This document provides information on the efficacy and safety of pre-treatment with antiplatelet drugs prior to percutaneous coronary intervention (PCI) based on multiple clinical trials and studies. The key findings are:
1) The ACCOAST trial of over 4,000 patients found no difference in the primary efficacy endpoint of cardiovascular death, myocardial infarction, stroke, urgent revascularization or bailout GP IIb/IIIa inhibitor use at 7 and 30 days between patients pre-treated with prasugrel versus no pre-treatment.
2) For the subgroup of patients undergoing PCI, there was also no difference in the primary endpoint between pre-treatment and no pre-treatment.
3) Analysis of over 15
This document summarizes the results of the ARISE trial, which compared the Angio-Seal vascular closure device to manual compression using a radial artery approach in 240 patients undergoing coronary procedures for acute coronary syndrome. The trial found no significant differences in vascular complications, major bleeding, transfusion needs, or other safety outcomes between the two approaches at 30 days. Specifically, the risk difference for the primary endpoint of vascular complications was -0.83% (95% CI, -9.31-7.65) in favor of Angio-Seal, meeting the prespecified non-inferiority criterion. The results demonstrate that Angio-Seal is not inferior to manual compression in terms of safety and effectiveness when
This document discusses the use of bivalirudin as an anticoagulant for PCI procedures. It summarizes data from several clinical trials showing that bivalirudin reduces bleeding risks compared to unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor, without increasing ischemic risks. The presentation argues that since bleeding is a common complication of PCI and is associated with worse outcomes, and bivalirudin reduces bleeding while maintaining efficacy, it should be the preferred anticoagulant for PCI procedures for all patients. It acknowledges that while risk models can identify patients at higher risk of bleeding, it is difficult to separate bleeding risk from ischemic risk.
This document discusses the use of a slender 6Fr intra-aortic balloon pump (IABP) system compared to the standard 8Fr system. A study of 42 patients undergoing elective percutaneous coronary intervention with prophylactic IABP support found no complications with the 6Fr system, while the 8Fr system had re-bleeding and hematoma in some patients. The 6Fr system also allowed for shorter bed rest time. Trans-brachial insertion of the 6Fr IABP had even shorter bed rest and hospital stay times than transfemoral insertion. However, the 6Fr system has limitations such as a small balloon volume and inability to monitor pressure or use radial approaches.
Rotational atherectomy can be performed via the radial or femoral artery approaches with similar success rates. A study compared outcomes of 67 patients who underwent rotational atherectomy via the femoral approach to 52 patients who underwent it via the radial approach and found no significant differences in procedural characteristics, success rates, or in-hospital complications between the two groups except that pacing wires were inserted less often in the radial group. Overall, rotational atherectomy performed via the radial approach was found to be a feasible alternative to the femoral approach.
This document summarizes the results of several clinical trials evaluating renal denervation for the treatment of hypertension. The SYMPLICITY HTN-3 trial, the largest study to date, found no significant difference in blood pressure reduction between the renal denervation and sham procedure groups. Subgroup analyses found some predictors of greater blood pressure response, such as use of alpha-1 blockers or baseline blood pressure over 180 mmHg. Overall, the data from clinical trials on renal denervation is mixed, with early studies showing promising results but larger trials like SYMPLICITY HTN-3 finding no clear benefit over sham procedures.
This document discusses the evidence for using bivalirudin versus heparin during percutaneous coronary intervention (PCI). It summarizes several randomized controlled trials comparing outcomes of bivalirudin versus heparin, with or without glycoprotein IIb/IIIa inhibitors. The trials consistently show that bivalirudin reduces major bleeding compared to heparin, without increasing rates of ischemic events such as death, myocardial infarction, or target vessel revascularization. The document addresses common criticisms of the bivalirudin data but finds that its bleeding benefits held even in studies using vascular closure devices or transradial access.
1) The study compared transradial access (TRA) to transfemoral access (TFA) for coronary angiography in orthotopic heart transplant patients.
2) It found that while procedural time was similar, TRA was associated with higher contrast use, longer fluoroscopy time, and more catheters used for left coronary ostium cannulation compared to TFA.
3) However, no differences in adverse cardiac events or vascular complications between the two access routes were observed. The results suggest TRA may require a specific learning curve for operators, even for those experienced with radial procedures.
This document summarizes the results of the ARISE trial, which compared the Angio-Seal vascular closure device to manual compression using a radial artery approach in 240 patients undergoing coronary procedures for acute coronary syndrome. The trial found no significant differences in vascular complications, major bleeding, transfusion needs, or other safety outcomes between the two approaches at 30 days. Specifically, the risk difference for the primary endpoint of vascular complications was -0.83% (95% CI, -9.31-7.65) in favor of Angio-Seal, meeting the prespecified non-inferiority criterion. The results demonstrate that Angio-Seal is not inferior to manual compression in terms of safety and effectiveness when
This document discusses the use of bivalirudin as an anticoagulant for PCI procedures. It summarizes data from several clinical trials showing that bivalirudin reduces bleeding risks compared to unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor, without increasing ischemic risks. The presentation argues that since bleeding is a common complication of PCI and is associated with worse outcomes, and bivalirudin reduces bleeding while maintaining efficacy, it should be the preferred anticoagulant for PCI procedures for all patients. It acknowledges that while risk models can identify patients at higher risk of bleeding, it is difficult to separate bleeding risk from ischemic risk.
This document discusses the use of a slender 6Fr intra-aortic balloon pump (IABP) system compared to the standard 8Fr system. A study of 42 patients undergoing elective percutaneous coronary intervention with prophylactic IABP support found no complications with the 6Fr system, while the 8Fr system had re-bleeding and hematoma in some patients. The 6Fr system also allowed for shorter bed rest time. Trans-brachial insertion of the 6Fr IABP had even shorter bed rest and hospital stay times than transfemoral insertion. However, the 6Fr system has limitations such as a small balloon volume and inability to monitor pressure or use radial approaches.
Rotational atherectomy can be performed via the radial or femoral artery approaches with similar success rates. A study compared outcomes of 67 patients who underwent rotational atherectomy via the femoral approach to 52 patients who underwent it via the radial approach and found no significant differences in procedural characteristics, success rates, or in-hospital complications between the two groups except that pacing wires were inserted less often in the radial group. Overall, rotational atherectomy performed via the radial approach was found to be a feasible alternative to the femoral approach.
This document summarizes the results of several clinical trials evaluating renal denervation for the treatment of hypertension. The SYMPLICITY HTN-3 trial, the largest study to date, found no significant difference in blood pressure reduction between the renal denervation and sham procedure groups. Subgroup analyses found some predictors of greater blood pressure response, such as use of alpha-1 blockers or baseline blood pressure over 180 mmHg. Overall, the data from clinical trials on renal denervation is mixed, with early studies showing promising results but larger trials like SYMPLICITY HTN-3 finding no clear benefit over sham procedures.
