Background: Clopidogrel has largely replaced ticlopidine following coronary stent implantation. Recently, concern has been raised regarding the possibility of excess long term mortality in patients given clopidogrel r...Background: Clopidogrel has largely replaced ticlopidine following coronary stent implantation. Recently, concern has been raised regarding the possibility of excess long term mortality in patients given clopidogrel rather than ticlopidine following coronary stenting. Methods: We studied 1519 consecutive patients who underwent 2020 stent implantations and were discharged on dual antiplatelet regimens of either aspirin and ticlopidine or aspirin and clopidogrel given for up to 4 weeks. Thrombotic stent occlusion(TSO) was defined as ST elevation myocardial infarction in the stented artery territory associated with angiographic demonstration of complete stent occlusion. Mortality follow up was obtained for all patients by linkage to the Population Register. Follow up duration was 12 months. Results: TSO occurred in 37 stents at a median of 29 days post procedure. Of these cases, six occurred in the ticlopidine group(0.7%) and 31 in the clopidogrel group(2.8%)(p< 0.01). The median time to TSO was 34 days and 28 days in ticlopidine and clopidogrel treated patients, respectively(p< 0.01). After controlling for multiple demographic, clinical and angiographic variables clopidogrel(vs. ticlopidine) treatment remained the sole predictor of TSO(OR: 5.4,95%CI=1.2-24.1, p=0.028). Of even more concern, clopidogrel treatment was associated with an increased risk of 1 year mortality(OR: 1.8, 95%CI=1.2-2.8). Conclusions: Long term follow up after stent implantation in patients receiving the traditional 2-4 weeks course of dual antiplatelet therapy reveals increased rates of TSO and mortality in patients given clopidogrel as opposed to ticlopidine. Whether longer treatment with clopidogrel will change these observations deserves further study.展开更多
Background: Enoxaparin has gained wide acceptance in patients with acut e coron ary syndromes. However, there is uncertainty regarding management of patients wh o require coronary intervention while on enoxaparin. Som...Background: Enoxaparin has gained wide acceptance in patients with acut e coron ary syndromes. However, there is uncertainty regarding management of patients wh o require coronary intervention while on enoxaparin. Some physicians withhold th e morning dose of enoxaparin prior to coronary intervention while others switch patients to unfractionated heparin. Both methods do not provide optimal anticoag ulation in the hours preceding intervention. There are no published controlled data to assess the safety of coronary intervention using enoxaparin alone in patients with acute coronary syndromes. Methods: We p rospectively compared enoxaparin to unfractionated heparin during coronary angio graphy and intervention. Sixty four patients admitted to the coronary care unit( CCU)were given enoxaparin twice daily, including on the morning of procedure. Co ronary angiography and intervention were performed without additional unfraction ated heparin. The control group comprised of 52 patients admitted to Internal Me dicine for an acute coronary syndrome. These were also given enoxaparin but the morning dose was withheld and unfractionated heparin was used during procedure. Results: Patients in both groups had similar baseline characteristics. No signif icant differences were observed between the two groups in procedural success rat e, complications or bleeding. One year follow up showed similar rates of hospita lization and mortality. Conclusion: Enoxaparin seems to offer safe and effective procedural anticoagulation in patients undergoing percutaneous intervention for acute coronary syndromes. Patients given enoxaparin can probably have coronary intervention without interruption of enoxaparin treatment and without additional procedural anticoagulation. These findings require confirmation in larger, rand omized trials.展开更多
文摘Background: Clopidogrel has largely replaced ticlopidine following coronary stent implantation. Recently, concern has been raised regarding the possibility of excess long term mortality in patients given clopidogrel rather than ticlopidine following coronary stenting. Methods: We studied 1519 consecutive patients who underwent 2020 stent implantations and were discharged on dual antiplatelet regimens of either aspirin and ticlopidine or aspirin and clopidogrel given for up to 4 weeks. Thrombotic stent occlusion(TSO) was defined as ST elevation myocardial infarction in the stented artery territory associated with angiographic demonstration of complete stent occlusion. Mortality follow up was obtained for all patients by linkage to the Population Register. Follow up duration was 12 months. Results: TSO occurred in 37 stents at a median of 29 days post procedure. Of these cases, six occurred in the ticlopidine group(0.7%) and 31 in the clopidogrel group(2.8%)(p< 0.01). The median time to TSO was 34 days and 28 days in ticlopidine and clopidogrel treated patients, respectively(p< 0.01). After controlling for multiple demographic, clinical and angiographic variables clopidogrel(vs. ticlopidine) treatment remained the sole predictor of TSO(OR: 5.4,95%CI=1.2-24.1, p=0.028). Of even more concern, clopidogrel treatment was associated with an increased risk of 1 year mortality(OR: 1.8, 95%CI=1.2-2.8). Conclusions: Long term follow up after stent implantation in patients receiving the traditional 2-4 weeks course of dual antiplatelet therapy reveals increased rates of TSO and mortality in patients given clopidogrel as opposed to ticlopidine. Whether longer treatment with clopidogrel will change these observations deserves further study.
文摘Background: Enoxaparin has gained wide acceptance in patients with acut e coron ary syndromes. However, there is uncertainty regarding management of patients wh o require coronary intervention while on enoxaparin. Some physicians withhold th e morning dose of enoxaparin prior to coronary intervention while others switch patients to unfractionated heparin. Both methods do not provide optimal anticoag ulation in the hours preceding intervention. There are no published controlled data to assess the safety of coronary intervention using enoxaparin alone in patients with acute coronary syndromes. Methods: We p rospectively compared enoxaparin to unfractionated heparin during coronary angio graphy and intervention. Sixty four patients admitted to the coronary care unit( CCU)were given enoxaparin twice daily, including on the morning of procedure. Co ronary angiography and intervention were performed without additional unfraction ated heparin. The control group comprised of 52 patients admitted to Internal Me dicine for an acute coronary syndrome. These were also given enoxaparin but the morning dose was withheld and unfractionated heparin was used during procedure. Results: Patients in both groups had similar baseline characteristics. No signif icant differences were observed between the two groups in procedural success rat e, complications or bleeding. One year follow up showed similar rates of hospita lization and mortality. Conclusion: Enoxaparin seems to offer safe and effective procedural anticoagulation in patients undergoing percutaneous intervention for acute coronary syndromes. Patients given enoxaparin can probably have coronary intervention without interruption of enoxaparin treatment and without additional procedural anticoagulation. These findings require confirmation in larger, rand omized trials.
