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Laudani C, Capodanno D, Angiolillo DJ. Bleeding in acute coronary syndrome: from definitions, incidence, and prognosis to prevention and management. Expert Opin Drug Saf 2023; 22:1193-1212. [PMID: 38048099 DOI: 10.1080/14740338.2023.2291865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION In patients with acute coronary syndrome (ACS), the ischemic benefit of antithrombotic treatment is counterbalanced by the risk of bleeding. The recognition that bleeding events have prognostic implications (i.e. mortality) similar to recurrent ischemic events led to the development of treatment regimens aimed at balancing both ischemic and bleeding risks. AREAS COVERED This review aims at describing definitions, incidence, and prognosis related to bleeding events in ACS patients as well as bleeding-avoidance strategies for their prevention and management of bleeding complications. EXPERT OPINION Management of ACS patients has witnessed remarkable progress after the shift in focusing on the trade-off between ischemia and bleeding. Efforts in standardizing bleeding definitions will allow for better defining the prognostic impact of different types of bleeding events and enable to identify the high-bleeding risk patient. Such efforts will allow to balance the trade-off between the thrombotic and bleeding risk of the individual patient translating into better downward diagnostic and therapeutic decision-making. Novel strategies aiming at maximizing the safety and efficacy of antithrombotic regimens as well as the development of novel antithrombotic drugs and reversal agents and technological advances will allow for optimization of bleeding-avoidance strategies and management of bleeding complications.
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Affiliation(s)
- Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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Abstract
INTRODUCTION Platelets play a key role in arterial thrombosis and antiplatelet therapy is pivotal in the treatment of cardiovascular disease. Current antiplatelet drugs target different pathways of platelet activation and show specific pharmacodynamic and pharmacokinetic characteristics, implicating clinically relevant drug-drug interactions. AREAS COVERED This article reviews the role of platelets in hemostasis and cardiovascular thrombosis, and discusses the key pharmacodynamics, drug-drug interactions and reversal strategies of clinically used antiplatelet drugs. EXPERT OPINION Antiplatelet therapies target distinct pathways of platelet activation: thromboxane A2 synthesis, adenosine diphosphate-mediated signaling, integrin αIIbβ3 (GPIIb/IIIa), thrombin-mediated platelet activation via the PAR1 receptor and phosphodiesterases. Key clinical drug-drug interactions of antiplatelet agents involve acetylsalicylic acid - ibuprofen, clopidogrel - omeprazole, and morphine - oral P2Y12 inhibitors, all of which lead to an attenuated antiplatelet effect. Platelet function and genetic testing and the use of scores (ARC-HBR, PRECISE-DAPT, ESC ischemic risk definition) may contribute to a more tailored antiplatelet therapy. High on-treatment platelet reactivity presents a key problem in the acute management of ST-elevation myocardial infarction (STEMI). A treatment strategy involving early initiation of an intravenous antiplatelet agent may be able to bridge the gap of insufficient platelet inhibition in high ischemic risk patients with STEMI.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Sperry JD, Rose AE, Williams E, Dierks MR, Medow JE. Emergent Reversal of Antithrombotics and Treatment of Life-Threatening Bleeding from Coagulopathies: A Clinical Review. J Emerg Med 2022; 63:17-48. [PMID: 35918220 DOI: 10.1016/j.jemermed.2022.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/29/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Reversal of antithrombotic agents and treatment of life-threatening bleeding episodes from coagulopathies can be a stressful scenario for clinicians, especially when the selection of treatment options should occur quickly. Understanding the options available for these agents requires emergency physicians to be familiar with the current data surrounding new therapies and dosing strategies for the treatment of bleeding from reversible and nonreversible antithrombotics and coagulopathic conditions. OBJECTIVE To provide quick resource guides for the reversal of major or life-threatening bleeding caused by antithrombotic agents or in the setting of coagulopathies. METHODS A literature search for articles published through September 2021 related to antithrombotic reversal and treatment of acute bleeding from coagulopathies was conducted using the PubMed clinical database. Selected articles were used to generate 5 guidance tables in this clinical review. DISCUSSION Four guidance tables for how to treat major or life-threatening bleeding from antithrombotic agents and 1 table for how to manage life-threatening bleeding for coagulopathies are presented as a quick reference tool for the emergency physician. Additional information on upcoming reversal agents and possible treatment options are provided herein. CONCLUSIONS In this clinical review, a series of 5 tables were created to provide quick and comprehensive guidance for the emergency physician when treating major or life-threatening bleeding caused by antithrombotic agents or coagulopathies. © 2022 Elsevier Inc.
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Affiliation(s)
- Jeffrey D Sperry
- Department of Pharmacy, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Anne E Rose
- Department of Pharmacy, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Eliot Williams
- Department of Hematology, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Matthew R Dierks
- Department of Pharmacy, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Joshua Eric Medow
- Department of Neurosurgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
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Ha ACT, Bhatt DL, Rutka JT, Johnston SC, Mazer CD, Verma S. Intracranial Hemorrhage During Dual Antiplatelet Therapy: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78:1372-1384. [PMID: 34556323 DOI: 10.1016/j.jacc.2021.07.048] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 12/19/2022]
Abstract
Dual antiplatelet therapy (DAPT) with acetylsalicylic acid and a P2Y12 inhibitor is an established therapy for a broad spectrum of patients with cardiovascular disease. The ischemic benefit of DAPT is partially offset by its increased bleeding risk, with intracranial hemorrhage (ICH) being the most serious complication. Although uncommon (0.2%-0.3% annually), its cumulative burden can be substantial given the number of patients afflicted by cardiovascular disease worldwide. Patients with a history of stroke or transient ischemic attack harbor a particularly high risk for ICH when treated with DAPT. Prediction rules may assist clinicians when weighing the risk/benefit ratio of prescribing DAPT for patients with stroke/transient ischemic attack in the nonacute, ambulatory setting. Currently, there are no reversal agents that can rapidly and effectively reverse the effect of P2Y12 inhibitors in routine practice, although a reversal agent for ticagrelor is under clinical investigation.
