Jehangir Din

Delay in Filling First Clopidogrel Prescription After Coronary Stenting Is Associated With an Increased Risk of Death and Myocardial Infarction

Background Patients frequently experience difficulties with medication compliance after hospital discharge. We investigated the effect of a delay in filling a first clopidogrel prescription after hospital discharge on clinical outcomes subsequent to coronary stenting. Methods and Results Hospital administrative, community pharmacy, and cardiac revascularization data were determined for all patients receiving a coronary stent in British Columbia 2004–2006 with follow‐up out to 2 years. Coxs proportional hazard regression analysis, adjusting for baseline demographics and procedural variables, was performed to examine the effects of delay in filling a clopidogrel prescription after hospital discharge on clinical outcomes. Of 15 629 patients treated with coronary stents, 3599 received at least 1 drug‐eluting stent (DES), whereas 12 030 received bare metal stents (BMS) alone. In total, 1064 (30%) and 3758 (31%) patients in the DES and BMS groups, respectively, failed to fill a prescription within 3 days of discharge (median, 1 day; interquartile range [IQR], 1 to 3). After regression analysis, a delay of >3 days was predictive of mortality and recurrent myocardial infarction (MI) irrespective of stent type (DES: hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.7 to 3.4; and HR, 2.0; 95% CI, 1.5 to 2.7, respectively, and BMS: HR, 2.2; 95% CI, 1.9 to 2.6; and HR, 1.8; 95% CI, 1.5 to 2.1, respectively). This excess hazard was greatest in the 30‐day period immediately after hospital discharge (mortality: HR, 5.5; 95% CI, 3.5 to 8.6; and MI: HR, 3.1; 95% CI, 2.4 to 4.0, for all patients). Conclusions Delays in patients filling their first prescription for clopidogrel after coronary stenting are common and associated with adverse clinical outcomes, irrespective of stent type. Strategies to reduce delays have the potential to improve clinical outcomes.

Variation in practice and concordance with guideline criteria for length of stay after elective percutaneous coronary intervention.

Considerable variability remains as regards the appropriate and safe length of stay after elective PCI. We performed a survey of interventional cardiologists to identify current views on appropriate and safe length of stay after PCI.

Prolonged Clopidogrel Use is Associated with Improved Clinical Outcomes Following Drug-Eluting But Not Bare Metal Stent Implantation

AbstractBackgroundGuidelines recommend clopidogrel use for 6–12xa0months following drug-eluting stent (DES) implantation and 1–12xa0months following bare metal stent (BMS) implantation. The role of clopidogrel beyond 12xa0months is unclear.MethodsWe linked hospital administrative, community pharmacy and cardiac revascularization data to determine clopidogrel use and outcomes for all patients (those with acute presentations and those with stable angina) receiving a coronary stent in British Columbia 2004–2006, with follow-up until the end of 2008. Cox proportional hazard regression was performed to evaluate the effect of clopidogrel duration (≤12 vs. >12xa0months) on outcomes following BMS or DES implantation. Patients who died ≤12xa0months from index stent placement were excluded.ResultsA total of 15,629 patients were included in the study. Of 3599 patients who received at least one DES and 12,030 patients who received only BMS, 1326 (37xa0%) and 2121 (18xa0%), respectively, filled a prescription for clopidogrel >12xa0months from the index procedure. The mean duration of clopidogrel was 406xa0±xa035 days and 407xa0±xa037xa0days in the prolonged use (>12xa0months) DES and BMS cohorts, respectively, compared with 224xa0±xa0112xa0days (pxa0<xa00.001) and 122xa0±xa0117xa0days (pxa0<xa00.001), respectively, for patients receiving clopidogrel ≤12xa0months. Clopidogrel use beyond 12xa0months was associated with a reduction in mortality [hazard ratio (HR) 0.66, 95xa0% confidence interval (CI) 0.45–0.97] and the composite of mortality and readmission for myocardial infarction (HR 0.72, 95xa0% CI 0.55–0.94) in patients treated with DES, but not BMS alone. Prolonged clopidogrel use was not associated with bleeding-related mortality.ConclusionsClopidogrel use beyond 12xa0months was associated with a reduction in death and hospitalization for myocardial infarction following DES, but not BMS, implantation. Our findings support a longer duration of clopidogrel therapy for patients treated with DES.n

