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Lucke-Wold N, Hey G, Rivera A, Sarathy D, Rezk R, MacNeil A, Albright A, Lucke-Wold B. Optimizing Dual Antiplatelet Therapy in the Perioperative Period for Spine Surgery After Recent Percutaneous Coronary Intervention: A Comprehensive Review, Synthesis, and Catalyst for Protocol Formulation. World Neurosurg 2024; 185:267-278. [PMID: 38460814 DOI: 10.1016/j.wneu.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/03/2024] [Indexed: 03/11/2024]
Abstract
The increased incidence of spine surgery within the past decade has highlighted the importance of robust perioperative management to improve patient outcomes overall. Coronary artery disease is a common medical comorbidity present in the population of individuals who receive surgery for spinal pathology that is often treated with dual antiplatelet therapy (DAPT) after percutaneous coronary intervention. Discontinuation of DAPT before surgical intervention is typically indicated; however, contradictory evidence exists in the literature regarding the timing of DAPT use and discontinuation in the perioperative period. We review the most recent cardiac and spine literature on the intricacies of percutaneous coronary intervention and its associated risks in the postoperative period. We further propose protocols for DAPT use after both elective and urgent spine surgery to optimize perioperative care.
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Affiliation(s)
- Noelle Lucke-Wold
- Malcom Randall Veteran Affairs Medical Center, Gainesville, Florida, USA
| | - Grace Hey
- University of Florida College of Medicine, Gainesville, Florida, USA.
| | - Angela Rivera
- Malcom Randall Veteran Affairs Medical Center, Gainesville, Florida, USA
| | - Danyas Sarathy
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Rogina Rezk
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Andrew MacNeil
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ashley Albright
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
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Rao Y, Wang J, Yang F, Ni X. Safety of Continuing Aspirin Use in Patients With Coronary Heart Disease Who Undergo Thyroid Surgery During the Perioperative Period. EAR, NOSE & THROAT JOURNAL 2024:1455613241230844. [PMID: 38491759 DOI: 10.1177/01455613241230844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2024] Open
Abstract
Objective: To investigate the safety of continuing aspirin use in patients with coronary heart disease undergoing thyroid surgery during the perioperative period. Methods: Forty-four patients with coronary heart disease who underwent thyroid surgery in our department from July 2019 to June 2023 were selected as the observation group, and the observation group continued to use aspirin during the perioperative period. Forty-four patients who underwent the same surgery during the same period without coronary heart disease and without anticoagulant or antiplatelet therapy were selected as control group 1. Another 44 patients with coronary heart disease who underwent the same surgery from August 2015 to June 2019 and used low molecular weight heparin bridging during the perioperative period were selected as control group 2. Clinical data from the 3 groups of patients were collected for retrospective analysis. Results: The age and proportion of male patients in the observation group and control group 2 were higher than those in control group 1, and the total hospital stay in control group 2 was longer than in the observation group and control group 1, with statistically significant differences (all P < .05). There were no statistically significant differences in surgical time, intraoperative blood loss, postoperative drainage volume, duration of drainage tube retention, postoperative hospital stay, and perioperative hemoglobin, platelet, and international normalized ratio between the 3 groups of patients (all P > .05). All patients in the 3 groups successfully completed surgery without serious complications or death during the perioperative period. Conclusion: Continuing to use aspirin in patients with coronary heart disease who undergo thyroid surgery during the perioperative period can safely complete surgery without increasing the risk of intraoperative and postoperative bleeding.
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Affiliation(s)
- Yuansheng Rao
- Department of Otolaryngology, Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Department of Otolaryngology, Head and Neck Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jianhong Wang
- Department of Otolaryngology, Head and Neck Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Fan Yang
- Department of Otolaryngology, Head and Neck Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xin Ni
- Department of Otolaryngology, Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Agrawal-Patel S, Brar H, Elia M, Fulla J, Li B, Prasanchaimontri P, Li J, De S. Is it Safe to Continue Aspirin in Patients Undergoing Percutaneous Nephrolithotomy? Urology 2024; 183:32-38. [PMID: 37778475 DOI: 10.1016/j.urology.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/11/2023] [Accepted: 09/23/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE To evaluate peri-operative outcomes in patients on chronic aspirin therapy undergoing percutaneous nephrolithotomy (PCNL), with and without discontinuation of aspirin. Anti-coagulation and anti-platelet therapy are contraindications for PCNL per American Urological Association guidelines due to bleeding risk. However, there is potentially increased cardiovascular risk with peri-procedural aspirin withdrawal. METHODS Patients on chronic aspirin undergoing PCNL between January 2014 and May 2019 were retrospectively reviewed and stratified by continued or discontinued aspirin >5 days preoperatively. Hematologic complications, transfusions, and thrombotic complications were assessed with logistic regression model. RESULTS Three hundred twenty-five patients on chronic aspirin therapy underwent PCNL-85 continued and 240 discontinued aspirin. There were no significant differences in hemoglobin change, estimated blood loss, transfusions, creatinine change, thrombotic complications, 30-days re-admissions, complications, or 30-day emergency department visits. Patients who continued aspirin had longer length of stay (1.6 vs 1.9 days, P = .03). American Society of Anesthesiologists (ASA) score of 3 (OR 3.2, P = .02, 95% confidence intervals (CI) [1.2-8.4]), ASA score of 4 (OR 4.0, P = .02, 95% CI [1.2-13.1]), Black race, and previous smoking (OR 2.1, P = .02, 95% CI [1.1-3.9]) was associated with continued aspirin. Body mass index ≥30 was associated with aspirin discontinuation (OR 0.9, P = .004, 95% CI [0.9-1.0]). Increased postoperative hematologic complications were associated with additional anticoagulation medication (OR 2.9, P = .04, 95% CI [1.0-4.4]). CONCLUSION Continued aspirin use did not increase in postoperative complications in patients undergoing PCNL. Patients who are on additional anticoagulation medication are at risk of hematologic complications.
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Affiliation(s)
| | - Harmenjit Brar
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH
| | - Marlie Elia
- SUNY Downstate Health Sciences University, Brooklyn, NY
| | - Juan Fulla
- Department of Urology, University of Chile, Santiago, Chile
| | - Becky Li
- Nova Southeastern University, College of Allopathic Medicine, Davie, FL
| | | | - Jianbo Li
- Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, OH
| | - Smita De
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH
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Thilagar BP, Mueller MR, Ganesh R. Perioperative cardiac risk reduction in non cardiac surgery. Minerva Med 2023; 114:861-877. [PMID: 37140483 DOI: 10.23736/s0026-4806.23.08474-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
For patients undergoing nonemergent noncardiac surgery, care must be taken to identify patients at increased risk of major adverse cardiovascular events, as these remain a significant source of perioperative morbidity and mortality. Identification of at-risk patients requires careful attention to risk factors including assessment of functional status, medical comorbidities, and a medication assessment. After identification, to minimize perioperative cardiac risk, care should be taken through a combination of appropriate medication management, close monitoring for cardiovascular ischemic events, and optimization of pre-existing medical conditions. There are multiple society guidelines that aim to mitigate risk of cardiovascular morbidity and mortality in patients undergoing nonemergent noncardiac surgery. However, the rapid evolution of medical literature often creates gaps between the existing evidence and best practice recommendations. In this review, we aim to reconcile the recommendations made in the guidelines from the major cardiovascular and anesthesiology societies from the USA, Canada, and Europe, and to provide updated recommendations based on new evidence.
