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Davey MG, Joyce WP. Evaluating the safety profile of anti-platelet therapy in patients undergoing elective inguinal hernia repair: a systematic review and meta-analysis. Ir J Med Sci 2024; 193:897-902. [PMID: 37526871 PMCID: PMC10961273 DOI: 10.1007/s11845-023-03480-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/26/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION There remains no consensus surrounding the safety of prescribing anti-platelet therapies (APT) prior to elective inguinal hernia repair (IHR). AIMS To perform a systematic review and meta-analysis evaluating the safety profile of APT use in patients indicated to undergo elective IHR. METHODS A systematic review was performed in accordance with PRISMA guidelines. Meta-analyses were performed using the Mantel-Haenszel method using the Review Manager version 5.4 software. RESULTS Five studies including outcomes in 344 patients were included. Of these, 65.4% had APT discontinued (225/344), and 34.6% had APT continued (119/344). The majority of included patients were male (94.1%, 288/344). When continuing or discontinuing APT, there was no significant difference in overall haemorrhage rates (odds ratio (OR): 1.86, 95% confidence interval (CI): 0.29-11.78, P = 0.130) and in sensitivity analysis using only RCT data (OR: 0.63, 95% CI: 0.03-12.41, P = 0.760). Furthermore, there was no significant difference in reoperation rates (OR: 6.27, 95% CI: 0.72-54.60, P = 0.590); however, a significant difference was observed for readmission rates (OR: 5.67, 95% CI: 1.33-24.12, P = 0.020) when APT was continued or stopped pre-operatively. There was no significant difference in the estimated blood loss, intra-operative time, transfusion of blood products, rates of complications, cerebrovascular accidents, myocardial infarctions, or mortality observed. CONCLUSION This study illustrates the safety of continuing APT pre-operatively in patients undergoing elective IHR, with similar rates of haemorrhage, reoperation, and readmission observed. Clinical trials with larger patient recruitment will be required to fully establish the safety profile of prescribing APT in the pre-operative setting prior to elective IHR.
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Affiliation(s)
- Matthew G Davey
- Royal College of Surgeons Ireland, 123 St. Stephens Green, Dublin 2, D02 YN77, Ireland.
| | - William P Joyce
- Royal College of Surgeons Ireland, 123 St. Stephens Green, Dublin 2, D02 YN77, Ireland
- Department of Surgery, Galway Clinic, Co., Galway, H91 HHT0, Ireland
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2
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Khanafer A, Henkes H, Bücke P, Hennersdorf F, Bäzner H, Forsting M, von Gottberg P. Triple platelet inhibition in intracranial thrombectomy with additional acute cervical stent angioplasty due to tandem lesion: a retrospective single-center analysis. BMC Neurol 2024; 24:99. [PMID: 38500074 PMCID: PMC10946095 DOI: 10.1186/s12883-024-03597-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Acute stroke treatment with intracranial thrombectomy and treatment of ipsilateral carotid artery stenosis/occlusion ("tandem lesion", TL) in one session is considered safe. However, the risk of stent restenosis after TL treatment is high, and antiplatelet therapy (APT) preventing restenosis must be well balanced to avoid intracranial hemorrhage. We investigated the safety and 90-day outcome of patients receiving TL treatment under triple-APT, focused on stent-patency and possible disadvantageous comorbidities. METHODS Patients receiving TL treatment in the setting of acute stroke between 2013 and 2022 were analyzed regarding peri-/postprocedural safety and stent patency after 90 days. All patients received intravenous eptifibatide and acetylsalicylic acid and one of the three drugs prasugrel, clopidogrel, or ticagrelor. Duplex imaging was performed 24 h after treatment, at discharge and 90 days, and digital subtraction angiography was performed if restenosis was suspected. RESULTS 176 patients were included. Periprocedural complications occurred in 2.3% of the patients at no periprocedural death, and in-hospital death in 13.6%. Discharge mRS score was maintained or improved at the 90-day follow-up in 86%, 4.54% had an in-stent restenosis requiring treatment at 90 days. No recorded comorbidity considered disadvantageous for stent patency showed statistical significance, the duration of the endovascular procedure had no significant effect on outcome. CONCLUSION In our data, TL treatment with triple APT resulted in a low restenosis rate, low rates of sICH and a comparably high number of patients with favorable outcome. Aggressive APT in the initial phase may therefore have the potential to prevent recurrent stroke better than restrained platelet inhibition. Comorbidities did not influence stent patency.
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Affiliation(s)
- Ali Khanafer
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Hennersdorf
- Department of Diagnostic and Interventional Neuroradiology, University of Tübingen, Tübingen, Germany
| | - Hansjörg Bäzner
- Neurological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp von Gottberg
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.
- Klinik für Neuroradiologie, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany.
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Zhou S, Li W, Xiang Q, Wang Z, Zhang H, Mu G, Liu Z, Cui Y. Optimal anti-platelet therapy for older patients with acute coronary syndrome: a network meta-analysis of randomized trials comprising 59,284 older patients. J Thromb Thrombolysis 2024; 57:143-154. [PMID: 37548902 PMCID: PMC10830599 DOI: 10.1007/s11239-023-02875-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2023] [Indexed: 08/08/2023]
Abstract
The aim of this study was to identify the optimal anti-platelet therapy in older acute coronary syndrome (ACS) patients with a mean age ≥ 60 years by comparing the efficacy and safety of different anti-platelet therapies. The selection of antiplatelet therapy in older patients with ACS is a clinical challenge. Numerous evidences indicate that the de-escalation of dual anti-platelet therapy (DAPT) or P2Y12 inhibitor monotherapy may reduce bleeding risk without increasing thrombotic events. However, there is a lack of systematic reviews and optimal strategy analysis regarding older ACS patients. Randomized controlled trials (RCTs) of anti-platelet therapy in older ACS patients were identified. Major adverse cardiovascular events (MACE) were the primary outcome. Secondary outcomes included all death, cardiovascular death, myocardial infarction, stroke, stent thrombosis, and trial-defined major bleeding. Frequentist and Bayesian network meta-analyses were conducted. Treatments were ranked on posterior probability. Summary odds ratios (ORs) were estimated using Bayesian network meta-analysis. A total of 12 RCTs including 59,284 older ACS patients treated with five anti-platelet strategies were included. Ticagrelor monotherapy after 3 months DAPT was comparable to the other strategies (OR 0.73; 95% CI 0.32-1.6) in terms of MACE risk. Additionally, P score analysis and SUCRA Bayesian analysis showed that it was the most beneficial treatment for all deaths, cardiovascular death and revascularization. For safety, although there was no significant difference in direct comparisons, both SUCRA Bayesian (0.806) and P score (0.519) analysis suggested that ticagrelor monotherapy was the safest strategy. The current evidence demonstrated that ticagrelor monotherapy after 3 months DAPT may be a promising approach for achieving a more favorable balance between risk and benefit for older ACS patients, with a relatively low bleeding risk and without an increased risk of MACE events. Moreover, it remains the preferred option for clinical outcomes such as all death, CV death and revascularization. Further high-quality and long-term studies are required to validate anti-platelet therapies among older ACS patients.
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Affiliation(s)
- Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Wenhui Li
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China.
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China.
- School of Pharmaceutical Sciences, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China.
- Institute of Clinical Pharmacology, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China.
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Schmidbauer M, Wischmann J, Dimitriadis K, Kellert L. [Secondary prophylaxis of ischemic stroke]. Inn Med (Heidelb) 2023; 64:1171-1183. [PMID: 37947810 DOI: 10.1007/s00108-023-01615-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 11/12/2023]
Abstract
The secondary prophylaxis of ischemic stroke provides an enormous therapeutic potential due to the high frequency of recurrent thrombembolic events and the exceptional importance of modifiable cardiovascular risk factors for the individual risk of stroke. In this respect, anti-thrombotic, interventional and surgical treatment options must be selected based on the respective etiology. Furthermore, meticulous optimization of risk factors is essential for effective long-term care. Close interdisciplinary and intersectoral collaboration is crucial, especially in the long-term treatment.
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Affiliation(s)
- Moritz Schmidbauer
- Klinik und Poliklinik für Neurologie, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland.
