Journal of Invasive Cardiology

We would have tried to avoid taking this patient with an acute and life-threatening central nervous system bleed six hours earlier to the cardiac catheterization laboratory. He was hemodynamically stable with an inferior myocardial infarction that is associated with an acceptably low mortality, particularly in a young patient. The risks of any anticoagulation, including heparin or bivalirudin, or antiplatelet agents such as aspirin or clopidogrel, are clearly not quantifiable from available data in the literature. One can logically presume that this risk is not trivial and that the consequences could be permanent brain damage or death. We would have tried to initially manage this patient conservatively to avoid the potential risks associated with anticoagulation that would have been required to perform percutaneous intervention.

However, once the decision was made to perform emergency percutaneous coronary intervention, a few points are worthy of comment. The choice of bivalirudin instead of unfractionated heparin is a reasonable one. In the Bivalirudin Angioplasty Trial and in the subgroup of the REPLACE-1 trial that did not receive glycoprotein IIb/IIIa inhibitors, bivalirudin was associated with lower rates of major bleeding compared with unfractionated heparin. However, patients with acute ST-segment elevation myocardial infarction were excluded from these trials.

In this setting, we would have tried to avoid placement of a coronary stent if possible. The stent obligates this patient to both aspirin and clopidogrel in the acute setting. An adequate balloon angioplasty result would have accomplished the acute goal of restoring flow to salvage myocardium. The higher rate of restenosis associated with balloon angioplasty in comparison to a stent would have been less of an acute concern than the increased risk of bleeding associated with the addition of clopidogrel. Furthermore, a Hepacoat stent could have been considered to treat a suboptimal balloon angioplasty result since there are some data to suggest that the subacute stent thrombosis rate is acceptable with this stent in the absence of clopidogrel.

Finally, it is unclear why the lesion in the non-infarct related artery was treated. Percutaneous coronary intervention of a non “culprit” lesion during primary angioplasty is considered a Class III indication in the ACC/AHA Guidelines for Percutaneous Coronary Intervention. It seems as though “less” would be better in this situation, and it would be helpful to understand the author’s procedural strategy.

Luis M. de la Fuente, MD
Instituto Argentina de Diagnòstico y Tratamiento
Buenos Aires, Argentina

First of all, we would like to congratulate the authors of this work for the therapeutic success achieved, bearing in mind the complex and difficult situation with which this patient arrived to the ER. In response to the clinical management of the patient presented in this paper, although we share the authors’ therapeutic approach, we would like to point out a few things that differ in the procedure we would had followed, given that case.