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Affiliation(s)
- Bright P Thilagar
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael R Mueller
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA -
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Germans MR, Rohr J, Globas C, Schubert T, Kaserer A, Brandi G, Studt JD, Greutmann M, Geiling K, Verweij L, Regli L. Challenges in Coagulation Management in Neurosurgical Diseases: A Scoping Review, Development, and Implementation of Coagulation Management Strategies. J Clin Med 2023; 12:6637. [PMID: 37892774 PMCID: PMC10607506 DOI: 10.3390/jcm12206637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/13/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
Bleeding and thromboembolic (TE) complications in neurosurgical diseases have a detrimental impact on clinical outcomes. The aim of this study is to provide a scoping review of the available literature and address challenges and knowledge gaps in the management of coagulation disorders in neurosurgical diseases. Additionally, we introduce a novel research project that seeks to reduce coagulation disorder-associated complications in neurosurgical patients. The risk of bleeding after elective craniotomy is about 3%, and higher (14-33%) in other indications, such as trauma and intracranial hemorrhage. In spinal surgery, the incidence of postoperative clinically relevant bleeding is approximately 0.5-1.4%. The risk for TE complications in intracranial pathologies ranges from 3 to 20%, whereas in spinal surgery it is around 7%. These findings highlight a relevant problem in neurosurgical diseases and current guidelines do not adequately address individual circumstances. The multidisciplinary COagulation MAnagement in Neurosurgical Diseases (COMAND) project has been developed to tackle this challenge by devising an individualized coagulation management strategy for patients with neurosurgical diseases. Importantly, this project is designed to ensure that these management strategies can be readily implemented into healthcare practices of different types and with sustainable integration.
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Affiliation(s)
- Menno R. Germans
- Department of Neurosurgery, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (J.R.); (L.R.)
- Clinical Neuroscience Center, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (C.G.); (T.S.)
| | - Jonas Rohr
- Department of Neurosurgery, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (J.R.); (L.R.)
- Clinical Neuroscience Center, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (C.G.); (T.S.)
| | - Christoph Globas
- Clinical Neuroscience Center, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (C.G.); (T.S.)
- Department of Neurology, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland
| | - Tilman Schubert
- Clinical Neuroscience Center, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (C.G.); (T.S.)
- Department of Neuroradiology, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland;
| | - Giovanna Brandi
- Neurocritical Care Unit, Institute for Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland;
| | - Jan-Dirk Studt
- Department of Medical Oncology and Hematology, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland;
| | - Matthias Greutmann
- University Heart Center, Department of Cardiology, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland;
| | - Katharina Geiling
- Department of Geriatrics, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland;
| | - Lotte Verweij
- Institute for Implementation Science in Health Care, University of Zurich, Universitätstrasse 84, 8006 Zurich, Switzerland;
- Centre of Clinical Nursing Science, University Hospital Zurich, Universitätstrasse 84, 8006 Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (J.R.); (L.R.)
- Clinical Neuroscience Center, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (C.G.); (T.S.)
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Zou X, Wang L, Sun SS, Hu YX, Liu HW, Wang H, Cao J, Liu HB, Fan L. Incidence and impact of antiplatelet therapy cessation among very older patients with stable coronary artery disease. Front Pharmacol 2023; 14:1183839. [PMID: 37342591 PMCID: PMC10277504 DOI: 10.3389/fphar.2023.1183839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/23/2023] [Indexed: 06/23/2023] Open
Abstract
Objectives: Long-term use of evidence-based antiplatelet therapy is recommended for management of stable coronary artery disease (SCAD). However, non-adherence to antiplatelet drugs is common in older patients. This study aimed to evaluate the incidence and impact of antiplatelet therapy cessation on clinical outcomes of older patients with SCAD. Methods: A total of 351 consecutive eligible very older patients (≥80 years) with SCAD from the PLA General Hospital were included. Baseline demographics, clinical characteristics, and clinical outcomes were collected during follow-up. Patients were divided into cessation group and standard group based on whether discontinuing of antiplatelet drugs. The primary outcome was major adverse cardiovascular events (MACE) and secondary outcomes were minor bleeding and all-cause mortality. Results: A total of 351 participants, with a mean age of 91.76 ± 5.01 years old (range 80-106 years) were included in statistical analysis. The antiplatelet drug cessation rate was 60.1%. There were 211 patients in cessation group and 140 patients in standard group. During a median follow-up of 98.6 months, the primary outcome of MACE occurred in 155 patients (73.5%) in the cessation group and 84 patients (60.0%) in the standard group (HR = 1.476, 95% CI:1.124-1.938, p = 0.005). Cessation of antiplatelet drugs increased the rates of angina (HR = 1.724, 95% CI:1.211-2.453, p = 0.002) and non-fatal MI (HR = 1.569, 95% CI:1.093-2.251, p = 0.014). The secondary outcomes of minor bleeding and all-cause mortality were similar between the two groups. Conclusion: Among very older patients with SCAD, antiplatelet therapy cessation significantly increased the risk of MACE, and continuous antiplatelet drug therapy didn't increase the risk of minor bleeding.
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Affiliation(s)
- Xiao Zou
- Cardiology Department of the Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Liang Wang
- Cardiology Department of the Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Sha-Sha Sun
- Cardiology Department of the Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Yi-Xin Hu
- The Forth Healthcare Department of the Second Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Hong-Wei Liu
- Cardiology Department of the Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Hao Wang
- Cardiology Department of the Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Jian Cao
- Cardiology Department of the Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Hong-Bin Liu
- Cardiology Department of the Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Li Fan
- Cardiology Department of the Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
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Relvas M, Gonçalves J, Castro I, Diniz H, Mendonça L, Coentrão L. Effects of Aspirin on Kidney Biopsy Bleeding Complications: A Systematic Review and Meta-Analysis (PROSPERO 2021 CRD42021261005). KIDNEY360 2023; 4:700-710. [PMID: 36951435 PMCID: PMC10278841 DOI: 10.34067/kid.0000000000000091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 01/27/2023] [Indexed: 03/24/2023]
Abstract
Postprocedural bleeding is the main complication of percutaneous kidney biopsy (PKB). Therefore, aspirin is routinely withheld in patients undergoing PKB to reduce the bleeding risk. The authors aimed to examine the association between aspirin use and bleeding during PKB. This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The article search was performed on MEDLINE and Scopus using queries specific to each database. Article inclusion was limited to primary studies. The meta-analysis compared the risk of major bleeding events between the aspirin-exposed versus nonexposed group. Pooled effect estimate was examined using random effects presented as odds ratio with 95% confidence intervals. Heterogeneity was assessed through Cochrane I 2 test statistics. Sensitivity and subgroup analyses were also performed according to kidney type. Ten studies were included in the review and four studies were included in the meta-analysis, reviewing a total of 34,067 PKBs. Definitions for significant aspirin exposure were inconsistent between studies, limiting comparisons. Studies with broader definitions for aspirin exposure mostly showed no correlation between aspirin use and postbiopsy bleeding. Studies with strict definitions for aspirin exposure found an increased risk of hemorrhagic events in the aspirin-exposed group. No significant differences were found between the aspirin-exposed and comparison groups regarding major bleeding events (odds ratio 1.72; 95% confidence interval 0.50 to 5.89, I 2 =84%). High-quality evidence on the effect of aspirin on the bleeding risk is limited. Our meta-analysis did not show a significantly increased risk of major bleeding complications in aspirin-exposed patients. Further studies are needed to define a more comprehensive approach for clinical practice.
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Affiliation(s)
- Miguel Relvas
- Nephrology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Joana Gonçalves
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Inês Castro
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Hugo Diniz
- Nephrology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Luís Mendonça
- Nephrology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Luís Coentrão
- Nephrology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
- Nephrology & Infectious Diseases R&D, i3S—Institute for Research & Innovation in Health, Porto, Portugal
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Hjelmdal C, Draegert C, Vester-Andersen M, Kowark A, Coburn M, Rasmussen LS, Lundstrøm LH, Steinmetz J. Intra-operative blood transfusion in elderly patients on antithrombotic therapy. Acta Anaesthesiol Scand 2023; 67:412-421. [PMID: 36636858 DOI: 10.1111/aas.14197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 12/10/2022] [Accepted: 01/06/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND Many elderly patients are receiving antithrombotics, which may increase intra-operative blood loss. We aimed to assess whether chronic antithrombotic therapy was associated with intra-operative transfusion of packed red blood cells in patients at least 80 years of age undergoing elective procedures. METHODS We performed a secondary analysis of the prospective, observational European multicentre study entitled POSE (peri-interventional outcome study in the elderly) including 9497 surgical patients aged 80 years and older in 177 centres from October 2017 to December 2018. In this secondary analysis we included POSE patients who underwent elective procedures and with available data on chronic antithrombotic therapy. The primary outcome was intra-operative transfusion of packed red blood cells and results were analysed using multiple logistic regression model. We adjusted for the following predetermined explanatory variables: Age, sex, body mass index, American Society of Anaesthesiologists Physical Status Classification System, baseline haemoglobin concentration, disseminated cancer, and type and severity of surgery. RESULTS A total of 7174 patients were included of whom 4073 (56.8%) were on antithrombotic therapy. Among patients on antithrombotic therapy 191 (4.7%) received intra-operative blood transfusion compared with 98 (3.2%) of patients not on chronic antithrombotic therapy (crude odds ratio: 1.51, 95% CI 1.18-1.94). Following multiple logistic regression analysis, the adjusted odds ratio was 0.98; 0.73-1.32. We found that chronic antithrombotic therapy was associated with intra-operative transfusion of packed red blood cells in elderly patients undergoing elective procedures in an unadjusted analysis, but not in a multivariate adjusted model.