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Toragall V, Hale EJ, Hulugalla KR, Werfel TA. Correction Notice: Microscopy and Plate Reader-based Methods for Monitoring the Interaction of Platelets and Tumor Cells in vitro. Bio Protoc 2023; 13:e4907. [PMID: 38023792 PMCID: PMC10665630 DOI: 10.21769/bioprotoc.4907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 12/01/2023] Open
Abstract
Platelets and their activation status play an essential role in cancer metastasis. Therefore, the anti-metastatic potential of antiplatelet drugs has been investigated for many years. However, the initial screening of these antiplatelet drugs to determine which agents can inhibit the interactions of platelets and tumor cells is very limited due to reliance upon expensive, time-consuming, and low-throughput animal experiments for screening. In vitro models of the platelet-tumor cell interaction can be a useful tool to rapidly screen multiple antiplatelet drugs and compare their ability to disrupt platelet-tumor cell interactions, while also identifying optimal concentrations to move forward for in vivo validation. Hence, we adopted methods used in platelet activation research to isolate and label platelets before mixing them with tumor cells (MDA-MB-231-RFP cells) in vitro in a static co-culture model. Platelets were isolated from other blood components by centrifugation, followed by fluorescent labeling using the dye CMFDA (CellTrackerTM Green). Labeling platelets allows microscopic observation of the introduced platelets with tumor cells grown in cell culture dishes. These methods have facilitated the study of platelet-tumor cell interactions in tissue culture. Here, we provide details of the methods we have used for platelet isolation from humans and mice and their staining for further interaction with tumor cells by microscopy and plate reader-based quantification. Moreover, we show the utility of this assay by demonstrating decreased platelet-tumor cell interactions in the presence of the T-Prostanoid receptor (TPr) inhibitor ifetroban. The methods described here will aid in the rapid discovery of antiplatelet agents, which have potential as anti-metastatic agents as well. Key features • Analysis of platelet-tumor cell binding dynamics. • In vitro methods developed for measuring platelet-tumor cell binding to enable rapid testing of antiplatelet and other compounds. • Complementary analysis of platelet-tumor cell binding by imaging and fluorimetry-based readings. • Representative results screening the effect of the antiplatelet drug, ifetroban, on platelet-tumor cell binding using the protocol. • Validation results were presented with both a TPr agonist and ifetroban (antagonist).
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Affiliation(s)
- Veeresh Toragall
- Department of Biomedical Engineering, University of Mississippi, MS, USA
| | - Elizabeth J. Hale
- Department of Biomedical Engineering, University of Mississippi, MS, USA
| | - Kenneth R. Hulugalla
- Department of Biomedical Engineering, University of Mississippi, MS, USA
- Department of BioMolecular Sciences, University of Mississippi, MS, USA
| | - Thomas A. Werfel
- Department of Biomedical Engineering, University of Mississippi, MS, USA
- Department of BioMolecular Sciences, University of Mississippi, MS, USA
- Department of Chemical Engineering, University of Mississippi, MS, USA
- Cancer Center and Research Institute, University of Mississippi Medical Center, Jackson, MS, USA
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Tan SEM, Heng KWJ. Capsular warning syndrome-a case of atrial fibrillation and corona radiata infarct. Int J Emerg Med 2023; 16:62. [PMID: 37752459 PMCID: PMC10521567 DOI: 10.1186/s12245-023-00541-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 09/19/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Capsular warning syndrome (CWS) is a rare clinical syndrome characterised by recurrent and transient episodes of focal neurological deficits with high risk of infarction. The exact physiological mechanism of CWS remains unclear but is most commonly believed to be a result of haemodynamic insufficiency in diseased, small penetrating vessels. There are no defined treatment guidelines or established effective therapy. CASE PRESENTATION We describe the case of a 65-year-old man who presented to the emergency department with recurrent episodes of dysarthria coupled with right facial droop and right-sided weakness. Symptoms recurred a total of ten times within a span of 3 h. He had new onset atrial fibrillation. An initial cerebral angiogram showed mild intracranial atherosclerotic disease with no proximal large vessel occlusion or acute infarct. Magnetic resonance imaging 1 h later demonstrated an infarct in the left corona radiata. CONCLUSIONS This case illustrates an uncommon etiology of CWS. We will also discuss the lack of consensus in treatment options for CWS to mitigate a complete stroke.
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Affiliation(s)
- Sarah En Mei Tan
- Department of Emergency Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| | - Kenneth Wei Jian Heng
- Department of Emergency Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
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Bhuta S, Ariss RW, Ding L, Nazir S, Magee GA, Garg PK, Gupta R. Oral factor Xa inhibitor underutilization following lower extremity peripheral vascular intervention. J Vasc Surg 2023; 78:498-505.e1. [PMID: 37100234 PMCID: PMC10524143 DOI: 10.1016/j.jvs.2023.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVE Patients undergoing peripheral vascular intervention (PVI) (ie, endovascular revascularization) for symptomatic lower extremity peripheral artery disease remain at high risk for major adverse limb and cardiovascular events. High-quality evidence demonstrates the addition of a low-dose oral factor Xa inhibitor to single antiplatelet therapy, termed dual pathway inhibition (DPI), reduces the incidence of major adverse events in this population. This study aims to describe the longitudinal trends in factor Xa inhibitor initiation after PVI, identify patient and procedural characteristics associated with factor Xa inhibitor use, and describe temporal trends in antithrombic therapy post-PVI before vs after VOYAGER PAD. METHODS This retrospective cross-sectional study was performed using data from the Vascular Quality Initiative PVI registry from January 2018 through June 2022. Multivariate logistic regression was utilized to determine predictors of factor Xa inhibitor initiation following PVI, reported as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS A total of 91,569 PVI procedures were deemed potentially eligible for factor Xa inhibitor initiation and were included in this analysis. Overall rates of factor Xa inhibitor initiation after PVI increased from 3.5% in 2018 to 9.1% in 2022 (P < .0001). The strongest positive predictors of factor Xa inhibitor initiation after PVI were non-elective (OR, 4.36; 95% CI, 4.06-4.68; P < .0001) or emergent (OR, 8.20; 95% CI, 7.14-9.41; P < .0001) status. The strongest negative predictor was postoperative dual antiplatelet therapy prescription (OR, 0.20; 95% CI, 0.17-0.23; P < .0001), highlighting significant hesitation about use of DPI after PVI and limited translation of VOYAGER PAD findings into clinical practice. Antiplatelet medications remain the most common antithrombotic regimen after PVI, with almost 70% of subjects discharged on dual antiplatelet therapy and approximately 20% discharged on single antiplatelet therapy. CONCLUSIONS Factor Xa inhibitor initiation after PVI has increased in recent years, although the absolute rate remains low, and most eligible patients are not prescribed this treatment.
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Affiliation(s)
- Sapan Bhuta
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Robert W Ariss
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Li Ding
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Salik Nazir
- Section of Cardiology, Baylor College of Medicine, Houston, TX
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Parveen K Garg
- Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Rajesh Gupta
- Division of Cardiovascular Medicine, University of Toledo, Toledo, OH.
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Chong B, Goh RSJ, Kong G, Sim FRE, Ng CH, Teo XYV, Quek JX, Lim O, Chin YH, Chan SP, Chan MY, Tan HC, Chew NWS, Loh PH. Comparison of biodegradable and newer generation durable polymer drug-eluting stents with short-term dual antiplatelet therapy: a systematic review and Bayesian network meta-analysis of randomized trials comprising of 43,875 patients. J Thromb Thrombolysis 2022. [PMID: 34981305 DOI: 10.1007/s11239-021-02628-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/27/2021] [Indexed: 12/17/2022]
Abstract
Newer generation durable polymer drug-eluting stents (DP-DES) and biodegradable polymer DES (BP-DES) have similar efficacy with dual-antiplatelet therapy (DAPT) duration of > 6 months. However, this difference in outcomes have not been well studied in shorter DAPT regime. This study compares the safety and efficacy profiles of DP-DES and BP-DES based on short-term (1-3 months), intermediate-term (4-6 months) and standard DAPT (6-12 months) durations. A search was conducted on Embase and Medline for Randomized Controlled Trials (RCTs) comparing stent types, and DAPT durations. Primary endpoints include cardiac death, myocardial infarction (MI), definite stent thrombosis, stroke, target vessel revascularization (TVR) and major bleeding. Network analysis was conducted to summarize the evidence. A total of 15 RCTs involving 43,875 patients were included. DP-DES was associated with significantly lower major bleeding rates compared to BP-DES (RR 0.44, Crl 0.22-0.83) in short-term DAPT. Among DP-DES patients, short-term DAPT was associated with lower major bleeding risk compared to standard DAPT (RR 0.47, CrI 0.32-0.69). This favorable bleeding profile with short DAPT was not found in BP-DES patients. Cardiac death, MI, definite stent thrombosis, stroke and TVR rates were similar across the various DAPT durations and stent types. Our preliminary findings demonstrated comparable efficacy and safety outcomes between BP-DES and newer generation BP-DES across various DAPT durations. In patients requiring short DAPT, DP-DES had more favourable major bleeding profile compared to BP-DES, without compromising anti-thrombotic efficacy.
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Abstract
This concise review of the epidemiology, pathophysiology, evaluation, acute management, and prevention of ischemic stroke targets internists, family practitioners, and emergency physicians who manage patient with stroke.
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Affiliation(s)
- Steven K Feske
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
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Honda S, Nishihira K, Kojima S, Takegami M, Asaumi Y, Suzuki M, Kosuge M, Takahashi J, Sakata Y, Takayama M, Sumiyoshi T, Ogawa H, Kimura K, Yasuda S. Characteristics and clinical outcomes of patients with de-escalation from prasugrel to clopidogrel after acute myocardial infarction - Insights from the prospective Japan Acute Myocardial Infarction Registry (JAMIR). J Cardiol 2021; 78:99-106. [PMID: 33745775 DOI: 10.1016/j.jjcc.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/09/2021] [Accepted: 02/15/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND De-escalation of P2Y12 inhibitor may occur for various clinical reasons in patients with acute myocardial infarction (AMI). We aimed to assess the characteristics and outcomes of patients who underwent a de-escalation strategy in real-world clinical practice. METHODS AND RESULTS We studied 2604 AMI patients initially treated with prasugrel using the Japan Acute Myocardial Infarction Registry (JAMIR) database. Of these, 110 (4%) were discharged on clopidogrel [de-escalation group; switching 4 days after admission (median)] and the remaining 2494 continued prasugrel at discharge (continuation group). The de-escalation group had higher incidence of heart failure or history of cerebrovascular disease, and were more likely to receive mechanical circulatory support, and oral anticoagulation than the continuation group. During mean follow-up of 309±133 days post-discharge, no significant differences were observed in ischemic events (2.2% vs. 2.8%, p = 0.74) or major bleeding (1.1% vs. 1.6%, p = 0.72) between the de-escalation and continuation groups. CONCLUSIONS Although, patients with de-escalation from prasugrel to clopidogrel had higher bleeding risk profile than those continued on prasugrel, post discharge ischemic and bleeding events were similar between patients with and without de-escalation. De-escalation strategy may be an option for AMI patients with high risk for bleeding.