This document discusses the evidence for using bivalirudin versus heparin during percutaneous coronary intervention (PCI). It summarizes several randomized controlled trials comparing outcomes of bivalirudin versus heparin, with or without glycoprotein IIb/IIIa inhibitors. The trials consistently show that bivalirudin reduces major bleeding compared to heparin, without increasing rates of ischemic events such as death, myocardial infarction, or target vessel revascularization. The document addresses common criticisms of the bivalirudin data but finds that its bleeding benefits held even in studies using vascular closure devices or transradial access.
1) The study compared transradial access (TRA) to transfemoral access (TFA) for coronary angiography in orthotopic heart transplant patients.
2) It found that while procedural time was similar, TRA was associated with higher contrast use, longer fluoroscopy time, and more catheters used for left coronary ostium cannulation compared to TFA.
3) However, no differences in adverse cardiac events or vascular complications between the two access routes were observed. The results suggest TRA may require a specific learning curve for operators, even for those experienced with radial procedures.
Radial access for primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) patients reduces bleeding complications compared to femoral access. Several randomized controlled trials showed lower all-cause mortality with radial versus femoral access when performed by experienced radial operators. However, the studies only included radial operators, so it is unclear if the benefits seen with radial access would apply if femoral operators performed radial procedures or vice versa. Additionally, radial access requires experienced operators at high-volume centers, and the definition of an experienced radial operator remains uncertain due to the steep learning curve for radial procedures. The primary goal of primary PCI in STEMI is restoring blood flow to the heart, not avoiding access site complications.
This document discusses anticoagulation options for percutaneous coronary intervention (PCI). It summarizes trials comparing unfractionated heparin (UFH) to bivalirudin. The HEAT-PPCI trial found UFH was better than bivalirudin for reducing major adverse cardiac events, with equivalent rates of major bleeding. A meta-analysis of 16 trials found UFH reduced MACE compared to bivalirudin, with equivalent major bleeding when provisional glycoprotein IIb/IIIa inhibitors were used symmetrically. The document concludes that UFH at doses of 50-70 units/kg is the preferred anticoagulant for PCI based on superior efficacy and equivalent safety compared to b
This document summarizes a systematic review and meta-analysis comparing radiation exposure between transradial and transfemoral access for cardiac catheterization. The analysis included 68 studies with over 666,000 patients. It found that while transradial access was initially associated with slightly higher fluoroscopy times and dose-area products, the difference has decreased over time as operator experience has increased, and recent studies show less than a 1 minute difference between approaches. Transradial access may also reduce operator radiation exposure.
1) The AURA OF ARTEMIS study was a randomized trial comparing transulnar versus transradial arterial access as the default strategy for coronary procedures.
2) In the interim analysis, the composite primary endpoint was significantly higher in the ulnar arm compared to the radial arm, with a 24.3% difference between arms. The study was terminated early due to the inferiority of the transulnar approach.
3) Complications associated with the transulnar approach included pseudoaneurysms, perforations, occlusions and arteriovenous fistulas. Crossover from ulnar to other access sites was also more common.
This document discusses tips and tricks for successful transradial primary PCI. It begins with an introduction and disclosure from the author. It then reviews several studies that found high rates of success (90-100%) and normalization of coronary blood flow with transradial PCI for AMI. No major vascular complications occurred in these studies. Additional studies showed similar success rates and procedural times for transradial PCI compared to transfemoral, with lower rates of major vascular complications. Bleeding complications were associated with increased mortality. The experience of over 880 AMIs at one center using a transradial approach found no major vascular complications. While transradial PCI can present challenges in complex cases, it allows intervention even if thrombolysis was used
This document discusses anticoagulation options for coronary procedures. Unfractionated heparin (UFH) is the most cost-effective option. The goals of anticoagulation are to prevent radial artery occlusion after angiography, avoid complications like stent thrombosis during percutaneous coronary intervention (PCI), and reduce bleeding. UFH 5000 IU is effective for preventing radial occlusion after angiography. For planned PCI, STEMI, or NSTEMI, UFH or low molecular weight heparin are first-line options, though bivalirudin reduces bleeding. The benefit of bivalirudin may be mitigated for radial procedures and its high cost is a limitation. More data is needed on anticoagulant
The document discusses several studies on vascular complications in overweight patients undergoing percutaneous coronary interventions (PCI) and coronary angiography. The TROP study analyzed outcomes in 346 overweight patients undergoing PCI or angiography. It found the radial approach reduced complications compared to femoral. Other studies also found lower risks with radial access, especially in obese patients. Overall, obesity is a risk factor for cardiovascular disease and complications, and the radial approach may help reduce risks in overweight and obese patients undergoing coronary procedures.
This document summarizes the results of the DRAGON trial which compared the radial versus femoral approach for percutaneous coronary intervention (PCI) in over 1,700 patients. The trial found that the radial approach (TRI) was non-inferior to the femoral approach (TFI) for the primary endpoint of major adverse cardiac events at 12 months. TRI also had significantly less major bleeding complications at 7 days compared to TFI, meeting the secondary endpoint for superiority. Propensity score matching was used to adjust for baseline differences between the groups. The trial demonstrated that an ad-hoc radial approach strategy can provide similar clinical outcomes to femoral approach with less bleeding risks.
This document summarizes several studies on the risk of acute kidney injury following percutaneous coronary intervention (PCI) via the radial versus femoral artery access site. Registry data from British Columbia and a large US study found that femoral access was associated with significantly higher odds of adverse kidney outcomes after adjusting for risk factors. A single-center study also found higher rates of post-PCI acute kidney injury with femoral compared to radial access after propensity matching. While patient characteristics and contrast load are major risk factors for procedure-associated acute kidney injury, available data suggests radial access may have renoprotective effects compared to the femoral approach.
Impact of access site on bleeding and ischemic events in patients with non-ST-segment elevation myocardial infarction treated with prasugrel at the time of percutaneous coronary intervention or as pretreatment at the time of diagnosis: the ACCOAST access substudy
This document summarizes a study on performing transradial cardiac catheterization in patients with a negative Allen's test. The study found:
1) The radial artery occlusion rate was similar between patients with a negative (6.2%) and positive (4.8%) Allen's test.
2) Factors like sheath size, post-procedure compression time, anticoagulation use were more predictive of preventing radial occlusion than the Allen's test.
3) Transradial procedures can be performed safely and effectively regardless of pre-procedure Allen's test results.
Cardiogenic shock is a leading cause of death in AMI patients, with mortality rates between 30-60%. While radial access has been shown to reduce bleeding complications, patients presenting with cardiogenic shock are often treated via transfemoral access. Recent studies have demonstrated that radial access PCI is feasible in cardiogenic shock patients, with one study showing a reduction in in-hospital mortality for radial versus transfemoral access. However, experienced radial centers only use the radial approach in around 50% of cardiogenic shock cases, indicating radial access is still underutilized despite potential benefits in this high-risk group.
This randomized clinical trial compared transradial catheterization performed with or without prophylactic nitroglycerin to prevent radial artery spasm. 328 patients undergoing transradial cardiac catheterization were randomly assigned to receive either intra-arterial nitroglycerin or a saline placebo after sheath insertion. The trial found no significant differences in patient pain levels, procedure duration, radiation exposure, or need for analgesics between the two groups. However, the operators' subjective impression of artery spasm was lower in the nitroglycerin group. The study concluded that prophylactic nitroglycerin does not provide clear advantages and may not be necessarily required for transradial procedures.
