No abstract

According to current guidelines, in patients without additional risk factors who have undergone aortic valve replacement with a bioprosthesis, anticoagulation in the first 3 months after surgery is still a matter of debate. According to current evidence, aspirin in low doses is a reasonable alternative to vitamin K antagonists (VKA). A comparison is made between the incidence of thrombotic and haemorrhagic complications in patients with low thrombotic risk who underwent aortic valve replacement with a bioprosthesis in the National Institute of Cardiology of Ignacio Chávez of Mexico. The hypothesis: aspirin as monotherapy has a beneficial effect compared to VKA. The studied patients were the low thrombotic risk patients who underwent aortic valve replacement with a bioprosthesis in the National Institute of Cardiology of Ignacio Chávez of Mexico from 2011 to 2015. The groups studied were: aspirin only, VKA only, and the combination of VKA plus aspirin. The patients were retrospectively followed-up for 12 months, and the thrombotic and haemorrhagic complications were documented. Of the 231 patients included in the study, only one patient in the VKA only group presented with a haemorrhagic complication. No thrombotic complications were observed. In the present study no thrombotic complications were observed in patients who did not receive anticoagulation in the first 3 months after an aortic valve replacement with a bioprosthesis after a follow up period of 12 months. This suggests that the use of aspirin only is safe during this period.

Introducción: En las guías actuales europeas para el manejo del infarto de miocardio posterior a la colocación de endoprótesis coronaria (stent), no existe consenso sobre la duración ideal de la terapia antiagregante plaquetaria dual (DAPT, dual antiplatelet therapy) para prevenir la trombosis-reestenosis del stent sin aumentar el riesgo significativo de sangrado. Objetivo: Reportar el porcentaje de sangrado mayor y de eventos cardiovasculares mayores asociados a la DAPT prolongada en pacientes atendidos en el Instituto Nacional de Cardiología y tratados con intervención coronaria percutánea primaria y stent. Métodos: Se realizó un estudio longitudinal, prospectivo observacional y descriptivo no experimental. Los pacientes fueron captados de noviembre de 2016 a diciembre de 2017. Resultados: Fueron seleccionados 135 pacientes con una media de edad de 57 ± 10 años, quienes cumplieron un seguimiento clínico por tres años. La obesidad y la hipertensión destacaron como principales factores de riesgo. Posterior al uso de DAPT durante tres años, se registró 3.7 % de mortalidad, 1.48 % de sangrado mayor y 4.4 % de trombosis-reestenosis. Conclusiones: El uso prolongado de DAPT estaría justificado por la alta incidencia de trombosis-reestenosis, sin incremento significativo en el riesgo de sangrado y con disminución de los eventos cardiovasculares mayores.

images in clinical medicineT h e n e w e ng l a n d j o u r na l o f m e dic i n e n engl j med 362;7 nejm.org february 18, 2010 e20 A 33-year-old man with rheumatic heart disease presented with an acute onset of chest pain. Five years earlier, the patient had undergone replacement of the mitral and aortic valves (Bjork-Shiley and ATS Medical, respectively). On physical examination, he had diaphoresis with normal vital signs and without evidence of congestive heart failure, acute aortic regurgitation, or abnormal prosthetic heart sounds. Electrocardiography that was performed 4 hours after the onset of pain showed ST elevation in left-sided leads V 8 and V 9 , which was suggestive of inferoposterior myocardial injury (see the Supplementary Appendix). Laboratory evaluation revealed an elevated international normalized ratio (>12; normal range, 2.5 to 3.5), a creatine kinase level of 39 U per liter (normal range, 0 to 150), a creatine kinase MB level of 5.5 U per liter (normal range, 0.6 to 6.3), and a troponin I level of 0.24 ng per milliliter (normal range, 0.01 to 0.03). Cardiac catheterization showed that the prosthetic aortic valve was significantly displaced with each heartbeat (Panels A and B, arrows, and video); no abnormality of the mitral valve was observed. The patient underwent urgent excision and replacement of the dehisced aortic valve, which was found to be infected with Staphylococcus aureus, with associated vasculitis; the mitral valve was not affected. The patient had postoperative mediastinal bleeding and died from irreversible shock 24 hours later.

Introduction:In current European guidelines for the management of myocardial infarction after coronary stent placement, there is no consensus on dual antiplatelet therapy (DAPT) ideal duration to prevent stent thrombosis-restenosis without significantly increasing the bleeding risk. Objective: To report the percentage of major bleeding and presence of major cardiovascular events associated with prolonged DAPT in patients recruited at the National Institute of Cardiology, treated with primary percutaneous coronary intervention and stent. Methods: A longitudinal, prospective, observational, non-experimental, descriptive study was carried out. Patients were recruited from November 2016 to December 2017. Results: One hundred and thirty-five patients with a mean age of 57 ± 10 years who completed the three-year follow-up were selected. Obesity and hypertension stood out as the main risk factors. After using DAPT for three years, 3.7% of mortality, 1.48% of major bleeding, and 4.4% of thrombosis-restenosis were recorded. Conclusions: Prolonged use of DAPT would be justified by the high incidence of thrombosis-restenosis, without a significant increase in bleeding risk, as well as a decrease in major cardiovascular events.