PCI of pLCx and pLAD with dedicated 2 Stent Technique and OCT Imaging – September 2018
65 year old male with known extensive CAD and prior PCI’s in 2008, presented with NSTEMI (TnI 0.54). A Cardiac Cath on August 6, 2018 revealed 3 V CAD: Subtotal prox RCA and 90% mid RCA DES ISR, 70% proximal LAD DES ISR, 95% multiple calcified proximal LCx lesions, and subtotal small LCx-LPL1 with SYNTAX Score of 25 and LVEF of 60%. Patient underwent successful intervention of culprit proximal and mid RCA using rotational atherectomy and two Promus Premier DES. Subsequently patient had stress MPI revealing moderate to severe lateral and interolateral ischemia and mild anterior ischemia. Patient is now planned for staged PCI of proximal LCx and proximal LAD with dedicated 2 stent technique and OCT imaging guidance.
QRegarding the three back to back NEJM publications regarding use and safety of Aspirin, which publication is the most relevant?
A.All 3 publications showing no overall benefit of aspirin despite slight decrease in cV events in various primary prevention settings are important as they also showed slight increase in GI hemorrhage and cancer. Hence be away from aspirin unless you had CAD symptoms or ACS.
QWhat is its unambiguous take home message?
A.The aspirin message is clear that aspirin should not be routinely prescribed for primary prevention even in diabetics.
QWhat could be the reason of higher cancers?
A.The reasons for higher cancer in aspirin group is not clear and is being intensely studied currently.
QHave you begun to act regarding your patients following this unprecedented press?
A.Yes, I am asking pts not to take aspirin for the indication of primary prevention.
QHave you already begun changing your recommendations for the healthy elderly?
A.Yes. No need to take aspirin unless you have ACS or CAD or had a procedure.
QSo, for which patient is Aspirin recommended now?
A.Aspirin is indicated in ACS & CAD pts, post PCI pts and post CABG pts.
A.Aspirin 75-100mg daily. In pts weighing >80kg, I will recommend 162mg daily.
QAnd for which patients is Aspirin not recommended now?
A.Aspirin is not recommended in the primary prevention and diabetic setting.
QAre we looking at complete elimination of Aspirin and COX 2 inhibitors in the future from Interventional Cardiology?
A.Only future trials will show the final role of aspirin in the CAD pts and may very well be eliminated from the therapeutic armamentarium.
QBased upon these three publications, can one expect guidelines modifications?
A.Yes, upcoming guideline will incorporate these updated recommendations.