Antithrombotic Management in AF Patients Following Percutaneous Coronary Intervention: A European Perspective

AF is a highly prevalent disease, often requiring long-term oral anticoagulation to prevent stroke or systemic embolism. Coronary artery disease, which is common among AF patients, is often referred for myocardial revascularisation by percutaneous coronary intervention (PCI), which requires dual antiplatelet therapy to minimise the risk of stent-related complications. The overlap of AF and PCI is a clinical conundrum, especially in the early post-procedural period, when both long-term oral anticoagulation and dual antiplatelet therapy are theoretically indicated as a triple antithrombotic therapy. However, stacking drugs is not a desirable option because of the increased bleeding risk. Several strategies have been investigated to mitigate this concern, including shortening triple antithrombotic therapy duration and switching to a dual antithrombotic regimen. This review analyses the mechanisms underlying thrombotic complications in AF-PCI, summarises evidence surrounding antithrombotic therapy regimens and reports and comments on the latest European guidelines.

Microembolic signal monitoring in patients with HeartMate 3 and HeartWare left ventricular assist devices: Association with antithrombotic treatment and cerebrovascular events

BACKGROUND

In patients with left ventricular assist devices (LVADs), ischemic and hemorrhagic stroke are dreaded complications. Predictive markers for these events are lacking. This study aimed to investigate the prevalence and predictive value of microembolic signals (MES) for stroke, detected by Transcranial Doppler sonography (TCD) in patients with HeartMate 3 (HM 3) or HeartWare (HW).

METHODS

A thirty-minute bilateral TCD monitoring of the middle cerebral artery (MCA) was performed in 62 outpatients with LVAD (HM 3 N = 31, HW N = 31) and 31 healthy controls. Prevalence and quantity of MES were investigated regarding clinical and laboratory parameters. Cerebrovascular events (CVE) were recorded on follow-up at 90 and 180 days.

RESULTS

MES were detected in six patients with HM 3, three patients with HW, and three controls. Within the LVAD groups, patients on monotherapy with vitamin-K-antagonist (VKA) without antiplatelet therapy were at risk for a higher count of MES (negative binomial regression: VKA: 1; VKA + ASA: Exp(B) = 0.005, 95%CI 0.001-0.044; VKA + clopidogrel: Exp(B) = 0.012, 95%CI 0.002-0.056). There was no association between the presence of MES and CVE or death on follow-up (p > 0.05).

CONCLUSION

For the first time, the prevalence of MES was prospectively investigated in a notable outpatient cohort of patients with HM 3 and HW. Despite optimized properties of the latest LVAD, MES remain detectable depending on antithrombotic therapy. No association between MES and CVE could be detected.

Outcomes of systemic bivalirudin and sodium bicarbonate purge solution for Impella 5.5

BACKGROUND

Impella 5.5 (Abiomed; Danvers, MA) (IMP5) is a commonly used, surgically implanted, tMCS device that requires systemic anticoagulation and purge solution to avoid pump failure. To avoid heparin-induced thrombocytopenia (HIT) from unfractionated heparin (UFH) use, our program has explored the utility of bivalirudin (BIV) for systemic anticoagulation and sodium bicarbonate-dextrose purge solution (SBPS) in IMP5.5.

METHODS

This single center, retrospective study included 34 patients supported on IMP5.5 with BIV based AC and SBPS between December 1st 2020 to December 1st 2021.The efficacy and safety end points were incidence of development of HIT, Tissue Plasminogen Activator (tPA) use for suspected pump thrombosis, stroke, and device failure as well as clinically significant bleeding.

RESULTS

The median duration of IMP5.5 support was 9.8 days (IQR: 6-15). Most patients were bridged to HTX (58%) followed by recovery (27%) and LVAD implantation (15%). Patients were therapeutic on bivalirudin for 64% of their IMP5.5 support. One patient (2.9%) suffered from ischemic stroke and 26.5% (9) patients developed clinically significant bleeding. tPA was administered to 7(21%) patients. One patient in the entire cohort developed HIT.

CONCLUSIONS

Our experience supports the use of systemic BIV and SBPS as a method to avoid heparin exposure in a patient population predisposed to the development of HIT.

