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Improving outcomes in patients undergoing percutaneous coronary intervention: role of prasugrel.

ABSTRACT: Dual oral antiplatelet therapy, aspirin plus thienopyridine, has permitted a rapid increase in the use of coronary intervention procedures. Clopidogrel is the thienopyridine of choice for dual antiplatelet therapy in patients treated with percutaneous coronary intervention. However, there are two issues with clopidogrel: (1) clopidogrel's antiplatelet activity is delayed because the drug needs to be metabolized into its active form and (2) variability in patient response to clopidogrel has been demonstrated. To overcome these shortcomings of clopidogrel, new more potent inhibitors of P2Y12 receptors, which have a more rapid onset of action have been introduced for clinical evaluation. This article is a nonexhaustive review of the literature and concentrates on prasugrel, a third-generation, oral thienopyridine. The purpose is to summarize the current knowledge about the benefits and risks of prasugrel and to outline the most prudent strategies for the drug's clinical use.

SUBMITTER: Motovska Z

PROVIDER: S-EPMC2686264 | biostudies-other | 2009

REPOSITORIES: biostudies-other

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Improving outcomes in patients undergoing percutaneous coronary intervention: role of prasugrel.

Motovska Zuzana Z Widimsky Petr P

Vascular health and risk management 20090101 1

Dual oral antiplatelet therapy, aspirin plus thienopyridine, has permitted a rapid increase in the use of coronary intervention procedures. Clopidogrel is the thienopyridine of choice for dual antiplatelet therapy in patients treated with percutaneous coronary intervention. However, there are two issues with clopidogrel: (1) clopidogrel's antiplatelet activity is delayed because the drug needs to be metabolized into its active form and (2) variability in patient response to clopidogrel has been ...[more]

PMID: 19475783

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Project description:Studies have shown variation in the use of red blood cell transfusion among patients with acute coronary syndromes. There are no definitive data for the efficacy of transfusion in improving outcomes, and concerning data exist about possible association with harm. Current transfusion practices in patients undergoing percutaneous coronary intervention (PCI) are not well understood.To determine the current patterns of blood transfusion among patients undergoing PCI and the association of transfusion with adverse cardiac outcomes across hospitals in the United States.Retrospective cohort study of all patient visits from the CathPCI Registry from July 2009 to March 2013 that included PCI, excluding those with missing data on bleeding complications or who underwent in-hospital coronary artery bypass graft surgery (N?=?2,258,711 visits).Transfusion rates in the overall population and by hospital (N?=?1431) were the primary outcomes. The association of transfusion with myocardial infarction, stroke, and death after accounting for a patient's propensity for transfusion was also measured.The overall rate of transfusion was 2.14% (95% CI, 2.13%-2.16%) and quarterly transfusion rates slightly declined from July 2009 to March 2013 (from 2.11% [95% CI, 2.03%-2.19%] to 2.04% [95% CI, 1.97%-2.12%]; P?<?.001). Patients who were more likely to receive transfusion were older (mean, 70.5 vs 64.6 years), were women (56.3% vs 32.5%), and had hypertension (86.4% vs 82.0%), diabetes (44.8% vs 34.6%), advanced renal dysfunction (8.7% vs 2.3%), prior myocardial infarction (33.0% vs 30.2%), or prior heart failure (27.0% vs 11.8%). Overall, 96.3% of sites gave a transfusion to less than 5% of patients and 3.7% of sites gave a transfusion to 5% of patients or more. Variation in hospital risk-standardized rates of transfusion persisted after adjustment, and hospitals showed variability in their transfusion thresholds. Receipt of transfusion was associated with myocardial infarction (42,803 events; 4.5% vs 1.8%; odds ratio [OR], 2.60; 95% CI, 2.57-2.63), stroke (5011 events; 2.0% vs 0.2%; OR, 7.72; 95% CI, 7.47-7.98), and in-hospital death (31,885 events; 12.5% vs 1.2%; OR, 4.63; 95% CI, 4.57-4.69), irrespective of bleeding complications.Among patients undergoing PCI at US hospitals, there was considerable variation in blood transfusion practices, and receipt of transfusion was associated with increased risk of in-hospital adverse cardiac events. These observational findings may warrant a randomized trial of transfusion strategies for patients undergoing PCI.

Project description:BackgroundPatients with peripheral arterial disease (PAD) have known to a high risk of cardiac mortality. However, the effectiveness of the routine evaluation of coronary arteries such as routine coronary angiography (CAG) in PAD patients receiving percutaneous transluminal angioplasty (PTA) is unclear.MethodsA total of 765 consecutive PAD patients underwent successful PTA and 674 patients (88.1%) underwent routine CAG. Coronary artery disease (CAD) was defined as angiographic stenosis ≥70%. Patients were divided into three groups; 1) routine CAG and a presence of CAD (n = 413 patients), 2) routine CAG and no CAD group (n = 261 patients), and 3) no CAG group (n = 91 patients). To adjust for any potential confounders that could cause bias, multivariable Cox-proportional hazards regression and propensity score matching (PSM) analysis was performed. Clinical outcomes were evaluated by Kaplan-Meier curved analysis at 5-year follow-up.ResultsIn this study, the 5-year survival rate of patients with PAD who underwent PTA was 88.5%. Survival rates were similar among the CAD group, the no CAD group, and the no CAG group, respectively (87.7% vs. 90.4% vs. 86.8% P = 0.241). After PSM analysis between the CAD group and the no CAD group, during the 5-year clinical follow-up, there were no differences in the incidence of death, myocardial infarction, strokes, peripheral revascularization, or target extremity surgeries between the two groups except for repeat PCI, which was higher in the CAD group than the non-CAD group (9.3% vs. 0.8%, P<0.001).ConclusionPAD patients with CAD were expected to have very poor long-term survival, but they are shown no different long-term prognosis such as mortality compared to PAD patients without CAD. These PAD patients with CAD had received PCI and/or optimal medication treatment after the CAG. Therefore a strategy of routine CAG and subsequent PCI, if required, appears to be a reasonable strategy for mortality risk reduction of PAD patients. Our results highlight the importance for evaluation for CAD in patients with PAD.

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Improving outcomes in patients undergoing percutaneous coronary intervention: role of prasugrel.

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Improving outcomes in patients undergoing percutaneous coronary intervention: role of prasugrel.

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