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Antithrombotic Drug Therapy in Cardiovascular Disease
For other titles published in this series, go to
www.springer.com/series/7677

Antithrombotic
Drug Therapy in
Cardiovascular Disease
Edited by
Arman T. Askari, MD
Western Reserve Heart Care, Hudson, OH, USA
A. Michael Lincoff, MD
The Cleveland Clinic Foundation, Cleveland, OH, USA

Editors
Arman T. Askari
Western Reserve Heart Care
Hudson, OH 44236
USA
arman.askari64@gmail.org
A. Michael Lincoff
Department of Cardiovascular Medicine
Cleveland Clinic
9500 Euclid Avenue
Cleveland, OH 44195
USA
lincofa@ccf.org
ISBN 978-1-60327-234-6 e-ISBN 978-1-60327-235-3
DOI 10.1007/978-1-60327-235-3
Springer Dordrecht Heidelberg London New York
Library of Congress Control Number: 2009928625
© Humana Press, a part of Springer Science+Business Media, LLC 2010
All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Humana
Press, c/o Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection
with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer
software, or by similar or dissimilar methodology now known or hereafter developed is for-bidden.
The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be
taken as an expression of opinion as to whether or not they are subject to proprietary rights.
Printed on acid-free paper
Springer is part of Springer Science+Business Media (www.springer.com)

To my wife Jamie and our children Alexa, Amanda,
and Jacob and to my parents Ali and Houri for their
continued support and understanding.
Arman T. Askari, MD
I would like to recognize the support and patience of
my wife Debra and our children Gabrielle, Aaron, and
Jacob.
A. Michael Lincoff, MD
v
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It is now well established that pathologic thrombosis plays a central role in the pathogenesis of
acute coronary syndromes (ACS), ischemic complications of percutaneous coronary intervention
(PCI), venous thromboembolic disease, and embolic complications of arrhythmias and various cardio-
myopathies. Born out of the understanding of the integral role of thrombus formation across the
spectrum of cardiovascular diseases is the burgeoning field of antithrombotic therapies. Rigorous
investigation of individual or various combinations of the available antithrombotic regimens including
fibrinolytic agents, antiplatelet therapies (aspirin, the thienopyridines, glycoprotein IIb/IIIa inhibi-
tors), and anticoagulant therapies (unfractionated heparin, low-molecular-weight heparins, direct
thrombin inhibitors, and synthetic factor X inhibitors) has lead to a marked improvement in outcomes
for patients with a thrombotic event. Nevertheless, a substantial morbidity and mortality remains
associated with these thrombotic events. This realization has fueled the rapid expansion of the avail-
able armamentarium to combat pathologic thrombosis.
Antithrombotic Drug Therapy in Cardiovascular Disease will serve as a resource for individuals
charged with caring for patients across the spectrum of cardiovascular diseases. This text is a compre-
hensive, up-to-date overview of the pathophysiology, including the genetics, of arterial and venous
thrombosis followed by detailed overviews of the use of antithrombotic therapies for managing
patients with various thrombotic disorders. Antithrombotic Drug Therapy in Cardiovascular Disease,
a compilation of work by thought leaders in the field, is broken down into seven parts which will
provide rapid access to various therapies used for each of the major classes of thrombotic disorders
commonly encountered by clinicians.
The first part of Antithrombotic Drug Therapy in Cardiovascular Disease is comprised of four
chapters that will provide a comprehensive overview of the basic principles of thrombosis. Chapters
1 and 2 review the key components of thrombosis, the platelet and the coagulation cascade, respec-
tively. Chapter 3 then develops the link between inflammation, a process demonstrated to be involved
in atherogenesis, and thrombosis. Chapter 4 then provides a comprehensive view of the genetics of
thrombosis.
Parts II–IV then provide data and clinical recommendations for the use of antithrombotic therapies
for common atherothrombotic disorders including stable coronary artery disease (Part II, Chaps. 5 and
6), non-ST-segment elevation (NSTE) ACS (Part III, Chaps. 7–10), and ST-segment elevation myo-
cardial infarction (STEMI) (Part IV, Chaps. 11–13).