Trans Radial Excimer Laser Coronary Atherectomy Application During Complex PCI

Lasers were first introduced for the treatment of vascular atherosclerosis in the 1980’s, initially for the treatment of critical limb ischaemia, with subsequent trials that supported its use in the coronary circulation. However, first generation catheters and technique were rudimentary, and were associated with significant complications. Catheter technology development and safer lasing techniques consequently led to significant improvement in clinical outcomes and an increase in uptake amongst interventional cardiologists. Simultaneously this has occurred over a period of change in the vascular access landscape for coronary intervention with adaptation from transfemoral to transradial approach and modification of some techniques to treat complex lesion subsets have evolved. This chapter describes the current indications for the use of Excimer Laser atherectomy in modern interventional practice, which is by default now considered from the transradial approach.A detailed description of the ELCA technique and its potential pitfalls has been illustrated with complex interventional cases performed exclusively from the radial artery. This technology provides a solution to a variety of problems that may be encountered, including massive intra-coronary thrombus, uncrossable lesions including chronic total occlusions and when confronted with stent under expansion. Careful case selection, proper utilization of the laser equipment and incorporation of a safe, efficacious lasing technique play a crucial role in successful laser interventions and ensuring optimal patient outcome.

Late stent collapse identified with OCT – An underdiagnosed mechanism of restenosis?

Very late stent recoil is a rare albeit recognized phenomenon leading to subsequent in-stent restenosis. Angiography alone may not be adequate in making the diagnosis, and intravascular imaging with optical coherence tomography (OCT) is far superior in confirming the diagnosis and guiding subsequent management. We describe a case with interesting coronary angiogram and OCT images demonstrating very rare diagnosis of the late stent collapse. These images provide a valuable insight into a novel mechanism responsible for late target lesion failure. These images highlight the importance of modern intra-coronary imaging techniques in understanding the mechanisms underlying target-lesion failure, and guiding appropriate management.

Feasibility and Efficacy of Herculink Elite ((TM)) Biliary Stent Implantation in Large Coronary Arteries (≥ 5 mm) and Venous Conduits: An Observational Study.

BACKGROUND AND OBJECTIVESnPercutaneous coronary intervention (PCI) in patients with lesions of large calibre coronary arteries (≥ 5 mm) and saphenous venous grafts (≥ 5 mm) can be challenging. There are no separate guidelines available to treat these vessels with PCI. Standard coronary stents of 4 mm diameter are used to treat these lesions conventionally but carry the risk of under deployment, distortion of stent architecture and future stent thrombosis even if they are subsequently expanded beyond 5 mm.nnnMETHODS AND RESULTSnBiliary stents (Herculink Elite™) provide a better alternative to standard coronary stents in these patients. These stents are of larger diameter (5-7 mm) and can be safely delivered over a 6 French sheath. In our case series, we demonstrate the use of intravascular ultrasound examination to confirm that biliary stents provide improved stent strut apposition within the coronary artery associated with extremely low repeat revascularisation rates.nnnCONCLUSIONnOur paper highlights that PCI of lesions in patients with large calibre coronary arteries can successfully be achieved using biliary stents.

Huge aortic pseudoaneurysm arising from the coronary anastomosis after aortic root replacement.

An 87-year-old man was admitted with chest pain. His troponin was elevated and his electrocardiogram showed anterior ST depression. The patient had undergone aortic root replacement 13 years earlier using a mechanical valved conduit with re-implantation of the coronary arteries. Although lost to follow-up, he continued on warfarin. He initially received treatment for a suspected acute coronary syndrome. However, a subsequent echocardiogram suggested a circumferential haematoma around the aorta.nnContrast computed tomography (CT) demonstrated a large aortic pseudoaneurysm arising from the …