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Affiliation(s)
- Satoshi Honda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kensaku Nishihira
- Department of Cardiovascular Medicine, Miyazaki Medical Association Hospital, Japan
| | - Sunao Kojima
- Department of General Internal Medicine 3, Kawasaki Medical School, Okayama, Japan
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Makoto Suzuki
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan
| | - Masami Kosuge
- Department of Cardiovascular Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University, 1-1, Seiryomachi, Aoba-ku, Sendai, Sendai 980-8574, Japan
| | - Yasuhiko Sakata
- Department of Cardiovascular Medicine, Tohoku University, 1-1, Seiryomachi, Aoba-ku, Sendai, Sendai 980-8574, Japan
| | - Morimasa Takayama
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan
| | - Tetsuya Sumiyoshi
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazuo Kimura
- Department of Cardiovascular Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University, 1-1, Seiryomachi, Aoba-ku, Sendai, Sendai 980-8574, Japan.
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Kiboshi R, Satoh S, Mikami K, Kitajima M, Urushizaka M, Metoki N, Osanai T. Serum Albumin, Body Mass Index, and Preceding Xa and P2Y12 Inhibitors Predict Prognosis of Recurrent Ischemic Stroke. J Stroke Cerebrovasc Dis 2021; 30:105681. [PMID: 33652345 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/05/2021] [Accepted: 02/10/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND A third to half of recurrent stroke occur while on antiplatelet therapy, but no study has explored factors relating to prognosis of recurrent ischemic stroke. This study aimed to clarify the risk factors to determine the clinical outcome of recurrent ischemic stroke. METHODS A total of 1,333 consecutive acute ischemic stroke patients (first n = 492, recurrent n = 841) were enrolled. We explored factors influencing the modified Rankin Scales (mRS) at discharge that included platelet aggregability, preceding medicines, and well-known risks of biochemical data using Chi-square test or Fisher's exact probability test. RESULTS As to preceding medicines, the proportion of patients who were functionally independent (mRS 0-2) at discharge was higher in preceding P2Y12 inhibitor that suppressed ADP- and collagen-induced macro-aggregation of platelet and Xa inhibitor or warfarin in cardioembolic stroke, but lower in P2Y12 inhibitor and Xa inhibitor or warfarin in lacunar stroke compared with no medicine. Regardless of LDL-cholesterol and HA1c, the mRS at discharge ≤ 2 was increased in the third tertile of serum albumin and body mass index (BMI) in atherothrombotic stroke; serum albumin and high-density lipoprotein cholesterol (HDL-C) in lacunar stroke; and serum albumin, HDL-C and BMI in cardioembolic stroke. Logistic regression analysis identified the following independent predictors for clinical outcome: serum albumin, HDL-C, BMI, and preceding Xa inhibitor and P2Y12 inhibitor. CONCLUSION Regardless of well-known risk factors such as diabetes and high LDL-C, preceding treatment for Xa inhibitor or P2Y12 inhibitor, serum albumin, HDL-C, and BMI were associated with prognosis in recurrent ischemic stroke.
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Affiliation(s)
- Ryusei Kiboshi
- Department of Nursing Science, Hirosaki University Graduate School of Health Science, Hirosaki, Japan..
| | - Sousuke Satoh
- Department of Nursing Science, Hirosaki University Graduate School of Health Science, Hirosaki, Japan
| | - Kasumi Mikami
- Department of Nursing Science, Hirosaki University Graduate School of Health Science, Hirosaki, Japan
| | - Maiko Kitajima
- Department of Nursing Science, Hirosaki University Graduate School of Health Science, Hirosaki, Japan
| | - Mayumi Urushizaka
- Department of Nursing Science, Hirosaki University Graduate School of Health Science, Hirosaki, Japan
| | | | - Tomohiro Osanai
- Department of Nursing Science, Hirosaki University Graduate School of Health Science, Hirosaki, Japan..
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Jiwani S, Mustafa U, Desai S, Dominic P. Survival Benefit of Aspirin in Patients With Congestive Heart Failure: A Meta-Analysis. J Clin Med Res 2021; 13:38-47. [PMID: 33613799 PMCID: PMC7869561 DOI: 10.14740/jocmr4389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/10/2020] [Indexed: 11/25/2022] Open
Abstract
Background There is no clear consensus on the use of aspirin (ASA) in patients with congestive heart failure (CHF) due to its reported interaction with other cardio-prudent medications. The aim was to evaluate the effect of ASA on all-cause mortality and the frequency of hospitalization for heart failure in patients with CHF using meta-analysis, as well as to study the potential variables interacting with this effect. Methods Eligible studies were identified via a PubMed search, the “related article” feature and a manual search of references. Studies were included if they had a study population with CHF of any etiology, compared ASA to no ASA or placebo, and reported one or both of the following outcomes: 1) all-cause mortality and 2) the frequency of hospitalization for heart failure. Data were extracted and verified. We used the inverse variance method in a random-effects model to combine effect sizes. Results A total of 14 studies with a combined study population of 64,550 patients were included in the final analysis. All-cause mortality was found to be significantly lower in patients who were taking ASA (P = 0.003). When examining the use of ASA, no significant difference was found in the frequency of hospitalization for heart failure. ASA use was demonstrated to be more beneficial against mortality in studies with a larger percentage of patients on nitrates (P = 0.008) and oral anticoagulants (P = 0.04). A significantly lower rate of hospitalization for heart failure was observed in patients who used oral anticoagulants and ASA concurrently (P = 0.02). Conclusions ASA may have beneficial effects on mortality in patients with heart failure of all etiologies.
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Affiliation(s)
- Sania Jiwani
- Louisiana State University Health Sciences Center - Center for Cardiovascular Diseases and Sciences, Shreveport, LA, USA
| | - Usman Mustafa
- Louisiana State University Health Sciences Center - Center for Cardiovascular Diseases and Sciences, Shreveport, LA, USA
| | - Sapna Desai
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, USA
| | - Paari Dominic
- Louisiana State University Health Sciences Center - Center for Cardiovascular Diseases and Sciences, Shreveport, LA, USA
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Mori H, Takahashi J, Sato K, Miyata S, Takagi Y, Tsunoda R, Sumiyoshi T, Matsui M, Tanabe Y, Sueda S, Momomura S, Kaikita K, Yasuda S, Ogawa H, Shimokawa H, Suzuki H; Japanese Coronary Spasm Association. The impact of antiplatelet therapy on patients with vasospastic angina: A multicenter registry study of the Japanese Coronary Spasm Association. Int J Cardiol Heart Vasc 2020; 29:100561. [PMID: 32551361 DOI: 10.1016/j.ijcha.2020.100561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/01/2020] [Indexed: 12/23/2022]
Abstract
Background Antiplatelet therapy (APT) is generally used in patients with coronary artery disease. However, for patients with vasospastic angina (VSA), the impact of APT is not fully understood. Methods In a multicenter registry study of the Japanese Coronary Spasm Association (n = 1429), patients with or without APT were compared. The primary endpoint was major adverse cardiac events (MACEs), defined as cardiac death, non-fatal myocardial infarction, unstable angina, heart failure and appropriate ICD (Implantable cardioverter defibrillator) shock. Propensity score matching and a multivariable cox proportional hazard model were used to adjust for selection bias for treatment and potential confounding factors. Results In the whole population, 669 patients received APT, while 760 patients did not receive APT. Patients with APT had a greater prevalence of comorbidities, such as hypertension, diabetes, dyslipidemia and smoking, than those without APT. The prevalences of previous myocardial infarction, spontaneous ST changes, significant organic stenosis and medications including calcium channel blocker, nitrate, statin and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker were greater in patients with APT than those without APT. After propensity matching (n = 335 for both groups), during the median follow-up period of 32 months, the incidence rate of MACE was comparable between the patients with and without APT (P = 0.24). MACEs occurred in 5.7% of patients with APT and in 3.6% of those without APT (P = 0.20). All-cause death occurred in 0.6% of patients with APT and 1.8% of those without APT (p = 0.16). Conclusion In this multicenter registry study, anti-platelet therapy exerted no beneficial effects for VSA patients.
