Cardiovascular Medicine Book

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AngioplastyAka: Percutaneous Coronary Intervention, PTCA

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  1. Indications
    1. Cardiac Ischemia
    2. Myocardial Infarction
  2. Timing: Perioperative Stent Implications
    1. Recent PTCA
      1. Balloon angioplasty
        1. Time since surgery <14 days: Delay non-urgent or elective surgery
        2. Time since surgery >14 days: Proceed to surgery with Aspirin
      2. Bare-metal stent
        1. Time since surgery <30-45 days: Delay non-urgent or elective surgery
        2. Time since surgery >45-90 days: Proceed to surgery with Aspirin
      3. Drug-eluting stent
        1. Time since surgery <365 days: Delay non-urgent or elective surgery
        2. Time since surgery >365 days: Proceed to surgery with Aspirin
    2. PTCA required to stabilize acute cardiovascular status prior to surgery
      1. Surgery with low risk of bleeding: Stent and continue dual-antiplatelet therapy
      2. Time to surgery 14 to 29 days: Balloon angioplasty
      3. Time to surgery 30 to 365 days: Bare-metal stent
      4. Time to surgery >365 days: Drug-eluting stent
  3. Efficacy
    1. Initial: 95% effective in coronary ischemia
    2. Angioplasty without stent: 35% re-stenosis at 6 months
    3. Angioplasty with stenting: 17% re-stenosis at one year
    4. Angioplasty with stenting and radiotherapy
      1. Lowers re-stenosis rate at 6 months
      2. Lowers need for revascularization at one year
      3. Does not alter mortality rate
      4. Does not alter Myocardial Infarction rate
      5. Waksman (2002) N Engl J Med 346:1194
    5. Angioplasty with drug eluting stent
      1. Overall restenosis rate: 10%
      2. Drug eluting stents have a higher rate of thrombus formation in first 6-12 months
        1. See adverse effects below
      3. Initial studies: 6.9% re-stenosis at 9 months
        1. Moses (2003) N Engl J Med 349:1315
  4. Trials
    1. START (Stent versus directional coronary atherectomy)
      1. Atherectomy superior to primary stenting
    2. References
      1. Tsuchikane (1999) J Am Coll Cardiol 34:1050
  5. Adverse Effects: Thrombosis at drug eluting stent site
    1. May be related to polymer used to bind the drugs to the stent
    2. Requires concurrent Aspirin 81 mg and Clopidogrel (Plavix) 75 mg for at least 12 months
      1. Minimizing Aspirin dose decreases serious bleeding events
      2. Significantly reduces cardiovascular events
    3. Peri-operative management within one year of drug eluting stent placement
      1. Delay elective surgeries for >1 year from PTCA placement
      2. Less invasive procedures (e.g. endoscopy) can be performed without stopping dual agents
      3. Protocol for more invasive urgent procedures
        1. Continue Aspirin 81 mg throughout perioperative period
        2. Stop Clopidogrel 5 days before surgery and restart on same day of surgery postoperatively
          1. First dose on restarting Clopidogrel should be loading dose of 300 mg
    4. References
      1. Kopacky (2008) Mayo Selected Topics in Internal Medicine, Lecture
      2. Mehta (2001) Lancet 358:527
  6. References
    1. Serruys (2001) N Engl J Med 344:1117

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