Heart-Brain Team Approach of Acute Myocardial Infarction Complicating Acute Stroke: Characteristics of Guideline-Recommended Coronary Revascularization and Antithrombotic Therapy and Cardiovascular and Bleeding Outcomes

Background Acute myocardial infarction (AMI) infrequently occurs after acute stroke. The Heart-brain team approach has a potential to appropriately manage this poststroke cardiovascular complication. However, clinical outcomes of AMI complicating acute stroke (AMI-CAS) with the heart-brain team approach have not been characterized. The current study investigated cardiovascular outcomes in patients with AMI-CAS managed by a heart-brain team. Methods and Results We retrospectively analyzed 2390 patients with AMI at our institute (January 1, 2007-September 30, 2020). AMI-CAS was defined as the occurrence of AMI within 14 days after acute stroke. Major adverse cerebral/cardiovascular events (cardiac-cause death, nonfatal myocardial infarction, and nonfatal stroke) and major bleeding events were compared in subjects with  AMI-CAS and those without acute stroke. AMI-CAS was identified in 1.6% of the subjects. Most AMI-CASs (37/39=94.9%) presented ischemic stroke. Median duration of AMI from the onset of acute stroke was 2 days. Patients with AMI-CAS less frequently received primary percutaneous coronary intervention (43.6% versus 84.7%; P<0.001) and dual-antiplatelet therapy (38.5% versus 85.7%; P<0.001), and 33.3% of them did not receive any antithrombotic agents (versus 1.3%; P<0.001). During the observational period (median, 2.4 years [interquartile range, 1.1-4.4 years]), patients with AMI-CAS exhibited a greater likelihood of experiencing major adverse cerebral/cardiovascular events (hazard ratio [HR], 3.47 [95% CI, 1.99-6.05]; P<0.001) and major bleeding events (HR, 3.30 [95% CI, 1.34-8.10]; P=0.009). These relationships still existed even after adjusting for clinical characteristics and medication use (major adverse cerebral/cardiovascular event: HR, 1.87 [95% CI, 1.02-3.42]; P=0.04; major bleeding: HR, 2.67 [95% CI, 1.03-6.93]; P=0.04). Conclusions Under the heart-brain team approach, AMI-CAS was still a challenging disease, reflected by less adoption of primary percutaneous coronary intervention and antithrombotic therapies, with substantially elevated cardiovascular and major bleeding risks. Our findings underscore the need for a further refined approach to mitigate their ischemic/bleeding risks.

Secondary prevention of antithrombotic therapy in patients with stable cardiovascular disease at high ischemic risk: A network meta-analysis of randomized controlled trials

Aims

Antithrombotic secondary prevention in stable cardiovascular disease (SCVD) patients at high ischemic risk remains unclear. We compared the efficacy and safety of aspirin monotherapy, clopidogrel monotherapy, ticagrelor monotherapy, rivaroxaban monotherapy, clopidogrel plus aspirin, ticagrelor plus aspirin, and rivaroxaban plus aspirin in the high-risk ischemic cohorts.

Methods and results

Eleven randomized controlled trials were included (n = 111737). The primary outcomes were major cardiovascular and cerebrovascular events (MACEs) and major bleeding. A random effects model was used for frequentist network meta-analysis. Odds ratio (OR) and 95% credible intervals (CI) were reported as a summary statistic. Compared with aspirin monotherapy, rivaroxaban plus aspirin [OR 0.79 (95% CI, 0.69, 0.89)], ticagrelor plus aspirin [0.88 (0.80, 0.98)], clopidogrel plus aspirin [0.56 (0.41, 0.77)] were associated with a reduced risk of MACEs, but rivaroxaban monotherapy [0.92 (0.79, 1.07)], ticagrelor monotherapy [0.68 (0.45, 1.05)], and clopidogrel monotherapy [0.67 (0.43, 1.05)] showed no statistically significant difference. However, rivaroxaban monotherapy and all dual antithrombotic strategies increased the risk of major bleeding to varying degrees, with ticagrelor plus aspirin associated with the highest risk of major bleeding. The net clinical benefit favored clopidogrel or ticagrelor monotherapy, which have a mild anti-ischemic effect without an increase in bleeding risk.

Conclusion

The present network meta-analysis suggests that clopidogrel or ticagrelor monotherapy may be recommended first in this cohort of SCVD at high ischemic risk. But clopidogrel plus aspirin or rivaroxaban plus aspirin can still be considered for use in patients with recurrent MACEs.

Venous Thromboembolism and Bleeding after Transurethral Resection of the Prostate (TURP) in Patients with Preoperative Antithrombotic Therapy: A Single-Center Study from a Tertiary Hospital in China

BACKGROUND

Venous thromboembolism (VTE) and postoperative hemorrhage are unavoidable complications of transurethral resection of the prostate (TURP). At present, more and more patients with benign prostate hyperplasia (BPH) need long-term antithrombotic therapy before operation due to cardiovascular diseases or cerebrovascular diseases. The purpose of this study was to investigate the effect of preoperative antithrombotic therapy history on lower extremity VTE and bleeding after TURP.