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Affiliation(s)
- Caroline Hjelmdal
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christina Draegert
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Department of Anesthesiology, Copenhagen University Hospital, Herlev-Gentofte Hospital, Herlev, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Ana Kowark
- Department of Anaesthesia, University Hospital RWTH, Aachen, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Mark Coburn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Lars S Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Lars H Lundstrøm
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Anaesthesia, Nordsjaellands Hospital, Hillerød, Denmark
| | - Jacob Steinmetz
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Danish Air Ambulance, Aarhus, Denmark
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9
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Liu CH, Wu YL, Hsu CC, Lee TH. Early Antiplatelet Resumption and the Risks of Major Bleeding After Intracerebral Hemorrhage. Stroke 2023; 54:537-545. [PMID: 36621820 DOI: 10.1161/strokeaha.122.040500] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/28/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND The appropriate timing of resuming antithrombotic therapy after intracerebral hemorrhage (ICH) remains unclear. The aim of this study was to compare the risks of major bleeding between early and late antiplatelet resumption in ICH survivors. METHODS Between 2008 and 2017, ICH patients were available in the National Health Insurance Research Database. Patients with a medication possession ratio of antiplatelet treatment ≥50% before ICH and after antiplatelet resumption were screened. We excluded patients with atrial fibrillation, heart failure, under anticoagulant or hemodialysis treatment, and developed cerebrovascular events or died before antiplatelet resumption. Finally, 1584 eligible patients were divided into EARLY (≤30 days) and LATE groups (31-365 days after the index ICH) based on the timing of antiplatelet resumption. Patients were followed until the occurrence of a clinical outcome, end of 1-year follow-up, death, or until December 31, 2018. The primary outcome was recurrent ICH. The secondary outcomes included all-cause mortality, major hemorrhagic events, major occlusive vascular events, and ischemic stroke. Cox proportional hazard model after matching was used for comparison between the 2 groups. RESULTS Both the EARLY and LATE groups had a similar risk of 1-year recurrent ICH (EARLY versus LATE: 3.12% versus 3.27%; adjusted hazard ratio [AHR], 0.967 [95% CI, 0.522-1.791]) after matching. Both groups also had a similar risk of each secondary outcome at 1-year follow-up. Subgroup analyses disclosed early antiplatelet resumption in the patients without prior cerebrovascular disease were associated with lower risks of all-cause mortality (AHR, 0.199 [95% CI, 0.054-0.739]) and major hemorrhagic events (AHR, 0.090 [95% CI, 0.010-0.797]), while early antiplatelet resumption in the patients with chronic kidney disease were associated with a lower risk of ischemic stroke (AHR, 0.065 [95% CI, 0.012-0.364]). CONCLUSIONS Early resumption of antiplatelet was as safe as delayed antiplatelet resumption in ICH patients. Besides, those without prior cerebrovascular disease or with chronic kidney disease may benefit more from early antiplatelet resumption.
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Affiliation(s)
- Chi-Hung Liu
- Department of Neurology, Linkou Chang Gung Memorial Hospital, and College of Medicine, Chang Gung University, Taoyuan, Taiwan (C.-H.L., T.-H.L.)
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei (C.-H.L.)
| | - Yi-Ling Wu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan (Y.-L.W., C.-C. H.)
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan (Y.-L.W., C.-C. H.)
- National Center for Geriatrics and Welfare Research, National Health Research Institutes, Yunlin, Department of Family Medicine, Min-Sheng General Hospital, Taoyuan, and Department of Health Services Administration, China Medical University, Taichung, Taiwan (C.-C. H.)
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, and College of Medicine, Chang Gung University, Taoyuan, Taiwan (C.-H.L., T.-H.L.)
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10
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Neuendorff NR, Boshikova B, Frankenstein L, Kirchner M, Rohde C, Goldschmidt H, Frey N, Müller-Tidow C, Jordan K, Sauer S, Janssen M. Aspirin use and bleeding events during thrombocytopenia after autologous stem-cell transplantation for multiple myeloma. Front Oncol 2023; 13:1168120. [PMID: 37182183 PMCID: PMC10174307 DOI: 10.3389/fonc.2023.1168120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/06/2023] [Indexed: 05/16/2023] Open
Abstract
Background In patients with cardiovascular (CV) comorbidities that necessitate antiplatelet therapy (APT), its optimal management during chemotherapy-induced thrombocytopenia remains elusive, as the risk of bleeding has to be balanced against the risk of CV events. The purpose of this study was to assess the risk for bleeding with APT during thrombocytopenia in patients with multiple myeloma undergoing high-dose chemotherapy and subsequent autologous stem-cell transplantation (ASCT) with and without acetylsalicylic acid (ASA) as comedication. Methods We assessed patients who underwent ASCT at the Heidelberg University Hospital between 2011 and 2020 for bleeding events, management strategies for ASA intake during thrombocytopenia, transfusion requirements, and the occurrence of CV events. Results There were 57/1,113 patients who continued ASA until at least 1 day after ASCT; thus, a continuous platelet inhibition during thrombocytopenia was assumed. Most of the patients (41/57) continued ASA until they had a platelet count of 20-50/nl. This range reflects the kinetics of thrombocytopenia and nondaily measurements of platelets during ASCT. A tendency toward a higher risk for bleeding events in the ASA group was demonstrated (1.9% (control group) vs. 5.3% (ASA), p = 0.082). The risk factors for bleeding in multivariate analysis were the duration of thrombocytopenia < 50/nl, a history of gastrointestinal bleeding, and diarrhea. The factors predicting the duration of thrombocytopenia were age >60 years, a hematopoietic stem-cell transplantation comorbidity index ≥3, and an impaired bone marrow reserve at admission. CV events occurred in three patients; none of them took ASA or had an indication for APT. Conclusions The intake of ASA until thrombocytopenia with a platelet count of 20-50/nl appears safe, although an elevated risk cannot be excluded. If ASA is indicated for the secondary prevention of CV events, the evaluation of risk factors for bleeding and a prolonged time of thrombocytopenia before conditioning is crucial to adapt the strategy for ASA intake during thrombocytopenia.