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Abdulhamid AK. Evaluation of the use of anti-platelet therapy throughout the peri-operative period in patients with femoral neck fracture surgery. A retrospective cohort study. Int Orthop 2020; 44:1805-13. [PMID: 32447430 DOI: 10.1007/s00264-020-04633-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/12/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Fracture neck of femur (hip fracture) is a very common problem among old age group. Such elderly patients usually have some comorbidities for which they may use anti-platelet therapy (such as clopidogrel, aspirin, or others) for long duration (chronic use). These anti-platelet medications might make the blood thin and increase bleeding tendency. So, if these elderly people present with fracture neck of femur requiring surgical intervention, they might be at increased risk of bleeding and other complications if the use of these anti-platelet agents was continued throughout the peri-operative period. OBJECTIVES This current study aims to find out whether it is safe or not to continue the use of anti-platelet drugs during the peri-operative period in patients with hip fracture surgery. If it is safe and there are no complications, then there is no harm to continue the use of these drugs peri-operatively without any surgical delay. But if it is unsafe and there is increased risk of bleeding or blood transfusion or other complications, then such medications must be stopped peri-operatively. Thus, the medical practice and care will be improved to achieve patient safety. METHODS It was a retrospective study which reviewed files and notes of patients who had hip fracture surgery. These patients were divided into 2 groups. First group was on long-term anti-platelet treatment (APTG), and the use of these medicines continued during the peri-operative phase. The second group was not on anti-platelet treatment at all (NAPTG). Then, a comparison was done between both groups in terms of the following parameters during the peri-operative (pre- and post-operative) period: (i) intra-operative blood loss, (ii) operative time in minutes (length of surgery), (iii) pre-operative haemoglobin level, (iv) the need for blood transfusion, (v) haematoma formation, (vi) re-operation for any reason, (vii) post-operative wound infection, and (viii) duration in days to achieve complete wound healing post-operatively. So these measures are good parameters to assess bleeding tendency and bleeding risk. Data was collected, and statistical analysis was done using Pearson's chi-squared test and independent sample t test as appropriate. RESULTS 325 participants were enrolled in the study. There were 163 patients in the APTG (Anti-Platelet Treatment Group) and 162 patients in the NAPTG (Non-Anti-Platelet Treatment Group). It has been found that there was no statistically significant difference between the APTG and NAPTG in terms of these peri-operative parameters: (i) intra-operative blood loss, (ii) operative time in minutes (length of surgery), (iii) pre-operative haemoglobin level, (iv) the need for blood transfusion, (v) haematoma formation, (vi) re-operation for any reason, (vii) post-operative wound infection, and (viii) duration in days to achieve complete wound healing post-operatively (P > 0.650). CONCLUSION It is safe to continue the use of anti-platelet therapy throughout the peri-operative phase in patients with hip fracture surgery. The continuation of such therapy is not associated with increased risk of bleeding or blood transfusion or other complications in patients who had surgical treatment for femoral neck fracture.
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Abstract
Excluding the left atrial appendage in patients with nonvalvular atrial fibrillation is a mechanical way to decrease stroke risk. During endothelialization, the closure device is exposed to circulating blood, which might activate the coagulation cascade. In excessive proportions, possibly resulting in the development of device-related thrombus, requiring a bridging period with optimal antithrombotic treatment. Initial protocol treatment is less suitable for patients with contraindications to anticoagulation. Less intensive antithrombotic regimens investigated suggest safety and efficacy, however further research is required. A tailored treatment, considering bleeding and thromboembolic risk based on patient/procedural characteristics in every patient, is probably the best approach.
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Affiliation(s)
- Moniek Maarse
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435CM Nieuwegein, The Netherlands.
| | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435CM Nieuwegein, The Netherlands
| | - Lucas V A Boersma
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435CM Nieuwegein, The Netherlands; Department of Cardiology, Amsterdam UMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Kinnaird T, Kwok CS, Davies R, Calvert PA, Anderson R, Gallagher S, Sirker A, Ludman P, deBelder M, Stables R, Johnson TW, Kontopantelis E, Curzen N, Mamas M. Coronary perforation complicating percutaneous coronary intervention in patients presenting with an acute coronary syndrome: An analysis of 1013 perforation cases from the British Cardiovascular Intervention Society database. Int J Cardiol 2019; 299:37-42. [PMID: 31253528 DOI: 10.1016/j.ijcard.2019.06.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 05/15/2019] [Accepted: 06/12/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND The evidence base for coronary perforation occurring during percutaneous coronary intervention in patients presenting with an acute coronary syndrome (ACS-PCI) is limited and the specific role of acute pharmacology in its clinical presentation unclear. METHODS AND RESULTS Using the BCIS PCI database, data were analysed on all ACS-PCI procedures performed in England and Wales between 2007 and 2014. Multiple regressions were used to identify predictors of coronary perforation and its association with outcomes. Propensity score matching was used to evaluate the association between differing P2Y12 inhibitors or glycoprotein inhibitors (GPI) and CP. During 270,329 ACS-PCI procedures, 1013 coronary perforations were recorded (0.37%) with a stable annual incidence. In multiple regression analysis, covariates associated with increased frequency of coronary perforation included age, female gender, CTO intervention, number and length of stents used, and rotational atherectomy use, whilst differing P2Y12 inhibitors were not predictive. Using propensity score matching, use of a GPI was independently associated with tamponade (OR 1.50, [1.08-2.06], p = 0.014). The adjusted odds ratios for all clinical outcomes were adversely affected by coronary perforation. CONCLUSIONS Coronary perforation is an infrequent event during ACS-PCI but is closely associated with adverse clinical outcomes. GPI use was associated with higher rates of tamponade.
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Affiliation(s)
- Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, UK; Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, UK.
| | - Chun Shing Kwok
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, UK; Royal Stoke Hospital, UHNM, Stoke-on-Trent, UK
| | - Rhodri Davies
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Patrick A Calvert
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Sean Gallagher
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Alex Sirker
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - Peter Ludman
- Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
| | - Mark deBelder
- Department of Cardiology, The James Cook University Hospital, Middlesbrough, UK
| | - Rod Stables
- Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital NHS Foundation Trust, UK
| | | | - Evan Kontopantelis
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, UK
| | - Nick Curzen
- Coronary Research Group, University Hospital Southampton NHS Trust, School of Medicine, University of Southampton, Southampton, UK
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, UK; Royal Stoke Hospital, UHNM, Stoke-on-Trent, UK
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Wiernek SL, Jiang B, Gustafson GM, Dai X. Cardiac implications of thrombotic thrombocytopenic purpura. World J Cardiol 2018; 10:254-266. [PMID: 30622684 PMCID: PMC6314883 DOI: 10.4330/wjc.v10.i12.254] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/20/2018] [Accepted: 11/26/2018] [Indexed: 02/06/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a multisystem disorder that essentially can affect any organ in the human body. The hallmark of the pathogenesis in TTP is the large von Willebrand factor multimers on platelet-mediated micro-thrombi formation, leading to microvascular thrombosis. Autopsy studies showed that cardiac arrest and myocardial infarction are the most common immediate causes of death in these patients. Clinical manifestations of cardiac involvement in TTP vary dramatically, from asymptomatic elevation of cardiac biomarkers, to heart failure, MI and sudden cardiac death. There is limited knowledge about optimal cardiac evaluation and management in patients with TTP. The absence of typical cardiac symptoms, combined with complicated multi-organ involvement in TTP, may contribute to the under-utilization of cardiac evaluation and treatment. Prompt diagnosis and timely initiation of effective therapy could be critically important in selected cases. Based on our experience and this review of the literature, we developed several recommendations for focused cardiac evaluation for patients with acute TTP: (1) patients with suspected or confirmed TTP should be screened for the potential presence of cardiac involvement with detailed history and physical, electrocardiogram and cardiac enzymes; (2) clinical deterioration of TTP patients warrants immediate cardiac reevaluation; (3) TTP patients with clinical evidence of cardiac involvement should be monitored for telemetry, cardiac biomarkers and evaluated with transthoracic echocardiography. These patients require urgent targeted TTP treatment as well as cardiac-specific treatment. Aspirin therapy is indicated for all TTP patients. Since epicardial coronary artery involvement is rare, cardiac catheterization is usually not required, given the high risk for hemorrhage and kidney injury; (4) we recommend evidence-based medical therapy for ischemic symptoms and heart failure. TTP patients with evidence of cardiac involvement would also benefit from routine cardiology follow up during remission.
