A randomized trial comparing phosphorylcholine-coated stenting with balloon angioplasty as well as abciximab with placebo for restenosis reduction in small coronary arteries

Comparison of Clinical Outcomes Among Various Percutaneous Coronary Intervention Strategies for Small Coronary Artery Disease

It remains unclear which percutaneous coronary intervention (PCI) strategy is the most preferable in patients with small-vessel coronary artery disease (CAD). We sought to evaluate the clinical efficacy of various PCI strategies for patients with small-vessel CAD through a network meta-analysis of randomized controlled trials (RCTs). We searched multiple databases for RCTs investigating the efficacy of the following PCI strategies for small-vessel CAD (<3 mm in diameter): drug-coated balloons (DCB), early-generation paclitaxel-eluting stents and sirolimus-eluting stents (SES), newer-generation drug-eluting stents (DES), bare-metal stents (BMS), cutting balloon angioplasty, and balloon angioplasty (BA). The primary outcome was the trial-defined major adverse cardiovascular events (MACE), mostly defined as a composite of death, myocardial infarction, and revascularization. The secondary outcomes included each component of MACE and angiographic binary restenosis. We performed a sensitivity analysis for RCTs without BMS or first-generation DES. Our search identified 29 eligible RCTs, including 8,074 patients among the 8 PCI strategies. SES significantly reduced MACE compared with BA (hazard ratio 0.23, 95% confidence interval 0.10 to 0.54) with significant heterogeneity (I2 = 55.9%), and the rankogram analysis showed that SES was the best. There were no significant differences between DCB and newer-generation DES in any clinical outcomes, which was consistent in the sensitivity analysis. BMS and BA were ranked as the worst 2 for most clinical outcomes. In conclusion, SES was ranked as the best for reducing MACE. There were no significant differences in clinical outcomes between DCB and newer-generation DES. BMS and BA were regarded as the worst strategies for small-vessel CAD.

Integrin ß1 polymorphisms and bleeding risk after coronary artery stenting

Bleeding complications following percutaneous coronary intervention associate with increased mortality. However, the underlying molecular mechanisms are insufficiently understood. Platelet recruitment and activation at sites of vascular injury depends on the function of integrin adhesion receptors. Besides GPIIbIIIa as the most abundant integrin receptor, platelets relevantly express ß1 integrins. Experimental evidence from in vivo studies suggests a significant role of ß1 integrins in primary haemostasis. However, little is known about the clinical impact of genetic alterations of the β1 subunit, which might contribute to bleeding complications in patients. In this study, we performed DNA sequencing of patients suffering from bleeding complications after coronary artery stenting according to TIMI or BARC classification. We isolated DNA samples from 741 patients out of a cohort from 14,160 patients recruited in seven randomized clinical trials between June 2000 and May 2011. Subsequently, Sanger sequencing was performed covering the β1 integrin cytoplasmic activation domain (exon16) and its non-coding upstream region. Out of 764 patients suffering from bleeding complications, 741 DNA samples were successfully sequenced. Genotype variation was detected for SNP rs2153875 located within the non-coding upstream region with following allele frequency in study population: CC (7.3%), CA (35%) and AA (57.8%), which is similar to a general population cohort. Further, genotype variation in SNP rs2153875 do not associate with the frequency of TIMI or BARC classified access or non-access site bleedings. Genotype variations of the β1 integrin activation domain do not associate with bleeding risk after PCI.

Impact of bivalirudin on post-procedural epicardial blood flow, risk of stent thrombosis and mortality after percutaneous coronary intervention

AIMS

We aimed to assess the association of bivalirudin with post-procedural Thrombolysis In Myocardial Infarction (TIMI) flow, acute (≤24 hours) and 30-day stent thrombosis (ST), and one-year mortality.

METHODS AND RESULTS

The study included 11,623 patients undergoing percutaneous coronary intervention (PCI). The primary outcomes were post-procedural TIMI flow grade ≤2 and definite acute ST. In groups treated with bivalirudin (n=3,135), abciximab plus unfractionated heparin (UFH; n=3,539) and UFH alone (n=4,949), post-procedural TIMI was ≤2 in 5.2%, 3.2% and 3.2% of patients, respectively (adjusted odds ratio [OR]=1.96 [95% confidence interval] 1.47-2.56 for bivalirudin versus abciximab plus UFH and OR=1.56 [1.20-2.04] for bivalirudin versus UFH). Definite acute ST occurred in two patients (0.06%) treated with bivalirudin, two patients (0.06%) treated with abciximab plus UFH, and seven patients (0.14%) treated with UFH (p=0.47). Bivalirudin was not associated with increased risk of 30-day ST (hazard ratio [HR]=1.20 [0.59-2.43] versus abciximab plus UHF, and HR=0.93 [0.48-1.82] versus UFH) or one-year mortality (HR=0.95 [0.70-1.28] versus abciximab plus UHF, and HR=1.05 [0.78-1.41] versus UFH).

CONCLUSIONS

Bivalirudin was associated with higher risk of suboptimal post-PCI TIMI flow but not with increased risk of acute or 30-day definite ST or one-year mortality compared with abciximab plus UFH or UFH alone.

Is there an alternative to systemic anticoagulation, as related to interventional biomedical devices?

To reduce the toxic effects, related clinical problems and complications such as bleeding disorders associated with systemic anticoagulation, it has been hypothesized that by coating the surfaces of medical devices, such as stents, bypass grafts, extracorporeal circuits, guide wires and catheters, there will be a significant reduction in the requirement for systemic anticoagulation or, ideally, it will no longer be necessary. However, current coating processes, even covalent ones, still result in leaching followed by reduced functionality. Alternative anticoagulants and related antiplatelet agents have been used for improvement in terms of reduced restenosis, intimal hyperphasia and device failure. This review focuses on existing heparinization processes, their application in clinical devices and the updated list of alternatives to heparinization in order to obtain a broad overview, it then highlights, in particular, the future possibilities of using heparin and related moieties to tissue engineer scaffolds.

