirolimus (58%) or paclitaxel (42%)]. The duration of follow-up was 9.0+/-3.4 months [mean+/-1 standard deviation (S.D.)]. A total of 154 patients (type 2 diabetes: 91%) were included in the study (age: 66+/-10 years), and the total number of implanted stents was 184. Two subjects died from cardiac causes, while myocardial infarction and (un)stable angina were observed in 3 (2%) and 39 (25%) patients, respectively. In-stent restenosis, appraised by angiography, was observed in 17 individuals (11%) after a mean follow-up of five months. Mean HbA(1c) in patients with restenosis was 7.6+/-1.8%. There was no difference in the rate of restenosis with sirolimus-(n=8) compared with paclitaxel-(n=9) eluting stents. Male gender, oral therapy for diabetes and stent diameter were predictors of in-stent restenosis. In conclusion, even over a medium-term period, in-stent restenosis remains a potential risk for coronary diabetic patients treated with drug-eluting devices.
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Affiliation(s)
- M Kitoga
- Service d'endocrinologie et nutrition, université catholique de Louvain, cliniques universitaires Saint-Luc, 10, avenue Hippocrate, 1200 Bruxelles, Belgium
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Effect of CYP3A5*3 genotype on the pharmacokinetics and antiplatelet effect of clopidogrel in healthy subjects. Eur J Clin Pharmacol 2008; 64:589-97. [DOI: 10.1007/s00228-008-0471-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2007] [Accepted: 02/02/2008] [Indexed: 10/22/2022]
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The effect of CYP2C19 polymorphism on the pharmacokinetics and pharmacodynamics of clopidogrel: a possible mechanism for clopidogrel resistance. Clin Pharmacol Ther 2008; 84:236-42. [PMID: 18323861 DOI: 10.1038/clpt.2008.20] [Citation(s) in RCA: 216] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
We evaluated the effect of the CYP2C19 genotype on the pharmacokinetics and pharmacodynamcis of clopidogrel. Twenty-four subjects were divided into three groups on the basis of their CYP2C19 genotype: homozygous extensive metabolizers (homoEMs, n = 8), heterozygous EMs (heteroEMs, n = 8), and poor metabolizers (PMs, n = 8). After a single 300-mg loading dose of clopidogrel on day 1, followed by a 75-mg daily maintenance dose from days 2 to 7, we measured the plasma levels of clopidogrel and assessed the antiplatelet effect as pharmacodynamics. The mean clopidogrel area under the curve (AUC) for PMs was 1.8- and 2.9-fold higher than that for heteroEMs and homoEMs, respectively (P = 0.013). The mean peak plasma concentration in PMs was 1.8- and 4.7-fold higher than that of heteroEMs and homoEMs, respectively (P = 0.008). PMs exhibited a significantly lower antiplatelet effect than heteroEMs or homoEMs (P < 0.001). From these findings it is clear that the CYP2C19 genotype affects the plasma levels of clopidogrel and modulates the antiplatelet effect of clopidogrel.
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Gengo FM, Rainka M, Robson M, Gengo MF, Forrest A, Hourihane M, Bates V. Prevalence of platelet nonresponsiveness to aspirin in patients treated for secondary stroke prophylaxis and in patients with recurrent ischemic events. J Clin Pharmacol 2008; 48:335-43. [PMID: 18223144 DOI: 10.1177/0091270007313324] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To determine the prevalence of platelet nonresponsiveness to aspirin treatment for secondary stroke prophylaxis, the authors studied consecutive patients during a 29-month period. Information regarding their ischemic events, risk factors, and medications was collected. Platelet aggregation in response to collagen and arachidonic acid was used to determine platelet responsiveness to aspirin. A total of 653 patients were evaluated. Of these, 129 patients (20%) were determined to be nonresponsive to aspirin based on continued platelet aggregation in response to collagen, arachidonic acid, or both. A total of 87 (13%) of the 653 patients were clinical aspirin failures (ie, presented with new focal cerebral ischemic symptoms while taking aspirin). Of the patients with new cerebral ischemic symptoms, 57 (66%) were determined to be platelet nonresponsive to aspirin. The odds ratio for platelet nonresponsiveness to aspirin in patients who suffered a recurrent ischemic event while taking aspirin was 14.25 (95% confidence interval: 8.5-23.7; P < .5). Continued platelet aggregation despite aspirin treatment occurred in 20% of ambulatory patients treated for secondary stroke prophylaxis. The prevalence of nonresponsiveness to aspirin was statistically higher in those patients who suffered recurrent cerebral ischemia while taking aspirin (P < .5) compared with patients who remained without new ischemic symptoms.
