Search Results (87)

In patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI), antiplatelet therapy is the cornerstone of treatment for secondary prevention. Although dual antiplatelet therapy (DAPT) consisting of aspirin and a P2Y₁₂ inhibitor is the current standard of care, being, respectively, recommended for 6 and 12 months in patients with chronic and acute coronary syndrome without a need for oral anticoagulation, the continuous improvement in PCI technology and pharmacology have significantly reduced the need for long-term DAPT. Mounting evidence supports the administration of P2Y₁₂ inhibitor monotherapy, particularly ticagrelor, after a short period of DAPT following PCI as a strategy to reduce bleeding without a trade-off in ischemic events compared to standard DAPT. In addition, there is a growing literature supporting P2Y₁₂ inhibitor monotherapy also for long-term secondary prevention of ischemic events. However, the data to this extent are not as robust as compared to the first-year post-PCI period, with aspirin monotherapy still remaining the mainstay of treatment for most patients. This review aims to summarize the rationale for long-term antiplatelet therapy, the pharmacology of current antiplatelet drugs tested for long-term administration as monotherapy, and current evidence on the available comparisons between different long-term antiplatelet monotherapies in patients with CAD. Full article

Cardiovascular disease (CVD) is the leading cause of death worldwide, with pathophysiological mechanisms often involving platelet activation and chronic inflammation. While antiplatelet agents targeting adenosine diphosphate (ADP)-mediated pathways are well established in CVD management, less is known about drug interactions with the platelet-activating factor (PAF) pathway, a key mediator of inflammation. This study aimed to evaluate the effects of several commonly used cardiovascular and anti-inflammatory drug classes—including clopidogrel, non-steroidal anti-inflammatory drugs (NSAIDs), angiotensin II receptor blockers (ARBs), β-blockers, and analgesics—on platelet function via both the ADP and PAF pathways. Using human platelet-rich plasma (hPRP) from healthy donors, we assessed platelet aggregation in response to these two agonists in the absence and presence of graded concentrations of each of these drugs or of their usually prescribed combinations. The study identified differential drug effects on platelet aggregation, with some agents showing pathway-specific activity. Clopidogrel and NSAIDs demonstrated expected antiplatelet effects, while some (not all) antihypertensives exhibited additional anti-inflammatory potential. These findings highlight the relevance of evaluating pharmacological activity beyond traditional targets, particularly in relation to PAF-mediated inflammation and thrombosis. This dual-pathway analysis may contribute to a broader understanding of drug mechanisms and inform the development of more comprehensive therapeutic strategies for the prevention and treatment of cardiovascular, hypertension, and inflammation-driven diseases. Full article

The current management of patients with acute coronary syndrome (ACS) and bleeding disorders, such as hemophilia, is supported by small retrospective studies or expert consensus documents. Moreover, people with hemophilia are less likely to receive invasive treatments like percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for ACS compared to those without hemophilia, which could affect their cardiovascular outcomes. A multidisciplinary team with an expert hematologist is essential to properly define the therapeutic strategy, which should balance both the thrombotic and bleeding risks. We report a clinical case that illustrates an alternative revascularization strategy for hemophilic patients presenting with ACS and with a pattern of diffuse coronary atherosclerotic disease (CAD), encompassing drug-coated balloons (DCBs) in combination with spot stenting. The proposed approach might avoid a full-length drug-eluting stent (DES) implantation and also allow a short dual antiplatelet therapy (DAPT) regimen that is desirable in patients at a very high bleeding risk (HBR) like hemophiliacs. Furthermore, we have provided a review of the available literature on this topic and a focus on the main recommendations for managing ACS, in response to the presented clinical case. Finally, this article aims to share information and develop more confidence in the current guidelines on the treatment of hemophiliacs who need myocardial revascularization. Full article

