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Graham LA, Maddox TM, Itani KMF, Hawn MT. Coronary Stents and Subsequent Surgery: Reported Provider Attitudes and Practice Patterns. Am Surg 2020. [DOI: 10.1177/000313481307900528] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Management of antiplatelet therapy in patients with cardiac stents who need subsequent surgery is complex. Current guidelines recommend delaying elective surgery or, if surgery is emergent, proceeding without aspirin cessation. This study assessed provider knowledge, attitudes, and practices for patients with cardiac stents needing subsequent surgery. A national survey was administered to Veterans Administration surgeons, anesthesiologists, and cardiologists. Questions examined guideline awareness and agreement, perceptions of bleeding risk and stent thrombosis, practice patterns for antiplatelet therapy management, and experience with perioperative stent thrombosis. Chi-square tests and generalized estimating equations were used to examine differences in reported practices. Among 295 respondents, guideline awareness (92%) and agreement (93%) were high but higher among cardiologists and anesthesiologists than surgeons. Guideline agreement and personal experience with stent thrombosis were also associated with reported practice patterns. In adjusted models for early surgeries, cardiologists and anesthesiologists were more likely to report continuation of dual therapy as compared with surgeons regardless of stent type (drug-eluting P = 0.03; bare metal P < 0.01). Despite successful guideline adoption, significant variations in practice patterns by provider type were found. Understanding reasons behind the variation and outcomes of various antiplatelet management strategies are important steps in optimizing care of patients with coronary stents undergoing noncardiac surgery.
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Affiliation(s)
- Laura A. Graham
- Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham VA Medical Center, Birmingham, Alabama; the
| | - Thomas M. Maddox
- VA Eastern Colorado Health Care System, University of Colorado Denver, Denver, Colorado
| | - Kamal M. F. Itani
- VA Eastern Colorado Health Care System, University of Colorado Denver, Denver, Colorado
| | - Mary T. Hawn
- Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham VA Medical Center, Birmingham, Alabama; the
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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2
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Childers CP, Maggard-Gibbons M, Ulloa JG, MacQueen IT, Miake-Lye IM, Shanman R, Mak S, Beroes JM, Shekelle PG. Perioperative management of antiplatelet therapy in patients undergoing non-cardiac surgery following coronary stent placement: a systematic review. Syst Rev 2018; 7:4. [PMID: 29321066 PMCID: PMC5763575 DOI: 10.1186/s13643-017-0635-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 11/23/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The correct perioperative management of antiplatelet therapy (APT) in patients undergoing non-cardiac surgery (NCS) is often debated by clinicians. American College of Cardiology (ACC) and American Heart Association (AHA) guidelines recommend postponing elective NCS at least 3 months after stent implantation. Regardless of the timing of surgery, ACC/AHA guidelines recommend continuing at least ASA throughout the perioperative period and ideally continuing dual APT (DAPT) therapy "unless surgery demands discontinuation." The objective of this review was to ascertain the risks and benefits of APT in the perioperative period, to assess how these risks and benefits vary by APT management, and the significance of length of time since stent implantation before operative intervention. METHODS PubMed, Web of Science, and Scopus were searched from inception through October 2017. Articles were included if patients were post PCI with stent placement (bare metal [BMS] or drug eluting [DES]), underwent elective NCS, and had rates of major adverse cardiac events (MACE) or bleeding events associated with pre and perioperative APT therapy. RESULTS Of 4882 screened articles, we included 16 studies in the review (1 randomized controlled trial and 15 observational studies). Studies were small (< 50: n = 5, 51-150: n = 5, >150: n = 6). All studies included DES with 7 of 16 also including BMS. Average time from stent to NCS was variable (< 6 months: n = 3, 6-12 months: n = 1, > 12 months: n = 6). At least six different APT strategies were described. Six studies further utilized bridging protocols using three different pharmacologic agents. Studies typically included multiple surgical fields with varying degrees of invasiveness. Across all APT strategies, rates of MACE/bleeding ranged from 0 to 21% and 0 to 22%. There was no visible trend in MACE/bleeding rates within a given APT strategy. Stratifying the articles by type of surgery, timing of discontinuation of APT therapy, bridging vs. no bridging, and time since stent placement did not help explain the heterogeneity. CONCLUSIONS Evidence regarding perioperative APT management in patients with cardiac stents undergoing NCS is insufficient to guide practice. Other clinical factors may have a greater impact than perioperative APT management on MACE and bleeding events. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016036607.
