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De Servi S, Landi A, Savonitto S. Clopidogrel induced reduction in neutrophil count: An overlooked beneficial effect? Eur J Intern Med 2024:S0953-6205(24)00135-3. [PMID: 38582734 DOI: 10.1016/j.ejim.2024.03.026] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/02/2024] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
Complement-stimulated neutrophils are able to adhere to the endothelium and damage endothelial cells both in vitro and in vivo. These blood cells participate in the early stages, growth and complications of atherosclerotic plaques. Recent findings, based on mendelian randomization analysis, support the concept that high neutrophil counts are a causal risk factor for ischemic heart disease and myocardial infarction . Clopidogrel decreases leukocyte count and inflammatory markers in patients with acute coronary syndromes; this off-target effect, which is independent of the antiplatelet action, may help explaining secondary prevention data showing a superiority of clopidogrel over aspirin in reducing new cardiovascular events.
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Affiliation(s)
- Stefano De Servi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.
| | - Antonio Landi
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), University of Italian Switzerland, CH-6900, Lugano, Switzerland
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Jebrin R, El Nekidy WS, Abidi E, John TLS, Kesav P, Hussain SI, Abdelsalam M, Khaled L, Raj D, John S. Racial differences in P2Y12 inhibitor responsiveness in patients undergoing neuro-endovascular procedures: A cohort from the Middle East. Clin Neurol Neurosurg 2024; 239:108167. [PMID: 38402103 DOI: 10.1016/j.clineuro.2024.108167] [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: 10/21/2023] [Revised: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Data on P2Y12 inhibitors responsiveness from the middle east is scarce. We sought to investigate patient responsiveness to P2Y12 inhibitors within a cohort of major races that characterize the UAE population. The secondary objective was to assess risk factors for hyper and hypo-responsiveness in this population. METHODS We conducted a cross-sectional study on adults who received either clopidogrel or ticagrelor treatments and had platelet responsiveness testing before undergoing neuro-endovascular interventions at our quaternary care hospital between March 2015 and April 2019. RESULTS During the study period, 249 subjects met the inclusion criteria. Overall, 17.3 % were hyper-responsive and 25.7 % were hypo-responsive to P2Y12 inhibitors. When comparing between the P2Y12 inhibitors, rates of hyper-responsiveness were significantly higher to ticagrelor when compared to clopidogrel (11 versus 6 %, p = 0.02 respectively). Contrarily, hypo-responsiveness rates were significantly higher in clopidogrel treated patients compared to their ticagrelor treated counterparts (23 versus 2 %, p < .001 respectively). Patients of Middle-Eastern origin showed a significantly higher rate of hypo-responsiveness to both clopidogrel and ticagrelor when compared to other races (41.1 % and 26.7 %, P < 0.001 respectively). Asians showed the highest rates of hyper-responsiveness for both agents. Multivariate logistic regression analysis showed that proton pump inhibitors and statin combination, (OR: 6.39, 95 %CI [1.60, 25.392]), and Middle East vs. Indian subcontinent patients (OR: 4.67, 95 %CI [1.79-12.14]) were independent predictors of hypo-responsiveness to both P2Y12 inhibitors. CONCLUSION This study demonstrated a high rate of hypo-responsiveness to P2Y12 inhibitors in a UAE cohort of patients undergoing neuro-endovascular procedures. In addition, therapeutic responsiveness to P2Y12 inhibitors varied markedly based on the racial background. Future larger studies are needed to evaluate genetic variations that may contribute to this rate of hypo-responsiveness in our population.
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Affiliation(s)
- Rita Jebrin
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | - Wasim S El Nekidy
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Emna Abidi
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | | | - Praveen Kesav
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Syed I Hussain
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | | | - Luna Khaled
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | - Divya Raj
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | - Seby John
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States.
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Kumar N, Palmisciano P, Dhawan S, Boakye M, Drazin D, Sharma M. Spontaneous Spinal Hematoma in Patients Using Antiplatelets and Anticoagulants: A Systematic Review. World Neurosurg 2024; 184:e185-e194. [PMID: 38278210 DOI: 10.1016/j.wneu.2024.01.082] [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: 09/20/2023] [Revised: 01/13/2024] [Accepted: 01/16/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Spontaneous spinal hematoma (SSH) is a debilitating complication in patients taking either antiplatelet (AP) or anticoagulation (AC) medications. SSH is rare and, therefore, a systematic review is warranted to re-examine and outline trends, clinical characteristics, and outcomes associated with SSH formation. METHODS PubMed, EMBASE, Scopus, and Web-of-Science were searched. Studies reporting clinical data of patients with SSH using AC medications were included. In addition, clinical studies meeting our a priori inclusion criteria limited to SSH were further defined in quality through risk bias assessment. RESULTS We included 10 studies with 259 patients' pooled data post-screening 3083 abstracts. Within the cohort (n = 259), the prevalence of idiopathic, nontraumatic SSH with concomitant treatment with AC medications was greater 191 (73.75%) compared with AP treatment (27%). The lumbar spine was the most common site of hematoma (41.70%), followed by the cervical (22.01%) and thoracic (8.49%) spine. Most patients had surgical intervention (70.27%), and 29.73% had conservative management. The pooled data suggest that immediate diagnosis and intervention are the best prognostic factors in clinical outcomes. American Spinal Injury Association grading at initial symptom onset and post-treatment showed the greatest efficacy in symptomatic relief (87.64%) and return of motor and sensory symptoms (39.19%). CONCLUSIONS Our review suggested that AC medications were related to SSH in most patients (74%), followed by APs (27%) and combined ACs + APs (1.9%). We recommend prompt intervention, a high suspicion for patients with neurologic deficits and diagnostic imaging before intervention to determine a case-specific treatment plan.
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Affiliation(s)
- Nitesh Kumar
- Clinical Medicine, Windsor University School of Medicine, Chicago, Illinois, USA
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sanjay Dhawan
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Doniel Drazin
- Department of Neurosurgery, Providence Everett Neuroscience Center, Everett, Washington, USA
| | - Mayur Sharma
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.
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Momic J, Yassin N, Kim MY, Walser E, Smith S, Ball I, Moffat B, Parry N, Vogt K. Antiplatelets versus anticoagulants in the treatment of blunt cerebrovascular injury (BCVI) - A systematic review and meta-analysis. Injury 2024; 55:111485. [PMID: 38452701 DOI: 10.1016/j.injury.2024.111485] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/20/2024] [Accepted: 02/25/2024] [Indexed: 03/09/2024]
Abstract
INTRODUCTION Blunt cerebrovascular injury (BCVI) occurs in 1-3% of blunt traumas and is associated with stroke, disability, and mortality if unrecognized and untreated. Early detection and treatment are imperative to reduce the risk of stroke, however, there is significant variation amongst centers and trauma care providers in the specific medical management strategy used. This study compares antiplatelets vs. anticoagulants to determine BCVI-related stroke risk and bleeding complications to better understand the efficacy and safety of various treatment strategies. METHODS A systematic review of MEDLINE, Embase, and Cochrane CENTRAL databases was conducted with the assistance of a medical librarian. The search was supplemented with manual review of the literature. Included studies reported treatment-stratified risk of stroke following BCVI. All studies were screened independently by two reviewers, and data was extracted in duplicate. Meta-analysis was conducted using pooled estimates of odds ratios (OR) with a random-effects model using Mantel-Haenszel methods. RESULTS A total of 3315 studies screened yielded 39 studies for inclusion, evaluating 6552 patients (range 8 - 920 per study) with a total of 7643 BCVI. Stroke rates ranged from 0% to 32.8%. Amongst studies included in the meta-analysis, there were a total of 405 strokes, with 144 (35.5%) occurring on therapy, for a total stroke rate of 4.5 %. Meta-analysis showed that stroke rate after BCVI was lower for patients treated with antiplatelets vs. anticoagulants (OR 0.57; 95% CI 0.33-0.96, p = 0.04); when evaluating only the 9 studies specifically comparing ASA to heparin, the stroke rate was similar between groups (OR 0.43; 95% CI 0.15-1.20, p = 0.11). Eleven studies evaluated bleeding complications and demonstrated lower risk of bleeding with antiplatelets vs. anticoagulants (OR 0.29; 95% CI 0.13-0.63, p = 0.002); 5 studies evaluating risk of bleeding complications with ASA vs. heparin showed lower rates of bleeding complications with ASA (OR 0.16; 95% CI 0.04-0.58, p = 0.005). CONCLUSIONS Treatment of patients with BCVI with antiplatelets is associated with lower risks of stroke and bleeding complications compared to treatment with anticoagulants. Use of ASA vs. heparin specifically was not associated with differences in stroke risk, however, patients treated with ASA had fewer bleeding complications. Based on this evidence, antiplatelets should be the preferred treatment strategy for patients with BCVI.
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Affiliation(s)
- Jovana Momic
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada.
| | - Nouf Yassin
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Mella Y Kim
- Schulich School of Medicine and Dentistry, University of Western Ontario, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Eric Walser
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Shane Smith
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada; Division of Vascular Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Ian Ball
- Department of Medicine, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Bradley Moffat
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Neil Parry
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Kelly Vogt
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
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Wong PS, Narasimhalu K, Tio SL, Shankari G, Doshi K, De Silva DA. Adherence to secondary stroke prevention medications in Singapore: a single center study. J Stroke Cerebrovasc Dis 2024; 33:107561. [PMID: 38218048 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107561] [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: 08/23/2023] [Revised: 12/27/2023] [Accepted: 01/06/2024] [Indexed: 01/15/2024] Open
Abstract
OBJECTIVES Recurrent strokes are associated with greater disability and mortality than first-time strokes. However, adherence to secondary stroke prevention medications has been reported to be suboptimal. We assessed medication adherence to antihypertensives, antiplatelets, and statins after acute ischemic stroke and identified factors associated with non-adherence behavior to each drug class. METHODS This single center study is an extension of a larger prospective cohort study of ischemic stroke patients assessed at an outpatient post stroke clinic. Medication adherence behavior and medication knowledge was determined by direct questioning, and perceptions towards medications via the Beliefs about Medicines Questionnaire. Factors associated with non-adherence in each drug class were determined using logistic regression. RESULTS Rates of adherence differed between antihypertensives (77.9%), antiplatelets (80.3%), and statins (64.7%) (p < 0.001) amongst the 193 patients surveyed. Non-adherence to antihypertensives was associated with living alone, taking < 5 medications, and stronger beliefs that medications are harmful. For antiplatelets, non-diabetic patients and patients with stronger beliefs that medications are harmful were more likely to be non-adherent. Patients non-adherent to statins were more likely to have a longer time since ischemic event and have a transient ischemic attack as the index event. CONCLUSIONS Overall, medication adherence behavior to secondary stroke prevention medications was poor, with statins the least adhered to. Factors associated with non-adherence to each drug class could guide the development of tailored interventions to improve adherence to secondary stroke prevention medications.
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Affiliation(s)
- Pei Shieen Wong
- Department of Pharmacy, Singapore General Hospital, Singapore; Department of Pharmacy, National University of Singapore, Singapore.
| | - Kaavya Narasimhalu
- Department of Neurology (Singapore General Hospital Campus), National Neuroscience Institute, Singapore
| | - Siaw Li Tio
- Department of Pharmacy, National University of Singapore, Singapore
| | - G Shankari
- Department of Neurology (Singapore General Hospital Campus), National Neuroscience Institute, Singapore; MOH Holdings Pte Ltd., Singapore
| | - Kinjal Doshi
- Department of Psychology, National University of Singapore, Singapore
| | - Deidre Anne De Silva
- Department of Neurology (Singapore General Hospital Campus), National Neuroscience Institute, Singapore
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Ntalouka MP, Brotis A, Karagianni MD, Arvaniti C, Mermiri M, Solou M, Stamoulis K, Bareka M, Fountas KN, Arnaoutoglou EM. Perioperative management of antithrombotics in elective intracranial procedures: systematic review, critical appraisal. Acta Neurochir (Wien) 2024; 166:97. [PMID: 38383680 DOI: 10.1007/s00701-024-05990-7] [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: 12/07/2023] [Accepted: 12/29/2023] [Indexed: 02/23/2024]
Abstract
PURPOSE Perioperative management of patients medicated with antithrombotics requiring elective intracranial procedures is challenging. We ought to (1) identify the clinical practice guidelines (CPGs) and recommendations (CPRs) on perioperative management of antithrombotic agents in elective intracranial surgery and (2) assess their methodological quality and reporting clarity. METHODS The study was conducted following the 2020 PRISMA guidelines for a systematic review and has been registered (PROSPERO, CRD42023415710). An electronic search was conducted using PubMed, Scopus, and Google Scholar. The search terms used were "adults," "antiplatelets," "anticoagulants," "guidelines," "recommendations," "english language," "cranial surgery," "brain surgery," "risk of bleeding," "risk of coagulation," and "perioperative management" in all possible combinations. The search period extended from 1964 to April 2023 and was limited to literature published in the English language. The eligible studies were evaluated by three blinded raters, by employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool. RESULTS A total of 14 sets of guidelines were evaluated. Two guidelines from the European Society of Anaesthesiology and one from the American College of Chest Physicians found to have the highest methodological quality and reporting clarity according to the AGREE-II tool. The interrater agreement was good with a mean Cohens Kappa of 0.70 (range, 46.5-94.4%) in the current analysis. CONCLUSION The perioperative management of antithrombotics in intracranial procedures may be challenging, complex, and demanding. Due to the lack of high quality data, uncertainty remains regarding the optimal practices to balance the risk of thromboembolism against that of bleeding.