Background/Objectives: Large clinical trials have established the optimal antiplatelet strategy in the wide spectrum of coronary artery disease. However, data are scarce regarding MINOCA and the aim of our study is to present data from the current clinical practice. Methods: A total of 151 patients were included in this study after exclusion of 27 patients with myocarditis and other diagnoses. A cardiac magnetic resonance (CMR) performed at 123/151 patients demonstrated an ischemic pattern of late gadolinium enhancement (LGE) confirming the diagnosis of true acute myocardial infarction (AMI) in 42 cases (28%). Based on multimodality imaging and clinical judgement, Takotsubo syndrome (TTS) was diagnosed in 55 patients (36%), whereas CMR failed to reveal abnormal findings in 54 cases (36%), categorized as MINOCA of unknown origin. Results: Regarding antithrombotic prescriptions at discharge, 38% of patients received dual antiplatelet (DAPT) or dual antithrombotic therapy (DAT, 1 antiplatelet plus 1 anticoagulant), 49.7% received single antiplatelet (SAPT) or anticoagulant, and 12% received no antithrombotic treatment. Univariate analysis showed that the likelihood of prescribing DAPT or DAT was associated with left ventricular ejection fraction (LVEF) (r = 0.202, p = 0.013), atherosclerotic lesions on coronary angiography (r = 0.303, p < 0.001), prior use of anticoagulants (r = −0.258, p = 0.001), and marginally with the INTERTAK score (r = −0.198, p = 0.044). A multivariable model, adjusted for age, LVEF, ECG abnormalities, and history of anticoagulant use, confirmed the independent association between angiographic evidence of atherosclerosis and the decision for DAPT/DAT (OR: 0.334, 95% CI: 0.307–0.813, p < 0.001). However, the initial treatment decision did not seem to impact 2-year prognosis in our population. Conclusions: Our study results reveal that decision making in the antithrombotic strategy for MINOCA patients poses a challenge in clinical practice. More robust data are required for definite conclusions on the prognostic implications. Full article

The optimal long-term antithrombotic treatment of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) remains controversial. Current guidelines recommend a short initial period of triple antithrombotic therapy (e.g., 1 week), followed by dual therapy consisting of an oral anticoagulation agent and a single antiplatelet agent for 6 months in patients undergoing elective PCI and 12 months in patients with acute coronary syndromes. After this course of combination therapy, anticoagulation monotherapy is recommended. In daily practice, however, the optimal strategy for long-term antithrombotic therapy remains debated. A growing body of evidence supports the safety and efficacy of oral anticoagulation monotherapy, but its use in clinical practice remains inconsistent. This review aims to evaluate the available evidence on chronic antithrombotic regimens in patients with AF undergoing PCI, with a focus on key clinical considerations, such as the selection of optimal long-term therapy that balances ischemic and bleeding risks. It also highlights that, despite robust supporting evidence, significant gaps persist in real-world implementation. Full article

Drug-coated balloons (DCBs) have emerged as a compelling alternative to drug-eluting stents in the treatment of coronary artery disease (CAD), offering the advantage of local drug delivery without permanent vascular scaffold implantation. Initially developed for managing in-stent restenosis, DCBs seem appealing for broader indications, particularly in small vessel disease and bifurcation lesions. While paclitaxel-based DCBs remain the most investigated, newer limus formulations are showing promise and appear to be a valid alternative in early trials. Evidence from recent randomized clinical trials (RCTs) and meta-analyses highlights DCBs as a safe and effective option in selected patients, with potential benefits including lower restenosis rates, reduced need for dual antiplatelet therapy, and avoidance of late stent-related complications. As new large-scale trials near completion, DCBs are poised to take on a broader role in the treatment of CAD, particularly in patients where “leaving nothing behind” offers a clinical advantage. This review offers an overview of the DCB platforms commercially available, showing pharmacological differences, providing current indications in practical guidelines, and analyzing the most recent and impactful RCTs and meta-analyses in the field. Full article

Introduction: A direct head-to-head comparison between potent P2Y12 inhibitors: prasugrel versus ticagrelor is still lacking. Purpose: In this single-center study, we sought to address the efficacy and safety of these two third-generation antiplatelet drugs, after about a decade of practical use. Methods: A retrospective observational study included all patients who were admitted with acute coronary syndrome between January 2010 and December 2019 and were discharged with aspirin and either prasugrel or ticagrelor after percutaneous coronary intervention. Patients were divided into two groups based on the dual antiplatelet drugs prescribed. Primary endpoint: A composite endpoint of cardiovascular death, recurrent coronary syndrome, or ischemic stroke at one year. Secondary endpoint: Significant bleeding according to the BARC classification (types 3, 4, or 5). Results: During this period, 746 patients met the inclusion criteria. The primary endpoint was reached in 70 patients (9.4%): 24 patients (8.0%) in the group treated with ticagrelor and 46 patients (10.3%) in the group treated with prasugrel (p-value = 0.303). In terms of safety events, significant bleeding was not statistically different between the ticagrelor and prasugrel groups: 13 (2.9%) vs. 9 (3%), respectively (p-value = 0.9). More patients discontinued their treatment before the end of the year among those treated with ticagrelor compared to those treated with prasugrel (16.7% vs. 9.6%, p-value = 0.003). Conclusions: There was no significant difference in the occurrence of recurrent cardiac events, stroke, or cardiovascular death, nor significant bleeding among ACS patients treated either with prasugrel or ticagrelor. Full article

