Prof. Eva Swahn,
At the Sunday lunch session, two presentations on difficult, complicated, tricky patients were discussed. The first case presented by Nicolas Meneveau from France dealt with management of a STEMI-patient with chronic kidney disease. An intensive dual platelet inhibition precath was followed with bivalirudin at the cathlab where a BMS was put in place. Immediately after the procedure the renal function showed a CrCl of 29 mL/min. Next day a massive maelena occurred associated with shock and drop in haemoglobin level from 12.1 to 7.1 g/dL as a result of a peptic ulcer. Aspirin was discontinued, resulting in stent-thrombosis and aspirin was re-instituted in combination with PPI. Patients with renal insufficiency are at increased risk of bleeding because of platelet dysfunction, prolonged half-life and reduced elimination of antithrombotic drugs. They are also at increased risk of thrombosis because of platelet dysfunction and prolonged time needed to reach maximum treatment effect. Guidelines acknowledge the lack of sufficient studies, and this precludes specific recommendations for this type of patient. The second case presented by Nicolo Grieco from Italy, dealt with NSTEMI in a diabetic patient with atrial fibrillation (AF). Six to 8% of these patients have an indication for long term anticoagulation. A problem arises as in patients with AF, DES should be avoided but are recommended in patients with diabetes. The delicate balance between thromboembolism and bleeding is intricate. Hyperglycaemia contributes to a prothrombotic state and maybe also to bleeding. In the 2010 ESC guidelines for the management of AF, it is mandatory to treat with oral anticoagulants in patients with AF and CHADS score > 1 risk factor. The panel discussion, lead by Yonathan Hasin from Israel, boiled down to the conclusion that there is not enough knowledge to give guidance in these situations. Every patient has to be individually assessed and treated accordingly.
Optimising antithrombotic therapy: a tailored approach?
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