A 45-year-old man benefited from primary PCI for STEMI. The adjunctive antithrombotic therapy consisted of aspirin, heparin, and abciximab.
The addition of abciximab is associated with:
No significant difference in the risk of stroke. Abciximab, a potent inhibitor of the platelet glycoprotein IIb/IIIa receptor, reduces thrombotic complications in high-risk patients undergoing PCI in the setting of ACS compared with a regimen of aspirin and UFH. Akkerhuis et al. combined analysis of data from 8,555 patients undergoing PCI assigned to receive a bolus and infusion of abciximab (n = 5,476) or matching placebo (n = 3,079). No significant difference in stroke rate was observed between patients assigned abciximab (n = 22 [0.40%]) and those assigned placebo (n = 9 [0.29%]; P = 0.46). The rate of nonhemorrhagic stroke was 0.17% in patients treated with abciximab and 0.20% in patients treated with placebo (difference: –0.03%; 95% CI: –0.23% to 0.17%), and the rates of hemorrhagic stroke were 0.15% and 0.10%, respectively (difference: 0.05%; 95% CI: –0.11% to 0.21%). Abciximab in addition to aspirin and heparin does not increase the risk of stroke in patients undergoing PCI.
A 65-year-old diabetic man known for a multivessel coronary disease underwent revascularization with CABG.
What is the target LDL-C that should be aimed?
70 mg/dL. For patients with established CAD, LDL-lowering therapies significantly reduce the risk of MACE and yield highly favorable costeffectiveness ratios. In high-risk persons, the recommended LDL-C goal is <100 mg/dL. An LDL-C goal of <70 mg/dL is a therapeutic option on the basis of available clinical trial evidence, especially for patients at very high risk. Diabetic patients with established advanced CAD, like the mentioned patient, should be considered at very high risk for MACE and qualify for the ambitious target of LDL <70 mg/dL.
A 62-year-old man was hospitalized for an NSTEMI and underwent invasive strategy with DES-based PCI.
Which of the following statements about antiplatelet therapy is wrong?
Additional aspirin (81 to 325 mg) is recommended in all patients on chronic aspirin therapy before PCI. The 2011 AHA/ACC PCI guidelines recommend the use of antiplatelet therapy before PCI. 5 Aspirin reduced ischemic CV events after PCI and should be given at least 2 hours before PCI after which aspirin has to be continued indefinitely. In addition to aspirin, a loading dose of P2Y12 receptor inhibitor might be given to patients undergoing PCI with stenting. Options include clopidogrel 600 mg, prasugrel 60 mg, or ticagrelor 180 mg. The duration of P2Y12 receptor inhibitor after stent implantation (BMS or DES) for ACS should be of at least 12 months. Options include clopidogrel 75 mg daily, prasugrel 10 mg daily, and ticagrelor 90 mg twice daily. In patients receiving DES for a non-ACS indication, clopidogrel 75 mg daily should be given for 12 months if patients are not at high risk for bleeding. In patients receiving BMS for a non-ACS indication, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months. A benefit of additional aspirin in patients on chronic aspirin undergoing PCI has never been demonstrated.
A 59-year-old man was successfully treated with PCI for NSTEMI. During the procedure, the patient received bivalirudin. Due to closure device failure, the patient suffered a major bleeding at the access site difficult to control with manual compression and you are in need of reversing the anticoagulation.
Your treatment of choice is:
Prothrombin complex. Bivaluridin is a naturally occurring anticoagulant secreted by the salivary glands of the leech Hirudo medicinalis. It is a potent and specific anticoagulant and exerts its action by binding directly to the active catalytic site of thrombin. Unlike heparin, it does not require a cofactor (antithrombin) and does not appear to cause immune-mediated thrombocytopenia. It is also a more potent inhibitor of platelet function than heparin, probably because of a direct inhibitory effect on thrombin. Unlike heparin, which is readily neutralized by protamine or platelet factor 4, a specific agent useful in reversing the effects of bivalirudin is unavailable. Irani et al. demonstrated the first clinical experience, suggesting benefit from prothrombin complex concentrate in neutralizing the effect of rhirudin. Although the specific mechanism of action remains unclear, the generation of additional thrombin probably plays a role. Also, epinephrineinduced platelet aggregation in hirudinized platelet-rich plasma is restored by addition of prothrombin complex concentrate, most probably by additional thrombin generation. Adverse effects of prothrombin complex concentrate include intravascular thrombosis, particularly in patients with liver disease and possible viral hepatitis. As the product contains some activated clotting factors (II, VII, IX, and X) and has thrombogenic potential, it should be used as a last resort, especially in patients with liver disease. Clinical experience suggests that prothrombin complex concentrate in a dose of 25 to 30 UI/kg can be considered for patients with lifethreatening hemorrhage caused by bivalirudin.
A 63-year-old man presents typical chest pain at moderate exertion in the preceding month and he is admitted to the hospital for coronary angiography. While considering the best access for the procedure, which of the following statements is not correct regarding a radial vascular access?
The radial vascular access is more frequently performed in the United States than in Europe. Radial site access is used more frequently in Europe and Canada than in the United States. The 2011 AHA/ACC PCI guidelines recommend radial artery access to decrease access site complications. 5 In fact, it has been demonstrated that radial access, compared with femoral access, decreases the rate of access-related bleeding and complications. 47 Its utility is more pronounced in patients at higher risk for bleeding or vascular access complications such as in patients with coagulopathy, anticoagulated, or morbid obesity.
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