Part V provides data and recommendation for the use of various antithrombotic therapies as
adjuncts to interventional procedures. Chapter 14 focuses on the use of antithrombotic therapies for
PCI, while Chapter 15’s focus is on carotid and peripheral interventions. Chapter 16 will provide a
detailed review of monitoring of the various antithrombotic therapies in the peri-interventional
period.
Part VI focuses on venous thromboembolic diseases. This part of Antithrombotic Drug Therapy in
Cardiovascular Disease will provide the data necessary to manage patients with deep vein thrombosis
(DVT) and pulmonary embolism (PE) in an evidence-based fashion. Chapter 17 focuses on
prophylaxis
Preface
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viii
viii Preface
and treatment for patients with DVT/PE. Chapter 18 synthesizes the data on the use of fibrinolysis for
PE. Chapter 19 completes the section with a detailed, yet concise overview of the recommended dura-
tions of therapy for patients with venous thromboembolic diseases.
The final part of Antithrombotic Drug Therapy in Cardiovascular Disease provides detailed over-
views of the use of antithrombotic therapies in several clinical conditions commonly encountered in
the field of cardiology including atrial fibrillation (Chap. 20), valvular heart disease (Chap. 21), and
cardiomyopathy (Chap. 22). Chapter 23 focuses on the pathophysiology and management of heparin-
induced thrombocytopenia. Finally, an analysis of the increasingly encountered scenario of aspirin
and clopidogrel resistance will be addressed in Chapter 24.
In summary, this textbook will provide detailed, up-to-date data regarding the use of the currently
available antithrombotic therapies for commonly encountered clinical situations in cardiology.
Arman T. Askari,
m d
A. Michael Lincoff, m d
Cleveland, OH
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Contents
ix
Preface ...................................................................... vii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Part I Basic Principles
1 Platelets in Arterial Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Edward F. Plow and Peter Kelly
2
The Role of Coagulation in Arterial and Venous Thrombosis . . . . . . . . . . . . . . . . . . . . . . . 19
Kandice Kottke-Marchant
3
The Link Between Inflammation and Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
John H. Cleator and Mark Robbins
4
The Genetics of Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Svati H. Shah and Richard C. Becker
Part II Antithrombotic Therapy for Stable Coronary Atherosclerotic Disease
5
Aspirin in Primary and Secondary Prevention of Cardiovascular Disease . . . . . . . . . . . . . . 117
Jinesh Kochar and J. Michael Gaziano
6
Thienopyridines in Stable Coronary Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Marcus D. Flather and Dipak Kotecha
Part III Antithrombotic Therapy for NSTE ACS
7
Antiplatelet Therapies in Unstable Angina and Non-ST Segment Elevation
Myocardial Infarction
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Saif Anwaruddin and Deepak L. Bhatt
8
Unfractionated Heparin and Enoxaparin for the Management of Non-ST-Segment
Elevation Acute Coronary Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Pierluigi Tricoci and Kenneth W. Mahaffey
9
Direct Thrombin Inhibitors in Acute Coronary Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . 183
Tyler L. Taigen, James E. Harvey, and A. Michael Lincoff
10
Synthetic Factor Xa Inhibition in Acute Coronary Syndromes ....................... 203
Michael S. Kim, Robert L. Page, and Ivan P. Casserly
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x
x Contents
Part IV Antithrombotic Therapy for STEMI
11
Antiplatelet Therapies: Aspirin, Clopidogrel and Thienopyridines,
and Glycoprotein IIb/IIIa Inhibitors for the Management of ST-Segment
Elevation Myocardial Infarction
.............................................. 219
Rory B. Weiner and Marc S. Sabatine
12
