CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Eugenio Stabile, MD, PhD* and
Paolo Rubino, MD
* Cardiac Catheterization Laboratories, Division of Cardiology, Clinica Montevergine, Via Mario Malzoni 1, Mercogliano AV 83013, Italy (Email: geko50{at}hotmail.com).
We would like to thank Dr. Denardo for his interest in our work (1), and we appreciate his quoting a proverb that well depicts our paper's take-home message. The CIAO (Coronary Interventions Antiplatelet-based Only) trial is a first step on a journey into exclusive dual antiplatelet therapy (aspirin and thienopyridine) alone during percutaneous coronary intervention (PCI), without scheduled antithrombin or glycoprotein inhibitor therapy.
We disagree with the accompanying editorial (2), which states that dual antiplatelet therapy alone may lack an essential "safety net" that could be provided by antithrombin therapy or, perhaps, glycoprotein inhibitor therapy. As pointed out by Dr. Denardo, the use of aspirin, combined with adequate patient pretreatment with a thienopyridine, will guarantee an adequate inhibition of platelet activity and lack of triggering for the coagulation cascade during a planned PCI (3,4).
Moreover, the use of the glycoprotein IIb/IIIa inhibitors (e.g., abciximab) will not add a further inhibition of the the final common pathway of platelet aggregation in stable patients in chronic treatment with thienopiridine. Solid clinical data proving the opposite are still lacking.
So far, the the only proof of this theory is the absence of thrombotic occlusions and the lower ischemic complications during PCI (i.e., periprocedural myocardial damage) in the placebo group of the CIAO trial (1).
An additional point is related to procedural costs. Our approach is aimed at a safe and efficient removal of expensive, unnecessary drugs from elective procedures. This is valid, both for inhibitors of the anticoagulation cascade, and for glycoprotein IIb/IIIa receptor inhibitors. We truly believe that these drugs, in this clinical setting, can only increase the incidence of bleeding and raise the costs without improving the patient's outcome.
However, as pointed out by Dr. Denardo, further trials are needed to make a second step along this path. Testing our hypothesis for the treatment of more complicated lesions is crucial to prove the clinical value of CIAO findings.
Finally, we want to thank Dr. Denardo, who has inspired our work. Thanks to his pioneering experience, together with the results of the REMOVE (Reduction in Major and Minor Adverse Events With Eptifibatide-based Pharmacotherapy in Percutaneous Coronary Intervention) (5) and CIAO (1) trials, exclusive antiplatelet therapy is not considered heretical any more.
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References
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1. Stabile E, Nammas W, Salemme L, et al. The CIAO (Coronary Interventions Antiplatelet-based Only) study: a randomized study comparing standard anticoagulation regimen to absence of anticoagulation for elective percutaneous coronary intervention J Am Coll Cardiol 2008;52:1293-1298.[Abstract/Free Full Text]2. Dauerman HL. Coronary intervention without a safety net J Am Coll Cardiol 2008;52:1299-1301.[Free Full Text] 3. Stein B, Fuster V, Israel DH, et al. Platelet inhibitor agents in cardiovascular disease: an update J Am Coll Cardiol 1989;14:813-836.[Abstract] 4. Rosing J, van Rijn JL, Bevers EM, van Dieijen G, Comfurius P, Zwaal RF. The role of activated human platelets in prothrombin and factor X activation Blood 1985;65:319-332.[Abstract/Free Full Text] 5. Valencia R, Price MJ, Sawhney N, et al. Efficacy and safety of triple antiplatelet therapy with and without concomitant anticoagulation during elective percutaneous coronary intervention (the REMOVE trial) Am J Cardiol 2007;100:1099-1102.[CrossRef][Web of Science][Medline]
Related Article
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Exclusive Antiplatelet Therapy for Percutaneous Coronary Intervention
- Scott J. Denardo
J. Am. Coll. Cardiol. 2009 53: 1921-1922.
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