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Affiliation(s)
- Szymon L Wiernek
- Division of Cardiology, McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
| | - Bo Jiang
- Division of Cardiology, McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
| | - Gregory M Gustafson
- Division of Cardiology, Lang Research Center, New York Presbyterian Medical Group – Queens Hospital, Flushing, NY 11355, United States
| | - Xuming Dai
- Division of Cardiology, Lang Research Center, New York Presbyterian Medical Group – Queens Hospital, Flushing, NY 11355, United States
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Zhang XL, Fu HJ, Yang GR, Wan G, Li D, Zhu LX, Xie RR, Lv YJ, Zhang JD, Li YL, Dai QF, Ji Y, Gao DY, Cui XL, Liu DY, Yuan SY, Yuan MX. The effects of cardiovascular risk factor combined anti-platelet therapy and the risk of cerebrovascular events in patients with T2DM in an urban community over 96-months follow-up: The Beijing communities diabetes study 19. Diabetes Res Clin Pract 2018; 144:236-244. [PMID: 30218743 DOI: 10.1016/j.diabres.2018.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 08/28/2018] [Accepted: 09/07/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE We investigated the prognostic significance of metabolic risk scores and aspirin with respect to cerebrovascular events. METHODS A total of 25 communities of diabetic patients were enrolled in Beijing Community Diabetes Study (BCDS) from 2008. 3413 patients with T2DM in BCDS have complete screening data, including blood glucose, blood pressure, lipid profiles and anti-platelet therapy, which were assigned metabolic score (MS) and add up to the total metabolic score (TMS). According to the total metabolic score (TMS), the patients were divided into four equal groups: Group 1 (24 < TMS < 40), Group 2 (40 < TMS < 47), Group 3 (47 < TMS < 55) and Group 4 (55 < TMS < 87). After 96 months, patients were followed-up to assess the long-term effects of the multifactorial interventions. RESULTS During 96-months follow-up, a total of 91 cerebrovascular events occurred, including acute cerebral infarction, acute cerebral hemorrhage and transient ischemic attack (TIA). The incidence of cerebrovascular events was higher in the Group 4 than in the Group 1. In Cox multivariate analyses, there are significant differences in incidences of cerebral infarction events among the four groups during the 96-months follow-up. Cox proportional hazards analysis revealed that, HbA1c (p ≤ 0.001), systolic pressure (p ≤ 0.001), aspirin free treatment (P = 0.0023) are independent predictor for cerebrovascular events in diabetic patients. CONCLUSIONS This study indicates that total metabolic score (TMS) influences the incidence of cerebrovascular events in diabetic patients. In addition to good control of blood glucose, blood pressure and lipid profiles, anti-platelet therapy is important for the prevention of cerebrovascular events in T2DM. TRIAL REGISTRATION ChiCTR-TRC-13003978, ChiCTR-OOC-15006090.
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Affiliation(s)
- Xue-Lian Zhang
- Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Han-Jing Fu
- Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Guang-Ran Yang
- Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Gang Wan
- Medical Records and Statistics Department, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Dongmei Li
- Clinical and Translational Science Institute, School of Medicine and Dentistry, University of Rochester, USA
| | - Liang-Xiang Zhu
- Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Rong-Rong Xie
- Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yu-Jie Lv
- Cuigezhuang Community Health Service Center, Beijing, China
| | | | - Yu-Ling Li
- Xinjiekou Community Health Service Center, Beijing, China
| | - Qin-Fang Dai
- Yuetan Community Health Service Center of Fuxing Hospital, Capital Medical University, Beijing, China
| | - Yu Ji
- Department of Endocrinology, Beijing Aerospace General Hospital, Beijing, China
| | | | - Xue-Li Cui
- Sanlitun Community Health Service Center, Beijing, China
| | - De-Yuan Liu
- Zuojiazhuang Community Health Service Center, Beijing, China
| | - Shen-Yuan Yuan
- Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
| | - Ming-Xia Yuan
- Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
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Abstract
The association between coagulation and cancer development has been observed for centuries. However, the connection between inflammation and malignancy is also well-recognized. The plethora of evidence indicates that among multiple hemostasis components, platelets play major roles in cancer progression by providing surface and granular contents for several interactions as well as behaving like immune cells. Therefore, the anticancer potential of anti-platelet therapy has been intensively investigated for many years. Anti-platelet agents may prevent cancer, decrease tumor growth, and metastatic potential, as well as improve survival of cancer patients. On the other hand, there are suggestions that antiplatelet treatment may promote solid tumor development in a phenomenon described as "cancers follow bleeding." The controversies around antiplatelet agents justify insight into the subject to establish what, if any, role platelet-directed therapy has in the continuum of anticancer management.
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Affiliation(s)
- Marek Z Wojtukiewicz
- Department of Oncology, Medical University of Bialystok, 12 Ogrodowa St., 15-025, Bialystok, Poland.
| | - Dominika Hempel
- Department of Radiotherapy, Comprehensive Cancer Center in Bialystok, Bialystok, Poland
| | - Ewa Sierko
- Department of Clinical Oncology, Comprehensive Cancer Center in Bialystok, Bialystok, Poland
| | - Stephanie C Tucker
- Department of Pathology-School of Medicine, Bioactive Lipids Research Program, Detroit, MI, 48202, USA
| | - Kenneth V Honn
- Department of Pathology-School of Medicine, Bioactive Lipids Research Program, Detroit, MI, 48202, USA.,Departments of Chemistry, Wayne State University, Detroit, MI, 48202, USA.,Department of Oncology, Karmanos Cancer Institute, Detroit, MI, 48202, USA
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Abstract
GOALS Transcatheter aortic valve or leaflets thrombosis are mainly misapprehended. It negatively impacts the long-term efficiency of such prosthesis. Moreover, its incidence is presumably higher than previously described. EPIDEMIOLOGY Recently reported subclinical leaflet thrombosis, occurring between first to third months after implantation, is about 10to 15%. All prosthesis are concerned by potential thrombosis. DIAGNOSIS Transcatheter aortic valve thrombosis is usually detected on the basis of increased transvalvular pressure gradients or symptoms at routine follow-up. Main causes of post-TAVI thrombosis are: elderly patients, incomplete TAVI expansion, incomplete TAVI apposition to the aortic wall, areas of diminished blood flow and stagnation around the prosthesis. Main risk-factors of thrombosis are: large valves, patients with ejection fraction lower than 35%, valve-in-valve implantation, males, patients with large sinus of Valsalva, patients without anticoagulants. TREATMENT Post-TAVI anti thrombotic regimen remains empirical. It is based on aspirin alone or dual antiplatelet therapy for 1-6months, followed by aspirin for life. Symptomatic patients with thrombus-based valve dysfunction are to be treated by oral anticoagulation (i.e., VKA or new oral anticoagulants NOAC). This treatment allows the restoration of normal leaflet motion in patients with a median time of 14 days.
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Affiliation(s)
- D Leguay
- Unité de cardiologie interventionnelle, polyclinique de Courlancy, 38, rue de Courlancy, 51100 Reims, France
| | - S Duval
- Unité de cardiologie interventionnelle, polyclinique de Courlancy, 38, rue de Courlancy, 51100 Reims, France
| | - M Leroux
- Unité de cardiologie interventionnelle, polyclinique de Courlancy, 38, rue de Courlancy, 51100 Reims, France
| | - A Monnier
- Unité de cardiologie interventionnelle, polyclinique de Courlancy, 38, rue de Courlancy, 51100 Reims, France
| | - Y Davienne
- Unité de cardiologie interventionnelle, polyclinique de Courlancy, 38, rue de Courlancy, 51100 Reims, France
| | - C Brasselet
- Unité de cardiologie interventionnelle, polyclinique de Courlancy, 38, rue de Courlancy, 51100 Reims, France.
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Boccalandro F, Dhindsa M, Subramaniyam P, Mok M. Feasibility of coronary fractional flow reserve with dual anti-platelet therapy in low risk coronary lesions without systemic anticoagulation-results of the SMART-FFR study. Cardiovasc Revasc Med 2017; 19:343-347. [PMID: 28927636 DOI: 10.1016/j.carrev.2017.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 08/13/2017] [Accepted: 08/15/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Fractional flow reserve (FFR) is used to assess the functional significance of coronary artery stenoses. The optimal anti-thrombotic regimen for FFR has not been studied. PURPOSE The goal of this study was to determine whether FFR could be safely performed in Type A coronary lesions, using only upstream dual anti-platelet therapy (DAT) with aspirin and clopidogrel, compared with DAT plus anticoagulation in low risk coronary lesions. METHODS/MATERIALS Two hundred patients undergoing FFR for Type A intermediate coronary lesions were blindly randomized into two groups of 100 patients each. Group 1: Upstream DAT, without intra-procedural anti-coagulation and Group 2: Upstream DAT plus intra-procedural bivalirudin. The primary end-points were any coronary thrombotic complications during the index hospital stay, and a composite end-point of any major adverse cardiovascular events (MACE) at 30-days. Secondary end-points included post-procedure troponin levels and TIMI major and minor bleeding scores. RESULTS There were no thrombotic complications reported. At 30-days, two MACE occurred in Group 1, and three in Group 2 (p=0.83). No difference was seen in the post-procedure troponin levels (p=0.72), or TIMI bleeding scores study between groups (p=093). CONCLUSIONS This initial study evaluating a simplified anti-thrombotic regimen for FFR, suggests that FFR can be performed in low risk coronary lesions using DAT without the need for intra-procedural anticoagulation, with similar results as DAT plus anticoagulation with bivalirudin. Further research in this area is needed to determine the optimal and most cost-effective anti-thrombotic regimen for FFR calculation.