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Affiliation(s)
- Maria P Ntalouka
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece.
| | - Alexandros Brotis
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Maria D Karagianni
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Christina Arvaniti
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Maria Mermiri
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Maria Solou
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Konstantinos Stamoulis
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Metaxia Bareka
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Konstantinos N Fountas
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Eleni M Arnaoutoglou
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
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Landi A, Aboyans V, Angiolillo DJ, Atar D, Capodanno D, Fox KAA, Halvorsen S, James S, Jüni P, Leonardi S, Mehran R, Montalescot G, Navarese EP, Niebauer J, Oliva A, Piccolo R, Price S, Storey RF, Völler H, Vranckx P, Windecker S, Valgimigli M. Antithrombotic therapy in patients with acute coronary syndrome: similarities and differences between a European expert consensus document and the 2023 European Society of Cardiology guidelines. Eur Heart J Acute Cardiovasc Care 2024; 13:173-180. [PMID: 38170562 DOI: 10.1093/ehjacc/zuad158] [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] [Received: 10/26/2023] [Accepted: 12/22/2023] [Indexed: 01/05/2024]
Abstract
Antithrombotic therapy represents the cornerstone of the pharmacological treatment in patients with acute coronary syndrome (ACS). The optimal combination and duration of antithrombotic therapy is still matter of debate requiring a critical assessment of patient comorbidities, clinical presentation, revascularization modality, and/or optimization of medical treatment. The 2023 European Society of Cardiology (ESC) guidelines for the management of patients with ACS encompassing both patients with and without ST segment elevation ACS have been recently published. Shortly before, a European expert consensus task force produced guidance for clinicians on the management of antithrombotic therapy in patients with ACS as well as chronic coronary syndrome. The scope of this manuscript is to provide a critical appraisal of differences and similarities between the European consensus paper and the latest ESC recommendations on oral antithrombotic regimens in ACS patients.
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Affiliation(s)
- Antonio Landi
- Ente Ospedaliero Cantonale (EOC), Cardiocentro Ticino Institute, Tesserete, 48. CH-6900, Lugano, Switzerland
- Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and INSERM 1094 & IRD, University of Limoges, 2, Martin Luther King Ave, 87042, Limoges, France
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Dan Atar
- Oslo University Hospital Ulleval, Department of Cardiology, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia, 78, Catania 95123, Italy
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Sigrun Halvorsen
- Institute of Clinical Medicine, University of Oslo, Blindern, P.O. Box 1078, N-0316, Oslo, Norway
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
| | - Stefan James
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala 751 85, Sweden
| | - Peter Jüni
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sergio Leonardi
- University of Pavia and Coronary Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY, NewYork, USA
| | - Gilles Montalescot
- ACTION Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Eliano Pio Navarese
- Clinical Experimental Cardiology, Department of Clinical Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy
| | - Josef Niebauer
- University Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
| | - Angelo Oliva
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele-Milan, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Susanna Price
- Royal Brompton Hospital, National Heart and Lung Institute, Imperial College, London, UK
| | - Robert F Storey
- Cardiovascular Research Unit, Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Heinz Völler
- Department of Rehabilitation Medicine, Faculty of Health Science Brandenburg, University of Potsdam, Potsdam, Germany
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Marco Valgimigli
- Ente Ospedaliero Cantonale (EOC), Cardiocentro Ticino Institute, Tesserete, 48. CH-6900, Lugano, Switzerland
- Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
- University of Bern, Bern, Switzerland
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Llagostera-Martín M, Cainzos M, Salvatella N, Cubero-Gallego H, Mas-Stachurska A, Sánchez-Carpintero A, Tizón-Marcos H, Calvo-Fernández A, Molina L, Vaquerizo B. Single antiplatelet therapy after left atrial appendage closure in patients with AF: safety and effectiveness. Rev Esp Cardiol (Engl Ed) 2024; 77:150-157. [PMID: 37879431 DOI: 10.1016/j.rec.2023.06.020] [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] [Received: 02/22/2023] [Accepted: 06/16/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION AND OBJECTIVES The optimal antithrombotic strategy following left atrial appendage closure (LAAC) is poorly defined in patients with nonvalvular atrial fibrillation. We assessed the safety and effectiveness of a single antiplatelet treatment (SAPT) strategy after LAAC in a population at high risk of ischemic and bleeding events. METHODS This single-center, observational, prospective study included a consecutive cohort of patients who underwent LAAC using the LAmbre device (Lifetech Scientific, China) and who were discharged with SAPT. The primary outcome was a composite of stroke, systemic embolism, and device-related thrombosis during follow-up. Secondary endpoints were cardiovascular mortality and major bleeding events (BARC ≥3a). Clinical follow-up was performed at 1, 6, and 12 months and subsequently on an annual basis. Transesophageal echocardiography was performed at 1 and 12 months of follow-up. RESULTS The study comprised 74 patients. The median age was 77 [72-83] years and 43% were women. The cohort exhibited a high prevalence of comorbidities and cardiovascular risk factors. The median CHA2DS2-VASc and HAS-BLED scores were 4 [3-6] and 4 [4-5], respectively. The median length of follow-up was 2.5 years (188 patients-year). During follow-up, device-related thrombosis occurred in 3 patients (4%). Ischemic stroke occurred in 1 patient (1.3%, rate 0.5%/y), representing a 90.9% relative risk reduction compared with the risk predicted by CHA2DS2-VASc. Major bleeding events occurred in 12 patients (16%, 6.4%/y), with a relative risk reduction of 26.4% of that predicted by HAS-BLED. Cardiovascular-related mortality was observed in 2 patients (2.7%). CONCLUSIONS SAPT appears to be a safe and effective treatment following LAAC in patients at high ischemic and hemorrhagic risk. Further studies are needed to confirm our findings.
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Affiliation(s)
| | - Miguel Cainzos
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | | | - Héctor Cubero-Gallego
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | - Aleksandra Mas-Stachurska
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Helena Tizón-Marcos
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Alicia Calvo-Fernández
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Departamento de Medicina, Universidad Pompeu Fabra, Barcelona, Spain
| | - Luis Molina
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Departamento de Medicina, Universidad Pompeu Fabra, Barcelona, Spain
| | - Beatriz Vaquerizo
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Departamento de Medicina, Universidad Pompeu Fabra, Barcelona, Spain; Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain
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Khandelwal A, Kakati A, Ali A. Cervical epidural hematoma masquerading as thrombosis of intracranial flow diverter in situ: A diagnostic and therapeutic conundrum. Med J Armed Forces India 2024; 80:98-101. [PMID: 38261807 PMCID: PMC10793230 DOI: 10.1016/j.mjafi.2022.12.015] [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: 10/11/2022] [Accepted: 12/21/2022] [Indexed: 02/10/2023] Open
Abstract
Cervical epidural hematoma (EDH) is a rare but very serious cause of acute neurologic compression that needs early diagnosis and rapid intervention. Acute hemiparesis is an infrequent presentation of cervical EDH and often mimics cerebrovascular accident. In this case, we describe the management of a case of cervical EDH presenting as acute hemiparesis in an elderly female patient which mimicked as thrombosis of intracranial flow diverter in situ. The report emphasizes that cervical EDH should be considered as differential diagnosis in patients who present with acute hemiparesis especially, who are on antiplatelets or anticoagulants. Also, in a patient considered high-risk for surgery, conservative management can be considered under close supervision and intensive monitoring, especially, in non-expanding hematoma and non-progressive neurological deterioration.
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Affiliation(s)
- Ankur Khandelwal
- Associate Professor (Anaesthesiology, Critical Care & Pain Medicine), All India Institute of Medical Sciences (AIIMS), Guwahati, Assam, India
| | - Arindom Kakati
- Senior Neurosurgeon (Neurosciences), Hayat Superspeciality Hospital, Guwahati, Assam, India
| | - Asman Ali
- Associate Professor (Neurosurgery), Guwahati Medical College and Hospital (GMCH), Guwahati, Assam, India
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10
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Al-Sadawi M, Tao M, Dhaliwal S, Masson R, Bhagat AA, Parikh PB, Lawson WE, Reilly JP. Association of antiplatelet therapy with clinical outcomes in patients with peripheral artery disease. Cardiovasc Revasc Med 2023:S1553-8389(23)00965-X. [PMID: 38176961 DOI: 10.1016/j.carrev.2023.12.013] [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: 10/11/2023] [Revised: 12/11/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND The beneficial role of dual anti-platelet therapy (DAPT) in coronary artery disease is well established. However, there is limited data describing the effects of DAPT in patients with atherosclerotic peripheral artery disease (PAD). The aim of this meta-analysis is to compare clinical outcomes associated with DAPT versus single anti-platelet therapy (SAPT) in patients with symptomatic PAD. METHODS We performed a literature search for studies assessing the risk of adverse cardiovascular and limb events in cohorts receiving either DAPT or SAPT. The primary endpoint was all cause mortality. The secondary endpoints included graft failure, amputation, total bleeding, severe bleeding and fatal bleeding. The search included the following databases: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. RESULTS A total of 11 studies with 54,331 participants (24,449 on SAPT and 29,882 on DAPT) were included. Patients with PAD treated with SAPT had higher all-cause mortality compared to patients treated with DAPT (OR 1.37, 95 % CI 1.09-1.74; p < 0.01). There was no difference in risk of graft failure or amputation between patients treated with SAPT or DAPT (OR 0.9, 95 % CI 0.77-1.06; p = 0.19; OR 1.11, 95 % CI 0.88-1.41; p = 0.37). Patients treated with SAPT had lower total bleeds compared to patients treated with DAPT (OR 0.53, 95 % CI 0.36-0.77; p < 0.01). However, For SAPT plus AC vs SAPT, a total of 8 studies with 17,100 participants (3447 with SAPT plus AC and 8619 with only SAPT) were included. Patients on SAPT plus AC did not have a statistically significant difference in risk for all-cause mortality, (OR 0.91, 95 % CI 0.67-1.24; p = 0.56). SAPT plus AC had significantly lower risk of MI (OR 0.82, 95 % CI 0.69-0.97; p = 0.02), amputation (OR 0.72, 95 % CI 0.53-0.97; p = 0.03), and graft failure (OR 0.66, 95 % CI 0.48-0.93; p = 0.02). There was no significant different in risk of fatal bleeding be-tween the two groups (OR 1.60, 95 % CI 0.76-3.35; p = 0.22). CONCLUSIONS In patients with symptomatic PAD, a strategy of DAPT may confer a mortality benefit when compared to SAPT without significantly increasing the risk of serious bleeding events.
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Affiliation(s)
- Mohammed Al-Sadawi
- Division of Cardiology, University of Michigan Hospital, Ann Arbor, MI, USA.
| | - Michael Tao
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Simrat Dhaliwal
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Ravi Masson
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Aditi A Bhagat
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Puja B Parikh
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - William E Lawson
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - John P Reilly
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
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11
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Macherey-Meyer S, Braumann S, Heyne S, Meertens MM, Tichelbäcker T, Baldus S, Lee S, Adler C. [Preclinical loading in patients with acute chest pain and acute coronary syndrome - PRELOAD survey]. Med Klin Intensivmed Notfmed 2023:10.1007/s00063-023-01087-8. [PMID: 38032364 DOI: 10.1007/s00063-023-01087-8] [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: 05/05/2023] [Revised: 10/05/2023] [Accepted: 10/29/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Guidelines on myocardial infarction (MI) recommend antithrombotic and anticoagulatory treatment at time of diagnosis. MI with ST segment elevation (STEMI) is mostly a certain diagnosis. Acute coronary syndrome without ST segment elevation (NSTE-ACS) has diagnostic uncertainty and remains a working diagnosis in the prehospital setting. OBJECTIVE Assessment of prehospital loading with aspirin and heparin depending on ACS subtype and pretreatment with oral anticoagulants. METHODS The PRELOAD survey was a nationwide German study. STEMI/NSTE-ACS scenarios were designed and varied in pretreatment: I) no pretreatment, II) new oral anticoagulants (NOAC), III) vitamin K antagonist (VKA). Loading strategy was assessed and included: a) aspirin (ASA), b) unfractionated heparin (UFH), c) ASA + UFH, d) no loading. RESULTS A total of 708 emergency physicians were included. In NSTE-ACS without pretreatment, 79% chose loading (p < 0.001). ASA + UFH (71.4%) was the preferred option. In corresponding STEMI scenario, 100% chose loading and 98.6% preferred ASA + UFH (p < 0.001). In NSTE-ACS with NOAC pretreatment, 69.8% favored loading (p < 0.001); in VKA pretreatment the corresponding rate was 72.3% (p < 0.001). In each scenario, ASA was the preferred option. In STEMI with NOAC pretreatment, 97.5% chose loading (p < 0.001); analogous rate was 96.8% in STEMI with VKA pretreatment (p < 0.001). ASA was the preferred option again. CONCLUSIONS Prehospital loading was the preferred treatment strategy despite the diagnostic uncertainty in NSTE-ACS and guidelines recommending loading at time of diagnosis. Pretreatment with oral anticoagulants resulted in a strategy shift to loading with only aspirin. In STEMI patients, this indicates potential undertreatment.
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Affiliation(s)
- Sascha Macherey-Meyer
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - Simon Braumann
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Sebastian Heyne
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Max Maria Meertens
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Tobias Tichelbäcker
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Stephan Baldus
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Samuel Lee
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Christoph Adler
- Medizinische Fakultät und Uniklinik Köln, Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
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12
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Sharma H, Afzal S, Leick J, Werner N, Doshi SN, Nadir MA. Antithrombotic therapy following transcatheter aortic valve intervention. Pharmacol Ther 2023; 250:108509. [PMID: 37572882 DOI: 10.1016/j.pharmthera.2023.108509] [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: 06/03/2023] [Revised: 07/27/2023] [Accepted: 08/08/2023] [Indexed: 08/14/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is increasingly being performed to treat symptomatic patients with aortic stenosis and annual procedure volume has overtaken surgical aortic valve replacement in the United States. However, current international guidelines were written prior to the publication of several important recent studies. Furthermore, European and American guidelines differ in their recommendations of antithrombotic therapy following TAVR. Consequently, there is a need to examine the literature to provide clinicians guidance on the optimum antithrombotic strategy, particularly as different patient populations exist. In this review, we examine the data for antiplatelet and anticoagulation therapy post-TAVR.