Radialists perform better femoral PCI according to a study. While radial access has benefits, not all hospitals and operators have adopted it due to challenges like a learning curve. Studies show that default radial operators in a radial center who occasionally need to use femoral access have lower rates of access site complications and mortality compared to femoral operators. Analysis of large datasets from the UK also indicate reduced access site complications and mortality with radial access compared to femoral for PCI.
This document discusses techniques for performing percutaneous coronary intervention (PCI) via the transradial approach. It aims to debunk myths that complex PCI cannot be done through the radial artery. The key principles discussed are preparing patients with antiplatelet and anticoagulant medications pre-procedure, using the appropriate guidewires and catheters to access tortuous anatomy, and performing techniques such as balloon-assisted guide engagement and sheathless guide insertion to facilitate complex cases through the radial artery. The conclusion emphasizes that the basic principles of PCI still apply and that with practice of the techniques discussed, transradial PCI can be successfully performed for many cases, even in complex situations traditionally done via the femoral approach.
Radial access for primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) patients reduces bleeding complications compared to femoral access. Several randomized controlled trials showed lower all-cause mortality with radial versus femoral access when performed by experienced radial operators. However, the studies only included radial operators, so it is unclear if the benefits seen with radial access would apply if femoral operators performed radial procedures or vice versa. Additionally, radial access requires experienced operators at high-volume centers, and the definition of an experienced radial operator remains uncertain due to the steep learning curve for radial procedures. The primary goal of primary PCI in STEMI is restoring blood flow to the heart, not avoiding access site complications.
This document discusses anticoagulation options for percutaneous coronary intervention (PCI). It summarizes trials comparing unfractionated heparin (UFH) to bivalirudin. The HEAT-PPCI trial found UFH was better than bivalirudin for reducing major adverse cardiac events, with equivalent rates of major bleeding. A meta-analysis of 16 trials found UFH reduced MACE compared to bivalirudin, with equivalent major bleeding when provisional glycoprotein IIb/IIIa inhibitors were used symmetrically. The document concludes that UFH at doses of 50-70 units/kg is the preferred anticoagulant for PCI based on superior efficacy and equivalent safety compared to b
This document summarizes a systematic review and meta-analysis comparing radiation exposure between transradial and transfemoral access for cardiac catheterization. The analysis included 68 studies with over 666,000 patients. It found that while transradial access was initially associated with slightly higher fluoroscopy times and dose-area products, the difference has decreased over time as operator experience has increased, and recent studies show less than a 1 minute difference between approaches. Transradial access may also reduce operator radiation exposure.
1) The AURA OF ARTEMIS study was a randomized trial comparing transulnar versus transradial arterial access as the default strategy for coronary procedures.
2) In the interim analysis, the composite primary endpoint was significantly higher in the ulnar arm compared to the radial arm, with a 24.3% difference between arms. The study was terminated early due to the inferiority of the transulnar approach.
3) Complications associated with the transulnar approach included pseudoaneurysms, perforations, occlusions and arteriovenous fistulas. Crossover from ulnar to other access sites was also more common.
This document discusses tips and tricks for successful transradial primary PCI. It begins with an introduction and disclosure from the author. It then reviews several studies that found high rates of success (90-100%) and normalization of coronary blood flow with transradial PCI for AMI. No major vascular complications occurred in these studies. Additional studies showed similar success rates and procedural times for transradial PCI compared to transfemoral, with lower rates of major vascular complications. Bleeding complications were associated with increased mortality. The experience of over 880 AMIs at one center using a transradial approach found no major vascular complications. While transradial PCI can present challenges in complex cases, it allows intervention even if thrombolysis was used
This document discusses anticoagulation options for coronary procedures. Unfractionated heparin (UFH) is the most cost-effective option. The goals of anticoagulation are to prevent radial artery occlusion after angiography, avoid complications like stent thrombosis during percutaneous coronary intervention (PCI), and reduce bleeding. UFH 5000 IU is effective for preventing radial occlusion after angiography. For planned PCI, STEMI, or NSTEMI, UFH or low molecular weight heparin are first-line options, though bivalirudin reduces bleeding. The benefit of bivalirudin may be mitigated for radial procedures and its high cost is a limitation. More data is needed on anticoagulant
The document discusses several studies on vascular complications in overweight patients undergoing percutaneous coronary interventions (PCI) and coronary angiography. The TROP study analyzed outcomes in 346 overweight patients undergoing PCI or angiography. It found the radial approach reduced complications compared to femoral. Other studies also found lower risks with radial access, especially in obese patients. Overall, obesity is a risk factor for cardiovascular disease and complications, and the radial approach may help reduce risks in overweight and obese patients undergoing coronary procedures.
This document summarizes the results of the DRAGON trial which compared the radial versus femoral approach for percutaneous coronary intervention (PCI) in over 1,700 patients. The trial found that the radial approach (TRI) was non-inferior to the femoral approach (TFI) for the primary endpoint of major adverse cardiac events at 12 months. TRI also had significantly less major bleeding complications at 7 days compared to TFI, meeting the secondary endpoint for superiority. Propensity score matching was used to adjust for baseline differences between the groups. The trial demonstrated that an ad-hoc radial approach strategy can provide similar clinical outcomes to femoral approach with less bleeding risks.
This document summarizes several studies on the risk of acute kidney injury following percutaneous coronary intervention (PCI) via the radial versus femoral artery access site. Registry data from British Columbia and a large US study found that femoral access was associated with significantly higher odds of adverse kidney outcomes after adjusting for risk factors. A single-center study also found higher rates of post-PCI acute kidney injury with femoral compared to radial access after propensity matching. While patient characteristics and contrast load are major risk factors for procedure-associated acute kidney injury, available data suggests radial access may have renoprotective effects compared to the femoral approach.
Impact of access site on bleeding and ischemic events in patients with non-ST-segment elevation myocardial infarction treated with prasugrel at the time of percutaneous coronary intervention or as pretreatment at the time of diagnosis: the ACCOAST access substudy
This document summarizes a study on performing transradial cardiac catheterization in patients with a negative Allen's test. The study found:
1) The radial artery occlusion rate was similar between patients with a negative (6.2%) and positive (4.8%) Allen's test.
2) Factors like sheath size, post-procedure compression time, anticoagulation use were more predictive of preventing radial occlusion than the Allen's test.
3) Transradial procedures can be performed safely and effectively regardless of pre-procedure Allen's test results.
Cardiogenic shock is a leading cause of death in AMI patients, with mortality rates between 30-60%. While radial access has been shown to reduce bleeding complications, patients presenting with cardiogenic shock are often treated via transfemoral access. Recent studies have demonstrated that radial access PCI is feasible in cardiogenic shock patients, with one study showing a reduction in in-hospital mortality for radial versus transfemoral access. However, experienced radial centers only use the radial approach in around 50% of cardiogenic shock cases, indicating radial access is still underutilized despite potential benefits in this high-risk group.