Platelet glycoprotein IIb/IIIa blockers during percutaneous coronary intervention and as the initial medical treatment of non-ST segment elevation acute coronary syndromes

BACKGROUND

During percutaneous coronary intervention (PCI), and in non-ST segment elevation acute coronary syndromes (NSTEACS), the risk of acute vessel occlusion by thrombosis is high. Glycoprotein IIb/IIIa blockers strongly inhibit platelet aggregation and may prevent mortality and myocardial infarction. This is an update of a Cochrane review first published in 2001, and previously updated in 2007 and 2010.

OBJECTIVES

To assess the efficacy and safety effects of glycoprotein IIb/IIIa blockers when administered during PCI, and as initial medical treatment in patients with NSTEACS.

SEARCH METHODS

We updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 12, 2012), MEDLINE (OVID, 1946 to January Week 1 2013) and EMBASE (OVID, 1947 to Week 1 2013) on 11 January 2013.

SELECTION CRITERIA

Randomised controlled trials comparing intravenous IIb/IIIa blockers with placebo or usual care.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, assessed trial quality and extracted data. We collected major bleeding as adverse effect information from the trials. We used odds ratios (OR) and 95% confidence intervals (CI) for effect measures.

MAIN RESULTS

Sixty trials involving 66,689 patients were included. During PCI (48 trials with 33,513 participants) glycoprotein IIb/IIIa blockers decreased all-cause mortality at 30 days (OR 0.79, 95% CI 0.64 to 0.97) but not at six months (OR 0.90, 95% CI 0.77 to 1.05). All-cause death or myocardial infarction was decreased both at 30 days (OR 0.66, 95% CI 0.60 to 0.72) and at six months (OR 0.75, 95% CI 0.64 to 0.86), although severe bleeding was increased (OR 1.39, 95% CI 1.21 to 1.61; absolute risk increase (ARI) 8.0 per 1000). The efficacy results were homogeneous for every endpoint according to the clinical condition of the patients, but were less marked for patients pre-treated with clopidogrel, especially in patients without acute coronary syndromes.As initial medical treatment of NSTEACS (12 trials with 33,176 participants), IIb/IIIa blockers did not decrease mortality at 30 days (OR 0.90, 95% CI 0.79 to 1.02) or at six months (OR 1.00, 95% CI 0.87 to 1.15), but slightly decreased death or myocardial infarction at 30 days (OR 0.91, 95% CI 0.85 to 0.98) and at six months (OR 0.88, 95% CI 0.81 to 0.96), although severe bleeding was increased (OR 1.29, 95% CI 1.14 to 1.45; ARI 1.4 per 1000).

AUTHORS' CONCLUSIONS

When administered during PCI, intravenous glycoprotein IIb/IIIa blockers reduce the risk of all-cause death at 30 days but not at six months, and reduce the risk of death or myocardial infarction at 30 days and at six months, at a price of an increase in the risk of severe bleeding. The efficacy effects are homogeneous but are less marked in patients pre-treated with clopidogrel where they seem to be effective only in patients with acute coronary syndromes. When administered as initial medical treatment in patients with NSTEACS, these agents do not reduce mortality although they slightly reduce the risk of death or myocardial infarction.

Incidence and prognostic value of bleeding after percutaneous coronary intervention in patients older than 75 years of age

OBJECTIVES

We aimed to assess the impact of bleeding after percutaneous coronary intervention (PCI) on the outcome of patients >75 years of age.

BACKGROUND

Limited information exists on the impact of post-PCI bleeding on the outcome in elderly patients.

METHODS

This study included 3,255 patients >75 years of age. Bleeding events were assessed using the Bleeding Academic Research Consortium (BARC) criteria. The primary outcome was 1-year mortality.

RESULTS

Within 30 days after PCI, bleeding occurred in 501 patients (15.4%). Bleeding according to BARC was: class 1 (170 patients; 33.9%), class 2 (81 patients; 16.2%), class 3a (177 patients; 35.3%), class 3b (65 patients; 13.0%), class 3c (four patients; 0.8%), and class 4 (four patients; 0.8%). There were 201 deaths within the first year after PCI: 61 deaths (12.3%) among bleeders and 140 deaths (5.1%) among nonbleeders (adjusted hazard ratio = 2.03, 95% confidence interval [CI] 1.42-2.91, P < 0.001). Bleeding improved the discriminatory power of multivariable model for mortality prediction (P = 0.001). Female sex (adjusted odds ratio [OR] = 1.49 [1.17-1.88], P = 0.001) and reduced renal function (adjusted OR = 1.30 [1.04-1.63], P = 0.019 for each 30 ml/min decrease in the creatinine clearance) were independent associates of increased bleeding risk. Bivalirudin reduced the bleeding risk by 24% compared with unfractionated heparin and 33% compared with abciximab plus unfractionated heparin.

CONCLUSIONS

Post-PCI bleeding is an important prognostic factor in patients >75 years of age. The risk for bleeding in this age category is increased in women and patients with impaired renal function. Bleeding risk is reduced by bivalirudin.

Platelet glycoprotein IIb/IIIa blockers during percutaneous coronary intervention and as the initial medical treatment of non-ST segment elevation acute coronary syndromes

BACKGROUND

During percutaneous coronary intervention (PCI), and in non-ST segment elevation acute coronary syndromes (NSTEACS), the risk of acute vessel occlusion by thrombosis is high. Glycoprotein IIb/IIIa blockers strongly inhibit platelet aggregation and may prevent mortality and myocardial infarction. This is an update of a Cochrane review first published in 2001, and previously updated in 2007 and 2010.

OBJECTIVES

To assess the efficacy and safety effects of glycoprotein IIb/IIIa blockers when administered during PCI, and as initial medical treatment in patients with NSTEACS.

SEARCH METHODS

We updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 12, 2012), MEDLINE (OVID, 1946 to January Week 1 2013) and EMBASE (OVID, 1947 to Week 1 2013) on 11 January 2013.