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Affiliation(s)
- Harish Sharma
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Shazia Afzal
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Jürgen Leick
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Nikos Werner
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Sagar N Doshi
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - M Adnan Nadir
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK.
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13
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Raymond K, Sterling A, Roberts M, Holland III RW, Galwankar S, Mishra RK, Agrawal A. Analysis of traumatic intracranial hemorrhage and delayed traumatic intracranial hemorrhage in patients with isolated head injury on anticoagulation and antiplatelet therapy. J Neurosci Rural Pract 2023; 14:686-691. [PMID: 38059222 PMCID: PMC10696333 DOI: 10.25259/jnrp_270_2023] [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: 05/16/2023] [Accepted: 06/03/2023] [Indexed: 12/08/2023] Open
Abstract
Objectives Anticoagulants and antiplatelet (ACAP) agents are increasingly and frequently used, especially in the elderly. The present study was carried out to assess the prevalence of delayed traumatic intracranial hemorrhage (dtICH) after a normal result on an initial head computed tomography (CT) in adults who were taking ACAP medication. Materials and Methods The present retrospective included all adult patients who arrived in the emergency department between January 2017 and January 2021 with a history of fall from the patient's own height, while being on ACAP medication with an isolated head injury. The Institutional Review Board approved the study with a waiver of consent. The primary outcome measures were prevalence of dtICH in patients who had initial normal CT scan brain and were on ACAP medication. Results There were 2137 patients on ACAP medication, of which 1062 were male, and 1075 were of the female gender. The mean age of the patients was 82.1 years. About 8.2% had positive first CT scans (176/2137), while 0.023 (27/1149) had dtICH. The most common positive finding on the CT scan was subarachnoid hemorrhage followed by subdural hemorrhage. Male gender positively correlated with increased risk for first CT being positive (P = 0.033). Patient's with comorbidity of cirrhosis and chemotherapy had higher risk of dtICH (P = 0.47, 0.011). Conclusion There was a very low (0.023%) prevalence of dtICH. Dual therapy or Coumadin therapy made up the majority of tICH. Cirrhosis and chemotherapy were associated with the risk of a repeat CT scan being positive with an initial CT scan negative.
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Affiliation(s)
- Kevin Raymond
- Department of Emergency Medicine, Sarasota Memorial Hospital, Sarasota, Florida, United States
| | - Alexander Sterling
- Department of Emergency Medicine, Sarasota Memorial Hospital, Sarasota, Florida, United States
| | - Mary Roberts
- Department of Emergency Medicine, Sarasota Memorial Hospital, Sarasota, Florida, United States
| | - Reuben W. Holland III
- Department of Emergency Medicine, Sarasota Memorial Hospital, Sarasota, Florida, United States
| | - S Galwankar
- Department of Emergency Medicine, Sarasota Memorial Hospital, Sarasota, Florida, United States
| | - Rakesh Kumar Mishra
- Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Amit Agrawal
- Department of Neurosurgery , All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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14
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El Issaoui M, Elissaoui S, Elmelund M, Klarskov N. Bleeding risk in female patients undergoing intravesical injection of onabotulinumtoxinA for overactive bladder: a Danish retrospective cohort study. Int Urogynecol J 2023; 34:2581-2585. [PMID: 37329356 PMCID: PMC10590281 DOI: 10.1007/s00192-023-05579-1] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/15/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION AND HYPOTHESIS We aimed to examine the risk of bleeding in female patients undergoing intravesical onabotulinumtoxinA (BTX-A) treatments and provide clinical recommendations for the perioperative management of patients on antithrombotic therapy prior to BTX-A treatments. METHODS This was a retrospective cohort of Danish female patients, who had their first BTX-A treatment because of an overactive bladder at the Department of Gynecology and Obstetrics, Herlev and Gentofte University Hospital, between January 2015 and December 2020. Data extraction was from an electronic medical journal system. BTX-A, Botox® Allergan was injected in the detrusor at 10-20 sites. Significant bleeding during or after a BTX-A treatment was defined as persistent macroscopic hematuria. Bleeding reporting was based on information obtained from journal notes. RESULTS We included 400 female patients, who had a total of 1,059 BTX-A treatments. Median age at first BTX-A treatment was 70 years (IQR 21), and median number of BTX-A treatments was 2 (range 1-11). In total, 27.8% (n=111) received antithrombotic therapy. Within this group, 30.6% and 69.4% were on anticoagulant and antiplatelet therapy. No cases of hematuria were reported in our cohort. We found that no patients stopped their antithrombotic therapy, were bridged, or monitored by International Normalized Ration (INR) levels. CONCLUSIONS We suggest that BTX-A treatments might be classified as low-risk procedures. Discontinuation of antithrombotic therapy is not required in the perioperative management of this patient group.
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Affiliation(s)
- Meryam El Issaoui
- Department of Gynecology and Obstetrics, Herlev and Gentofte University Hospital, Borgmester Ib Juuls Vej 1, 16. Etage, 2730, Herlev, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Sophia Elissaoui
- Department of Gynecology and Obstetrics, Herlev and Gentofte University Hospital, Borgmester Ib Juuls Vej 1, 16. Etage, 2730, Herlev, Denmark
| | - Marlene Elmelund
- Department of Gynecology and Obstetrics, Herlev and Gentofte University Hospital, Borgmester Ib Juuls Vej 1, 16. Etage, 2730, Herlev, Denmark
| | - Niels Klarskov
- Department of Gynecology and Obstetrics, Herlev and Gentofte University Hospital, Borgmester Ib Juuls Vej 1, 16. Etage, 2730, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Amllay A, Becerril-Gaitan A, Hunt A, Jain P, Chen CJ, El Naamani K, Abbas R, Rudick L, Tjoumakaris SI, Gooch MR, Herial NA, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour PM. Safety of Mechanical Thrombectomy in Patients on Antiplatelet/Anticoagulation. World Neurosurg 2023; 176:e476-e484. [PMID: 37257646 DOI: 10.1016/j.wneu.2023.05.084] [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: 03/13/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is performed in patients who are already on anticoagulation (AC)/antiplatelet therapy (AP). However, data are insufficient regarding MT's safety and efficacy profiles in these patients. OBJECTIVE Investigate the outcome of stroke patients already on anticoagulation/antiplatelet receiving MT. METHODS We included consecutive acute ischemic stroke patients treated with MT for 10 years (2012-2022) in a comprehensive stroke center. Baseline variables, efficacy (recanalization [Thrombolysis in Cerebral Infraction] ≥ 2b), good functional outcome (modified Ranking Scale ≤ 2 at 3 months), and safety (symptomatic intracranial hemorrhage [sICH], mortality rates) were evaluated. Additionally, we conducted a subgroup analysis of patients with prior single-AP versus DAPT. RESULTS Six hundred forty-six patients were included (54.5% women, median age 71 years), 84 (13%) were on AC, 196 (30.3%) on AP, and 366 (56.7%) in the control group. The AC and AP groups were older and had more comorbidities. sICH occurred in 7.3% of cases. There was no significant difference in sICH incidence across the groups. The AC group had a lower rate of intravenous thrombolysis (15.9%; P < 0.001), a higher rate of sICH (11.9% vs. AP 7.7% and control 6%; P = 0.172), and higher mortality at discharge (17.9% vs. AP 8.7% and control 10.4%; P = 0.07). However, the groups had similar functional outcomes and mortality rates at 3 months. Successful recanalization was achieved in 92.7% and was similar across groups. Multivariable logistic regression and the subgroup analysis (single-AP vs. dual AP) did not reveal statistically significant associations. CONCLUSIONS MT in patients with prior anticoagulation and AP presenting with acute ischemic strokeis feasible, effective, and safe.
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Affiliation(s)
- Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Adam Hunt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Levi Rudick
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
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Kudsi OY, Kaoukabani G, Bou-Ayash N, Gokcal F. Do antiplatelets and anticoagulants have an impact on the clinical outcomes of robotic ventral hernia repair? Am J Surg 2023; 226:213-217. [PMID: 37095043 DOI: 10.1016/j.amjsurg.2023.04.007] [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: 02/17/2023] [Revised: 03/19/2023] [Accepted: 04/11/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND We sought to study the impact of antithrombotics(antiplatelets and anticoagulants) on robotic ventral hernia repair(RVHR). METHODS RVHR cases were divided into antithrombotic (AT) (-) and AT (+) groups. After comparing both groups, a logistic regression analysis was performed. RESULTS 611 patients had no AT-medication. The AT(+) group had 219 patients of which 153 were only on antiplatelets, 52 only on anticoagulants, and 14(6.4%) patients on both antithrombotics. Mean age, American Society of Anesthesiology scores, and comorbidities were significantly higher in the AT(+) group. Intraoperative blood loss was greater in the AT(+) group. Postoperatively, the AT(+) group had greater rates of Clavien-Dindo grade-II and IV-a complications(p=0.001, and p=0.013, respectively), and postoperative hematomas(p=0.013). Mean follow-up was greater than 40 months. Age[Odds Ratio(OR): 1.034] and anticoagulants(OR: 3.121) were associated with increased bleeding-related events. CONCLUSION There were no associations between maintained antiplatelet therapy and postoperative bleeding-related events in RVHR whereas age and anticoagulants had the highest association.
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Affiliation(s)
| | | | | | - Fahri Gokcal
- Good Samaritan Medical Center, Brockton, MA, USA
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17
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Janquli M, Selvarajah L, Moloney MA, Kavanagh E, O'Neill DC, Medani M. Long-term outcome of cervical artery dissection. J Vasc Surg 2023; 78:158-165. [PMID: 36918105 DOI: 10.1016/j.jvs.2023.03.020] [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: 12/22/2022] [Revised: 02/17/2023] [Accepted: 03/05/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE The aim of the study is to evaluate the natural history of extracranial cervical artery dissection (CAD) including comorbidities, symptoms at presentation, recurrence of symptoms, and long-term outcome following different treatment approaches. METHODS A retrospective review of patients treated for acute CAD was performed over a 5-year period from January 2017 to April 2022. RESULTS Thirty-nine patients were included in the study, 25 (64.1%) with acute internal carotid artery dissection and 14 (35.9%) with acute vertebral artery dissection. Thirty-four patients (87.1%) had spontaneous CAD, and five patients (12.8%) had traumatic CAD. The mean age of the cohort was 54.2 years. The mean time from symptom onset to presentation was 4.34 days. The most common symptoms in internal carotid artery dissection were unilateral weakness (44%), headache (44%), slurred speech (36%), facial droop (28%), unilateral paraesthesia (24%), neck pain (12%), visual disturbance (8%), and Horner's syndrome (8%). The most common symptoms in vertebral artery dissection were headache (35.7%), neck pain (35.7%), vertigo (28.57%), ataxia (14.28%), and slurred speech (14.28%). The imaging modalities used for diagnosis included computed tomography angiography (48.7%), magnetic resonance angiography (41%), and duplex ultrasound (10.2%). In patients with carotid artery dissection, 57% had severe stenosis, 24% had moderate stenosis, and 20% had mild stenosis. All patients treated were managed conservatively with either anticoagulation or antiplatelets. Long-term clinical follow-up was available for 33 patients (84.6%). Thirty patients (90.9%) reported complete resolution of symptoms, and three patients (9%) reported persistent symptoms. Anatomic follow-up with imaging was available for 17 patients (43.58%). Thirteen patients (76.47%) had complete resolution of dissection, two patients (11.76%) had partial resolution of dissection, and two patients (11.76%) had persistent dissection. There was one death unrelated to CAD in a multi-trauma patient. There were four early recurrent symptoms in the first 3 to 8 weeks post discharge. The mean follow-up time was 308.27 days. CONCLUSIONS The majority of CADs can be managed conservatively with good clinical and anatomical outcome and low rates of recurrence.
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Affiliation(s)
- Mohammed Janquli
- Department of Vascular Surgery, University Hospital Limerick, University of Limerick, Limerick, Ireland; Department of Radiology, University Hospital Limerick, University of Limerick, Limerick, Ireland.
| | - Logeswaran Selvarajah
- Department of Vascular Surgery, University Hospital Limerick, University of Limerick, Limerick, Ireland; Department of Radiology, University Hospital Limerick, University of Limerick, Limerick, Ireland
| | - Michael Anthony Moloney
- Department of Vascular Surgery, University Hospital Limerick, University of Limerick, Limerick, Ireland; Department of Radiology, University Hospital Limerick, University of Limerick, Limerick, Ireland
| | - Eamon Kavanagh
- Department of Vascular Surgery, University Hospital Limerick, University of Limerick, Limerick, Ireland; Department of Radiology, University Hospital Limerick, University of Limerick, Limerick, Ireland
| | - Damien Christopher O'Neill
- Department of Vascular Surgery, University Hospital Limerick, University of Limerick, Limerick, Ireland; Department of Radiology, University Hospital Limerick, University of Limerick, Limerick, Ireland
| | - Mekki Medani
- Department of Vascular Surgery, University Hospital Limerick, University of Limerick, Limerick, Ireland; Department of Radiology, University Hospital Limerick, University of Limerick, Limerick, Ireland
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Koulas I, Goldin M, Schulman S, Spyropoulos AC. Antithrombotic therapy in the management of hospitalised patients with COVID-19. Br J Hosp Med (Lond) 2023; 84:1-11. [PMID: 37235671 DOI: 10.12968/hmed.2022.0519] [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] [Indexed: 05/28/2023]
Abstract
Hospitalised patients with coronavirus disease 2019 (COVID-19) are at a significantly higher risk of having thromboembolic events while in hospital and in the immediate post-hospital discharge period. Based on early data from observational studies, multiple high quality randomised controlled trials have been conducted worldwide to evaluate optimal thromboprophylaxis regimens to reduce thromboembolism and other COVID-19-related adverse outcomes in hospitalised patients. The International Society on Thrombosis and Haemostasis has published evidence-based guideline recommendations using established methodology for the management of antithrombotic therapy of COVID-19 patients, both in-hospital and in the immediate post-hospital discharge period. A good clinical practice statement supplemented these guidelines based on topics for which there was no or limited high-quality evidence. This review summarises the main recommendations of these documents to serve as a quick access tool for hospital doctors to use in their everyday practice when treating COVID-19 patients.
