Management of the thrombotic lesion

Jump to navigation Jump to search

WikiDoc Resources for Management of the thrombotic lesion

Articles

Most recent articles on Management of the thrombotic lesion

Most cited articles on Management of the thrombotic lesion

Review articles on Management of the thrombotic lesion

Articles on Management of the thrombotic lesion in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Management of the thrombotic lesion

Images of Management of the thrombotic lesion

Photos of Management of the thrombotic lesion

Podcasts & MP3s on Management of the thrombotic lesion

Videos on Management of the thrombotic lesion

Evidence Based Medicine

Cochrane Collaboration on Management of the thrombotic lesion

Bandolier on Management of the thrombotic lesion

TRIP on Management of the thrombotic lesion

Clinical Trials

Ongoing Trials on Management of the thrombotic lesion at Clinical Trials.gov

Trial results on Management of the thrombotic lesion

Clinical Trials on Management of the thrombotic lesion at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Management of the thrombotic lesion

NICE Guidance on Management of the thrombotic lesion

NHS PRODIGY Guidance

FDA on Management of the thrombotic lesion

CDC on Management of the thrombotic lesion

Books

Books on Management of the thrombotic lesion

News

Management of the thrombotic lesion in the news

Be alerted to news on Management of the thrombotic lesion

News trends on Management of the thrombotic lesion

Commentary

Blogs on Management of the thrombotic lesion

Definitions

Definitions of Management of the thrombotic lesion

Patient Resources / Community

Patient resources on Management of the thrombotic lesion

Discussion groups on Management of the thrombotic lesion

Patient Handouts on Management of the thrombotic lesion

Directions to Hospitals Treating Management of the thrombotic lesion

Risk calculators and risk factors for Management of the thrombotic lesion

Healthcare Provider Resources

Symptoms of Management of the thrombotic lesion

Causes & Risk Factors for Management of the thrombotic lesion

Diagnostic studies for Management of the thrombotic lesion

Treatment of Management of the thrombotic lesion

Continuing Medical Education (CME)

CME Programs on Management of the thrombotic lesion

International

Management of the thrombotic lesion en Espanol

Management of the thrombotic lesion en Francais

Business

Management of the thrombotic lesion in the Marketplace

Patents on Management of the thrombotic lesion

Experimental / Informatics

List of terms related to Management of the thrombotic lesion

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

Overview

The presence of angiographically apparent thrombus is associated with poorer outcomes in patients undergoing PCI. Thrombus often embolizes distally and causes no reflow and associated myonecrosis. There are two broad strategies to reduce thrombus burden: mechanical strategies and pharmacologic strategies.

Differentiating Thrombus from Other Angiographic Abnormalities

  • Coronary spasm can also lead to a focal narrowing of the lumen and should be treated with vasodilators
  • A dissection can cause a hazy appearance to the lumen and should be treated with intracoronary stenting

Goals of Treatment

Goals in the management of the thrombotic lesion include:

Step-By-Step Strategy in the Management of the Thrombotic Lesion

  • The first strategy is to prevent the occurrence of thrombus through the use of upstream antiplatelet and antithrombotic pharmacotherapies including aspirin, thienopyridines, and glycoprotein 2b3a inhibition.
  • The second strategy is to mechanically aspirate thrombus.
  • The third strategy is to direct stent the lesion without pre-dilation to minimize distal embolization.
  • The fourth strategy is to utilize intracoronary fibrinolytic therapy to dissolve clot that is refractory to other forms of treatment and dissolve clot inside branches that may be accessible to mechanical devices.
  • Alternate / additional strategies include the use of distal protection and saphenous vein grafts to minimize distal embolization.

Pharmacologic Therapy

Antiplatelet Therapy

  • The incidence of thrombus on the coronary angiogram can be reduced by and complications of the PCI procedure can be reduced by upstream pharmacologic therapy with antiplatelet therapy including aspirin, platelet glycoprotein IIb/IIIa receptor (GP IIb/IIIa) antagonists in patients who are troponin positive (abciximab, eptifibatide, tirofiban), and ADP receptor/P2Y12 inhibitors (plavix, ticagrelor, prasugrel)
  • 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).

Antithrombin Therapy

Thrombolytic Therapy

  • Thrombolytic Therapy: Urokinase (UK), tissue plasminogen activator (tPA) for STEMI when other pharmacologic and mechanical treatments are not successful. Caution: intracoronary administration of fibrinolytic agents is an "off label" the use of these agents (this mode of administration is not been approved by the FDA, but fibrinolytic agents are an FDA approved drug). The total dose of tPA is 20 mg which is approximately the 1/5 of that generally used for systemic fibrinolysis. tPA can it be administered 2 mg at a time to evaluate its efficacy.

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
  • Transluminal Extraction Catheter (TEC)
  • Rheolytic Thrombectomy (Possis Angiojet)

Advantages of Each Choice

  • 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[2]) or Filterwire (PROMISE trial[3]).

Management of No Reflow

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).

References

  1. White HD, Braunwald E, Murphy SA; et al. (2007). "Enoxaparin vs. unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction in elderly and younger patients: results from ExTRACT-TIMI 25". Eur. Heart J. 28 (9): 1066–71. doi:10.1093/eurheartj/ehm081. PMID 17456482. Unknown parameter |month= ignored (help)
  2. Nikolsky E, Stone GW, Lee E; et al. (2009). "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". EuroIntervention. 5 (4): 417–24. PMID 19755327. Unknown parameter |month= ignored (help)
  3. Gick M, Jander N, Bestehorn HP; et al. (2005). "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". Circulation. 112 (10): 1462–9. doi:10.1161/CIRCULATIONAHA.105.545178. PMID 16129793. Unknown parameter |month= ignored (help)


Template:WikiDoc Sources