This ppt will tell us about the problem which a cardiologist has to face after implantation of Drug eluting stent in a patient of coronary artery diseases. Although there are lots of problem but i am going to describe only three major problem.
rotablation is procedure used in complex pci with heavily calcified lesion for adequate expansion of stent.if used in indicated case and well aware of contraindication is necessary for achieving good results.
Coronary CTO is characterized by heavy atherosclerotic plaque burden within the artery, resulting in complete (or nearly complete) occlusion of the vessel. Although the duration of the occlusion is difficult to determine on clinical grounds, a total occlusion must be present for at least 3 months to be considered a true CTO. Patients with CTO typically have collateralization of the distal vessel on coronary angiography, but these collaterals may not provide sufficient blood flow to the myocardial bed, resulting in ischemia and anginal symptoms. CTO is clinically distinct from acute coronary occlusion, which occurs in the setting of ST-segment–elevation myocardial infarction, or subacute coronary occlusion, discovered with delayed presentation after ST-segment–elevation myocardial infarction. Clinical features and treatment considerations of these entities differ considerably from CTO.
Among patients who have a clinical indication for coronary angiography, the incidence of CTO has been reported to be as high as 15% to 30%. Patients with CTO are referred for angiography because of anginal symptoms or significant ischemia on noninvasive ischemia testing. Patients who are symptomatic will have stable exertional angina resulting from a limitation of collateral vessel flow to meet myocardial oxygen demand with stress. Of patients referred for PCI in clinical trials of CTO PCI, only 10% to 15% of patients are asymptomatic. It is likewise uncommon for patients with CTO to present with an acute coronary syndrome caused by the CTO itself.
Significant, defined as a greater than 50 percent narrowing, left main coronary artery disease is found in 4 to 6 percent of all patients who undergo coronary arteriography. When present, it is associated with multivessel coronary artery disease about 70 percent of the time
A stent is a small, expandable tube. During a procedure called angioplasty, the stent is inserted into a coronary artery and expanded using a small balloon. A stent is used to open a narrowed or clotted artery.
rotablation is procedure used in complex pci with heavily calcified lesion for adequate expansion of stent.if used in indicated case and well aware of contraindication is necessary for achieving good results.
Coronary CTO is characterized by heavy atherosclerotic plaque burden within the artery, resulting in complete (or nearly complete) occlusion of the vessel. Although the duration of the occlusion is difficult to determine on clinical grounds, a total occlusion must be present for at least 3 months to be considered a true CTO. Patients with CTO typically have collateralization of the distal vessel on coronary angiography, but these collaterals may not provide sufficient blood flow to the myocardial bed, resulting in ischemia and anginal symptoms. CTO is clinically distinct from acute coronary occlusion, which occurs in the setting of ST-segment–elevation myocardial infarction, or subacute coronary occlusion, discovered with delayed presentation after ST-segment–elevation myocardial infarction. Clinical features and treatment considerations of these entities differ considerably from CTO.
Among patients who have a clinical indication for coronary angiography, the incidence of CTO has been reported to be as high as 15% to 30%. Patients with CTO are referred for angiography because of anginal symptoms or significant ischemia on noninvasive ischemia testing. Patients who are symptomatic will have stable exertional angina resulting from a limitation of collateral vessel flow to meet myocardial oxygen demand with stress. Of patients referred for PCI in clinical trials of CTO PCI, only 10% to 15% of patients are asymptomatic. It is likewise uncommon for patients with CTO to present with an acute coronary syndrome caused by the CTO itself.
Significant, defined as a greater than 50 percent narrowing, left main coronary artery disease is found in 4 to 6 percent of all patients who undergo coronary arteriography. When present, it is associated with multivessel coronary artery disease about 70 percent of the time
A stent is a small, expandable tube. During a procedure called angioplasty, the stent is inserted into a coronary artery and expanded using a small balloon. A stent is used to open a narrowed or clotted artery.