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Affiliation(s)
- Ioannis Koulas
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Mark Goldin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Alex C Spyropoulos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY, USA
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Bhatia K, Ladd LM, Carr KH, Di Napoli M, Saver JL, McCullough LD, Hosseini Farahabadi M, Alsbrook DL, Hinduja A, Ortiz Garcia JG, Sabbagh SY, Jafarli A, Divani AA. Contemporary Antiplatelet and Anticoagulant Therapies for Secondary Stroke Prevention: A Narrative Review of Current Literature and Guidelines. Curr Neurol Neurosci Rep 2023; 23:235-262. [PMID: 37037980 DOI: 10.1007/s11910-023-01266-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE OF REVIEW Stroke is a leading cause of death and disability worldwide. The annual incidence of new or recurrent stroke is approximately 795,000 cases per year in the United States, of which 87% are ischemic in nature. In addition to the management of modifiable high-risk factors to reduce the risk of recurrent stroke, antithrombotic agents (antiplatelets and anticoagulants) play an important role in secondary stroke prevention. This review will discuss the published literature on the use of antiplatelets and anticoagulants in secondary prevention of acute ischemic stroke and transient ischemic attack (TIA), including their pharmacology, efficacy, and adverse effects. We will also highlight the role of dual antiplatelet therapy (DAPT) in secondary stroke prevention, along with supporting literature. RECENT FINDINGS Single antiplatelet therapy (SAPT) with aspirin or clopidogrel reduces the risk of recurrent ischemic stroke in patients with non-cardioembolic ischemic stroke or TIA. However, as shown in recent trials, short-term DAPT with aspirin and clopidogrel or ticagrelor for 21-30 days is more effective than SAPT in patients with minor acute non-cardioembolic stroke or high-risk TIA. Although short-term DAPT is highly effective in preventing recurrent stroke, a more prolonged course can increase bleeding risks without additional benefit. DAPT for 90 days, followed by aspirin monotherapy for patients with large vessel intracranial atherosclerotic disease, is suitable for secondary stroke prevention. However, patients need to be monitored for both minor (e.g., bruising) and major (e.g., intracranial) bleeding complications. Conversely, oral warfarin and newer direct oral anticoagulant (DOACs) such as dabigatran, rivaroxaban, apixaban, and edoxaban are the agents of choice for secondary stroke prevention in patients with non-valvular cardioembolic strokes. DOACs may be preferred over warfarin due to decreased bleeding risks, including ICH, lack of need for international normalized ratio monitoring, no dietary restrictions, and limited drug-drug interactions. The choice between different antiplatelets and anticoagulants for prevention of ischemic stroke depends on the underlying stroke mechanism, cytochrome P450 2C19 polymorphisms, bleeding risk profile, compliance, drug tolerance, and drug resistance. Physicians must carefully weigh each patient's relative benefits and bleeding risks before initiating an antiplatelet/anticoagulant treatment regimen. Further studies are warranted to study the optimal duration of DAPT in symptomatic intracranial atherosclerosis since the benefit is most pronounced in the short term while the bleeding risk remains high during the extended duration of therapy.
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Affiliation(s)
- Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Lindsey M Ladd
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kelsey H Carr
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, L'Aquila, Italy
| | - Jeffrey L Saver
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Louise D McCullough
- Department of Neurology, McGovern Medical School, University of Texas Health Sciences Center, Houston, TX, USA
| | | | - Diana L Alsbrook
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jorge G Ortiz Garcia
- Department of Neurology, the University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sara Y Sabbagh
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Alibay Jafarli
- Department of Neurology, Tufts Medical Center, Boston, MA, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA.
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Choi HH, Jang D, Na H, Hong N, Lee SH, Kim KM, Kang HS, Kim JE, Shin A, Cho WS. Population-Attributable Risk Fractions for Antiplatelets and Anticoagulants in Spontaneous Intracranial Hemorrhages. Cerebrovasc Dis 2023; 52:624-633. [PMID: 36889296 DOI: 10.1159/000529312] [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: 10/30/2022] [Accepted: 01/02/2023] [Indexed: 03/10/2023] Open
Abstract
INTRODUCTION Concerns about spontaneous intracranial hemorrhages (sICHs) have increased over time with the increasing use of antithrombotic agents. Hence, we aimed to analyze the risk and risk fractions for antithrombotics in sICHs in South Korea. METHODS From the National Health Insurance Service-National Sample Cohort including 1,108,369 citizens, 4,385 cases, aged 20 years or more and newly diagnosed as sICHs between 2003 and 2015, were included in this study. A total of 65,775 sICH-free controls were randomly selected at a ratio of 1:15 from individuals with the same birth year and sex according to a nested case-control study design. RESULTS Although the incidence rate of sICHs started to decrease from 2007 onward, the use of antiplatelets, anticoagulants, and statins continued to increase. Antiplatelets (adjusted odds ratio [OR] 3.59, 95% confidence interval [CI] 3.18-4.05), anticoagulants (adjusted OR 7.46, 95% CI 4.92-11.32), and statins (adjusted OR 1.98, 95% CI 1.79-2.18) were significant risk factors for sICHs even after adjusting for hypertension, alcohol intake, and cigarette smoking. From 2003-2008 to 2009-2015, the population-attributable fractions changed from 28.0% to 31.3% for hypertension, from 2.0% to 3.2% for antiplatelets, and from 0.5% to 0.9% for anticoagulants. CONCLUSION Antithrombotic agents are significant risk factors for sICHs, and their contribution is increasing over time in Korea. These findings are expected to draw the attention of clinicians to precautions to be taken when prescribing antithrombotic agents.
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Affiliation(s)
- Hyun Ho Choi
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Doeun Jang
- Department of Preventive Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Interdiscipliary Program in Cancer Biology, Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Hyuntak Na
- Department of Preventive Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Interdiscipliary Program in Cancer Biology, Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
- Integrated Major in Innovative Medical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Noah Hong
- Department of Neurosurgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kang Min Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Aesun Shin
- Department of Preventive Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Interdiscipliary Program in Cancer Biology, Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
- Integrated Major in Innovative Medical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Nash M, Bloch S, Golan D. Safety of lumbar puncture for people who are treated with ADP receptor antagonists. J Neurol 2023. [PMID: 36813930 DOI: 10.1007/s00415-023-11628-y] [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: 01/26/2023] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Current guidelines state that clopidogrel and other adenosine-diphosphate receptor antagonists (ADPra) should be stopped for at least 7 days before lumbar puncture (LP). This practice may delay the diagnosis of treatable neurological emergencies and may increase the risk of cardiovascular morbidity due to withholding antiplatelets. We aimed to summarize all cases under our care, in which LP was performed without discontinued ADPra. METHODS A retrospective case series study of all patients who underwent LP without interruption of ADPRa or with treatment interruption that was shorter than 7 days. Medical records were searched for documented complications. Traumatic tap was defined as cerebrospinal fluid red cell count ≥ 1000 cell/μL. Incidence of traumatic tap among people who underwent LP under ADPRa was compared to traumatic tap incidence in two control groups: LP under aspirin and LP without any anti-platelet. RESULTS 159 patients underwent LP under ADPRa [Age: 68.4 ± 12.1, Female: 63 (40%), 81 (51%) were treated with both aspirin and ADPRa]. 116 procedures were carried out without any interruption of ADPRa. In the other 43, the median delay between treatment interruption and the procedure was 2 days (range: 1-6 days). Incidence of traumatic tap was 8/159 (5%), 9/159 (5.7%) and 4/160 (2.5%) among those who underwent LP under ADPRa, under aspirin and without any anti-platelet, respectively. [X2(2) = 2.13, P = 0.35)]. No patient developed spinal hematoma or any neurological deficit. CONCLUSIONS Lumbar puncture without discontinuation of ADP receptor antagonists seems safe. Similar case series may ultimately lead to guidelines change.
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Giri S, Afzalpurkar S, Anirvan P, Angadi S, Kasturi S, Varghese J, Sundaram S. Risk of Bleeding with Endoscopic Ultrasound-Guided Tissue Acquisition in Patients on Antithrombotic Therapy: A Systematic Review and Meta-Analysis. Dig Dis Sci 2023; 68:1950-1958. [PMID: 36609733 DOI: 10.1007/s10620-022-07808-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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/17/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND The present guidelines stratify endoscopic ultrasound-guided tissue acquisition (EUS-TA) as a high-bleeding risk procedure in patients on antithrombotics. However, the data regarding the same are conflicting. Therefore, this meta-analysis aimed to analyze the bleeding event rates associated with EUS-TA in patients receiving antithrombotic therapy. METHODS A literature search from January 2000 to August 2022 was done for studies on EUS-guided TA in patients receiving antithrombotics. The primary outcome was incidence of overall and major bleeding. Pooled event rates across studies were expressed with summative statistics. RESULTS A total of 12 studies were included in the meta-analysis. The pooled risk of overall bleeding and major bleeding in patients on antithrombotics was 2.0% (0.6-3.4) and 0.8% (0.0-1.6), respectively. In patients taking thienopyridine or anticoagulants, the pooled risk of overall bleeding and major bleeding was 2.4% (0.9-3.9) and 1.7% (0.4-3.1), respectively. Patients on antithrombotics had a higher odd of overall bleeding (OR 2.12, 1.20-3.83) and major bleeding (OR 3.58, 1.11-11.52) compared to controls. The odds of overall bleeding (OR 0.95, 95%CI 0.38-2.42) and major bleeding (OR 1.57, 95%CI 0.45-5.54) were comparable between patients on antithrombotics who continued and those who discontinued it preprocedural. CONCLUSION Despite an increase risk of bleeding with EUS-TA in patients on antithrombotics, the pooled incidence remains low. Compared to the previous guidelines stating thienopyridine use as high risk for bleeding, the present analysis showed a bleeding rate of less than 1%. Discontinuing antithrombotics prior to EUS-TA does not reduce the bleeding risk significantly, requiring strict monitoring.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Shivaraj Afzalpurkar
- Institute of Gastrosciences and Liver, Apollo Multispecialty Hospital, Kolkata, India
| | - Prajna Anirvan
- Department of Gastroenterology, SCB Medical College & Hospital, Cuttack, India
| | - Sumaswi Angadi
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Sunil Kasturi
- Department of Gastroenterology, Fortis Hospital, Bengaluru, India
| | - Jijo Varghese
- Department of Gastroenterology, KM Cherian Institute of Medical Sciences, Kallissery, India
| | - Sridhar Sundaram
- Department of Digestive Disease and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India.
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23
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Djordjevic N. Genotyping genetic variants of CYP2C19 for precision antiplatelet dosing: state of the art and future perspectives. Expert Opin Drug Metab Toxicol 2022; 18:817-830. [PMID: 36606363 DOI: 10.1080/17425255.2022.2166486] [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] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Clopidogrel is the only antiplatelet agent whose activity is significantly affected by CYP2C19 polymorphism. AREAS COVERED This review has summarized the available evidence on the clinically significant association between CYP2C19 polymorphism and clopidogrel-based therapy; reviewed the current recommendations for clinical use of CYP2C19 genotype test results in patients on clopidogrel treatment; and discussed possible pitfalls of routine application, and future perspectives of antiplatelets pharmacogenetics. EXPERT OPINION The available body of evidence, reflected in several meta-analyses and high-quality clinical practice guidelines, shows that the presence of CYP2C19 LOF alleles, especially CYP2C19*2, correlates with impaired activation of clopidogrel and variable platelet inhibition, followed by minimal or no antiplatelet effect, and higher risk of treatment failure. In combination with other known risk factors, CYP2C19 genetic testing could be very valuable in predicting low clopidogrel efficacy. At the same time, it could be very successful in selecting patients who will most probably benefit from the clopidogrel-based therapy, thus decreasing the pool of those who might need more expensive and otherwise riskier antiplatelet alternatives.
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Affiliation(s)
- Natasa Djordjevic
- Faculty of Medical Sciences, Department of Pharmacology and Toxicology, University of Kragujevac, Svetozara Markovica 69, 34 000 Kragujevac, Serbia
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Wang B, Yao J, Sethwala A, Hawson J, Stevenson I. Risk Factors of Haematoma Formation Following Cardiac Implantable Electronic Device Procedures. Heart Lung Circ 2022; 31:1539-1546. [PMID: 36031550 DOI: 10.1016/j.hlc.2022.07.005] [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: 05/24/2022] [Accepted: 07/07/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE A single-centre cohort of 2,100 adults who consecutively underwent cardiac implantable electronic device procedures were retrospectively analysed to identify and quantify risk factors of perioperative pocket haematoma formation. RESULTS Dual antiplatelet therapy was significantly associated with increased odds of haematoma formation (OR 11.7 for aspirin and clopidogrel, OR 11.8 for aspirin and ticagrelor and OR 104 for aspirin and prasugrel, p<0.05) on multivariate binomial logistic regression analysis. Aspirin monotherapy was also associated with increased bleeding risk (OR 3.02, p<0.01). Direct oral anticoagulants and warfarin were also each associated with increased odds of haematoma formation although to a lesser extent than dual anti platelet therapy (DAPT). Amongst oral anticoagulants, apixaban was associated with the lowest bleeding risk (OR 2.59, p=0.03) whilst dabigatran was associated with the highest (OR 3.81, p=0.04). There was a significant incremental reduction in bleeding risk by 8% per 10x103/μL increase in platelet count. CONCLUSION DAPT was associated with increased odds of pocket haematoma formation following cardiovascular implantable electronic device (CIED) procedure. This likelihood was higher than with oral anticoagulation therapy. Timely medication reconciliation of P2Y12 inhibitors according to guidelines is important to avoid post-procedural bleeding complications. Perioperative policies which account for the half-life of withheld anticoagulant agents may help reduce the haematoma risk.
