Ticagrelor reduces ischemic risk in patients with a history of acute myocardial infarction, but it increases the risk of bleeding. Keeping a delicate balance is paramount when prescribing long-term ticagrelor to patients with a history of infarction. The PEGASUS-TIMI 54 study randomized 21,162 patients with a history of infarction on a 1:1:1 ratio: some received ticagrelor…
Pending Challenges in Transradial Access
The recent SAFARI-STEMI study compared transradial and femoral access in patients with ST-segment elevation myocardial infarction, and no significant differences were found. These results have a sour taste for those in favor of transradial access, as they are convinced of its benefits and unwilling to go back to previous practices. This bitter taste is based…
Transfusion in TAVR: Caution Is Best
Periprocedural red blood cell transfusion in transcatheter aortic valve replacement (TAVR) correlates with increased mortality and acute kidney injury. It also resulted an independent predictor of 30-day mortality, irrespective of bleeding and vascular complications. The global trend that limits transfusion, in all procedures in general, has finally reached TAVR. The multicenter registry TRITAVI (Transfusion Requirements…
ProGlide vs. Prostar XL to Close Post-TAVR Access
Minimalist transcatheter aortic valve replacement (TAVR) is a strategy that is here to stay. We have previously published papers comparing local vs. general anesthesia, use of transthoracic vs. transesophageal echocardiography, and early discharge in TAVR. In all these papers, the “minimalist approach” included percutaneous closure of vascular access. However, few papers compare closure devices in…
The Transradial Approach Continues to Be the Best for Primary PCI
The transradial approach has been associated to lower mortality and bleeding rates in patients receiving primary PCI for ST elevation MI. This had been called into question by the recent SAFARI-STEMI, but after including its outcomes in a new meta-analysis, the scales tilted slightly in favor of the transradial approach vs. the transfemoral. The transradial…
AHA 2020 | RIVER: Rivaroxaban as Alternative to Warfarin in Patients with Atrial Fibrillation and Bioprosthetic Mitral Valve
Rivaroxaban seems to be a reasonable alternative to warfarin in patients with atrial fibrillation and bioprosthetic mitral valve. These results arise from the RIVER Study presented at the American Heart Association (AHA) 2020 Congress and simultaneously published in the New England Journal of Medicine (NEJM). After 5 years of follow-up, rivaroxaban reached the non-inferiority criterion…
Antiplatelet Therapy in Elderly Population: Are the New P2Y12 Inhibitors Safe?
Should elderly patients stick to clopidogrel? The first large study on prasugrel showed an unacceptable increase of bleeding in elderly patients, suggesting the use of 5 mg (although the sample size was small, which hindered the determination of dose efficacy). Later, ticagrelor showed better efficacy than clopidogrel without apparent safety concerns. However, specific evidence on elderly…
TCT 2020 | Xience in Favor of Short Dual Antiaggregation Therapy with High Bleeding Risk
Following with aspirin alone after a short period of dual antiaggregation therapy (DAPT), 1 to 3 months, did not increase ischemic events in patients receiving a Xience stent while significantly reducing bleeding. This study endorses the safety of short DAPT with contemporary drug eluting stents (DES) in patients presenting high bleeding risk. The XIENCE Short…
How To De-Escalate Prasugrel After Acute Coronary Syndrome?
Patients who undergo coronary angioplasty after acute coronary syndrome could de-escalate dual antiplatelet therapy with prasugrel to maintain the protection against ischemic events while lowering their hemorrhagic risk. The HOST-REDUCE-POLYTECH-ACS study (recently published in The Lancet) included 2338 patients who underwent coronary angioplasty in a setting of acute coronary syndrome. Patients were randomized to a year-long…
ESC 2020 | Acute Myocardial Infarction and Anemia: Are Transfusions Necessary?
In anemic patients undergoing acute myocardial infarction, a restrictive transfusion strategy is as safe as a more liberal approach, in addition to saving costs. The cutoff value to decide for a transfusion would be < 8 g/dl hemoglobin. The REALITY outcomes were presented during the virtual ESC 2020 sessions. Anemia is relatively common in patients…