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Affiliation(s)
- Nina Rosa Neuendorff
- Department of Medicine V–Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Hematology and Stem-Cell Transplantation, University Hospital Essen, Essen, Germany
| | - Boryana Boshikova
- Department of Medicine V–Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- Clinic for Cardiology and General Internal Medicine, Städtisches Klinikum Solingen gemeinnützige GmbH, Solingen, Germany
| | - Lutz Frankenstein
- Department of Medicine III–Cardiology, Angiology and Intensive Care, University Hospital Heidelberg, Heidelberg, Germany
| | - Marietta Kirchner
- Institute of Medical Biometry (IMBI), University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Rohde
- Department of Medicine V–Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hartmut Goldschmidt
- Department of Medicine V–Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Norbert Frey
- Department of Medicine III–Cardiology, Angiology and Intensive Care, University Hospital Heidelberg, Heidelberg, Germany
| | - Carsten Müller-Tidow
- Department of Medicine V–Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Karin Jordan
- Department of Medicine V–Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- Klinikum Ernst von Bergmann–Department for Hematology, Oncology and Palliative Care, Potsdam, Germany
| | - Sandra Sauer
- Department of Medicine V–Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Maike Janssen
- Department of Medicine V–Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- *Correspondence: Maike Janssen,
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Yong CW, Tan SHX, Teo GN, Tan TS, Ng WH. Should we stop dual anti-platelet therapy for dental extractions? An umbrella review for this dental dilemma. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e708-e716. [PMID: 35691560 DOI: 10.1016/j.jormas.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 05/28/2022] [Accepted: 06/08/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Dual Anti-platelet Therapy (DAPT) are prescribed to patients who had or are at risk of cerebrovascular or cardiovascular ischemic events. This umbrella review appraises existing systematic reviews on the risk of bleeding related complications during and after dental extractions for patients on DAPT. STUDY DATA AND SOURCES This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered to the PROSPERO (International prospective register of systematic reviews) database. A systematic electronic literature search was conducted according to the PRISMA guidelines, via PubMed, Ovid, Cochrane and Embase. STUDY SELECTION Four systematic reviews met the inclusion criteria and were included the analysis. They show DAPT increases the risk of bleeding related complications after dental extractions, but the differences may not be clinically significant as local haemostatic measures were adequate in controlling bleeding. CONCLUSION Despite the increased risk of bleeding after dental extractions in patients on DAPT, it may not be necessary to interrupt the anti-platelet therapy. Local haemostatic agents may be sufficient in controlling both the primary or secondary bleeding. On the other hand, the complications of discontinuing DAPT may be more severe and fatal.
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Affiliation(s)
- Chee Weng Yong
- Discipline of Oral Maxillofacial Surgery, Faculty of Dentistry, National University Centre for Oral Health, 9 Lower Kent Ridge Road, 119085, Singapore
| | - Sharon Hui Xuan Tan
- Saw Swee Hock School of Public Health, National University of Singapore, 16 Medical Dr,117597, Singapore; School of Health and Social Sciences (Oral Health Therapy), Nanyang, Polytechnic, Singapore
| | - Guo Nian Teo
- Department of Oral & Maxillofacial Surgery, National Dental Centre Singapore, 5 Second Hospital Avenue, 168938, Singapore
| | - Teng Seng Tan
- Department of Oral & Maxillofacial Surgery, National Dental Centre Singapore, 5 Second Hospital Avenue, 168938, Singapore
| | - Wee Hsuan Ng
- Discipline of Oral Maxillofacial Surgery, Department of Dentistry, Khoo Teck Puat Hospital, Level 1, 90 Yishun Central, 768828, Singapore.
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Lahu S, Ndrepepa G, Neumann FJ, Menichelli M, Bernlochner I, Richardt G, Wöhrle J, Witzenbichler B, Hemetsberger R, Mayer K, Akin I, Cassese S, Gewalt S, Xhepa E, Kufner S, Valina C, Sager HB, Joner M, Ibrahim T, Laugwitz KL, Schunkert H, Schüpke S, Kastrati A. Pre-admission antiplatelet therapy and treatment effect of ticagrelor vs. prasugrel in patients with acute coronary syndromes-a subgroup analysis of the ISAR-REACT 5 trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:687-694. [PMID: 35191982 DOI: 10.1093/ehjcvp/pvac007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/18/2022] [Indexed: 06/14/2023]
Abstract
AIMS To assess whether the efficacy and safety of ticagrelor vs. prasugrel in patients with acute coronary syndromes (ACSs) are influenced by pre-admission treatment with aspirin and/or clopidogrel. METHODS AND RESULTS Patients (n = 4018) were categorized into two groups: pre-admission aspirin and/or clopidogrel group (n = 1455) and no pre-admission aspirin or clopidogrel group (n = 2563). The primary endpoint was the composite of all-cause death, myocardial infarction, or stroke; the secondary safety endpoint was Bleeding Academic Research Consortium (BARC) type 3-5 bleeding, both at 1 year. Patients in the pre-admission aspirin and/or clopidogrel group had a higher risk of ischaemic events, but a similar risk of bleeding to patients in the no pre-admission aspirin or clopidogrel group (cumulative incidences 10.5% vs. 6.7%, and 5.7% vs. 5.7%, respectively). The primary endpoint occurred in 81/717 patients assigned to ticagrelor and 69/738 patients assigned to prasugrel in the pre-admission aspirin and/or clopidogrel group [11.5% vs. 9.5%; hazard ratio (HR) = 1.23; 95% confidence interval (CI) 0.89-1.69], and in 103/1295 patients assigned to ticagrelor and 68/1268 patients assigned to prasugrel in the no pre-admission aspirin or clopidogrel group [8.0% vs. 5.4%; HR = 1.50 (1.10-2.03); Pint = 0.38]. BARC type 3-5 bleeding events did not differ between ticagrelor and prasugrel in patients in the pre-admission aspirin and/or clopidogrel (6.2% vs. 4.5%) or no pre-admission aspirin or clopidogrel (5.3% vs. 5.1%) group (Pint = 0.54). CONCLUSION In patients with ACS, pre-admission therapy with aspirin and/or clopidogrel has no influence on the relative efficacy and safety of ticagrelor and prasugrel.
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Affiliation(s)
- Shqipdona Lahu
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Gjin Ndrepepa
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | | | - Isabell Bernlochner
- I. Medizinische Klinik und Poliklinik Innere Medizin, Klinikum Rechts der Isar, Munich, Germany
| | | | - Jochen Wöhrle
- Department of Cardiology and Intensive Care, Medical Campus Lake Constance, Friedrichshafen, Germany
| | | | | | - Katharina Mayer
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Salvatore Cassese
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Senta Gewalt
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Erion Xhepa
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Sebastian Kufner
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Christian Valina
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Hendrik B Sager
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael Joner
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Tareq Ibrahim
- I. Medizinische Klinik und Poliklinik Innere Medizin, Klinikum Rechts der Isar, Munich, Germany
| | - Karl-Ludwig Laugwitz
- I. Medizinische Klinik und Poliklinik Innere Medizin, Klinikum Rechts der Isar, Munich, Germany
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Stefanie Schüpke
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
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14
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Gaballah K, Hassan M. Knowledge and Practice of Dentists Managing Patients on Antithrombotic Medications: A Cross-Sectional Survey. Eur J Dent 2022; 16:775-780. [PMID: 35016232 DOI: 10.1055/s-0041-1739436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES In this article, we explored the level of knowledge and practice of licensed dentists in the United Arab Emirates regarding managing patients on antithrombotic medications. Moreover, to assess the need for educational intervention in this area is one of the objectives. MATERIALS AND METHODS A total of 502 dentists answered 22 close-ended questionnaires. The sample size was determined based on the registry of the Ministry of Health. RESULTS Only 5.6 and 5.9% showed satisfactory overall awareness about aspirin and plavix, respectively, as drugs may hamper hemostasis. A substantial proportion of dentists consider aspirin (63.1%) and clopidogrel (52.2%) discontinuation before treatment. More than one-third of the participants shall not consider extracting teeth before physician approval, and one-quarter to one-third of them refer patients on such medications to oral surgeons to perform tooth extraction. Most respondents did not adequately answer the questions about the additional hemostatic measures and postoperative analgesia. A significantly high number of participants (n = 440, 87.6%) want to attend updated courses on the dental management of such patients. CONCLUSIONS The dentists demonstrate a contrasting diversity of knowledge and practice approaches to patient management on antiplatelet agents. There is an apparent demand to raise understanding of the evidence-based management of a patient on such medications. It is vital to keep formalized training sessions and provide the necessary expertise to students and dentists to prevent unwanted complications.