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Affiliation(s)
- Christopher P Childers
- Department of Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., CHS 72-247, Los Angeles, CA, 90095, USA. .,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.
| | - Melinda Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., CHS 72-247, Los Angeles, CA, 90095, USA.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Jesus G Ulloa
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Surgery, UCSF School of Medicine, San Francisco, CA, USA
| | - Ian T MacQueen
- Department of Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., CHS 72-247, Los Angeles, CA, 90095, USA.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Isomi M Miake-Lye
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | | | - Selene Mak
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Jessica M Beroes
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Paul G Shekelle
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Von Keudell AG, Thornhill TS, Katz JN, Losina E. Mortality Risk Assessment of Total Knee Arthroplasty and Related Surgery After Percutaneous Coronary Intervention. Open Orthop J 2017; 10:706-716. [PMID: 28144380 PMCID: PMC5220172 DOI: 10.2174/1874325001610010706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 09/30/2016] [Accepted: 10/05/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The optimal antiplatelet therapy (APT) treatment strategy after Coronary Artery Stenting (CAS) in non-cardiac surgery, such as total knee arthroplasty (TKA) or urgent TKA-related surgery remains unknown. METHODS We built a decision tree model to examine the mortality outcomes of two alternative strategies for APT after CAS use in the perioperative period namely, continuous use and discontinuation. RESULTS If surgery was performed in the first month after CAS placement, discontinuing APT led to an estimated 30-day post TKA mortality of 10.5%, compared to 1.0% in a strategy with continuous APT use. Mortality with both strategies decreased with longer intervals. CONCLUSION Our model demonstrated that APT discontinuation in patients undergoing TKA or urgent TKA related surgery after CAS placement might lead to greater 30-day mortality up to one year.
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Affiliation(s)
- Arvind G Von Keudell
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, JNK), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, JNK), Department of Orthopedic Surgery (AGvK, TST, JNK, EL), Brigham and Women's Hospital, Boston, MA, Massachusetts; Harvard Medical School, Boston, MA, Massachusetts (TST, JNK, EL); Department of Epidemiology, Harvard School of Public Health (JNK), Department of Biostatistics, Boston University School of Public Health, Boston, MA, Massachusetts (EL), USA
| | - Thomas S Thornhill
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, JNK), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, JNK), Department of Orthopedic Surgery (AGvK, TST, JNK, EL), Brigham and Women's Hospital, Boston, MA, Massachusetts; Harvard Medical School, Boston, MA, Massachusetts (TST, JNK, EL); Department of Epidemiology, Harvard School of Public Health (JNK), Department of Biostatistics, Boston University School of Public Health, Boston, MA, Massachusetts (EL), USA
| | - Jeffrey N Katz
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, JNK), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, JNK), Department of Orthopedic Surgery (AGvK, TST, JNK, EL), Brigham and Women's Hospital, Boston, MA, Massachusetts; Harvard Medical School, Boston, MA, Massachusetts (TST, JNK, EL); Department of Epidemiology, Harvard School of Public Health (JNK), Department of Biostatistics, Boston University School of Public Health, Boston, MA, Massachusetts (EL), USA
| | - Elena Losina
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, JNK), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, JNK), Department of Orthopedic Surgery (AGvK, TST, JNK, EL), Brigham and Women's Hospital, Boston, MA, Massachusetts; Harvard Medical School, Boston, MA, Massachusetts (TST, JNK, EL); Department of Epidemiology, Harvard School of Public Health (JNK), Department of Biostatistics, Boston University School of Public Health, Boston, MA, Massachusetts (EL), USA