SELECTION CRITERIA

Randomised controlled trials comparing intravenous IIb/IIIa blockers with placebo or usual care.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, assessed trial quality and extracted data. We collected major bleeding as adverse effect information from the trials. We used odds ratios (OR) and 95% confidence intervals (CI) for effect measures.

MAIN RESULTS

Sixty trials involving 66,689 patients were included. During PCI (48 trials with 33,513 participants) glycoprotein IIb/IIIa blockers decreased all-cause mortality at 30 days (OR 0.79, 95% CI 0.64 to 0.97) but not at six months (OR 0.90, 95% CI 0.77 to 1.05). All-cause death or myocardial infarction was decreased both at 30 days (OR 0.66, 95% CI 0.60 to 0.72) and at six months (OR 0.75, 95% CI 0.64 to 0.86), although severe bleeding was increased (OR 1.39, 95% CI 1.21 to 1.61; absolute risk increase (ARI) 8.0 per 1000). The efficacy results were homogeneous for every endpoint according to the clinical condition of the patients, but were less marked for patients pre-treated with clopidogrel, especially in patients without acute coronary syndromes.As initial medical treatment of NSTEACS (12 trials with 33,176 participants), IIb/IIIa blockers did not decrease mortality at 30 days (OR 0.90, 95% CI 0.79 to 1.02) or at six months (OR 1.00, 95% CI 0.87 to 1.15), but slightly decreased death or myocardial infarction at 30 days (OR 0.91, 95% CI 0.85 to 0.98) and at six months (OR 0.88, 95% CI 0.81 to 0.96), although severe bleeding was increased (OR 1.29, 95% CI 1.14 to 1.45; ARI 1.4 per 1000).

AUTHORS' CONCLUSIONS

When administered during PCI, intravenous glycoprotein IIb/IIIa blockers reduce the risk of all-cause death at 30 days but not at six months, and reduce the risk of death or myocardial infarction at 30 days and at six months, at a price of an increase in the risk of severe bleeding. The efficacy effects are homogeneous but are less marked in patients pre-treated with clopidogrel where they seem to be effective only in patients with acute coronary syndromes. When administered as initial medical treatment in patients with NSTEACS, these agents do not reduce mortality although they slightly reduce the risk of death or myocardial infarction.

Incidence and impact on prognosis of bleeding during percutaneous coronary interventions in patients with chronic kidney disease

BACKGROUND

Limited information exists on the prognostic impact of bleeding after percutaneous coronary intervention (PCI) in patients with chronic kidney disease (CKD). We investigated the impact of bleeding after PCI on the outcome of these patients.

METHODS

The study included 2,934 patients with estimated creatinine clearance <60 ml/min. Bleeding events within 30 days after PCI were assessed using the Bleeding Academic Research Consortium (BARC) criteria. The primary outcome was 1-year mortality.

RESULTS

Bleeding events occurred in 485 patients (16.5 %). BARC classes were: class 1 (n = 155), class 2 (n = 73), class 3a (n = 182), class 3b (n = 68), class 3c (n = 6) and class 4 (n = 1). There were 212 deaths over the first year after PCI: 60 deaths in patients who bled and 152 deaths in patients who did not bleed (Kaplan-Meier [KM] estimates, 12.5 and 6.3 %; odds ratio [OR] = 2.11, 95 % confidence interval [CI] 1.57-2.83, P < 0.001). Nonfatal myocardial infarction occurred in 71 patients who bled and in 141 patients who did not bleed (KM estimates, 14.8 and 5.8 %; OR = 2.70 [2.05-3.55], P < 0.001). After adjustment, bleeding was independently associated with increased risk of 1-year mortality (adjusted hazard ratio [HR] = 1.90 [1.33-2.72], P < 0.001) and myocardial infarction (adjusted HR = 2.74 [1.99-3.78], P < 0.001). Bleeding improved the discriminatory power of the multivariable model for prediction of mortality (absolute and relative integrated discrimination improvement [IDI], 0.011 and 15.4 %; P = 0.004) or myocardial infarction (absolute and relative IDI, 0.017 and 70.8 %; P < 0.001).

CONCLUSIONS

Peri-PCI bleeding in patients with CKD is independently associated with the increased risk of 1-year mortality and nonfatal myocardial infarction.

Bleeding after percutaneous coronary intervention in women and men matched for age, body mass index, and type of antithrombotic therapy

BACKGROUND

Factors underlying the increased risk of bleeding after percutaneous coronary intervention (PCI) in women compared with men remain incompletely understood.

METHODS

The study included 3,351 women and 3,351 men matched for age, body mass index, and type of antithrombotic therapy. Bleeding within the 30 days after PCI was defined using the Bleeding Academic Research Consortium criteria. The main outcome was 1-year mortality.

RESULTS

Bleeding occurred in 518 women and 354 men (15.5% vs 10.6%, odds ratio [OR] 1.55, 95% CI 1.34-1.79, P < .001). Severe (Bleeding Academic Research Consortium class ≥2) bleeds (9.4% vs 6.5%, P < .001) and access site bleeds (10.1% vs 5.4%, P < .001) were more common in women. After adjustment, female sex remained an independent correlate of any bleeding (adjusted OR 1.61 [1.35-1.92], P < .001) and access site (adjusted OR 2.00 [1.59-2.50], P < .001) but not of nonaccess site (adjusted OR 1.18 [0.91-1.54], P = .205) bleeding. There were 248 deaths: 32 deaths among men with bleeding versus 107 deaths among men with no bleeding (9.1% vs 3.6%, OR 2.68 [1.78-4.05], P < .001) and 40 deaths among women with bleeding vs 69 deaths among women with no bleeding (7.8% vs 2.5%, OR 3.35 [2.24-5.01], P < .001). No difference in mortality was observed among women and men who bled (P = .487). Bleeding was independently associated 1-year mortality (adjusted hazard ratio 2.18 [1.68-2.84], P < .001) with no bleeding-by-sex interaction (P = .439).

