Reintroduction of anticoagulant therapy after intracranial haemorrhage: If and when?

Antiplatelet Therapy for Atherothrombotic Disease in 2022—From Population to Patient-Centered Approaches

Antiplatelet agents, with aspirin and P2Y₁₂ receptor antagonists as major key molecules, are currently the cornerstone of pharmacological treatment of atherothrombotic events including a variety of cardio- and cerebro-vascular as well as peripheral artery diseases. Over the last decades, significant changes have been made to antiplatelet therapeutic and prophylactic strategies. The shift from a population-based approach to patient-centered precision medicine requires greater awareness of individual risks and benefits associated with the different antiplatelet strategies, so that the right patient gets the right therapy at the right time. In this review, we present the currently available antiplatelet agents, outline different management strategies, particularly in case of bleeding or in perioperative setting, and develop the concept of high on-treatment platelet reactivity and the steps toward person-centered precision medicine aiming to optimize patient care.

A review of anticoagulation in patients with central nervous system malignancy: between a rock and a hard place

The incidence and prevalence of patients who develop primary and secondary metastatic central nervous system cancer (CNS) is increasing. This is a consequence of advancements in the sensitivity and availability of diagnostic imaging, and improved therapeutic options, leading to increased detection of CNS malignancies and improved survival. These patients are at very high risk of thrombosis as well as haemorrhage, and the optimum management of anticoagulation can be challenging for treating clinicians, particularly as robust prospective evidence is sparse. In this focused review, we discuss (1) risk factors for thrombosis and bleeding in these patients, (2) management of acute venous thromboembolism (VTE) including evidence for direct oral anticoagulants, and how to approach patients with contraindications to anticoagulation, (3) ambulatory VTE prophylaxis, (4) VTE prophylaxis in patients who have undergone craniotomy for cancer, and (5) management of anticoagulation-related intracranial haemorrhage. Based on review of the available literature and author opinion, we propose practical management algorithms to aid clinicians faced with treating CNS cancer patients with thrombosis or CNS haemorrhage.

Indications and use of, and incidence of major bleeding with, antithrombotic agents in myelodysplastic syndrome

Myelodysplastic syndrome (MDS) and antithrombotic medication both increase the risk of bleeding. We set out to analyze the prevalence of use, indications and bleeding risk of antithrombotic therapy in patients with MDS in a retrospective, single-center study including all patients with MDS with >20 × 10⁹/L platelets. 193 patients (59% male, median age 75 years) were included; 122 did not receive antithrombotic treatment, 51 received antiplatelet agents and 20 received anticoagulants. The cumulative incidence of major bleeding was higher in both the antiplatelet group (11.8% at 4 years, 95% confidence interval [95%CI]: 4.7-22.3%) and the anticoagulation group (21.2% at 4 years, 95%CI 6-42.5%) than in the control group (2.8% at 4 years 95%CI: 0.7-7.3%). The prevalence of use of antithrombotic medication in this cohort of patients with MDS was high and bleeding risk was increased in these patients.