Background/Objectives: Patients with atrial fibrillation and mitral regurgitation (MR) undergoing transcatheter edge-to-edge mitral valve repair (M-TEER) often have concomitant indications for left atrial appendage occlusion (LAAO), mandating a more personalized treatment approach. This study aimed to examine the effectiveness and safety of combining M-TEER/LAAO in one procedure. Methods: MEDLINE (PubMed), Scopus, and Cochrane were searched through 21 March 2025 for studies examining M-TEER/LAAO with or without control (M-TEER only). Double-independent study selection, extraction, and quality assessments were performed. Frequentist random-effects models were used to calculate mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs). Results: Seven studies (223 participants) were included. For M-TEER/LAAO, the mean procedural time was 101.6 min (95% CI = [85.06, 118.13]), the mean radiation time was 29.97 min (95% CI = [23.85, 36.09]), the mean length of stay was 5.21 days (95% CI = [3.31, 7.12]), procedural success was achieved in 89.5% of cases (95% CI = [73.4, 96.3], and post-procedure MR > 2+ occurred in 14.8% of cases (95% CI = [3.6, 44.5]). Compared to M-TEER only, patients with M-TEER/LAAO had similar procedural (RR = 0.91, 95% CI = [0.71, 1.17]) and technical success (RR = 1, 95% CI = [0.94, 1.06]) with a similar risk of acute kidney injury (RR = 1, 95% CI = [0.07, 15.12]), bleeding (RR = 0.40, 95% CI = [0.01, 18.06]), and all-cause death (RR = 0.59, 95% CI = [0.22, 1.54]). M-TEER/LAAO was non-significantly associated with in-hospital death (RR = 3, 95% CI = [0.13, 70.23]), stroke (RR = 3, 95% CI = [0.13, 70.23]), and vascular complications (RR = 1.55, 95% CI = [0.43, 5.59]) compared to M-TEER only. Most patients (34.2%, 95% CI = [2.8, 90.4]) received dual antiplatelet therapy at discharge, followed by anticoagulation only (20.2%, 95% CI = [7.5, 44.3]). Conclusions: M-TEER/LAAO can be combined into a single procedure with good peri-procedural outcomes. Safety was also satisfactory; however, some concerns may arise regarding in-hospital death, stroke, and vascular complications. Further research is needed to explore the effectiveness and safety of this combined strategy and elucidate the risk–benefit profile of this personalized treatment approach. Full article

Bleeding complications are a significant concern in the management of acute coronary syndromes (ACS). The evidence from clinical trials demonstrates the need for balancing efficacy in reducing ischemic events with safety concerns, as bleeding events adversely affect prognosis and mortality. Pharmacological agents like aspirin, P2Y12 inhibitors (e.g., prasugrel, ticagrelor), glycoprotein IIb/IIIa inhibitors, and heparins are fundamental to ACS treatment but carry varying bleeding risks depending on individual patient profile. Recent advancements in risk stratification tools have enabled tailored approaches to dual antiplatelet therapy (DAPT), optimizing its duration based on bleeding and thrombotic risks. Further Emerging therapies, including shortened DAPT protocols and P2Y12 inhibitor monotherapy, have shown promise in minimizing bleeding while maintaining clinical efficacy. The findings underscore the importance of personalized antithrombotic regimens in ACS management, emphasizing precise risk assessment to enhance outcomes and mitigate adverse events. This review examines the mechanisms, risk factors, and strategies to mitigate bleeding associated with anticoagulant and antiplatelet therapies in ACS. Full article

Background: Atrial fibrillation (AF) is prevalent in patients undergoing transcatheter aortic valve replacement (TAVR). However, the optimal antithrombotic strategy tailored to individual patient profiles remains unclear. This study aims to evaluate the outcomes of personalized antithrombotic regimens in patients with AF after TAVR. Methods: We enrolled 121 AF patients who underwent TAVR from 2009 to 2023. Patients were grouped into seven groups based on individualized post-procedural antithrombotic regimens. The regimens included the following: single antiplatelet therapy (SAPT) + direct oral anticoagulant (DOAC) (n = 44, 36.3%); DOACs only (n = 25, 20.6%), SAPT + warfarin (n = 17, 14%); dual antiplatelet therapy (DAPT) (n = 13, 10.7%); warfarin only (n = 8, 6.6%); DAPT + warfarin (n = 7, 5.8%); and DAPT + DOACs (n = 7, 5.8%). The study outcomes included incidences of strokes or transient ischemic attacks (TIAs), major bleeding, and survival. Results: The median follow-up was 27 months. The incidence of stroke, TIA, or major bleeding was similar among the seven treatment groups. However, a trend toward a higher rate of stroke was observed in the triple regimen containing warfarin (28.6%); also, the highest rate of major bleeding was observed in the warfarin-only group (25%). Survival for patients discharged and placed under various antithrombotic regimens did not differ significantly despite some numerical variations being present across the groups, with the lowest mortality reported with SAPT + warfarin (7%) and the highest with DAPT + warfarin (57%). Conclusions: This study highlights the outcomes related to stroke, major bleeding, and mortality across personalized antithrombotic regimens in patients with AF after TAVR. While no statistically significant differences were observed, findings emphasize the need for further large-scale studies to define optimal personalized antithrombotic strategies based on individual patient characteristics. Full article