METHODS

Patients who underwent TURP in the Department of Urology, Xiangya Hospital, Central South University, from January 2017 to December 2021 and took antithrombotic drugs before operation were retrospectively analyzed. The baseline data of patients were collected, including age, prostate volume, preoperative International Prostate Symptom Score (IPSS), complications, surgical history within one month, indications of preoperative antithrombotic drugs, drug types, medication duration, etc. Main outcome measures included venous thromboembolism after TURP, intraoperative and postoperative bleeding, and perioperative blood transfusion. Secondary outcome measures included operation duration and postoperative hospitalization days, the duration of stopping antithrombotic drugs before operation, the recovery time of antithrombotic drugs after operation, the condition of lower limbs within 3 months after operation, major adverse cardiac events (MACEs), and cerebrovascular complications and death.

RESULTS

A total of 31 patients after TURP with a long preoperative history of antithrombotic drugs were included in this study. Six patients (19.4%) developed superficial venous thrombosis (SVT) postoperatively. Four of these patients progressed to deep vein thrombosis (DVT) without pulmonary thromboembolism (PE). Only one patient underwent extra bladder irrigation due to blockage of their urinary catheter by a blood clot postoperatively. The symptoms of hematuria mostly disappeared within one month postoperatively and lasted for up to three months postoperatively. No blood transfusion, surgical intervention to stop bleeding, lower limb discomfort such as swelling, MACEs, cerebrovascular complications, or death occurred in all patients within three months after surgery.

CONCLUSION

Short-term preoperative discontinuation may help patients with antithrombotic therapy to obtain a relatively safe opportunity for TURP surgery after professional evaluation of perioperative conditions. The risks of perioperative bleeding, VTE, and serious cardiovascular and cerebrovascular complications are relatively controllable. It is essential for urologists to pay more attention to the perioperative management of these patients. However, further high-quality research results are needed for more powerful verification.

Effects of medication intake on the risk of hemorrhage in patients with sporadic cerebral cavernous malformations

Objective

Recurrent intracerebral hemorrhage (ICH) poses a high risk for patients with cerebral cavernous malformations (CCMs). This study aimed to assess the influence of medication intake on hemorrhage risk in sporadic CCMs.

Methods

From a database of 1,409 consecutive patients with CCM (2003-2021), subjects with sporadic CCMs and complete magnetic resonance imaging data were included. We evaluated the presence of ICH as a mode of presentation, the occurrence of ICH during follow-up, and medication intake, including beta blockers, statins, antithrombotic therapy, and thyroid hormones. The impact of medication intake on ICH at presentation was calculated using univariate and multivariate logistic regression with age and sex adjustment. The longitudinal cumulative 5-year risk for (re-)hemorrhage was analyzed using the Kaplan-Meier curves and the Cox regression analysis.

Results

A total of 1116 patients with CCM were included. Logistic regression analysis showed a significant correlation (OR: 0.520, 95% CI: 0.284-0.951, p = 0.034) between antithrombotic therapy and ICH as a mode of presentation. Cox regression analysis revealed no significant correlation between medication intake and occurrence of (re-)hemorrhage (hazard ratios: betablockers 1.270 [95% CI: 0.703-2.293], statins 0.543 [95% CI: 0.194-1.526], antithrombotic therapy 0.507 [95% CI: 0.182-1.410], and thyroid hormones 0.834 [95% CI: 0.378-1.839]).

Conclusion

In this observational study, antithrombotic treatment was associated with the tendency to a lower rate of ICH as a mode of presentation in a large cohort of patients with sporadic CCM. Intake of beta blockers, statins, and thyroid hormones had no effect on hemorrhage as a mode of presentation. During the 5-year follow-up period, none of the drugs affected the further risk of (re-)hemorrhage.

