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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Coronary heart disease is the leading cause of death among the elderly (> 65 years) and the very elderly (> 85 years). Little information is available regarding the outcome of very elderly patients referred for PCI in the current era of improved techniques, devices, and pharmacotherapy. The objective of the current study was to evaluate the clinical characteristics and outcomes of very elderly patients > or = 85 years of age in a large, contemporary, multi-institutional PCI database. Five hospitals in the New York City metropolitan area contributed these prospectively defined data elements on consecutive patients undergoing PCI from 1 January 1998 to 1 October 1999. Of 10,847 patients, 5,341 (49%) were younger than 65 years, 3,342 (31%) were 65-74 years, 1,885 (17%) were 75-84 years, and 279 (2.6%) were at least 85 years of age. Following PCI, the very elderly developed stroke (P < 0.001) and renal failure requiring dialysis (P = 0.002) more commonly than younger patients following PCI. The very elderly had a significantly increased in-hospital mortality rate at 2.5% (P < 0.001). However, on multivariate analysis, age > or = 85 years was not an independent predictor of in-hospital mortality (OR = 1.22; 95% CI = 0.37-4.07). The very elderly should not be refused PCI on the basis of advanced age alone.
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PMID:In-hospital outcomes of contemporary percutaneous coronary interventions in the very elderly. 1259 1

There is a lack of consensus among cardiologists regarding the length of time patients should be hospitalized after an uncomplicated acute myocardial infarction (AMI) and successful direct percutaneous coronary intervention (d-PCI). The purpose of this study was to evaluate the feasibility and safety of early discharge (discharge <4 days after the procedure) for low risk patients with AMI who underwent successful d-PCI. From May 1996 through December 2001, d-PCI was performed in 898 consecutive patients with AMI. Of these 898 patients, 463 (51.6%) were stratified to be at low risk. Lower risk was defined as: (1) Killip classification < or = 2 on admission; (2) the infarct-related artery achieved normal blood flow without recurrent ischemia or reinfarction in the first 24 hours; (3) no mechanical or electrical complications after d-PCI. (4) no acute renal failure, acute stroke, or major bleeding complication; (5) no advanced congestive heart failure (defined as > or = New York Heart Association functional class 3); and (6) no sepsis. Patients who were discharged <4 days after undergoing the procedure were enrolled in group 1 (n = 266). Patients who were discharged > or = 4 days after undergoing the procedure were enrolled in group 2 (n = 197). Univariate analysis demonstrated that group 2 patients had a significantly longer hospital stay (P = 0.0001) than group 1 patients. At the first 30-day follow-up examination, there were no significant differences in the combined major cardiac events (death, recurrent isehemia, reinfarction, revascularization. or advanced congestive heart failure) between the group 1 and group 2 patients (1.50% vs 1.52%, P = 0.92). There were also no significant differences in the combined major noncardiac complications (acute stroke, acute renal failure, bleeding complications requiring blood transfusion, vascular sequelae, or sepsis) between the group 1 and group 2 patients (1.13% vs 0.51%. P = 0.89). Early discharge was feasible in a majority of the patients who experienced AMI and were at lower risk 24 hours after successful d-PCI. Thus, the patients had a shortened hospital stay and no increased risk.
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PMID:The feasibility and safety of early discharge for low risk patients with acute myocardial infarction after successful direct percutaneous coronary intervention. 1262 36

