Coronary Stent Placement in Patients With Acute Myocardial Infarction: Comparison of Clinical and Angiographic Outcome After Randomization to Antiplatelet or Anticoagulant Therapy

Schömig, Albert; Neumann, Franz‐Josef; Walter, Hanna; Schühlen, Helmut; Hadamitzky, Martin; Zitzmann-Roth, Eva-Maria; Dirschinger, Josef; Hausleiter, Jörg; Blasini, R; Schmitt, Claus; Alt, Eckhard; Kastrati, Adnan

doi:10.1016/s0735-1097(96)00450-0

Cited by 122 publications

(54 citation statements)

References 36 publications

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“…Recent clinical trials [1][2][3] have concluded that antiplatelet therapy with a combination of ticlopidine and aspirin is superior to aspirin alone or anticoagulation with coumadin and aspirin for patients with elective stent deployment. Likewise, the regimen of ticlopidine and aspirin was associated with better outcomes than coumadin-aspirin combination in patients stented for evolving acute myocardial infarction 14 and in those patients at high risk for stent-vessel occlusion. 13 The benefit of adjunctive platelet GP IIb/IIIa blockade in patients having emergency coronary stent deployment for threatened or abrupt coronary closure was reported from the IMPACT II trial of Integrilin, a parenteral competitive antagonist of the RGD binding site on the GP IIb/IIIa receptor.…”

Section: Discussionmentioning

confidence: 96%

Abciximab Therapy and Unplanned Coronary Stent Deployment

Kereiakes

Lincoff²,

Miller³

et al. 1998

Circulation

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Background-The clinical and angiographic demographics of patients requiring unplanned coronary stent deployment and the optimal adjunct pharmacotherapy in this population are not well described. This report details the EPILOG trial experience with unplanned coronary stent deployment and the effect of abciximab platelet glycoprotein IIb/IIIa blockade to improve clinical outcomes during 6 months of follow-up. Methods and Results-After randomization in the EPILOG double-blind, placebo-controlled trial of abciximab therapy during percutaneous coronary intervention, 326 (12%) of 2792 patients required unplanned coronary stent deployment. Although stented patients were not distinguished by clinical variables, they had greater coronary lesion complexity by American Heart Association/American College of Cardiology criteria (Pϭ.003) and greater incidence of lesion length Ͼ10 mm (Pϭ.002), lesion eccentricity (Pϭ.027), irregular lesion contour (Pϭ.001), and bifurcation involvement (Pϭ.019) than nonstented patients. Unplanned stents were required less often in patients treated with abciximab and low-dose, weight-adjusted heparin than in patients receiving placebo and standard-dose heparin (9.0% versus 13.7%; Pϭ.001). Although adverse clinical outcomes including target-vessel revascularization and bleeding events were more frequent in patients requiring unplanned coronary stent deployment, abciximab therapy reduced adverse outcomes in these patients at 30 days and 6 months to a greater extent than was observed in patients not requiring stent placement. Among stented patients, abciximab therapy did not increase bleeding events. Conclusions-Patients requiring unplanned coronary stent deployment have more complex coronary lesion morphology and a more complicated clinical course after coronary intervention. Abciximab therapy both reduces the need for unplanned stent deployment and confers clinical benefit to patients requiring an unplanned stent, without increasing bleeding complications. (Circulation. 1998;97:857-864.)

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Section: Discussionmentioning

confidence: 96%

Abciximab Therapy and Unplanned Coronary Stent Deployment

Kereiakes

Lincoff²,

Miller³

et al. 1998

Circulation

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“…[23][24][25][26] However, more recent methods using intravascular ultrasound, high-pressure post-dilatation, and an anti-platelet regimen with aspirin and ticlopidine have lead to a dramatic reduction in the rate of thrombosis to 0.5-2.5% [27][28][29][30][31][32] and most events occur within 5 days of the procedure. 31,32 The predisposing factors of stent thrombosis that have been identified in previous studies 29,31 include low ejection fraction, absence of hypertension, a combination of different stents, longer stent length, residual dissections, slow flow, and final lumen diameter, but no study has identified ETT or training as a predisposing or triggering factor.…”

Section: Predisposing Factors To Stent Thrombosismentioning

confidence: 99%

Safety and Implementation of Exercise Testing and Training After Coronary Stenting in Patients With Acute Myocardial Infarction.