This randomized clinical trial compared transradial catheterization performed with or without prophylactic nitroglycerin to prevent radial artery spasm. 328 patients undergoing transradial cardiac catheterization were randomly assigned to receive either intra-arterial nitroglycerin or a saline placebo after sheath insertion. The trial found no significant differences in patient pain levels, procedure duration, radiation exposure, or need for analgesics between the two groups. However, the operators' subjective impression of artery spasm was lower in the nitroglycerin group. The study concluded that prophylactic nitroglycerin does not provide clear advantages and may not be necessarily required for transradial procedures.
Radialists perform better femoral PCI according to a study. While radial access has benefits, not all hospitals and operators have adopted it due to challenges like a learning curve. Studies show that default radial operators in a radial center who occasionally need to use femoral access have lower rates of access site complications and mortality compared to femoral operators. Analysis of large datasets from the UK also indicate reduced access site complications and mortality with radial access compared to femoral for PCI.
This document discusses techniques for performing percutaneous coronary intervention (PCI) via the transradial approach. It aims to debunk myths that complex PCI cannot be done through the radial artery. The key principles discussed are preparing patients with antiplatelet and anticoagulant medications pre-procedure, using the appropriate guidewires and catheters to access tortuous anatomy, and performing techniques such as balloon-assisted guide engagement and sheathless guide insertion to facilitate complex cases through the radial artery. The conclusion emphasizes that the basic principles of PCI still apply and that with practice of the techniques discussed, transradial PCI can be successfully performed for many cases, even in complex situations traditionally done via the femoral approach.
The document describes a new fingertip-mounted ultrasound probe called the Soniceye device. It contains 3 sentences:
The Soniceye device is a fingertip-mounted ultrasound probe that was created to guide radial artery access. It has a high frequency 128 channel linear array probe and is compatible with numerous existing ultrasound devices through Bluetooth. The document concludes that the Soniceye device is easy to learn and would be most useful for situations where the radial pulse is low or faint.
Acute kidney injury - A european perspective. Comparison of risk of acute kidney injury following primary PCI with the transradial approach vs the transfemoral approach: The PRIPITENA Urban Registry.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
This document summarizes a randomized trial comparing radial versus femoral approaches for primary PCI in STEMI patients. The trial aims to enroll 700 STEMI patients across 4 centers. The primary endpoints are major bleeding and access site complications within 30 days. Secondary endpoints include mortality, reinfarction, procedural success, and length of stay. The trial is investigator-initiated and supported by grants, with the goal of showing radial access reduces bleeding complications compared to femoral.
This document summarizes the results of the SAFE-PCI for Women Trial, which compared radial versus femoral approaches for percutaneous coronary intervention (PCI) in women. The trial was terminated early due to lower than expected rates of bleeding and vascular complications. In both the total randomized cohort and PCI cohort, radial access was associated with significantly lower rates of bleeding/vascular complications and procedural failure compared to femoral access. Secondary endpoints showed no significant differences in outcomes between approaches. The results suggest an initial strategy of radial access is reasonable for PCI in women.
Access vs non-access site bleeding and risk of subsequent mortality and MACE
This study aimed to analyze the incidence and prognostic impact of access site versus non-access site bleeding in patients undergoing percutaneous coronary intervention (PCI). The meta-analysis included 38 studies and over 520,000 patients. It found that access site bleeding occurred in 11.2% of patients while non-access site bleeding occurred in 10.2% of patients. However, non-access site bleeding was associated with a higher crude mortality rate of 8.3% compared to 2.8% for access site bleeding. Further analyses confirmed that non-access site bleeding carried a greater risk of subsequent mortality and major adverse cardiac events than access site bleeding. The
This document discusses using 5 French compatible thrombosuction in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). It notes that thrombosuction can be performed through 5 French sheaths and catheters in selected patients. The document presents two case examples where thrombosuction was successfully performed through 5 French sheathless guide catheters using aspiration catheters compatible with 5 French systems. It concludes that a personalized approach using thrombosuction when needed may be preferable for STEMI patients.
This study compared ambulation times to discharge for 367 patients who received radial or femoral access for cardiac catheterization. It found that patients with radial access were discharged 41-122 minutes sooner than those with femoral access, depending on the specific procedure. Radial access was associated with shorter discharge times even after controlling for various patient characteristics and procedural factors. The study concluded that radial access results in shorter hospital stays compared to femoral access for cardiac catheterization.
This document summarizes a study presented by Lukasz Koltowski on quality of life in patients undergoing percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) via radial or femoral access. The study was a single-center, randomized trial that assessed quality of life measures like the EQ-5D and MacNew scales at various time points after PCI. The results showed that radial access was associated with better short-term quality of life, especially for mobility and anxiety/depression, though differences diminished after a few days. The conclusions were that radial access facilitated quicker recovery and should be preferred when considering patient satisfaction.
1) Percutaneous angioplasty is a feasible treatment for critical hand ischemia, with a technical success rate of 88-96% and clinical success rate of 85-100% based on a study of 75 patients.
2) Complications occurred in 6-16% of patients and included perforation, distal embolization, dissection, and access site issues.
3) Long term follow up showed a high rate of major adverse events (22.6% at 1 year) and target lesion revascularization (16%).
This document discusses transradial access for treating erectile dysfunction. It provides background on the definition and causes of ED, and the relationship between ED and coronary artery disease. Treatment options for ED are discussed including oral medications, injections, devices, and angioplasty of the internal iliac arteries, pudendal arteries, and penile arteries performed through radial artery access. The results of one physician's experience with this technique are presented, showing high success rates and low complications. Ultrasound is also summarized as a diagnostic tool for evaluating penile blood flow velocities and identifying venous leakage.
This document discusses techniques for radial artery puncture for catheter procedures. It provides guidance on the ideal puncture point being at least 10 mm proximal to the Radial-Ulnar line. It outlines the steps for radial cannulation which include local anesthesia, skin incision, needle puncture, insertion of a guide wire and sheath. Ultrasound guidance is recommended for difficult punctures or when distinguishing between the radial artery and vein. Alternative access sites like the ulnar artery or femoral artery are mentioned if radial puncture is not feasible.
This document summarizes the O2 FIM study which evaluated the performance of the Optowire and Optomonitor system for measuring fractional flow reserve (FFR). The study found that the Optowire was able to cross all types of coronary lesions except chronic total occlusions and could reliably obtain pre- and post-percutaneous coronary intervention (PCI) FFR measurements with no drift. The Optowire also performed well as a PCI wire and the Optomonitor was easy to use with recording capabilities. The study concluded that fiber optic technology allowed for an improved floppy wire with stable pressures and connectivity suitable for integrated FFR measurements in the catheterization laboratory.
This document discusses same day discharge after elective percutaneous coronary intervention (PCI). It reviews the literature on criteria for selecting low-risk patients suitable for same day discharge. Studies show same day discharge is safe and feasible in properly selected patients and can provide significant cost savings compared to overnight admission. The document outlines one institution's protocol for same day discharge following radial PCI, including clinical, procedural, and socio-demographic criteria for patient selection. It emphasizes focusing on low risk patients, procedures, and clinical scenarios to safely implement a same day discharge program.
