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1.
Future Cardiol ; 11(5): 521-4, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26403439

RESUMO

Acute lower extremities peripheral artery disease represents a clinical emergency. Peripheral artery disease incidence ranges from 2.5 to 22% and has progressively increased due to the world population aging phenomenon and associates with coronary artery disease with a rate of 40-60%. The authors present the case of an 89-year-old man coming to their attention with acute lower extremities ischemia and unstable angina. Despite the short-to-midterm favorable outcome, doubts remain about the opportunity of treating 'very old' patients. The lack of dedicated randomized trials and of defined guidelines is a problem the scientific community needs to face considering that patients over 85 years represent a raising quote of the whole population of our catheterization laboratories.


Assuntos
Angina Instável/cirurgia , Artéria Femoral , Intervenção Coronária Percutânea/métodos , Doença Arterial Periférica/cirurgia , Stents , Procedimentos Cirúrgicos Vasculares/métodos , Idoso de 80 Anos ou mais , Angina Instável/complicações , Angina Instável/diagnóstico por imagem , Angiografia , Seguimentos , Humanos , Masculino , Doença Arterial Periférica/complicações , Doença Arterial Periférica/diagnóstico por imagem , Fatores de Tempo
2.
J Am Coll Cardiol ; 56(18): 1447-55, 2010 Oct 26.
Artigo em Inglês | MEDLINE | ID: mdl-20951320

RESUMO

OBJECTIVES: The purpose of this study was to investigate the long-term outcome after elective percutaneous coronary intervention in low-risk patients screened for aspirin and/or clopidogrel responsiveness in the 3T/2R (Tailoring Treatment With Tirofiban in Patients Showing Resistance to Aspirin and/or Resistance to Clopidogrel) trial. BACKGROUND: The impact of aspirin and/or clopidogrel poor response on long-term outcome is debated. METHODS: Aspirin and clopidogrel response was measured with the VerifyNow system aspirin and P2Y12 assays. After percutaneous coronary intervention (PCI), death, stroke, and myocardial infarction were assessed up to 1 year. RESULTS: Overall, 1,277 patients were screened, and 826 (65%) were treated with PCI. In all, 124 patients were found to be aspirin poor responders, and there were 179 clopidogrel poor responders (totally, 278 poor responders). The 1-year end point was significantly higher in poor responders as compared to full responders (15.8% vs. 8.6%, p=0.002), which is principally due to more myocardial infarction occurrence. At multivariable analysis, clopidogrel poor response emerged as an independent predictor (hazard ratio: 1.15, 95% confidence interval: 1.03 to 1.28). Receiver-operator characteristic analysis identifies≤23 of percentage of platelet inhibition and ≥208 of P2Y12 reactivity units as optimal cut offs to predict 1-year end point. Excluding periprocedural events, also peri-PCI myocardial infarction, which is strongly related to aspirin/clopidogrel poor response, was an independent predictor (hazard ratio: 1.25, 95% confidence interval: 1.14 to 1.37). Glycoprotein IIb/IIIa inhibitor administration reduces this risk in poor responders (21.2% vs. 34.7%, p=0.02), but not in full responders (6.3% vs. 6.5%, p=0.8). CONCLUSIONS: Poor response to clopidogrel is an independent predictor of periprocedural myocardial infarction and worse 1-year outcome in low-risk patients undergoing PCI, whereas poor response to aspirin failed to predict a worse outcome. Contrary to what was observed in poor responders, glycoprotein IIb/IIa inhibitor therapy failed to provide a benefit in aspirin and/or clopidogrel full responders.


Assuntos
Angioplastia Coronária com Balão/tendências , Aspirina/uso terapêutico , Resistência a Medicamentos , Procedimentos Cirúrgicos Eletivos/tendências , Ticlopidina/análogos & derivados , Tirosina/análogos & derivados , Idoso , Idoso de 80 Anos ou mais , Clopidogrel , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/prevenção & controle , Valor Preditivo dos Testes , Estudos Prospectivos , Ticlopidina/uso terapêutico , Fatores de Tempo , Tirofibana , Resultado do Tratamento , Tirosina/uso terapêutico
4.
Circulation ; 119(25): 3215-22, 2009 Jun 30.
Artigo em Inglês | MEDLINE | ID: mdl-19528337