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Affiliation(s)
- Andrew C T Ha
- University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, USA.
| | - James T Rutka
- University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - S Claiborne Johnston
- The Dean's Office, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - C David Mazer
- University of Toronto, Toronto, Ontario, Canada; St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Subodh Verma
- University of Toronto, Toronto, Ontario, Canada; St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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Sumann G, Moens D, Brink B, Brodmann Maeder M, Greene M, Jacob M, Koirala P, Zafren K, Ayala M, Musi M, Oshiro K, Sheets A, Strapazzon G, Macias D, Paal P. Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel. Scand J Trauma Resusc Emerg Med 2020; 28:117. [PMID: 33317595 PMCID: PMC7737289 DOI: 10.1186/s13049-020-00790-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments. Objective To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments. Eligibility criteria All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms. Sources of evidence PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles. Charting methods Evidence was searched according to clinically relevant topics and PICO questions. Results Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland. Conclusions Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.
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Affiliation(s)
- G Sumann
- Austrian Society of Mountain and High Altitude Medicine, Emergency physician, Austrian Mountain and Helicopter Rescue, Altach, Austria
| | - D Moens
- Emergency Department Liège University Hospital, CMH HEMS Lead physician and medical director, Senior Lecturer at the University of Liège, Liège, Belgium
| | - B Brink
- Mountain Emergency Paramedic, AHEMS, Canadian Society of Mountain Medicine, Whistler Blackcomb Ski Patrol, Whistler, Canada
| | - M Brodmann Maeder
- Department of Emergency Medicine, University Hospital and University of Bern, Switzerland and Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - M Greene
- Medical Officer Mountain Rescue England and Wales, Wales, UK
| | - M Jacob
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Hospitallers Brothers Saint-Elisabeth-Hospital Straubing, Bavarian Mountain Rescue Service, Straubing, Germany
| | - P Koirala
- Adjunct Assistant Professor, Emergency Medicine, University of Maryland School of Medicine, Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | - K Zafren
- ICAR MedCom, Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA.,Alaska Native Medical Center, Anchorage, AK, USA
| | - M Ayala
- University Hospital Germans Trias i Pujol, Badalona, Spain
| | - M Musi
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - K Oshiro
- Department of Cardiovascular Medicine and Director of Mountain Medicine, Research, and Survey Division, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - A Sheets
- Emergency Department, Boulder Community Health, Boulder, CO, USA
| | - G Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,The Corpo Nazionale Soccorso Alpino e Speleologico, National Medical School (CNSAS SNaMed), Milan, Italy
| | - D Macias
- Department of Emergency Medicine, International Mountain Medicine Center, University of New Mexico, Albuquerque, NM, USA
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria.
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Andersen LK, Hvas AM, Hvas CL. Effect of Desmopressin on Platelet Dysfunction During Antiplatelet Therapy: A Systematic Review. Neurocrit Care 2020; 34:1026-1046. [PMID: 32748210 DOI: 10.1007/s12028-020-01055-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 07/16/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE An increasing number of patients receive antiplatelet therapy. Patients exposed to surgery while receiving platelet inhibitors hold an increased bleeding risk. Especially in neurosurgery and neurocritical care patients, bleeding and hematoma expansion are feared complications as even minor bleedings may be hazardous. The objective of this systematic review was to investigate the effect of desmopressin (1-deamino-8-D-arginine vasopressin, DDAVP) on platelet function during antiplatelet therapy in patients undergoing non-cardiac surgery, patients who experience spontaneous or traumatic hemorrhage, healthy individuals and in animals. METHODS Studies were identified through a systematic literature search in PubMed and EMBASE on August 19, 2019, with an update on May 2, 2020, and from reference lists of the included studies. Data on clinical and biochemical effect of DDAVP were extracted from included studies for a qualitative data synthesis. RESULTS In total, 22 studies were included: 18 human studies and four animal studies. Overall, DDAVP improved bleeding time and increased platelet aggregation in patients undergoing non-cardiac surgery, patients suffering intracerebral or subarachnoid hemorrhage while receiving antiplatelet therapy as well as in healthy individuals and animals exposed to antiplatelet therapy. Observational data indicate that DDAVP may mitigate hematoma expansion in patients with intracerebral hemorrhage or traumatic brain injury. CONCLUSIONS The present data hold biochemical evidence that DDAVP improves platelet function during antiplatelet therapy in humans and animals. The need for randomized trials is evident in order to evaluate the potential clinical effect of DDAVP in management of patients with spontaneous or traumatic hemorrhage, or undergoing neurosurgery, while receiving antiplatelet therapy.
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Affiliation(s)
- Lise Kjær Andersen
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.
| | - Christine Lodberg Hvas
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
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Management of Bleeding Events Associated with Antiplatelet Therapy: Evidence, Uncertainties and Pitfalls. J Clin Med 2020; 9:jcm9072318. [PMID: 32708228 PMCID: PMC7408739 DOI: 10.3390/jcm9072318] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 11/16/2022] Open
Abstract
Bleeding complications are common in patients treated with antiplatelet agents (APA), but their management relies on poor evidence. Therefore, practical guidelines and guidance documents are mainly based on expert opinion. The French Working Group on Perioperative Haemostasis provided proposals in 2018 to enhance clinical decisions regarding the management of APA-treated patients with a bleeding event. In light of these proposals, this review discusses the evidence and uncertainties of the management of patients with a bleeding event while on antiplatelet therapy. Platelet transfusion is the main option as an attempt to neutralise the effect of APA on primary haemostasis. Nevertheless, efficacy of platelet transfusion to mitigate clinical consequences of bleeding in patients treated with APA depends on the type of antiplatelet therapy, the time from the last intake, the mechanism (spontaneous versus traumatic) and site of bleeding and the criteria of efficacy (in vitro, in vivo). Specific antidotes for APA neutralisation are needed, especially for ticagrelor, but are not available yet. Despite the amount of information that platelet function tests are expected to give, little data support the clinical benefit of using such tests for the management of bleeding events in patients treated or potentially treated with APA.