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Affiliation(s)
- Kamis Gaballah
- Department of Oral and Craniofacial Health Sciences, College of Dental Medicine, University of Sharjah, United Arab Emirates
| | - Mawada Hassan
- College of Dentistry, Ajman University, Ajman, United Arab Emirates
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15
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Wang X, Tang B, Liu Y, Wang X, Wang S, An Z, Wang H. Clinical practice guidelines for management of dual antiplatelet therapy in patients with noncardiac surgery: A critical appraisal using the AGREE II instrument. J Clin Pharm Ther 2021; 47:652-661. [PMID: 34939677 DOI: 10.1111/jcpt.13593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 01/22/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Despite the availability of clinical practice guidelines (CPGs), there are considerable differences in their recommendations in the perioperative management of stented patients who need elective noncardiac surgery. Our aim was to systematically review the quality of CPGs for perioperative management of dual antiplatelet therapy (DAPT) and summarize the recommendations. METHODS A systematic search for perioperative DAPT guidelines was conducted on PubMed, Embase and websites of guideline organizations and professional societies until 4 February 2021. Independently, two assessors appraised the quality of CPGs using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument and extracted the data. Recommendations were summarized, and a comparative study was conducted to analyse the consistency among guidelines. RESULTS AND DISCUSSION A total of 10 guidelines fulfilled our inclusion criteria. The domain of scope and purpose and clarity of presentation obtained the highest median scores, while the domain of stakeholder involvement and rigour of development obtained the lowest median scores. Three guidelines (ACCP, ESC/ESA and ACC/AHA) with a score of at least 60% in most AGREE II domains were recommended. Recommendations across perioperative management of DAPT guidelines were inconsistent. WHAT IS NEW AND CONCLUSION The ACCP, ESC/ESA and ACC/AHA CPGs were recommended. There is a need for high-quality prospective studies assessing different management strategies on this issue. Given the lack of consensus, the results of this study will help to guide perioperative dual antiplatelet management strategies for patients with coronary stents who are undergoing noncardiac surgery.
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Affiliation(s)
- Xin Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Borui Tang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Ying Liu
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xinrui Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.,Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Shihui Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zhuoling An
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Huaguang Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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16
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Hada G, Zhang S, Song Y, Jaiswar M, Xie Y, Jian F, Lei W. Safety of Inguinal Hernia Repair in the Elderly with Perioperative Continuation of Antithrombotic Therapy. Visc Med 2021; 37:315-322. [PMID: 34540948 DOI: 10.1159/000509895] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/02/2020] [Indexed: 02/05/2023] Open
Abstract
Introduction This study aimed to evaluate the safety of an inguinal hernia repair (IHR) under local anesthesia (LA) in the elderly with a perioperative continuation of antithrombotic therapy (AT). Methods A total of 120 patients undergoing elective primary IHR between August 2018 and August 2019 at the West China Hospital of China were prospectively studied, among which 60 patients also had coexisting cardiovascular diseases and had a continuation of AT perioperatively (antithrombotic group); the other 60 patients were not on any prior AT (control group). The primary endpoints were intra- and postoperative hemorrhagic complications, the required interventions for complications based on the Clavien-Dindo classification, and postoperative thromboembolic complications. The secondary endpoints were nonhemorrhagic complications, intraoperative duration, and postoperative length of stay (LOS). Results None of the patients in both groups had significant intraoperative bleeding >10 mL, and there were no significant differences between the 2 groups in terms of the postoperative hemorrhagic complications: bruising (2 vs. 0%, p = 1.000), serosanguinous soakage (7 vs. 3%, p = 0.679), and no hematoma was observed. Interventions required for encountered complications based on the Clavien-Dindo classification grade I (7 vs. 5%, p = 1.000) were assessed. There were no episodes of postoperative thromboembolic complications within 60 days in both groups. There were also no significant differences between the 2 groups in terms of nonhemorrhagic complications, intraoperative duration, and postoperative LOS (p > 0.05 in all). Conclusions The perioperative continuation of AT did not increase the risk of intra- and postoperative hemorrhagic complications following IHR in the elderly. Thus, IHR under LA seems to be safe and feasible in this setting.
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Affiliation(s)
- Gonish Hada
- Department of Gastrointestinal Surgery, Hernia Center, West China Hospital, Sichuan University, Chengdu, China
| | - Sen Zhang
- Department of Gastrointestinal Surgery, Hernia Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yinghan Song
- Department of Day Care Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Mukesh Jaiswar
- Department of Gastrointestinal Surgery, Hernia Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yanyan Xie
- Department of Gastrointestinal Surgery, Hernia Center, West China Hospital, Sichuan University, Chengdu, China
| | - Fushan Jian
- Department of Gastrointestinal Surgery, Hernia Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wenzhang Lei
- Department of Gastrointestinal Surgery, Hernia Center, West China Hospital, Sichuan University, Chengdu, China
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17
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Shenoy A, Panicker P, Vijayan A, George AL. Prospective Comparative Evaluation of Post-extraction Bleeding in Cardiovascular-Compromised Patients with and without Antiplatelet Medications. J Maxillofac Oral Surg 2021; 20:486-495. [PMID: 34408378 PMCID: PMC8313627 DOI: 10.1007/s12663-019-01315-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/30/2019] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND OBJECTIVE A considerable number of patients consulting a dental surgeon are on antiplatelet therapy, and an interruption of these agents for 3 to 7 days has been practised by majority of them prior to dental surgical intervention fearing excessive bleeding, risking the patient for the occurrence of adverse thrombotic events. The dental and medical literature shows a very low risk of excessive bleeding associated on the continuation of antiplatelet therapy. The objective of this study is to compare the bleeding following single-firm molar tooth extraction in patients who interrupt and those who continue antiplatelet therapy perioperatively. METHODOLOGY This is a prospective descriptive study on 170 patients on long-term low-dose antiplatelet therapy with 2 groups, each containing 85 patients-Group 1 with patients who interrupted antiplatelet therapy for 5 days before extraction and Group 2, patients who continued it perioperatively. A single molar tooth extraction was done under local anaesthesia with a vasoconstrictor. Gauze pressure pack was placed for 60 min. Socket was observed every 15 min for 1 h to look for excessive post-extraction bleeding. RESULTS No statistically significant differences were found in post-extraction bleeding between the patients who stopped antiplatelet therapy and those who continued it. CONCLUSION The bleeding risk when continuing long-term low-dose antiplatelet therapy following a single molar tooth extraction is minimal. Bleeding, if excessive, can be easily controlled by gauze pressure pack or other local haemostatic agents. Thus, dental extractions can be performed on these patients without interrupting the antiplatelet drug pre-operatively provided a thorough medical history, physician's consent and coagulation profile have been obtained prior to the procedure.
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Affiliation(s)
- Archana Shenoy
- Victoria Dental Centre, No. 201, 2nd Floor Divya Deepa Towers, Mangalore, Karnataka India
| | - Prasanth Panicker
- Department of Oral and Maxillofacial Surgery, Sree Anjaneya Institute of Dental Sciences, Calicut, Kerala India
- Indira Gandhi Hospital, Ernakulam, Kochi, Kerala India
| | - Ajoy Vijayan
- Department of Oral and Maxillofacial Surgery, Mahe Institute of Health Sciences, Mahé, Kerala India
| | - Ashford Lidiya George
- Department of Oral and Maxillofacial Surgery, Sree Anjaneya Institute of Dental Sciences, Calicut, Kerala India
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Ganesh R, Kebede E, Mueller M, Gilman E, Mauck KF. Perioperative Cardiac Risk Reduction in Noncardiac Surgery. Mayo Clin Proc 2021; 96:2260-2276. [PMID: 34226028 DOI: 10.1016/j.mayocp.2021.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 02/20/2021] [Accepted: 03/04/2021] [Indexed: 11/21/2022]
Abstract
Major adverse cardiovascular events are a significant source of morbidity and mortality in the perioperative setting, estimated to occur in approximately 5% of patients undergoing nonemergent noncardiac surgery. To minimize the incidence and impact of these events, careful attention must be paid to preoperative cardiovascular assessment to identify patients at high risk of cardiovascular complications. Once identified, cardiovascular risk reduction is achieved through optimization of medical conditions, appropriate management of medication, and careful monitoring to allow for early identification of-and intervention for-any new conditions that would increase the risk of adverse cardiovascular outcomes. The major cardiovascular and anesthesiology societies in the United States, Europe, and Canada have published guidelines for perioperative management of patients undergoing noncardiac surgery. However, since publication of these guidelines, there has been a practice-changing evolution in the medical literature. In this review, we attempt to reconcile the recommendations made in these 3 comprehensive guidelines, while updating recommendations, based on new evidence, when available.
