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Revision as of 13:35, 6 August 2010

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editors-In-Chief:

Goals of Treatment

There are several main goals in treating thrombotic lesions, including:

Reperfusion of the epicardial artery and the downstream microvasculature
Resolution/reduction of [[thrombus burden
Avoid/minimize distal embolization
Avoid/reduce thrombotic major adverse cardiac events (death, MI, recurrent ischemia, urgent target vessel revascularization (TVR))

Treatment Choices

Pharmacologic Therapy

Antiplatelet therapy: Aspirin, platelet glycoprotein IIb/IIIa receptor (GP IIb/IIIa) antagonists (abciximab, eptifibatide, tirofiban), ADP receptor/P2Y12 inhibitors (plavix, ticagrelor, prasugrel)

Antithrombin Therapy: Ufractionated heparin (UFH), low molecular weight heparin (LMWH). Fondaparinux not recommended in primary PCI.

Direct Thrombin Inhibitors: hirudin, bivalirudin, argatroban

Thrombolytic Therapy: Urokinase (UK), tissue plasminogen activator (tPA) for STEMI when other pharmacologic and mechanical treatments are not successful

Mechanical Therapy

Aspiration Catheter: (Export, Pronto) is the choice prior to the other interventions listed below

Percutaneous Coronary Intervention (PCI): Bare metal or drug-eluting stent particularly direct stenting without pre-dilation by conventional balloon angioplasty

Distal Protection: (Percusurge guardwire, Triactive, Spider wire, Proxis) particularly in saphenous vein grafts

Percutaneous Transluminal Coronary Angioplasty (PTCA)

Directional Atherectomy.

Transluminal Extraction Catheter (TEC)

Rheolytic Thrombectomy (Possis Angiojet)