Antithrombotic therapy and digestive endoscopy

Antithrombotic therapy and digestive endoscopy Antithrombotic therapy comprises anticoagulation and antiplatelet treatment. The number of patients treated with various forms of antithrombotic therapy is growing. Procedures of digestive endoscopy are very frequently indicated by general practitioners and doctors of various specialisations. Interdisciplinary cooperation and mutual understanding are required in order for digestive endoscopy to be effective and safe. Hence, we present an overview based on recent European, British (1), and North American guidelines (2) for endoscopic procedures, with respect to guidelines for perioperative care in general (3). Antithrombotic therapy management in patients undergoing digestive endoscopy procedures is based on individual consideration of postprocedural bleeding (particularly a delayed one) on one hand, and thromboembolic risk on the other hand, ideally in cooperation with the physician prescribing antithrombotic therapy. Despite all efforts, patients taking antithrombotic medication are at a higher risk of postprocedural bleeding in comparison with those without this risk; this fact should be accepted by attending physicians and patients should be informed of it. Postprocedural bleeding is mostly manageable with a subsequent endoscopic procedure. By contrast, cerebral and cardiovascular thromboembolic complications are often life-threatening and not uncommonly disabling. One should always consider postponing an elective procedure in a patient with temporary antithrombotic therapy (after pulmonary embolism or after coronary stent insertion). Basic principles of administration of antithrombotic therapy in the context of an endoscopic procedure are described in Table 1. Digestive endoscopy procedures can be categorized according to postprocedural bleeding risk (Table 2). Postprocedural bleeding risk can be specifically reduced in some procedures (ERCP with papillary balloon dilation instead of sphincterotomy, mechanical securing of polypectomy base, etc.). Acetylsalicylic acid administered as secondary prevention (primary preventive indications are very narrow nowadays) should not be discontinued perioperatively (discontinuation is associated with an approximately threefold increase in thrombotic complications!). The riskiest procedures are the only exception in which discontinuation is explicitly requested by the digestive endoscopist. Reduction of dual antiplatelet therapy is better abandoned in high-risk patients - particularly those with recently implanted coronary stents (Table 3) - and postponement of an elective procedure should always be considered. Bridging of warfarin with low-molecular-weight heparin (LMWH) is not indicated routinely (in some cases, this practice increases the bleeding risk). Bridging with LMWH is appropriate in patients with high (or moderate) thromboembolic risk (Table 5). Furthermore, LMWH therapy carries specific risks, particularly in patients with renal function impairment (Table 4). In patients with a high thromboembolic risk, a statement of the physician indicating anticoagulation is always appropriate before an elective procedure (Table 6). Direct oral anticoagulants (DOACs) should not be administered on the day of the procedure, not even in one with a low risk (e.g., biopsy); a longer withdrawal is recommended in high-risk procedures (this cessation should not be bridged with LMWH given the rapid onset and elimination half-time) (Table 7). Recommencement of antithrombotic therapy after a high-risk endoscopic procedure should always be determined by the endoscopist and the recommended intervals should be considered minimal: 1-2 days after the procedure in the case of P2Y12 inhibitors; 2-3 days after the procedure in the case of DOACs; in the evening of the day of the procedure for warfarin with a maintenance (not saturation) dose; and 48 hours after the procedure in the case of LMWH at a therapeutic dose. Earlier administration of a lower-than-therapeutic dose of LMWH (twice a day per weight) can be considered in this context: prophylactic (once a day) or higher prophylactic (once a day per weight) doses. In general, a full anticoagulation effect should not be achieved earlier than approximately 48 hours after the procedure. The patient should be properly informed of the course of antithrombotic therapy before and after the endoscopic procedure, including a written form (a calendar can be downloaded online for this purpose).

Efficacy and safety of rivaroxaban versus placebo after lower extremity bypass surgery: A post hoc analysis of a "CASPAR like" outcome from VOYAGER PAD

BACKGROUND

The Clopidogrel and Acetylsalicylic Acid in Bypass Surgery for Peripheral Arterial Disease (CASPAR) trial is the only large, double-blind, placebo-controlled trial of dual antiplatelet therapy (DAPT) versus aspirin in patients with peripheral artery disease (PAD) after lower extremity revascularization (LER). The trial was neutral for index-graft occlusion/revascularization, amputation or death (hazard ratio [HR] 0.98, 95% confidence interval [CI] 0.78-1.23, p = .87) with an excess of global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries moderate or severe bleeding (HR 2.84, 95% CI 1.32-6.08, p = .007).

HYPOTHESIS AND METHODS

VOYAGER-PAD demonstrated that rivaroxaban significantly reduces acute limb ischemia (ALI), major amputation, myocardial infarction (MI), stroke and CV death but increased bleeding. The relative efficacy and safety of rivaroxaban in a CASPAR like population and for similar outcomes is unknown. The current analysis is a post-hoc exploratory analysis of a "CASPAR like" composite of ALI, unplanned index limb revascularization (UILR), amputation or CV death in surgical patients.

RESULTS

In the 2185 who underwent surgical LER, rivaroxaban reduced the CASPAR endpoint at 1 (HR 0.76, 95% CI 0.62-0.95, p = .0133) and 3 years (HR 0.84, 95% CI 0.71-1.00, p = .0461, Figure). There were similar reductions in composites of ALI, amputation or CV death (HR 0.79, p = .0228) and ALI, UILR, amputation, MI, IS or CV death (HR 0.85, p = .0410).

