Low-Dose Aspirin Discontinuation and Risk of Cardiovascular Events

Genetic variation at the coronary artery disease risk locus GUCY1A3 modifies cardiovascular disease prevention effects of aspirin

AIMS

Efficacy of aspirin in primary prevention of cardiovascular disease (CVD) may be influenced by a common allele in guanylate cyclase GUCY1A3, which has been shown to modify platelet function and increase CVD risk.

METHODS AND RESULTS

We investigated whether homozygotes of the GUCY1A3 rs7692387 risk (G) allele benefited from aspirin in two long-term, randomized placebo-controlled trials of aspirin in primary CVD prevention: the Women's Genome Health Study (WGHS, N = 23 294) and a myocardial infarction (MI, N = 550) and stroke (N = 382) case-control set from the Physician's Health Study (PHS, N = 22 071). Bleeding risk was evaluated in the WGHS. In the placebo group of the WGHS, the GUCY1A3 risk (G) allele was confirmed to increase CVD risk [hazard ratio 1.38; 95% confidence interval (CI) 1.08-1.78; P = 0.01]. Random-effects meta-analysis of the WGHS and PHS revealed that aspirin reduced CVD events among risk allele homozygotes [G/G: odds ratio (OR) 0.79; 95% CI 0.65-0.97; P = 0.03] but increased CVD events among non-risk allele carriers (e.g. G/A: OR 1.39; 95% CI 1.03-1.87; P = 0.03) thus implying an interaction between genotype stratum and aspirin intake (Pinteraction = 0.01). Bleeding associated with aspirin increased in all genotype groups, with higher risks in heterozygotes.

CONCLUSION

In two randomized placebo-controlled trials in the setting of primary prevention, aspirin reduced the incidence of CVD events in individuals homozygous for the GUCY1A3 risk (G) allele, whereas heterozygote individuals had more events when taking aspirin.

[Decreasing cardiovascular morbidity: how to improve adherence to the treatment in the translational era]

Cardiovascular diseases are the main drivers of the morbidity and mortality in Russian Federation. We briefly discussed the poor adherence of the patients and outlined the solutions of this problem.

A Comprehensive Update on Aspirin Management During Noncardiac Surgery

Aspirin is considered critical lifelong therapy for patients with established cardiovascular (CV) disease (including coronary artery, cerebrovascular, and peripheral arterial diseases) and is consequently one of the most widely used medications worldwide. However, the indications for aspirin use continue to evolve and recent trials question its efficacy for primary prevention. Although one third of patients undergoing noncardiac surgery and at risk for a major adverse CV event receive aspirin perioperatively, uncertainty still exists about how aspirin should be optimally managed in this context, and significant practice variability remains. Recent trials suggest that the risks of continuing aspirin during the perioperative period outweigh the benefits in many cases, but data on patients with high CV risk remain limited. We performed a comprehensive PubMed and Medline literature search using the following keywords: aspirin, aspirin withdrawal, perioperative, coronary artery disease, cerebrovascular disease, peripheral artery disease, and CV disease; we manually reviewed all relevant citations for inclusion. Patients taking aspirin for the primary prevention of CV disease should likely discontinue it during the perioperative period, especially when there is a high risk of bleeding. Patients with established CV disease but without a coronary stent should likely continue aspirin during the perioperative period unless undergoing closed-space surgery. Patients with a history of coronary stenting also likely need aspirin continuation throughout the perioperative period for nonclosed space procedures. Perioperative clinicians need to balance the risks of ceasing aspirin before surgery against its continuation during the perioperative interval using a patient-specific strategy. The guidance on decision-making with regard to perioperative aspirin cessation or continuation using currently available clinical data from studies in high-risk patients along with nonclinical aspirin studies is conflicting and does not enable a simplified or unified answer. However, pertinent guidelines on CV disease management provide a basic framework for aspirin management, and large trial findings provide some insight into the safety of perioperative aspirin cessation in some contexts, although uncertainty on perioperative aspirin still exists. This review provides an evidence-based update on perioperative aspirin management in patients undergoing noncardiac surgery with a focus on recommendations for perioperative clinicians on continuing versus holding aspirin during this context.