A presentation regarding a analysis of the marketplace for stents and also how Abbott could enter the market with their new stent technology in order to acquire the most amount of customers.
MT5007: The coronary stent revolution (A group project for the Management of ...Stefan
This project tracks the development of coronary artery disease interventions, ranging from early method of cardiac bypass to balloon angioplasty to the development of biomedical stents. Analyses of the competitive climate in the biomedical stents industry is discussed. New market and technology strategies are proposed for a regional MNC to leverage domestic industry infrastructure within emerging economies accompanied by a projected 30% growth in CAD due to increased consumption trends and lifestyle factors, e.g. smoking.
Noncardiac surgery (NCS) is associated with a considerable risk of adverse cardiac events among individuals with coronary artery or aortic valve disease
Thrombolysis and thrombectomy for acute ischaemic strokeHan Naung Tun
Reperfusion by intravenous thrombolysis or endovascular
mechanical thrombectomy improves functional outcomes
after stroke, but benefit for both treatment modalities is highly
time-dependent. Maximum benefit requires minimisation
of onset-to-treatment times. The safety and efficacy of IV
rtPA is established across a broad range of clinical scenarios.
Endovascular treatment now offers greatly improved outcome
among patients with poor response to IV rtPA but efficacy
has been established only in the context of highly organised
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In this ppt, I am going to discuss the role of ICD in the patient with Non-ischemic cardiomyopathy. I am going to discuss all the major trials done in the patient with non-ischemic cardiomyopathy.
2015 Jones criteria for the diagnosis of rheumatic feverPRAVEEN GUPTA
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June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
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at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
1. Problem associated with Drug eluting stent
Presenter
Dr PRAVEEN GUPTA
Moderator
Dr. Ajith Ananthakrishna
Pillai
Date
16/09/2016
Departement of Cardiology,
JIPMER,
Pondicherry (India)
1
2. Stent thrombosis
Introduction
Most feared complication
with low-pressure inflation
and single-antiplatelet
therapy, 20% ST
Dual-antiplatelet therapy
(DAPT) ,adequate stent
expansion using high-
pressure balloon inflation
achieved 1.6% rate of ST
at 6-month follow-up
Up to 1 year follow-up for
DES - 0.6% to 3.2%
2
7. Clinical Presentation,
Chest pain
Ischemic electrocardiographic changes in the target
vessel territory.
Sudden death,
It can be asymptomatic in the setting of collateral
vessels.
7
8. Angiographic characteristics of definite stent thrombosis: role
of thrombus grade, collaterals, epicardial coronary flow, and
myocardial perfusion.
8
The majority of ST patients present with late/very late ST with high
thrombus burden and STEMI. Presence of collateral vessels and low
thrombus burden is cardioprotective, while reduced initial TIMI flow is
associated with larger infarct size and recurrent ST.
9. Diagnosis
Angiographic detection of thrombus is the presence of a filling
defect.
intravascular ultrasound (IVUS) For underlying mechanism
responsible for stent thrombosis
optical coherence tomography (OCT)
9
10. Mechanisms
DES induce platelet adhesion, activation and thrombus
formation
Cytotoxic drugs-inhibit endothelialisation .
Sirolimus & paclitaxel -activation of the coagulation system.
The polymers -hypersensitivity reaction / prothrombotic
environment
10
11. Mechanisms
Persistent slow coronary blood flow and low shear stress
leading to activation of the intrinsic pathway;
Premature discontinuation of DAPT
Systemic prothrombotic state (e.g., due to ACS or
malignancy).
• Most consistently reported predictors are early DAPT
discontinuation, the extent of coronary artery disease, and
total stent length
11
12. Early ST
technical and procedural
factors are important.
