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Background: Elderly patients are at high risk of ischaemic and bleeding events. Platelet function monitoring offers the possibility to individualise antiplatelet therapy to improve the therapeutic risk-benefit ratio. We aimed to assess the effect of platelet function monitoring with treatment adjustment in elderly patients stented for an acute coronary syndrome., Methods: We did this multicentre, open-label, blinded-endpoint, randomised controlled superiority study at 35 centres in France. Patients aged 75 years or older who had undergone coronary stenting for acute coronary syndrome were randomly assigned (1:1), via a central interactive voice-response system based on a computer-generated permuted-block randomisation schedule with randomly selected block sizes, to receive oral prasugrel 5 mg daily with dose or drug adjustment in case of inadequate response (monitoring group) or oral prasugrel 5 mg daily with no monitoring or treatment adjustment (conventional group). Randomisation was stratified by centre. Platelet function testing was done 14 days after randomisation and repeated 14 days after treatment adjustment in patients in the monitoring group. Study investigators and patients were not masked to treatment allocation, but allocation was concealed from an independent clinical events committee responsible for endpoint adjudication. The primary endpoint was a composite of cardiovascular death, myocardial infarction, stroke, stent thrombosis, urgent revascularisation, and Bleeding Academic Research Consortium-defined bleeding complications (types 2, 3, or 5) at 12 months' follow-up. We did analysis by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01538446., Findings: Between March 27, 2012, and May 19, 2015, we randomly assigned 877 patients to the monitoring group (n=442) or the conventional group (n=435). The primary endpoint occurred in 120 (28%) patients in the monitoring group compared with 123 (28%) patients in the conventional group (hazard ratio [HR], 1·003, 95% CI 0·78-1·29; p=0·98). Rates of bleeding events did not differ significantly between groups., Interpretation: Platelet function monitoring with treatment adjustment did not improve the clinical outcome of elderly patients treated with coronary stenting for an acute coronary syndrome. Platelet function testing is still being used in many centres and international guidelines still recommend platelet function testing in high-risk situations. Our study does not support this practice or these recommendations., Funding: Eli Lilly and Company, Daiichi Sankyo, Stentys, Accriva Diagnostics, Medtronic, and Fondation Coeur et Recherche., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Elderly patients are at high risk for both ischemic and bleeding events. Platelet monitoring offers the opportunity to individualized antiplatelet therapy to optimize the therapeutic risk/benefit ratio., Study Design: The ANTARCTIC study is designed to demonstrate the superiority of a strategy of platelet function monitoring with dose and drug adjustment in patients initially on prasugrel 5 mg as compared with a more conventional strategy using prasugrel 5 mg without monitoring and without adjustment (Conventional Treatment Arm) to reduce the primary end point evaluated 1 year after stent percutaneous coronary intervention in elderly patients presenting with an acute coronary syndrome (ACS). ANTARCTIC is a multicenter, prospective, open-label study with 2 parallel arms. A total of 852 elderly patients (≥ 75 years) undergoing stent percutaneous coronary intervention for ACS are to be enrolled. The primary end point is the time to first occurrence of cardiovascular death, myocardial infarction, stroke, definite stent thrombosis, urgent revascularization, and bleeding complications (Bleeding Academic Research Consortium definition 2, 3, or 5). Platelet function analyses will be performed 14 days after randomization and repeated 14 days later in patients who require a change in treatment., Conclusion: ANTARCTIC is a nationwide, prospective, open-label study testing a strategy of platelet function monitoring with dose and drug adjustment to reduce ischemic and bleeding complications in elderly ACS patients undergoing coronary stenting., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Patients' responses to oral antiplatelet therapy are subject to variation. Bedside monitoring offers the opportunity to improve outcomes after coronary stenting by individualizing therapy., Methods: We randomly assigned 2440 patients scheduled for coronary stenting at 38 centers to a strategy of platelet-function monitoring, with drug adjustment in patients who had a poor response to antiplatelet therapy, or to a conventional strategy without monitoring and drug adjustment. The primary end point was the composite of death, myocardial infarction, stent thrombosis, stroke, or urgent revascularization 1 year after stent implantation. For patients in the monitoring group, the VerifyNow P2Y12 and aspirin point-of-care assays were used in the catheterization laboratory before stent implantation and in the outpatient clinic 2 to 4 weeks later., Results: In the monitoring group, high platelet reactivity in patients taking clopidogrel (34.5% of patients) or aspirin (7.6%) led to the administration of an additional bolus of clopidogrel, prasugrel, or aspirin along with glycoprotein IIb/IIIa inhibitors during the procedure. The primary end point occurred in 34.6% of the patients in the monitoring group, as compared with 31.1% of those in the conventional-treatment group (hazard ratio, 1.13; 95% confidence interval [CI], 0.98 to 1.29; P=0.10). The main secondary end point, stent thrombosis or any urgent revascularization, occurred in 4.9% of the patients in the monitoring group and 4.6% of those in the conventional-treatment group (hazard ratio, 1.06; 95% CI, 0.74 to 1.52; P=0.77). The rate of major bleeding events did not differ significantly between groups., Conclusions: This study showed no significant improvements in clinical outcomes with platelet-function monitoring and treatment adjustment for coronary stenting, as compared with standard antiplatelet therapy without monitoring. (Funded by Allies in Cardiovascular Trials Initiatives and Organized Networks and others; ARCTIC ClinicalTrials.gov number, NCT00827411.).