The document discusses the relationship between procedure volume and outcomes for transradial PCI procedures. It summarizes several studies that found higher volume radial operators and centers achieved better efficacy and safety outcomes compared to lower volume ones. In particular, a meta-analysis of trials found reduced mortality, heart attacks, bleeding, and crossover to femoral access at higher volume sites. The document concludes there is strong evidence that higher procedure volumes are associated with better outcomes for transradial PCI, supporting a "radial first" approach where radial access is prioritized.
1) The TRITON-TIMI 38 trial compared the antiplatelet drug prasugrel to clopidogrel in 13,608 patients with acute coronary syndrome undergoing percutaneous coronary intervention.
2) Prasugrel was found to significantly reduce the primary composite endpoint of cardiovascular death, myocardial infarction, or stroke compared to clopidogrel, from 12.1% to 9.9%. However, prasugrel was also associated with an increased risk of bleeding.
3) In the overall study population, the superior efficacy of prasugrel in reducing ischemic events outweighed the increased risk of bleeding, representing a net clinical benefit. However, prasugrel appeared to have less benefit or
Reestenosis, Síndrome coronario agudo. Rol actual de los nuevos antiplaquetarios en el síndrome coronario agudo. Congreso SOLACI Chile 2011.Dr. Ramón Corbalán. Encuentre más presentaciones en la página www.solaci.org/
4 dan atar - anticoagulation af pci - what do trials saywebevo5
Professor Dan Atar presented on anticoagulation for atrial fibrillation and percutaneous coronary intervention based on recent trial results. The WOEST trial found that dual therapy with a vitamin K antagonist (VKA) and clopidogrel reduced bleeding compared to triple therapy with a VKA, aspirin, and clopidogrel, with a potential mortality benefit. The PIONEER AF-PCI trials found that rivaroxaban dual or triple therapy was associated with significantly less bleeding than VKA triple therapy, with comparable efficacy. The RE-LY-DUAL PCI study found dabigatran dual therapy significantly reduced bleeding compared to warfarin triple therapy. Guidelines recommend balancing the risks of bleeding from
- Primary PCI is the preferred reperfusion strategy for STEMI when it can be performed at an experienced center within 120 minutes of first medical contact. Fibrinolysis is an alternative if PCI cannot be performed within this time window.
- Clopidogrel in combination with aspirin results in significant improvements in outcomes for STEMI patients over aspirin alone based on the CLARITY-TIMI 28 and COMMIT trials.
- Enoxaparin is superior to unfractionated heparin as an anticoagulant to support reperfusion therapy for STEMI based on the ExTRACT-TIMI 25 trial.
1. The document discusses a symposium on the role of prasugrel in managing acute coronary syndrome patients undergoing percutaneous coronary intervention (ACS-PCI).
2. It summarizes results from the TRITON-TIMI 38 trial comparing prasugrel to clopidogrel in treating ACS-PCI patients. Prasugrel showed a statistically significant reduction in cardiovascular events compared to clopidogrel in all ACS-PCI patients and those with diabetes at 12 months.
3. In STEMI-PCI patients, prasugrel also reduced cardiovascular events compared to clopidogrel at 12 months, though the trial was not powered for this subgroup. Increased risks of bleeding were seen
Prasugrel Compared to Clopidogrel in Patients with Acute Coronary Syndromes Undergoing PCI with Stenting: the TRITON - TIMI 38 Stent Analysis trial found that intensive antiplatelet therapy with prasugrel compared to clopidogrel resulted in a 52% reduction in stent thrombosis across various patient groups and stent types. Prasugrel provided significant reductions in ischemic events but increased major bleeding compared to clopidogrel. The net clinical benefit of prasugrel supported its efficacy in reducing stent thrombosis and ischemic events.
Ticagrelor is a reversible P2Y12 platelet inhibitor that was developed as an alternative to clopidogrel for dual antiplatelet therapy following acute coronary syndromes or percutaneous coronary interventions.
The PLATO trial found that ticagrelor was more effective than clopidogrel at reducing the primary endpoint of cardiovascular death, myocardial infarction, and stroke in patients with acute coronary syndrome, with no significant difference in major bleeding risks. However, ticagrelor was associated with higher rates of dyspnea and asymptomatic ventricular pauses.
The PEGASUS trial showed that long-term use of ticagrelor on a background of aspirin reduced the risk of cardiovascular events in patients
1) The PLATO trial compared ticagrelor to clopidogrel for prevention of cardiovascular events in patients with acute coronary syndromes. It involved over 18,000 patients across 43 countries.
2) The primary endpoint was a composite of death from vascular causes, myocardial infarction, or stroke. At 12 months, this occurred in 9.8% of ticagrelor patients compared to 11.7% of clopidogrel patients, showing ticagrelor was more effective at reducing cardiovascular events.
3) The primary safety endpoint of major bleeding at 12 months occurred in 11.6% of ticagrelor patients and 11.2% of clopidogrel patients, showing no significant
Prasugrel provides faster, stronger, and more consistent platelet inhibition compared to clopidogrel. However, it also increases the risk of bleeding, especially in high-risk groups such as those over age 75, weighing less than 60kg, or with a history of stroke or transient ischemic attack. The TRITON-TIMI 38 trial found that prasugrel reduced cardiovascular events compared to clopidogrel in acute coronary syndrome patients undergoing percutaneous coronary intervention, but increased major bleeding risks. Subgroup analyses identified populations that may derive particular benefit or face specific bleeding risks with prasugrel.
The document summarizes the ARMYDA-5 clinical trial which compared administering a 600 mg clopidogrel loading dose in the catheterization lab versus 4-8 hours before the procedure. The trial found no significant differences in death, heart attack, or repeat procedures between the two groups within 30 days. Levels of biomarkers for heart damage and platelet reactivity also did not meaningfully differ. The in-lab clopidogrel strategy was concluded to be a safe and effective alternative to pre-treatment hours before the procedure.
12 Reasons to Prescribe Ticagrelor & Affordability of Generics.pptxAkhilSharma221092
This document discusses 12 reasons why the author prefers the antiplatelet drug ticagrelor over other options. Some key points from the document include:
1. Ticagrelor can be safely given to pre-hospital patients with STEMI and benefits include reduced rates of ST resolution and TIMI 3 flow.
2. Ticagrelor provides a mortality benefit compared to clopidogrel based on results from the PLATO trial, with a number needed to treat of 54.
3. Ticagrelor's benefits are seen across the spectrum of ACS patients regardless of invasive or non-invasive management based on sub-group analyses from PLATO.