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Affiliation(s)
- Benjamen Wang
- Cardiology Department, The Royal Melbourne Hospital, Melbourne, Vic, Australia.
| | - Jessica Yao
- Cardiology Department, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Anver Sethwala
- Cardiology Department, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Joshua Hawson
- Cardiology Department, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Irene Stevenson
- Cardiology Department, The Royal Melbourne Hospital, Melbourne, Vic, Australia
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25
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Prandoni P, Bilora F, Pesavento R, Sancho T, Accassat S, Casado I, Di Micco P, Monreal M. The hazard of combining anticoagulants with antiplatelets in patients with venous thromboembolism: Findings from the RIETE registry. Thromb Res 2022; 218:44-47. [PMID: 35988443 DOI: 10.1016/j.thromres.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/12/2022] [Accepted: 08/10/2022] [Indexed: 11/30/2022]
Affiliation(s)
| | - Franca Bilora
- Department of Medicine, University Hospital of Padua, Italy
| | | | - Teresa Sancho
- Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
| | - Sandrine Accassat
- Department of Médecine et Thérapeutique, Hôpital Nord - CHU St-Etienne, Saint-Etienne, France
| | - Ignacio Casado
- Department of Pneumonology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | - Manuel Monreal
- Faculty of Health Sciences, UCAM - Universidad Católica San Antonio de Murcia, Murcia, Spain
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Chutoo P, Kulinskaya E, Bakbergenuly I, Steel N, Pchejetski D, Brown B. Long term survival after a first transient ischaemic attack in England: A retrospective matched cohort study. J Stroke Cerebrovasc Dis 2022; 31:106663. [PMID: 35907306 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106663] [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: 04/20/2022] [Revised: 07/03/2022] [Accepted: 07/17/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Transient ischaemic attacks (TIA) serve as warning signs for future stroke, and the impact of TIA on long term survival is uncertain. We assessed the long-term hazards of all-cause mortality following a first episode of a transient ischaemic attack (TIA). DESIGN Retrospective matched cohort study. METHODS Cohort study using electronic primary health care records from The Health Improvement Network (THIN) database in the United Kingdom. Cases born in or before 1960, resident in England, with a first diagnosis of TIA between January 1986 and January 2017 were matched to three controls on age, sex and general practice. The primary outcome was all-cause mortality. The hazards of all-cause mortality were estimated using a time-varying Double-Cox Weibull survival model with a random frailty effect of general practice, while adjusting for different socio-demographic factors, medical therapies, and comorbidities. RESULTS 20,633 cases and 58,634 controls were included. During the study period, 24,176 participants died comprising of 7,745 (37.5%) cases and 16,431(28.0%) controls. In terms of hazards of mortality, cases aged 39 to 60 years at the first TIA event had the highest hazard ratio (HR) of mortality compared to their 39-60 years matched controls (HR = 3.04 (2.91 - 3.18)). The HR for cases aged 61-70 years, 71-76 years and 77+ years were 1.98 (1.55 - 2.30), 1.79 (1.20 - 2.07) and 1.52 (1.15 - 1.97) compared to their same-aged matched controls. Cases aged 39-60 at TIA onset who were prescribed aspirin were associated with reduced HR of 0.93 (0.84 - 1.01), 0.90 (0.82 - 0.98) and 0.88 (0.80 - 0.96) at 5, 10 and 15 years respectively, compared to the same aged cases who were not prescribed any antiplatelet. Statistically significant reductions in hazard ratios were observed with aspirin at 10 and 15 years in all age groups. Hazard ratio point estimates for other antiplatelets (dipyridamole or clopidogrel) and dual antiplatelet therapy were very similar to aspirin at 5, 10 and 15 years but with wider confidence intervals that included 1. There was no survival benefit associated with antiplatelet prescription in controls. CONCLUSIONS The overall risk of death was considerably elevated in all age groups after a first-ever TIA event. Aspirin prescription was associated with a reduced risk. These findings support the use of aspirin in secondary prevention for people with a TIA. The results do not support the use of antiplatelet medication in people without TIA.
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Bhave VM, Stone LE, Rennert RC, Steinberg JA. Complementary Tools in Cerebral Bypass Surgery. World Neurosurg 2022; 163:50-9. [PMID: 35436579 DOI: 10.1016/j.wneu.2022.03.146] [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] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 12/15/2022]
Abstract
Cerebral revascularization surgery has been advanced by the refinement of several adjunctive tools. These tools include perioperative blood thinners, intraoperative spasmolytic agents, electrophysiological monitoring, and methods for assessing bypass patency or marking arteriotomies. Despite the array of options, the proper usage and comparative advantages of different complements in cerebral bypass have not been well-cataloged elsewhere. In this literature review, we describe the appropriate usage, benefits, and limitations of various bypass adjuncts. Understanding these adjuncts can help surgeons ensure that they receive reliable intraoperative information about bypass function and minimize the risk of serious complications. Overall, this review provides a succinct reference for neurosurgeons on various cerebrovascular bypass adjuncts.
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Maina G, Ooi E. A retrospective review of spontaneous epistaxis outcomes for patients on novel oral anticoagulants compared to antiplatelets and warfarin. Am J Otolaryngol 2022; 43:103488. [PMID: 35537230 DOI: 10.1016/j.amjoto.2022.103488] [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: 04/21/2022] [Accepted: 05/01/2022] [Indexed: 11/01/2022]
Abstract
AIMS The incidence of epistaxis-related admissions amongst elderly patients is rising due to the increasing use of anticoagulants and antiplatelet agents. This retrospective study evaluates the differences in outcomes for patients on warfarin, novel anticoagulants (NOACs) and antiplatelets over two different time periods. METHODOLOGY Retrospective case-control study with data from patients admitted with epistaxis through the Flinders Medical Centre Emergency Department in the first six months of 2013 and compared to the same period in 2018. The latter coincides with integration of NOACs into Australian prescribing practices. Included participants were ≥50 years with spontaneous epistaxis which coincides with peak incidence in adults. Exclusion criteria were epistaxis due to trauma, intrinsic coagulopathy, or recent post-surgery. Linear regression and binary logistic regression models were the statistical methods used. RESULTS Data from 85 patients were analysed for length of stay (LOS), readmission rates and method of haemostasis. In 2013, 41 patients were included compared to 44 in 2018, suggesting a 7% increase in admissions rates but this was not statistically significant (p = 0.96). The proportion of patients admitted with epistaxis while taking an anticoagulant or antiplatelet agent increased from 66% in 2013 to 93% in 2018. Thirty six percent of patients in 2018 were taking NOACs, however, LOS was 2 times shorter (mean ratio = 2.08 days, 95% CI: 1.03, 4.19). Seven percent of patients in 2018 had bleeding requiring surgery or interventional radiology, compared to 12% in 2013, but this was not statistically significant. There was no statistically significant difference in readmission rates (p = 0.82) or intervention required (p = 0.74) between the two time periods. CONCLUSIONS Epistaxis admissions at our institution have increased since the introduction of NOACs. However, most patients can be managed successfully with intranasal packing and cautery alone. NOACs are not associated with increased rated of invasive haemostatic measures and patients have a shorter LOS.
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Savage P, Cox B, Linden K, Coburn J, Shahmohammadi M, Menown I. Advances in Clinical Cardiology 2021: A Summary of Key Clinical Trials. Adv Ther 2022; 39:2398-437. [PMID: 35482250 DOI: 10.1007/s12325-022-02136-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 03/03/2022] [Accepted: 03/16/2022] [Indexed: 12/22/2022]
Abstract
Introduction Over the course of 2021, numerous key clinical trials with valuable contributions to clinical cardiology were published or presented at major international conferences. This review seeks to summarise these trials and reflect on their clinical context. Methods The authors reviewed clinical trials presented at major cardiology conferences during 2021 including the American College of Cardiology (ACC), European Association for Percutaneous Cardiovascular Interventions (EuroPCR), European Society of Cardiology (ESC), Transcatheter Cardiovascular Therapeutics (TCT), American Heart Association (AHA), European Heart Rhythm Association (EHRA), Society for Cardiovascular Angiography and Interventions (SCAI), TVT-The Heart Summit (TVT) and Cardiovascular Research Technologies (CRT). Trials with a broad relevance to the cardiology community and those with potential to change current practice were included. Results A total of 150 key cardiology clinical trials were identified for inclusion. Interventional cardiology data included trials evaluating the use of new generation novel stent technology and new intravascular physiology strategies such as quantitative flow ratio (QFR) to guide revascularisation in stable and unstable coronary artery disease. New trials in acute coronary syndromes focused on shock, out of hospital cardiac arrest (OOHCA), the impact of COVID-19 on ST-elevation myocardial infarction (STEMI) networks and optimal duration/type of antiplatelet treatment. Structural intervention trials included latest data on transcatheter aortic valve replacement (TAVR) and mitral, tricuspid and pulmonary valve interventions. Heart failure data included trials with sodium-glucose cotransporter 2 (SGLT2) inhibitors, sacubitril/valsartan and novel drugs such as mavacamten for hypertrophic cardiomyopathy (HCM). Prevention trials included new data on proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. In electrophysiology, new data regarding atrial fibrillation (AF) screening and new evidence for rhythm vs. rate control strategies were evaluated. Conclusion This article presents a summary of key clinical cardiology trials published and presented during the past year and should be of interest to both practising clinicians and researchers.
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Kaura S, Rai R, Satia G, Budhiraja
N, Mohan B. Assessment of Bleeding in Patients on Antiplatelets Undergoing Dental Implants. J Maxillofac Oral Surg 2022; 21:260-264. [PMID: 35400896 PMCID: PMC8934814 DOI: 10.1007/s12663-021-01510-7] [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: 08/13/2020] [Accepted: 01/04/2021] [Indexed: 10/22/2022] Open
Abstract
Introduction Antiplatelet drugs are used for the secondary prevention of cardiac and cerebrovascular diseases. Clopidogrel and Aspirin are the most commonly prescribed drugs for these patients. Physicians and dentists have to weigh bleeding risks versus thrombotic risks in interrupting antiplatelet regimen. The balance of these risks for an individual patient is the primary consideration in management of dental patients who are taking antiplatelet drugs and require dental implants. The study was undertaken to assess the risk of bleeding in patients on single and dual antiplatelets undergoing dental implants. Materials and method 65 patients were assessed for bleeding after placement of dental implants. They were divided into 2 groups: group I included 48 patients on single antiplatelets (Aspirin) and group II included 17 patients on dual antiplatelets (Aspirin and Clopidogrel) based upon the timing of coronary intervention. Bleeding was evaluated intra-operatively and post-operatively. Results Significant difference in bleeding was noted between group I and group II based on the Visual Analog Scale (VAS) for bleeding severity after implant placement both intra-operatively (P = 0.000) and post-operatively (P = 0.004) within 24 h. However, post-operative complication after 24 h was non-significant (P = 0.277). Conclusion Dental implants can be safely placed in patients on single antiplatelet drugs without discontinuing them. In patients on dual antiplatelets, risk of bleeding is mild to moderate if the drugs are continued. Consultation with treating cardiologist is a must before any kind of dental invasive surgery in patients on antiplatelets.
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Affiliation(s)
- Sameer Kaura
- Department of Oral and Maxillofacial Surgery, B J S Dental College, Hospital and Research Institute, Ludhiana, India
| | - Rita Rai
- grid.413495.e0000 0004 1767 3121Department of Dentistry, Dayanand Medical College and Hospital, Ludhiana, 141001 India
| | - Gagandeep Satia
- grid.413495.e0000 0004 1767 3121Department of Dentistry, Dayanand Medical College and Hospital, Ludhiana, 141001 India
| | - Namita Budhiraja
- grid.413495.e0000 0004 1767 3121Department of Dentistry, Dayanand Medical College and Hospital, Ludhiana, 141001 India
| | - Bishav Mohan
- Department of Cardiology, Hero DMC Heart Institute, Ludhiana, 141001 India
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Saka E, Canbaz M, Abdullah T, Dinc T, Polat O, Sabanci PA, Akinci IO, Tugrul KM, Ali A. Perioperative myocardial injury after elective neurosurgery: incidence, risk factors, and effects on mortality. Neurosurg Rev 2022; 45:2151-2159. [PMID: 35018524 DOI: 10.1007/s10143-021-01722-y] [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: 05/25/2021] [Revised: 11/20/2021] [Accepted: 12/20/2021] [Indexed: 10/19/2022]
Abstract
Perioperative myocardial injury is an important reason of mortality and morbidity after neurosurgery. It usually is missed due to its asymptomatic character. In the present study, we investigated myocardial injury after noncardiac surgery (MINS) incidence, the risk factor for MINS, and association of MINS with 30-day mortality in neurosurgery patients. Patients with cardiac risk who underwent elective neurosurgery were enrolled to present prospective cohort study. The patients' demographics, comorbidities, medications used, medical history, and type of operation were recorded. The high-sensitivity cardiac troponin (hs-cTn) levels of the patients were measured 12, 24, and 48 h after surgery. The patients were considered MINS-positive if at least one of their postoperative hs-cTn measurement values was ≥ 14 ng/l. All the patients were followed up for 30 days after surgery for evaluation of their outcomes, including total mortality, mortality due to cardiovascular cause, and major cardiac events. A total of 312 patients completed the study and 64 (20.5%) of them was MINS-positive. Long antiplatelet or anticoagulant drug cessation time (OR: 4.9, 95% CI: 2.1-9.4) was found the most prominent risk factor for MINS occurrence. The total mortality rate was 2.4% and 6.2% in patients MINS-negative and MINS-positive, respectively (p = 0.112). The mortality rate due to cardiovascular reasons (0.8% for without MINS, 4.7 for with MINS, and p = 0.026) and incidence of the major cardiac events (4% for without MINS, 10.9 for with MINS, and p = 0.026) were significantly higher in patients with MINS. MINS is a common problem after neurosurgery, and high postoperative hs-cTn level is associated with mortality and morbidity.
