Intervenção coronária percutânea no paciente com alto risco de hemorragia / Percutaneous coronary intervention in the patient at high risk of bleeding

Na atualidade, as intervenções coronárias percutâneas são responsáveis por mais de 80% dos procedimentos de revascularização miocárdica. Esse resultado é possível por dois grandes avanços: o desenvolvimento de stents farmacológicos eficazes e seguros, somado a uma farmacoterapia antitrombótica potente e efetiva na prevenção de eventos aterotrombóticos, a qual, em geral, deve ser mantida por cerca de 6 a 12 meses após a intervenção índice. No entanto, expressivo contingente de casos, que a literatura situa em até 20% dos pacientes tratados, apresenta risco para desenvolver hemorragias significantes, que podem ter grave impacto no prognóstico. Assim, essa população requer uma série de cuidados relacionados com a indicação, a realização e o acompanhamento tardio. O processo se inicia pela identificação dos casos mais predispostos, o que, na maior parte das situações, é simples, havendo inclusive escores de risco que auxiliam o car­ diologista. Na sequência, a indicação do procedimento deve ser feita com propriedade. Os cuidados são iniciados pela prescrição preferencial do clopidogrel ao invés dos demais inibidores da P2Y12; no momento do procedimento, sempre que viável, a opção pela via radial é vantajosa, em especial em síndromes coronárias agudas. O uso de um modelo de stent com liberação de medicamentos também é recomendado nesses casos, pois os stents contemporâneos são seguros a ponto de permitirem a abreviação com segurança do tempo de uso do esquema antiplaquetário duplo. Por fim, mais recentemente, tem sido discutida a monoterapia com inibidores do receptor P2Y12, na qual a suspensão precoce do ácido acetilsalicílico não comprometeria a segurança e, ao mesmo tempo, seria capaz de prevenir eventos hemorrágicos de vulto.

Currently, percutaneous coronary interventions account for more than 80% of myocardial revascularization procedures. This result was enabled by two major advances: the development of effective and safe drug­eluting stents, in addition to a potent and effective antithrombotic pharmacotherapy in the prevention of atherothrombotic events, which, in general, should be maintained for about 6 to 12 months after the index intervention. However, a significant number of cases (up to 20% of treated patients according to literature) are at risk for developing significant bleeding, which can have a serious impact on prognosis. Therefore, this population requires a series of care measures related to indication, performance of the procedure, and late follow­up. The process begins with the identification of the most predisposed cases, which, in most situations, is simple, and there are risk scores that help the cardiologist. Next, the indication of the procedure should be done appropriately. Care begins with the preferential prescription of clopidogrel instead of other P2Y12 inhibitors; at the time of the procedure, whenever feasible, the option for the radial access is advantageous, especially in acute coronary syndromes. The use of a drug­eluting stent is also recommended in these cases, since contemporary stents are safe enough to safely shorten the duration of use of the dual antiplatelet regimen. Finally, more recently, monotherapy with P2Y12 receptor inhibitors has been discussed, in which early withdrawal of acetylsalicylic acid would not compromise safety and, at the same time, it would be able to prevent major bleeding events.

Low level of high-density lipoprotein cholesterol predicts contrast induced-acute kidney injury after percutaneous coronary interventions in patients with coronary heart disease / 中华急诊医学杂志

Objective To investigate the relationship of low level of high-density lipoprotein cholesterol to contrast induced-acute kidney injury (CI-AKI) after percutaneous coronary intervention (PCI) in patients with coronary heart disease.Methods A total of 1500 consecutive patients,who underwent PCI from January 2009 to May 2011,were enrolled in this study.There was no limit on age or sex,and all patients were self-identified as Han ethnic group.Patients were excluded from this study,however,if they had a history of malignant tumor,urinary tract infection,nephrectomy operation,chronic peritoneal or hemodialysis,or if they had been exposed to contrast media within the past 14 days.CI-AKI was defined as an absolute increase in serum creatinine ≥44.2 μmol/L or a relative ≥25％ increase in serum creatinine within 72 hours after procedure.Low level of HDL-C was defined as ＜ 1.04 mmol/L.Monofactorial and multivariate analysis was performed to identify risk factors for CI-AKI and low level of HDL-C in these patients.Results Among the 1500 patients with coronary heart disease,CI-AKI occurred in 246 patients after PCI and the overall incidence of CI-AKI was 16.4％.The patients with low level of HDL-C had a higher incidence of CI-AKI than those without it (21.5％ vs.13.3％ in total,P ＜0.01),no matter that they had suffered from chronic kidney disease (39.8％ vs.26.5％,P ＜ 0.05) or not (17.7％ vs.9.7％,P ＜ 0.01).By multivariate analysis,low level of HDL-C was identified as an independent risk factor for CI-AKI and smoke,great BMI as well as anemia were considered as prediction factors for low level of HDL-C.Conclusion The patients with low level of HDL-C have a higher incidence of CI-AKI after PCI.Low level of HDL-C is one of risk factors for CI-AKI after PCI in patients either with chronic kidney disease or not.Great BMI,smoking as well as anemia are independent predictors for low HDL-C level in these patients.