RESUMO

BACKGROUND: Inhibition of platelet aggregation after aspirin or clopidogrel intake varies greatly among patients, and previous studies have suggested that poor response to oral antiplatelet agents may increase the risk of thrombotic events, especially after coronary angioplasty. Whether this reflects suboptimal platelet inhibition per se, which might benefit from more potent antiplatelet agents such as tirofiban, is unknown. METHODS AND RESULTS: We screened 1277 patients to enroll 93 aspirin, 147 clopidogrel, and 23 dual poor responders, based on a point-of-care assay, who underwent elective coronary angioplasty at 10 European sites for stable or low-risk unstable coronary artery disease. Patients were randomly assigned in a double-blind manner to receive either tirofiban (n=132) or placebo (n=131) on top of standard aspirin and clopidogrel therapy. The primary end point, consisting of troponin I/T elevation at least 3 times the upper limit of normal, was attained in 20.4% (n=27) in the tirofiban group compared with 35.1% (n=46) in the placebo group (relative risk, 0.58; 95% confidence interval, 0.39 to 0.88; P=0.009). The rate of major adverse cardiovascular events within 30 days in the tirofiban group also was reduced (3.8% versus 10.7%; P=0.031). The overall incidence of bleeding was low, likely explained by a substantial use of the transradial approach, and did not differ between the 2 groups. CONCLUSIONS: In low-risk patients according to clinical presentation who had poor responsiveness to standard oral platelet inhibitors via a point-of-care assay, intensified platelet inhibition with tirofiban lowers the incidence of myocardial infarction after elective coronary intervention.


Assuntos
Angioplastia Coronária com Balão , Doença da Artéria Coronariana/tratamento farmacológico , Trombose Coronária/prevenção & controle , Resistência a Medicamentos , Inibidores da Agregação Plaquetária/administração & dosagem , Tirosina/análogos & derivados , Idoso , Aspirina/uso terapêutico , Plaquetas/efeitos dos fármacos , Clopidogrel , Terapia Combinada , Doença da Artéria Coronariana/epidemiologia , Trombose Coronária/epidemiologia , Método Duplo-Cego , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/prevenção & controle , Inibidores da Agregação Plaquetária/efeitos adversos , Estudos Prospectivos , Fatores de Risco , Ticlopidina/análogos & derivados , Ticlopidina/uso terapêutico , Tirofibana , Tirosina/administração & dosagem , Tirosina/efeitos adversos
5.
EuroIntervention ; 5(5): 589-98, 2009 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-20142180

RESUMO

AIMS: We aimed to determine the success, safety and long-term durability of carotid artery stenting (CAS) in stroke prevention for all-comers managed with mandatory neuroprotection and a tailored-approach to intervention. METHODS AND RESULTS: From our CAS registry (beginning July 1997) all procedures up to September 2007 with intention-to-treat by stenting under distal filter or proximal occlusion neuroprotection devices were analysed (N=1523; mean age 72 years [237 >or=80 years, 15.5%]). Indications included symptomatic stenoses >or=50% (366, 24.1%) and asymptomatic stenoses >or=80% (1157, 75.9%). CAS success was 99.6% and the 30-day all-stroke/death rate was 1.5% (minor stroke 11 [0.7%], major stroke 8 [0.5%], death 5 [0.3%]). The risk was 1.2% for asymptomatic patients and 2.7% for symptomatic patients (p=0.042). Regarding octogenarians this risk was 2.1% versus 1.5% for patients or=80 1.2%, symptomatic or=80 4.5%. The event free survival rates from all strokes or stroke-related deaths at eight years were 96% for asymptomatic and 92% for symptomatic patients. CONCLUSIONS: Results from this large cohort show that carotid stenting in a real-world setting is safe and efficacious, and durable in the long-term prevention of stroke.


Assuntos
Angioplastia/instrumentação , Estenose das Carótidas/terapia , Stents , Acidente Vascular Cerebral/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Angioplastia/efeitos adversos , Angioplastia/mortalidade , Estenose das Carótidas/complicações , Estenose das Carótidas/mortalidade , Distribuição de Qui-Quadrado , Intervalo Livre de Doença , Humanos , Itália , Estimativa de Kaplan-Meier , Modelos Logísticos , Pessoa de Meia-Idade , Razão de Chances , Estudos Prospectivos , Sistema de Registros , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
6.
J Endovasc Ther ; 15(6): 655-62, 2008 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-19090627