Antiplatelet drugs have been shown to prevent a range of atherothrombotic events, including transient ischaemic attack (TIA) and ischaemic stroke. Clopidogrel and ticlopidine are adenosine diphosphate (ADP)-receptor antagonists that inhibit ADP-induced fibrinogen binding to platelets, a necessary step in the platelet aggregation process. The Antithrombotic Trialists' Collaboration recently published a major meta-analysis that assessed the effect of antiplatelet therapy in patients with various manifestations of atherosclerosis. In total, this analysis included 135,000 patients in comparisons of antiplatelet agents versus control and 77,000 patients in comparisons of different antiplatelet regimens. This meta-analysis found that overall, antiplatelet therapy reduces the combined odds of stroke, myocardial infarction (MI) or vascular death by 22%, and that antiplatelet agents reduce the odds of a non-fatal stroke by 25% over a wide range of patients with or without a history of cerebrovascular disease. In the CAPRIE trial of clopidogrel versus acetylsalicylic acid (ASA), there was a 10% odds reduction for stroke, MI or vascular death in favour of clopidogrel (p = 0.03). In a meta-analysis performed by the Cochrane Stroke Group, ADP-receptor antagonist therapy significantly reduced the odds of a serious vascular event (stroke, MI or vascular death) by 9% (2p = 0.01) and of any stroke by 12%. The safety/tolerability profile of clopidogrel was superior to that of ticlopidine, and at least as good as that of ASA. In CURE, a long-term benefit was observed with the use of clopidogrel on top of standard therapy (including ASA in all patients), with a 20% relative risk reduction for the primary endpoint of cardiovascular death, MI or stroke (p < 0.001) in patients with unstable angina and non-Q-wave MI. A consistent benefit was seen across all patient subgroups, including patients with a previous history of stroke. More recently, CREDO has demonstrated the incremental benefit of prolonged use of clopidogrel on top of ASA in patients undergoing elective PCI, with a 27% reduction in the combined risk of death, MI or stroke after 12 months of therapy (p = 0.02) and a 25% reduction in stroke over the same time period. The MATCH trial is currently being conducted to test the hypothesis that long-term administration of clopidogrel on top of ASA is superior to clopidogrel alone for the reduction of major ischaemic events in patients with recent TIA or ischaemic stroke who are at high risk of atherothrombotic recurrence. Further trials of clopidogrel on top of standard therapy (including ASA) are planned in neurology; these include SPS3, in patients with small subcortical strokes, and ATARI, in patients who have recently recovered from a TIA.
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PMID:Evidence with antiplatelet therapy and ADP-receptor antagonists. 1269 15

Aspirin (acetylsalicylic acid) is the most widely studied and prescribed antiplatelet drug for patients at high risk of vascular disease. It affects a single pathway in the platelet activation process and provides incomplete protection against cardiovascular events. Adenosine diphosphate receptor antagonists, by blocking an alternate pathway of platelet activation, are slightly more effective than aspirin in reducing serious vascular events in patients at high risk, with similar results for the subset of transient ischaemic attack/ischaemic stroke patients. Clopidogrel is an effective and safe alternative in patients who do not tolerate aspirin, in diabetics, in hypercholesterolaemic patients, or in those with a previous history of cardiac surgery. Moreover, antiplatelet combination therapy using agents with different mechanisms of action is an attractive preventive approach. In this way, dipyridamole combined with aspirin is being tested in the European/Australian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT) in cerebrovascular disease patients. Clinical and preclinical studies have demonstrated that therapy with clopidogrel and aspirin provides synergistic antiplatelet effects. The Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) and PCI-CURE trials demonstrate the benefit of this combination therapy in patients who suffer from unstable angina or non-Q-wave myocardial infarction treated or not by percutaneous coronary intervention. The relative risk reduction in ischaemic events in long-term use was 20%. This antiplatelet regimen was safe and well tolerated. Currently, this therapeutic option is tested in individuals with ischaemic stroke in the Management of Atherothrombosis with Clopidogrel in High-Risk Patients with Recent Transient Ischaemic Attacks or Ischaemic Stroke (MATCH) Trial.
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PMID:Antiplatelet drugs in ischemic stroke prevention: from monotherapy to combined treatment. 1469 84

Several studies published recently show the superiority of a primary percutaneous coronary intervention (I degree PCI) on thrombolysis in the treatment of acute myocardial infarction. This holds true even if PCI is delayed by 2 or 3 hours due to the secondary transfer to a hospital disposing of a cath lab. The advantage consists in a significant decrease in the number of secondary ischemia, recurrent myocardial infarction, hemorrhagic stroke and mortality. We retrospectively analysed the patients admitted in our hospital during 2001 with acute myocardial infarction and criteria for thrombolysis. A third of these patients underwent I degree PCI in a reference center, two thirds underwent thrombolysis in our hospital; 87% of thrombolysed patients underwent secondary PCI during the same hospital stay; in all patients (except one) coronary angiography was completed by a percutaneous (25/30) or surgical (4/30) revascularisation. Given the data in the recent literature and our experience, we consider that I degree PCI has to be favored over thrombolysis for most of the patients presenting to our hospital with acute myocardial infarction.
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PMID:[Thrombolysis or primary PCI: the gold standard in the management of acute myocardial infarction in 2003?]. 1508 48