CONCLUSIONS

The combination of rivaroxaban and aspirin significantly reduces ischemic outcomes in patients with PAD after LER. Although no formal head-to-head comparison exists, in a similar population and for similar outcomes, this regimen demonstrated benefit where trials of DAPT were neutral. These data suggest that factor Xa inhibition may provide specific benefits in this population and that DAPT should not be considered a proven substitution.

Mortality Rate in Upper Gastrointestinal Bleeding Associated with Anti-Thrombotic Therapy Before and During Covid-19 Pandemic

INTRODUCTION

During the last few years, a progressive higher proportion of patients have had upper gastrointestinal bleeding (UGIB) related to antithrombotic therapy. The introduction of direct oral anticoagulant (DOAC) and COVID-19 pandemic may change the incidence, mortality, and follow-up, especially in patients at high risk of bleeding.

PATIENTS AND METHODS

We studied the use of anti-thrombotic therapy (AT) in patients with upper gastrointestinal bleeding for 5 years (January 2017-December 2021) including Covid-19 pandemic period (March 2020-December 2021). We analyzed mortality rate, rebleeding rate and need for transfusion in patients with AT therapy compared with those without AT therapy and risk factors for mortality, and also the incidence of gastrointestinal bleeding in patients admitted for COVID-19 infection.

RESULTS

A total of 824 patients were admitted during Covid-19 pandemic period and 1631 before pandemic period; a total of 426 cases of bleeding were recorded in patients taking antithrombotic therapy and the frequency of antithrombotic therapy in patients with UGIB was higher in pandemic period (24.39% versus 13.8%). Unadjusted mortality was 12.21%, similar with patients with no antithrombotic treatment but age-adjusted mortality was 9.62% (28% lower). The rate of endoscopy was similar but fewer therapeutic procedures were required. Mean Hb level was 10% lower, and more than 60% of patients required blood transfusion.

CONCLUSION

Mortality was similar compared with patients with no antithrombotic therapy, fewer therapeutic endoscopies were performed and similar rebleeding rate and emergency surgery were noted. Hb level was 10% lower and a higher proportion of patients required blood transfusions. Mortality was higher in DOAC treatment group compared with VKA patients but with no statistical significance. The rate of upper gastrointestinal bleeding in Covid-19 positive hospitalized cases was 0.58%. The mortality risk in multivariate analysis was associated with GB score, with no endoscopy performed, with obscure and variceal bleeding and with LMWH versus VKA therapy.

Pathophysiological mechanisms of thrombosis in acute and long COVID-19

COVID-19 patients have a high incidence of thrombosis, and thromboembolic complications are associated with severe COVID-19 and high mortality. COVID-19 disease is associated with a hyper-inflammatory response (cytokine storm) mediated by the immune system. However, the role of the inflammatory response in thrombosis remains incompletely understood. In this review, we investigate the crosstalk between inflammation and thrombosis in the context of COVID-19, focusing on the contributions of inflammation to the pathogenesis of thrombosis, and propose combined use of anti-inflammatory and anticoagulant therapeutics. Under inflammatory conditions, the interactions between neutrophils and platelets, platelet activation, monocyte tissue factor expression, microparticle release, and phosphatidylserine (PS) externalization as well as complement activation are collectively involved in immune-thrombosis. Inflammation results in the activation and apoptosis of blood cells, leading to microparticle release and PS externalization on blood cells and microparticles, which significantly enhances the catalytic efficiency of the tenase and prothrombinase complexes, and promotes thrombin-mediated fibrin generation and local blood clot formation. Given the risk of thrombosis in the COVID-19, the importance of antithrombotic therapies has been generally recognized, but certain deficiencies and treatment gaps in remain. Antiplatelet drugs are not in combination with anticoagulant treatments, thus fail to dampen platelet procoagulant activity. Current treatments also do not propose an optimal time for anticoagulation. The efficacy of anticoagulant treatments depends on the time of therapy initiation. The best time for antithrombotic therapy is as early as possible after diagnosis, ideally in the early stage of the disease. We also elaborate on the possible mechanisms of long COVID thromboembolic complications, including persistent inflammation, endothelial injury and dysfunction, and coagulation abnormalities. The above-mentioned contents provide therapeutic strategies for COVID-19 patients and further improve patient outcomes.

Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline

BACKGROUND

The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug.

METHODS

Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines.

RESULTS

A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures.

CONCLUSIONS

Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.

Executive Summary: Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline

BACKGROUND

The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug.

METHODS

Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines.

RESULTS

A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures.

CONCLUSIONS

Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.

Gender-differences in antithrombotic therapy across the spectrum of ischemic heart disease: Time to tackle the Yentl syndrome?