Not all aspirin products have equivalent antiplatelet efficacy-Aspirin formulated with magnesium stearate is less effective in preventing ischemic stroke

PURPOSE

Magnesium stearate (MgSt) is a widely used excipient in pharmaceutical formulations but should be avoided in aspirin preparations as it hydrolyzes aspirin. We hypothesized that preparations of aspirin-containing MgSt (MgSt-ASA) are less effective in preventing thrombosis in clinical settings. The risk of composite cardiovascular events in patients treated with MgSt-ASA preparations for preventing secondary stroke was evaluated.

METHODS

This retrospective cohort study used Taiwan's claims data from 1997 to 2013. Patients who were discharged after ischemic stroke (IS) and administered with only MgSt-ASA or non-MgSt-ASA preparations were enrolled. Composite events including all-cause mortality, IS hospitalization, and myocardial infarction-related hospitalization in the follow-up period under therapy with MgSt-ASA or non-MgSt-ASA preparations were considered primary outcomes. Hazard ratios (HRs) were adjusted with the baseline comorbidities and medications using the Cox model.

RESULTS

A total of 19 500 patients with IS (60% males, average age 67 years) were identified, which included 2064 patients receiving MgSt-ASA treatment initially and 17 436 patients receiving non-MgSt-ASA preparation initially. The crude incidence of composite events was 11.65 per 100 person-years, whereas it was 11.45 and 13.90 per 100 person-years for patients receiving non-MgSt-ASA and MgSt-ASA treatments, respectively. The risk of composite events was higher in patients receiving MgSt-ASA preparations than in those receiving non-MgSt-ASA formulations, with the adjusted HR being 1.23 at 95% confidence interval of 1.02 to 1.47.

CONCLUSIONS

MgSt-ASA preparation use was associated with a higher risk of composite events than non-MgSt-ASA preparations. Review of aspirin formulations under regulatory intervention is warranted.

Lifelong Aspirin for All in the Secondary Prevention of Chronic Coronary Syndrome: Still Sacrosanct or Is Reappraisal Warranted?

Four decades have passed since the first trial suggesting the efficacy of aspirin in the secondary prevention of myocardial infarction. Further trials, collectively summarized by the Antithrombotic Trialists' Collaboration, solidified the historical role of aspirin in secondary prevention. Although the benefit of aspirin in the immediate phase after a myocardial infarction remains incontrovertible, a number of emerging lines of evidence, discussed in this narrative review, raise some uncertainty as to the primacy of aspirin for the lifelong management of all patients with chronic coronary syndrome (CCS). For example, data challenging the previously unquestioned role of aspirin in CCS have come from recent trials where aspirin was discontinued in specific clinical scenarios, including early discontinuation of the aspirin component of dual antiplatelet therapy after percutaneous coronary intervention and the withholding of aspirin among patients with both CCS and atrial fibrillation who require anticoagulation. Recent primary prevention trials have also failed to consistently demonstrate net benefit for aspirin in patients treated to optimal contemporary cardiovascular risk factor targets, indicating that the efficacy of aspirin for secondary prevention of CCS may similarly have changed with the addition of more modern secondary prevention therapies. The totality of recent evidence supports further study of the universal need for lifelong aspirin in secondary prevention for all adults with CCS, particularly in stable older patients who are at highest risk for aspirin-induced bleeding.

Continuation of antithrombotic therapy increases minor bleeding but does not increase the risk other morbidities in open inguinal hernia repair: A propensity score-matched analysis

PURPOSE

An aging population has led to an increased number of patients with cardiovascular comorbidities requiring antithrombotic therapy. Perioperatively, surgeons should consider the increased risk of bleeding and thrombotic events in patients continuing or discontinuing these medications. We aimed to analyze the safety of continued antithrombotic therapy during open inguinal hernia repair.

METHODS

In this single-center, retrospective study, 4870 adult patients who underwent open inguinal hernia repair surgery by the same surgeon from 2008 January to 2019 March were included. Patients who underwent surgery while continuing antithrombotic therapy were included in the antithrombin group (n = 523) while those who were not under any antithrombotic therapy during the surgery were included in the control group (n = 4333). Using propensity score-matching, we then selected patients from each group with similar backgrounds. Surgery time, anesthesia time, postoperative bleeding, reoperation, and thrombotic event data were compared between the groups. Subgroup analysis based on the type of medications used was performed within the antithrombin group.

RESULTS

Ten patients in the antithrombin group and seven patients in the control group experienced postoperative bleeding (p < 0.001). The rate of postoperative bleeding was the highest in patients taking multiple medications. However, most were managed conservatively. Three patients from the antithrombin group experienced thrombotic events postoperatively (p = 0.001).