4. Long-term secondary
This document summarizes several studies on antiplatelet therapy in patients with acute coronary syndrome (ACS). It discusses the optimal P2Y12 inhibitor choice for older patients based on the Gimbel et al. study, which was a randomized trial comparing clopidogrel to ticagrelor or prasugrel in patients aged 70 years or older with non-ST-elevation ACS. The trial found no significant differences in safety or efficacy outcomes between treatment groups. Modalities for switching between oral P2Y12 inhibitors are discussed, along with bleeding risks associated with ticagrelor compared to clopidogrel based on the PLATO trial. Factors favoring de-escalation of dual antiplate
The document analyzes data from the Horizons-AMI trial to identify predictors of acute, subacute, and late stent thrombosis after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). It finds that bivalirudin monotherapy is associated with significantly lower rates of acute stent thrombosis compared to unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor. A clopidogrel loading dose of 600 mg is associated with lower rates of stent thrombosis compared to 300 mg among patients treated with unfractionated heparin and a glycoprotein IIb/IIIa inhibitor. Pre-randomization unfractionated heparin is an independent predictor of acute stent thrombosis
Primary PCI is the preferred treatment for STEMI, achieving success rates of around 90% compared to 50% for thrombolysis. While thrombolysis has mortality rates of 7-10% in trials and 10-17% in registries, primary PCI has lower mortality rates of 5% in trials and 5-9% in registries. The PRAGUE studies showed lower combined endpoints of death, re-infarction and stroke for primary PCI compared to thrombolysis. Guidelines now recommend primary PCI as the default reperfusion strategy for STEMI when it can be performed in a timely manner.
1) The PLATO study found that ticagrelor was superior to clopidogrel for reducing cardiovascular events in patients with acute coronary syndrome, with a relative risk reduction of 16% and number needed to treat of 54.
2) The ATLAS study found that rivaroxaban was effective for secondary prevention of cardiovascular events with lower rates of bleeding compared to aspirin alone.
3) Several studies explored new antiplatelet and anticoagulant drugs for treatment and secondary prevention of acute coronary syndrome.
1) Atrial fibrillation prevalence increases with age and is a global epidemic. It is more common in patients with cardiovascular disease or multiple risk factors. (2) Patients with atrial fibrillation have higher rates of cardiovascular events compared to those without. (3) NOACs (non-vitamin K antagonist oral anticoagulants) such as dabigatran, rivaroxaban, apixaban, and edoxaban were shown to be as effective or more effective than warfarin for stroke prevention, with lower rates of hemorrhagic stroke and intracranial bleeding in major clinical trials.
XXVII Reunión anual de la sección de Hemodinámica y Cardiología Intervencionista
16 y 17 de junio de 2016 León
http://secardiologia.es/xxvii-reunion-anual-de-la-seccion-de-hemodinamica-y-cardiologia-intervencionista
Novedades en farmacología en intervencionismo
Antonio Fernández Ortiz (Hosp. Clínico San Carlos. Madrid)
26.09.13 how to choose your bride among three sistersRajeev Agarwala
1. The document discusses how to choose a bride among three sisters.
2. It notes that choosing a bride is a delicate matter that requires considering compatibility, personality, family background, and health of each sister.
3. The best approach is to carefully evaluate each sister individually based on these factors and choose the one who is most suitable and with whom you can have a happy marriage.
26.9.13 antiplatelet how to choose your bride among three sistersRajeev Agarwala
1. The document discusses how to choose a bride among three sisters.
2. It notes that choosing a bride is a difficult decision that requires carefully considering each sister's personality, family background, and your compatibility with each.
3. The best approach is to spend quality individual time with each sister to truly get to know them before making a decision in order to choose the partner you feel you can build a strong, happy marriage with.
Similar to Montalescot G - AIMRADIAL 2013 - Prasugrel and radial (20)
This document summarizes Tim Fischell's presentation on innovation in cardiovascular medicine. It discusses Fischell's history of medical device innovations, including the Arrow-Fischell sheath, brachytherapy devices, stents, and the AngelMed Guardian system. It provides guidance on developing new ideas into real innovations, including evaluating intellectual property, regulatory pathways, prototype testing, and clinical trials. Fischell emphasizes the importance of understanding unmet clinical needs and having a team approach to translating ideas into impactful new technologies.
This document discusses opportunities for developing and manufacturing medical devices in Latin America, including coronary stents with an estimated $500M annual market. It outlines the roadmap needed to design, test, manufacture, and gain regulatory approval for a novel stent concept, including requirements for structure and flow, deployability and patency, and clinical performance. Design considerations are discussed such as structural rigidity, flexural rigidity, surface finish, and hemodynamic simulations. The potential for low-cost manufacturing and animal studies are also mentioned.
This document summarizes the evidence from multiple randomized clinical trials that support a Class IA recommendation for the use of radial artery access (TRA) over femoral artery access (TFA) for cardiac catheterization procedures. The data show that TRA is associated with lower rates of major vascular complications and major bleeding compared to TFA, with numbers needed to treat of 21 and 47 respectively. TRA may also reduce mortality in patients with acute coronary syndrome, with a number needed to treat of 100. Both the 2018 AHA guidelines and ESC/EACTS guidelines were updated to strongly recommend a radial-first approach in light of the overwhelming data demonstrating benefits of TRA over TFA.
This document discusses best practices for same day discharge after cardiac procedures. It provides an overview of the history and evidence supporting same day discharge. Key points include:
- Same day discharge has been shown to be safe and effective in studies dating back to the 1990s.
- Dedicated lounges and infrastructure improve outcomes for same day discharge by allowing for close monitoring and care in the immediate post-procedure period.
- The author's hospital has successfully performed over 7,000 same day discharge procedures over 10 years using a dedicated radial lounge with trained nursing staff who provide care and arrange discharge. Complication rates are low with their protocol.
This document describes a case of critical hand ischemia treated through multiple endovascular interventions over several years. Initially, the patient underwent brachial artery recanalization and stenting from left radial access, but presented two days later with stent thrombosis. A second procedure recanalized the stent and treated a brachial dissection with another stent. However, two years later the patient returned with re-occlusion of arm vessels and iliac arteries. Further interventions were needed to recanalize stenosed iliac and brachial arteries over time. In conclusion, long term patency of arm interventions is unknown, and stent CTO recanalization in the arms poses similar challenges to the legs.
This document discusses expanding the FDA indication for protected PCI procedures using the Impella heart pump. Key points include:
1. A study of 891 patients found that those with mildly/moderately reduced ejection fraction (LVEF >35%) undergoing protected PCI had favorable outcomes similar to those with severely reduced LVEF, despite being older with more comorbidities and complex coronary disease.
2. Protected PCI with Impella led to improved LVEF and quality of life in multiple studies. The Protect II trial showed Impella reduced MACCE by 29% compared to IABP at 30 days.
3. Guidelines recommend protected PCI for patients with severe/moderate/mild reduced LVE
This document summarizes the findings of a study analyzing 19,482 left main stem percutaneous coronary intervention (LMS-PCI) procedures from the British Cardiovascular Intervention Society National Database between 2007-2014:
1) Use of radial artery access for LMS-PCI increased significantly over time and radial access was associated with reduced vascular complications, major bleeding, and shorter hospital stays.
2) Radial access was independently associated with lower in-hospital mortality and major adverse cardiac and cerebrovascular events (MACE) compared to femoral access.
