PREVENTION AND MANAGEMENT OF THROMBOTIC COMPLICATIONS DURING CORONARYINTERVENTIONS - COMBINATION THERAPY WITH ANTITHROMBINS, ANTIPLATELETS, AND OR THROMBOLYTICS - RISKS AND BENEFITS/

Acute occlusions after percutaneous transluminal coronary intervention occur in about 5 % of cases. The incidence of these serious adverse e vents may be reduced by the identification of risk factors, appropriat e indication for the intervention, and by medical therapy with antipla telets and antithrombins. The medical management of complications duri ng percutaneous transluminal interventions also may include thrombolyt ics. Aspirin has been shown to significantly reduce the incidence of p rocedure-related corollary occlusion and ischaemic events. Available d ata suggest pre-treatment with 250-500 mg followed by 100-300 mg aspir in after the intervention. Ticlopidine seems to be equally effective; however, because of its sine effects it should be used only in cases o f a contraindication to aspirin. The second indispensable therapeutic concept in the prevention of acute thrombotic events during PTCA is th rombin inhibition. The level of anticoagulation achieved by heparin se ems to be critically important. Therefore the recommendation for hepar in dosing is a bolus of 10 000 U followed by an intravenous infusion o ver 24 h of either 1000 U.h(-1) or an infusion adjusted to keep the aP TT above 3 times control, but lower doses of shorter duration may be e qually effective in uncomplicated cases. Prolonged pre-treatment with heparin may be useful if the pre-intervention angiogram is suggestive of intracoronary thrombus. Thrombolysis as an adjunct to PTCA did riot reduce the rate of periprocedural coronary occlusions, but pre-treatm ent with thrombolysis may be useful in patients with recanalization of occluded vein grafts or in patients with large amounts of thrombotic material. In acute coronary occlusion, thrombolysis has rarely been us ed as a sole rescue therapy and results have not been encouraging, alt hough a thrombotic process often is Involved. Thrombolysis as an adjun ct to rescue angioplasty showed no better clinical outcome than prolon ged balloon inflation or stenting. Because of serious bleeding complic ations, thrombolysis should only be considered as a treatment option i f thrombosis is unequivocally the major cause of the acute occlusion.