CONCLUSIONS

Patients receiving continued antithrombotic therapy had an increased risk of minor postoperative bleeding; however, they are a high-risk group for thrombotic events.

Association of Aspirin with Hepatocellular Carcinoma and Liver-Related Mortality

BACKGROUND

More information is needed about the long-term effects of low-dose aspirin (≤160 mg) on incident hepatocellular carcinoma, liver-related mortality, and gastrointestinal bleeding in persons with chronic hepatitis B or hepatitis C virus infection.

METHODS

Using nationwide Swedish registries, we identified all adults who received a diagnosis of chronic hepatitis B or hepatitis C from 2005 through 2015 and who did not have a history of aspirin use (50,275 patients). Patients who were starting to take low-dose aspirin (14,205 patients) were identified by their first filled prescriptions for 90 or more consecutive doses of aspirin. We constructed a propensity score and applied inverse probability of treatment weighting to balance baseline characteristics between groups. Using Cox proportional-hazards regression modeling, we estimated the risk of hepatocellular carcinoma and liver-related mortality, accounting for competing events.

RESULTS

With a median of 7.9 years of follow-up, the estimated cumulative incidence of hepatocellular carcinoma was 4.0% among aspirin users and 8.3% among nonusers of aspirin (difference, -4.3 percentage points; 95% confidence interval [CI], -5.0 to -3.6; adjusted hazard ratio, 0.69; 95% CI, 0.62 to 0.76). This inverse association appeared to be duration-dependent; as compared with short-term use (3 months to <1 year), the adjusted hazard ratios were 0.90 (95% CI, 0.76 to 1.06) for 1 to less than 3 years of use, 0.66 (95% CI, 0.56 to 0.78) for 3 to less than 5 years of use, and 0.57 (95% CI, 0.42 to 0.70) for 5 or more years of use. Ten-year liver-related mortality was 11.0% among aspirin users and 17.9% among nonusers (difference, -6.9 percentage points [95% CI, -8.1 to -5.7]; adjusted hazard ratio, 0.73 [95% CI, 0.67 to 0.81]). However, the 10-year risk of gastrointestinal bleeding did not differ significantly between users and nonusers of aspirin (7.8% and 6.9%, respectively; difference, 0.9 percentage points; 95% CI, -0.6 to 2.4).

CONCLUSIONS

In a nationwide study of patients with chronic viral hepatitis in Sweden, use of low-dose aspirin was associated with a significantly lower risk of hepatocellular carcinoma and lower liver-related mortality than no use of aspirin, without a significantly higher risk of gastrointestinal bleeding. (Funded by the National Institutes of Health and others.).

Exercise-Related Acute Cardiovascular Events and Potential Deleterious Adaptations Following Long-Term Exercise Training: Placing the Risks Into Perspective-An Update: A Scientific Statement From the American Heart Association

Epidemiological and biological plausibility studies support a cause-and-effect relationship between increased levels of physical activity or cardiorespiratory fitness and reduced coronary heart disease events. These data, plus the well-documented anti-aging effects of exercise, have likely contributed to the escalating numbers of adults who have embraced the notion that "more exercise is better." As a result, worldwide participation in endurance training, competitive long distance endurance events, and high-intensity interval training has increased markedly since the previous American Heart Association statement on exercise risk. On the other hand, vigorous physical activity, particularly when performed by unfit individuals, can acutely increase the risk of sudden cardiac death and acute myocardial infarction in susceptible people. Recent studies have also shown that large exercise volumes and vigorous intensities are both associated with potential cardiac maladaptations, including accelerated coronary artery calcification, exercise-induced cardiac biomarker release, myocardial fibrosis, and atrial fibrillation. The relationship between these maladaptive responses and physical activity often forms a U- or reverse J-shaped dose-response curve. This scientific statement discusses the cardiovascular and health implications for moderate to vigorous physical activity, as well as high-volume, high-intensity exercise regimens, based on current understanding of the associated risks and benefits. The goal is to provide healthcare professionals with updated information to advise patients on appropriate preparticipation screening and the benefits and risks of physical activity or physical exertion in varied environments and during competitive events.