The incidence and clinical presentation of ischemic heart disease (IHD), as well as thrombotic and bleeding risks, appear to differ between genders. Compared with men, women feature an increased thrombotic risk, probably related to an increased platelet reactivity, higher level of coagulation factors, and sex-associated unique cardiovascular risk factors, such as pregnancy-related (i.e., pre-eclampsia and gestational diabetes), gynecological disorders (i.e., polycystic ovary syndrome, early menopause) and autoimmune or systemic inflammatory diseases. At the same time, women are also at increased risk of bleeding, due to inappropriate dosing of antithrombotic agents, smaller blood vessels, lower body weight and comorbidities, such as diabetes and chronic kidney disease. Pharmacological strategies focused on the personalization of antithrombotic treatment may, therefore, be particularly appealing in women in light of their higher bleeding and ischemic risks. Paradoxically, although women represent a large proportion of cardiovascular patients in our practice, adequate high-quality clinical trial data on women remain scarce and inadequate to guide decision-making processes. As a result, IHD in women tends to be understudied, underdiagnosed and undertreated, a phenomenon known as a "Yentl syndrome." It is, therefore, compelling for the scientific community to embark on dedicated clinical trials to address underrepresentation of women and to acquire evidence-based knowledge in the personalization of antithrombotic therapy in women.

Impact of admitting department on the management of acute coronary syndrome after an out of hospital cardiac arrest

AIM

This study aimed to analyze the influence of the hospital admitting department on adherence to the Guidelines of European Society of Cardiology for management of acute coronary syndromes in patients after out-of-hospital cardiac arrest (OHCA) of coronary etiology.

METHODS

We studied retrospective-prospective register of 102 consecutive patients with OHCA as a manifestation of acute coronary syndrome (ACS). Patients were admitted to the coronary care unit (CCU) 52, general intensive care unit (GICU) 21, or GICU after initial Cath lab treatment (CAG-GICU) 29. This study compared the differences in the management of ACS in patients with OHCA of coronary etiology based on the admitting department in a tertiary care institution.

RESULTS

Twelve of the 21 (57.1%) patients admitted to the GICU were evaluated as having ACS on-site where they experienced OHCA. In the CCU group, 50 out of 52 (96.2%) and 28 of 29 (100%) patients in the CAG-GICU group (P<0.001). Coronary angiography was performed in 10 of 21 patients (48%) admitted to the GICU. It was performed in 49 out of 52 (94%) CCU patients and, in the CAG-GICU group, 28 out of 29 patients. The mean time to CAG differed significantly across groups (that is, GICU 200.7 min., CCU 71.2 min., and CAG-GICU 7.5 min. (P<0.001)). Aspirin was used in 48% of GICU, 96% of CCU, and 79% of CAG-GICU patients (P<0.001), while in the pre-hospital phase, aspirin was used in 9.5% of GICU, 71.2% of CCU, and 50% of CAG-GICU patients (P<0.001). P2Y12 inhibitor prescriptions were lower in patients admitted to the GICU (33% vs. 89% CCU and 57% CAG-GICU, P<0.001). The department's choice significantly affected the time to initiation of antithrombotics, which was the longest in the GICU.

CONCLUSION

The choice of admission department for patients with OHCA caused by ACS was found to affect the extent to which the recommended treatments were used. An examination of OHCA patients by a cardiologist upon admission to the hospital increased the likelihood of an early diagnosis of ACS as the cause of OHCA.

Stroke prevention during and after transcatheter aortic valve implantation: From cerebral protection devices to antithrombotic management

Since its conception, transcatheter aortic valve implantation (TAVI) has undergone important improvements both in the implantation technique and in transcatheter devices, allowing an enthusiastic adoption of this therapeutic approach in a wide population of patients previously without a surgical option and managed conservatively. Nowadays, patients with severe symptomatic aortic stenosis are typically managed with TAVI, regardless of their risk to surgery, improving the prognosis of patients and thus achieving an exponential global expansion of its use. However, thromboembolic and hemorrhagic complications remain a latent concern in TAVI recipients. Both complications can appear simultaneously in the periprocedural period or during the follow-up, and when minor, they resolved without apparent sequelae, but in a relevant percentage of cases, they are devastating, overshadowing the benefit achieved with TAVI. Our review outlines the etiology and incidence of thromboembolic complications associated with TAVI, the main current strategies for their prevention, and the implications of its pharmacological management at the follow-up in a TAVI population, mostly frail and predisposed to bleeding complications.