Reperfusion therapy in acute ST-elevation myocardial infarction includes thrombolytic therapy and primary percutaneous transluminal coronary angioplasty (pPTCA) or primary coronary intervention (pPCI). Many clinical trials have been done to compare the efficacy of treatment of patients with acute myocardial infarction with thrombolytic therapy vs. primary coronary angioplasty. A meta-analysis of 23 randomized trials including 7739 patients with acute myocardial infarction (AMI) showed better results with pPCI in reducing overall short-term death (7% vs. 9%, p = 0.0002), non-fatal reinfarction (2.5% vs. 6.8%, p < 0.0001), death excluding cardiogenic shock (5% vs. 7, p = 0.0003) and combined endpoint of death, non-fatal reinfarction and stroke (8% vs. 14%, p < 0.0001). Primary PCI was better than thrombolytic therapy irrespective of the type of thrombolytic agent used even then when reperfusion was delayed because of patient transfer to a corresponding teriary center for primary PCI. Primary PCI is more effective than thrombolytic therapy for the treatment of ST-segment elevation AMI.
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PMID:[Thrombolysis or percutaneous coronary intervention in acute myocardial infarct]. 1520

Ischemic heart diseases continue to be leading causes of death throughout the world. Blood platelets play a pivotal role not only in haemostasis but also in the pathogenesis of thrombosis and atherosclerosis, platelet aggregation being an essential step in the formation of either an effective haemostatic plug or an intravascular thrombus. The benefits of various antiplatelet therapies ranging from aspirin, ticlopidine, Clopidogrel, and intravenous platelet GPIIb/IIIa antagonists in various thromboembolic disorders are well documented. The studies of CAPRIE, CURE, PCI-CURE and MATCH have shown that the clopidogrel has a highly advantageous preventive effect in the ischaemic vascular diseases, that is why clopidogrel be highly recommended in the stroke prevention.
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PMID:[Clopidogrel in the prevention of stroke]. 1571 89

In patients with stable CAD, PCI can be considered a valuable initial mode of revascularization in all patients with objective large ischaemia in the presence of almost every lesion subset, with only one exception: chronic total occlusions that cannot be crossed. In early studies, there was a small survival advantage with CABG surgery compared with PCI without stenting. The addition of stents and newer adjunctive medications improved the outcome for PCI. The decision to recommend PCI or CABG surgery will be guided by technical improvements in cardiology or surgery, local expertise, and patients' preference. However, until proved otherwise, PCI should be used only with reservation in diabetics with multi-vessel disease and in patients with unprotected left main stenosis. The use of drug-eluting stents might change this situation. Patients presenting with NSTE-ACS (UA or NSTEMI) have to be stratified first for their risk of acute thrombotic complications. A clear benefit from early angiography (<48 h) and, when needed, PCI or CABG surgery has been reported only in the high-risk groups. Deferral of intervention does not improve outcome. Routine stenting is recommended on the basis of the predictability of the result and its immediate safety. In patients with STEMI, primary PCI should be the treatment of choice in patients presenting in a hospital with PCI facility and an experienced team. Patients with contra-indications to thrombolysis should be immediately transferred for primary PCI, because this might be their only chance for quickly opening the coronary artery. In cardiogenic shock, emergency PCI for complete revascularization may be life-saving and should be considered at an early stage. Compared with thrombolysis, randomized trials that transferred the patients for primary PCI to a 'heart attack centre' observed a better clinical outcome, despite transport times leading to a significantly longer delay between randomization and start of the treatment. The superiority of primary PCI over thrombolysis seems to be especially clinically relevant for the time interval between 3 and 12 h after onset of chest pain or other symptoms on the basis of its superior preservation of myocardium. Furthermore, with increasing time to presentation, major-adverse-cardiac-event rates increase after thrombolysis, but appear to remain relatively stable after primary PCI. Within the first 3 h after onset of chest pain or other symptoms, both reperfusion strategies seem equally effective in reducing infarct size and mortality. Therefore, thrombolysis is still a viable alternative to primary PCI, if it can be delivered within 3 h after onset of chest pain or other symptoms. Primary PCI compared with thrombolysis significantly reduced stroke. Overall, we prefer primary PCI over thrombolysis in the first 3 h of chest pain to prevent stroke, and in patients presenting 3-12 h after the onset of chest pain, to salvage myocardium and also to prevent stroke. At the moment, there is no evidence to recommend facilitated PCI. Rescue PCI is recommended, if thrombolysis failed within 45-60 min after starting the administration. After successful thrombolysis, the use of routine coronary angiography within 24 h and PCI, if applicable, is recommended even in asymptomatic patients without demonstrable ischaemia to improve patients' outcome. If a PCI centre is not available within 24 h, patients who have received successful thrombolysis with evidence of spontaneous or inducible ischaemia before discharge should be referred to coronary angiography and revascularized accordingly--independent of 'maximal' medical therapy.
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PMID:Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. 1676 Feb 7