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Affiliation(s)
- Esra Saka
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Mert Canbaz
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Taner Abdullah
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Tugce Dinc
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Ozlem Polat
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Pulat Akin Sabanci
- Department of Neurosurgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ibrahim Ozkan Akinci
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Kamil Mehmet Tugrul
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey
| | - Achmet Ali
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Turgut Özal cad, Istanbul, Turkey. .,İ.Ü. İstanbul Tıp Fakültesi Anesteziyoloji A.D., Turgut Özal cad, İstanbul, Türkiye.
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Chang WH, Mueller SH, Tan YY, Lai AG. Antithrombotic therapy in patients with liver disease: population-based insights on variations in prescribing trends, adherence, persistence and impact on stroke and bleeding. Lancet Reg Health Eur 2021; 10:100222. [PMID: 34806071 PMCID: PMC8589727 DOI: 10.1016/j.lanepe.2021.100222] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND Patients with liver disease have complex haemostasis and due to such contraindications, landmark randomised controlled trials investigating antithrombotic medicines have often excluded these patients. As a result, there has been limited consensus on the safety, efficacy and monitoring practices of anticoagulant and antiplatelet therapy in patients with liver disease. This study aims to investigate prescribing prevalence, adherence, persistence and impact of adherence on bleeding and stroke risk in people with and without liver disease taking anticoagulants and antiplatelets. METHODS We employed a population-based cohort consisting of person-level linked records from primary care, secondary care and the death registry. The cohort consisted of 3,929,596 adults aged ≥ 30 years during the study period of 1998 to 2020 and registered with an NHS general practitioner in England. The primary outcome was prescribing prevalence, adherence to and persistence with anticoagulant and antiplatelet therapy comparing patients with and without liver disease. Risk factors for non-adherence and non-persistence were analysed using multivariable logistic regression and Cox regression. Impact of adherence on bleeding and ischaemic stroke was assessed. FINDINGS Among patients with any of the six liver diseases (ALD, autoimmune liver disease, cirrhosis, HBV, HCV and NAFLD), we identified 4,237 individuals with incident atrial fibrillation (indication for anticoagulants) and 4,929 individuals with incident myocardial infarction, transient ischaemic attack, unstable angina or peripheral arterial disease (indication for antiplatelets). Among patients without liver disease, 321,510 and 386,643 individuals were identified as having indications for anticoagulant and antiplatelet therapy, respectively. Among drug-naïve individuals, prescribing prevalence was lower in patients with liver disease compared with individuals without liver disease: anticoagulants (20.6% [806/3,921] vs. 33.5% [103,222/307,877]) and antiplatelets (56.2% [2,207/3,927] vs. 71.1% [249,258/350,803]). Primary non-adherence rates (stopping after one prescription) were higher in patients with liver disease, compared with those without liver disease: anticoagulants (7.9% [64/806] vs. 4.7% [4,841/103,222]) and antiplatelets (6.2% [137/2,207] vs. 4.4% [10,993/249,258]). Among individuals who were not primary non-adherent and had at least 12 months of follow-up, patients with liver disease however had a higher one-year adherence rate: anticoagulants (33.1% [208/628] vs. 29.4% [26,615/90,569]) and antiplatelets (40.9% [743/1,818] vs. 34.4% [76,834/223,154]). Likelihood of non-adherence was lower in apixaban and rivaroxaban (relative to warfarin) and lower in clopidogrel (relative to aspirin). Increased comorbidity burden (by CHA2DS2VASc score) was associated with decreased risk of non-adherence and non-persistence with anticoagulants. Overall rates of 'non-adherent, non-persistent' were highest in warfarin (compared with apixaban and rivaroxaban) and aspirin (compared with clopidogrel or dipyridamole) in patients with and without liver disease. Among patients without liver disease, not taking antithrombotic medications for >3 months was associated with a higher risk of stroke, however, adherence to these medications was also associated with a small increase in risk of bleeding. Patients with liver disease (when compared with those without liver disease) had higher risks of stroke, especially when they stopped taking antiplatelets for >3 months. Patients with liver disease who were adherent to antiplatelets, however, had a higher risk of bleeding compared with patients without liver disease. INTERPRETATION Use of antithrombotic medicines in patients with and without liver disease is suboptimal with heterogeneity across medicines. As patients with liver disease are excluded from major randomised trials for these drugs, our results provide real-world evidence that may inform medicine optimisation strategies. We outline challenges and opportunities for tackling non-adherence, which begins with understanding patients' views of medicines to help them make informed decisions about appropriate use. FUNDING AGL is supported by funding from the Wellcome Trust (204841/Z/16/Z), National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre (BRC714/HI/RW/101440), NIHR Great Ormond Street Hospital Biomedical Research Centre (19RX02), the Health Data Research UK Better Care Catalyst Award (CFC0125) and the Academy of Medical Sciences (SBF006\1084). The funders have no role in the writing of the manuscript or the decision to submit it for publication.
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Affiliation(s)
- Wai Hoong Chang
- Institute of Health Informatics, University College London, London, UK
| | | | - Yen Yi Tan
- Institute of Health Informatics, University College London, London, UK
| | - Alvina G. Lai
- Institute of Health Informatics, University College London, London, UK
- Corresponding author.
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Sylaja PN, Nair SS, Pandian J, Khurana D, Srivastava MVP, Kaul S, Arora D, Sarma PS, Singhal AB. Impact of Pre-Stroke Antiplatelet Use on 3-Month Outcome After Ischemic Stroke. Neurol India 2021; 69:1645-1649. [PMID: 34979663 DOI: 10.4103/0028-3886.333484] [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] [Indexed: 11/04/2022]
Abstract
Background Pre-stroke anti-platelet (PAP) therapy can potentially influence the severity and outcome after ischemic stroke. Methods We analyzed data from the prospective multicenter Indo-US collaborative stroke project for the impact of PAP therapy. Outcome measures included the admission National Institute of Health Stroke Scale (NIHSS) score, 3-month modified Rankin scale (mRS) score, and rates of in-hospital mortality and post-ischemic intracerebral hemorrhage. Results Among 2048 of 2066 patients (M:F = 2:1) with known pre-stroke medication status, 336 (16.3%) were on PAP therapy. As compared to the non-PAP group, the PAP group had significantly higher mean age (62.2 vs 57.4 years, P < 0.001) and significantly more men, vascular risk factors, cerebral microbleeds (12.8% vs 6.2%, P = 0.001) and intravenous thrombolysis treatment (17% vs. 10.6%, P = 0.001). Cardioembolic strokes were significantly more in the PAP group (P < 0.001), but not large artery atherosclerosis. No significant differences were observed in the median NIHSS score (9 vs. 10, P = 0.274), 3-month mRS (score 0-2,51.4% vs. 49.0%, P = 0.428), in-hospital mortality (8.6% vs. 7.8%, P = 0.592), or symptomatic post ischemic intracerebral haemorrhage (12.2% vs. 10.6%, P = 0.382). The PAP group had more stroke recurrence (6.6% vs. 2.9%, P = 0.002) which was not significant (P = 0.065) after multivariate regression analysis adjusting for age, sex and vascular risk factors. PAP therapy was not an independent predictor of initial stroke severity or stroke outcome. Conclusion PAP therapy has no significant effect on initial stroke severity, rates of post-ischemic hemorrhage with or without thrombolysis, in-hospital mortality, stroke recurrence, and 3-month outcome after ischemic stroke.
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Affiliation(s)
- P N Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Sruthi S Nair
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Dheeraj Khurana
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - M V Padma Srivastava
- Department of Neurology, All India Institutes of Medical Sciences, New Delhi, India
| | - Subhash Kaul
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Deepti Arora
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - P Sankara Sarma
- Department of Biostatistics, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Aneesh B Singhal
- Department of Neurology, Stroke Service, Massachusetts General Hospital, Boston, USA
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De Luca L, Putini RL, Natale E, Terranova A, Piazza V, Pugliese M, De Lio L, Biffani E, Bellettini E, Uguccioni M, Musumeci F. One-year clinical outcome of patients with left ventricular thrombus after acute myocardial infarction discharged on triple or dual antithrombotic therapy. J Thromb Thrombolysis 2021; 53:410-416. [PMID: 34613575 DOI: 10.1007/s11239-021-02577-2] [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] [Accepted: 09/19/2021] [Indexed: 11/30/2022]
Abstract
In patients with left ventricular thrombus (LVT) after acute myocardial infarction (MI), both anticoagulant and antiplatelet therapies are needed. It is unknown whether dual antithrombotic therapy (DAT) is able to reduce the incidence of bleeding complications without significantly increasing the number of thromboembolic events, compared to triple antithrombotic therapy (TAT). We retrospectively evaluated all post-MI patients with LVT discharged on TAT or DAT from our tertiary hospital in the last decade. The primary outcome was the occurrence of all-cause mortality, thromboembolic events, hospitalizations for re-MI or heart failure and any bleeding at 1 year. A propensity-score matching was performed in order to compare the primary outcome between TAT and DAT. Out of 2564 acute MI patients, 83 (3.2%) had an LVT at echocardiography: 51 (61.4%) discharged on TAT and 32 (38.6%) on DAT. At clinical follow-up, completed in 93% of cases, the incidence of the primary outcome was 18.2% (25.5% in TAT and 6.7% in DAT group; p = 0.04). More than 2/3 of the events included in the primary outcome were related to bleeding complications and occurred during the first month from hospital discharge. In the matched cohort of 42 patients with follow-up data available, the primary outcome occurred in 9 (42.9%) patients in the TAT and 2 (9.5%) in the DAT group (p = 0.03). In post-MI patients with LVT, DAT seems more effective than TAT in reducing clinical outcome, especially early bleeding complications. A randomized study is warranted to confirm this hypothesis.
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Affiliation(s)
- Leonardo De Luca
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy.
| | - Rita Lucia Putini
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Enrico Natale
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Antonio Terranova
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Vito Piazza
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Marco Pugliese
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Lucia De Lio
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Elisabetta Biffani
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Elisa Bellettini
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Massimo Uguccioni
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Francesco Musumeci
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
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Al-Taee AM, Ghoulam E, Lee P, Edwards M, Mohammed KA, Hachem CY. Underutilization of Peptic Ulcer Disease Prophylaxis Among Elderly Users of Antiplatelets and Anticoagulants. Dig Dis Sci 2021; 66:3476-81. [PMID: 33085015 DOI: 10.1007/s10620-020-06665-w] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 10/07/2020] [Indexed: 12/09/2022]
Abstract
INTRODUCTION Peptic ulcer disease (PUD) develops in approximately 25% of chronic users of non-steroidal anti-inflammatory drugs (NSAIDs). The incidence of uncomplicated PUD has been declining over the past 3 decades unlike that of complicated PUD in the elderly. An expert consensus document published jointly in 2008 by the American College of Gastroenterology (ACG), the American College of Cardiology Foundation (ACCF), and the American Heart Association (AHA) provided recommendations on prevention of PUD among users of antiplatelets and anticoagulants. This work aimed to evaluate physicians' compliance with these guidelines in a tertiary academic setting. METHODS We examined our medical record database for the 9 month period extending from April 2018 until December 2018. Using this database, we identified elderly patients (> 64 years old) who were chronic (> 3 months) users of low dose aspirin (81 mg once daily) and had an indication for PUD prophylaxis as per the ACG-ACCF-AHA guideline document. We performed a retrospective chart review of patients included in this study. Descriptive statistics were compared using χ2 and independent sample t tests. RESULTS A total of 852 patients were included in this study. The mean age was 75 years old, and 43% of patients were females. In addition to aspirin, patients were prescribed P2Y12 inhibitors (45.5%), direct oral anticoagulants (DOACs) (23%), warfarin (12%), steroids (9%) or enoxaparin (1%). Users of DOACs were most commonly prescribed apixaban (16%), followed by rivaroxaban (6%) and dabigatran (1%). Overall, only 40% of patients with an indication for PUD prophylaxis received a proton pump inhibitor. CONCLUSION PUD prophylaxis may be underutilized in elderly patients. This finding, along with increasing rates of NSAID use and an aging population, may help explain the increased incidence of complicated PUD in the elderly. Efforts are needed to raise physician awareness of PUD prophylaxis guidelines.
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Pop C, Țînț D, Petris A. Management of antithrombotic therapy in patients with atrial fibrillation and acute coronary syndromes. Rev Cardiovasc Med 2021; 22:659-675. [PMID: 34565068 DOI: 10.31083/j.rcm2203076] [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: 06/09/2021] [Revised: 07/14/2021] [Accepted: 07/22/2021] [Indexed: 11/06/2022] Open
Abstract
If atrial fibrillation (AF) and acute coronary syndrome (ACS) coexist, they should be treated with combined antithrombotic therapy. To reduce the risk of bleeding while maintaining the desired antithrombotic effect, choices should be made for each patient according to the balance between the bleeding and the thrombotic risk. There are many ways to select the type and dose of the oral anticoagulant (OAC) and P2Y12 inhibitors. As a rule of thumb, aspirin and P2Y12 inhibitors should be recommended to all patients. The duration of this combination therapy is a matter of debate; available data promote an initial period of one to four weeks of triple antithrombotic association with aspirin and P2Y12 inhibitors (clopidogrel in the absence of high ischaemic risk) and preferable direct oral anticoagulants (DOACs). On discontinuing aspirin, double therapy with P2Y12 inhibitors and a DOAC provides similar efficacy and superior safety for many patients on ACS medical or interventional treatment, especially if the risk of bleeding is high and that of thrombosis is low. Further studies are needed to clarify the concerns for a slight augmentation in the number of ischaemic cases (myocardial infarction and stent thrombosis) with double antithrombotic regimen in patients at high ischaemic risk.