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Affiliation(s)
- Francis M Gengo
- Dent Neurologic Institute, 3980 Sheridan Drive, Amherst, NY 14226, USA.
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64
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Campbell CY, Rivera JJ, Blumenthal RS. Residual risk in statin-treated patients: Future therapeutic options. Curr Cardiol Rep 2007; 9:499-505. [DOI: 10.1007/bf02938395] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Layton KF, Cloft HJ, Gray LA, Lewis DA, Kallmes DF. Balloon-assisted coiling of intracranial aneurysms: evaluation of local thrombus formation and symptomatic thromboembolic complications. AJNR Am J Neuroradiol 2007; 28:1172-5. [PMID: 17569982 PMCID: PMC8134166 DOI: 10.3174/ajnr.a0490] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Remodeling balloons are used to assist in endovascular coiling of aneurysms. We evaluated our experience with balloon-assisted coiling (BAC) in an attempt to determine whether this technique increased the rate of thrombus formation or symptomatic thromboembolic complications. MATERIALS AND METHODS In 3 years, we treated 221 patients with intracranial aneurysms. Statistical analysis was performed to assess whether BAC increased the rate of thrombus formation or symptomatic thromboembolic complications. Patient demographics, aneurysm size, location, neck width, antiplatelet therapy, and rupture status were evaluated. RESULTS We detected no statistically significant difference in rates of thrombus formation (14% versus 9% with and without BAC, respectively, P=0.35) or symptomatic thromboembolic events (7% versus 5% with and without BAC, respectively, P=0.76), though our power to detect small differences was limited. There was also no correlation with age, sex, rupture status, aneurysm size, or location. There was a significant increase in the rates of thrombus formation (6% versus 16%, P=0.02) and symptomatic thromboembolic complications (3% versus 10%, P=0.04) in aneurysms that were classified as narrow- or wide-necked, respectively. The use of clopidogrel was associated with a decrease in the rate of complications (P=0.01). CONCLUSION In this series, we detected no significant increase in the rates of either intraprocedural thrombus formation or symptomatic thromboembolic events in patients treated with BAC. Larger studies are required to confirm our observations. Wide-necked aneurysms were independently associated with increased rates of thrombus formation and symptomatic thromboembolic complications, whereas the use of clopidogrel was protective (P=0.01).
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Affiliation(s)
- K F Layton
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.
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Hodgson JM, Stone GW, Lincoff AM, Klein L, Walpole H, Bottner R, Weiner BH, Leon MB, Feldman T, Babb J, Dehmer GJ. Late stent thrombosis: considerations and practical advice for the use of drug-eluting stents: a report from the Society for Cardiovascular Angiography and Interventions Drug-eluting Stent Task Force. Catheter Cardiovasc Interv 2007; 69:327-33. [PMID: 17219373 DOI: 10.1002/ccd.21093] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- John McB Hodgson
- St. Joseph's Hospital and Medical Center, 350 West Thomas Road, Phoenix, AZ 85013, USA.