Antithrombotic therapy in peripheral arterial disease

Background

Patients with peripheral arterial disease (PAD) are at increased risk for major adverse cardiovascular events (MACE) such as cardiovascular death, myocardial infarction, and stroke as well as major adverse limb events (MALE) such as amputation and acute limb ischemia. Therefore, prevention of thrombotic events is crucial to improve the prognosis of PAD patients. This review article concludes current evidence and guideline recommendations about antithrombotic therapy in PAD patients.Antithrombotic therapy is highly effective to reduce MACE and MALE events in PAD patients. Recently, the concept of dual pathway inhibition (low-dose rivaroxaban plus acetylic salicylic acid (ASA) has been tested in the COMPASS and VOYAGER-PAD trial. Compared to ASA alone dual pathway inhibition was superior to prevent MACE and MALE. After peripheral revascularization, in particular the risk for acute limb ischemia was reduced. In contrast, the risk for major bleeding is increased. Therefore, current guidelines recommend the combination of low-dose rivaroxaban and ASA in PAD patients with low bleeding risk. In patients with high bleeding risk, a single antiplatelet drug (preferable clopidogrel) is indicated. In patients with atherosclerotic vascular disease and indication for oral anticoagulation, no additional antiplatelet drug is necessary, as this would increase the risk of bleeding without improving the prognosis.

Conclusion

Antithrombotic treatment reduces MACE and MALE and is recommended in all patients with PAD. Individual bleeding risk should always be considered based on the current data situation and an individual benefit-risk assessment must be carried out.

Clinical Presentation, Treatment, and Outcome of Nontraumatic Subarachnoid Hemorrhage in Patients with Preceding Antithrombotic Therapy

With the aging of the population, the number of people taking antithrombotic drugs is increasing. Few reports have described the clinical presentation, treatment, and outcomes of nontraumatic subarachnoid hemorrhage (SAH) in patients with preceding antithrombotic therapy. This study included 459 patients with nontraumatic SAH who had been treated between April 2009 and May 2021. Overall, 39 of the 459 patients with aneurysmal SAH were on antithrombotic therapy before ictus (8.5%). Therefore, we classified patients into two groups: Group A (n = 39), patients with preceding antithrombotic therapy and Group B (n = 420), patients without preceding antithrombotic therapy. Hunt and Kosnik (H&K) grade on admission was significantly higher in Group A than in Group B (p = 0.02). Patients in Group A more frequently received endovascular treatment. The rate of endovascular therapy for symptomatic vasospasm after SAH was significantly lower in Group A (2.6%) than in Group B (15.5%; p = 0.03). The outcomes at 3 months after onset were significantly poorer in Group A patients than in Group B patients (p = 0.03). Patients with preceding antithrombotic drugs tended to be at greater risk of unfavorable outcomes, but this difference was not significant in the univariate analysis. In the multivariate analysis, patient age, H&K grade ≥4, and subdural hematoma remained as risk factors for poor outcomes; however, preceding use of antithrombotic drugs was not a significant risk factor.

Evaluation of Thrombocytopenia in Patients Receiving Percutaneous Mechanical Circulatory Support With an Impella Device

Evaluate the time course of thrombocytopenia in patients with Impella devices (Abiomed, Danvers, MA).

Good practice statements for antithrombotic therapy in the management of COVID-19: Guidance from the SSC of the ISTH

Despite the emergence of high quality randomized trial data with the use of antithrombotic agents to reduce the risk of thromboembolism, end-organ failure, and possibly mortality in patients with coronavirus disease 2019 (COVID-19), questions still remain as to optimal patient selection for these strategies, the use of antithrombotics in outpatient settings and in-hospital settings (including critical care units), thromboprophylaxis in special patient populations, and the management of acute thrombosis in hospitalized COVID-19 patients. In October 2021, the International Society on Thrombosis and Haemostasis (ISTH) formed a multidisciplinary and international panel of content experts, two patient representatives, and a methodologist to develop recommendations on treatment with anticoagulants and antiplatelet agents for COVID-19 patients. The ISTH Guideline panel discussed additional topics to be well suited to a non-Grading of Recommendations Assessment, Development, and Evaluation (GRADE) for Good Practice Statements (GPS) to support good clinical care in the antithrombotic management of COVID-19 patients in various clinical settings. The GPS panel agreed on 17 GPS: 3 in the outpatient (pre-hospital) setting, 12 in the hospital setting both in non-critical care (ward) as well as intensive care unit settings, and 2 in the immediate post-hospital discharge setting based on limited evidence or expert opinion that supports net clinical benefit in enacting the statements provided. The antithrombotic therapies discussed in these GPS should be available in low- and middle-income countries.

Antithrombotic therapy after transcatheter aortic valve implantation

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) is a treatment option for patients with symptomatic severe aortic stenosis across the entire spectrum of surgical risk. TAVI conveys some risk for thrombotic complications, requiring antithrombotic drugs for their prevention. Bleeding events represent the major drawback of antithrombotic therapy, which should be carefully tailored over the individual patient's risk profile.