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Affiliation(s)
- Călin Pop
- Emergency Clinical County Hospital of Baia Mare, 430031 Baia Mare, Romania.,Faculty of Medicine Arad, "Vasile Goldis" University, 310025 Arad, Romania
| | - Diana Țînț
- Faculty of Medicine, "Transilvania" University, B-dulEroilor 29, 500036 Brașov, Romania
| | - Antoniu Petris
- Cardiology Clinic, "St. Spiridon" County Emergency Hospital, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iaşi, Romania
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Abstract
Anticoagulant and antiplatelet drugs target a specific portion of the coagulation cascade or the platelet activation and aggregation pathway. The primary toxicity associated with these agents is hemorrhage. Understanding the pharmacology of these drugs allows the treating clinician to choose the correct antidotal therapy. Reversal agents exist for some of these drugs; however, not all have proven patient-centered outcomes. The anticoagulants covered in this review are vitamin K antagonists, heparins, fondaparinux, hirudin derivatives, argatroban, oral factor Xa antagonists, and dabigatran. The antiplatelet agents reviewed are aspirin, adenosine diphosphate antagonists, dipyridamole, and glycoprotein IIb/IIIa antagonists. Additional notable toxicities are also reviewed.
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Affiliation(s)
- David B Liss
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University in St. Louis, 660 South Euclid Avenue, CB 8072, St Louis, MO 63110, USA.
| | - Michael E Mullins
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University in St. Louis, 660 South Euclid Avenue, CB 8072, St Louis, MO 63110, USA
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Yu X, Wu L, Ou Y, Xu L, Guo X, Yang C, Liu W. Clinical characteristics and outcomes of chronic subdural hematoma in patients with a history of antiplatelet therapy. Clin Neurol Neurosurg 2021; 208:106817. [PMID: 34388598 DOI: 10.1016/j.clineuro.2021.106817] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Chronic subdural hematoma (CSDH) is a common neurosurgical disease. Many patients with CSDH take antiplatelet (AP) drugs. Several studies have focused merely on the relationship between AP drug use and recurrence without deeply analyzing the specific clinical features of these patients. The primary objective of this study was to investigate the detailed clinical characteristics and outcomes of CSDH patients with a history of AP therapy. METHODS A total of 1181 CSDH patients over 40 years of age who received burr-hole craniostomy were enrolled. Clinical information, computed tomographic findings, and data on long-term outcomes and recurrence among these patients were gathered. We divided these patients into two groups according to whether they had a history of AP therapy. Percentages and χ2 tests were applied for categorical variables. Standard deviations and 2-sided unpaired t-tests were applied for continuous variables. Univariate and multivariate logistic regression analyses were performed to identify independent factors of the outcomes (6 months after discharge). RESULTS AP therapy was not related to the outcomes of patients with CSDH (P = 0.48), and there were no differences in recurrence between the AP and non-AP group. Only Bender grade (P < 0.01, B = -3.14, Exp (B) = 0.04, 95% CI 0.01-0.29) was associated with the outcomes of patients in the AP group. The incidence of complications in the AP group was higher than that in the non-AP group (P < 0.01). Postoperative thrombotic events may be more likely to occur in the AP group than in the non-AP group (P = 0.02). Patients in the AP group were older (P < 0.01) and had more comorbidities (P < 0.01). CONCLUSIONS Patients treated with AP therapy had more complications. The outcomes of patients treated with AP therapy were associated with their status of admission. Patients treated with AP therapy were at greater risk for postoperative thrombotic events. The recurrence rate of CSDH did not appear to be affected by AP therapy.
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Affiliation(s)
- Xiaofan Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liang Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Yunwei Ou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beihang University, Beijing, China
| | - Long Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xufei Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Cheng Yang
- The Third Clinical Medical College, Ningxia Medical University, Yinchuan, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Neurological Center, People's Hospital of Ningxia Hui Autonomous Region (The Third Clinical Medical College, Ningxia Medical University), Yinchuan, China.
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39
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Younsi A, Riemann L, Habel C, Fischer J, Beynon C, Unterberg AW, Zweckberger K. Relevance of comorbidities and antithrombotic medication as risk factors for reoperation in patients with chronic subdural hematoma. Neurosurg Rev 2021; 45:729-739. [PMID: 34240268 PMCID: PMC8827308 DOI: 10.1007/s10143-021-01537-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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 02/14/2021] [Accepted: 03/24/2021] [Indexed: 10/26/2022]
Abstract
In an aging Western society, the incidence of chronic subdural hematomas (cSDH) is continuously increasing. In this study, we reviewed our clinical management of cSDH patients and identified predictive factors for the need of reoperation due to residual or recurrent hematomas with a focus on the use of antithrombotic drugs. In total, 623 patients who were treated for cSDH with surgical evacuation between 2006 and 2016 at our department were retrospectively analyzed. Clinical and radiological characteristics and laboratory parameters were investigated as possible predictors of reoperation with univariate and multivariate analyses. Additionally, clinical outcome measures were compared between patients on anticoagulants, on antiplatelets, and without antithrombotic medication. In univariate analyses, patients on anticoagulants and antiplatelets presented significantly more often with comorbidities, were significantly older, and their risk for perioperative complications was significantly increased. Nevertheless, their clinical outcome was comparable to that of patients without antithrombotics. In multivariate analysis, only the presence of comorbidities, but not antithrombotics, was an independent predictor for the need for reoperations. Patients on antithrombotics do not seem to necessarily have a significantly increased risk for residual hematomas or rebleeding requiring reoperation after cSDH evacuation. More precisely, the presence of predisposing comorbidities might be a key independent risk factor for reoperation. Importantly, the clinical outcomes after surgical evacuation of cSDH are comparable between patients on anticoagulants, antiplatelets, and without antithrombotics.
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Affiliation(s)
- Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany.
| | - Lennart Riemann
- Department of Neurosurgery, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Cleo Habel
- Department of Neurosurgery, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Jessica Fischer
- Department of Neurosurgery, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Christopher Beynon
- Department of Neurosurgery, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Klaus Zweckberger
- Department of Neurosurgery, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
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40
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Shigematsu T, Dier E, Yaeger KA, Morgenstern PF, Glass LD, Kellner CP, Berenstein A. Middle Meningeal Artery Embolization of a Pediatric Patient With Progressive Chronic Subdural Hematoma. Oper Neurosurg (Hagerstown) 2021; 21:E274-E277. [PMID: 33957675 DOI: 10.1093/ons/opab144] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/14/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Evidence suggests middle meningeal artery (MMA) embolization benefits adult patients with chronic subdural hematoma (CSDH) at high risk for recurrence or hemorrhagic complications. Yet, there has not been any report discussing MMA embolization in the pediatric population. Thus, we present a case of an infant with CSDH successfully managed with MMA embolization without surgical management. CLINICAL PRESENTATION A 5-mo-old girl with idiopathic dilated cardiomyopathy underwent surgical implantation of a left ventricular assist device for a bridge to heart transplantation. This was complicated by left ventricular thrombus causing stroke. She was placed on dual antiplatelet antithrombotic therapy on top of bivalirudin infusion. She sustained a left middle cerebral artery infarction, but did not have neurological deficits. Subsequent computed tomography scans of the head showed a progressively enlarging asymptomatic CSDH, and the heart transplant was repeatedly postponed. The decision was made to proceed with MMA embolization at the age of 7 mo. Bilateral modified MMA embolization, using warmed, low-concentration n-butyl-cyanoacrylate (n-BCA) from distal microcatheter positioning, allowed the embolic material to close the distal MMA and subdural membranous vasculature. The patient underwent successful heart transplant and the CSDH improved significantly. She remained neurologically asymptomatic and had normal neurological development after the MMA embolization. CONCLUSION MMA embolization may represent a safe and effective minimally invasive option for pediatric CSDH, especially for patients at high risk for surgery or hematoma recurrence.
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Affiliation(s)
- Tomoyoshi Shigematsu
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Evelyn Dier
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kurt A Yaeger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter F Morgenstern
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lauren D Glass
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alejandro Berenstein
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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41
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Nakajima M, Inatomi Y, Ueda A, Ito Y, Kouzaki Y, Takita T, Wada K, Yonehara T, Terasaki T, Hashimoto Y, Ando Y. Preceding direct oral anticoagulant administration reduces the severity of stroke in patients with atrial fibrillation - K-PLUS registry. J Clin Neurosci 2021; 89:106-112. [PMID: 34119252 DOI: 10.1016/j.jocn.2021.04.027] [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: 09/06/2020] [Revised: 02/17/2021] [Accepted: 04/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Stroke severity can be mitigated by preceding anticoagulant administration in acute ischemic stroke patients with atrial fibrillation (AF). We investigated if such mitigative effects are different between warfarin and direct oral anticoagulants (DOACs). MATERIAL AND METHODS We collected data from a regional multicenter stroke registry. Ischemic stroke or transient ischemic attack patients with AF were included. Background characteristics, National Institutes of Health Stroke Scale (NIHSS) score on admission, lesion characteristics, and in-hospital death were analyzed according to preceding antithrombotic agents at onset. RESULTS A total of 2173 patients had AF; 628 were prescribed warfarin, 272 DOACs, 429 antiplatelets alone, and 844 no antithrombotics. The NIHSS score on admission was lowest in the DOACs group compared to the other groups. In neuroimaging analysis, small ischemic lesions were observed more frequently in the DOACs group, while large ischemic lesions were less frequent in this group. When the no antithrombotics group was used as a reference, the adjusted odds ratio for moderate to severe stroke was 0.56 (95% confidence interval, 0.40-0.78) in the DOACs group, while it was 0.98 (0.77-1.24) in the warfarin group and 0.94 (0.72-1.22) in the antiplatelets group. In-hospital mortality was lowest in the DOACs group compared to the other groups. CONCLUSION Preceding DOAC administration might mitigate the severity of stroke in AF patients more strongly than other antithrombotics, possibly leading to a better outcome in patients with stroke.
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Affiliation(s)
- Makoto Nakajima
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | | | - Akihiko Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Yasuyuki Ito
- Department of Neurology, Minamata City General Hospital & Medical Center, Minamata, Japan
| | - Yanosuke Kouzaki
- Department of Neurology, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Tomohiro Takita
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Kuniyasu Wada
- Department of Neurology, Kumamoto City Hospital, Kumamoto, Japan.
| | | | - Tadashi Terasaki
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan.
| | | | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; Department of Amyloidosis, Nagasaki International University, Sasebo, Japan.
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42
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Borchert RJ, Simonato D, R Hickman C, Fuschi M, Thibault L, Henkes H, Fiorella D, Tan BY, Yeo LL, D Makalanda HL, Wong K, Bhogal P. P2Y12 inhibitors for the neurointerventionalist. Interv Neuroradiol 2021; 28:92-103. [PMID: 33947251 PMCID: PMC8905084 DOI: 10.1177/15910199211015042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The use of antiplatelets is widespread in clinical practice. However, for neurointerventional procedures, protocols for antiplatelet use are scarce and practice varies between individuals and institutions. This is further complicated by the quantity of antiplatelet agents which differ in route of administration, dosage, onset of action, efficacy and ischemic and hemorrhagic complications. Clarifying the individual characteristics for each antiplatelet agent, and their associated risks, will increasingly become relevant as the practice of mechanical thrombectomy, stenting, coiling and flow diversion procedures grows. The aim of this review is to summarize the existing literature for the use of P2Y12 inhibitors in neurointerventional procedures, examine the quality of the evidence, and highlight areas in need of further research.
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Affiliation(s)
- Robin J Borchert
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Davide Simonato
- Department of Neuroradiology, Oxford University Hospital NHS Foundation Trust, Oxford, UK.,Institute of Radiology, University of Padova, Padova, Italy
| | - Charlotte R Hickman
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Maurizio Fuschi
- Department of Neuroradiology, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | | | - Hans Henkes
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - David Fiorella
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Benjamin Yq Tan
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Leonard Ll Yeo
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | | | - Ken Wong
- Royal London Hospital, London, UK
| | - Pervinder Bhogal
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
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Ye X, Shami JJ, Yan VK, Kang W, Blais JE, Zhao J, Lau WC, Wei L, Wong IC, Chan EW. Global antiplatelet sales trend: A focus on P2Y12 inhibitors from 2008 to 2018. Am Heart J Plus 2021; 4:100020. [PMID: 38559679 PMCID: PMC10976188 DOI: 10.1016/j.ahjo.2021.100020] [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] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/01/2021] [Indexed: 04/04/2024]
Abstract
Background P2Y12 inhibitors are an important component of dual antiplatelet therapy. Yet, their accessibility and affordability across countries stratified by income levels have not been studied. Methods Sales data were retrieved from the IQVIA Multinational Integrated Data Analysis System for the description of P2Y12 inhibitors global sales. Countries were stratified into 38 high-income countries and 27 middle-income countries. Results Global sales of P2Y12 inhibitors increased from 0.80 SU per year per person in 2008 to 1.79 in 2018. Growth in sales of P2Y12 inhibitors was greater in middle-income countries compared to high-income countries. Clopidogrel had the highest sales volume in both high-income and middle-income countries from 2008 to 2018, while ticagrelor sales volume increased mainly in high-income countries. Conclusions Despite current guideline recommendations favoring ticagrelor and prasugrel for the prevention of atherothrombotic complications in patients with an acute coronary syndrome, clopidogrel retained the highest sales volume among the P2Y12 inhibitors from 2008 to 2018.