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Affiliation(s)
- Fernando Boccalandro
- ProCare - Odessa Heart Institute, Odessa, TX, United States; Permian Research Foundation, Odessa, TX, United States; Department of Internal Medicine, Texas Tech University Health Science Center, Odessa, TX, United States.
| | - Mandeep Dhindsa
- Department of Internal Medicine, Texas Tech University Health Science Center, Odessa, TX, United States
| | - Prem Subramaniyam
- Michigan State University, Department of Internal Medicine, Lansing, MI, United States
| | - Mary Mok
- University of Texas San Antonio, Department of Internal Medicine, San Antonio, TX, United States
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Ebisawa S, Ueki Y, Mochidome T, Senda K, Nishimura H, Saigusa T, Miura T, Motoki H, Koyama J, Ikeda U. Comparison of platelet aggregation response in switching regimen from prasugrel to clopidogrel between CYP2C19 extensive versus non-extensive metabolizers. Cardiovasc Interv Ther 2018; 33:277-84. [PMID: 28681220 DOI: 10.1007/s12928-017-0482-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 06/23/2017] [Indexed: 10/19/2022]
Abstract
Little is known about the response of platelet aggregation in patients with acute coronary syndrome (ACS) when prasugrel is changed to clopidogrel. In this study, we evaluated the pharmacodynamic effects of this medication switch. Twenty-one consecutive ACS patients received prasugrel 20 mg as a loading dose before emergent percutaneous coronary intervention and 3.75 mg as a maintenance dose on days 2-7 (prasugrel phase). From day 8, prasugrel was switched to clopidogrel 75 mg/day (clopidogrel phase). P2Y12 reaction units (PRU) were measured 2-4 h after prasugrel loading, and on days 7, 11, 13, 15, and 42. Eight patients had the CYP2C19 extensive metabolizer (EM) genotype variant, while 13 were non-EM. In the EM group, no changes were observed in PRU level between days 7 and 15 (136.8 ± 51.2 vs. 166.2 ± 41.9, P = 0.07). However, in the non-EM group, a significant increase in PRU levels was observed between days 7 and 15 (165.8 ± 57.2 vs. 223.6 ± 60.9, P = 0.002). However, 2 patients in the non-EM group (15%) showed high on-clopidogrel treatment platelet reactivity (HTPR) 2-4 h after prasugrel loading, and during the clopidogrel phase there were significant differences in the incidence of HTPR between the EM and non-EM groups. Ischemic and bleeding events were not observed during this period. In the acute phase of ACS, changing from prasugrel to clopidogrel therapy decreased the effects of suppressing platelet aggregation. However, this change was not associated with increased ischemic or bleeding events.
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Jones LM, Coffey RA, Natwa MP, Bailey JK. The use of intravenous tPA for the treatment of severe frostbite. Burns 2017; 43:1088-1096. [PMID: 28159151 DOI: 10.1016/j.burns.2017.01.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/02/2016] [Accepted: 01/07/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE tPA and anticoagulation for treatment of severe frostbite have been reported suggesting differences in imaging techniques, route of tPA administration and management of patients after tPA infusion. This is a report of our results following a protocol of Tc-99m scanning, intravenous tPA administration, followed by either systemic anticoagulation or antiplatelet therapy. METHODS Patients admitted to our burn center between February 13, 2015 and February 13, 2016 for frostbite who met inclusion criteria were treated with Tc-99m scan and intravenous tPA followed by systemic anticoagulation or antiplatelet therapy. Inclusion criteria included rewarming had not started more than 24h prior to the scan and no contraindications to the use of tPA. RESULTS Fifteen patients met inclusion criteria and 12 were treated according to the protocol. Nine received scans with 2 showing normal perfusion. Seven displayed perfusion defects and received intravenous tPA. Five recovered fully after tPA. Two who showed improved but abnormal scans after tPA experienced bleeding complications necessitating stopping heparin/Coumadin. Those two went on to partial amputation of digits. CONCLUSION The use of intra-arterial or intravenous tPA along with angiography or Tc-99m scanning followed by systemic anticoagulation or antiplatelet therapy may be beneficial to patients suffering frostbite.
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Affiliation(s)
- Larry M Jones
- Department of Surgery, Division of Critical Care, Trauma and Burn, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - Rebecca A Coffey
- Department of Surgery, Division of Critical Care, Trauma and Burn, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - Mona P Natwa
- Department of Radiology, Division of Nuclear Medicine, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - J Kevin Bailey
- Department of Surgery, Division of Critical Care, Trauma and Burn, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH 43210, USA.
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Hally KE, La Flamme AC, Larsen PD, Harding SA. Toll-like receptor 9 expression and activation in acute coronary syndrome patients on dual anti-platelet therapy. Thromb Res 2016; 148:89-95. [PMID: 27815972 DOI: 10.1016/j.thromres.2016.10.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/05/2016] [Accepted: 10/25/2016] [Indexed: 01/22/2023]
Abstract
INTRODUCTION The Toll-like receptor 9 (TLR9) pathway can activate platelets but its role in acute coronary syndromes (ACS) is unknown. This study examined TLR9 expression and platelet activation in response to ODN2006, a TLR9 agonist, in healthy subjects and in ACS subjects treated with dual anti-platelet therapy (DAPT). MATERIALS AND METHODS TLR9 expression was examined in both resting and thrombin receptor activator peptide (TRAP)-activated platelets (1 and 10μM) from healthy and ACS subjects by flow cytometry. In both cohorts, ODN2006-mediated platelet activation (5μM) was examined in whole blood (WB) and platelet-rich plasma (PRP) using cell-surface CD62p and CD63 expression by flow cytometry. RESULTS Baseline TLR9 expression was significantly greater in ACS subjects compared to healthy subjects (p<0.01). Following TRAP activation, TLR9 expression increased dose-dependently in healthy subjects. However, no difference in TLR9 expression was seen in ACS platelets following TRAP activation. ODN2006 treatment resulted in significant increases in cell-surface expression of CD62p and CD63 in both WB (all p<0.001) and PRP (all p<0.001) in comparison to unstimulated platelets in healthy subjects. Despite DAPT, ODN2006 treatment produced significant increases in both activation markers in the ACS cohort across WB and PRP (all p<0.0001). Elevated baseline expression of TLR9 in ACS platelets may indicate increased sensitivity to TLR9 agonists and contribute to increased platelet activation in these patients. Furthermore, ODN2006 stimulation can activate platelets in ACS subjects despite treatment with DAPT. CONCLUSION This study demonstrates TLR9 expression and activation to be of potential therapeutic importance in ASC patients.
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Affiliation(s)
- Kathryn E Hally
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand; Wellington Cardiovascular Research Group, Wellington, New Zealand.
| | - Anne C La Flamme
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand; Wellington Cardiovascular Research Group, Wellington, New Zealand
| | - Peter D Larsen
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand; Wellington Cardiovascular Research Group, Wellington, New Zealand; Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Scott A Harding
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand; Wellington Cardiovascular Research Group, Wellington, New Zealand; Department of Cardiology, Wellington Hospital, Wellington, New Zealand
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Elgafy H, Peters N, Lea JE, Wetzel RM. Hemorrhagic lumbar synovial facet cyst secondary to transforaminal epidural injection: A case report and review of the literature. World J Orthop 2016; 7:452-457. [PMID: 27458557 PMCID: PMC4945513 DOI: 10.5312/wjo.v7.i7.452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 03/12/2016] [Accepted: 05/11/2016] [Indexed: 02/06/2023] Open
Abstract
A 64-year-old-female presented with progressive left foot weakness, low back and radicular pain after a left sided S1 transforaminal epidural steroid injection (ESI). Magnetic resonance imaging revealed left side L5-S1 large extradural heterogeneous mass with layering areas suggesting different stages of hematoma formation. Past medical history was significant for peripheral vascular disease and transient ischemic attacks, for which she took aspirin and clopidogrel (antiplatelet agent). These medications were discontinued one week prior to ESI. Although synovial cysts associated with facet arthropathy are common, hemorrhagic cyst is not. To the best of the authors’ knowledge, this is the first reported case of symptomatic hemorrhagic lumbar facet synovial cyst following ESI on a patient taking anti-platelet medications.
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Binderup HG, Houlind K, Madsen JS, Brasen CL. Aspirin resistance may be identified by miR-92a in plasma combined with platelet distribution width. Clin Biochem 2016; 49:1167-1172. [PMID: 27208561 DOI: 10.1016/j.clinbiochem.2016.04.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 04/15/2016] [Accepted: 04/16/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Aspirin is a widely used drug for prevention of thrombotic events in cardiovascular patients, but approximately 25% of patients experience insufficient platelet inhibition due to aspirin, and remain in risk of cardiovascular events. This study aimed to investigate the value of circulating miR-92a and platelet size as biomarkers of the individual response to aspirin therapy. METHODS Blood samples were collected from 50 healthy blood donors without antithrombotic medication and 50 patients with intermittent claudication on daily aspirin therapy. Based on results from the arachidonic acid stimulated aggregation test on Multiplate®analyzer (ASPItest), patients were defined as aspirin resistant (n=10) or aspirin responders (n=40). Plasma levels of miR-92a were evaluated by RT-qPCR analysis and platelet distribution width (PDW) was used to assess platelet size variability. Receiver operating characteristic curves for miR-92a levels and PDW were used to set cut-off values for discrimination between aspirin responding and aspirin resistant patients. RESULTS When defining aspirin resistance as an ASPItest ≥30U, the optimal cut-off values for discrimination of aspirin responders and aspirin resistant patients were found to be PDW>11.8fL and a relative expression level of miR-92a>4.5. Using these cut-off values we could define a PDW/miR-92a-score with a specificity of 97.5% and a sensitivity of 80.0% in relation to detect aspirin resistance. The corresponding positive and negative predictive values were found to be 88.9% and 95.1%, respectively. CONCLUSION Aspirin resistance can potentially be identified by miR-92a levels in plasma combined with PDW.
