Bridging with glycoprotein IIb/IIIa inhibitors for periprocedural management of antiplatelet therapy in patients with drug eluting stents.

OBJECTIVE: To describe outcomes when glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors are used as bridging antiplatelet therapy for surgical procedures in patients with drug eluting stents (DES). BACKGROUND: The optimal management of patients with DES who require surgical procedures prior to completion of antiplatelet therapy is unclear. In high risk patients, the use of GP IIb/IIIa inhibitors as bridging therapy while antiplatelet therapy is held has been described, but safety and efficacy data remain sparse. METHODS: A pharmacy database was used to identify GP IIb/IIIa inhibitor orders at our hospital between January 1, 2007 and July 31, 2009. Indication for GP IIb/IIIa inhibitor administration and other clinical data were gathered through retrospective review of medical records. End points assessed were stent thrombosis, major bleeding, minor bleeding, postoperative acute coronary syndrome, and death within 30 days. RESULTS: Four thousand one hundred seventy-six separate orders for GP IIb/IIIa inhibitors were identified (January 1, 2007 to July 31, 2009). Six patients underwent non-cardiac and thirteen underwent cardiac surgery. Clopidogrel was discontinued a median of 6 days before surgery and 2 days prior to initiating GP IIb/IIIa inhibitor. All bridging patients were treated with eptifibatide infusion prior to procedure. There were no stent thromboses, deaths, or acute coronary syndrome events. Major bleeding occurred in 7 (53.9%) cardiac surgery patients and none of the non-cardiac surgery patients, while minor bleeding occurred in 1 (7.7%) and 1 (16.6%) patients, respectively. CONCLUSIONS: In patients with DES, who require cessation of clopidogrel before surgery, bridging with GP IIb/IIIa inhibitors appears effective in preventing adverse cardiac outcomes but may be associated with bleeding in patients undergoing cardiac surgery.

Pathophysiology of concomitant atrial fibrillation and heart failure: implications for management.

Atrial fibrillation (AF) and heart failure (HF) are two conditions regularly encountered in clinical practice. They share many common risk factors, and are often seen concurrently in an individual patient. Global aging of the population is likely to lead to an increase in the prevalence of both AF and HF alone, as well as in their combined state. The relationship between these two diseases is not simply coincidental; clinical and experimental data have defined multiple pathophysiological mechanisms to explain how either condition contributes to the de novo development of the other. The development of AF in the setting of HF, and vice versa, is associated with clinical deterioration and worsening prognosis, which indicates the need for an improved understanding of the clinical and pathological relationships between these conditions. Future research on pharmacologic therapies, such as antiarrhythmic medications, and nonpharmacologic strategies including atrioventricular nodal ablation and pulmonary vein isolation, will help to define the optimal therapeutic approach for concurrent AF and HF. This step is vital to improve both the outcomes of patients affected by these conditions and the cost-effectiveness of their care.