AREAS COVERED

This review aimed at exploring the rationale for the adoption of a tailored antithrombotic therapy after successful TAVI, with a description and analysis of common complications and their impact on therapy selection. In addition, we aimed at reviewing and discussing current knowledge in this area, with a main focus on the high-quality evidence supporting latest guideline recommendations. Finally, ongoing studies and future directions on antithrombotic therapy after TAVI were outlined.

EXPERT OPINION

Initial experience with antithrombotic therapy after TAVI was derived from percutaneous coronary intervention practice. Accruing evidence in the field led to the current monotherapy paradigm, which prioritizes oral anticoagulant and single antiplatelet therapy in patients with or without an established indication for long-term anticoagulation, respectively. Future studies will investigate the role of alternative antithrombotic strategies to improve clinical outcomes of TAVI patients by minimizing both thrombotic and bleeding complications.

Antithrombotic Effects of Fostamatinib in Combination with Conventional Antiplatelet Drugs

New antithrombotic medications with less effect on haemostasis are needed for the long-term treatment of acute coronary syndromes (ACS). The platelet receptor glycoprotein VI (GPVI) is critical in atherothrombosis, mediating platelet activation at atherosclerotic plaque. The inhibition of spleen tyrosine kinase (Syk) has been shown to block GPVI-mediated platelet function. The aim of our study was to investigate if the Syk inhibitor fostamatinib could be repurposed as an antiplatelet drug, either alone or in combination with conventional antiplatelet therapy. The effect of the active metabolite of fostamatinib (R406) was assessed on platelet activation and function induced by atherosclerotic plaque and a range of agonists in the presence and absence of the commonly used antiplatelet agents aspirin and ticagrelor. The effects were determined ex vivo using blood from healthy volunteers and aspirin- and ticagrelor-treated patients with ACS. Fostamatinib was also assessed in murine models of thrombosis. R406 mildly inhibited platelet responses induced by atherosclerotic plaque homogenate, likely due to GPVI inhibition. The anti-GPVI effects of R406 were amplified by the commonly-used antiplatelet medications aspirin and ticagrelor; however, the effects of R406 were concentration-dependent and diminished in the presence of plasma proteins, which may explain why fostamatinib did not significantly inhibit thrombosis in murine models. For the first time, we demonstrate that the Syk inhibitor R406 provides mild inhibition of platelet responses induced by atherosclerotic plaque and that this is mildly amplified by aspirin and ticagrelor.

Bleeding Complications After Breast Core-needle Biopsy-An Approach to Managing Patients on Antithrombotic Therapy

Image-guided core-needle breast and axillary biopsy (CNB) is the standard-of-care procedure for the diagnosis of breast cancer. Although the risks of CNB are low, the most common complications include bleeding and hematoma formation. Post-procedural bleeding is of particular concern in patients taking antithrombotic therapy, but there is currently no widely established standard protocol in the United States to guide antithrombotic therapy management. In the face of an increasing number of patients taking antithrombotic therapy and with the advent of novel classes of anticoagulants, the American College of Radiology guidelines recommend that radiologists consider cessation of antithrombotic therapy prior to CNB on a case-by-case basis. Lack of consensus results in disparate approaches to patients on antithrombotic therapy undergoing CNB. There is further heterogeneity in recommendations for cessation of antithrombotic therapy based on the modality used for image-guided biopsy, target location, number of simultaneous biopsies, and type of antithrombotic agent. A review of the available data demonstrates the safety of continuing antithrombotic therapy during CNB while highlighting additional procedural and target lesion factors that may increase the risk of bleeding. Risk stratification of patients undergoing breast interventional procedures is proposed to guide both pre-procedural decision-making and post-procedural management. Radiologists should be aware of antithrombotic agent pharmacokinetics and strategies to minimize post-procedural bleeding to safely manage patients.

Acute thrombotic occlusion of a brachiocephalic branch graft and pseudoaneurysm formation after debranching surgery for a "non-A non-B" aortic dissection

Non-A non-B aortic dissection is a pathology with potentially life-threatening consequences, and aortic debranching followed by thoracic endovascular aortic repair is one of the possible treatment options. Branch graft occlusion is an infrequent complication and no definite guidelines exist about postoperative antithrombotic therapy nor preoperative evaluation of individual anatomical characteristics-in particular regarding cerebral circulation-in such patients. We present the case of a 54-year-old man undergoing an aortic debranching procedure for a thoracoabdominal aortic dissection originating in the aortic arch, complicated by thrombotic occlusion of the brachiocephalic branch of the prosthesis and pseudoaneurysm of the ascending aorta, with our management and considerations.