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Retrospective Assessment of Desmopressin Effectiveness and Safety in Patients With Antiplatelet-Associated Intracranial Hemorrhage. Crit Care Med 2020; 47:1759-1765. [PMID: 31567345 DOI: 10.1097/ccm.0000000000004021] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Current international guidelines offer a conditional recommendation to consider a single dose of IV desmopressin (DDAVP) for antiplatelet-associated intracranial hemorrhage based on low-quality evidence. We provide the first comparative assessment analyzing DDAVP effectiveness and safety in antiplatelet-associated intracranial hemorrhage. DESIGN Retrospective chart review. SETTING Single tertiary care academic medical center. PATIENTS Adult patients taking at least one antiplatelet agent based on presenting history and documented evidence of intracranial hemorrhage on cerebral CT scan were included. Patients were excluded for the following reasons: repeat cerebral CT scan not performed within the first 24 hours, noncomparative repeat cerebral CT scan, chronic anticoagulation, administration of fibrinolytic medications, concurrent ischemic stroke, and neurosurgical intervention. In total, 124 patients were included, 55 received DDAVP and 69 did not. INTERVENTIONS DDAVP treatment at recognition of antiplatelet-associated intracranial hemorrhage versus nontreatment. MEASUREMENTS AND MAIN RESULTS Primary effectiveness outcome was intracranial hemorrhage expansion greater than or equal to 3 mL during the first 24 hospital hours. Primary safety outcomes were the largest absolute decrease from baseline serum sodium during the first 3 treatment days and new-onset thrombotic events during the first 7 days. DDAVP was associated with 88% decreased likelihood of intracranial hemorrhage expansion during the first 24 hours ([+] DDAVP, 10.9% vs [-] DDAVP, 36.2%; p = 0.002; odds ratio [95% CI], 0.22 [0.08-0.57]). Largest median absolute decrease from baseline serum sodium ([+] DDAVP, 0 mEq/L [0-5 mEq/L] vs [-] DDAVP, 0 mEq/L [0-2 mEq/L]; p = 0.089) and thrombotic events ([+] DDAVP, 7.3% vs [-] DDAVP, 1.4%; p = 0.170; odds ratio [95% CI], 5.33 [0.58-49.16]) were similar between groups. CONCLUSIONS DDAVP was associated with a decreased likelihood of intracranial hemorrhage expansion during the first 24 hours. DDAVP administration did not significantly affect serum sodium and thrombotic events during the study period.
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Song JC, Liu SY, Zhu F, Wen AQ, Ma LH, Li WQ, Wu J. Expert consensus on the diagnosis and treatment of thrombocytopenia in adult critical care patients in China. Mil Med Res 2020; 7:15. [PMID: 32241296 PMCID: PMC7118900 DOI: 10.1186/s40779-020-00244-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/20/2020] [Indexed: 01/14/2023] Open
Abstract
Thrombocytopenia is a common complication of critical care patients. The rates of bleeding events and mortality are also significantly increased in critical care patients with thrombocytopenia. Therefore, the Critical Care Medicine Committee of Chinese People's Liberation Army (PLA) worked with Chinese Society of Laboratory Medicine, Chinese Medical Association to develop this consensus to provide guidance for clinical practice. The consensus includes five sections and 27 items: the definition of thrombocytopenia, etiology and pathophysiology, diagnosis and differential diagnosis, treatment and prevention.
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Affiliation(s)
- Jing-Chun Song
- Department of Critical Care Medicine, the 908th Hospital of Joint Logistics Support Forces of Chinese PLA, Nanchang, 360104, China.
| | - Shu-Yuan Liu
- Emergency Department, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China
| | - Feng Zhu
- Burns and Trauma ICU, Changhai Hospital, Naval Medical University, Shanghai, 200003, China
| | - Ai-Qing Wen
- Department of Blood Transfusion, Daping Hospital of Army Medical University, Chongqing, 400042, China
| | - Lin-Hao Ma
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Wei-Qin Li
- Surgery Intensive Care Unit, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China.
| | - Jun Wu
- Department of Clinical Laboratory, Peking University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing, 100035, China.
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Porta Bonete G, Godier A, Gaussem P, Belleville-Rolland T, Leuci A, Poirault-Chassac S, Bachelot-Loza C, Martin AC. Comparative In Vitro Study of Various α 2-Adrenoreceptor Agonist Drugs for Ticagrelor Reversal. J Clin Med 2020; 9:jcm9030809. [PMID: 32188130 PMCID: PMC7141185 DOI: 10.3390/jcm9030809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 12/17/2022] Open
Abstract
Ticagrelor, an antiplatelet adenosine diphosphate (ADP)-P2Y12 receptor antagonist, increases the risk of bleeding. Its management is challenging because platelet transfusion is ineffective and no specific antidote is currently available. Epinephrine, a vasopressor catecholamine prescribed during shock, restores platelet functions inhibited by ticagrelor through stimulation of α2A-adrenoreceptors. It subsequently inhibits cyclic adenosine monophosphate (cAMP) pathway and PI3K signaling. However, since epinephrine may expose a patient to deleterious hemodynamic effects, we hypothesized that other α2-adrenoreceptor agonist drugs used in clinical practice with fewer side effects could reverse the antiplatelet effects of ticagrelor. We compared in vitro the efficacy of clonidine, dexmedetomidine, brimonidine, and norepinephrine with epinephrine to restore ADP- and PAR-1-AP-induced washed platelet aggregation inhibited by ticagrelor, as well as resulting platelet cAMP levels. In ticagrelor-free samples, none of the α2-adrenoreceptor agonists induced aggregation by itself but all of them potentiated ADP-induced aggregation. Compared with epinephrine, norepinephrine, and brimonidine partially restored ADP- and fully restored PAR-1-AP-induced aggregation inhibited by ticagrelor while clonidine and dexmedetomidine were ineffective. Indeed, this lack of effect resulted from a lower decrease in cAMP concentration elicited by these partial α2-adrenoreceptor agonists, clonidine, and dexmedetomidine, compared with full α2-agonists. Our results support the development of specific full and systemic α2-adrenoreceptor agonists for ticagrelor reversal.