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Affiliation(s)
- Helle Glud Binderup
- Department of Clinical Immunology and Biochemistry, Lillebaelt Hospital, Kabbeltoft 25, 7100 Vejle and Skovvangen 2-8, 6000 Kolding, Denmark.
| | - Kim Houlind
- Department of Vascular Surgery, Lillebaelt Hospital, Skovvangen 2-8, 6000 Kolding, Denmark; Institute of Regional Health Research, University of Southern Denmark, Denmark
| | - Jonna Skov Madsen
- Department of Clinical Immunology and Biochemistry, Lillebaelt Hospital, Kabbeltoft 25, 7100 Vejle and Skovvangen 2-8, 6000 Kolding, Denmark; Institute of Regional Health Research, University of Southern Denmark, Denmark
| | - Claus Lohman Brasen
- Department of Clinical Immunology and Biochemistry, Lillebaelt Hospital, Kabbeltoft 25, 7100 Vejle and Skovvangen 2-8, 6000 Kolding, Denmark
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Sadhasivam G, Bhushan S, Chiang KC, Agarwal N, Vasundhar PL. Clinical Trial Evaluating the Risk of Thromboembolic Events During Dental Extractions. J Maxillofac Oral Surg 2016; 15:506-11. [PMID: 27833344 DOI: 10.1007/s12663-016-0904-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 03/24/2016] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Discontinuation of anti-platelet therapy increases the risk of thrombotic complications whereas its continuation is believed to increase the risk of prolonged post-extraction bleeding. We therefore, performed this study to evaluate the risk of significant bleeding following dental extractions and also to assess the necessity of discontinuing anti-platelet therapy. PATIENTS AND METHODS Three hundred patients requiring dental extraction were included in the study in which 200 patients were on anti-platelet therapy. Patients were divided into three groups of 100 patients each. Group 1 consisted of patients continuing their anti-platelet therapy, Group 2 consisted of patients whose anti-platelet therapy was interrupted and Group 3 comprised of healthy patients not on anti-platelet therapy. Preoperative bleeding and clotting time were determined for all patients. The procedure involved single or multiple teeth (>3 teeth) extractions under local anesthesia with a vasoconstrictor. Pressure pack was given in all cases as in routine dental extractions and bleeding was checked after 15, 30 min, 1, 24, 48 h and 1 week. Immediate post-extraction bleeding was considered to be prolonged if it continued beyond 30 min in spite of the pressure pack. Late and very late bleeding was considered to be clinically significant if it extended beyond 12 and 24 h respectively. RESULTS The mean bleeding time in Groups 1, 2, and 3 were 1 min and 32 s, 1 min and 25 s, and 1 min and 27 s, respectively. Prolonged immediate post-extraction bleeding (bleeding after 30 min) was present among 9 patients in Group 1 (9 %) and 15 patients in Group 2 (15 %) whereas it was not seen in any patient of Group 3. Bleeding after 1 h was present in 9 patients of Group 2 (9 %) and was controlled with gelatin sponge within half an hour thereafter. None of the patients in any group reported with bleeding after 24, 48 h and 1 week. CONCLUSION Dental extractions can be safely carried out in patients on anti-platelet therapy without the risk of significant post-extraction bleeding thus averting the risk of thromboembolic events that might take place on temporary discontinuation of antiplatelet therapy.
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Kagawa Y, Shiode N, Kawase T, Tamekiyo H, Okimoto T, Hayashi Y. A case of subacute stent thrombosis after drug-coated balloon coronary angioplasty for in-stent restenosis under single anti-platelet therapy. Cardiovasc Interv Ther 2017; 32:170-3. [PMID: 26979600 DOI: 10.1007/s12928-016-0386-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 02/29/2016] [Indexed: 10/22/2022]
Abstract
This report describes a case of subacute stent thrombosis (SAT) after drug-coated balloon (DCB). A 79-year-old male was investigated for stable angina. An in-stent restenosis (ISR) lesion was detected by coronary angiography. A skin reaction related to the anti-platelet agent thienopyridine was also observed at this time. Therefore, DCB was used to treat the ISR lesion under single anti-platelet therapy (aspirin). However, 3 days after percutaneous coronary intervention, SAT occurred. OCT did not reveal the underlying cause of SAT. Further data are needed to clarify the optimal duration of dual anti-platelet therapy after DCB.
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Huang HP, Lin WH, Chen SG, Chen LZ, Chen MY, Che CH. Comparative Efficacy and Safety of Nine Anti-Platelet Therapies for Patients with Ischemic Stroke or Transient Ischemic Attack: a Mixed Treatment Comparisons. Mol Neurobiol 2017; 54:1456-66. [PMID: 26846361 DOI: 10.1007/s12035-016-9739-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 01/20/2016] [Indexed: 10/22/2022]
Abstract
Anti-platelet treatments, an effective anti-thrombotic therapy, are widely used in non-cardioembolic ischemic stroke or transient ischemic attack (TIA), including aspirin, cilostazol, clopidogrel, and other mono or dual therapies, while the optimal choice remains uncertain. All the literatures of 38 eligible randomized control trials were searched in PubMed, Embase, and China National Knowledge Internet (CNKI) without language limitation. And, nine anti-platelet therapies were assessed, including aspirin, clopidogrel, cilostazol, ticlopidine, triflusal, terutroban, sarpogrelate, dipyridamole plus aspirin, and clopidogrel plus aspirin. Additionally, we extract data of composite vascular events, major bleeding, ischemic stroke, intracranial hemorrhage, and all-cause death, as indicators of efficacy and safety. And among them, composite vascular events were the primary outcome. The binary outcomes were expressed as odds ratios (ORs) with corresponding 95 % confidence intervals (CIs). Both traditional meta-analysis and network meta-analysis were performed. Besides, for each outcome, the rank order was applied to reflect the superiority of every therapy compared with others, using the surface under the cumulative ranking curve (SUCRA). A cluster analysis was also conducted. Through the network meta-analysis, the synthesized data shows that cilostazol performed best on composite vascular events compared with placebo (OR = 0.62, 95 % CI 0.46-0.83) and aspirin (OR = 0.71, 95 % CI 0.53-0.95). In terms of ischemic stroke, clopidogrel plus aspirin seems the optimal, and it has significant difference between placebo (OR = 0.53, 95 % CI 0.35-0.74) and aspirin (OR = 0.75, 95 % CI 0.61-0.95). Meanwhile, cilostazol is also the first rank in major bleeding, especially when it is in contrast to aspirin (OR = 0.13, 95 % CI 0.02-0.70) and clopidogrel plus aspirin (OR = 0.09, 95 % CI 0.01-0.50). There is no significant difference among these nine treatments and placebo, as to all-cause death and intracranial hemorrhage. According to the cluster analysis, cilostazol can be the best choice with comprehensive assessment of composite vascular events, ischemic stroke and major bleeding. Based on this network meta-analysis, cilostazol was recommended as the optimal choice with good performance in both efficacy and safety for patient with ischemic stroke or TIA among nine anti-platelet therapies.
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Habib A, Finn AV. Endothelialization of drug eluting stents and its impact on dual anti-platelet therapy duration. Pharmacol Res 2014; 93:22-7. [PMID: 25533811 DOI: 10.1016/j.phrs.2014.12.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 12/12/2014] [Accepted: 12/13/2014] [Indexed: 01/12/2023]
Abstract
Coronary artery disease is a leading cause of death and disability worldwide with contemporary treatment strategies employing both optimal medical therapy and catheter based percutaneous coronary intervention (PCI) with drug eluting stents (DES). While DES have dramatically reduced restenosis rates, their use has been associated with an increased risk of late stent thrombosis and accelerated neointimal atherosclerosis (i.e. "neoatherosclerosis") both major contributors to late stent failure. The underlying substrate of late DES failure is likely related to vascular endothelial dysfunction such as poor endothelial regrowth and barrier function (i.e. "endothelial healing"). Initial concerns with 1st generation DES have lead to improvements in mechanical and biologic properties of current 2nd generation DES, which inhibit endothelial regrowth to a lesser extent, lessening late stent failure and resulting in an overall improved safety profile. Current guidelines recommend duration of at least one year of dual anti-platelet therapy with aspirin and a thienopyridine agent such as clopidogrel or prasugrel as sufficient to prevent late thrombotic complications. Recent studies, however, suggest a shorter duration of dual anti-platelet therapy may be equally as safe and efficacious in preventing stent thrombosis with newer generation DES. However, higher risk populations such as patients receiving 1st generation DES or those with increased risk for future ischemic events may benefit from a longer duration (i.e. 30 months) of DAPT to prevent major cardiovascular events with the caveat that such an approach may be associated with an increased risk for bleeding. This review examines the vascular responses to 1st and second generation DES and recent clinical trials examining DAPT duration.
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Affiliation(s)
- Anwer Habib
- Department of Internal Medicine, Division of Cardiology, Emory University School of Medicine, 101 Woodruff Circle, WMB319B, Atlanta, GA 30322, United States
| | - Aloke V Finn
- Department of Internal Medicine, Division of Cardiology, Emory University School of Medicine, 101 Woodruff Circle, WMB319B, Atlanta, GA 30322, United States.
