Drug-eluting coronary artery stents

Scott and White Healthcare, 2401 South 31 St., Temple, TX 76508, USA.
American family physician (Impact Factor: 2.18). 12/2009; 80(11):1245-51.
Source: PubMed


Many advances have been made in the percutaneous treatment of coronary artery disease during the past 30 years. Although balloon angioplasty alone is still performed, the use of coronary artery stents is much more common. Approximately 40 percent of patients treated with balloon angioplasty developed restenosis, and this was reduced to roughly 30 percent with the use of bare-metal stents. However, restenosis within the stent can occur and is difficult to treat. Drug-eluting stents were developed to lower the rate of restenosis, which now occurs in less than 10 percent of patients treated with these stents. There have been concerns about abrupt thrombosis within drug-eluting stents occurring late after their implantation, leading to acute myocardial infarction and death. Recent studies have alleviated, but not completely dispelled, these concerns. Strict adherence to dual antiplatelet therapy with aspirin and a thienopyridine is required after stent placement, and the premature discontinuation of therapy is the most important risk factor for acute stent thrombosis. Adequate communication between cardiologists and primary care physicians is essential not only to avoid the premature discontinuation of therapy, but also to identify, before stent placement, those patients in whom prolonged antiplatelet therapy may be ill-advised. Elective surgery following stent placement should be delayed until the recommended course of dual antiplatelet therapy has been completed.

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    • "Restenosis usually occurs within three to nine months after PCI [3]. PCI restenosis rate without stenting range between 20% and 65%, depending on the method of follow-up and the criteria used to define restenosis [3-9]. Successfully dilated total coronary occlusions have a higher rate of angiographic restenosis at 6 months than dilated stenoses [13, 14]. "
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    ABSTRACT: Coronary artery disease (CAD) is the most prevalent form of cardiovascular disease affecting about 13 million Americans, while more than one million percutaneous transluminal intervention (PCI) procedures are performed annually in the USA. The relative high occurrence of restenosis, despite stent implementation, seems to be the primary limitation of PCI. Over the last decades, single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), has proven an invaluable tool for the diagnosis of CAD and patients’ risk stratification, providing useful information regarding the decision about revascularization and is well suited to assess patients after intervention. Information gained from post-intervention MPI is crucial to differentiate patients with angina from those with exo-cardiac chest pain syndromes, to assess peri-intervention myocardial damage, to predict-detect restenosis after PCI, to detect CAD progression in non-revascularized vessels, to evaluate the effects of intervention if required for occupational reasons and to evaluate patients’ long-term prognosis. On the other hand, chest pain and exercise electrocardiography are largely unhelpful in identifying patients at risk after PCI. Although there are enough published data demonstrating the value of myocardial perfusion SPECT imaging in patients after PCI, there is still debate on whether or not these tests should be performed routinely.
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    ABSTRACT: Whereas the development of coronary stents has been a major breakthrough in the treatment of coronary artery disease, stent thrombosis, associated with myocardial infarction and death, has introduced a new challenge in the care of patients with coronary stents undergoing noncardiac surgery. This review presents the authors' recommendations regarding the optimal management of such patients. Elective surgery should be postponed for at least 6 weeks and optimally 3 months for a bare-metal stent and at least 1 year for a drug-eluting stent. On the other hand, managing a patient undergoing non-elective surgery is more difficult and necessitates a case-by-case assessment of bleeding risk versus thrombotic risk based on patient comorbidities, type of stents present, details of the coronary intervention, and type of surgical procedure. Patients with a risk of bleeding that outweighs the risk of stent thrombosis should discontinue at least clopidogrel, whereas all other patients should continue dual antiplatelet therapy throughout the perioperative period.
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