Effect of topical tranexamic acid in total hip arthroplasty patients who receive continuous aspirin for prevention of cardiovascular or cerebrovascular events: A prospective randomized study

BACKGROUND

Due to differences in pharmacological mechanism of action, the effect of tranexamic acid (TA) on aspirin-related bleeding remains unknown. We therefore conducted a prospective randomized study to elucidate: (1) the effect of topical TA administration on blood loss and transfusion rate in total hip arthroplasty (THA) patients receiving continuous aspirin for prevention of cardiovascular or cerebrovascular events; (2) 90-day complications of topical TA administration; (3) possible variables contributing to blood transfusion.

HYPOTHESIS

Topical TA administration reduces blood loss and transfusion rate in THA patients receiving continuous aspirin.

PATIENTS AND METHODS

A total of 102 consecutive THA patients taking continuous aspirin were enrolled and randomized into two groups. In the topical TA (TTA) group (n=55), topical TA was administered at three points during THA; in the control group (n=47), the patients received saline solution as placebo. Based on drop in hemoglobin concentration, total estimated blood loss was calculated as the main assessment criterion. Secondary assessment criteria included transfusion rate and 90-day complications. Finally, a multivariate regression model was used to assess possible predictive factors for blood transfusion.

RESULTS

(1) Significantly lower total blood loss was observed in the TTA group than in the control group (897±177ml vs. 1153±345ml, p<0.001). Furthermore, lower transfusion rate was observed in the TTA group than in the control group (10.9% vs. 34.0%, p=0.005). (2) No significant difference was observed between the two groups regarding 90-day complications. (3) We identified higher preoperative hemoglobin level (OR=0.675, p=0.002) and topical TA administration (OR=0.002, p=0.012) as negative predictive factors for blood transfusion.

DISCUSSION

Topical application of TA was safe and beneficial in THA patients receiving continuous aspirin for prevention of cardiovascular or cerebrovascular events, to reduce blood loss and transfusion rate, without increasing the risk of 90-day complications.

Aspirin in primary prevention: the triumph of clinical judgement over complex equations

Aspirin, in 2017, has celebrated its 120th birthday. The efficacy and safety of low-dose aspirin in secondary prevention of cardiovascular disease is well supported by many studies, instead in primary prevention it remains controversial, especially in the aftermath of the publication in 2018 of three novel primary prevention randomized clinical trials, showing that the benefit of low-dose aspirin, although additive to that of statin, is counterbalanced by an excess of (mainly gastrointestinal) bleeding events. The signal for a net benefit seems to be even more controversial in the elderly starting aspirin after the age of 70 years. While international guidelines have promptly downgraded their recommendations to more conservative indications, the practicing clinician is called to make the effort to individualize the treatment, after careful evaluation of the haemorrhagic risk vis-a-vis the risk to develop, in the mid-term and long-term follow-up, major cardiovascular events or cancer. This is a particularly complex task, given the different immediate and long-term impact of diverse outcomes on health, the dynamic nature over time of the benefit/risk balance, prompting periodic re-assessments of its indication, and the interindividual variability in aspirin response. The chemopreventive properties of aspirin, anticipated by a large body of epidemiological and mechanistic evidence, are awaiting their final confirmation by the long-term follow-up of the latest trials specifically designed to assess this endpoint, with the expectation to subvert the delicate benefit/risk balance of aspirin in primary prevention. This review is intended to provide an interpretation of past and current evidence to guide clinical decision making on the contemporary patient.

Trajectories of Adherence to Low-Dose Aspirin Treatment Among the French Population

BACKGROUND

Previous studies have shown that adherence to low-dose aspirin (LDA) is suboptimal. However, these studies were based on an average measure of adherence during follow-up, ignoring its dynamic process over time. We described the trajectories of adherence to LDA treatment among the French population over 3 years of follow-up.

METHODS

We identified a cohort of 11 793 new LDA users, aged ≥50 years in 2010, by using the French national health-care database. Patients included had at least 3 years of history in the database before study entry to exclude prevalent aspirin users and to assess baseline comorbidities. They were followed from the first date of LDA supply (the index date) until the first date among death, exit from the database, or 3 years after the index date. Adherence to LDA was assessed every 3 months by using the proportion of days covered (PDC) and dichotomized with a cutoff of PDC of 0.8. We used group-based trajectory modeling to identify trajectories of LDA adherence. Predictors of LDA adherence trajectory membership were identified by multinomial logistics regression.