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Affiliation(s)
- Guillaume Porta Bonete
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM 1140, 75006 Paris, France; (G.P.B.); (A.G.); (P.G.); (T.B.-R.); (A.L.); (S.P.-C.); (C.B.-L.)
| | - Anne Godier
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM 1140, 75006 Paris, France; (G.P.B.); (A.G.); (P.G.); (T.B.-R.); (A.L.); (S.P.-C.); (C.B.-L.)
- AP-HP, Service d’Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, 75015 Paris, France
| | - Pascale Gaussem
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM 1140, 75006 Paris, France; (G.P.B.); (A.G.); (P.G.); (T.B.-R.); (A.L.); (S.P.-C.); (C.B.-L.)
- AP-HP, Service d’Hématologie Biologique, Hôpital Européen Georges Pompidou, 75015 Paris, France
| | - Tiphaine Belleville-Rolland
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM 1140, 75006 Paris, France; (G.P.B.); (A.G.); (P.G.); (T.B.-R.); (A.L.); (S.P.-C.); (C.B.-L.)
- AP-HP, Service d’Hématologie Biologique, Hôpital Européen Georges Pompidou, 75015 Paris, France
| | - Alexandre Leuci
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM 1140, 75006 Paris, France; (G.P.B.); (A.G.); (P.G.); (T.B.-R.); (A.L.); (S.P.-C.); (C.B.-L.)
| | - Sonia Poirault-Chassac
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM 1140, 75006 Paris, France; (G.P.B.); (A.G.); (P.G.); (T.B.-R.); (A.L.); (S.P.-C.); (C.B.-L.)
| | - Christilla Bachelot-Loza
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM 1140, 75006 Paris, France; (G.P.B.); (A.G.); (P.G.); (T.B.-R.); (A.L.); (S.P.-C.); (C.B.-L.)
| | - Anne-Céline Martin
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM 1140, 75006 Paris, France; (G.P.B.); (A.G.); (P.G.); (T.B.-R.); (A.L.); (S.P.-C.); (C.B.-L.)
- AP-HP, Service de Cardiologie, Hôpital Européen Georges Pompidou, 75015 Paris, France
- Correspondence: ; Tel.: +33-1-56-09-54-09
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Martin AC, Zlotnik D, Bonete GP, Baron E, Decouture B, Belleville-Rolland T, Le Bonniec B, Poirault-Chassac S, Alessi MC, Gaussem P, Godier A, Bachelot-Loza C. Epinephrine restores platelet functions inhibited by ticagrelor: A mechanistic approach. Eur J Pharmacol 2019; 866:172798. [PMID: 31738933 DOI: 10.1016/j.ejphar.2019.172798] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/11/2019] [Accepted: 11/14/2019] [Indexed: 12/29/2022]
Abstract
Ticagrelor, an antagonist of the platelet adenosine diphosphate (ADP)-P2Y12 receptor is recommended for patients with acute coronary syndromes. However, ticagrelor exposes to a risk of bleeding, the management of which is challenging because platelet transfusion is ineffective, and no antidote is yet available. We hypothesized that the vasopressor drug epinephrine could counter the antiplatelet effects of ticagrelor and restore platelet functions. We assessed in vitro the efficiency of epinephrine in restoring platelet aggregation inhibited by ticagrelor and investigated the underlying mechanisms. Washed platelet aggregation and secretion were measured upon stimulation by epinephrine alone or in combination with ADP, in the presence or absence of ticagrelor. Mechanistic investigations used P2Y1 and phosphoinositide 3-kinase (PI3K) inhibitors and included vasodilator-stimulated phosphoprotein (VASP) and Akt phosphorylation assays as well as measurement of Ca2+ mobilisation. We found that epinephrine restored ADP-induced platelet aggregation, but not dense granule release. Epinephrine alone failed to induce aggregation whereas it fully induced VASP dephosphorylation and Akt phosphorylation regardless of the presence of ticagrelor. In the presence of ticagrelor, blockage of the P2Y1 receptor prevented restoration of platelet aggregation by the combination of epinephrine and ADP, as well as intracellular Ca2+ mobilisation. In combination with ADP, epinephrine induced platelet aggregation of ticagrelor-treated platelets through inhibition of the cAMP pathway and activation of the PI3K pathway, thus enabling the P2Y1 receptor signalling and subsequent Ca2+ mobilisation. This proof-of-concept study needs to be challenged in vivo for the management of bleeding in ticagrelor-treated patients.