Background/Objective: Gastrointestinal bleeding is a major complication of dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI). Malignancy may be detected due to gastrointestinal bleeding, necessitating critical decisions regarding treatment selection and influencing patient prognosis. Methods: This single-center, retrospective, observational study included 501 Japanese patients who underwent initial PCI between January 2019 and January 2023. Of these patients, 393 who underwent perioperative upper and lower gastrointestinal endoscopy were evaluated for the presence of gastrointestinal malignancy. Results: Of the total patients, 36% presented with acute coronary syndrome (ACS). Gastrointestinal malignancies were identified in 30 patients (8%), including 18 cases of colorectal cancer and eight cases of gastric cancer. No difference in the frequency of malignancies was observed between patients with ACS and chronic coronary syndrome (CCS) (p = 0.7398). Malignancies were significantly more common in patients with positive fecal immunochemical testing (FIT) (p < 0.0001); however, FIT did not detect all malignancies. The 1500-day survival rate for patients with gastrointestinal malignancies was 64%, with no difference in overall survival between treatment modalities. Conclusions: A considerable proportion of Japanese patients undergoing PCI had gastrointestinal malignancies, regardless of whether they had ACS or CCS, and their prognosis was poor. Gastrointestinal endoscopic evaluation in the perioperative period of PCI could detect malignancy without complications and might lead to appropriate cancer treatment. Full article

Background/Objectives: Vulnerable coronary plaques are strongly associated with acute coronary events, posing significant therapeutic challenges despite statin therapy. This case report evaluates the impact of Evolocumab, a PCSK-9 inhibitor, on stabilizing high-risk plaques and promoting phenotypic transformation, assessed through coronary CT angiography (CCTA). Methods: A 50-year-old male with chronic coronary syndrome and a history of myocardial infarction underwent a CCTA, revealing a high-risk plaque (approximately 50%) in the proximal LAD. Despite achieving LDL-C targets with statin therapy, the plaque showed vulnerability features. Evolocumab (140 mg subcutaneously every two weeks) was added to therapy, combined with dietary counseling and dual antiplatelet therapy. Results: A follow-up CCTA at 24 months demonstrated significant reductions in plaque volume and positive remodeling, with a transformation from a mixed phenotype to a predominantly calcified plaque. LDL-C levels decreased from 71 mg/dL to 18 mg/dL. The patient remained asymptomatic, with no cardiovascular events reported during the follow-up. Conclusions: This case highlights the role of PCSK-9 inhibitors in stabilizing high-risk plaques, achieving structural changes that promote stability beyond LDL-C reduction. Advanced imaging techniques such as CCTA proved essential for risk stratification and monitoring therapy efficacy. Evolocumab offers a promising adjunctive treatment for high-risk patients unsuitable for elective revascularization, potentially redefining the standard of care for plaque stabilization in this setting. Full article

Kounis syndrome (KS) is a rare condition where hypersensitivity reactions trigger coronary vasospasm, destabilization of atherosclerotic plaques, or stent thrombosis, posing diagnostic and therapeutic challenges due to its overlap with acute coronary syndrome (ACS) and the absence of specific guidelines. This study reviews cases of KS from the Institute of Cardiovascular Disease to highlight clinical presentations, triggers, and treatment strategies. We analyzed four cases of KS treated at our institution between 2019 and 2024. Detailed clinical histories, laboratory findings, imaging studies, and treatment plans were reviewed. Patients were classified by KS subtype based on coronary anatomy and pathophysiological mechanisms. Management strategies were tailored to each subtype, combining myocardial revascularization, antiplatelet therapy, and treatment for allergic reactions. The series included two cases of Type I KS in patients with structurally normal coronary arteries and two cases of Type II KS involving pre-existing atherosclerosis. No Type III KS was observed. Triggers included insect stings, antibiotics, iodinated contrast agents, and anesthetics. Coronary angiography confirmed the diagnosis in all cases. Treatments included percutaneous coronary interventions, dual antiplatelet therapy, and prophylactic antihistamines or corticosteroids. All patients experienced favorable outcomes, although diagnostic delays were noted in cases with atypical presentations. KS remains underdiagnosed, especially in emergency settings where it mimics ACS. Early recognition and multidisciplinary management involving allergology and cardiology are crucial. Future research should focus on safer diagnostic tools, understanding the pathophysiology, and developing evidence-based preventive strategies. Increasing the awareness of KS and its inclusion in ACS differentials are essential to improving patient outcomes and preventing recurrences. Full article