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Affiliation(s)
- Xuxiao Ye
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region
| | - Jessica J.P. Shami
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region
| | - Vincent K.C. Yan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region
| | - Wei Kang
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region
| | - Joseph E. Blais
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region
| | - Jiaxi Zhao
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region
| | - Wallis C.Y. Lau
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region
- Laboratory of Data Discovery for Health, Hong Kong Special Administrative Region
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Li Wei
- Laboratory of Data Discovery for Health, Hong Kong Special Administrative Region
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Ian C.K. Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region
- Laboratory of Data Discovery for Health, Hong Kong Special Administrative Region
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- The University of Hong Kong Shenzhen Institute of Research and Innovation, Shenzhen, China
| | - Esther W. Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region
- Laboratory of Data Discovery for Health, Hong Kong Special Administrative Region
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- The University of Hong Kong Shenzhen Institute of Research and Innovation, Shenzhen, China
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Eastman DK, Spilman SK, Tang K, Sidwell RA, Pelaez CA. Platelet Reactivity Testing for Aspirin Patients Who Sustain Traumatic Intracranial Hemorrhage. J Surg Res 2021; 263:186-192. [PMID: 33677146 DOI: 10.1016/j.jss.2021.01.039] [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: 03/06/2020] [Revised: 11/12/2020] [Accepted: 01/15/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients who take aspirin and sustain traumatic intracranial hemorrhage (tICH) are often transfused platelets in an effort to prevent bleeding progression. The efficacy of platelet transfusion is questionable, however, and some medical societies recommend that platelet reactivity testing (PRT) should guide transfusion decisions. The study hypothesis was that utilization of PRT to guide platelet transfusion for tICH patients suspected of taking aspirin would safely identify patients who did not require platelet transfusion. METHODS This was a retrospective study of patients with blunt tICH who received PRT for known or suspected aspirin use between June 2014 and December 2017 at a level I trauma center. Chart abstraction was conducted to determine home aspirin status, and PRT values were used to classify patients as therapeutic or nontherapeutic on aspirin. Differences were assessed with Kruskal-Wallis and chi-square tests. RESULTS 157 patients met study inclusion criteria, and 118 (75%) patients had documented prior aspirin use. PRT results were available approximately 1.7 h (IQR: 0.9, 3.2) after arrival. Upon initial PRT, 70% of patients were considered inhibited and 88% of those patients had aspirin documented as a home medication. Conversely, 18% of patients with home aspirin use had normal platelet reactivity. Clinically significant worsening of the tICH did not significantly differ when comparing those who received platelet transfusion with those who did not (8% versus 7%, P = 0.87). CONCLUSIONS Platelet reactivity testing can detect platelet inhibition related to aspirin and should guide transfusion decisions for head injured patients in the initial hours after trauma.
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Affiliation(s)
- Darla K Eastman
- Drake University, College of Pharmacy and Health Sciences, Des Moines, Iowa.
| | | | - Kelly Tang
- Osteopathic Medicine Program, Des Moines University, Des Moines, Iowa
| | - Richard A Sidwell
- Trauma Services, UnityPoint Health, Des Moines, Iowa; Trauma Surgery, The Iowa Clinic, Des Moines, Iowa
| | - Carlos A Pelaez
- Trauma Services, UnityPoint Health, Des Moines, Iowa; Trauma Surgery, The Iowa Clinic, Des Moines, Iowa
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Hanna F, Hyppa A, Prakash A, Vithanarachchi U, Dawar HU, Sanga Z, Olabode G, Crisp H, Khalafallah AA. Real-World Data on Characteristics and Management of Community Patients Receiving Anticoagulation Therapy Who Presented with Acute Bleeding to the Emergency Department at a Regional Australian Hospital: A Prospective Observational Study. Mediterr J Hematol Infect Dis 2021; 13:e2021017. [PMID: 33747398 DOI: 10.4084/MJHID.2021.017] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/05/2021] [Indexed: 11/08/2022] Open
Abstract
Objective To study patients receiving anticoagulants with or without antiplatelet therapy presenting at a regional Australian hospital with bleeding. The main aims are to explore: (1) patients' characteristics and management provided; (2) association between the type of anticoagulant and antiplatelet agent used and the requirement of reversal; (3) and the length of hospital stay (LoS) in conjunction with bleeding episode and management. Methods A prospective cross-sectional review of medical records of all patients who presented at a tertiary referral centre with bleeding while receiving anticoagulation therapy between January 2016 and June 2018. Data included: patients, demographics, investigations (kidney and liver function tests, coagulation profile, FBC), LoS, bleeding site, type of and reason for anticoagulation therapy, and management provided. Data analysis included descriptive statistics, χ2 association, and regression models. Results Among the 144 eligible patients, 75 (52.1%) were male, and the mean age was 76 years (SD=11.1). Gastrointestinal tract bleeding was the most common (n=48, 33.3%), followed by epistaxis (n=32, 22.2%). Atrial fibrillation was the commonest reason for anticoagulation therapy (n=65, 45.1%). Warfarin was commonly used (n=74, 51.4%), followed by aspirin (n=29, 20.1%), rivaroxaban (n=26, 18.1%), and apixaban (n=12, 8.3%). The majority had increased blood urea nitrogen (n=67, 46.5%), while 58 (40.3%) had an elevated serum creatinine level, and 59 (41.0%) had a mild reduction in eGFR. Thirty-five of the warfarinised patients (47.3%) had an INR above their condition's target range despite normal liver function. Severe anaemia (Hb<80g/L) was reported in 88 patients (61.1%). DOACs were associated with a reduced likelihood of receiving reversal (B= -1.7, P=<.001), and with a shorter LoS (B= -4.1, P=.046) when compared with warfarin, LMWH, and antiplatelet therapy. Conclusion Warfarin use was common among patients who presented with acute bleeding, and the INR in many warfarinised patients exceeded the target for their condition. DOACs were associated with a reduced likelihood of receiving reversal and a shorter LoS than warfarin, LMWH, which might support a broader application of DOACs into community practice.
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Pearce S, Maingard JT, Kuan Kok H, Barras CD, Russell JH, Hirsch JA, Chandra RV, Jhamb A, Thijs V, Brooks M, Asadi H. Antiplatelet Drugs for Neurointerventions: Part 2 Clinical Applications. Clin Neuroradiol 2021; 31:545-558. [PMID: 33646319 DOI: 10.1007/s00062-021-00997-4] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/15/2021] [Indexed: 02/06/2023]
Abstract
Endovascular techniques have expanded to include balloon and stent-assistance, flow diversion and individualized endovascular occlusion devices, to widen the treatment spectrum for more complex aneurysm morphologies. While usually well-tolerated by patients, endovascular treatment of intracranial aneurysms carries the risk of complications, with procedure-related ischemic complications being the most common. Several antiplatelet agents have been studied in a neurointerventional setting for both prophylaxis and in the setting of intraprocedural thrombotic complications. Knowledge of these antiplatelet agents, evidence for their use and common dosages is important for the practicing neurointerventionist to ensure the proper application of these agents.Part one of this two-part review focused on basic platelet physiology, pharmacology of common antiplatelet medications and future directions and therapies. Part two focuses on clinical applications and evidence based therapeutic regimens.
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Affiliation(s)
- Samuel Pearce
- Department of Radiology, Western Health, 160 Gordon St, 3011, Footscray, Victoria, Australia. .,Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.
| | - Julian T Maingard
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
| | - Hong Kuan Kok
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Interventional Radiology Service, Northern Health Radiology, Melbourne, Victoria, Australia
| | - Christen D Barras
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jeremy H Russell
- Department of Neurosurgery, Austin Health, Melbourne, Victoria, Australia
| | - Joshua A Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ronil V Chandra
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Department of Imaging, Monash University, Melbourne, Victoria, Australia
| | - Ash Jhamb
- Interventional Neuroradiology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Austin Health, Melbourne, Victoria, Australia
| | - Mark Brooks
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Interventional Neuroradiology service, Radiology Department, Austin Health, Melbourne, Victoria, Australia
| | - Hamed Asadi
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Interventional Neuroradiology service, Radiology Department, Austin Health, Melbourne, Victoria, Australia
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Abstract
Risk of both ischemic and hemorrhagic stroke is increased in the chronic kidney disease (CKD) population, particularly in end-stage kidney disease patients. Uremic factors that contribute to stroke risk include blood pressure variability, vascular calcification, build-up of vascular toxins, chronic inflammation, platelet dysfunction and increased brain microbleeds. This paper discusses the controversial evidence for stroke prevention strategies including blood pressure control, statins, antiplatelet agents, and anticoagulation in the CKD population. Only a few randomized clinical trials included patients with advanced CKD, thus evidence is derived mostly from observational cohorts and real-world data. Overall, targeting a lower systolic blood pressure below 120 mmHg and statin prescription do not appear to decrease stroke risk in CKD. Antiplatelet agents have not shown a clear benefit for secondary stroke prevention, but aspirin may reduce incident stroke in hypertensive CKD stage 3B-5 patients. Observational data suggests that the factor Xa inhibitor apixaban has a favorable profile over warfarin in dialysis patients with atrial fibrillation; apixaban being associated with lower stroke risk and fewer major bleeding events.
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Affiliation(s)
- Wei Ling Lau
- Division of Nephrology and Hypertension, University of California Irvine, Irvine, 333 City Blvd West, Suite 400, Orange, CA, USA.
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Alam S, Dharia RN, Miller E, Rincon F, Tzeng DL, Bell RD. Coronavirus Positive Patients Presenting with Stroke-Like Symptoms. J Stroke Cerebrovasc Dis 2021; 30:105588. [PMID: 33549863 PMCID: PMC7796668 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105588] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/14/2020] [Accepted: 12/28/2020] [Indexed: 12/12/2022] Open
Affiliation(s)
- Shaista Alam
- Department of Neurology, Thomas Jefferson University, Thomas Jefferson University Hospital, Philadelphia PA 19107.
| | - Robin N Dharia
- Department of Neurology, Thomas Jefferson University, Thomas Jefferson University Hospital, Philadelphia PA 19107
| | - Elan Miller
- Department of Neurology, Thomas Jefferson University, Thomas Jefferson University Hospital, Philadelphia PA 19107
| | - Fred Rincon
- Department of Neurology, Thomas Jefferson University, Thomas Jefferson University Hospital, Philadelphia PA 19107
| | - Diana L Tzeng
- Department of Neurology, Thomas Jefferson University, Thomas Jefferson University Hospital, Philadelphia PA 19107
| | - Rodney D Bell
- Department of Neurology, Thomas Jefferson University, Thomas Jefferson University Hospital, Philadelphia PA 19107
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Castro A, Cassinello N, Alfonso R, Ortega J. Preoperative risk factors for early hemorrhagic complications in bariatric surgery: a case-control study. Surg Endosc 2021; 36:430-434. [PMID: 33523271 DOI: 10.1007/s00464-021-08302-7] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 01/09/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Although a reliable procedure in morbid obesity treatment, bariatric surgery may be associated with serious complications such as leakage or bleeding. We aimed to analyze the preoperative factors involved in patients with early postoperative hemorrhage after any type of bariatric surgery who required conservative treatment or reoperation for this complication. METHODS Retrospective case-controlled study (1:3) of 2 patient cohorts (postoperative bleeding/controls) matched by type of surgical intervention. RESULTS Hypertension (Odds Ratio 5.029; 95% Confidence Interval 1.78-14.13) and history of antiplatelet medication (OR 13.263; 95% CI 1.39-125.9) were independent risk factors in the bivariate analyses, confirmed in the logistic regression model on multivariate analysis. CONCLUSIONS With no between-group differences in Body Mass Index (BMI) and type 2 Diabetes (T2D), early hemorrhagic complications were found to be more frequent in patients with hypertension or antiplatelet drug treatment.
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Affiliation(s)
- Andrés Castro
- General Surgery Department. Clínica Juan N Corpas, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Norberto Cassinello
- General Surgery Department. Bariatric Surgery Unit, Hospital Clínico Universitario, Avenida Blasco Ibáñez 17, 46010, Valencia, Spain. .,Surgery Department, University of Valencia, Valencia, Spain.
| | - Raquel Alfonso
- General Surgery Department. Bariatric Surgery Unit, Hospital Clínico Universitario, Avenida Blasco Ibáñez 17, 46010, Valencia, Spain
| | - Joaquín Ortega
- General Surgery Department. Bariatric Surgery Unit, Hospital Clínico Universitario, Avenida Blasco Ibáñez 17, 46010, Valencia, Spain.,Surgery Department, University of Valencia, Valencia, Spain
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Mahtta D, Lee MT, Ramsey DJ, Akeroyd JM, Krittanawong C, Khan SU, Sinh P, Alam M, Garratt KN, Schofield RS, Ballantyne CM, Petersen LA, Virani SS. Significant Facility-Level Variation in Utilization of and Adherence with Secondary Prevention Therapies Among Patients with Premature Atherosclerotic Cardiovascular Disease: Insights from the VITAL (Veterans wIth premaTure AtheroscLerosis) Registry7. Cardiovasc Drugs Ther 2021. [PMID: 33400053 DOI: 10.1007/s10557-020-07125-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 12/08/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE We investigated facility-level variation in the use and adherence with antiplatelets and statins among patients with premature and extremely premature ASCVD. METHODS Using the 2014-2015 nationwide Veterans wIth premaTure AtheroscLerosis (VITAL) registry, we assessed patients with premature (age at first ASCVD event: males < 55 years, females < 65 years) and extremely premature ASCVD (< 40 years). We examined frequency and facility-level variation in any statin, high-intensity statin (HIS), antiplatelet use (aspirin, clopidogrel, ticagrelor, prasugrel, and ticlopidine), and statin adherence (proportion of days covered ≥ 0.8) across 130 nationwide VA healthcare facilities. Facility-level variation was computed using median rate ratios (MRR), a measure of likelihood that two random facilities differ in use of statins or antiplatelets and statin adherence. RESULTS Our analysis included 135,703 and 7716 patients with premature and extremely premature ASCVD, respectively. Across all facilities, the median (IQR) prescription rate of any statin therapy, HIS therapy, and antiplatelets among patients with premature ASCVD was 0.73 (0.70-0.75), 0.36 (0.32-0.41), and 0.77 (0.73-0.81), respectively. MRR (95% CI) for any statin use, HIS use, and antiplatelet use were 1.53 (1.44-1.60), 1.58 (1.49-1.66), and 1.49 (1.42-1.56), respectively, showing 53, 58, and 49% facility-level variation. The median (IQR) facility-level rate of statin adherence was 0.58 (0.55-0.62) and MRR for statin adherence was 1.13 (1.10-1.15), showing 13% facility-level variation. Similar median facility-level rates and variation were observed among patients with extremely premature ASCVD. CONCLUSIONS There is suboptimal use and significant facility-level variation in the use of statin and antiplatelet therapy among patients with premature and extremely premature ASCVD. Interventions are needed to optimize care and minimize variation among young ASCVD patients.
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