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Affiliation(s)
- Anne-Céline Martin
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM, F-75006 Paris, France; AP-HP, Service de Cardiologie, Hôpital Européen Georges Pompidou, Paris, France.
| | - Diane Zlotnik
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM, F-75006 Paris, France; AP-HP, Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, Paris, France
| | - Guillaume Porta Bonete
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM, F-75006 Paris, France
| | - Elodie Baron
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM, F-75006 Paris, France
| | - Benoît Decouture
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM, F-75006 Paris, France
| | - Tiphaine Belleville-Rolland
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM, F-75006 Paris, France; AP-HP, Service d'Hématologie Biologique, Hôpital Européen Georges Pompidou, Paris, France
| | - Bernard Le Bonniec
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM, F-75006 Paris, France
| | - Sonia Poirault-Chassac
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM, F-75006 Paris, France
| | | | - Pascale Gaussem
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM, F-75006 Paris, France; AP-HP, Service d'Hématologie Biologique, Hôpital Européen Georges Pompidou, Paris, France
| | - Anne Godier
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM, F-75006 Paris, France; AP-HP, Service de Cardiologie, Hôpital Européen Georges Pompidou, Paris, France
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Cave B, Rawal A, Ardeshna D, Ibebuogu UN, Sai-Sudhakar CB, Khouzam RN. Targeting ticagrelor: a novel therapy for emergency reversal. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:410. [PMID: 31660309 DOI: 10.21037/atm.2019.08.08] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Newer P2Y12 inhibitors are prescribed in place of clopidogrel for patients with acute coronary syndrome (ACS) and are associated with significant bleeding risks. Currently, limited options exist for the management of life-threatening bleeding or acute reversal for patients on P2Y12 inhibitor therapy, specifically ticagrelor. Various interventions, including platelet transfusion and desmopressin, have been studied for ticagrelor reversal demonstrating limited success. PB2452 is a novel monoclonal antibody which binds to both ticagrelor and its active metabolite resulting in a rapid return of platelet aggregation. PB2452 has been studied in animal models and, most recently, in a Phase I trial in healthy volunteers. In animal models, PB2452 displayed rapid reversal of ticagrelor and its metabolites and return to near normal levels of platelet aggregation within 60 min. In healthy human volunteers, cohorts that received higher dose bolus and infusions of PB2452 over 12-16 h resulted in maximal and sustained reversal of ticagrelor inhibition of platelet aggregation. While it is currently not US Food and Drug Administration approved, future Phase 2 and 3 studies are currently underway that may lead to new directions for patients on ticagrelor therapy who require urgent reversal.
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Affiliation(s)
- Brandon Cave
- Department of Pharmacy, Methodist University Hospital, Memphis, TN, USA
| | - Aranyak Rawal
- Department of Medicine-Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Devarshi Ardeshna
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Uzoma N Ibebuogu
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Chittoor B Sai-Sudhakar
- Department of Cardiac Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Rami N Khouzam
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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Godier A, Garrigue D, Lasne D, Fontana P, Bonhomme F, Collet JP, de Maistre E, Ickx B, Gruel Y, Mazighi M, Nguyen P, Vincentelli A, Albaladejo P, Lecompte T. Management of antiplatelet therapy for non elective invasive procedures of bleeding complications: proposals from the French working group on perioperative haemostasis (GIHP), in collaboration with the French Society of Anaesthesia and Intensive Care Medicine (SFAR). Anaesth Crit Care Pain Med 2019; 38:289-302. [DOI: 10.1016/j.accpm.2018.10.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 10/07/2018] [Indexed: 12/12/2022]
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Cohort analysis of desmopressin effect on hematoma expansion in patients with spontaneous intracerebral hemorrhage and documented pre-ictus antiplatelet use. J Clin Neurosci 2019; 66:33-37. [PMID: 31160199 DOI: 10.1016/j.jocn.2019.05.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 04/04/2019] [Accepted: 05/21/2019] [Indexed: 11/23/2022]
Abstract
Antiplatelet therapy at the time of spontaneous intracerebral hemorrhage (sICH) may increase risk for hemorrhage expansion and mortality. Current guidelines recommend considering a single dose of desmopressin in sICH associated with cyclooxygenase-1 inhibitors or adenosine diphosphate receptor inhibitors. Adult subjects with sICH and concomitant antiplatelet therapy admitted to a large, tertiary care center were included. We sought to compare the risk of hematoma expansion in patients that received desmopressin for antiplatelet reversal in the setting of sICH to similar patients that did not receive desmopressin. The primary outcomes were the incidence of relative and absolute hematoma expansion. In total, 71 patients (29 received desmopressin, 42 did not receive desmopressin) were analyzed. All patients in the desmopressin group received a 0.3 mcg/kg intravenous dose prior to hematoma expansion assessment. Relative hematoma expansion occurred in 5/29 (17%) with desmopressin compared to 11/42 (26%) without desmopressin (OR 0.59 [95% CI 0.18-1.92]). Absolute hematoma expansion occurred in 9/29 (30%) with desmopressin compared to 12/42 (28%) without desmopressin (OR 1.13 [95% CI 0.40-3.16]). Multiple logistic regression controlling for significant covariates did not reveal a significant effect of desmopressin on relative or absolute hematoma expansion (OR 0.65 [95% CI 0.18-2.43] and OR 1.55 [0.48-4.99], respectively). We failed to find evidence that desmopressin administration for antiplatelet reversal in sICH reduces the incidence of hematoma expansion. Larger studies, focusing on the early phase of sICH, are needed to characterize the clinical efficacy and safety of desmopressin for antiplatelet reversal before widespread implementation.