A suboptimal procedural
result
slow flow,
inadequate post-procedural
lumen dimensions,
residual dissection,
tissue prolapse
discontinuation of
DAPT
Stenting in
prothrombotic
conditions in patients
with ACS/malignancy
12
13. Late and very late ST
Delayed endothelial coverage, persistent fibrin deposition, &
ongoing vessel inflammation
DES compared with BMS
Late stent malapposition more commonly in DES compared
with BMS
neoatherosclerotic plaques - rupture, causing ST
13
14. In-stent Restenosis
Introduction
gradual re-narrowing of the
stented segment occurs mostly
between 3 to 12 months after
stent placement.
DES -restenosis rates 0%- 16%
target vessel revascularization
(TVR), 5% to 10
Presents as recurrent angina,
but can present as acute
myocardial infarction in
approximately 10 percent of
patients.
14
15. Definition
Angiographic” restenosis means recurrent diameter stenosis
(late lumen loss – LLL) >50% within the stent segment or its
edges (5 mm segments adjacent to the stent) in follow-up
“Clinical” restenosis, symptoms or ischemia recurrence with
>50% diameter stenosis or >70% diameter stenosis without
symptoms
15
17. Morphological classification of ISR
Mehran system,
Pattern I – focal (ISR ≤ 10
mm),
Pattern II – diffuse (ISR > 10
mm),
Pattern 3 – proliferative (ISR >
10 mm extending outside the
stent)
Pattern IV – occlusion
(occlusive ISR)
This system was primarily
created concerning BMS-ISR,
but it also has prognostic value
in DES-ISR
17
20. Biological factors
Resistance to antiproliferative drugs.
Mutations of the gene polymorphism that encode mTOR -
resistance to sirolimus (rapamycin).
Hypersensitivity reactions to the polymer
Inflammatory response associated with sirolimus eluting stents
(SES) /everolimus-eluting stent (EES)
Hypersensitivity reactions to the metallic stent platform
20
21. Arterial factors
High-shear stress areas like carina of the bifurcation can
potentially limit progression of atherosclerosis,
Low-shear stress areas like ostium of a bifurcation may lead to
promotion of atherosclerosis or enhancement of neointimal
proliferation.
Positive vessel remodeling may be also a contributable factor
for development of DES-ISR.
21
23. Stent factors
stent underexpansion
( major risk-factor for ISR)
stent malapposition
stent fracture,
type of DES (type of drug
and polymer release
kinetics),
23
24. Stent factors
nonuniform drug deposition/ distribution,
strut thickness and polymer disruption or peeling.
Type of drug and polymer release kinetics
24
25. Stent factors
thicker stent struts -increased risk from ISR
Polymer disruption, peeling and cracking -increasing the risk
for ISR
aggressive kissing-balloon postdilatation
After using non-compliant balloons on high pressure
atmospheres.
25
27. Noncardiac surgery after percutaneous coronary
intervention
5 to 10% of patients
undergo noncardiac surgery
within one year of stent
implantation
risks of ACS with premature
cessation and bleeding with
continuation of antiplatelet
therapy
27
28. COMPLICATIONS
patients who undergo major noncardiac surgery within six
weeks, and particularly within two weeks, of PCI with bare-
metal (BMS) or drug-eluting stents (DES) have an increased
risk of adverse cardiovascular events.
These events are often due to stent thrombosis, which lead to
high rates of myocardial infarction (50 to 70 percent) and
death (10 to 40 percent
28
29. Causes
• Premature cessation of antiplatelet therapy
• Prothrombotic and proinflammatory effects of surgery
• Incomplete strut coverage
29
31. Noncardiac surgery after percutaneous coronary
intervention
• The importance of the continuation of antiplatelet therapy in
the perioperative period was evaluated and confirmed in a
multicenter, retrospective study of 666 patients with prior
coronary stenting who subsequently underwent cardiac or non-
cardiac (86 percent) surgery
31
32. Noncardiac surgery after percutaneous coronary
intervention
• Comparing those who discontinued therapy to those who did
not, the following findings were noted:
• The rate of MACE was higher (7.5 versus 0.3 percent; p =
0.027)
• After adjustment, perioperative antiplatelet discontinuation
was the strongest independent predictor of MACE
32
33. Noncardiac surgery after percutaneous coronary intervention
• Continuation of aspirin was associated with a significantly
lower risk of MACE
• For non-CABG surgical patients, aspirin alone or with
P2Y12 receptor blocker increases the risk of bleeding by as
much as 20 and 50 percent, respectively, and these rates are
dependent on the location of the surgery . This excess bleeding
leads to an increase in red blood cell transfusion, but not to an
increase in surgical mortality or morbidity
33
34. Approach to a patient for major surgery following recent
coronary artery stenting
• No accepted standard approach
• Multidisciplinary discussion should take place.