A case of a 72-year-old male with coronary artery disease, history of two myocardial infarctions, ejection fraction of 30% and CABG performed in 1990, is described. In 2001 he underwent PCI of two grafts. The procedure was complicated by ischaemic stroke. In 2003 the patient underwent another PCI of the occluded venous graft which was complicated by no-reflow phenomenon and acute myocardial infarction. A few months later cardiac resynchronization pacing system was implanted. The patient improved, however, one year later died due to progressive heart failure. Diagnosis and treatment of the no reflow phenomenon are discussed.
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PMID:[No-reflow phenomenon following PCI of venous graft -- a case report]. 1669 89

Atherothrombosis is the most common cause of an acute ischemic event. Antiplatelet agents form the cornerstone of atherothrombosis prevention. The purpose of this article is to review the use of antiplatelet agents in patients that are at particularly high risk of atherothrombotic events. To undertake this review, we searched the literature to identify key studies on the use of antiplatelet agents in this group of patients. Antiplatelet agents, such as aspirin and clopidogrel, play a fundamental role in the treatment and management of secondary thrombotic events. The routine use of aspirin is recommended, as it has been shown to reduce the risk of thrombotic events by approximately 25%. Additional benefit has been demonstrated with clopidogrel, both as a monotherapy and in combination with aspirin. In the CAPRIE trial, 19,185 patients with atherosclerotic vascular disease were randomized to receive clopidogrel (75 mg/day) or aspirin (325 mg/day) for a mean duration of follow-up of 1.91 years. Clopidogrel provided an additional 8.7% relative risk reduction in the primary composite endpoint of ischemic stroke, myocardial infraction or vascular death compared with aspirin. In the CURE trial, the addition of clopidogrel to background aspirin was associated with a 20% relative risk reduction in a composite of death from cardiovascular causes, nonfatal myocardial infarction or stroke compared with aspirin alone. In patients undergoing PCI as part of the PCI-CURE substudy, clopidogrel was associated with a 30% relative reduction in the incidence of cardiovascular events in the first 30 days after intervention compared with aspirin. The benefits of antiplatelet therapy continue to be investigated. Whether dual antiplatelet therapy is superior to aspirin monotherapy for high-risk primary prevention is unknown. The ongoing CHARISMA trial aims to determine the relative efficacies of aspirin monotherapy and aspirin/clopidogrel combination therapy in a broad range of high-risk patient populations. In addition, the REACH registry, a worldwide survey of symptomatic and high-risk patients, has been set up to provide vital epidemiological information regarding the risks of atherothrombosis in order to contribute to the development of better preventive strategies and management regimens for at-risk patients.
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PMID:Antiplatelet therapy in populations at high risk of atherothrombosis. 1739 57


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