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Uchiyama S, Ozaki Y, Satoh K, Kondo K, Nishimaru K. Effect of Sarpogrelate, a 5-HT 2A Antagonist, on Platelet Aggregation in Patients with Ischemic Stroke: Clinical-Pharmacological Dose-Response Study. Cerebrovasc Dis 2007; 24:264-70. [PMID: 17622759 DOI: 10.1159/000105135] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Accepted: 05/22/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE It is widely accepted that antiplatelet therapy is effective for secondary prevention of atherosclerotic vascular diseases. We performed a double-blind, controlled clinical-pharmacological study to investigate the antiplatelet efficacy of sarpogrelate, a selective 5-hydroxytryptamine (5-HT(2A)) receptor antagonist, in patients with ischemic stroke, using a new assessment system employing combinations of 5-HT and epinephrine as agonists. METHODS Forty-seven patients with ischemic stroke were randomly assigned to three groups: 15 patients received 25 mg sarpogrelate (group L), 16 patients received 50 mg (group M), and 15 patients received 100 mg (group H) orally, three times daily for 7 days. The effect was expressed as maximum intensity of platelet aggregation on the last day of medication. Two combinations of agonists, 0.5 micromol/l 5-HT plus 3 micromol/l epinephrine, and 1 micromol/l 5-HT plus 3 micromol/l epinephrine, were used to induce platelet aggregation. RESULTS With both combinations of agonists, sarpogrelate treatment inhibited platelet aggregation dose-dependently (p < 0.025, Jonckheere test). In multiple-group comparison, the effect in group H was greater than that in group L or M (p < 0.025, Wilcoxon rank-sum test). CONCLUSION Sarpogrelate treatment inhibited platelet aggregation dose-dependently in patients with ischemic stroke, as judged by a new assessment system employing combinations of 5-HT and epinephrine as agonists.
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Affiliation(s)
- Shinichiro Uchiyama
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.
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71
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Abstract
Clopidogrel resistance has been used as one of the terms employed in the literature to describe different degrees of ex vivo low platelet inhibition after clopidogrel administration. In addition to the diverse nomenclature, the characterisation of clopidogrel resistance has also been problematic because different authors have given different definitions. The mechanisms responsible for this decreased platelet response are not yet clearly defined, some hypotheses have been put forward but not yet demonstrated. Although there have been no large prospective studies demonstrating that the degree of platelet inhibition is directly related to clinical outcomes, several recent studies and reports have shown an association between less platelet inhibition and more adverse events after percutaneous coronary interventions with clopidogrel therapy suggesting that clopidogrel resistance may be a marker for increased risk of recurrent cardiovascular events. Larger scale investigations are needed to support these findings.
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Affiliation(s)
- Ernesto Oqueli
- Epworth Hospital, Richmond, Melbourne, Victoria, Australia.
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72
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Uneventful Removal of an Epidural Catheter Guided by Impedance Aggregometry in a Patient With Recent Coronary Stenting and Treated With Clopidogrel and Acetylsalicylic Acid. Reg Anesth Pain Med 2007. [DOI: 10.1097/00115550-200707000-00014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kedia G, Lee MS. Stent thrombosis with drug-eluting stents: A re-examination of the evidence. Catheter Cardiovasc Interv 2007; 69:782-9. [PMID: 17394249 DOI: 10.1002/ccd.21061] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The excitement of drug-eluting stents and their promise for reduced restenosis rates have been tempered by recent reports of stent thrombosis. The mechanism of stent thrombosis is multifactorial but appears to be related to delayed endothelialization and healing, late stent malapposition, and antiplatelet resistance. The most important risk factor appears to be the discontinuation of dual antiplatelet therapy. The data from clinical trials suggest that drug-eluting stents are associated with increased incidence of death or myocardial infarction compared with bare metal stents at long-term follow-up, suggesting that the window of thrombotic risk with drug-eluting stents may extend far beyond that for bare metal stents. Measures to possibly decrease the incidence of stent thrombosis include improvements in antiplatelet regimens and newer generation of drug-eluting stents which have biodegradable polymers or are polymer-free. In addition, percutaneous coronary intervention with bare metal stents in patients may be helpful in those known to be intolerant or noncompliant to antiplatelet therapy, have planned procedures or surgeries, or have overwhelming risks which may require discontinuation of dual antiplatelet therapy.
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Affiliation(s)
- Gautam Kedia
- Cedars-Sinai Medical Center, Los Angeles, California, USA
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Affiliation(s)
- Jang-Young Kim
- Department of Cardiology, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Junghan Yoon
- Department of Cardiology, Wonju College of Medicine, Yonsei University, Wonju, Korea
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