Background/Objectives: Intracranial atherosclerosis (ICAS) is a major cause of ischemic stroke, disproportionately affecting populations with significant vascular risk factors. Although ICAS imposes a considerable health burden, research on this condition in Central Asia remains scarce, especially among the Kazakh population. This study analyzes demographic characteristics, treatment outcomes, and procedural challenges associated with ICAS in 216 patients treated at a single institution. Methods: This retrospective study included patients with ≥70% intracranial artery stenosis confirmed by imaging and presenting with ischemic symptoms. All patients underwent angioplasty and stenting with dual antiplatelet therapy (DAPT). Data collected included demographics, comorbidities, stenosis characteristics, procedural details, and outcomes assessed by the modified Rankin Scale (mRS). Results: The median age was 63.5 years (IQR: 57–68.6), and 73.7% were male. Hypertension was the most common comorbidity (98%), followed by ischemic heart disease (58%) and diabetes mellitus (40.9%). Multi-location ICAS was significantly associated with patients over 75 years of age (p = 0.025). Additionally, obesity and stenosis severity greater than 70% showed trends toward significance, with p-values of 0.064 and 0.079, respectively. Stenosis predominantly affected the internal carotid artery (54.5%) and vertebrobasilar system (31.6%). The average hospital stay was longer for posterior circulation stenosis (7.1 days) compared to anterior circulation (4.7 days). The periprocedural complication rate was 0.7%, with two deaths attributed to ischemic complications. At follow-up, four patients experienced worsening mRS scores (>2), particularly those with severe stenosis in the basilar artery and M1 segment. Conclusions: ICAS in the Kazakh population is strongly associated with hypertension and aging, with posterior circulation stenosis contributing disproportionately to worse outcomes. The low complication rates highlight the safety of modern endovascular techniques. However, further research is needed to optimize treatment strategies for severe and multi-location ICAS, particularly in Central Asian populations. Full article

Background and Objectives: Percutaneous coronary intervention (PCI) is a proven therapy for acute myocardial infarction (AMI) cardiogenic shock (CS). Dual anti-platelet therapy (i.e., aspirin plus an oral P2Y12 inhibitor) is recommended in patients treated with PCI. However, CS patients present severe hemodynamic instability, deranged hemostatic balance, and the need for invasive mechanical circulatory support (MCS) alongside invasive procedures, resulting in an increased risk of both bleeding and thrombotic complications, leaving uncertainty about the best anti-thrombotic treatment. Recently, the parenteral short-acting P2Y12 inhibitor has been increasingly used in the acute cardiac care setting, mainly in light of its favourable pharmacokinetic profile and organ-independent metabolism. Materials and Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a systematic review and single-arm meta-analysis of the safety and efficacy outcomes (i.e., rates of major bleeding, occurrence of stent/any thrombosis, and hospital survival) of all existing original studies reporting on the intravenous administration of cangrelor in AMI-CS patients. Results: Ten studies (678 patients with CS) published between 2017 and 2023 were included in the present review: nine were observational and one had a randomized design. Percutaneous revascularization was performed in >80% of patients across the studies. Moreover, 26% of patients were treated with temporary MCS, and in all studies, concomitant systemic anticoagulation was performed. Cangrelor was administered intravenously at the dosage of 4 mcg/kg/min in 57% of patients, 0.75 mcg/kg/min in 37% of patients, and <0.75 mcg/kg/min in 6%. The pooled rate of major bleeding was 17% (11–23%, confidence interval [CI]), and the pooled rate of stent thrombosis and any thrombosis were 1% (0.3–2.3% CI) and 3% (0.4–7% CI), respectively. Pooled hospital survival was 66% (59–73% CI). Conclusions: Cangrelor administration in AMI-CS patients was feasible and safe with a low rate of thromboembolic complications. Haemorrhagic complications were more frequent than thrombotic events. Nevertheless, to date, the optimal dosage of cangrelor in this clinical context still remains not universally recognized. Full article