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van Diepen S, Tricoci P, Podder M, Westerhout CM, Aylward PE, Held C, Van de Werf F, Strony J, Wallentin L, Moliterno DJ, White HD, Mahaffey KW, Harrington RA, Armstrong PW. Efficacy and Safety of Vorapaxar in Non-ST-Segment Elevation Acute Coronary Syndrome Patients Undergoing Noncardiac Surgery. J Am Heart Assoc 2015; 4:e002546. [PMID: 26672080 PMCID: PMC4845287 DOI: 10.1161/jaha.115.002546] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 10/30/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Perioperative antiplatelet agents potentially increase bleeding after non-ST-segment elevation (NSTE) acute coronary syndromes (ACS). The protease-activated receptor 1 antagonist vorapaxar reduced cardiovascular events and was associated with increased bleeding versus placebo in NSTE ACS, but its efficacy and safety in noncardiac surgery (NCS) remain unknown. We aimed to evaluate ischemic, bleeding, and long-term outcomes of vorapaxar in NCS after NSTE ACS. METHODS AND RESULTS In the TRACER trial, 2202 (17.0%) patients underwent major or minor NCS after NSTE ACS over 1.5 years (median); continuing study treatment perioperatively was recommended. The primary ischemic end point for this analysis was cardiovascular death, myocardial infarction, stent thrombosis, or urgent revascularization within 30 days of NCS. Safety outcomes included 30-day NCS bleeding and GUSTO moderate/severe bleeding. Overall, 1171 vorapaxar and 1031 placebo patients underwent NCS. Preoperative aspirin and thienopyridine use was 96.8% versus 97.7% (P=0.235) and 89.1% versus 86.1% (P=0.036) for vorapaxar versus placebo, respectively. Within 30 days of NCS, no differences were observed in the primary ischemic end point between vorapaxar and placebo groups (3.4% versus 3.9%; adjusted odds ratio 0.81, 95% CI 0.50 to 1.33, P=0.41). Similarly, no differences in NCS bleeding (3.9% versus 3.4%; adjusted odds ratio 1.41, 95% CI 0.87 to 2.31, P=0.17) or GUSTO moderate/severe bleeding (4.2% versus 3.7%; adjusted odds ratio 1.15, 95% CI, 0.72 to 1.83, P=0.55) were observed. In a 30-day landmarked analysis, NCS patients had a higher long-term risk of the ischemic end point (adjusted hazard ratio 1.62, 95% CI 1.33 to 1.97, P<0.001) and GUSTO moderate/severe bleeding (adjusted hazard ratio 5.63, 95% CI 3.98 to 7.97, P<0.001) versus patients who did not undergo NCS, independent of study treatment. CONCLUSION NCS after NSTE ACS is common and associated with more ischemic outcomes and bleeding. Vorapaxar after NSTE ACS was not associated with increased perioperative ischemic or bleeding events in patients undergoing NCS.
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Affiliation(s)
- Sean van Diepen
- Divisions of Critical Care and CardiologyUniversity of AlbertaEdmontonAlbertaCanada
- Canadian VIGOUR CentreUniversity of AlbertaEdmontonAlbertaCanada
| | - Pierluigi Tricoci
- Duke Clinical Research InstituteDuke University Medical CenterDurhamNC
| | - Mohua Podder
- Canadian VIGOUR CentreUniversity of AlbertaEdmontonAlbertaCanada
| | | | | | - Claes Held
- Department of Medical SciencesUppsala Clinical Research CenterUppsalaSweden
| | | | | | - Lars Wallentin
- Department of Medical SciencesUppsala Clinical Research CenterUppsalaSweden
| | - David J. Moliterno
- Gill Heart Institute and Division of Cardiovascular MedicineUniversity of KentuckyLexingtonKY
| | - Harvey D. White
- Green Lane Cardiovascular ServiceAuckland City HospitalAucklandNew Zealand
| | | | | | - Paul W. Armstrong
- Canadian VIGOUR CentreUniversity of AlbertaEdmontonAlbertaCanada
- Division of CardiologyUniversity of AlbertaEdmontonAlbertaCanada
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Anastasiou I, Petousis S, Hamilos M. Current strategies for bridging dual antiplatelet therapy in patients requiring surgery. Interv Cardiol 2015. [DOI: 10.2217/ica.14.75] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Bolsin SN, Gillett J. Drug-eluting stents and noncardiac surgery. Chest 2014; 145:1174. [PMID: 24798851 DOI: 10.1378/chest.14-0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Capodanno D, Angiolillo DJ. Management of Antiplatelet Therapy in Patients With Coronary Artery Disease Requiring Cardiac and Noncardiac Surgery. Circulation 2013; 128:2785-98. [DOI: 10.1161/circulationaha.113.003675] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Davide Capodanno
- From the Ferrarotto Hospital, University of Catania, Catania, Italy (D.C.); and University of Florida College of Medicine-Jacksonville, Jacksonville, FL (D.C., D.J.A.)
| | - Dominick J. Angiolillo
- From the Ferrarotto Hospital, University of Catania, Catania, Italy (D.C.); and University of Florida College of Medicine-Jacksonville, Jacksonville, FL (D.C., D.J.A.)