RESULTS

We identified 4 trajectories of adherence among new LDA users: the not-adherents (4737 [40.2%]), the delayed not-adherents (gradual decrease in adherence probability, 1601 [13.6%]), the delayed adherents (gradual increase in adherence probability, 1137 [9.6%]), and the persistent adherents (4318 [36.6%]). The probability of belonging to the not-adherent group was increased with female sex, low socioeconomic status, and polymedication and was reduced with a secondary indication for LDA use, such as diabetes, hypertension, and dementia, at least 4 consultations in the previous year, or 1 hospitalization or a cardiologist consultation in the 3 months before the index date.

CONCLUSION

This study provides a dynamic picture of adherence behaviors among new LDA users and underlines the presence of critical trajectories that intervention could target to improve adherence.

An aspirin a day? Clinical utility of aspirin therapy for the primary prevention of cardiovascular disease

Introduction: Cardiovascular disease remains a leading cause of morbidity and mortality. Since the description of its therapeutic potential, aspirin has been a cornerstone of therapy following vascular events. However, aspirin in the primary prevention setting is controversial and major guideline groups provide inconsistent recommendations. Thus, there is variability in practice as providers are faced with a balance of therapeutic benefit and drug-induced harm. Areas covered: This article provides a critical appraisal of both past and present data for aspirin in the primary prevention setting. PubMed and Cochrane Central Register databases were searched from inception to May 1^st, 2019. Expert opinion: The decision to initiate or withdraw aspirin for primary prevention requires an understanding of the equilibrium between efficacy and safety. In adults greater than 70 years of age, low to moderate cardiovascular risk, controlled diabetes, or at high risk of bleeding, initiation of aspirin for primary prevention should generally be avoided. Instead, risk factor modification should be prioritized. The net benefit of aspirin in those at high risk for cardiovascular disease and in those with uncontrolled diabetes is largely unknown. Ultimately, initiation or withdrawal of aspirin therapy must involve discussion of the patient's wishes and treatment expectations.

Frequency of Bleeding Complications After Percutaneous Core Needle Biopsy and the Association With Aspirin Usage and Length of Aspirin Discontinuation

OBJECTIVE. The purpose of this study is to report the frequency of major bleeding after percutaneous image-guided core biopsy and its association with aspirin usage and duration of prebiopsy aspirin abstinence. MATERIALS AND METHODS. A retrospective review of percutaneous image-guided core biopsies performed at our institution between September 1, 2005, and September 1, 2016, was performed (n = 30,966). Patients were excluded if aspirin usage data were missing (n = 633). Bleeding complications were defined using the Common Terminology Criteria for Adverse Events and were considered significant if they were grade 3 or higher. Multivariate models were adjusted for age, sex, platelet count, international normalized ratio, and biopsy target. Three categorizations of aspirin use were examined: any use within 10 days before biopsy, duration of abstinence (> 10 days or no aspirin, 8-10 days, 4-7 days, and 0-3 days before biopsy), and use on the day of biopsy. Associations with bleeding complications were modeled using logistic regression models. A p < 0.05 was considered significant. RESULTS. The study included 30,333 biopsies in 21,938 subjects (57% male; median age, 60 years; interquartile range, 49-70 years). Of the biopsies, 7921 (26.1%) were performed in patients who received aspirin within 10 days of biopsy, and 3761 (47.5%) of those biopsies were performed in patients who took aspirin within 3 days. Ninety-eight (0.32%) significant bleeding complications occurred overall, including 34 (0.43%) in patients who used aspirin within 10 days before biopsy (odds ratio, 1.5; 95% CI, 0.96-2.3; p = 0.08). Duration of abstinence was associated with a significantly increased bleeding risk only between 0-3 days versus more than 10 days or no aspirin (odds ratio, 2.1; 95% CI, 1.3-3.6; p = 0.004). Aspirin use on the day of biopsy showed the greatest increase in risk (1.9%; odds ratio, 6.6; 95% CI, 3.8-11.5; p < 0.001). CONCLUSION. Significant bleeding complications after biopsy remain rare even among patients with recent aspirin usage, although shorter duration of prebiopsy abstinence increases bleeding risk, most significantly if aspirin is taken the day of biopsy.

Aspirin in people with diabetes: Time to clean up the prescription list?

The effect of aspirin in primary cardiovascular (CV) prevention in people with diabetes is still a matter of debate. Recent results of ASCEND trial suggest that the absolute benefit on CV events is largely counter-balanced by the bleeding risk. However, one crucial question is whether aspirin should be maintained or withdrawn from the prescription list of those who are already under this therapy since a while ago. Indeed, large epidemiological data reported that the aspirin discontinuation was associated to an increased risk of CV events. Moreover, besides the CV outcome, potential positive impact of aspirin on cancer is still under investigation. To conclude, there is no more systematic indication for aspirin in people with diabetes free of CV disease, especially when diabetes and all other CV risk factors are optimally controlled. For those already on aspirin, data are not conclusive enough for a systematic approach and benefit/risk balance must be discussed with patients to take a shared decision.

Metamizole inhibits arachidonic acid-induced platelet aggregation after surgery and impairs the effect of aspirin in hospitalized patients

PURPOSE

The inhibitory effect of metamizole on platelet aggregation is known for several years, but most studies were conducted in healthy volunteers with contradictory results. Recent studies have shown an inhibitory effect of metamizole on acetylsalicylic acid (ASA)-induced platelet aggregation. We aimed to investigate the effect of metamizole on platelet aggregation after an elective surgery and the effect of metamizole on ASA-induced platelet aggregation in hospitalized patients.

METHODS

We performed platelet aggregation analysis after induction with ADP, arachidonic acid (AA), epinephrine, and collagen in 37 patients prior to an elective visceral or thoracic surgery and on postoperative day (POD) 1 and POD 3 1-2 h and 5-6 h after metamizole. In another cohort of 10 hospitalized patients receiving the combination of metamizole and ASA for more than 7 days, AA-induced platelet aggregation was analyzed in the morning prior to the intake of both drugs.

RESULTS

Metamizole induced a strong inhibitory effect on AA-induced platelet aggregation at all time points being detectable up to 41 h in some patients. Besides a less pronounced effect on collagen-induced platelet aggregation on POD 3 1-2 h after metamizole, all other inductors showed no effect. In 4 out of 10 hospitalized patients, no ASA-induced inhibition of platelet aggregation was detectable without correlation to sequence of administration.

CONCLUSIONS

The reason why some patients have a long-lasting inhibitory effect of metamizole on COX-induced platelet aggregation that might interfere with ASA should be investigated in a larger cohort of patients.

Aspirin to Prevent Sudden Cardiac Death in Athletes with High Coronary Artery Calcium Scores

While proficient cardiac resuscitation has improved survival following cardiac arrest during road races in Japan, this accomplishment does not address coronary artery disease as the underlying cause of an increasing frequency of cardiac arrest in middle-aged men during marathons and ironman triathlons in the United States since the year 2000. Based on the high prevalence of subclinical coronary artery disease by cardiac computed tomography in endurance athletes with low conventional cardiac risk-factor profiles, we recommend coronary artery calcium scores as a more reliable and independent predictor of incident cardiac events, including death, as validated among adults aged 30-46 years. Scores of over 100 Agatston units indicate a 10-year cardiac risk of 7.5%, at which additional measures for primary prevention are recommended, including aspirin, as shown conclusively to reduce first myocardial infarctions in same-aged men in a prospective double-blind controlled trial. Targeted screening for subclinical coronary atherosclerosis with coronary artery calcium scores is prudent to guide appropriately dosed aspirin use to mitigate the increasing frequency of sports-related sudden cardiac death due to plaque rupture.

Diabetes and Vascular Disease: Is It All About Glycemia?

BACKGROUND

Diabetes is increasing over time, mainly driven by obesity, aging, and urbanization. Classical macro- and microvascular complications represent the final result of a complex interplay involving atherosclerosis at all stages.

METHODS

In this review, we aim at focusing on current updates in the pathophysiology of vascular disease in diabetes and discussing how new therapies might influence the management of these patients at high cardiovascular risk. Diabetes shows accelerated atherosclerosis with a larger inflammatory cell infiltrate, thus favoring the development of heart failure. 'Diabetic cardiomyopathy' perfectly describes a specific ischemia- and hypertension- independent entity due to diabetes-related metabolic alterations on myocardial function. Moreover, platelets from subjects with diabetes display a typical hyperreactivity explaining the stronger adhesion, activation, and aggregation. Additionally, diabetes provokes an exaggerated stimulation of the endothelium, with an increased release of reactive oxygen species and a reduced release of nitric oxide, both key elements of the endothelial dysfunction. Also, the coagulation cascade and leukocytes activate contributing to this pro-thrombotic environment. Neutrophils have been recently recognized to play a pivotal role by releasing neutrophil extracellular traps. Finally, microparticles from platelets, neutrophils or monocytes are detrimental effectors on the vessel wall and are involved both in vascular dysfunction and in thrombotic complications.

CONCLUSION

In light of these findings, the therapeutic management of diabetes needs to be mostly focused on limiting the progression of complications by targeting precise pathophysiological mechanisms rather than the mere glycemic control, which failed to markedly reduce the risk for macrovascular complications and mortality.

The Cytotoxicity and Synergistic Potential of Aspirin and Aspirin Analogues Towards Oesophageal and Colorectal Cancer

Background

Oesophageal cancer (OC) is a deadly cancer because of its aggressive nature with survival rates that have barely improved in decades. Epidemiologic studies have shown that low-dose daily intake of aspirin can decrease the incidence of OC.

Methods

The toxicity of aspirin and aspirin derivatives to OC and a CRC cell line were investigated in the presence and absence of platins.

Results

The data in this study show the effects of a number of aspirin analogues and aspirin on OC cell lines that originally presented as squamous cell carcinoma (SSC) and adenocarcinoma (ADC). The aspirin analogues fumaryldiaspirin (PN517) and the benzoylsalicylates (PN524, PN528 and PN529), were observed to be more toxic against the OC cell lines than aspirin. Both quantitative and qualitative apoptosis experiments reveal that these compounds largely induce apoptosis, although some necrosis was evident with PN528 and PN529. Failure to recover following the treatment with these analogues emphasized that these drugs are largely cytotoxic in nature. The OE21 (SSC) and OE33 (ADC) cell lines were more sensitive to the aspirin analogues compared to the Flo-1 cell line (ADC). A non-cancerous oesophageal primary cells NOK2101, was used to determine the specificity of the aspirin analogues and cytotoxicity assays revealed that analogues PN528 and PN529 were selectively toxic to cancer cell lines, whereas PN508, PN517 and PN524 also induced cell death in NOK2101. In combination index testing synergistic interactions of the most promising compounds, including aspirin, with cisplatin, oxaliplatin and carboplatin against the OE33 cell line and the SW480 colorectal cancer (CRC) cell line were investigated. Compounds PN517 and PN524, and to a lesser extent PN528, synergised with cisplatin against OE33 cells. Cisplatin and oxaliplatin synergised with aspirin and PN517 when tested against the SW480 cell line.

Conclusion

These findings indicate the potential and limitations of aspirin and aspirin analogues as chemotherapeutic agents against OC and CRC when combined with platins

Renal biopsy: it is time for pragmatism and consensus

To obtain truly informed consent, we must be able to advise our patients accurately about the relative risk and benefit of any treatment plan. Percutaneous renal biopsy remains the gold standard investigation in the evaluation of intrinsic renal disease. There have been significant improvements in practice over the past decades with regards to percutaneous renal biopsy. Across centres, we appear now to have reached agreement on many aspects of this procedure, such as the need for blood pressure control, avoidance of coagulopathy, use of spring-loaded needles under direct imaging guidance and a need to monitor for complications. The authors from Rush University Medical Centre provide reassurance that renal biopsy in the modern era remains a safe procedure with a low rate of significant bleeding. There remain areas of divergence in practice that may have unintended and deleterious consequences: administration of desmopressin and discontinuation of aspirin, for example, both carry a risk of thrombosis. It is our opinion that it is time to reach consensus on our interpretation of the available data and to draw up guidelines to standardize our biopsy practice internationally.

A review and study of aspirin utilization for the primary prevention of cardiovascular events in a psychiatric population

In April 2016, the US Preventive Service Task Force (USPSTF) updated the aspirin guidelines for the primary prevention of cardiovascular disease (CVD) and colorectal cancer. This review assesses the importance of appropriate use of aspirin for the primary prevention of CVD and, specifically, how individuals with psychiatric disorders may benefit from such use. This study examined how current prescribing practices of aspirin in a state psychiatric hospital align with these new guidelines and how inappropriate prescribing may jeopardize patient safety. A retrospective chart review of 93 patients was performed to evaluate whether aspirin therapy would be recommended for primary prevention of CVD based on the new USPSTF guidelines. A secondary analysis of these data was performed using the 2009 USPSTF recommendations to strengthen the assumption that practitioners were no longer using the old guidelines. Drug interactions between aspirin and concurrently prescribed pharmacotherapy were classified based on of severity, and the past events of bleeding were quantified. Based on the 2016 guidelines, 25 of the 93 patients included in this study were identified as potential candidates who would benefit from aspirin use for the primary prevention of CVD; of whom 22 (88%) were not prescribed aspirin. The remaining 68 patients did not meet the criteria for aspirin use for primary prevention, although 11 (16.2%) of these patients were taking low-dose aspirin. Based on the 2009 guidelines, 49 of the 93 patients included in our study would have been identified as potential candidates who would benefit from the use of aspirin for the primary prevention of CVD; 41 (83.7%) of whom were not prescribed aspirin. The remaining 44 patients did not meet the previous criteria for aspirin use for primary prevention, although six (13.6%) of these individuals were taking low-dose aspirin daily. The results above indicate a difference between prescribing practices of aspirin use for the primary prevention of CVD. We identified a similar rate of underuse; however, there was a slight increase in the appropriate prescribing according to the 2016 guidelines compared with the 2009 guidelines (88 vs. 83.7%, respectively). Also, there was a higher incidence of unnecessary prescribing (overutilization) of aspirin for the primary prevention of CVD in 2016 compared with 2009 despite the more restrictive criteria (and smaller candidate pool) published in these newer guidelines. There were 47 drug interactions identified when patients' aspirin and concurrent medication regimens were reviewed for our entire sample population. These interactions could potentially lead to an adverse drug reaction in the future. Our safety analysis revealed that none of the patients who were prescribed aspirin had any bleeding events while on therapy within the period of this study. Inappropriate omission of aspirin (underutilization) was more prevalent in our psychiatric institution than overutilization; however, the overall percentage of both underuse and overuse were greater when patients were evaluated according to the 2016 guidelines and then compared with the 2009 statistics. Overutilization did not pose a serious risk for those on aspirin therapy in this sample, as there were no major episodes of bleeding. However, future harm from aspirin still exists based on the significant number of major and moderate potential drug interactions with aspirin and the increased risk of decreased adherence to critical psychiatric medications due to increased pill burden and regimen complexity. Our findings demonstrate that there is an opportunity to educate prescribers on the updated 2016 USPSTF guidelines to improve preventive care and patient safety, which include harm reduction by initiating aspirin in those who are at a risk of cardiovascular events, continuing aspirin in those who are currently receiving aspirin appropriately, and discontinuing aspirin in those who are not considered to be at a high risk of CVD and who may also be at a risk of experiencing an increased risk of bleeding.

Aspirin Increases the Risk of Nondiagnostic Yield of Fine-Needle Aspiration and Biopsy of Thyroid Nodules

BACKGROUND

The link between the diagnostic yield of thyroid fine-needle aspiration and biopsy (FNAB) in patients taking antithrombotic or anticoagulant medications (AT/AC) remains poorly characterized.

OBJECTIVES

We studied the risk of obtaining a nondiagnostic sample with ultrasound-guided thyroid FNAB in patients taking AT/AC medications.

METHODS

This is a retrospective cohort study using medical rec-ords of 556 patients who underwent thyroid FNAB. All cytology samples were reported using the Bethesda classification. For patients with a nondiagnostic cytology, logistic regression was used to calculate OR for patients taking AT/AC medications. Multivariate regression was used to adjust for potential confounding variables including age, cystic ultrasound features, presence of eggshell calcifications, number of passes performed, cystic aspirate on FNAB, and position of the nodule.

RESULTS

Out of 556 patients, cytology results were available for 547 patients. Of these, 46 subjects were taking aspirin and 1 was on warfarin. Among the entire cohort, 17.5% of the subjects had a nondiagnostic cytology. Among the patients on AT/AC medications, 34% had a nondiagnostic result compared to 16% for those not taking them (OR = 2.70, p = 0.003). The subgroup of patients taking aspirin had similarly higher odds of a nondiagnostic cytology (OR = 2.78, p = 0.002). These differences remained statistically significant after multivariate adjustment.

CONCLUSIONS

This is the first study to demonstrate a 3-fold independently greater risk of a nondiagnostic FNAB cytology in patients taking aspirin. Our results highlight the importance of evaluating the need for continuation of aspirin in patients undergoing thyroid FNAB as this may impact the diagnostic yield of the procedure.

[Direct oral anticoagulants (DOACS): A necessary focus]

In 2008, we decided to enter the era of direct oral anticoagulants (DOACS). Was that the right decision to make? The answer will depend on how well we meet the conditions of proper use. This means avoiding underdosing and overdosing as well as understanding how DOACS were validated so that our prescriptions fulfill their role in the management of thrombotic disease.