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Affiliation(s)
- Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Esayas Kebede
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Michael Mueller
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Elizabeth Gilman
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Karen F Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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19
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Cheng B, Li J, Peng L, Wang Y, Sun L, He S, Wei J, Zhang S. Efficacy and safety of restarting antiplatelet therapy for patients with spontaneous intracranial haemorrhage: A systematic review and meta-analysis. J Clin Pharm Ther 2021; 46:957-965. [PMID: 33537999 DOI: 10.1111/jcpt.13377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 01/22/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE The benefits and risks of restarting antiplatelet therapy (APT) for patients with spontaneous intracranial haemorrhage (ICH) remain controversial. This meta-analysis was performed to explore the efficacy and safety of restarting APT for these patients. METHODS We followed the recommended PRISMA guidelines for systematic reviews. Studies from PubMed, Embase, Web of Science, CNKI and the Cochrane Library were systematically retrieved from the inception of each database to 31 July 2020. We also manually retrieved studies of reference. RESULTS AND DISCUSSION In this study, seven cohort studies and one randomized controlled trial (RCT) with subjects were included. APT resumption after spontaneous ICH did not significantly increase the risk of major haemorrhagic events (HR 1.15; 95% CI: 0.70-1.89; p = .59). However, it did not significantly reduce the risk of a composite endpoint concerning occlusive/thromboembolic events (HR 0.98; 95% CI: 0.81-1.19; p = .83) and all-cause mortality (HR 0.93; 95% CI: 0.80-1.08; p = .35). WHAT IS NEW AND CONCLUSION Restarting APT for patients with spontaneous ICH is generally safe. However, the benefits of reducing the risk of ischaemic vascular events and all-cause mortality were not apparent. More RCTs are required.
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Affiliation(s)
- Bo Cheng
- Department of Neurology, The Affiliated Hospital of Medical College, North Sichuan Medical College (University, Nanchong, China
| | - Jinze Li
- Department of Urology, People's Hospital of Deyang City, Deyang, China
| | - Lei Peng
- Department of Urology, Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College (University, Nanchong, China
| | - Yirong Wang
- Department of Neurology, Chengdu Second People's Hospital, Chengdu, China
| | - Ling Sun
- Department of Neurology, The Affiliated Hospital of Medical College, North Sichuan Medical College (University, Nanchong, China
| | - Shijia He
- Department of Neurology, The Affiliated Hospital of Medical College, North Sichuan Medical College (University, Nanchong, China
| | - Jing Wei
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Shushan Zhang
- Department of Neurology, The Affiliated Hospital of Medical College, North Sichuan Medical College (University, Nanchong, China
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20
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Al-Ansari A. Acquired bleeding disorders through antithrombotic therapy: the implications for dental practitioners. Br Dent J 2020; 229:729-734. [PMID: 33311678 DOI: 10.1038/s41415-020-2399-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/28/2020] [Indexed: 11/09/2022]
Abstract
Antithrombotic medications are one of the most common causes of an acquired bleeding disorder. The majority of these medications are administered orally for a variety of clinical indications. It is important that dental surgeons are aware of these medications, their mechanisms of action and how they can influence the dental management of patients, particularly when undertaking procedures which carry a risk of bleeding.
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Affiliation(s)
- Anmar Al-Ansari
- Dental Core Trainee 1 in Oral and Maxillofacial Surgery, Forth Valley Royal Hospital, Stirling Rd, Larbert, FK5 4WR, UK.
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21
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Tung YC, See LC, Chang SH, Liu JR, Kuo CT, Chang CJ. Impact of bleeding during dual antiplatelet therapy in patients with coronary artery disease. Sci Rep 2020; 10:21345. [PMID: 33288822 PMCID: PMC7721794 DOI: 10.1038/s41598-020-78400-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 11/10/2020] [Indexed: 11/09/2022] Open
Abstract
This nationwide retrospective cohort study used the National Health Insurance Research Database of Taiwan to compare the impact of bleeding on clinical outcomes in patients with acute myocardial infarction (AMI) versus chronic coronary syndrome (CCS). Between July 2007 and December 2010, patients with AMI (n = 15,391) and CCS (n = 19,724) who received dual antiplatelet therapy after coronary stenting were identified from the database. AMI was associated with increased risks of MI (AMI vs. CCS: 0.38 vs. 0.16 per 100 patient-months; p < 0.01), all-cause death (0.49 vs. 0.32 per 100 patient-months; p < 0.01), and BARC type 3 bleeding (0.22 vs. 0.13 per 100 patient-months; p < 0.01) at 1 year compared with CCS, while the risk of BARC type 2 bleeding was marginally higher in the CCS patients than in the AMI patients (1.32 vs. 1.4 per 100 person-months; p = 0.06). Bleeding was an independent predictor of MI, stroke, and all-cause death in this East Asian population, regardless of the initial presentation. Among the patients with bleeding, AMI was associated with a higher risk of ischemic events at 1 year after bleeding compared with CCS (MI: 0.34 vs. 0.25 per 100 patient-months; p = 0.06; ischemic stroke: 0.22 vs. 0.13 per 100 patient-months; p = 0.02). The 1-year mortality after bleeding was comparable between the two groups after propensity score weighting. In conclusion, bleeding conferred an increased risk of adverse outcomes in East Asian patients with AMI and CCS.
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Affiliation(s)
- Ying-Chang Tung
- Cardiovascular Department, Linkou Chang Gung Memorial Hospital, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 33305, Taiwan, ROC.,College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan, ROC.,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Shu-Hao Chang
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Chi-Tai Kuo
- Cardiovascular Department, Linkou Chang Gung Memorial Hospital, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 33305, Taiwan, ROC.,College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Chi-Jen Chang
- Cardiovascular Department, Linkou Chang Gung Memorial Hospital, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 33305, Taiwan, ROC. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC.
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Dangers L, Giovannelli J, Mangiapan G, Alves M, Bigé N, Messika J, Morawiec E, Neuville M, Cracco C, Béduneau G, Terzi N, Huet I, Dhalluin X, Bautin N, Quiot JJ, Appere-de Vecchi C, Similowski T, Chenivesse C. Antiplatelet Drugs and Risk of Bleeding After Bedside Pleural Procedures: A National Multicenter Cohort Study. Chest 2020; 159:1621-1629. [PMID: 33290789 DOI: 10.1016/j.chest.2020.10.092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 09/10/2020] [Accepted: 10/29/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The decision-making on antiplatelet drug withdrawal or continuation before performing a pleural procedure is based on the balance between the risk of bleeding associated with the antiplatelet therapy and the risk of arterial thrombosis due to its interruption. Knowledge on antiplatelet therapy-associated risk of bleeding after pleural procedures is lacking. RESEARCH QUESTION Is the risk of bleeding associated with antiplatelet drugs increased in patients undergoing pleural procedures? STUDY DESIGN AND METHODS We conducted a French multicenter cohort study in 19 centers. The main outcome was the occurrence of bleeding, defined as hematoma, hemoptysis, or hemothorax, during the 24 h following a pleural procedure. Serious bleeding events were defined as bleeding requiring blood transfusion, respiratory support, endotracheal intubation, embolization, or surgery, or as death. RESULTS A total of 1,124 patients was included (men, 66%; median age, 62.6 ± 27.7 years), of whom 182 were receiving antiplatelet therapy and 942 were not. Fifteen patients experienced a bleeding event, including eight serious bleeding events. The 24-h incidence of bleeding was 3.23% (95% CI, 1.08%-5.91%) in the antiplatelet group and 0.96% (95% CI, 0.43%-1.60%) in the control group. The occurrence of bleeding events was significantly associated with antiplatelet therapy in univariate analysis (OR, 3.44; 95% CI, 1.14-9.66; P = .021) and multivariate analysis (OR, 4.13; 95% CI, 1.01-17.03; P = .044) after adjusting for demographic data and the main risk factors for bleeding. Likewise, antiplatelet therapy was significantly associated with serious bleeding in univariate analysis (OR, 8.61; 95% CI, 2.09-42.3; P = .003) and multivariate analysis (OR, 7.27; 95% CI, 1.18-56.1; P = .032) after adjusting for the number of risk factors for bleeding. INTERPRETATION Antiplatelet therapy was associated with an increased risk of post-pleural procedure bleeding and serious bleeding. Future guidelines should take into account these results for patient safety.