3) Independent predictors of 12-month mortality following LMS-PCI included acute kidney injury, older age, chronic renal failure, acute coronary syndrome presentation, and
This document discusses accessing the right heart and central venous system through the radial vein as a safer alternative to traditional femoral access. It provides tips for establishing venous access through the forearm, including using ultrasound or no-touch technology to locate veins and heparin locks to improve efficiency. Challenges like low venous pressure, valves, and junctions are addressed. Images demonstrate techniques for navigating the radial artery into the right atrium, including using flushes of saline. Potential contraindications like arm trauma or breast cancer are noted. The document argues learning both arterial and venous radial techniques will improve cardiologist skills and safety.
This document discusses techniques for radial artery puncture for cardiovascular procedures. It notes that the radial artery is smaller in diameter than the femoral artery. Successful radial access requires correctly positioning and securing the wrist. Ultrasound guidance can help find and access the radial artery, especially for trainees. The initial puncture approach can be anterior wall only or use a counterpuncture technique. Sheath size, length, and coating impact radial artery spasm and occlusion. Cocktails including nitroglycerine and calcium channel blockers are commonly used but acid in the cocktail may damage the artery if felt by the patient.
This document summarizes a presentation given by Dr. Olivier Bertrand on post-PCI FFR measurement. It discusses studies showing that a post-PCI FFR of 0.90 or higher is associated with lower rates of re-PCI and major adverse cardiac events. It then outlines the proposed PREDICT randomized study to evaluate whether routine post-PCI FFR measurement can guide PCI strategy and completion. The study would measure FFR after successful PCI in all-comers and randomize patients to clinical follow-up alone or with guidance from the post-PCI FFR results. The goal is to establish if physiology-guided PCI optimization can improve outcomes and reduce costs.
This document summarizes lessons learned from the DEFINE-FLAIR and iFR-SWEDEHEART clinical trials. The trials found:
1) Decision-making based on instantaneous wave-free ratio (iFR) was non-inferior to fractional flow reserve (FFR) for guiding revascularization and reducing major adverse cardiac events over 1-2 years.
2) iFR-guided decisions resulted in significantly less revascularization procedures compared to FFR.
3) Subgroup analysis found increased event rates among diabetic patients evaluated with FFR compared to iFR.
4) iFR has been upgraded to a Class IA recommendation in European Society of Cardiology guidelines based on these trials
1. The document discusses the use of physiology in acute coronary syndrome (ACS) patients, including trials evaluating fractional flow reserve (FFR) and index myocardial resistance (IMR) measurements.
2. Several trials showed that FFR-guided revascularization in multivessel disease STEMI patients reduced major cardiac events compared to culprit-only PCI or medical therapy. Ongoing trials are further evaluating FFR in ACS.
3. IMR predicts mortality and heart failure in STEMI patients and adversely remodeling post-STEMI.
4. Incomplete revascularization is common in ACS and associated with worse outcomes; FFR may help guide more complete revascularization. The clinical utility of physiology in ACS
This document discusses the potential use of 4 French (4F) catheters for fractional flow reserve (FFR) measurements as a less invasive alternative to larger catheters. It notes that 4F catheters have a smaller profile but can lack the ability to directly perform percutaneous coronary intervention if needed. The document outlines key considerations for using 4F catheters, including ensuring the catheter lumen is well flushed and the pressure transducer is not damped. It concludes that improvements are still needed, such as reducing friction between the pressure wire and catheter, in order to maximize the benefits of using the smallest catheter size possible.
This document discusses using fractional flow reserve (FFR) to evaluate ambiguous left main coronary artery disease. It presents a case of an 82-year-old woman with chest pain and a recent stent in the circumflex artery. FFR measurements of the left main and left anterior descending artery were 0.64, indicating significance. Intravascular ultrasound also suggested significance. The left main and proximal left anterior descending artery were stented, and post-procedure FFR measurements improved. The document reviews evidence that FFR can safely guide decisions about revascularization of ambiguous left main lesions.
This document summarizes a presentation on CT-derived fractional flow reserve (FFR-CT). It discusses how FFR-CT increases the positive predictive value of coronary CT angiography (CTCA). Several landmark studies are summarized that evaluated the diagnostic accuracy of FFR-CT compared to CTCA. The PACIFIC trial findings showing high diagnostic accuracy of FFR-CT are described. Ongoing and upcoming clinical trials using FFR-CT like PRECISION and DECISION are mentioned. Novel applications of FFR-CT for biomechanics analysis and PCI planning are presented. Finally, new methods like user-generated CT-FFR that may reduce processing time are introduced, though accuracy needs further evaluation.
This document summarizes the results of a study evaluating the diagnostic accuracy of quantitative flow ratio (QFR) compared to fractional flow reserve (FFR) as the reference standard. The study included 317 lesions in 273 patients. Key results included:
- QFR showed superior sensitivity and specificity for detecting functionally significant lesions compared to 2D quantitative coronary angiography.
- QFR values correlated well with invasive FFR measurements.
- QFR could be computed within a similar time frame as FFR measurements.
- A hybrid approach using QFR and FFR may allow pressure wire-free assessment in 68% of lesions while maintaining high diagnostic accuracy.
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Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
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Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
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3. CURE Efficacy
