Antithrombotic Therapy for Percutaneous Coronary Intervention
Section snippets
Platelet biology
Comprehension of platelet biology has provided the basis for the current standard of antiplatelet therapy in PCI. Circulating platelets traverse the vasculature in an inactivated state until they are exposed to collagen fibrils in the connective tissue matrix underlying normal endothelial cells. Exposure to this matrix, which occurs universally after vessel injury induced by PCI, results in a complex series of events leading to platelet activation and aggregation. Activated platelets change
Aspirin
The use of aspirin is ubiquitous in patients undergoing coronary intervention. By acetylating the cyclooxygenase-1 enzyme, aspirin inhibits the synthesis of thromboxane A2, resulting in irreversible inhibition of platelet function. Daily administration of 30 to 50 mg of aspirin results in virtually complete suppression of thromboxane A2 synthesis by 7 to 10 days [1], [2]. Justification for the use of aspirin in PCI is based primarily on a number of early trials that compared aspirin and
Anticoagulants
It has long been known that antiplatelets alone cannot substantially reduce platelet activation in an environment of high thrombin activity. Because vessel injury during PCI induces a substantial amount of thrombin generation through TF activation of the coagulation cascade, the concominant use of antithrombotic therapy during this procedure has been intuitive.
Novel antithrombin agents
The advancement in pharmacotherapy during PCI over the last several years has been impressive. The promise of continued improvements in efficacy and safety exists as next-generation compounds in existing drug classes and entirely new classes of agents continue to be developed. One such class includes the direct factor Xa inhibitors, which by exerting their effect upstream in the coagulation cascade may provide more amplified inhibition of thrombin. Fondaparinux, an existing indirect inhibitor
Summary
The extensive clinical study of antiplatelet and anticoagulant therapy in PCI documented in this review has not only justified the standard of care but also provided the framework for the introduction of novel therapeutic agents such as those discussed previously. Although the evolution to this current standard has been relatively rapid and there have been substantial advancements made in this arena, there remains a clinically relevant rate of ischemic and bleeding complications. This fact,
References (137)
- et al.
Effect of pretreatment with aspirin versus aspirin plus dipyridamole on frequency and type of acute complications of percutaneous transluminal coronary angioplasty
Am J Cardiol
(1990) - et al.
Aspirin resistance and atherothrombotic disease
J Am Coll Cardiol
(2005) - et al.
A prospective, blinded determination of the natural history of aspirin resistance among stable patients with cardiovascular disease
J Am Coll Cardiol
(2003) - et al.
Reduction in angioplasty complications after the introduction of coronary stents: results from a consecutive series of 2242 patients
Am Heart J
(1996) - et al.
Coronary stent placement in patients with acute myocardial infarction: comparison of clinical and angiographic outcome after randomization to antiplatelet or anticoagulant therapy
J Am Coll Cardiol
(1997) - et al.
Neutropenia with ticlopidine plus aspirin
Lancet
(1997) - et al.
Meta-analysis of randomized and registry comparisons of ticlopidine with clopidogrel after stenting
J Am Coll Cardiol
(2002) - et al.
Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study
Lancet
(2001) - et al.
Influence of treatment duration with a 600-mg dose of clopidogrel before percutaneous coronary revascularization
J Am Coll Cardiol
(2004) - et al.