CONCLUSIONS

Despite matching for age, body mass index, and type of antithrombotic therapy, bleeding risk after PCI remained significantly higher in women than in men. Bleeding was associated with increased risk of 1-year mortality with no bleeding-by-sex interaction.

Stenting in Acute STEMI Intervention

Stenting in acute myocardial infarction (AMI) has the benefits of achieving acute optimal angiographic results and correcting residual dissection to decrease the incidence of restenosis and reocclusion. Studies have shown that percutaneous transluminal coronary angioplasty for primary treatment after AMI is superior to thrombolytic therapy regarding the restoration of normal coronary blood flow. Coronary stenting improves initial success rates, decreases the incidence of abrupt closure, and is associated with a reduced rate of restenosis. In the presence of thrombus-containing lesions, coronary stenting constitutes an effective therapeutic strategy, either after failure of initial angioplasty or electively as the primary procedure.

Antiplatelet drugs: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

The article describes the mechanisms of action, pharmacokinetics, and pharmacodynamics of aspirin, dipyridamole, cilostazol, the thienopyridines, and the glycoprotein IIb/IIIa antagonists. The relationships among dose, efficacy, and safety are discussed along with a mechanistic overview of results of randomized clinical trials. The article does not provide specific management recommendations but highlights important practical aspects of antiplatelet therapy, including optimal dosing, the variable balance between benefits and risks when antiplatelet therapies are used alone or in combination with other antiplatelet drugs in different clinical settings, and the implications of persistently high platelet reactivity despite such treatment.

Validation of the Bleeding Academic Research Consortium Definition of Bleeding in Patients With Coronary Artery Disease Undergoing Percutaneous Coronary Intervention

Background—

The Bleeding Academic Research Consortium (BARC) has recently proposed a unified definition of bleeding in patients receiving antithrombotic therapy. We investigated the relationship between bleeding events as defined by BARC and 1-year mortality in patients undergoing percutaneous coronary intervention (PCI) and assessed whether the BARC bleeding definition is superior to existing bleeding definitions in regard to mortality prediction in patients after PCI procedures.

Methods and Results—

This study represents a patient-level pooled analysis of 12 459 patients recruited in 6 randomized trials of patients undergoing PCI. Bleeding events were assessed with the use of BARC, Thrombolysis in Myocardial Infarction (TIMI), and Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE-2) trial criteria. The primary outcome was 1-year mortality. Bleeding occurred in 1233 patients (9.9%) according to BARC (679 patients or 5.4% with BARC class ≥2 bleeding), in 374 patients (3.0%) according to TIMI, and in 491 patients (3.9%) according to REPLACE-2 criteria. There were 340 deaths (2.7%) over the first year after PCI. BARC class ≥2 bleeding was associated with a significant increase in 1-year mortality (adjusted hazard ratio 2.72; 95% confidence interval, 2.03–3.63). The predictivity of a multivariable model for 1-year mortality was significantly improved after inclusion of bleeding defined according to BARC to an extent comparable to that provided by TIMI and REPLACE-2 criteria.

Conclusions—

The present study demonstrated a close association between bleeding events defined according to BARC and 1-year mortality after PCI.

P2Y12 antagonists in acute coronary syndrome: in whom should they be started, and when?

Acute coronary syndromes reflect a spectrum of disease related, most commonly, to the sudden reduction in blood flow to a portion of myocardium. The underlying pathogenesis of the reduction in coronary flow is related to the sudden rupture of an atherosclerotic plaque, with subsequent thrombus formation leading to either vascular occlusion or microembolization. Clinicians combat this process with antithrombotic therapy, which typically includes both anticoagulant and antiplatelet therapy, and mechanical therapies, such as percutaneous coronary interventions, nearly always using stents. This review focuses on P2Y12 antagonists as one component of our armamentarium of antiplatelet therapies, specifically on data addressing in whom, when, which agent, and in what dose such agents should be administered.

Platelet glycoprotein IIb/IIIa blockers during percutaneous coronary intervention and as the initial medical treatment of non-ST segment elevation acute coronary syndromes

BACKGROUND

During percutaneous coronary intervention (PCI), and in non-ST segment elevation acute coronary syndromes (NSTEACS), the risk of acute vessel occlusion by thrombosis is high. IIb/IIIa blockers strongly inhibit platelet aggregation and may prevent mortality and myocardial infarction (MI). This is an update of a Cochrane review first published in 2001, and previously updated in 2007.

OBJECTIVES

To assess the effects and safety of IIb/IIIa blockers when administered during PCI, and as initial medical treatment in patients with NSTEACS.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 3, 2009), MEDLINE (1966 to October 2009), and EMBASE (1980 to October 2009).

SELECTION CRITERIA

Randomised controlled trials comparing intravenous IIb/IIIa blockers with placebo or usual care.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, assessed trial quality and extracted data. We collected major bleeding as adverse effect information from the trials. Odds ratios (OR) and 95% confidence intervals (CI) were used for effect measures.

MAIN RESULTS

Forty-eight trials involving 62,417 patients were included. During PCI, IIb/IIIa blockers decreased mortality at 30 days (OR 0.76, 95% CI 0.62 to 0.95) and at six months (OR 0.84, 95% CI 0.71 to 1.00). Death or MI was decreased both at 30 days (OR 0.65, 95% CI 0.60 to 0.72), and at 6 months (OR 0.70, 95% CI 0.61 to 0.81), although severe bleeding was increased (OR 1.38, 95% CI 1.20 to 1.59; absolute risk increase (ARI) 8.0 per 1000). The efficacy results were homogeneous for every endpoint according to the clinical condition of the patients, but were less marked for patients pre-treated with clopidogrel, especially in patients without ACS.As initial medical treatment of NSTEACS, IIb/IIIa blockers did not decrease mortality at 30 days (OR 0.91, 95% CI 0.80 to 1.03) or at six months (OR 1.00, 95% CI 0.87 to 1.15), but slightly decreased death or MI at 30 days (OR 0.92, 95% CI 0.86 to 0.99) and at six months (OR 0.88, 95% CI 0.81 to 0.96), although severe bleeding was increased (OR 1.27, 95% CI 1.12 to 1.43; ARI 1.4 per 1000).