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Singla S, Sachdeva R, Uretsky BF. The risk of adverse cardiac and bleeding events following noncardiac surgery relative to antiplatelet therapy in patients with prior percutaneous coronary intervention. J Am Coll Cardiol 2012; 60:2005-16. [PMID: 23083781 DOI: 10.1016/j.jacc.2012.04.062] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 04/06/2012] [Accepted: 04/10/2012] [Indexed: 11/28/2022]
Abstract
Noncardiac surgery (NCS) may be required within the first year after percutaneous coronary intervention (PCI) in approximately 4% of patients and is the second most common reason for premature discontinuation of antiplatelet therapy (APT),which may, in turn, increase the risk of perioperative ischemic events, particularly stent thrombosis. Its continuation may increase the risk of perioperative bleeding. We review current information on the incidence of these events, particularly related to APT, describe potentially useful strategies to minimize the risks of adverse outcomes, and provide recommendations on APT use.
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Affiliation(s)
- Sandeep Singla
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Hollis RH, Graham LA, Richman JS, Deierhoi RJ, Hawn MT. Adverse cardiac events in patients with coronary stents undergoing noncardiac surgery: a systematic review. Am J Surg 2012; 204:494-501. [DOI: 10.1016/j.amjsurg.2012.04.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 04/06/2012] [Accepted: 04/06/2012] [Indexed: 11/24/2022]
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10
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Tandar A, Velagapudi KN, Wilson BD, Boden WE. Perioperative antiplatelet management in patients with coronary artery stenting. Hosp Pract (1995) 2012; 40:118-30. [PMID: 22615086 DOI: 10.3810/hp.2012.04.977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Coronary artery disease is the primary cause of mortality in men and women in the United States. Transcatheter coronary intervention is the mainstay of treatment for patients with acute coronary artery disease presentations and patients with stable disease. Although percutaneous intervention initially only included balloon angioplasty, it now typically involves the placement of intracoronary stents. To overcome the limitations of bare-metal stents, namely in-stent restenosis, stents have been developed that remove pharmaceuticals that reduce neointimal hyperplasia and in-stent restenosis. However, these pharmaceutical agents also delay stent endothelialization, posing a prolonged risk of in situ thrombosis. Placement of an intracoronary stent (eg, bare-metal or drug-eluting stent) requires dual antiplatelet therapy to prevent the potentially life-threatening complication of stent thrombosis. The optimal duration of dual antiplatelet therapy following stent placement is unknown. This article discusses the factors to be considered when deciding when dual antiplatelet therapy can be safely discontinued. Unfortunately, in the hospital setting, this decision to interrupt dual antiplatelet therapy frequently must be made shortly after stent placement because of unanticipated surgical procedures or other unforeseen complications. The decision of when dual antiplatelet therapy can be safely interrupted needs to be individualized for each patient and involves factoring in the type of stent; the location and complexity of the lesion stented; post-stent lesion characteristics; the amount of time since stent placement; and the antiplatelet regimen currently in use, along with its implication for bleeding during the proposed procedure. Having a protocol in place, such as the protocol described in this article, can help guide this decision-making process and avoid confusion and potential error.
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Affiliation(s)
- Anwar Tandar
- Division of Cardiology, University of Utah School of Medicine, Salt Lake City, UT.
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The Incidence and Timing of Noncardiac Surgery after Cardiac Stent Implantation. J Am Coll Surg 2012; 214:658-66; discussion 666-7. [DOI: 10.1016/j.jamcollsurg.2011.12.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 12/15/2011] [Indexed: 11/23/2022]
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12
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Bolsin S, Conroy M, Osborne C. Tirofiban 'bridging' therapy for patients with drug-eluting stents undergoing non-cardiac surgery. Br J Anaesth 2010; 104:779; author reply 779-80. [PMID: 20460570 DOI: 10.1093/bja/aeq101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Conroy MM, Bolsin SNC. Very late stent thrombosis after discontinuation of clopidogrel therapy. Med J Aust 2009; 190:163. [DOI: 10.5694/j.1326-5377.2009.tb02327.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Accepted: 10/19/2008] [Indexed: 11/17/2022]
Affiliation(s)
- Myles M Conroy
- Department of Anaesthesia, Perioperative and Pain Medicine, The Geelong Hospital, Geelong, VIC
| | - Stephen N C Bolsin
- Department of Anaesthesia, Perioperative and Pain Medicine, The Geelong Hospital, Geelong, VIC
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Brown MA, Tran THD, Krone RJ. Drug-eluting stents: Are they still the answer? CURRENT CARDIOVASCULAR RISK REPORTS 2008. [DOI: 10.1007/s12170-008-0061-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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