Article Text
PDF
Statistics from Altmetric.com
- ACUITY, a randomized trial of Angiomax versus Clexane in patients undergoing early invasive management for acute coronary syndromes without ST segment elevation
- ASA, acetylsalicylic acid (aspirin)
- BAT, bivalirudin angioplasty trial
- CABG, coronary artery bypass grafting
- CLASSICS, clopidogrel aspirin stent international cooperative study
- CREDO, clopidogrel for the reduction of events during observation
- CURE, clopidogrel in unstable angina to prevent recurrent events
- EPIC, evaluation of c73 for prevention of ischemic complications
- EPILOG, evaluation in PTCA to improve long term outcome with abciximab GpIIb/IIIa blockade
- EPISTENT, evaluation of platelet Gp IIb/IIIa inhibitor for stenting
- ESPRIT, enhanced suppression of the platelet IIb/IIIa receptor with Integrilin therapy
- FANTASTIC, the full anticoagulation versus aspirin and ticlopidine
- Gp, glycoprotein
- ISAR REACT, intracoronary stenting and antithrombotic regimen-rapid early action for coronary treatment
- JUMBO-TIMI, joint utilization of medications to block platelets optimally
- LMWH, low molecular weight heparin
- MACE, major adverse cardiac events
- MATTIS, multicenter aspirin and ticlopidine trial after intracoronary stenting
- MI, myocardial infarction
- NICE, national investigators collaborating on enoxaparin
- PCICURE, percutaneous coronary intervention-CURE
- PCI, percutaneous coronary intervention
- REPLACE, randomized evaluation in PCI linking Angiomax to reduced clinical events
- STARS, stent anti-thrombotic regimen study
- STEEPLE, safety and efficacy of enoxaparin in PCI patients, an international randomized evaluation
- SYNERGY, superior yield of the new strategy of enoxaparin, revascularization and glycoprotein IIb/IIIa inhibitors
- TARGET, do tirofiban and ReoPro give similar efficacy outcomes trial
- TENACITY, tirofiban evaluation of novel dosing vs. abciximab with clopidogrel and inhibition of thrombin study
- TLR, target lesion revascularisation
- TVR, target vessel revascularisation
- UFH, unfractionated heparin
In the development of percutaneous intervention, Dotter first used unfractionated heparin (UFH) alone when performing peripheral angioplasty.1 In the 1970s Gruentzig added 1 g of aspirin (ASA) for three days in coronary angioplasty, which was started the day before the procedure.2 Over the ensuing years empiric attempts were made to improve patient outcomes using dextran and dipyridamole but without success. More recently, along with ASA and UFH, direct thrombin inhibitors, low molecular weight heparin (LMWH), warfarin, fibrinolytics, thienopyridines, and platelet glycoprotein (Gp) IIb/IIIa antagonists have all been studied in efforts to reduce the thrombotic complications associated with a percutaneous coronary intervention (PCI).
Of the multiple combinations of antithrombotic agents that have been tried and tested, only several have been unequivocally proven to be beneficial in placebo controlled trials. A number of others continue to be studied or have persisted empirically. ASA, thienopyridines, UFH, LMWH, direct thrombin inhibitors, and Gp IIb/IIIa antagonists are currently the most commonly utilised antithrombotic agents. As a result of improvements in the antithrombotic regimen, in conjunction with improvements in equipment and technique, the incidence of periprocedural major adverse cardiac events (MACE) and major bleeding have continued to improve.
ANTIPLATELET THERAPY
Aspirin
Aspirin (acetylsalicylic acid, ASA) has been available for over a century yet its cardiac and vascular benefits have only been realised in the last 50 years. The benefit of ASA as antiplatelet treatment in PCI is frequently under-appreciated, but has been well established in short and long term placebo controlled studies. Schwartz showed that the addition of aspirin to heparin in PCI was associated with a 77% relative risk reduction in MACE (p = 0.013).3 Similarly, White showed that aspirin when combined with heparin was associated with a 75% reduction in MACE (p < 0.001) compared to heparin alone.4 A longer duration of aspirin …