Heparin monotherapy for percutaneous coronary intervention?

564 www.thelancet.com Vol 384 August 16, 2014 The effi cacy and safety of percutaneous coronary intervention (PCI) has been substantially enhanced by refi nements in antithrombotic treatments. Ischaemic complications were reduced by as much as 50% with addition of platelet glycoprotein IIb/IIIa inhibitors (GPIs) to early regimens of aspirin and heparin. However, use of these potent platelet inhibitors was accompanied by increased risk of haemorrhagic complications, which are associated with increased mortality, morbidity, and costs. Development of antithrombotic drugs therefore focused on reducing risks of haemorrhagic events while maintaining protection against ischaemic complications. In several trials in patients undergoing PCI, substitution of the direct thrombin inhibitor bivalirudin for the combination of heparin and a GPI consistently reduced the incidence of major bleeding by about 40%. Although occurrence of the composite ischaemic endpoints of those trials was not signifi cantly increased by bivalirudin, there seemed to be more frequent periprocedural myocardial infarctions in several studies and rates of acute stent thrombosis were signifi cantly higher with bivalirudin than with heparin in patients with ST-elevation myocardial infarction (STEMI). However, long-term mortality was not increased with bivalirudin and this drug largely supplanted the combination of heparin plus a GPI during PCI. Advances in interventional practices have the potential to alter the balance between bleeding and ischaemic risks. Ticagrelor and prasugrel— potent and rapidly acting inhibitors of the platelet ADP receptor—reduce ischaemic events when used instead of clopidogrel in patients with acute Heparin monotherapy for percutaneous coronary intervention? do not seem to be substantial (table). Because all guidelines recommend prompt initiation of drug treatment in patients with hypertension stage II or III, estimates of total cardiovascular risk in this setting might not have a major eff ect on therapeutic decisions, but rather on the expectations of benefi t. In patients with hypertension stage I, with the notable exception of the Joint National Committee 8, the other guidelines take cardiovascular risk estimates into some account, by recommending the initiation of drug treatment when the risk is increased generally on the basis of target organ damage or established cardiovascular disease. Future studies should focus on stage I hypertension and clarify what is the most accurate and cost-eff ective approach to stratify cardiovascular risk and to estimate the expected benefi t of treatment in these patients.