Basic pharmacology of cardiac drugs
John Edward Boland, David W. M. Muller in Interventional Cardiology and Cardiac Catheterisation, 2019
tPA is a 527 amino acid glycoprotein made by many cell types including endothelial cells, liver and myocardium. It binds to fibrin as well as plasminogen (hence ‘clot-selectivity’). When given pharmacologically, any tPA that does not quickly bind to fibrin tends to bind to an inactivator (PAI-1) and circulates in blood in this inactive form. tPA has a redistribution half-life of 3–6 minutes and a beta half-life of 20–40 minutes. It was the agent used in many early trials of reperfusion therapy for acute myocardial infarction and these were very successful. Thrombolysis can clearly lead to satisfactory outcomes in acute infarction and should be administered in settings where percutaneous intervention with angioplasty and stenting is not available. However percutaneous coronary stenting has become the standard of care for hospitals with facilities to perform this procedure.
Cardiovascular Issues in Urologic Surgery
Kevin R. Loughlin in Complications of Urologic Surgery and Practice, 2007
Recent PCI may also complicate rather than improve perioperative outcomes with noncardiac surgery. For example, patients who have recently undergone percutaneous coronary stenting are at particular risk for catastrophic in-stent thrombosis if antiplatelet agents are discontinued prematurely to facilitate surgery. An observational study identified 40 patients who had bare metal coronary stents (BMS) placed less than six weeks prior to noncardiac (moderate to high-risk) general surgery. Seven patients suffered MI, with six MI-related fatalities (47). Risk of a cardiovascular complication was substantially higher in the patients who underwent stenting less than two weeks prior to their operative procedure, prompting the authors to recommend that elective/urgent surgery be delayed for a minimum of 14 days after coronary stenting, or that angioplasty without stenting be considered if surgery could not be safely delayed (47). A subsequent retrospective analysis from the Mayo clinic surgical database of 207 patients undergoing noncardiac surgery less than 60 days postcoronary stenting found a lower rate of events (eight major adverse cardiac events total), but confirmed that the risk of events was significantly increased in the early poststenting period, with maximal risk in the first six weeks poststenting (48).
Cardiology
Stephan Strobel, Lewis Spitz, Stephen D. Marks in Great Ormond Street Handbook of Paediatrics, 2019
In Kawasaki disease, an inflammatory myocarditis or pericarditis may occur at presentation. However, the major cardiac manifestation is the development of coronary artery aneurysms. Early treatment with immunoglobulin reduces the incidence of aneurysm formation; however, aneurysms are still seen, often in atypical cases or those that occur in infancy when it can be more difficult to recognise and give immunoglobulin early enough. Very large aneurysms are more liable to complications that include rupture (rarely) and stenosis with myocardial infarction. Stenosis can be treated by coronary stenting or bypass grafting. The long-term prognosis is still not defined but there is concern that even those without aneurysms may be at risk of accelerated atheromatous disease.
Acute myocardial infarction complicating ischemic stroke: is there room for cangrelor?
Published in Platelets, 2020
Nuccia Morici, Stefano Nava, Alice Sacco, Giovanna Viola, Jacopo Oreglia, Paolo Meani, Fabrizio Oliva, Marco Ranucci, Sergio Leonardi, Roberta Rossini
In the present cases, a coronary stenting was performed. In this setting, the labeled dosage is a bolus of 30 μg/kg followed by a 4.0 μg/kg/min. The dosage of 0.75 μg/kg/min has not been validated for the prevention of stent thrombosis immediately after PCI, when oral P2Y12 inhibitors are recommended. The reduced dosage might be used, though off-label, as bridge therapy in patients requiring the withdrawal of oral antiplatelet therapy due to surgery [15]. In the 2 case here presented the choice of cangrelor at a reduced, bridge dosage was due to hemorrhagic concerns. Nonetheless, it should be highlighted that this therapeutic strategy is currently off-label and should be taken into consideration with caution in very selected patients. Notably, in both patients, cangrelor infusion at a reduced dosage was maintained only for 48 h when oral antiplatelet therapy with P2Y12 inhibitors was administered.
Optimal duration of dual antiplatelet therapy after PCI: integrating procedural complexity, bleeding risk and the acuteness of clinical presentation
Published in Expert Review of Cardiovascular Therapy, 2018
Huazhen Chen, David Power, Gennaro Giustino
DAPT with aspirin and a P2Y12 inhibitor constitute the standard of care to prevent stent-related and non-stent-related adverse events after coronary stenting. Clinical decision-making on upfront duration and intensity of DAPT should take into account the offsetting risk of ischemia and bleeding on an individual-patient basis. Historically, clinical presentation at the time of index PCI constituted the major discriminator in deciding upon the dichotomous application of a prolonged (at least 12 months) or shorter (at least 3 or 6 months) duration of DAPT, in patients with versus without an ACS, respectively. Since then, multiple novel risk factors such as the complexity and extent of coronary stenting and the characterization of the bleeding risk profile have been developed and currently constitute an area of active clinical investigation. Alongside established clinical risk factors, the integration of the complexity of coronary stenting with the acuteness of clinical presentation may allow for better discrimination among patients that may or may not benefit of more intense or prolonged upfront DAPT regimens after PCI with DES.
Second generation drug-eluting stents: a focus on safety and efficacy of current devices
Published in Expert Review of Cardiovascular Therapy, 2021
Francesco Spione, Salvatore Brugaletta
This new generation of stents, such as the Nobori® (Terumo, Tokyo, Japan) and the BioMatrix® (Biosensors International, Kampong Ubi, Singapore) biolimus-eluting stent (BES) [13,14], have been developed with the aim of reducing the adverse long-term sequelae related to the persistence of durable polymers in the arterial wall beyond the period necessary to control drug release. Permanent polymer of first and second generation DES has been advocated as a trigger for chronic inflammatory response, which causes delayed vascular healing [15]. The subsequent degradation of the polymer coating, after a controlled drug-release, makes the stent surface similar to that of a BMS. Hence, the suppression of a chronic inflammatory stimulus may improve long-term clinical outcomes after coronary stenting [16].
Related Knowledge Centers
- Angioplasty
- Coronary Artery Disease
- Stenosis
- Femoral Artery
- Heart
- Radial Artery
- Percutaneous
- Coronary Arteries
- Stent
- Drug-Eluting Stent