AUTHORS' CONCLUSIONS

When administered during PCI, intravenous IIb/IIIa blockers reduce the risk of death and of death or MI at 30 days and at six months, at a price of an increase in the risk of severe bleeding. The efficacy effects are homogeneous but are less marked in patients pre-treated with clopidogrel where they seem to be effective only in patients with ACS. When administered as initial medical treatment in patients with NSTEACS, these agents do not reduce mortality although they slightly reduce the risk of death or MI.

ISAR--a story of trials with impact on practice

Since its inception approximately 15 years ago, the ISAResearch group has completed more than 40 randomized controlled trials (RCT) in the field of interventional cardiology, including more than 40,000 patients. Three main principles have characterized the ISAR trials: first, simplicity: 1 question 1 answer; second, a focus on issues that are relevant for practice at the given moment and third, a strong spirit of performing industry-independent studies. The seamless integration of clinical trials into everyday practice and a stringent study discipline allowed inclusion of more than 90% of the patients in 1 of the device or drug trials, the prerequisite for fast recruitment and evaluation of an all-comers population. Moreover, the early setup and maintenance of a comprehensive database with routine follow-up of all patients undergoing percutaneous coronary intervention made it possible to build up a large registry to answer questions beyond clinical trials. Finally, the close collaboration with basic research working groups within the department has triggered new innovations and facilitated translational research from bench to bedside.

Triple antiplatelet therapy for preventing vascular events: a systematic review and meta-analysis

BACKGROUND

Dual antiplatelet therapy is usually superior to mono therapy in preventing recurrent vascular events (VEs). This systematic review assesses the safety and efficacy of triple antiplatelet therapy in comparison with dual therapy in reducing recurrent vascular events.

METHODS

Completed randomized controlled trials investigating the effect of triple versus dual antiplatelet therapy in patients with ischaemic heart disease (IHD), cerebrovascular disease or peripheral vascular disease were identified using electronic bibliographic searches. Data were extracted on composite VEs, myocardial infarction (MI), stroke, death and bleeding and analysed with Cochrane Review Manager software. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using random effects models.

RESULTS

Twenty-five completed randomized trials (17,383 patients with IHD) were included which involving the use of intravenous (iv) GP IIb/IIIa inhibitors (abciximab, eptifibatide, tirofiban), aspirin, clopidogrel and/or cilostazol. In comparison with aspirin-based therapy, triple therapy using an intravenous GP IIb/IIIa inhibitor significantly reduced composite VEs and MI in patients with non-ST elevation acute coronary syndromes (NSTE-ACS) (VE: OR 0.69, 95% CI 0.55-0.86; MI: OR 0.70, 95% CI 0.56-0.88) and ST elevation myocardial infarction (STEMI) (VE: OR 0.39, 95% CI 0.30-0.51; MI: OR 0.26, 95% CI 0.17-0.38). A significant reduction in death was also noted in STEMI patients treated with GP IIb/IIIa based triple therapy (OR 0.69, 95% CI 0.49-0.99). Increased minor bleeding was noted in STEMI and elective percutaneous coronary intervention (PCI) patients treated with GP IIb/IIIa based triple therapy. Stroke events were too infrequent for us to be able to identify meaningful trends and no data were available for patients recruited into trials on the basis of stroke or peripheral vascular disease.

CONCLUSIONS

Triple antiplatelet therapy based on iv GPIIb/IIIa inhibitors was more effective than aspirin-based dual therapy in reducing VEs in patients with acute coronary syndromes (STEMI and NSTEMI). Minor bleeding was increased among STEMI and elective PCI patients treated with a GP IIb/IIIa based triple therapy. In patients undergoing elective PCI, triple therapy had no beneficial effect and was associated with an 80% increase in transfusions and an eightfold increase in thrombocytopenia. Insufficient data exist for patients with prior ischaemic stroke and peripheral vascular disease and further research is needed in these groups of patients.

Treatment of small coronary arteries with a paclitaxel-coated balloon catheter

BACKGROUND

Treatment of lesions in small coronary arteries by percutaneous transluminal coronary intervention is limited by a high recurrence rate. We assessed the use of a paclitaxel-coated balloon in this indication.

METHODS

One-hundred eighteen patients with stenoses in small coronary vessels were treated by a paclitaxel-coated balloon (3 microg/mm(2)). The main inclusion criteria encompassed diameter stenosis of > or =70% and < or =22 mm in length with a vessel diameter of 2.25-2.8 mm. Follow-up angiography was performed at scheduled 6-month post-intervention or whenever driven by clinical or electrocardiographic signs of ischemia. The primary endpoint was angiographic in-segment late lumen loss.

RESULTS

Eighty-two of 118 patients (70%) with a vessel diameter of 2.35 +/- 0.19 mm were treated with the drug-coated balloon only, while 32 patients required additional stent deployment. The mean in-segment late lumen loss was 0.28 +/- 0.53 mm. In patients treated with the drug-coated balloon only, the in-segment late lumen loss was 0.16 +/- 0.38 mm. At 12 months, the rate of major adverse cardiac events was 15% which was primarily due to the need for target lesion revascularization in 14 patients (12%). In those with additional bare metal stent implantation geographical mismatch between coated-balloon dilatation and stent implantation was significantly associated with the occurrence of restenosis.

CONCLUSION

Treatment of coronary stenosis in small coronary vessels with the paclitaxel-coated balloon was well tolerated. It may offer an alternative to the implantation of a drug-eluting stent (ClinicalTrials.gov Identifier: NCT00404144).

Abciximab in patients with acute ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention after clopidogrel loading: a randomized double-blind trial

BACKGROUND

The glycoprotein IIb/IIIa receptor inhibitor abciximab has improved the efficacy of primary percutaneous coronary interventions in patients with acute myocardial infarction. However, it is not known whether abciximab remains beneficial after adequate clopidogrel loading in patients with acute ST-segment-elevation myocardial infarction.