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 663] [Impact Index Per Article: 132.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022]
Abstract
Background Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. Methods The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. Results Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group’s belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. Conclusions A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient. Electronic supplementary material The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113, Usti nad Labem, Czech Republic.,Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005, Hradec Kralove, Czech Republic.,Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003, Hradec Kralove, Czech Republic.,Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275, Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328, Bucharest, Romania
| | - Beverley J Hunt
- King's College and Departments of Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000, Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924, Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76, Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181, Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
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Godier A, Garrigue D, Lasne D, Fontana P, Bonhomme F, Collet JP, de Maistre E, Ickx B, Gruel Y, Mazighi M, Nguyen P, Vincentelli A, Albaladejo P, Lecompte T. Management of antiplatelet therapy for non-elective invasive procedures or bleeding complications: Proposals from the French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Thrombosis and Haemostasis (GFHT), in collaboration with the French Society for Anaesthesia and Intensive Care (SFAR). Arch Cardiovasc Dis 2019; 112:199-216. [DOI: 10.1016/j.acvd.2018.10.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 10/09/2018] [Indexed: 12/21/2022]
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18
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Godier A, Dupont M, Desilles JP, Le Guerinel C, Taylor G, Perrin M, Martin AC, Gaussem P. Successful Use of Recombinant Activated Factor VII to Reverse Ticagrelor-Induced Bleeding Risk: A Case Report. TH OPEN 2018; 2:e346-e349. [PMID: 31249959 PMCID: PMC6524896 DOI: 10.1055/s-0038-1672211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 08/20/2018] [Indexed: 12/28/2022] Open
Abstract
Management of ticagrelor-associated bleeding is challenging, especially in neurosurgery. Platelet transfusion is inefficient and no antidote is currently available. We report here the first case of recombinant activated factor VII (rFVIIa) use to bypass ticagrelor-induced platelet inhibition. A woman treated with ticagrelor and requiring emergent neurosurgery for an intracranial hematoma received preoperative high-dose platelet transfusion and 60 μg/kg rFVIIa. Laboratory monitoring demonstrated that platelet transfusion failed to reverse ticagrelor-induced platelet inhibition while rFVIIa improved hemostasis by shortening the thromboelastometric clotting time. Neurosurgery occurred without any bleeding event but the patient presented with a postoperative pulmonary embolism. In conclusion, rFVIIa may decrease ticagrelor-induced bleeding risk but careful assessment of the benefit-risk balance is warranted before using rFVIIa to reverse ticagrelor effects.
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Affiliation(s)
- Anne Godier
- Service d'Anesthésie-Réanimation, Fondation Adolphe de Rothschild, Paris, France.,Sorbonne Paris Cité, Faculté de Pharmacie, Université Paris Descartes, Paris, France.,INSERM UMR-S1140, Paris, France
| | - Mélanie Dupont
- Service d'Anesthésie-Réanimation, Fondation Adolphe de Rothschild, Paris, France
| | - Jean-Philippe Desilles
- Département de Neuroradiologie Interventionnelle, Fondation Adolphe de Rothschild, Paris, France.,Sorbonne Paris Cité, Laboratory of Vascular Translational Science, Université Paris Diderot, Paris, France.,INSERM UMR 1148, Paris, France
| | | | - Guillaume Taylor
- Service d'Anesthésie-Réanimation, Fondation Adolphe de Rothschild, Paris, France
| | - Mathilde Perrin
- Service d'Anesthésie-Réanimation, Fondation Adolphe de Rothschild, Paris, France
| | - Anne-Céline Martin
- Sorbonne Paris Cité, Faculté de Pharmacie, Université Paris Descartes, Paris, France.,INSERM UMR-S1140, Paris, France.,Service de Cardiologie, Service de Santé des Armées, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Pascale Gaussem
- Sorbonne Paris Cité, Faculté de Pharmacie, Université Paris Descartes, Paris, France.,INSERM UMR-S1140, Paris, France.,Service d'hématologie Biologique, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
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19
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Evaluation of recombinant factor VIIa, tranexamic acid and desmopressin to reduce prasugrel-related bleeding. Eur J Anaesthesiol 2018; 35:208-214. [DOI: 10.1097/eja.0000000000000775] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Filaire L, Pham DT, d’Ostrevy N, Tran HT, Camilleri L, Azarnoush K. Inefficacy of Platelet Transfusion in a Heart Transplant Patient Under Continuous Ticagrelor. J Cardiothorac Vasc Anesth 2017. [DOI: 10.1053/j.jvca.2017.02.180] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Schoener L, Jellinghaus S, Richter B, Pfluecke C, Ende G, Christoph M, Quick S, Loehn T, Speiser U, Poitz DM, Mierke J, Strasser RH, Ibrahim K. Reversal of the platelet inhibitory effect of the P2Y 12 inhibitors clopidogrel, prasugrel, and ticagrelor in vitro: a new approach to an old issue. Clin Res Cardiol 2017; 106:868-874. [PMID: 28653184 DOI: 10.1007/s00392-017-1128-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/12/2017] [Indexed: 10/19/2022]
Abstract
AIM Platelet transfusion is an effective option to reverse platelet inhibition in thienopyridine-treated patients suffering from bleedings or requiring urgent surgery. However, in ticagrelor-treated patients, the previous studies revealed significant clinical effects to platelet rich plasma (PRP) but poor response to pooled platelets (PP) as used in clinical routine. The aim of this study was to elucidate a potential pathomechanism to explain the poor response of ticagrelor to PP. METHODS AND RESULTS From 79 whole blood samples of patients treated with ticagrelor, prasugrel, or clopidogrel, the PRI-VASP was determined before and after in vitro platelet supplementation of PP or PRP at increasing concentrations. Compared to prasugrel- and clopidogrel-treated patients, the PRI-VASP of ticagrelor-treated patients showed no significant increase after in vitro administration of PP. PRI-VASP was performed in ticagrelor-treated samples after in vitro addition of 1: centrifuged PRP platelets resuspended in PP buffer, 2: PP with human serum, 3: human serum alone. Surprisingly, PP with human serum or human serum alone were able to significantly increase PRI-VASP in samples of ticagrelor-treated patients (11.7 ± 10.9 → 61.3 ± 10.9%, p = 0.006; 11.7 ± 10.9 → 54.1 ± 2.7%, p < 0.001). This effect could also be shown using human albumin (18.9 ± 5.1% → 80 g/l human albumin: 48.1 ± 8.3%, p < 0.001). CONCLUSION The present study demonstrates that addition of human serum and human albumin alone is able to reverse the ticagrelor effects in vitro and supports our novel hypothesis of the importance of proteins in reversing the effects of ticagrelor by binding active ticagrelor.