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Affiliation(s)
- Laurence Dangers
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Jonathan Giovannelli
- CHU Lille, Clinique de Pneumologie, Lille, France; Univ Lille, INSERM, LIRIC UMR U995, Lille, France
| | - Gilles Mangiapan
- Centre Hospitalier Intercommunal de Créteil, Service de Pneumologie et Pathologies Professionnelles, Créteil, France
| | - Mikael Alves
- APHP, Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France; Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye, Service de Réanimation, Poissy, France
| | - Naïke Bigé
- Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye, Service de Réanimation, Poissy, France
| | - Jonathan Messika
- APHP, Hôpital Louis Mourier, Service de Réanimation Médico-Chirurgicale, Colombes, France; Sorbonne Paris Cité, Univ Paris Diderot, INSERM, IAME, UMR 1137, Paris, France
| | - Elise Morawiec
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Mathilde Neuville
- APHP, Hôpital Bichat-Claude Bernard, Service de Pneumologie, Paris, France
| | - Christophe Cracco
- Centre Hospitalier d'Angoulême Saint-Michel, Service de Réanimation Médicale, Saint-Michel, France
| | - Gaëtan Béduneau
- Centre Hospitalier Universitaire de Rouen, Service de Réanimation Médicale, Rouen, France
| | - Nicolas Terzi
- Centre Hospitalier Universitaire de Caen, Service de Réanimation Médicale, Caen, France
| | - Isabelle Huet
- Centre Hospitalier Universitaire de Toulouse, Service de Pneumologie, Toulouse, France
| | | | - Nathalie Bautin
- CHU Lille, Clinique de Pneumologie, Lille, France; Centre Hospitalier de Roubaix, Service de Pneumologie et Allergologie, Roubaix, France
| | - Jean-Jacques Quiot
- Centre Hospitalier Régional Universitaire de Brest, Département de Médecine Interne et de Pneumologie, Brest, France
| | | | - Thomas Similowski
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Cécile Chenivesse
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Paris, France; CHU Lille, Clinique de Pneumologie, Lille, France; Univ Lille, INSERM, CNRS, Institut Pasteur de Lille, CIIL, U1019, UMR 8204, Lille, France.
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23
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Singh S, Mandal S, Chugh A, Deora S, Jain G, Khan MA, Chugh VK. Clinical Post-operative Bleeding During Minor Oral Surgical Procedure and In Vitro Platelet Aggregation in Patients on Aspirin Therapy: Are they Coherent? J Maxillofac Oral Surg 2020; 20:132-137. [PMID: 33584054 DOI: 10.1007/s12663-020-01438-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022] Open
Abstract
Aim The risk of excessive bleeding prompts physicians to discontinue aspirin in patients on low-dose, long-term therapy which in turn puts them at the risk from adverse cardiovascular and thrombotic events. Effect of low-dose aspirin therapy on platelet function was assessed using platelet aggregation method. The aim was to correlate the laboratory platelet function with cutaneous and clinical oral bleeding time (BT). Materials and Methods One hundred one patients were enrolled in this prospective trial and were allocated into two groups. Interventional or test group consisted of patients who were on aspirin therapy (75 mg/100 mg) for primary or secondary prevention of angina, myocardial infarction and stroke. Minor oral surgical procedure was performed in this group without discontinuing aspirin therapy. Control group consisted of healthy patients (under no medication) undergoing minor oral surgical procedure. Cutaneous and clinical oral BT were recorded in both the groups. Venous blood sample was drawn, and percentage platelet aggregation function was analysed using adenosine diphosphate (ADP) and arachidonic acid (AA) reagents. The percentage of platelet aggregation was then correlated with cutaneous and clinical oral BT. Results A significant decrease in percentage platelet aggregation using ADP (aspirin-74.7 21.39; control-89.2 13.70) and AA (aspirin-47.6 23.11; control-82.3 20.17) was observed. However, there were no significant difference in mean cutaneous BT (aspirin-1.5 0.65 min; control-1.6 0.71 min) and clinical oral BT (aspirin-5.0 2.48 min; control-4.8 2.60 min) in aspirin and control groups. Conclusion Majority of the minor oral surgical procedures can be carried out safely without discontinuing aspirin in patients on low-dose long-term therapy. This is possible because despite significant platelet aggregation evident in laboratory evaluation there is lack of its clinical corroboration owing to aspirin resistance. Clinical Trial Registration CTRI/2018/02/012055.
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Affiliation(s)
- Surjit Singh
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Jodhpur, India
| | - Saptarshi Mandal
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Jodhpur, Jodhpur, India
| | - Ankita Chugh
- Department of Dentistry, All India Institute of Medical Sciences, Jodhpur, Jodhpur, India
| | - Surender Deora
- Department of Cardiology, All India Institute of Medical Sciences, Jodhpur, Jodhpur, India
| | - Gaurav Jain
- Department of Dentistry, All India Institute of Medical Sciences, Jodhpur, Jodhpur, India
| | - Md Atik Khan
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Jodhpur, Jodhpur, India
| | - Vinay Kumar Chugh
- Department of Dentistry, All India Institute of Medical Sciences, Jodhpur, Jodhpur, India
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24
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Bolliger D, Lancé MD, Siegemund M. Point-of-Care Platelet Function Monitoring: Implications for Patients With Platelet Inhibitors in Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:1049-1059. [PMID: 32807601 DOI: 10.1053/j.jvca.2020.07.050] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 12/13/2022]
Abstract
Although most physicians are comfortable managing the limited anticoagulant effect of aspirin, the recent administration of potent P2Y12 receptor inhibitors in patients undergoing cardiac surgery remains a dilemma. Guidelines recommend discontinuation of potent P2Y12 inhibitors 5- to- 7 days before surgery to reduce the risk of postoperative hemorrhage. Such a strategy might not be feasible before urgent surgery, due to ongoing myocardial ischemia or in patients at high risk for thromboembolic events. Recently, different point-of-care devices to assess functional platelet quality have become available for clinical use. The aim of this narrative review was to evaluate the implications and potential benefits of platelet function monitoring in guiding perioperative management and therapeutic options in patients treated with antiplatelets, including aspirin or P2Y12 receptor inhibitors, undergoing cardiac surgery. No objective superiority of one point-of-care device over another was found in a large meta-analysis. Their accuracy and reliability are generally limited in the perioperative period. In particular, preoperative platelet function testing has been used to assess platelet contribution to bleeding after cardiac surgery. However, predictive values for postoperative hemorrhage and transfusion requirements are low, and there is a significant variability between and within these tests. Further, platelet function monitoring has been used to optimize the preoperative waiting period after cessation of dual antiplatelet therapy before urgent cardiac surgery. Furthermore, studies assessing their value in therapeutic decisions in bleeding patients after cardiac surgery are scarce. A general and liberal use of perioperative platelet function testing is not yet recommended.