Percutaneous coronary interventions (PCI) of complex coronary lesions in patients with severely depressed left ventricular (LV) function may increasingly constitute an alternative to surgical revascularization. The availability of hemodynamic support devices offers a promising option to reduce PCI-related complications in such high-risk procedures. We report the case of a successful distal left main coronary artery T-stenting supported by the Impella Recover LP 2.5 assist device in a patient with severe LV dysfunction., (Copyright (c) 2008 Elsevier Masson SAS. All rights reserved.)

Percutaneous coronary intervention (PCI) of complex coronary lesions in patients with severely depressed left ventricular (LV) function may increasingly constitute an alternative to surgical revascularization. The availability of hemodynamic support devices offers a promising option to reduce PCI-related complications in such high-risk procedures. We report the case of successful distal left main coronary artery T-stenting supported by the Impella Recover LP 2.5 assist device in a patient with severe LV dysfunction.

Background: When administered in conjunction with primary coronary stenting for the treatment of acute myocardial infarction, a platelet glycoprotein IIb/IIIa inhibitor may provide additional clinical benefit, but data on this combination therapy are limited., Methods: We randomly assigned 300 patients with acute myocardial infarction in a double-blind fashion either to abciximab plus stenting (149 patients) or placebo plus stenting (151 patients) before they underwent coronary angiography. Clinical outcomes were evaluated 30 days and 6 months after the procedure. The angiographic patency of the infarct-related vessel and the left ventricular ejection fraction were evaluated at 24 hours and 6 months., Results: At 30 days, the primary end point--a composite of death, reinfarction, or urgent revascularization of the target vessel--had occurred in 6.0 percent of the patients in the abciximab group, as compared with 14.6 percent of those in the placebo group (P=0.01); at 6 months, the corresponding figures were 7.4 percent and 15.9 percent (P=0.02). The better clinical outcomes in the abciximab group were related to the greater frequency of grade 3 coronary flow (according to the classification of the Thrombolysis in Myocardial Infarction trial) in this group than in the placebo group before the procedure (16.8 percent vs. 5.4 percent, P=0.01), immediately afterward (95.1 percent vs. 86.7 percent, P=0.04), and six months afterward (94.3 percent vs. 82.8 percent, P=0.04). One major bleeding event occurred in the abciximab group (0.7 percent); none occurred in the placebo group., Conclusions: As compared with placebo, early administration of abciximab in patients with acute myocardial infarction improves coronary patency before stenting, the success rate of the stenting procedure, the rate of coronary patency at six months, left ventricular function, and clinical outcomes.

The frequency of early occlusion of coronary stents has fallen with the use of a powerful association of platelet antiaggregants (ticlopidine and aspirin) in the first month. The authors report the case of coronary stent occlusion after a negative exercise stress test, 11 days after implantation in a centre of cardiac rehabilitation. According to the literature, this type of complication would appear to be rare and related to the small size of the stent and the conditions of implantation (acute phase). It would be useful to compile a registry of complications related to coronary angioplasty during rehabilitation to determine their prevalence and, if necessary, change the protocols of physical training of these patients.

GENERAL CHARACTERISTICS: Several criteria are used for coronary stent design: biocompatibility, i.e. the capacity to resist thrombotic events and corrosion, flexibility, radial force sufficient to resist elastic recoil, percentage of the lesion covered, radio-opacity, minimal shortening at opening, absence of effect on collateral branches, possibility to use small calibre probe guides, and cost. TWO CATEGORIES: Both tubular stents (self-expanding stents and balloon stents) and filamentary stents (made of stainless steel or tantalum) are used, THE IDEAL STENT: There is no one ideal stent. Choice is dictated by the characteristics of the lesion and by the status of the artery to treat.

RATIONALE FOR ANTITHROMBOSIS THERAPY: Introducing a foreign body into the coronaries raises the risk of thrombosis in the acute phase and for the 4 following weeks. The objective of antithrombotic therapy is to inhibit platelet adhesion and aggregation or to induce hypocoagulability. AT IMPLANTATION: High-dose heparin is given in a bolus following pretreatment with aspirin. ASPIRIN-TICLOPIDINE COMBINATION: The risk of subacute thrombosis is low, about 1%, and the rate of vascular complications is minimal. Treatment is simple and compatible with short hospitalization.

BETTER THAN ANGIOPLASTY: Prolonging inflation with a perfusion balloon decreases the risk of acute coronary occlusion after angioplasty. The longer the artery remains patent, the greater the chances of 0% residual stenosis. This is what the sent allows. Stent act on both mechanisms of stenosis: elastic recoil and fibrous remodeling of the arterial plaque. TARGETTED ACTION: Stents improve angioplasty prevention of acute stenosis. They have a real action on preventing degeneration of the saphenous graft and lead to a significant reduction in the rate of restenosis of the dilated site. There are however two specific complications: subacute occlusion and greater incidence of vascular events. Stents are particularly indicated for the treatment of restenosis and chronic occlusions. TWO IMPROVEMENTS: Risks related to the implantation of a foreign body in the vascular system have been reduced with the use of ticlopidine and high-pressure stent implantation. POSITIVE RESULTS: Stents have produced better angiographic results. They limit restenosis and the number of revascularizations required in treated patients. Several questions concerning indications remain open.