Goto

Sumida

Ueshima

et al. 2002

Circ J

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n recent years, emergency percutaneous coronary intervention (PCI) using coronary stenting has rapidly become the treatment modality for patients with acute myocardial infarction (AMI). 1,2 In Japan, Watanabe et al reported that a multicenter survey showed 47.9% of 32,857 patients with AMI were treated by PCI in 1998PCI in -1999 The Japanese Coronary Intervention Study group reported that 37% of 2,673 patients with AMI who underwent PCI were treated with coronary stents in 1997, 4 and that the use of coronary stenting among all PCI procedures sharply increased from 39.5% in 1997 to 55.3% in 1999. 5 A recent report from the national registry in the USA showed that more than 70% of all PCI procedures involved placement of one or more coronary stents. 6 Exercise testing (ETT) is widely used as a routine method for detecting residual ischemia, assessment of exercise capacity and for the prognostic stratification of patients with AMI. The practice guidelines for patient management of AMI recommend a predischarge submaximal ETT to be performed at 4-6 days and a symptom-limited maximal ETT at 14-21 days after AMI. [7][8][9] Comprehensive (phase II) cardiac rehabilitation including exercise training (ie, exercise cardiac rehabilitation (ECR)) has been shown to improve functional capacity and quality of life and to reduce cardiovascular and total mortality in patients with AMI. 10,11 Therefore, both ETT and ECR are the standard modalities of post-AMI clinical assessment and treatment. 7 However, there are anecdotal case reports of thrombotic coronary occlusion associated with ETT after successful coronary stenting. [12][13][14] It is known that acute exercise can lead to a transient prothrombotic state in patients with coronary artery disease, 15 and questions have been raised about the safety of ETT after coronary stenting 12 because the true incidence of coronary thrombosis associated with ETT and ECR remains unclear. The guidelines do not have a specific statement about the safety or appropriate timing of ETT and ECR for patients with AMI who underwent coronary stenting. [7][8][9] In one study of the feasibility and safety of early ETT after AMI, patients who underwent PCI were excluded. 16 Thus, there is not general consensus on the safety and appropriate timing of ETT and ECR for patients with AMI who underwent coronary stenting. Accordingly, the purpose of the present study was to determine the incidence of subacute stent thrombosis related to ETT or exercise training and to obtain information about appropriate (safe The purpose of this study was to determine the incidence of subacute stent thrombosis related to exercise testing (ETT) or exercise training in cardiac rehabilitation (exercise cardiac rehabilitation (ECR)) and to clarify the appropriate timing of ETT and ECR in patients with acute myocardial infarction (AMI) treated with coronary stenting, because the safety and appropriate timing of ETT and ECR after coronary stenting for AMI have not been established. Forty-six institutes performing emergency percu...

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“…26 Several randomized trials have demonstrated the efficacy and safety of antiplatelet therapy alone (with aspirin and ticlopidine) relative to regimens including anticoagulation therapy (with warfarin) after stent placement. [27][28][29] The reduction in the risk of subacute stent thrombosis afforded by optimal stent expansion coupled with the reduced incidence of vascular and bleeding complications that have accompanied the discontinued use of warfarin after stent implantation has been responsible for the dramatic increase in stent use.…”

Section: Stents As Antirestenosis Devicesmentioning

confidence: 99%

A Call for Provisional Stenting

1998

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During the past 20 years, the equipment used to perform percutaneous coronary revascularization has undergone a dramatic transformation from simple balloon dilatation catheters to sophisticated mechanical devices and endoprostheses. The impetus for this evolution in technology was initially a byproduct of suboptimal immediate and long-term results obtained with standard balloon angioplasty. New techniques, including directional and rotational atherectomy, have resulted in improved procedural success rates, especially for more complex lesion subtypes, although their ability to curtail restenosis remains controversial.1,2 Intracoronary stents have had a dramatic impact on reduction of the incidence of acute complications after failed balloon angioplasty and represent the only currently available strategy shown to limit both clinical and angiographic restenosis. 3-12Based on these advantages, stent implantation is used in approximately half of all percutaneous interventions in the United States. However, despite their proven benefits, coronary stents continue to be accompanied by several theoretical and practical limitations: they are costly, typically associated with a more marked degree of neointimal formation than balloon angioplasty, and difficult to use with some lesion subsets such as bifurcation stenoses, and they have engendered the new and difficult-to-treat entity of in-stent restenosis.Although the major focus in the field of interventional cardiology over the past decade has been on the development of new devices and adjunctive pharmacological therapies, the short-and long-term success rates after standard balloon angioplasty have improved significantly. Part of the improvement is likely a manifestation of enhanced operator experience and better equipment, but the results of balloon angioplasty have also benefited greatly from the availability of coronary stents for both "bailout" (for actual or threatened abrupt closure) or "backup" (for suboptimal balloon results) indications, potentially allowing a strategy of more aggressive balloon dilatation than could be safely performed in the pre-stent era. This report details the forces that resulted in the shift from reliance on balloon angioplasty as the primary mode of therapy for the majority of percutaneous interventions and, with the use of data from several recent clinical trials, will provide the rationale for a potential return to the use of balloon angioplasty (with provisional stent placement) as the predominant means of coronary revascularization.

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Coronary Stent Placement in Patients With Acute Myocardial Infarction: Comparison of Clinical and Angiographic Outcome After Randomization to Antiplatelet or Anticoagulant Therapy

Abstract: This study demonstrates that combined antiplatelet therapy after stent placement in patients with acute myocardial infarction is associated with an overall better clinical and angiographic outcome than anticoagulant therapy.

Cited by 122 publications

References 36 publications

Abciximab Therapy and Unplanned Coronary Stent Deployment

Abciximab Therapy and Unplanned Coronary Stent Deployment

Safety and Implementation of Exercise Testing and Training After Coronary Stenting in Patients With Acute Myocardial Infarction.

A Call for Provisional Stenting

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