An increasing number of patients benefit from a dual antiplatelet therapy combining a low dose of acetylsalicylic acid and a platelet adenosine diphosphate (ADP) receptor antagonist (Clopidogrel, Prasugrel, Ticagrelor), generally indicated in presence of a coronary artery stent and/or a history of acute coronary syndrome. During invasive procedures (operations, biopsies, punctures, dental care, etc.) carried out electively or urgently, the management of this antiplatelet association is often problematic. It must weigh the thrombotic risks following their cessation against the hemorrhagic risks associated with their continuation. This brief article summarizes the practical strategies for managing antiplatelet associations during invasive procedures.
Stable angina is a common clinical syndrome characterized by discomfort in the chest, jaws, shoulders, back, or arms, typically induced by exercise or stress. The therapeutic management of this condition depends on the patient’s individual prognosis, which itself depends on clinical factors and non-invasive imaging. The treatment is based on managing cardiovascular risk factors and on pharmacological treatments. A certain number of patients may benefit from percutaneous or surgical revascularization techniques
Revisionism and negationism of the benefif/risk balance of statins in atherosclerosis The current, scientifically-unfounded revisionist trend directed against the entire class of statins poses a series of problems with respect to the immediate clinical management, including strengthening of drug adherence, while exposing patients who would interrupt their treatment to a sudden upsurge in fatal and non-fatal risk of incident cardiovascular disease.
A certain number of foodstuff and dietary supplements have been shown to affect lipid levels. Data as to their impact on cardiovascular mortality and morbidity are, however, limited. Red yeast rice contains natural substances that exert HMG-CoA reductase inhibitory activity. The lack of standardization, great variability among different brands, and risk of interaction prompt us to invite you to limit their use. Although vegetable sterols in margarines reduce LDL-C levels, they have not yet been clinically evaluated. In mouse models, there is even some evidence of harmful vascular effects. While the Mediterranean diet definitely reduces the risk of cardiovascular events, there is no single but there are several Mediterranean diets, all rich in fruits, vegetables, whole grains, beans, nuts, and seeds, comprising olive oil as primary source of fat.
The association between cholesterolemia and cardiovascular events decreases with aging, is neutral at the age of 75, and is reversed in octogenarians. To date, no randomized controlled trial has assessed the effects of statins in persons over 80 who, moreover, are a very heterogeneous population. In a patient aged 80 and older, the assessment of functional status, life expectancy, and preferences is essential when considering a preventive therapy (e.g. a statin). While scientific evidence is lacking, common sense suggests that, in patients aged 80 and older, a statin should be prescribed in secondary prevention patients with a life expectancy exceeding 1 year. It also suggests withholding or withdrawing a statin therapy in primary prevention patients (including patients with type 2 diabetes), regardless of their cholesterolemia, which should not be measured.
Myocardial revascularization has long been considered the treatment of choice for patients with multivessel disease. The introduction of stents, however, has altered this paradigm. While the Syntax and Syntax II studies have clarified the risk related to coronary artery lesions, the respective scores have proven instrumental in facilitating the discussion within the medical team, also termed Heart Team, in order to propose the coronary revascularization technique best tailored to each individual patient.
New anticoagulants paved the way for a new indication in secondary prevention after an acute coronary syndrome. First results have shown a significant reduction of cardiovascular events, yet an increased hemorrhagic risk. On the other hand, the use of new antiplatelet therapies in patients with acute coronary syndrome increases the cases where an additional new oral anticoagulant is required. The first studies on this association have revealed an increased risk of bleeding. However, numerous studies assessing the efficacy and risk of this association are ongoing
Coronary angioplasty has so far crossed several different borders. Thrombotic occlusions were the first to be treated by this novel approach, then acute myocardial infarctions by means of acute de-occlusion of the “culprit” artery. With time, the lesions treated by this method have become increasingly complex. Nowadays, bifurcation lesions and stenoses of the left main coronary artery can successfully be managed using coronary angioplasty. Lastly, coronary angioplasty has also proven able to address chronic total occlusions.
Percutaneous coronary intervention, or PCI, plays a central role in the treatment of acute coronary syndrome, including myocardial infarction, thereby reducing patient’s mortality. In patients with ST segment elevation myocardial infarction (STEMI), primary PCI is the recommended reperfusion strategy. It should be performed within 60 to 90 min from the first medical contact, which is considered as a good care quality indicator in this setting.
Since its introduction back in 1977 by Andreas Grüntzig in Zurich, percutaneous transluminal coronary angioplasty (PTCA) has taken a major place among myocardial revascularization techniques due to constant technical and pharmacological improvements. The introduction of metal stents, about 10 years after the first balloon catheters, has not only allowed the incidence of acute complications and delayed restenosis to be reduced, but the technique has since been applied to acute coronary syndrome patients. Owing to the development of drug-eluting stents a decade later, percutaneous coronary interventions have meanwhile been proven effective and reliable in coronary disease patients, as compared to surgery. This paper provides a brief review on these four last decades, pointing out the major stages and victories but also the doubts and difficulties inherent to these medical advances.