Antithrombin Therapy for Acute ST-Segment Elevation Myocardial Infarction . . . . . . . . . 235
John M. Galla and Arman T. Askari
13
Fibrinolysis and Facilitated PCI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Ryan D. Christofferson and Sorin J. Brener
Part V Antithrombotic Therapy in Interventional Cardiology
14
Antithrombotic Therapy in Percutaneous Coronary Intervention ..................... 261
Adrian W. Messerli
15
Antithrombotic Therapy in Carotid and Peripheral Intervention . . . . . . . . . . . . . . . . . . . . . 283
Thomas J. Helton and Samir R. Kapadia
16
Monitoring of Antithrombotic Therapies in Interventional Cardiology ................ 307
Kristofer Dosh and Steven Steinhubl
Part VI Antithrombotic Therapy in Venous Thromboembolism
17
Venous Thromboembolism .................................................. 331
Esther S.H. Kim and John R. Bartholomew
18
Fibrinolysis for Pulmonary Embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
Stavros V. Konstantinides
19
Duration of Anticoagulant Therapy After Venous Thromboembolism . . . . . . . . . . . . . . . . 363
Clive Kearon
Part VII Clinical Consideration
20 Antithrombotic Therapy for Atrial Fibrillation and Cardioversion . . . . . . . . . . . . . . . . . . . 389
Carmel M. Halley and Allan L. Klein
21
Antithrombotic Therapy for Valvular Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
Noah Rosenthal and Brian D. Hoit
22
Antithrombotic Therapy in Heart Failure and Cardiomyopathy ...................... 425
Zuheir Abrahams, George Sokos, and W.H. Wilson Tang
23
Heparin-Induced Thrombocytopenia ........................................... 435
John R. Bartholomew
24 Resistance to Antiplatelet Drugs .............................................. 449
Gerald C. Koenig and Hitinder S. Gurm
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
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Contributors
xi
Zuheir Abrahams, MD, PhD • Department of Cardiovascular Medicine, Cleveland Clinic,
Cleveland, OH, USA
Saif Anwaruddin, MD •
Western Reserve Heart Care, Hudson, OH, USA
Arman T. Askari, MD • Western Reserve Heart Care, Hudson, OH 44236, USA
John R. Bartholomew, MD • Departments of Cardiovascular Medicine and Hematology/
Oncology, Cleveland Clinic, Cleveland, OH, USA
Richard C. Becker, MD • Duke Clinical Research Institute, Duke University Medical Center,
Durham, NC, USA
Deepak L. Bhatt, MD, MPH • Department of Cardiology, VA Boston Healthcare System,
and Integrated Interventional Cardiovascular Program, Brigham and Women’s Hospital, Boston,
MA, USA
Sorin J. Brener, MD • Division of Cardiology, New York Methodist Hospital, Brooklyn, NY, USA
Ivan P. Casserly, MB, BCh • Section of Interventional Cardiology, University of Colorado Denver
and Health Sciences Center, Aurora, CO, USA; Department of Medicine, Denver Veterans Affairs
Medical Center, Denver, CO, USA
Ryan D. Christofferson, MD •
Department of Cardiovascular Medicine, Cleveland Clinic,
Cleveland, OH, USA
John H. Cleator, MD •
Division of Cardiovascular Medicine, Vanderbilt University Medical
Center, Nashville, TN, USA
Kristofer Dosh, MD • Gill Heart Institute, University of Kentucky, Lexington, KY, USA
Marcus D. Flather, MBBS, FRCP •
Royal Brompton and Harefield NHS Trust, National
Heart and Lung Institute, Imperial College, London, UK
John M. Galla, MD • Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland,
OH, USA
J. Michael Gaziano, MD, MPH • Divisions of Aging, Cardiology, and Preventive
Medicine, Department of Medicine, Brigham and Women’s Hospital; Massachusetts
Veterans Epidemiology, Research and Information Center, and Geriatric Research,
Education, and Clinical Center, Veterans Healthcare System Boston; and Harvard Medical
School, Boston, MA, USA
Hitinder S. Gurm, MD • Division of Cardiovascular Medicine, The University of Michigan,
Ann Arbor, MI, USA
Carmel M. Halley, MD • Department of Cardiovascular Medicine, Cleveland Clinic,
Cleveland, OH, USA
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