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Affiliation(s)
- Lisa Schoener
- Technische Universität Dresden, Heart Center Dresden, University Hospital Dresden, Fetscherstraße 76, 01307, Dresden, Germany.
| | - Stefanie Jellinghaus
- Technische Universität Dresden, Heart Center Dresden, University Hospital Dresden, Fetscherstraße 76, 01307, Dresden, Germany
| | - Bernhardt Richter
- Technische Universität Dresden, Heart Center Dresden, University Hospital Dresden, Fetscherstraße 76, 01307, Dresden, Germany
| | - Christian Pfluecke
- Technische Universität Dresden, Heart Center Dresden, University Hospital Dresden, Fetscherstraße 76, 01307, Dresden, Germany
| | - Georg Ende
- Technische Universität Dresden, Heart Center Dresden, University Hospital Dresden, Fetscherstraße 76, 01307, Dresden, Germany
| | - Marian Christoph
- Technische Universität Dresden, Heart Center Dresden, University Hospital Dresden, Fetscherstraße 76, 01307, Dresden, Germany
| | - Silvio Quick
- Technische Universität Dresden, Heart Center Dresden, University Hospital Dresden, Fetscherstraße 76, 01307, Dresden, Germany
| | - Tobias Loehn
- Technische Universität Dresden, Heart Center Dresden, University Hospital Dresden, Fetscherstraße 76, 01307, Dresden, Germany
| | - Uwe Speiser
- Technische Universität Dresden, Heart Center Dresden, University Hospital Dresden, Fetscherstraße 76, 01307, Dresden, Germany
| | - David M Poitz
- Technische Universität Dresden, Heart Center Dresden, University Hospital Dresden, Fetscherstraße 76, 01307, Dresden, Germany
| | - Johannes Mierke
- Technische Universität Dresden, Heart Center Dresden, University Hospital Dresden, Fetscherstraße 76, 01307, Dresden, Germany
| | - Ruth H Strasser
- Technische Universität Dresden, Heart Center Dresden, University Hospital Dresden, Fetscherstraße 76, 01307, Dresden, Germany
| | - Karim Ibrahim
- Technische Universität Dresden, Heart Center Dresden, University Hospital Dresden, Fetscherstraße 76, 01307, Dresden, Germany
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Martin AC, Houssany-Pissot S, Zlotnik D, Taylor G, Godier A. [Management of the bleeding risk associated with antiplatelet agents]. Rev Med Interne 2017; 38:467-473. [PMID: 28528236 DOI: 10.1016/j.revmed.2017.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 01/09/2017] [Accepted: 01/23/2017] [Indexed: 10/19/2022]
Abstract
Like all antithrombotic drugs, antiplatelet agents expose to a risk of bleeding complications. Clinical research has extensively focused on the efficacy of these drugs to reduce ischemic events. The bleeding risk associated with them was solely considered as an inevitable and acceptable complication. When two new potent P2Y12-receptor inhibitors, prasugrel and ticagrelor, were marketed, the risk of major bleeding increased. These new agents have modified the balance between the absolute risk reduction in ischemic events and the absolute risk increase in bleeding events. This paper is an update on the bleeding risk assessment associated with antiplatelet agents. It discusses the place of platelet function monitoring, and the optimal management of bleeding complications. It addresses the challenging issue of reversal of antiplatelet therapy, focusing especially on ticagrelor, which pharmacodynamics complicate bleeding management.
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Affiliation(s)
- A-C Martin
- Service de cardiologie, hôpital d'instruction des armées Percy, 92140 Clamart, France; Inserm UMRS 1140, faculté de pharmacie, université Paris Descartes, 75006 Paris, France.
| | - S Houssany-Pissot
- Service de cardiologie, hôpital d'instruction des armées Percy, 92140 Clamart, France
| | - D Zlotnik
- Inserm UMRS 1140, faculté de pharmacie, université Paris Descartes, 75006 Paris, France
| | - G Taylor
- Service d'anesthésie réanimation, fondation Adolphe-de-Rothschild, 75019 Paris, France
| | - A Godier
- Inserm UMRS 1140, faculté de pharmacie, université Paris Descartes, 75006 Paris, France; Service d'anesthésie réanimation, fondation Adolphe-de-Rothschild, 75019 Paris, France
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24
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Teng R, Carlson GF, Nylander S, Andersson TLG. Effects of autologous platelet transfusion on platelet inhibition in ticagrelor-treated and clopidogrel-treated subjects. J Thromb Haemost 2016; 14:2342-2352. [PMID: 27653814 DOI: 10.1111/jth.13511] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 08/30/2016] [Indexed: 01/19/2023]
Abstract
Essentials Limited data on hemostatic benefits of platelet transfusion (PT) exist. 44 healthy subjects had a single dose of ticagrelor or clopidogrel ± autologous PT post-dosing. PT did not reverse ticagrelor's antiplatelet effects and had minimal impact post clopidogrel. Post-ticagrelor, PT is unlikely to be beneficial, and the benefits post-clopidogrel are unknown. SUMMARY Background Antiplatelet agents increase bleeding risk. Few data on hemostatic benefits of platelet transfusion exist. Objective To assess the effect of autologous platelet transfusion on ticagrelor-mediated and clopidogrel-mediated platelet inhibition in a single-center, open-label, randomized, cross-over study (NCT01744288). Methods Forty-four healthy subjects received ticagrelor (180 mg) or clopidogrel (600 mg; two functional CYP2C19 alleles [*1 or *17] required) with or without platelet transfusion (14-day washout). Subjects received one autologous platelet apheresis unit (approximately six pooled donor platelet units) 24 h (n = 15) or 48 h (n = 13) after ticagrelor or 48 h after clopidogrel (n = 16). Platelet apheresis was conducted 72 h before transfusion. Aspirin (81 mg per day) was taken from after apheresis until 24 h before transfusion. P2Y12 reaction units (PRUs) and inhibition of platelet aggregation (IPA) induced by ADP were measured. Results Mean age and body mass index were 30 years (standard deviation [SD] 6 years) and 26.9 kg m-2 (SD 4.0 kg m-2 ), respectively; 98% of subjects were men, and 39 of 44 completed treatment. Platelet transfusion 24 h after ticagrelor had minimal effects on IPA or PRU values within 48 h after transfusion. Platelet transfusion 48 h after ticagrelor also had minimal effects on IPA or PRU values at most post-transfusion times. Platelet transfusion 48 h after clopidogrel, versus no transfusion, had a small reversing effect on IPA (24 h, 36 h, and 48 h) and PRU values (12 h, 24 h, and 36 h) after transfusion. Conclusions Autologous platelet transfusion is unlikely to be of clinical benefit in reversing the antiplatelet effects of ticagrelor. The clinical relevance of the small effects seen with clopidogrel is unknown.