Drug-eluting stent thrombosis: results from a pooled analysis including 10 randomized studies
J Am Coll Cardiol
(2005)
Resistance to clopidogrel: a review of the evidence
J Am Coll Cardiol
Clopidogrel added to aspirin versus aspirin alone in secondary prevention and high-risk primary prevention: rationale and design of the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial
Am Heart J
Integrins: a family of cell surface receptors
Cell
Inhibition of dog platelet function by in vivo infusion of F(ab')2 fragments of a monoclonal antibody to the platelet glycoprotein IIb/IIIa receptor
Blood
Outcomes at 1 year and economic implications of platelet glycoprotein IIb/IIIa blockade in patients undergoing coronary stenting: results from a multicentre randomised trial. EPISTENT Investigators. Evaluation of Platelet IIb/IIIa Inhibitor for Stenting
Lancet
Clinical benefit of glycoprotein IIb/IIIa blockade with abciximab is independent of gender: pooled analysis from EPIC, EPILOG and EPISTENT trials. Evaluation of 7E3 for the Prevention of Ischemic Complications. Evaluation in Percutaneous Transluminal Coronary Angioplasty to Improve Long-Term Outcome with Abciximab GP IIb/IIIa blockade. Evaluation of Platelet IIb/IIIa Inhibitor for Stenting
J Am Coll Cardiol
Multi-year follow-up of abciximab therapy in three randomized, placebo-controlled trials of percutaneous coronary revascularization
Am J Med
Abciximab reduces mortality in diabetics following percutaneous coronary intervention
J Am Coll Cardiol
Effect of glycoprotein IIb/IIIa receptor blockade with abciximab on clinical and angiographic restenosis rate after the placement of coronary stents following acute myocardial infarction
J Am Coll Cardiol
A randomized trial comparing primary infarct artery stenting with or without abciximab in acute myocardial infarction
J Am Coll Cardiol
Clinical pharmacology of eptifibatide
Am J Cardiol
Immediate and reversible platelet inhibition after intravenous administration of a peptide glycoprotein IIb/IIIa inhibitor during percutaneous coronary intervention
Am J Cardiol
Clinical pharmacology of higher dose eptifibatide in percutaneous coronary intervention (the PRIDE study)
Am J Cardiol
Thrombocytopenia complicating treatment with intravenous glycoprotein IIb/IIIa receptor inhibitors: a pooled analysis
Am Heart J
Six-month angiographic and clinical follow-up of patients prospectively randomized to receive either tirofiban or placebo during angioplasty in the RESTORE trial. Randomized Efficacy Study of Tirofiban for Outcomes and Restenosis
J Am Coll Cardiol
A risk score system for predicting adverse outcomes and magnitude of benefit with glycoprotein IIb/IIIa inhibitor therapy in patients with unstable angina pectoris
Am J Cardiol
The additive value of tirofiban administered with the high-dose bolus in the prevention of ischemic complications during high-risk coronary angioplasty: the ADVANCE Trial
J Am Coll Cardiol
Intravenous glycoprotein IIb/IIIa receptor antagonists reduce mortality after percutaneous coronary interventions
J Am Coll Cardiol
Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials
Lancet
Meta-analysis of effectiveness and safety of abciximab versus eptifibatide or tirofiban in percutaneous coronary intervention
Am J Cardiol
Heparin and low-molecular-weight heparin: mechanisms of action, pharmacokinetics, dosing, monitoring, efficacy, and safety
Chest
Heparin after percutaneous intervention (HAPI): a prospective multicenter randomized trial of three heparin regimens after successful coronary intervention
J Am Coll Cardiol
Heparin and low-molecular-weight heparin: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
Chest
Clinical pharmacology of platelet cyclooxygenase inhibition
Circulation
Selective cumulative inhibition of platelet thromboxane production by low-dose aspirin in healthy subjects
J Clin Invest
Aspirin and dipyridamole in the prevention of acute coronary thrombosis complicating coronary angioplasty
Circulation
Aspirin and dipyridamole in the prevention of restenosis after percutaneous transluminal coronary angioplasty
N Engl J Med
Effects of aspirin dose when used alone or in combination with clopidogrel in patients with acute coronary syndromes: observations from the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study
Circulation
A randomized trial of aspirin in PTCA: effect of high dose versus low dose aspirin on major complications and restenosis
J Am Coll Cardiol
ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention)
Circulation
The antiplatelet effects of ticlopidine and clopidogrel
Ann Intern Med
A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators
N Engl J Med
Randomized multicenter comparison of conventional anticoagulation versus antiplatelet therapy in unplanned and elective coronary stenting. The full anticoagulation versus aspirin and ticlopidine (FANTASTIC) study
Circulation
A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents
N Engl J Med
Randomized evaluation of anticoagulation versus antiplatelet therapy after coronary stent implantation in high-risk patients: the Multicenter Aspirin and Ticlopidine Trial after Intracoronary Stenting (MATTIS)
Circulation
Incidence and clinical course of thrombotic thrombocytopenic purpura due to ticlopidine following coronary stenting. EPISTENT Investigators. Evaluation of Platelet IIb/IIIa Inhibitor for Stenting
JAMA
Thrombotic thrombocytopenic purpura associated with ticlopidine in the setting of coronary artery stents and stroke prevention
Arch Intern Med
Double-blind study of the safety of clopidogrel with and without a loading dose in combination with aspirin compared with ticlopidine in combination with aspirin after coronary stenting: the Clopidogrel Aspirin Stent International Cooperative Study (CLASSICS)
Circulation
Ticlopidine and clopidogrel
Circulation
Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation
N Engl J Med
Cited by (2)
Novel antiplatelet therapies
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