METHODS AND RESULTS

A total of 800 patients with acute ST-segment-elevation myocardial infarction within 24 hours from symptom onset, all treated with 600 mg clopidogrel, were randomly assigned in a double-blind fashion to receive either abciximab (n=401) or placebo (n=399) in the intensive care unit before being sent to the catheterization laboratory. The primary end point, infarct size measured by single-photon emission computed tomography with technetium-99m sestamibi before hospital discharge, was 15.7+/-17.2% (mean+/-SD) of the left ventricle in the abciximab group and 16.6+/-18.6% of the left ventricle in the placebo group (P=0.47). At 30 days, the composite of death, recurrent myocardial infarction, stroke, or urgent revascularization of the infarct-related artery was observed in 20 patients in the abciximab group (5.0%) and 15 patients in the placebo group (3.8%) (relative risk, 1.3; 95% CI, 0.7 to 2.6; P=0.40). Major bleeding complications were observed in 7 patients in each group (1.8%).

CONCLUSIONS

Upstream administration of abciximab is not associated with a reduction in infarct size in patients presenting with acute myocardial infarction within 24 hours of symptom onset and receiving 600 mg clopidogrel.

Cytochrome P450 2C19 loss-of-function polymorphism and stent thrombosis following percutaneous coronary intervention

AIMS

Several studies have demonstrated that the mutant *2 allele of the CYP2C19 681G>A loss-of-function polymorphism is associated with diminished metabolization of clopidogrel into its active thiol metabolite and an attenuated platelet response to clopidogrel treatment. It is not known whether patients carrying the mutant CYP2C19*2 allele have a higher risk of stent thrombosis (ST) compared with homozygous CYP2C19*1 wild-type allele carriers following percutaneous coronary intervention (PCI). The aim of this study was to assess the impact of the CYP2C19 681G>A loss-of-function polymorphism on ST following PCI performed after pre-treatment with clopidogrel.

METHODS AND RESULTS

The study population included 2485 consecutive patients undergoing coronary stent placement after pre-treatment with 600 mg of clopidogrel. Genotypes were determined with a TaqMan assay. The primary endpoint of the study was the incidence of definite ST within 30 days following PCI. Of the patients studied, 1805 (73%) were CYP2C19 wild-type homozygotes (*1/*1) and 680 (27%) carried at least one *2 allele (*1/*2 or *2/*2). The cumulative 30-day incidence of ST was significantly higher in CYP2C19*2 allele carriers (*1/*2 or *2/*2) vs. CYP2C19 wild-type homozygotes (*1/*1) [10 patients (1.5%) in CYP2C19*2 allele carriers vs. 7 (0.4%) in CYP2C19 wild-type homozygotes (*1/*1), HR 3.81, 95% CI 1.45-10.02, P = 0.007; P = 0.006 after adjustment for confounding variables]. The risk of ST was highest (2.1%) in patients with the CYP2C19 *2/*2 genotype (P = 0.002).

CONCLUSION

CYP2C19*2 carrier status is significantly associated with an increased risk of ST following coronary stent placement.

Antiplatelet drugs: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)

This article about currently available antiplatelet drugs is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). It describes the mechanism of action, pharmacokinetics, and pharmacodynamics of aspirin, reversible cyclooxygenase inhibitors, thienopyridines, and integrin alphaIIbbeta3 receptor antagonists. The relationships among dose, efficacy, and safety are thoroughly discussed, with a mechanistic overview of randomized clinical trials. The article does not provide specific management recommendations; however, it does highlight important practical aspects related to antiplatelet therapy, including the optimal dose of aspirin, the variable balance of benefits and hazards in different clinical settings, and the issue of interindividual variability in response to antiplatelet drugs.

Effect of abciximab on clinical and angiographic restenosis in patients with non-ST-segment elevation acute coronary syndromes

The ISAR-REACT 2 trial was designed to assess the effect of abciximab in patients with acute coronary syndromes undergoing percutaneous coronary intervention after a 600-mg loading dose of clopidogrel. The aim of the present study was to investigate the impact of abciximab on clinical and angiographic restenosis after coronary stenting in patients with acute coronary syndromes. The angiographic substudy included 1,544 patients from the ISAR-REACT 2 trial randomly assigned to abciximab (771 patients) or placebo (773 patients). All patients were scheduled for routine angiographic follow-up at 6 to 8 months after intervention. The primary end point was incidence of angiographic in-segment binary restenosis. The secondary end point was 1-year incidence of target-lesion revascularization. Binary restenosis was observed in 21.9% of patients in the abciximab group and 24.5% of patients in the placebo group (p=0.29). Percentages of in-stent (29+/-22% vs 33+/-24%; p=0.02) and in-segment (35+/-20% vs 38+/-21%; p=0.04) diameter stenoses were significantly lower in the abciximab group than the placebo group. There was a strong trend toward lower 1-year incidence of target-lesion revascularization in patients treated with abciximab than in patients treated with placebo (13.6% vs 16.8%; p=0.08). In conclusion, in patients with non-ST-segment elevation acute coronary syndromes undergoing early percutaneous coronary intervention with stenting after a 600-mg loading dose of clopidogrel, abciximab therapy may have a slight positive impact on the prevention of restenosis.

Review of the 2005 American College of Cardiology, American Heart Association, and Society for Cardiovascular Interventions guidelines for adjunctive pharmacologic therapy during percutaneous coronary interventions: practical implications, new clinical data, and recommended guideline revisions

In 2006, the American College of Cardiology, American Heart Association, and Society for Cardiovascular Interventions published the 2005 update of the evidence-based guidelines for the treatment of patients undergoing percutaneous coronary intervention (PCI). Together with procedural recommendations, these guidelines for percutaneous coronary intervention provide clinicians with guidance in the appropriate use of adjunctive pharmacologic therapy in patients undergoing PCI. However, there remain substantial variations in practice among clinicians and within and across institutions. Furthermore, the guidelines (being a static document) cannot incorporate additional evidence that has accumulated since their publication. Several landmark trials, notably Intracoronary Stenting and Antithrombotic Regimen-Rapid Early Action for Coronary Treatment (ISAR-REACT 2) and Acute Catheterization and Urgent Intervention Triage strategY (ACUITY), have added substantially to the knowledge base about pharmacologic therapy since publication of the guidelines. This article is therefore intended to discuss implementation into clinical practice of the revised guidelines for antiplatelet and antithrombotic pharmacologic therapy during PCI and to evaluate recent clinical evidence and make recommendations for revision of the guidelines incorporating the outcomes of recently completed trials.

