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General Medical Emergencies
Published in Anthony FT Brown, Michael D Cadogan, Emergency Medicine, 2020
Anthony FT Brown, Michael D Cadogan
Organize primary percutaneous coronary intervention in preference to thrombolysis, when it is available locally in less than 90 min of patient arrival, or in less than 60 min if the chest pain onset was within the last hour. It is superior to thrombolysis, particularly in a high-volume centre preferably with cardiac surgery capability.It is preferred in cardiogenic shock, and if thrombolysis is contraindicated.Give thrombolysis with tenecteplase if the PCI will take longer than the 60–90 min to organize.
The ST segment
Published in Andrew R Houghton, Making Sense of the ECG, 2019
If one or two anti-anginal drugs fail to control symptoms adequately, or if non-invasive investigations indicate that the patient is at high risk of an acute coronary syndrome, consider coronary angiography with a view to: Percutaneous coronary interventionCoronary artery bypass surgery
The heart
Published in Laurie K. McCorry, Martin M. Zdanowicz, Cynthia Y. Gonnella, Essentials of Human Physiology and Pathophysiology for Pharmacy and Allied Health, 2019
Laurie K. McCorry, Martin M. Zdanowicz, Cynthia Y. Gonnella
Surgical reperfusion: Percutaneous coronary intervention (PCI)—may involve placing a balloon catheter in the affected coronary artery to restore blood flow. A spring-loaded metal stent is often placed in the vessel to help keep it open. Stents may be coated with drugs such as sirolimus that release slowly over time to prevent local cellular proliferation and reocclusion of the vesselCoronary artery bypass grafting (CABG)—the procedure involves replacing occluded coronary arteries with graft vessels taken from elsewhere in the bodyWith both PCI and CABG, reocclusion of coronary arteries may still occur over time
Critical appraisal of evidence for anti-Xa monitoring and dosing of low-molecular-weight heparin in renal insufficiency
Published in Expert Review of Clinical Pharmacology, 2022
M. P. H. van den Broek, Marjon V. Verschueren, C. A. J. Knibbe
A study by Montalescot et al. included 803 patients with ACS who received twice-daily enoxaparin, with death, myocardial infarction (MI), or major bleeding at 30 days as endpoints [9]. When indicated, catheterization was performed with ad hoc percutaneous coronary intervention (PCI), as needed. All patients were treated with enoxaparin and aspirin, and 75% of the population also received a P2Y12 inhibitor. Ten percent of the patients had a creatinine clearance of less than 30 mL/min. The authors observed an association between low anti-Xa concentrations and mortality. An anti-Xa peak concentration of < 0.5 IU/mL was a significant predictor for mortality or myocardial infarction at 30 days follow-up (OR 4.40) in a multivariate analysis. This study provides the main supporting evidence for the lower limit of 0.5 IU/mL for the anti-Xa therapeutic range.
Current status and prospects of IL-6–targeting therapy
Published in Expert Review of Clinical Pharmacology, 2022
Masashi Narazaki, Tadamitsu Kishimoto
IL-6 also plays a role in the pathology of acute myocardial infarction. Its level rapidly increases after myocardial infarction and is associated with worse prognosis [133]. In the first phase 2 trial of TCZ for non–ST-elevation myocardial infarction (which characteristically has elevated levels of troponin, ST depression, or T-wave inversion but no ST elevation in ECG), the median area under the curve for troponin T was lower in the intravenous TCZ group than in the placebo group [134]. This difference was observed mainly in patients included within 2 days of onset and those treated with percutaneous coronary intervention. However, in the second trial, no change in major adverse cardiac events was observed among patients who received a single dose of TCZ subcutaneously [135]. It is necessary to consider the method of TCZ administration, evaluation parameters, and selection of patients to confirm the effects of TCZ on myocardial infarction. Patients experiencing out-of-hospital cardiac arrest with comatose status after initial resuscitation are at high risk of mortality from post-cardiac arrest syndrome. Systemic inflammation is a major component of post-cardiac arrest syndrome, and IL-6 levels are associated with this syndrome severity. A phase 2 randomized trial showed that TCZ significantly reduced systemic inflammation and myocardial injury in comatose patients resuscitated from out-of-hospital cardiac arrest [136].
Effects of electret coating technology on coronary stent thrombogenicity
Published in Platelets, 2022
M. Urooj Zafar, Jose Javier Bravo-Cordero, Sergi Torramade-Moix, Gines Escolar, Didac Jerez-Dolz, Eli I. Lev, Juan Jose Badimon
Extrapolating the findings of our short in vitro study to gauge the possible performance of electret-coated stents in patients—where the contact with blood would be for exponentially longer periods—would be an educated guess. It is not unreasonable to posit however that the thrombogenic differences apparent after a few minutes of testing may be magnified, when the period of exposure to blood is extended to durations where acute (within 1 day) and subacute (within 1 month) stent thrombosis becomes a concern. Furthermore, a thrombo-resistant stent may also offer the possibility of reducing the need for some antiplatelet drug use. Long-term DAPT has become an integral part of any management plan involving stent placement and the absence/early discontinuation of DAPT has been shown to be the single most important predictor of early and late ST [39–41]. The use of DAPT is not without clinical consequences, however, and is associated with increased bleeding rates. Among patients who currently undergo percutaneous coronary intervention both for acute coronary syndromes and for stable angina indications, the proportion who have a high bleeding risk is significant, up to 2.8% at one year [42]. Any possibility to lower the use of DAPT, either in terms of dosage or treatment duration, could prove to be beneficial. Therefore, developing a stent with antithrombotic properties that could reduce the use of DAPT is of very high clinical importance. These possibilities need to be explored in future studies.