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O I, M O, A AS, Hh CH, W SF, Rahman M. Evaluation of Aspirin and Clopidogrel resistance in patients with Acute Coronary Syndrome by using Adenosine Diposphate Test and Aspirin Test. Pak J Med Sci 2013; 29:97-102. [PMID: 24353516 PMCID: PMC3809214 DOI: 10.12669/pjms.291.2820] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 10/04/2012] [Accepted: 10/05/2012] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To evaluate Aspirin and Clopidogrel resistance/non-responders in patients with acute coronary syndrome (ACS) by using adenosine diposphate and aspirin tests. METHODOLOGY In the study patients with ACS loaded with 300 mg of clopidogrel and 300 mg aspirin and patients on stable daily dose of 75 mg of clopidogrel (more than 3 days) underwent PCI. Response to clopidogrel and Aspirin was assessed by Adenosine Diphosphate (ADP) Test (20 µmol/L) and Aspirin Test (Acetyl Acid) (ASP) 20 µmol/L, respectively, using the Multiplate Platelet Function Analyzer (Dynabyte Medical, Munich, Germany). RESULTS Sixty four patients were included in this study out of which 57 were with ACS and 7 scheduled for percutaneous coronary intervention (PCI) electively. The proportion of Aspirin good responders and adequate responders were 76.56% and 18.75%, respectively while adequate response and good response to Clopidogrel accounted for 29.7 and 48.4%, respectively Hyperlipidaemia was only co-morbidity associated with higher AUC ADP value (p: 0.046). Hypertriglyceridaemia and serum calcium were weakly correlated with higher AUC ADP serum calcium r=0.08, triglyceride r=0.12. Patients admitted for scheduled PCI and on stable dose of 75mg clopidogrel exhibited lower AUC ADP value as compared to those admitted with acute coronary syndrome given loading dose of 300mg of Clopidogrel. Post loading dose measurement of anti-platelet therapy among ACS patients using the Multiplate Platelet Function Analyzer showed comparable results with other methods. Conclusions : As determined by Multiplate Platelet Function Analyzer, Aspirin resistance/non-responders in this study in acute coronary syndrome patients accounted for 4.69% while Non-responders in Clopidogrel was 21.9%.
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Affiliation(s)
- Ibrahim O
- Ibrahim O, Department of Medicine, Faculty of Medicine, University Kebangsaan Malaysia Medical Centre, Cheras 56000, Kula Lumpur, alaysia
| | - Oteh M
- Oteh M, Consultant Cardiologist, Unit Cardiology, Department of Medicine, Faculty of Medicine, University Kebangsaan Malaysia Medical Centre, Cheras 56000, Kula Lumpur, alaysia
| | - A Syukur A
- A Syukur A, Department of Medicine, Faculty of Medicine, University Kebangsaan Malaysia Medical Centre, Cheras 56000, Kula Lumpur, alaysia
| | - Che Hassan Hh
- Che Hassan HH, Department of Medicine, Faculty of Medicine, University Kebangsaan Malaysia Medical Centre, Cheras 56000, Kula Lumpur, alaysia
| | - S Fadilah W
- S Fadilah W, Consultant Haematologist and Head, Department of Medicine, Faculty of Medicine, University Kebangsaan Malaysia Medical Centre, Cheras 56000, Kula Lumpur, alaysia
| | - Mm Rahman
- MM Rahman, Professor, Department of Medical Microbiology & Immunology, Faculty of Medicine, University Kebangsaan Malaysia Medical Centre, Cheras 56000, Kula Lumpur, alaysia
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Litzler PY, Smail H, Barbay V, Nafeh-Bizet C, Bouchart F, Baste JM, Abriou C, Bessou JP. Is anti-platelet therapy needed in continuous flow left ventricular assist device patients? A single-centre experience. Eur J Cardiothorac Surg 2013; 45:55-9; discussion 59-60. [PMID: 23671203 DOI: 10.1093/ejcts/ezt228] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES We report our 5-year experience of continuous flow left ventricular assist device (LVAD) implantation without the use of anti-platelet therapy. METHODS Between February 2006 and September 2011, 27 patients (26 men; 1 woman) were implanted with a continuous flow LVAD (HeartMate II, Thoratec Corporation, Pleasanton, CA, USA). The mean age was 55.7 ± 9.9 years. The mean duration of support was 479 ± 436 (1-1555) days with 35.4 patient-years on support. Twenty-one patients were implanted as a bridge to transplantation and 6 for destination therapy. The anticoagulation regimen was fluindione for all patients, with aspirin for only 4 patients. At the beginning of our experience, aspirin was administered to 4 patients for 6, 15, 60 and 460 days. Due to gastrointestinal (GI) bleeding and epistaxis, aspirin was discontinued, and since August 2006, no patients have received anti-platelet therapy. RESULTS At 3 years, the survival rate during support was 76%. The most common postoperative adverse event was GI bleeding (19%) and epistaxis (30%) (median time: 26 days) for patients receiving fluindione and aspirin. The mean International Normalized Ratio (INR) was 2.58 ± 0.74 during support. Fifteen patients have been tested for acquired Von Willebrand disease. A diminished ratio of collagen-binding capacity and ristocetin cofactor activity to Von Willebrand factor antigen was observed in 7 patients. In the postoperative period, 2 patients presented with ischaemic stroke at 1 and 8 months. One of these 2 patients had a previous history of carotid stenosis with ischaemic stroke. There were no patients with haemorrhagic stroke, transient ischaemic attack or pump thrombosis. The event rate of stroke (ischaemic and haemorrhagic) per patient-year was 0.059 among the patients without aspirin with fluindione regimen only. CONCLUSIONS A fluindione regimen without aspirin in long-duration LVAD support appears to not increase thromboembolic events and could lead to a diminished risk of haemorrhagic stroke.
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Affiliation(s)
- Pierre-Yves Litzler
- Department of Thoracic and Cardiovascular Surgery, Rouen University Hospital Charles Nicolle, Rouen, France
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Brugaletta S, Martin-Yuste V, Ferreira-González I, Cola C, Alvarez-Contreras L, Antonio MD, Garcia-Moll X, García-Picart J, Martí V, Balcells-Iranzo J, Sabaté M. Adequate antiplatelet regimen in patients on chronic anti-vitamin K treatment undergoing percutaneous coronary intervention. World J Cardiol 2011; 3:367-73. [PMID: 22125672 PMCID: PMC3224870 DOI: 10.4330/wjc.v3.i11.367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 09/11/2011] [Accepted: 09/17/2011] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the impact of dual antiplatelet therapy (DAT) in patients on anti-vitamin K (AVK) regimen requiring percutaneous coronary intervention (PCI). METHODS Between February 2006 and February 2008, 138 consecutive patients under chronic AVK treatment were enrolled in this registry. Of them, 122 received bare metal stent implantation and 16 received drug eluting stent implantation. The duration of DAT, on top of AVK treatment, was decided at the discretion of the clinician. Adequate duration of DAT was defined according to type of stent implanted and to its clinical indication. RESULTS The baseline clinical characteristics of patients reflect their high risk, with high incidence of comorbid conditions (Charlson score ≥ 3 in 89% of the patients). At a mean follow-up of 17 ± 11 mo, 22.9% of patients developed a major adverse cardiac event (MACE): 12.6% died from cardiovascular disease and almost 6% had an acute myocardial infarction. Major hemorrhagic events were observed in 7.4%. Adequate DAT was obtained in only 44% of patients. In the multivariate analysis, no adequate DAT and Charlson score were the only independent predictors of MACE (both P = 0.02). CONCLUSION Patients on chronic AVK therapy represent a high risk population and suffer from a high MACE rate after PCI. An adequate DAT regimen and absence of comorbid conditions are strongly associated with better clinical outcomes.
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Affiliation(s)
- Salvatore Brugaletta
- Salvatore Brugaletta, Victoria Martin-Yuste, Luis Alvarez-Contreras, Manel Sabaté, Thorax Institute, Department of Cardiology, Hospital Clinic, 08036 Barcelona, Spain
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Kumar AJ, Kumari MM, Arora N, Haritha A. Is anti-platelet therapy interruption a real clinical issue? Its implications in dentistry and particularly in periodontics. J Indian Soc Periodontol 2011; 13:121-5. [PMID: 20379408 PMCID: PMC2848781 DOI: 10.4103/0972-124x.60223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2009] [Accepted: 11/27/2009] [Indexed: 11/12/2022] Open
Abstract
The use of anti-platelet therapy has reduced the mortality and morbidity of cardiovascular disease remarkably. A considerable number of patients presenting before a dentist or periodontist give a history of anti-platelet therapy. A clinical dilemma whether to discontinue the anti-platelet therapy or continue the same always confronts the practitioner. Diverse opinions exist regarding the management of such patients. While one group of researchers advise continuation of anti-platelet therapy rather than invite remote, but possible, thromboembolic events, another group encourages discontinuation for variable periods. This study aims at reviewing the current rationale of anti-platelet therapy and the various options available to a clinician, with regard to the management of a patient under anti-platelet therapy. Current recommendations and consensus favour no discontinuation of anti-platelet therapy. This recommendation, however, comes with a rider to use caution and consider other mitigating factors as well. With a large number of patients giving a history of anti-platelet therapy, the topic is of interest and helps a clinician to arrive at a decision.
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Affiliation(s)
- A Jaya Kumar
- Department of Periodontics, Sri Sai College of Dental Surgery, Vikarabad, Andhra Pradesh, India
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