RESUMO

PURPOSE: To report a prospective feasibility study of cutting balloon angioplasty (CBA) applied in the predilation phase of carotid artery stenting (CAS) in highly calcified lesions. METHODS: From January 2003 to February 2007, 178 consecutive patients (109 men; mean age 73.1+/-7.3 years) with highly calcified carotid lesions underwent CAS with CBA applied as a pre-specified strategy in the predilation phase of the procedure. All steps in the procedure were performed under cerebral filter protection. The cutting balloon ranged in diameter from 3 to 4 mm and was inflated at nominal pressures in the target lesion. Pre-CBA dilation with a low-profile coronary balloon was performed only when the cutting balloon was not able to cross the lesion. Selection of the filters and stents was at the operator's discretion. Primary endpoints were the all stroke and death rates at 30 days and 6 months. Secondary endpoints included cutting balloon success (positioning and full balloon inflation), CAS technical success (residual angiographic stenosis <30%), CAS procedural success (technical success and no complications), and in-hospital major complications. RESULTS: Cutting balloon success was achieved in all 178 patients. In 32 (18.0%), pre-CBA dilation was necessary due to inability to cross the lesion with the cutting balloon initially. CAS technical success was achieved in all patients. One (0.6%) patient suffered transient neurological intolerance due to flow cessation from massive debris in the distal filter; this event was completely resolved after the filter was removed (CAS procedural success 99.4%). One patient suffered a major stroke at day 15 (0.6% 30-day all stroke and death rate). At the 6-month follow-up, 174 (97.7%) patients were evaluated; 1 patient died from myocardial infarction at day 35, and 2 patients died from non-neurological or cardiac causes at days 103 and 158. The cumulative all stroke and death rate was 2.2%. CONCLUSION: These data suggest that CBA performed during the predilation phase of CAS in highly calcified lesion is a safe and useful method to prepare this lesion subset for stenting.


Assuntos
Angioplastia com Balão/métodos , Calcinose/terapia , Doenças das Artérias Carótidas/terapia , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/instrumentação , Angioplastia com Balão/mortalidade , Calcinose/diagnóstico por imagem , Calcinose/mortalidade , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/mortalidade , Estudos de Viabilidade , Feminino , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Projetos Piloto , Estudos Prospectivos , Desenho de Prótese , Radiografia , Medição de Risco , Stents , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
7.
EuroIntervention ; 4(3): 397-9; discussion 400-4, 2008 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-19110815

RESUMO

BACKGROUND: A 69-year-old male patient with severe asymptomatic carotid artery stenosis was treated percutaneously with implant of two self-expandable stents in the right carotid overlapped to each other by 5 mm. The 15-month follow-up colour-Doppler ultrasound (CDU) revealed a severe stenosis in the target vessel and an image suggesting migration of the distal stent. INVESTIGATIONS: Physical examination, laboratory test, CDU, carotid angiography, quantitative carotid angiography (QCA), brain computed tomography (CT). DIAGNOSIS: Migration of the distal stent associated with severe stenosis on the unsupported arterial segment. MANAGEMENT: Carotid artery angiography, QCA, antithrombotic therapy, carotid artery angioplasty and stenting (CAS).


Assuntos
Angioplastia/efeitos adversos , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/terapia , Migração de Corpo Estranho/diagnóstico por imagem , Stents/efeitos adversos , Idoso , Fluoroscopia , Humanos , Masculino , Ultrassonografia Doppler em Cores
8.
Cardiovasc Drugs Ther ; 22(4): 313-20, 2008 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-18561010

RESUMO

PURPOSE: To assess whether glycoprotein IIb/IIIa inhibition using tirofiban in low risk patients undergoing percutaneous coronary intervention (PCI) may reduce the risk of periprocedural myocardial infarction compared to standard care in poor responders to aspirin and/or clopidogrel. METHODS: We will enroll patients at ten European sites or more to participate in the Tailoring Treatment with Tirofiban in patients showing Resistance to aspirin and/or Resistance to clopidogrel (3T/2R) study with a pre-specified sample size of 240 patients out of 1,100 or more who will undergo screening. The primary outcome measure is troponin I or T elevation ratio at least three times the upper limit of normal within 48 h after completion of the PCI. CONCLUSION: The results of 3T/2R study will evaluate whether tailored intensification of anti-platelet treatment based on poor individual response to oral anti-platelet agents may modulate the risk of periprocedural myocardial infarction during PCI. Our findings attempt at unraveling a new era of individualized anti-platelet treatment through the use of point-of-care assessment.


Assuntos
Angioplastia Coronária com Balão/efeitos adversos , Aspirina/administração & dosagem , Resistência a Medicamentos , Infarto do Miocárdio/prevenção & controle , Inibidores da Agregação Plaquetária/administração & dosagem , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Ticlopidina/análogos & derivados , Tirosina/análogos & derivados , Biomarcadores/sangue , Clopidogrel , Método Duplo-Cego , Europa (Continente) , Humanos , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/metabolismo , Estudos Prospectivos , Projetos de Pesquisa , Ticlopidina/administração & dosagem , Tirofibana , Resultado do Tratamento , Troponina I/sangue , Troponina T/sangue , Tirosina/administração & dosagem
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