Abciximab offers greater benefits to insulin-dependent diabetic patients undergoing coronary stent implantation

INTRODUCTION AND OBJECTIVES

Abciximab use does not exceed 25% in most of the studies on diabetic patients undergoing stent implantation. The aim of this study was to evaluate whether abciximab could be more beneficial in different subgroups such as insulin-dependent (ID) patients and whether its use could provide additional benefits to those afforded by drug-eluting stents in these patients.

PATIENTS AND METHODS

A total of 373 consecutive diabetics [223 non-insulin-dependent (NID) and 150 ID patients] who had undergone stent implantation were examined with a follow-up of 25.6+/-16.2 months. Abciximab was used in 21.7%.

RESULTS

The abciximab-treated group had a lower rate of revascularization (26.8% vs. 15.8%. P=.02). The results by subgroups were as follows: NID nonabciximab, 23.5%; NID abciximab, 19% (P=NS); ID nonabciximab, 32.7%; ID abciximab, 12.2% (P=.05). In multivariate analysis, the restenosis predictors were insulin dependency (OR, 2.7), abciximab use (OR, 0.18), stent diameter (OR, 0.18).

CONCLUSIONS

Abciximab use in diabetics with stent implantation has a favorable effect by reducing the need for new revascularization. This benefit is more evident in ID patients; the negative prognosis effect of being insulin-dependent is eliminated, and the percentage of events in this population over a long follow-up period is equal to those in NID patients.

Pharmacological antithrombotic adjuncts to percutaneous coronary intervention

Stent thrombosis is the major cause of early adverse events during percutaneous coronary intervention. Its incidence has fallen considerably in recent years, principally due to the introduction of effective antithrombotic therapies. The selection of an appropriate antithrombotic regimen is critical in achieving a balance between reducing ischaemic events and minimising bleeding complications in patients undergoing percutaneous coronary intervention. In this article, evidence for the role of antiplatelet and anticoagulant therapies is discussed, including the thienopyridines, glycoprotein IIb/IIIa receptor antagonists, direct thrombin inhibitors and pentasaccharides.

Oral antiplatelet therapy for percutaneous coronary revascularization

Great strides in interventional pharmacotherapy have been made over the past few decades, virtually all focused on optimizing peri-PCI antithrombotic therapy in order to reduce thrombotic complications. Our understanding of the role of platelets and of antiplatelet therapies in this process continues to evolve. Today, dual or even triple antiplatelet therapy has become standard of care at the time of PCI followed by dual therapy long-term in the majority of patients. However, currently available oral regimens are hampered by limitations including the need to initiate treatment at least a few hours before the procedure to achieve maximum benefit and the safety issues surrounding irreversible platelet inhibition in the uncommon, but not rare situations when a patient requires surgical revascularization. These limitations have led to the suboptimal "real-world" utilization of these proven agents and have fostered the development of a wide variety of alternative platelet inhibitors with theoretical, but still unproven clinical benefits. There are ample clinical data that strongly support the use of aspirin and clopidogrel in virtually all patients undergoing a PCI today. This review will highlight these data as well as emphasize the gaps in our understanding. (c) 2007 Wiley-Liss, Inc.

Newer Pharmacotherapy in Patients Undergoing Percutaneous Coronary Interventions: A Guide for Pharmacists and Other Health Care Professionals

Significant advances in pharmacotherapy for patients undergoing percutaneous coronary intervention (PCI) have occurred during the past decade, including the introduction and approval of new antithrombin and antiplatelet therapies, as well as modifications in dosing, administration, and/or duration of older pharmacotherapy regimens. Also, off-label (i.e., not approved by the United States Food and Drug Administration) use of certain agents has become common. Given the novel nature of these agents and the nuances of therapy, the pharmacist and other health care professionals should play an integral role in collaboration with interventional cardiologists in development of hospital protocols, determination of appropriate agent selection, assessment of patient renal function and hematologic status, dosing, and monitoring for adverse effects. In this guide, the newer antiplatelet and antithrombin drugs that may be used during PCI are reviewed, and recommendations regarding the proper administration of these agents are provided.

Effects of abciximab on key pattern of human coronary restenosis in vitro: impact of the SI/MPL-ratio

Background

The significant reduction of angiographic restenosis rates in the ISAR-SWEET study (intracoronary stenting and antithrombotic regimen: is abciximab a superior way to eliminate elevated thrombotic risk in diabetes) raises the question of whether abciximab acts on clopidogrel-independent mechanisms in suppressing neointimal hyperplasia. The current study investigates the direct effect of abciximab on ICAM-1 expression, migration and proliferation.

Methods

ICAM-1: Part I of the study investigates in cytoflow studies the effect of abciximab (0.0002, 0.002, 0.02, 0.2, 2.0, and 20.0 μg/ml) on TNF-α induced expression of intercellular adhesion molecule 1 (ICAM-1). Migration: Part II of the study explored the effect of abciximab (0.0002, 0.002, 0.02, 0.2, 2.0, and 20.0 μg/ml) on migration of HCMSMC over a period of 24 h. Proliferation: Part III of the study investigated the effect of abciximab (0.0002, 0.002, 0.02, 0.2, 2.0, and 20.0 μg/ml) on proliferation of HUVEC, HCAEC, and HCMSMC after an incubation period of 5 days.

