Periprocedural Myocardial Injury in High-Risk Patients With NSTEMI Pretreated With Ticagrelor for Less or More Than 6 Hours Before PCI.

We assessed the impact on periprocedural myocardial injury of a ticagrelor loading dose given <6 or >6 hours before percutaneous coronary intervention (PCI) in non-ST-elevation myocardial infarction (NSTEMI) patients at high risk. All consecutive patients pretreated with ticagrelor and undergoing PCI for a high-risk NSTEMI have been included in the present analysis. Propensity-score matching was performed to compare the outcomes between patients pretreated with ticagrelor for >6 hours or ≤6 hours. The primary outcome was the rate of periprocedural myocardial injury after PCI. We also recorded clinical outcomes, including major adverse cardiovascular events and major bleedings at 1 month. A total of 1216 patients with NSTEMI were deemed eligible for the study: 481 received a ticagrelor loading dose ≤6 hours (mean time, 4.3 ± 1.2 h) and 735 >6 hours (16.1 ± 8.4 hours) before PCI. Patients pretreated with ticagrelor for >6 hours presented more risk factors and comorbidities compared to others. In patients pretreated with ticagrelor for >6 hours, the rate of periprocedural myocardial injury was significantly lower compared to the other group, in the overall population (19.6% vs 37.8%; P < .0001) and in the matched cohort of 644 patients (18.9% vs 33.5%; P < .0001). The rate of major adverse cardiovascular events and major bleeding events did not differ between the two groups, in both unmatched and matched populations. The present study suggests that ticagrelor pretreatment reduces periprocedural myocardial injury in high-risk patients with NSTEMI undergoing PCI with expected time intervals >6 hours.

One-year clinical outcome of patients with left ventricular thrombus after acute myocardial infarction discharged on triple or dual antithrombotic therapy.

In patients with left ventricular thrombus (LVT) after acute myocardial infarction (MI), both anticoagulant and antiplatelet therapies are needed. It is unknown whether dual antithrombotic therapy (DAT) is able to reduce the incidence of bleeding complications without significantly increasing the number of thromboembolic events, compared to triple antithrombotic therapy (TAT). We retrospectively evaluated all post-MI patients with LVT discharged on TAT or DAT from our tertiary hospital in the last decade. The primary outcome was the occurrence of all-cause mortality, thromboembolic events, hospitalizations for re-MI or heart failure and any bleeding at 1 year. A propensity-score matching was performed in order to compare the primary outcome between TAT and DAT. Out of 2564 acute MI patients, 83 (3.2%) had an LVT at echocardiography: 51 (61.4%) discharged on TAT and 32 (38.6%) on DAT. At clinical follow-up, completed in 93% of cases, the incidence of the primary outcome was 18.2% (25.5% in TAT and 6.7% in DAT group; p = 0.04). More than 2/3 of the events included in the primary outcome were related to bleeding complications and occurred during the first month from hospital discharge. In the matched cohort of 42 patients with follow-up data available, the primary outcome occurred in 9 (42.9%) patients in the TAT and 2 (9.5%) in the DAT group (p = 0.03). In post-MI patients with LVT, DAT seems more effective than TAT in reducing clinical outcome, especially early bleeding complications. A randomized study is warranted to confirm this hypothesis.

Effectiveness of fondaparinux vs unfractionated heparin following percutaneous coronary intervention in survivors of out-of-hospital cardiac arrest due to acute myocardial infarction.

AIM: There is no specific evidence on the antithrombotic management of survivors of out-of-hospital cardiac arrest (OHCA) due to acute myocardial infarction (AMI). We sought to compare the short-term outcome of unfractioned heparin (UFH) vs fondaparinux in OHCA survivors due to AMI admitted in our Institution in the last decade. METHODS: We performed a retrospective cohort study on survivors of OHCA due to AMI managed with UFH or fondaparinux during the hospitalization. The primary outcome was the occurrence of any bleeding, all-cause mortality, cerebrovascular accidents, re-MI, and unplanned revascularization at 1 month. A propensity-score matching was performed to compare the outcome between UFH and fondaparinux. RESULTS: Out of 2083 AMI patients undergoing successful PCI, OHCA was present in 94 (4.5%): 41 (43.6%) treated with UFH and 53 (56.4%) with fondaparinux. At clinical follow-up, the incidence of the primary outcome was 65.9% in UFH and 35.8% in fondaparinux group (p = 0.007). More than half of the events included in the primary outcome were related to bleeding complications. In the matched cohort of 56 patients, the primary outcome occurred in 46.4% and 25.0% (p = 0.16), while bleeding was present in 32.1% and 7.1% (p = 0.04), in the UFH and fondaparinux group, respectively. CONCLUSIONS: The present analysis suggests that fondaparinux is safer than UFH in the management of OHCA due to AMI by reducing early bleeding complications at one month.

Fondaparinux During Intra-Aortic Balloon Pump Counterpulsation in Acute Myocardial Infarction Patients Undergoing Percutaneous Coronary Intervention.

BACKGROUND: Although anticoagulation with unfractionated heparin (UFH) is commonly used during intra-aortic balloon pump (IABP) counterpulsation to prevent thromboembolic events, no data or guidelines exist to support this strategy, especially in the setting of acute myocardial infarction (AMI). This study sought to compare the short-term outcome of UFH vs fondaparinux in AMI patients who underwent successful percutaneous coronary intervention (PCI) and IABP insertion. METHODS: The anticoagulation therapy of revascularised AMI patients who received IABP counterpulsation and admitted to a tertiary hospital in the last decade was retrospectively evaluated. The primary outcome was the occurrence of all-cause mortality, stroke or transient ischaemic attack, reinfarction, unplanned revascularisation, major or minor limb ischaemia, and any bleeding at 1 month. Propensity score matching was performed to compare the primary outcome between UFH and fondaparinux. RESULTS: Of 1,355 AMI survivors at 2 days after hospital admission and who underwent successful PCI, an IABP was inserted in 197 (14.5%): 72 (36.5%) were treated with UFH and 125 (63.5%) with fondaparinux (2.5 mg o.d.). At clinical follow-up, completed in 98.5% of cases, the incidence of the primary outcome was 22.5% in UFH and 5.7% in fondaparinux groups (p=0.0009). More than two-thirds of the events included in the primary outcome were related to early bleeding complications. In the matched cohort of 62 patients, the primary outcome occurred in 14 (45.2%) patients in the UFH and two (6.5%) in the fondaparinux group (p=0.01). CONCLUSIONS: This study suggested that fondaparinux is safer, by reducing early bleeding complications at one month, than UFH in the management of IABP.