CREDO Efficacy
CURE Safety*
CREDO Safety**
Yusuf S, et al. N Engl J Med 2001;345:494-502
Steinhubl SR, et al. JAMA 2002;288:2411-2420
4. CURE: Cardiovascular Death/Myocardial Infarction/Stroke
During First 30 Days
25% NSTEMI (75% UA), ~21% revascularization
Cumulative Hazard Rates
0.06
Placebo + Aspirin
0.05
0.04
Clopidogrel + Aspirin
0.03
RRR=21%
95% CI (0.67-0.92)
p=0.003
0.02
0.01
0.0
0
Number:
Placebo
Clopidogrel
24-48h
6303
6259
10
20
30
Days of Follow-up
6108
6103
5998
6035
5957
5984
CURE Investigators. N Engl J Med 2001;345:494-502
5. CREDO: Effect of the Delay of Pre-treatment– 28 days
P=0.020 for interaction between the delay of pretreatment and the protection against ischemic events
Events (%)
Pre-treatment- No Pren
Clopidogrel treatment
< 6 hrs
7.9
7.0
9.4
851
No-PT
Better
893
6 to 24 hr * 5.8
PT-Clopidogrel
Better
RRR 38.6
P=0.05
RRR 18.5
P=0.23
Overall CREDO Results
0.4
-2
RRR -13.4
P=NS
0.6
0.8
1.0
1.2
Hazard ratio (95% CI)
Placebo
-3
-4
*Significant effect ≥ 15h after loading
-5
Clopidogrel
-6
0
5
10
15
20
25
30
Steinhubl SR, et al JAMA 2002;288:2411-2420
Steinhubl SR, et al. JACC 2006;47:939-943
6. PCI Pre-Treatment
(With 300 mg load) Events
Trial
CV Death or MI after PCI to 30 days
OR (95% CI)
PCI-CURE
CREDO
PCI-CLARITY
Overall
P=0.004
0.25
0.5
Favors
Pre-treatment
1.0
2.0
Favors
No Pre-treatment
Sabatine. et al. JAMA. 2005;294:1224-1232
7. P2Y12 Pre-treatment Recommendations
Title
Citation
Class
LOE
2011 ESC guidelines for the
management of acute coronary
syndromes in patients
presenting without persistent
ST-segment elevation
European Heart Journal
2011;32:2999–3054
“A P2Y12 inhibitor as
soon as possible”
Clopidogrel 600 mg
Ticagrelor
I
A
I
I
B
B
2010 ESC/EACTS guidelines on
myocardial revascularization
European Heart Journal
2010;31:20:2501–2555
“Clopidogrel 600 mg
as soon as possible”
I
C
2012 ACCF/AHA focused update
of the guideline for the
management of patients with
unstable angina/non-ST-elevation
myocardial infarction
Circulation
2012;126:875–910
“If invasive strategy,
before PCI”
Clopidogrel
Ticagrelor
*Prasugrel
I
I
B
B
2011 ACCF/AHA/SCAI guideline
for percutaneous
coronary intervention
Circulation
2011;124:e574–651
P2Y12 inhibitor
Clopidogrel
Prasugrel
Ticagrelor
I
I
I
I
A
B
B
B
* Prasugrel 60 mg may be considered for administration promptly upon presentation in patients with
UA/NSTEMI for whom PCI is planned, before definition of coronary anatomy if both the risk for bleeding is
low and the need for CABG is considered unlikely (Level of Evidence: IIb – C)
8. PRAGUE-8 - All Patients
PRAGUE-8 - PCI Patients
Widimsky P, et al. Eur Heart J 2008;29:1495-1503
ARMYDA-5 Efficacy
ARMYDA-5 Safety
Di Sciascio G, et al. J Am Coll Cardiol 2010;56:550-557
9. Death
1/204
1/164
13/933
18/1053
32/1313
0/103
1/513
66/4283
0/205
4/171
24/930
24/1063
31/1345
2/96
0/515
85/4325
Relative
Weight [%]
3·03 [0·12-74·80] 1·0%
0·26 [0·03-2·32] 2·2%
0·53 [0·27-1·05] 23·2%
0·75 [0·41-1·40] 28·3%
1·06 [0·64-1·75] 43·1%
0·18 [0·01-3·85] 1·2%
3·02 [0·12-74·25] 1·0%
0·80 [0·57-1·11] 100%
105/3511
114/5087
219/8598
49/1515
14/832
63/2347
0·92 [0·65-1·30]
1·34 [0·77-2·34]
1·04 [0·74-1·46]
68·2%
31·8%
100%
13/923
209/4879
12/217
18/467
6/1481
76/4477
334/12444
19/990
110/1076
6/166
18/574
18/2679
12/332
183/5817
0·73 [0·36-1·49]
0·39 [0·31-0·50]
1·56 [0·57-4·25]
1·24 [0·64-2·41]
0·60 [0·24-1·52]
0·46 [0·25-0·86]
0·68 [0·42-1·09]
16·2%
24·0%
11·9%
17·0%
12·9%
17·8%
100%
Events / Size, Clopidogrel
Pretreatment No Pretreat
Randomized CT
ARMYDA5 Preload
CIPAMI
CLARITY PCI
CREDO
PCI CURE
Davlouros et al.
PRAGUE 8
All N=8,608
OR [CI 95%]
OR=0·80 CI 95% [0·57-1·11] P=0·17
Observational from RCT
ACUITY PCI
REPLACE 2
All
N=10,945
OR=1·04 CI 95% [0·74-1·46] P=0·83
Observational
Amin et al.
Dorler et al.
Fefer et al.
Feldman et al.
Szuk et al.
Chan et al.
All
N=18,261
OR=0·68 CI 95% [0·42-1·09] P=0·11
Pre-treatment better
0
No Pre-treatment better
0.5
1
1.5
2
2.5
3
3.5
4
Bellemain-Appaix A et al. JAMA 2012;308:2507-2516
10. PCI-NSTEACS Death
Major Bleeding
MACE
Randomized CT
CREDO
PCI CURE
All
N=4 774
OR=0.93 CI 95% [0·63-1·36] p=0·69
OR=1·28 CI 95% [0·98-1·67] p=0·07
OR=0·75 CI 95% [0·64-0·87] p=0·0002
OR=1·19 CI 95% [0·90-1·58] p=0·22
OR=1.10 CI 95% [0·94-1·29] p=0·23
Observational from RCT
ACUITY-PCI
All
N=5 026
OR=0·92 CI 95% [0·65-1·30] p=0·65
Observational
Assali
Feldman et al.
TARGET
All
N=6 149
OR=0·58 CI 95% [0·23-1·48] p=0·26
All Studies
N=15 949
0.01
OR=0·81 CI 95% [0·58-1·13]
p=0·22
0.1
PreT better
1
No PreTt better 10 0.1
OR=0·89 CI 95% [0·48-1·65] p=0·72
OR=1·20 CI 95% [1·00-1·44]
p=0·048
PreTt better
1
No PreTt better
OR=0·86 CI 95% [0·59-1·25] p=0·43
OR=0·86 CI 95% [0·70-1·05]
p=0·14
10 0.1
PreTt better
1
No PreTt better
10
Bellemain-Appaix A et al. ESC 2013. P4846
11.
12. ACCOAST design
NSTEMI + Troponin ≥ 1.5 times ULN local lab value
Clopidogrel naive or on long term clopidogrel 75 mg
Randomize 1:1
n~4100 (event driven)
Double-blind
Prasugrel 30 mg
Coronary
Angiography
Coronary
Angiography
Prasugrel 30 mg
Prasugrel 60 mg
PCI
CABG
or
Medical
Management
(no more prasugrel)
Placebo
PCI
CABG
or
Medical
Management
(no prasugrel)
Prasugrel 10 mg or 5 mg (based on weight and age) for 30 days
1° Endpoint: CV Death, MI, Stroke, Urg Revasc, GP IIb/IIIa inh. Bailout, at 7 days
Montalescot G et al. Am Heart J 2011;161:650-656
26. Non-CABG TIMI Major Bleeding Endpoints
Through 7 Days (All Treated Patients)
3,0
Pre-treatment (N=2037)
Most Frequent Locations of Major Bleed
No Pre-treatment (N=1996)
Event Rate (%)
2,5
2,0
P=0.003
1,5
1,33
P=0.002
1,0
0,83
P not evaluable
0,45
0,5
0,05
0
0,15
0,0
N=
27
9
Non-CABG TIMI Major Bleeding
1
0
Fatal Bleeding
17
3
Life Threatening Bleeding
27. Conclusions
● In NSTE-ACS patients managed invasively within 48
hours of admission, pre-treatment with prasugrel does
not reduce major ischemic events through 30 days but
increases major bleeding complications.
● The results are consistent among patients undergoing
PCI supporting treatment with prasugrel once the
coronary anatomy has been defined.
● No subgroup appears to have a favorable risk/benefit
ratio of pre-treatment.
● Reappraisal of routine pre-treatment strategies in NSTEACS is needed.
Editor's Notes
See page 2538 of 2010 ESC/EACTS guidelines on myocardial revascularizationSee page 2587 of 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention[source: page 3018 Hamm et al Eur Heart J 2011;32(23):2999-3054. ][source: page 665-666 Jneid et al J Am CollCardiol 2012;60(7):645-81. ]