Results

ICAM-1: In human venous endothelial cells (HUVEC), human coronary endothelial cells (HCAEC) and human coronary medial smooth muscle cells (HCMSMC) no inhibitory or stimulatory effect on expression of ICAM-1 was detected. Migration: After incubation of HCMSMC with abciximab in concentrations of 0.0002 – 2 μg/ml a stimulatory effect on cell migration was detected, statistical significance was achieved after incubation with 0.002 μg/ml (p < 0.05), 0.002 μg/ml (p < 0.001), and 0.2 μg/ml (p < 0.05). Proliferation: Small but statistically significant antiproliferative effects of abciximab were detected after incubation of HUVEC (0.02 and 2.0 μg/ml; p = 0.01 and p < 0.01), HCAEC (2.0 and 20.0 μg/ml; p < 0.05 and p < 0,01), and HCMSMC (2.0 and 20.0 μg/ml; p < 0.05 and p < 0.05). The significant inhibition (SI) of cell proliferation found in HCAEC and HCMSMC was achieved with drug concentrations more than 10 times beyond the maximal plasma level (MPL), resulting in a SI/MPL-ratio > 1.

Conclusion

Thus, the anti-restenotic effects of systemically administered abciximab reported in the ISAR-SWEET-study were not caused by a direct inhibitory effect on ICAM-1 expression, migration or proliferation.

Randomized trial of paclitaxel- and sirolimus-eluting stents in small coronary vessels

AIMS

Sirolimus- and paclitaxel-eluting stents effectively reduce restenosis in small coronary vessels. The relative efficacy of these drug-eluting stents in this high-risk subset is not known.

METHODS AND RESULTS

A total of 360 patients undergoing percutaneous coronary intervention for de novo lesions in native coronary vessels with a diameter of <2.80 mm received randomly paclitaxel-eluting stents (n=180) or sirolimus-eluting stents (n=180). The primary endpoint was in-stent late luminal loss. Secondary endpoints were angiographic restenosis and need of target lesion revascularization. The study intended to show that the paclitaxel-eluting stent is not inferior to the sirolimus-eluting stent with respect to the primary endpoint. The non-inferiority margin was set at 0.16 mm. Follow-up angiography was performed in 87% of the patients. In-stent late luminal loss in the paclitaxel-eluting stent group was 0.32 mm (upper 95% boundary, 0.42 mm), which was greater than that in the sirolimus-eluting stent group, failing to show the non-inferiority of the paclitaxel-eluting stent to the sirolimus-eluting stent (P>0.99). Angiographic restenosis was found in 19.0% of the lesions in the paclitaxel-eluting stent group and 11.4% of the lesions in the sirolimus-eluting stent group (P=0.047). Target lesion revascularization was performed in 14.7% of the lesions treated with paclitaxel-eluting stents and 6.6% of the lesions treated with sirolimus-eluting stents (P=0.008).

CONCLUSION

The paclitaxel-eluting stent is associated with a greater late luminal loss and is less effective in reducing restenosis in small coronary vessels than the sirolimus-eluting stent.

Platelet glycoprotein IIb/IIIa blockers for percutaneous coronary revascularization, and unstable angina and non-ST-segment elevation myocardial infarction

BACKGROUND

During percutaneous coronary revascularisation (i.e. coronary angioplasty (PTCA) with or without stent implantation), and in unstable angina/non-ST-segment elevation myocardial infarction, the risk of acute vessel occlusion by thrombosis is high in spite of treatment with aspirin and heparin. GP IIb/IIIa antagonists inhibit platelet aggregation and may prevent mortality and myocardial infarction.

OBJECTIVES

To assess the efficacy and safety of GP IIb/IIIa blockers during percutaneous coronary revascularisation, and in patients with unstable angina/non-ST-segment elevation myocardial infarction.

SEARCH STRATEGY

We searched the Cochrane Library (issue 1, 2000), MEDLINE (1966 to June 2001), EMBASE (1980 to Nov 1999), reference list of articles, medical websites and handsearch among abstracts from cardiology congresses.

SELECTION CRITERIA

Randomized controlled trials comparing intravenous GP IIb/IIIa blockers with standard medical treatment during percutaneous coronary revascularisation, and in patients with unstable angina/non-ST-segment elevation myocardial infarction.

DATA COLLECTION AND ANALYSIS

A list of titles and abstracts was screened separately by two reviewers who assessed trial quality and extracted data.

MAIN RESULTS

Percutaneous coronary revascularisation: Fourteen trials involving 17,788 patients were included. GP IIb/IIIa blockers were associated with decreased mortality at 30 days (OR 0.71 (95% CI 0.52, 0.97)) but not at 6 months (OR 0.85 (0.66, 1.11)). Mortality or infarction was decreased both at 30 days (OR 0.62 (0.55, 0.70); ARR: 31 per 1,000), and at 6 months (OR 0.65 (0.58, 0.73); ARR: 38 per 1,000)), but severe bleeding was increased (10 per 1,000; OR 1.38 (1.04, 1.85)). Unstable angina/non-ST-segment elevation myocardial infarction: Eight trials involving 30,006 patients were included. GP IIb/IIIa blockers were not associated with decreased mortality at 30 days (OR 0.90 (0.80, 1.02)) or at 6 months (OR: 1.01 (0.88, 1.16)). Mortality or infarction was decreased at 30 days (OR 0.91 (0.85, 0.98); ARR: 13 per 1,000)) and at 6 months (OR 0,88 (0.81, 0.95); ARR: 13 per 1,000)), although severe bleeding was increased (1 per 1,000; OR 1.27 (1.12, 1.44)).

REVIEWER'S CONCLUSIONS

Intravenous GP IIb/IIIa blockers reduce the risk of death at 30 days and markedly that of death or MI at 30 days and 6 months in patients submitted to percutaneous coronary revascularisation at a price of a moderate increased risk of severe bleeding. In contrast, in patients with unstable angina/non-ST-segment elevation myocardial infarction, these agents do not reduce mortality, only slightly reduce the risk of death or MI, and slightly increase the risk for severe bleeding.