Antithrombotic and thrombolytic therapy in patients undergoing coronary artery interventions: a review.
The controlled arterial injury that occurs with balloon angioplasty and other coronary interventions is characterized by evanescent endothelial denudation and vascular disruption. As a consequence, platelet activation occurs at the treated site, and there is a risk of thrombotic occlusion. This risk is heightened by several factors including unstable clinical presentation, lesion complexity, deep injury, and dissection. Aspirin has been shown to unquestionably reduce, although not eliminate, acute complications and is now part of the routine periprocedural regimen. Heparinization with more intense anticoagulation than is conventionally used is also standard treatment and is initiated before vessel instrumentation. Adjunctive thrombolysis is rarely necessary unless refractory thrombus precedes or complicates the procedure. However, thrombolysis may have a role in the treatment of saphenous vein graft obstructive lesions in which guide wire- or catheter-induced distal thromboembolization may cause infarction in spite of successful graft recanalization. In contrast to their success in the periprocedural phase of coronary interventions, anticoagulants and a wide variety of platelet active agents have been ineffective in reducing the 30% to 40% incidence of restenosis. Only 7E3, which targets the final common pathway of platelet aggregation by irreversibly blocking the IIb/IIIa receptor, has been shown to decrease the 6-month clinical event rate after balloon angioplasty, possibly by a surface pacification mechanism. This suggests that newer more potent antiplatelet and anticoagulant agents may also find a role in the long-term management of these patients.
Schwartz
L
L
Toronto General Hospital, Ontario, Canada.
Seidelin
P H
PH
D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects*; D000925:Anticoagulants / Q000627:therapeutic use*; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D015539:Platelet Activation / Q000187:drug effects; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D011859:Radiography; D013927:Thrombosis / Q000097:blood / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology
D000925:Anticoagulants; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors