Optimal antiplatelet therapy for prevention of gastrointestinal injury evaluated by ANKON magnetically controlled capsule endoscopy: Rationale and design of the OPT-PEACE trial

Optimal Motion Control of a Capsule Endoscope in the Stomach Utilizing a Magnetic Navigation System with Dual Permanent Magnets

We propose a method to control the motion of a capsule endoscope (CE) in the stomach utilizing either a single external permanent magnet (EPM) or dual EPMs to extend the examination of the upper gastrointestinal tract. When utilizing the conventional magnetic navigational system (MNS) with a single EPM to generate tilting and rotational motions of the CE, undesired translational motion of the CE may prevent accurate examination. We analyzed the motion of the CE by calculating the magnetic torque and magnetic force applied to the CE using the point-dipole approximation model. Using the proposed model, we propose a method to determine the optimal position and orientation of the EPM to generate tilting and rotational motions without undesired translational motion of the CE. Furthermore, we optimized the weight of dual EPMs to develop a lightweight MNS. We prototyped the proposed MNS and experimentally verified that the developed MNS can generate tilting and rotational motions of the CE without any translational motion.

The Other Side of the Coin: Transesophageal Echocardiography Complications following Cardiac Surgery and Transcatheter Structural Heart Interventions

Transesophageal echocardiography (TEE) is widely used in cardiac surgery and interventional cardiology and is often an indispensable tool, giving supportive anatomical understanding and smooth guidance in both settings. Despite it being considered safe, fatal complications can commonly occur after a TEE examination in cardiac surgery operating rooms and catheterization laboratories. Currently, there is a lack of awareness of the scale of the problem, as there are only small amounts of data available, mainly derived from the surgical literature. This review summarizes the main predisposing factors for TEE-associated complications (classified as patient and procedure-related) and the main preventive strategies. We aim to apply preventive strategies more broadly, especially to patients at high risk of developing TEE-related serious adverse events.

Progression of Gastrointestinal Injury During Antiplatelet Therapy After Percutaneous Coronary Intervention: A Secondary Analysis of the OPT-PEACE Randomized Clinical Trial

Importance

Gastrointestinal injury progression induced by antiplatelet therapy in patients after percutaneous coronary intervention (PCI) has not been well studied.

Objective

To assess the association of aspirin, clopidogrel, and their combination with gastrointestinal injury progression among patients without high bleeding risk after PCI.

Design, Setting, and Participants

This secondary analysis assessed data from the Optimal Antiplatelet Therapy for Prevention of Gastrointestinal Injury Evaluated by ANKON Magnetically Controlled Capsule Endoscopy (OPT-PEACE) double-masked, placebo-controlled, multicenter randomized clinical trial. The OPT-PEACE trial was conducted at 28 centers in China, and recruitment took place from July 13, 2017, to July 13, 2019. The trial included patients with stable coronary artery disease or acute coronary syndromes without ST-segment elevation after PCI. Statistical analysis was conducted from September 13, 2022, to January 23, 2023.

Interventions

Patients underwent magnetically controlled capsule endoscopy (MCE) at baseline and after 6 months of dual antiplatelet therapy (DAPT) with aspirin (100 mg/d) plus clopidogrel (75 mg/d). Those with no evidence of gastrointestinal ulcers or bleeding (ie, the intention-to-treat [ITT] cohort) were randomized (1:1:1) to aspirin (100 mg/d) plus matching placebo (aspirin alone), clopidogrel (75 mg/d) plus matching placebo (clopidogrel alone), or DAPT for an additional 6 months. A third MCE was performed 12 months after PCI.

Main Outcomes and Measures

The primary outcome was the rate of gastric injury progression as assessed with the results of the 3 MCEs (at baseline, 6 months, and 12 months) in the modified intention-to-treat (mITT) population. The key secondary outcome was the rate of small-intestinal injury progression. Gastric or small-intestinal injury progression was defined as a quantitative increase in erosions or ulcers between the second and third MCEs (at 6 and 12 months, respectively).

Results

This study included the 394 patients in the mITT cohort. Their mean (SD) age was 56.9 (8.7) years, and most were men (296 [75.1%]). A total of 132 patients were randomized to aspirin alone, 132 to clopidogrel alone, and 130 to DAPT. Gastric injury progression occurred in 49 aspirin users (37.1%), 64 clopidogrel users (48.5%), and 69 DAPT users (53.1%) (P = .02), reflecting a lower rate of gastric injury progression among aspirin users vs DAPT users (risk ratio [RR], 0.70 [95% CI, 0.49-0.99]; P = .009). No significant difference was observed between clopidogrel alone and DAPT (48.5% vs 53.1%; P = .46) or between aspirin alone and clopidogrel alone (37.1% vs 48.5%; P = .06). A total of 51 aspirin users (38.6%), 65 clopidogrel users (49.2%), and 71 DAPT users (54.6%) (P = .03) developed progressive small-intestinal injury, reflecting a lower rate of small-intestinal injury among aspirin users vs DAPT users (RR, 0.71 [95% CI, 0.50-0.99]; P = .01). No difference was observed between patients treated with clopidogrel vs DAPT (49.2% vs 54.6%; P = .38) or with aspirin vs clopidogrel (38.6% vs 49.2%; P = .08).

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial, ongoing use of aspirin, clopidogrel, or their combination between 6 and 12 months after PCI was associated with progressive gastric and small-intestinal injury in a substantial proportion of patients, more so with DAPT than with monotherapy. Clopidogrel was at least as likely as aspirin to induce gastrointestinal injury progression. Future research is warranted to determine what impact the findings from MCEs would have on decision-making of antiplatelet therapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT03198741.

A systematic review on diagnosis and treatment of gastrointestinal diseases by magnetically controlled capsule endoscopy and artificial intelligence

Background

Magnetically controlled capsule endoscopy (MCCE) is a non-invasive, painless, comfortable, and safe equipment to diagnose gastrointestinal diseases (GID), partially overcoming the shortcomings of conventional endoscopy and wireless capsule endoscopy (WCE). With advancements in technology, the main technical parameters of MCCE have continuously been improved, and MCCE has become more intelligent.

Objectives

The aim of this systematic review was to summarize the research progress of MCCE and artificial intelligence (AI) in the diagnosis and treatment of GID.

Data Sources and Methods

We conducted a systematic search of PubMed and EMBASE for published studies on GID detection of MCCE, physical factors related to MCCE imaging quality, the application of AI in aiding MCCE, and its additional functions. We synergistically reviewed the included studies, extracted relevant data, and made comparisons.

Results

MCCE was confirmed to have the same performance as conventional gastroscopy and WCE in detecting common GID, while it lacks research in detecting early gastric cancer (EGC). The body position and cleanliness of the gastrointestinal tract are the main factors affecting imaging quality. The applications of AI in screening intestinal diseases have been comprehensive, while in the detection of common gastric diseases such as ulcers, it has been developed. MCCE can perform some additional functions, such as observations of drug behavior in the stomach and drug damage to the gastric mucosa. Furthermore, it can be improved to perform a biopsy.

Conclusion

This comprehensive review showed that the MCCE technology has made great progress, but studies on GID detection and treatment by MCCE are in the primary stage. Further studies are required to confirm the performance of MCCE.

Clinical guideline on magnetically controlled capsule gastroscopy (2021 edition)

With the development and generalization of endoscopic technology and screening, clinical application of magnetically controlled capsule gastroscopy (MCCG) has been increasing. In recent years, various types of MCCG are used globally. Therefore, establishing relevant guidelines on MCCG is of great significance. The current guidelines containing 23 statements were established based on clinical evidence and expert opinions, mainly focus on aspects including definition and diagnostic accuracy, application population, technical optimization, inspection process, and quality control of MCCG. The level of evidence and strength of recommendations were evaluated. The guidelines are expected to guide the standardized application and scientific innovation of MCCG for the reference of clinicians.

A novel intelligent chromo capsule endoscope for the diagnosis of neoplastic lesions in the gastrointestinal tract

Background

Chromoendoscopy has not been fully integrated into capsule endoscopy. This study aimded to develop and validate a novel intelligent chromo capsule endoscope (ICCE).

Methods

The ICCE has two modes: a white-light imaging (WLI) mode and an intelligent chromo imaging (ICI) mode. The performance of the ICCE in observing colors, animal tissues, and early gastrointestinal (GI) neoplastic lesions in humans was evaluated. Images captured by the ICCE were analysed using variance of Laplacian (VoL) values or image contrast evaluation.

Results

For color observation, conventional narrow-band imaging endoscopes and the ICI mode of the ICCE have similar spectral distributions. Compared with the WLI mode, the ICI mode had significantly higher VoL values for animal tissues (2.154 ± 1.044 vs 3.800 ± 1.491, P = 0.003), gastric precancerous lesions and early gastric cancers (2.242 ± 0.162 vs 6.642 ± 0.919, P < 0.001), and colon tumors (3.896 ± 1.430 vs 11.882 ± 7.663, P < 0.001), and significantly higher contrast for differentiating tumor and non-tumor areas (0.069 ± 0.046 vs 0.144 ± 0.076, P = 0.005). More importantly, the sensitivity, specificity, and accuracy of the ICI mode for early GI tumors were 95.83%, 91.67%, and 94.64%, respectively, which were significantly higher than the values of the WLI mode (78.33% [P < 0.001], 77.08% [P = 0.01], and 77.98% [P < 0.001], respectively).

Conclusions

We successfully integrated ICI into the capsule endoscope. The ICCE is an innovative and useful tool for differential diagnosis based on contrast-enhanced images and thus has great potential as a superior diagnostic tool for early GI tumor detection.

Epidemiology, Pathophysiology, and Management of Coronary Artery Disease in the Elderly

Elderly patients over the age of ≥ 75 years are especially susceptible to coronary artery disease (CAD) as age is an important nonmodifiable risk factors for atherosclerosis and a predictor of poorer outcomes. In fact, CAD is a major cause of mortality and morbidity in this population. Due to concerns of functional frailty, comorbidities, and patient preference of conservative to no treatment have played a role in reducing the interest in pursuing prospective studies in this high-risk group. In this review, we provide an overview of the epidemiology, pathophysiology, and management of CAD in older adults.

Efficacy and Safety of Proton Pump Inhibitors in Patients With Coronary Artery Diseases Receiving Oral Antiplatelet Agents and/or Anticoagulants: A Systematic Review and Meta-Analysis

ABSTRACT

The purpose of this meta-analysis was to evaluate the efficacy and safety of proton pump inhibitors (PPIs) plus antithrombotic strategy in patients with coronary artery diseases compared with antithrombotic strategy alone. We searched PubMed, EMBASE, Cochrane Library, and Chinese Biomedical Medical Literature databases to retrieve randomized controlled trials investigating PPIs combined with antithrombotic strategy in coronary artery diseases. The primary efficacy outcome was major adverse cardiovascular and cerebrovascular events (MACCE). The primary safety outcome was gastrointestinal events. Secondary outcomes included all-cause death, cardiovascular death, myocardial infarction, stent thrombosis, significant bleeding from gastroduodenal lesions, and gastroduodenal ulcer. Overall, 43,943 patients were enrolled from 19 trials. The incidence of MACCE [relative risk (RR) 1.05; 95% confidence interval (CI) 0.96-1.15], all-cause death (RR 0.84; 95% CI 0.69-1.01), cardiovascular death (RR 0.88; 95% CI 0.69-1.12), myocardial infarction (RR 0.98; 95% CI 0.88-1.09), stent thrombosis (RR 1.01; 95% CI 0.76-1.34), and gastroduodenal ulcer (RR 0.40; 95% CI 0.13-1.29) did not increase significantly in patients receiving PPIs compared with patients without those. There were significant differences in the risk of gastrointestinal events (RR 0.34; 95% CI 0.21-0.54) and significant bleeding from gastroduodenal lesions (RR 0.09; 95% CI 0.03-0.28) between the 2 groups. In patients with coronary artery diseases, PPIs plus antithrombotic strategy could reduce the risk of gastrointestinal events and significant bleeding from gastroduodenal lesions but may not affect the incidence of MACCE, all-cause death, cardiovascular death, myocardial infarction, stent thrombosis, and gastroduodenal ulcer (PROSPERO: CRD42021277899, date of registration October 10, 2021).

Magnetically-controlled Capsule Endoscopy for Assessment of Antiplatelet Therapy-induced Gastrointestinal Injury

BACKGROUND

Gastrointestinal bleeding is the most frequent major complication of antiplatelet therapy. In patients at low bleeding risk, however, clinically overt gastrointestinal bleeding is relatively uncommon.

OBJECTIVE

We sought to assess the effects of different antiplatelet regimens on gastrointestinal mucosal injury using a novel magnetically-controlled capsule endoscopy system in patients at low bleeding risk.

METHODS

Patients (n=505) undergoing percutaneous coronary intervention in whom capsule endoscopy demonstrated no ulcerations or bleeding (although erosions were permitted) after 6 months of dual antiplatelet therapy (DAPT) were randomly assigned to aspirin plus placebo (n=168), clopidogrel plus placebo (n=169), or aspirin plus clopidogrel (n=168) for an additional 6 months. The primary endpoint was the incidence of gastrointestinal mucosal injury (erosions, ulceration, or bleeding) at 6-month or 12-month capsule endoscopy.

RESULTS

Gastrointestinal mucosal injury through 12 months was less with single antiplatelet therapy (SAPT) compared with DAPT (94.3% vs. 99.2%, P=0.02). Aspirin and clopidogrel monotherapy had similar effects. Among 68 patients without any gastrointestinal injury at randomization (including no erosions), SAPT compared with DAPT caused less gastrointestinal injury (68.1% vs. 95.2%, P=0.006), including fewer new ulcers (8.5% vs. 38.1%, P=0.009). Clinical gastrointestinal bleeding between 6 and 12 months was less with SAPT compared with DAPT (0.6% vs. 5.4%, P=0.001).

CONCLUSIONS

Despite being at low risk of bleeding, nearly all patients receiving antiplatelet therapy developed gastrointestinal injury, although overt bleeding was infrequent. DAPT for 6 months followed by SAPT with aspirin or clopidogrel between 6 and 12 months resulted in less gastrointestinal mucosal injury and clinical bleeding compared with DAPT through 12 months.

Efficacy and Safety of Very Short-Term Dual Antiplatelet Therapy After Drug-Eluting Stents Implantation for Acute Coronary Syndrome: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Background and Objective: Dual antiplatelet therapy (DAPT) is the basis for preventing ischemic events after percutaneous coronary intervention (PCI), and DAPT for 12 months has been the standard strategy recommended by the guidelines. However, patients with acute coronary syndrome (ACS) have a higher risk of thrombosis, and the application of very short-term DAPT (1–3 months) in patients with ACS is consistently controversial. The purpose of this study is to explore the efficacy and safety of DAPT for 1–3 months in patients with ACS who were implanted with drug-eluting stents (DES).

Methods: We conducted a systematic review and meta-analysis of randomized controlled trials that compared the very short-term (3 months or less) with long-term (12 months or more) DAPT in patients with ACS after PCI. The randomized controlled trials were included by searching PubMed, EMBASE, and Cochrane Library database. The relative risk (RR) and 95% CIs for endpoint events were calculated by the fixed effects model, and trial sequential analysis was applied to calculate the anticipated sample size and assess the results.

Result: A total of eight randomized controlled trials with 16,492 patients who met the inclusion criteria were conducted. There were no significant statistic differences in myocardial infarction (RR 1.05, 0.82–1.35, P = 0.68), stents thrombosis (RR 1.32, 0.85–2.07, P = 0.22), all-cause death (RR 0.87, 0.66–1.13, P = 0.29), and target vessel revascularization (RR 0.93, 0.76–1.13, P = 0.47). However, there were significant differences in major bleeding (RR 0.60, 0.50–0.73, P < 0.00001) and the net adverse cardiac and cerebrovascular events (RR 0.84, 0.74–0.95, P = 0.007).

Conclusions: The strategy of DAPT for 1–3 months not only has a significant effect in patients with ACS who were implanted with DES but also reduces the risk of major bleeding. The scheme of short-term DAPT followed by P2Y₁₂ receptor inhibitor monotherapy is especially beneficial for patients with ACS. The results of this systematic review and meta-analysis are based on the application of new generation DES and new oral antiplatelet drugs in patients with ACS, which are difficult to use in the general population (Registered by PROSPERO, CRD 42020210520).

Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD 42020210520.