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Affiliation(s)
- R Teng
- AstraZeneca LP, Gaithersburg, MD, USA
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25
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Boosting the coagulation restores haemostasis in ticagrelor-treated mice. Blood Coagul Fibrinolysis 2016; 27:913-919. [DOI: 10.1097/mbc.0000000000000511] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mappus JL, Fellows SE, Anand S, Gandhi MA. The use of desmopressin acetate in patients presenting with intracranial hemorrhage: A review. TRAUMA-ENGLAND 2016. [DOI: 10.1177/1460408616669745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective This review presents current literature on desmopressin acetate as mono- and adjuvant therapy and its ability to stabilize platelet function in patients presenting with intracranial hemorrhage on pre-injury antiplatelet agents of aspirin, clopidogrel, prasugrel and/or ticagrelor. Design PubMed, MEDLINE and International Pharmaceutical Abstracts were searched through to 1st March 2016. Inclusion criteria were case reports, reviews, short communications and brief reports on reported patients with any type of intracranial hemorrhage while on oral antiplatelet agents. Reports on desmopressin acetate in surgical candidates were excluded due to the nature of the bleed. Results A scoping search was performed in three databases with 89 articles identified based on the search criteria. All returned articles were evaluated by the authors with four articles suitable for inclusion. Conclusion While desmopressin acetate has a promising mechanism of action for enhancing primary hemostasis, the articles reported conflicting results possibly due to limited study sample sizes, lack of standards on measuring platelet function, data on weight-based dosing and guidelines. Further research is needed to evaluate desmopressin acetate as monotherapy. If used, it should be considered adjunct therapy to platelet transfusions for patients on oral antiplatelet agents requiring emergent hemostasis.
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Affiliation(s)
- Jennifer L Mappus
- St John Fisher College, Wegmans School of Pharmacy, Rochester, NY, USA
| | - Shawn E Fellows
- St John Fisher College, Wegmans School of Pharmacy, Rochester, NY, USA
| | - Sridhar Anand
- St John Fisher College, Wegmans School of Pharmacy, Rochester, NY, USA
| | - Mona A Gandhi
- St John Fisher College, Wegmans School of Pharmacy, Rochester, NY, USA
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.Lange CM, Albert J. In Reply. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:541-542. [PMID: 27581511 PMCID: PMC5012168 DOI: 10.3238/arztebl.2016.0541c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
| | - Jörg Albert
- *Goethe Universitätsklinikum Frankfurt am Main,
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Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EAM, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100. [PMID: 27072503 PMCID: PMC4828865 DOI: 10.1186/s13054-016-1265-x] [Citation(s) in RCA: 594] [Impact Index Per Article: 74.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
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Affiliation(s)
- Rolf Rossaint
- />Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- />Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- />Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113 Usti nad Labem, Czech Republic
- />Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS B3H 2Y9 Canada
| | - Timothy J. Coats
- />Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH UK
| | - Jacques Duranteau
- />Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Cedex France
| | - Enrique Fernández-Mondéjar
- />Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013 Granada, Spain
| | - Daniela Filipescu
- />Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328 Bucharest, Romania
| | - Beverley J. Hunt
- />King’s College, Departments of Haematology, Pathology and Lupus, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- />Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- />Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152 Rome, Italy
| | - Edmund A. M. Neugebauer
- />Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Yves Ozier
- />Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Louis Riddez
- />Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- />Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- />Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R. Spahn
- />Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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Abstract
Despite advancements in treatments for acute coronary syndromes over the last 10 years, they continue to be life-threatening disorders. Currently, the standard of treatment includes dual antiplatelet therapy consisting of aspirin plus a P2Y12 receptor antagonist. The thienopyridine class of P2Y12 receptor antagonists, clopidogrel and prasugrel, have demonstrated efficacy. However, their use is associated with several limitations, including the need for metabolic activation and irreversible P2Y12 receptor binding causing prolonged recovery of platelet function. In addition, response to clopidogrel is variable and efficacy is reduced in patients with certain genotypes. Although prasugrel is a more consistent inhibitor of platelet aggregation than clopidogrel, it is associated with an increased risk of life-threatening and fatal bleeding. Ticagrelor is an oral antiplatelet agent of the cyclopentyltriazolopyrimidine class and also acts through the P2Y12 receptor. In contrast to clopidogrel and prasugrel, ticagrelor does not require metabolic activation and binds rapidly and reversibly to the P2Y12 receptor. In light of new data, this review provides an update on the pharmacokinetic, pharmacodynamic and pharmacogenetic profiles of ticagrelor in different study populations. Recent studies report that no dose adjustment for ticagrelor is required on the basis of age, gender, ethnicity, severe renal impairment or mild hepatic impairment. The non-P2Y12 actions of ticagrelor are reviewed, showing indirect positive effects on cellular adenosine concentration and biological activity, by inhibition of equilibrative nucleoside transporter-1 independently of the P2Y12 receptor. CYP2C19 and ABCB1 genotypes do not appear to influence ticagrelor pharmacodynamics. A summary of drug interactions is also presented.
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Kempfert J, Meyer A, Arsalan M, Walther T. Perioperativer Umgang mit moderner Thrombozytenaggregationshemmung. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2015. [DOI: 10.1007/s00398-014-1121-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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