• The key questions are
• When was the PCI done?
• What is the type of stent?
• How many stents were placed?
• Was the revascularization complete?
34
35. Approach to a patient for major surgery following recent
coronary artery stenting
• Drug regime and any irregularities of the treatment?
• History of any adverse cardiac event/stent thrombosis?
• Urgency of surgery? / Can the surgery be delayed?
• Bleeding risk during surgery?
• History of conditions prone to stent thrombosis
• Whether antiplatelet medication is to be maintained in
perioperative period or stopped before operation?
• Investigations for platelet count and platelet function should be
undertaken. Whole blood and platelet concentrates should be
arranged prior to surgery.
35
38. Approach to a patient for major surgery following recent
coronary artery stenting
• low risk for bleeding, continue DAPT
• Intermediate-bleeding-risk case-by-case basis.
• complex stent procedures and co-morbidities,
continue DAPT
38
39. Approach to a patient for major surgery following
recent coronary artery stenting
• High-bleeding-risk surgical procedures Patients with 12
months completed of DAPT and low risk for thrombosis of the
coronary artery stents can stop clopidogrel and ticagrelor 5
days prior to surgery and prasugrel 7 days before surgery
while continuing ASA.
• DAPT should be restarted as soon as possible postoperatively
(ideally within 24 hours) with a loading dose of 300 mg - 600
mg clopidogrel, or prasugrel 60 mg, or ticagrelor 180 mg.
39
40. Approach to a patient for major surgery following
recent coronary artery stenting
• For patients with coronary stents with high risk for thrombosis
presenting for high-risk bleeding surgical procedures, “bridge”
therapy has been suggested.
• Short-acting GP IIb/IIIa inhibitors, -tirofiban or eptifibatide,
as a bridge between the time of the thienopyridine
discontinuation and surgery.
• Given as infusion and requires patient admission to the
hospital 3 days after the discontinuation of thienopyridines
40
41. Approach to a patient for major surgery following recent
coronary artery stenting
• Infusion is stopped 4 to 6 hours prior to surgical
procedure and restarted as soon as possible after the
surgery
41
42. Approach to a patient for major surgery following recent
coronary artery stenting
• Cangrelor, an investigational parenteral, reversible,
direct P2Y12 platelet inhibitor with its extremely
short (5 to 9 minutes) half-life, may present an
alternative for “bridge” therapy in the near future.
42
43. Approach to a patient for major surgery following
recent coronary artery stenting
• Platelet Transfusion
• Blood transfusions
• hemorrhage that continues despite the usual
hemostatic techniques, however, platelet
transfusion may be considered as a strategy to
reverse bleeding, even if platelet count is
normal.
43
44. Take home message
• Stent thrombosis -Most
feared complication
• DES -restenosis rates 0%-
16%
• Perioperatvie cardiac
events are often due to
stent thrombosis
• Most consistently
reported predictors are
early DAPT
discontinuation
44
45. Take home message
• low risk for bleeding, continue DAPT
• Intermediate-bleeding-risk case-by-case basis.
• complex stent procedures and co-morbidities,
continue DAPT
• patients with stents in need of urgent surgical
procedures If the time is less than one year (or less
than one month for BMS), then the DAPT has to be
continued throughout, except for surgeries in
enclosed spaces.
45