Selecting an oral anticoagulant for patients with nonvalvular atrial fibrillation.

While the use of warfarin has been the cornerstone of thromboembolism prevention in patients with atrial fibrillation (AF), its limitations have led to the introduction of a new generation of direct-acting oral anticoagulants. Evidence from large phase III clinical trials, observational studies and pharmacokinetic analyses can guide clinicians to select the most effective and safest form of anticoagulation for patients with nonvalvular AF. This manuscript describes the main pharmacologic, clinical and epidemiological characteristics of each new oral anticoagulant and their use in selected clinical scenarios, including patients with: advanced age; at low or high risk of stroke; potential drug-drug interactions; on concomitant antiplatelet therapy; at high risk for acute coronary syndrome; with recent gastrointestinal bleeding; with renal impairment; and with hepatic dysfunction.

Comparison of the phase III clinical trial designs of novel oral anticoagulants versus warfarin for the treatment of nonvalvular atrial fibrillation: implications for clinical practice.

Although vitamin K antagonists (VKAs) have been the backbone of thromboprophylaxis in nonvalvular atrial fibrillation, their limitations have encouraged the development of a new generation of oral anticoagulants. This review compares the different designs and procedures used to conduct four phase III trials that tested dabigatran, rivaroxaban, apixaban, and edoxaban versus VKAs. Although pharmacologic characteristics and results of the main trials are briefly discussed, this review mainly focuses on study designs, enrollment criteria, populations studied, quality metrics, and transition strategies between oral anticoagulants. While each of the trials was of high quality, performed independently, and led by independent academic groups, substantial differences exist in terms of drug pharmacology and trial characteristics. Caution is advised when comparing results across trials as practicing clinicians strive to personalize anticoagulation treatments for their individual patients. We believe that the differences in the pharmacokinetic and pharmacodynamic profiles of the available novel oral anticoagulants (NOACs), coupled with substantial heterogeneity in the trial populations and designs and procedures used to conduct the trials, support an important role for each of the NOACs dependent upon the specific clinical scenario faced by the practicing clinician.

Left main coronary artery stenosis treatment with two paclitaxel-eluting stents in a patient with cardiac allograft vasculopathy / Tratamiento de una estenosis del tronco de la coronaria izquierda con dos stents liberadores de paclitaxel en un paciente con vasculopatía coronaria postrasplante

Cardiac transplantation is a well defined therapy for end stage heart failure. After the first year of transplantation, allograft coronary artery disease (ACAD) is the second main cause of death. The ACAD is defined as a diffuse process affecting the entire length of epicardial vessels. Once ACAD has been established, treatments such as coronary angioplasty, coronary stenting, and coronary bypass are performed. We present a case of successful stenting of the left main coronary artery (LMCA) in a patient with ACAD. The patient's medical history was significant for heart transplantation due to ischemic heart failure. Four years after transplantation the patient was admitted again due to sudden worsening of New York Heart Association functional class and extreme fatigue. Coronary angiogram showed a severe stenosis in the proximal segment of the LMCA; we performed stenting with a paclitaxel-eluting stent (PES). Six months after the procedure, the patient had an elective angiogram, where we discovered a new severe occlusion distally to the former stent; a second PES was implanted. Fourteen months after the second stenting, a new elective angiogram was performed without evidence of in-stent restenosis. After a 8-year follow-up since transplantation, the patient is free from dyspnea, angina, and adverse cardiovascular events. Our report suggests the efficacy of PES as ACAD treatment of the unprotected LMCA.

Left main coronary artery stenosis treatment with two paclitaxel-eluting stents in a patient with cardiac allograft vasculopathy.

Cardiac transplantation is a well defined therapy for end stage heart failure. After the first year of transplantation, allograft coronary artery disease (ACAD) is the second main cause of death. The ACAD is defined as a diffuse process affecting the entire length of epicardial vessels. Once ACAD has been established, treatments such as coronary angioplasty, coronary stenting, and coronary bypass are performed. We present a case of successful stenting of the left main coronary artery (LMCA) in a patient with ACAD. The patient's medical history was significant for heart transplantation due to ischemic heart failure. Four years after transplantation the patient was admitted again due to sudden worsening of New York Heart Association functional class and extreme fatigue. Coronary angiogram showed a severe stenosis in the proximal segment of the LMCA; we performed stenting with a paclitaxel-eluting stent (PES). Six months after the procedure, the patient had an elective angiogram, where we discovered a new severe occlusion distally to the former stent; a second PES was implanted. Fourteen months after the second stenting, a new elective angiogram was performed without evidence of in-stent restenosis. After a 8-year follow-up since transplantation, the patient is free from dyspnea, angina, and adverse cardiovascular events. Our report suggests the efficacy of PES as ACAD treatment of the unprotected LMCA.

Predictors of mortality and adverse outcome in elderly high-risk patients undergoing percutaneous coronary intervention.

OBJECTIVES: We sought to identify predictors of in-hospital and long-term (> 1 year) mortality and major adverse cardiac events (MACE) in elderly patients referred for percutaneous coronary intervention (PCI). METHODS: Seventy-three patients (> or = 80 years) were included. Clinical and interventional characteristics were collected retrospectively. Primary end points were in-hospital and long-term mortality, and a composite of non-fatal myocardial infarction, target vessel revascularization, urgent coronary artery bypass graft surgery, and death (MACE). RESULTS: Eighty-three percent of the patients had acute coronary syndromes, 43% three-vessel disease, and 42% heart failure. In-hospital mortality and MACE were 16.4% and 19%, respectively. Long-term mortality and MACE were 11.3% and 16.4%, respectively. Univariate characteristics associated with in-hospital mortality and MACE were: Killip Class III-IV, heart failure, cardiogenic shock, TIMI 0-2 flow prior and after intervention, diabetes mellitus, contrast nephropathy, and presence of A-V block or atrial fibrillation (AF). Long term predictors for mortality were the presence of heart failure, cardiogenic shock, diabetes mellitus, TIMI flow 0-2 before and after intervention, and A-V block or AF. CONCLUSION: The identification of the factors previously mentioned may help to predict complications in elderly patients.

Predictors of mortality and adverse outcome in elderly high-risk patients undergoing percutaneous coronary intervention / Predictores de mortalidad y mal pronóstico en pacientes ancianos y de alto riesgo que van a ser sometidos a intervención coronaria percutánea

OBJECTIVES: We sought to identify predictors of in-hospital and long-term (> 1 year) mortality and major adverse cardiac events (MACE) in elderly patients referred for percutaneous coronary intervention (PCI). METHODS: Seventy-three patients (> or = 80 years) were included. Clinical and interventional characteristics were collected retrospectively. Primary end points were in-hospital and long-term mortality, and a composite of non-fatal myocardial infarction, target vessel revascularization, urgent coronary artery bypass graft surgery, and death (MACE). RESULTS: Eighty-three percent of the patients had acute coronary syndromes, 43% three-vessel disease, and 42% heart failure. In-hospital mortality and MACE were 16.4% and 19%, respectively. Long-term mortality and MACE were 11.3% and 16.4%, respectively. Univariate characteristics associated with in-hospital mortality and MACE were: Killip Class III-IV, heart failure, cardiogenic shock, TIMI 0-2 flow prior and after intervention, diabetes mellitus, contrast nephropathy, and presence of A-V block or atrial fibrillation (AF). Long term predictors for mortality were the presence of heart failure, cardiogenic shock, diabetes mellitus, TIMI flow 0-2 before and after intervention, and A-V block or AF. CONCLUSION: The identification of the factors previously mentioned may help to predict complications in elderly patients.