Meta-Analysis of the Role of Cangrelor for Patients Undergoing Percutaneous Coronary Intervention.

Inhibition of the P2Y12 receptor by an oral P2Y12 inhibitor with loading doses along with Cyclooxygenase-1 inhibition by aspirin is considered a first-line treatment strategy in patients with the acute coronary syndrome and patients undergoing percutaneous coronary intervention (PCI). Limitations associated with oral P2Y12 receptor inhibitors include a requirement for in vivo conversion (thienopyridines), delayed onset of action, suboptimal inhibition, irreversible inhibition (thienopyridines), and delayed offset. In the acute setting, therapy with potent platelet inhibitors that have a fast onset and offset is desirable to attenuate thrombotic complications. Cangrelor, an intravenous agent, is an adenosine triphosphate analog, selectively and explicitly blocking P2Y12 receptor-mediated platelet activation. Cangrelor has been studied in a series of CHAMPION trials. A patient-level, meta-analysis of all 3 phase III trials (24,910 patients), demonstrated that cangrelor significantly reduced the rate of the composite outcome of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 hours and 30 days compared with clopidogrel, with no significant increase in major bleeding. It is approved for clinical use in patients undergoing PCI to reduce the risk of myocardial infarction, repeat revascularization, and stent thrombosis in patients who have not been treated with a P2Y12 platelet inhibitor and are not being given a GPIIbIIIa inhibitor. In conclusion, patients unable to take oral medications undergoing emergent/urgent PCI and those who had recent PCI with drug eluting stent in need for urgent cardiac or noncardiac surgery are potential candidates for cangrelor.

Oral antiplatelets in primary and secondary prevention of myocardial infarction: a review.

There are a number of guidelines and articles available for the use of oral antiplatelets for primary and secondary prevention of myocardial infarction (MI). Antiplatelet medications inhibit platelet activation, aggregation, and other pathways eventually inhibiting clot formation. Aspirin and clopidogrel have been the mainstay in the management of acute coronary syndrome for about a decade. We have discussed the role of aspirin, clopidogrel, ticagrelor, and prasugrel which are the most commonly used oral antiplatelet medications in the current era. We have also considered the role of newer thrombin inhibitor vorapaxar, and dual antiplatelet therapy. In this review paper, we have summarized the continuing controversy about the use of oral antiplatelet therapy and their role in primary as well as secondary prevention of MI by describing results from major clinical trials. The safety and the efficacy of the above medications have been reviewed and described in this paper.

Complete Heart Block From Chronic Marijuana Use.

Marijuana is the most commonly used illicit drug in the world. Over the last decade, the potency of marijuana has increased tremendously. Its use is associated with harmful health consequences including adverse cardiovascular effects, such as arrhythmias, myocardial infarction, cardiomyopathy and stroke. It has been reported to cause bradycardia. This report describes the case of a 51-year-old female with no significant past medical history who presented with complete heart block due to chronic marijuana use, requiring a permanent pacemaker. To our knowledge, this is the first reported case of complete heart block due to chronic marijuana use. Advanced conduction system abnormalities can be a potential complication of chronic marijuana use, which the physicians need to be aware of. With increasing push for medical marijuana, physicians are likely to encounter more of such cases.

Thrombus formation in left atrium on dabigatran therapy.

Dabigatran is a direct thrombin inhibitor, approved in the United States for stroke prevention in nonvalvular atrial fibrillation and prevention and treatment of thromboembolism. It has been also used in patients with documented left atrial thrombus, where treatment with dabigatran effectively led to thrombus resolution. We present a rare case of left atrial thrombus formation in a patient with chronic atrial fibrillation being treated with dabigatran 150 mg twice a day. The patient presented with multiple embolic strokes. There are only three such cases reported in the literature till date, all of whom had thrombus in the left atrium. The possible mechanisms of dabigatran failure include compensatory increase in upstream coagulation factors due to single level downstream blockade of thrombin, lack of inhibition of all available thrombin, and lack of monitoring measures that can be implemented in common clinical laboratories that lead to failure to assess adherence, which in turn can lead to dabigatran failure.