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-'''Associate Editors-In-Chief:''' Verun Khanna, M.D.; Anthony Smeglin, M.D.; Brian C. Bigelow, M.D.
+'''Associate Editors-In-Chief:'''
 ==Goals of Treatment==
-Some of the main goals in treating thrombotic lesions include the:
+There are several main goals in treating thrombotic lesions, including:
 *Reperfusion of the epicardial artery and the downstream [[microvasculature]]
-*Resolution/reduction of [[thrombus]] burden
+*Resolution/reduction of [[thrombus burden
-*Avoidance/minimizing of distal embolization
+*Avoid/minimize distal embolization
-*Avoidance/reduction of thrombotic major adverse cardiac events (death, MI, recurrent [[ischemia]], urgent target vessel [[revascularization]] (TVR))
+*Avoid/reduce thrombotic major adverse cardiac events (death, MI, recurrent [[ischemia]], urgent target vessel [[revascularization]] (TVR))
 ==Treatment Choices==
 ===Pharmacologic Therapy===
-*Antiplatelet therapy: [[Aspirin]], platelet glycoprotein IIb/IIIa receptor (GP IIb/IIIa) antagonists ([[abciximab]], [[eptifibatide]], [[tirofiban]]), [[ADP receptor|ADP receptor/P2Y12 inhibitors]] ([[plavix]], [[ticagrelor]], [[prasugrel]])
+'''Antiplatelet therapy:''' Aspirin, platelet glycoprotein IIb/IIIa receptor (GP IIb/IIIa) antagonists (abciximab, eptifibatide, tirofiban), ADP receptor/P2Y12 inhibitors (plavix, ticagrelor, prasugrel)
-*Antithrombin Therapy: [[UFH|Ufractionated heparin (UFH)]], [[LMWH|low molecular weight heparin (LMWH)]]. [[Fondaparinux]] is not recommended in primary [[PCI]].
+'''Antithrombin Therapy:''' Ufractionated heparin (UFH), low molecular weight heparin (LMWH). Fondaparinux not recommended in primary PCI.
-*Direct Thrombin Inhibitors: [[Hirudin]], [[bivalirudin]], [[argatroban]]
+'''Direct Thrombin Inhibitors:''' hirudin, bivalirudin, argatroban
-*Thrombolytic Therapy: [[Urokinase|Urokinase (UK)]], [[tPA|tissue plasminogen activator (tPA)]] for STEMI when other pharmacologic and mechanical treatments are not successful
+'''Thrombolytic Therapy:''' Urokinase (UK), tissue plasminogen activator (tPA) for STEMI when other pharmacologic and mechanical treatments are not successful
 ===Mechanical Therapy===
-*Aspiration Catheter: (Export, Pronto) is the choice prior to the other interventions listed below
+'''Aspiration Catheter:''' (Export, Pronto) is the choice prior to the other interventions listed below
-*Percutaneous Coronary Intervention (PCI): [[BMS|Bare metal]] or [[DES|drug-eluting stent]], particularly direct stenting without pre-dilation by conventional balloon angioplasty
-*Distal Protection: (Percusurge guardwire, Triactive, Spider wire, Proxis), particularly in [[SVG|saphenous vein grafts]]
-*[[PTCA|Percutaneous Transluminal Coronary Angioplasty (PTCA)]]
-*Directional [[Atherectomy]]
-*Transluminal Extraction Catheter (TEC)
-*Rheolytic Thrombectomy (Possis Angiojet)
-==Advantages of Each Choice==
+'''Percutaneous Coronary Intervention (PCI):''' Bare metal or drug-eluting stent particularly direct stenting without pre-dilation by conventional balloon angioplasty
-*Aspirin is a conventional therapy that reduces [[ischemic]] complications after [[PCI]].
-*GP IIb/IIIa antagonists are used adjunctively to treat and prevent [[thrombus]] formation and decreases [[ischemic]] complications post-PCI in patients with angiographic evidence of or suspected [[thrombus]].  In patients with STEMI undergoing primary PCI, GP IIb/IIIa antagonists have been shown to reduce mortality in meta-analyses.  There is an ongoing debate as to the optimal timing of their administration (upstream vs in-lab administration).
-*UFH is a conventionally used [[thrombin]] inhibitor that prevents arterial [[thrombus]] formation at the site of a vessel wall injury, on catheters, and on equipment during [[PCI]].
-*LMWH: ExTRACT-TIMI 25<ref name="pmid17456482">{{cite journal |author=White HD, Braunwald E, Murphy SA, ''et al.'' |title=Enoxaparin vs. unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction in elderly and younger patients: results from ExTRACT-TIMI 25 |journal=Eur. Heart J. |volume=28 |issue=9 |pages=1066–71 |year=2007 |month=May |pmid=17456482 |doi=10.1093/eurheartj/ehm081 |url=}}</ref> demonstrated that there were improved clinical outcomes with LMWH in patients with [[STEMI]] undergoing [[fibrinolysis]] and subsequent PCI.
-*Direct thrombin inhibitors (DTI) may be used as an alternative to [[heparin]] and [[GP IIb/IIIa]]. The optimal strategy is to pre-load with [[clopidogrel]] if a DTI is used, which is the drug of choice in patients with a history of heparin-induced [[thrombocytopenia]].
-*Thrombus aspiration is the preferred treatment and has been associated with improved myocardial perfusion and mortality.  Care should be exercised in very proximal lesions in the [[LAD]] and the [[circumflex]], as the clot may [[embolize]] into the other artery.
-*After aspiration, direct stenting is associated with improved rates of [[recurrent MI]] in meta-analyses, improved myocardial perfusion, and improved ST segment resolution.  Stenting reduces the risk of abrupt closure.
-*Rheolytic thrombectomy with Possis Angiojet was not found to have any benefit in the setting of [[STEMI]] in native coronary arteries in the AIMI trial. Infarct sizes were larger and mortality was higher.
-*Distal protection
-**Occlusive (Percusurge guardwire, Triactive) and filter (Filterwire) methods may improve safety and efficacy of PCI in patients with thrombotic lesions in SVG; SAFER study of Percusurge device demonstrated lower rate of death/MI
-**Distal embolic protection has not shown to be efficacious in the setting of [[STEMI]] in native coronary arteries with either Percusurge (EMERALD trial<ref name="pmid19755327">{{cite journal |author=Nikolsky E, Stone GW, Lee E, ''et al.'' |title=Correlations between epicardial flow, microvascular reperfusion, infarct size and clinical outcomes in patients with anterior versus non-anterior myocardial infarction treated with primary or rescue angioplasty: analysis from the EMERALD trial |journal=EuroIntervention |volume=5 |issue=4 |pages=417–24 |year=2009 |month=September |pmid=19755327 |doi= |url=}}</ref>) or Filterwire (PROMISE trial<ref name="pmid16129793">{{cite journal |author=Gick M, Jander N, Bestehorn HP, ''et al.'' |title=Randomized evaluation of the effects of filter-based distal protection on myocardial perfusion and infarct size after primary percutaneous catheter intervention in myocardial infarction with and without ST-segment elevation |journal=Circulation |volume=112 |issue=10 |pages=1462–9 |year=2005 |month=September |pmid=16129793 |doi=10.1161/CIRCULATIONAHA.105.545178 |url=}}</ref>).
-==Making a Selection==
+'''Distal Protection:''' (Percusurge guardwire, Triactive, Spider wire, Proxis) particularly in saphenous vein grafts
-Proper management of thrombotic lesions depends on the [[thrombus]] size, location, underlying severity of [[stenosis]], clinical stablility, age of thrombus, and candidacy for [[antithrombotic]] or [[thrombolytic]] therapy.  The treatment should be stratified according to thrombus burden.  Standard therapy includes: [[ASA]], [[UFH]], and a GP IIb/IIIa antagonist with the addition of a [[thienopyridine]] as soon as possible after the anatomy is defined.
-Consider direct thrombin inhibitor in setting of heparin-induced [[thrombocytopenia]].  Furthermore, avoid GP IIb/IIIa antagonist in patients with a high risk of bleeding complications.
+'''Percutaneous Transluminal Coronary Angioplasty (PTCA)'''
-==Anticipated Outcomes==
+'''Directional Atherectomy'''.
-The anticipated outcomes include the preservation of viable [[myocardium]] and the removal of thrombus while avoiding distal embolization, [[no-reflow]], and major adverse cardiac events.
-==Is Treatment Working?==
+'''Transluminal Extraction Catheter (TEC)'''
-When determining whether the treatment is effective, look for: resolution of [[thrombus]] by [[angiography]], TIMI grade 3 flow, TIMI grade 3 myocardial perfusion, and > 70% resolution of [[ST segment elevation]].
-==When to Change Treatment==
+'''Rheolytic Thrombectomy (Possis Angiojet)'''
-If thrombus persists despite [[aspirin]], glycoprotein inhibition, [[thienopyridine]] administration, mechanical aspiration, and stenting consider trying intracoronary [[fibrinolytic]] administration (2 mg of IC tPA at a time to a total dose of 20 mg. This is off label use of an approved drug.).  You should also treat the patient for potential spasm or [[no-reflow]] with a [[calcium channel blocker]], [[adenosine]] (100 mcg IC) or [[nitroprusside]] (100 mcg IC).  You should also consider the presence of a [[dissection]] in the differential diagnosis.
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