Texas Heart Institute journal
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Review Meta Analysis
Efficacy and safety of drug-eluting stents in patients with acute ST-segment-elevation myocardial infarction: a meta-analysis of randomized controlled trials.
We compared the efficacy and safety of drug-eluting stents with that of bare-metal stents in patients who experienced acute ST-segment-elevation myocardial infarction (STEMI) and underwent primary percutaneous coronary intervention. To do this, we performed a meta-analysis of 13 randomized controlled trials in which drug-eluting stents were compared with bare-metal stents in STEMI patients. The trials involved 6,769 patients (4,246 received drug-eluting stents and 2,523 received bare-metal stents) and follow-up periods of 6 to 48 months. ⋯ Moreover, no significant difference was found in the comparative risk of stent thrombosis (RR = 0.85; 95% CI, 0.63-1.14; P = 0.27). On the basis of risk ratio, we conclude that using drug-eluting stents in STEMI patients who undergo primary percutaneous coronary intervention is safe with regard to stent thrombosis within 48 months, and that drug-eluting stents improve clinical outcomes by reducing the risks of major adverse cardiac events, recurrent myocardial infarction, reintervention, and in-stent restenosis, compared with bare-metal stents. However, in order to investigate possible very late stent thrombosis, follow-up of these trials beyond 48 months is warranted.
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In Part 1 of this review, we discussed how plaque rupture is the most common underlying cause of most cases of unstable angina/non-ST-segment-elevation myocardial infarction (UA/NSTEMI) and how early risk stratification is vital for the timely diagnosis and treatment of acute coronary syndromes (ACS). Now, in Part 2, we focus on the medical therapies and treatment strategies (early conservative vs early invasive) used for UA/NSTEMI. We also discuss results from various large randomized controlled trials that have led to the contemporary standards of practice for, and reduced morbidity and death from, UA/NSTEMI. ⋯ An early-invasive-treatment strategy is of most benefit to high-risk patients, whereas an early-conservative strategy is recommended for low-risk patients. Adjunctive medical therapy with acetylsalicylic acid, clopidogrel or another adenosine diphosphate antagonist, glycoprotein IIb/IIIa inhibitors, and either low-molecular-weight heparin or unfractionated heparin, in the appropriate setting, further reduces the risk of ischemic events secondary to thrombosis. Short- and long-term inhibition of platelet aggregation should be achieved by appropriately evaluating the risk of bleeding complications in these patients.
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In pulmonary arterial hypertension, the blood vessels that carry blood between the heart and lungs are constricted, making it difficult for the heart to pump blood through the lungs. Prostacyclin, a prostanoid metabolized from endogenous arachidonic acid through the cyclooxygenase (COX) pathway, is a potent vasodilator that has been identified as one of the most effective drugs for the treatment of pulmonary arterial hypertension. Currently, prostacyclin and its analogues are widely used in the clinical management of pulmonary arterial hypertension patients. ⋯ More powerful therapeutic approaches are needed. This article briefly reviews the current management of pulmonary arterial hypertension to identify the problems associated with present therapies; then it focuses on the emerging technology of prostacyclin synthase gene therapy and cell-based therapy using native stem cells and engineered stem cells with enhanced prostacyclin production capacity. By using the recent advances in technology and the molecular understanding of prostacyclin synthesis, researchers are prepared to make significant advances in the treatment of pulmonary arterial hypertension.
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In this, the 1st part of a 2-part review, we discuss how plaque rupture is the most common underlying pathophysiologic cause of unstable angina and non-ST-segment-elevation myocardial infarction and how early risk stratification is vital in the timely diagnosis and treatment of acute coronary syndrome. Part 2 of this review (to be published in a later issue of this journal) will focus mainly on the various pharmacologic agents and treatment approaches (early invasive vs early conservative) to the management of unstable angina and non-ST-segment-elevation myocardial infarction.
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Review Case Reports
Drug-eluting stent thrombosis 1,659 days after stent deployment: case report and literature review.
Drug-eluting stents are considered to be superior to bare-metal stents in reducing restenosis rates at 6 months. However, drug-eluting stents appear to be subject to stent thrombosis, a concern that has been reported more frequently in recent times. In November 2003, a 64-year-old man with a medical history of hypertension, type 2 diabetes mellitus, and coronary artery disease underwent percutaneous coronary intervention for the deployment of a sirolimus-eluting stent in the left anterior descending coronary artery. ⋯ After undergoing emergent coronary angiography and the placement of 2 bare-metal stents, he resumed antiplatelet therapy, recovered uneventfully, and was discharged from the hospital in stable condition. To the best of our knowledge, 1,659 days is the longest reported interval between the deployment of a drug-eluting stent and the occurrence of a clinical event that was associated with very late stent thrombosis. Herein, we discuss the case of our patient, review the pertinent medical literature, reinforce the importance of continuous and uninterrupted antiplatelet therapy in drug-eluting stent recipients, and offer considerations regarding the use of drug-eluting stents.