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Affiliation(s)
- Daniel Bolliger
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
| | - Marcus D Lancé
- Department of Anesthesiology, Intensive Care Unit and Perioperative Medicine, Weill-Cornell Medicine-Qatar, Hamad Medical Corporation, Doha, Qatar
| | - Martin Siegemund
- Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
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25
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Malik AH, Majeed S. Effect of antiplatelet therapy on minor dental procedures. Natl J Maxillofac Surg 2020; 11:64-66. [PMID: 33041579 PMCID: PMC7518493 DOI: 10.4103/njms.njms_30_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/09/2019] [Accepted: 02/26/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction: Minor oral surgical procedures are very common. Acetylsalicylic acid generically known as aspirin is used clinically as an analgesic, antipyretic, anti-inflammatory, and as a medication to prevent platelet aggregation. Objective: The aim of this study was to determine if aspirin or clopidogrel was associated with bleeding after minor oral surgical procedures. Materials and Methods: One hundred patients who were planned for extraction of the third molar were divided into two groups. In Group A, patients on antiplatelets were included and in Group B, patients who discontinued the drug before 5 days of procedure were included. The bleeding time of all patients was checked before extraction. The surgical procedure involved simple extraction of a single third molar tooth under local anesthesia. The extraction socket was sutured with 3–0 silk. A pressure pack of gauze was given for 1 h. Bleeding after 1 h and 24 h was compared between two groups. A Chi-square test was used to compare the variables. Results: None of the patients showed active bleeding in the postoperative period. The results for postsurgical bleeding were statistically insignificant with P = 0.05. Conclusion: Minor surgical procedures such as single-tooth extraction can be carried out without discontinuation of the antiplatelet therapy.
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Affiliation(s)
- Altaf Hussain Malik
- Department of Oral and Maxillofacial Surgery, Govt. Dental College, Srinagar, Jammu and Kashmir, India
| | - Shabnum Majeed
- Department of Health and Medical Education, Srinagar, Jammu and Kashmir, India
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26
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The Practice of Continuation of Anti-platelet Therapy During the Perioperative Period in Lumbar Minimally Invasive Spine Surgery (MISS): How Different Is the Morbidity in This Scenario? Spine (Phila Pa 1976) 2020; 45:673-678. [PMID: 32358305 DOI: 10.1097/brs.0000000000003357] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cohort. OBJECTIVE To evaluate perioperative morbidity in patients undergoing minimally invasive spine surgery of the lumbar spine while continuing the antiplatelet drug (APD) perioperatively as compared with those not continuing these drugs and those not on these drugs. SUMMARY OF BACKGROUND DATA While discontinuation of antiplatelet drugs carries with it the risk of thrombosis of the cardiac stents, myocardial infarction, peripheral vascular occlusion, cerebro-vascular events and other thrombotic complications, continuation of these drugs has the risk of intra spinal bleeding and the serious consequences of subsequent epidural hematoma with associated spinal cord compression. METHODS This institutional review board approved study included 1587 patients from 2011 to 2018. Perioperative parameters were analyzed for 216 patients who underwent spinal surgery after the discontinuation of anticoagulation therapy, 240 patients who continued to take APD daily through the perioperative period and 1131 patients who were never exposed to APD therapy. The operative time, intraoperative estimated blood loss, length of hospital stay, incidence of clinically evident hematoma, and transfusion of blood products were also recorded and compared in three cohorts. RESULTS The patients who continued taking APD in the perioperative period had a longer length of hospital stay on average (2.5 ± 0.67 vs. 1.59 ± 0.76 and 1.67 ± 0.83, P < 0.05), whereas there was no significant difference in the operative time, estimated blood loss, the amount of blood products transfused, and overall intra and postoperative complication rate. There were no instances of postoperative wound soakage or neurological deficit suggestive of possible spinal epidural hematomas in either of the study groups. CONCLUSION The current study has observed no appreciable increase in perioperative morbidities including bleeding related complication rates in patients undergoing lumbar minimally invasive spine surgery while continuing to take APD compared with patients who either discontinued APD prior to surgery or those not taking APD. LEVEL OF EVIDENCE 4.
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27
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Abraham NS. Antiplatelets, anticoagulants, and colonoscopic polypectomy. Gastrointest Endosc 2020; 91:257-265. [PMID: 31585125 PMCID: PMC7386094 DOI: 10.1016/j.gie.2019.09.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/17/2019] [Indexed: 02/07/2023]
Abstract
The management of antiplatelet and anticoagulant (ie, antithrombotic) agents is challenging in the periendoscopic setting. In this state-of-the-art update, we review current best practice recommendations focusing on the risk of immediate and delayed postpolypectomy bleeding in the context of drug discontinuation (ie, temporary interruption) and drug continuation. The data regarding polypectomy technique (cold snare vs conventional thermal-based) and prophylactic placement of hemostatic clips are evaluated to assess whether these endoscopic techniques are beneficial in reducing postpolypectomy bleeding. Finally, clinical takeaways are provided to facilitate safer polypectomy among patients on antiplatelet and anticoagulant agents.
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Affiliation(s)
- Neena S Abraham
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA; Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
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28
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Prather JC, Montgomery TP, Crowther D, McGwin G, Ghavam C, Theiss SM. Elective spine surgery with continuation of clopidogrel anti-platelet therapy: Experiences from the community. J Clin Orthop Trauma 2020; 11:928-931. [PMID: 32879582 PMCID: PMC7452213 DOI: 10.1016/j.jcot.2020.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/05/2020] [Accepted: 06/06/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE This retrospective study aimed to assess the feasibility of continuing clopidogrel therapy during the perioperative period in elective cervical and thoracolumbar surgery. METHODS After IRB approval, medical records of patients requiring one or two-level surgery over a two-year period (2015-2017) while receiving clopidogrel were reviewed for relevant outcomes. Over the same period, a control group of patients not receiving clopidogrel perioperatively was formed. RESULT In total, 136 patients were included: 37 clopidogrel and 99 control, with a mean age of 64.8 years. Between clopidogrel and control respectively, operative time was 86.7 min and 86.7 min (p = 0.620); blood loss was 127.0 cc and 117.5 cc (p = 0.480); drain output was 171.2 cc and 190.7 cc (p = 0.354); length of stay was 1.8 days and 1.5 days (p = 0.103). Two clopidogrel patients and 1 control patient had complications. Two clopidogrel patients and 1 control patient were readmitted within 30 days. CONCLUSIONS Remaining on clopidogrel therapy during elective spine surgery results in no difference in operative time, blood loss, drain output, length of stay, or readmission. Precaution should be taken in cervical procedures as the drain output in clopidogrel patients was increased and complications in this region can be severe.
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Affiliation(s)
- John C. Prather
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA
| | - Tyler P. Montgomery
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA
| | - Doug Crowther
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA
| | - Gerald McGwin
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA
| | - Cyrus Ghavam
- Franciscan Orthopaedic Associates 16259 SW Sylvester Rd suite 301 Burien, WA 98166 USA
| | - Steven M. Theiss
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA,Corresponding author. 1313 13th Street South, Birmingham, AL, 35205, USA
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Mokhtar AT, Baghaffar A, Jackson SD, Horne D. When is the optimal time to discontinue clopidogrel before in-hospital coronary bypass surgery? A closer look at the current literature. J Card Surg 2019; 35:413-421. [PMID: 31803992 DOI: 10.1111/jocs.14371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clopidogrel and other P2Y12 inhibitors have become the standard of care among patients presenting with acute coronary syndromes. A substantial proportion of these patients require surgical revascularization during index hospitalization. HYPOTHESIS Guidelines recommend a 5-day waiting period off clopidogrel before coronary artery bypass grafting (CABG) to reduce hemorrhagic complications. These recommendations are not routinely followed in clinical practice, while recent studies also propose shorter waiting periods off clopidogrel for patients awaiting in-hospital CABG. METHODS A preliminary PubMed search was conducted using the following MeSH terms under the publication type "Hemorrhage:" "Clopidogrel," AND "Coronary Artery Bypass." Relevant studies and guidelines were then reviewed and selected based on a predetermined criteria. Studies that formulated the current recommendations for stopping clopidogrel preoperative to CABG are discussed in detail this review. RESULTS A comprehensive review of recent evidence illustrates mixed bleeding and transfusion outcomes among CABG patients with preoperative exposure to clopidogrel in less than 5 days. CONCLUSIONS The optimal discontinuation time of clopidogrel before CABG is still poorly defined. The recommendation of a 5-day washout period for clopidogrel should be reconsidered to be on par with current clinical practice.
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Affiliation(s)
- Ahmed T Mokhtar
- Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abdullah Baghaffar
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Simon D Jackson
- Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - David Horne
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Raggio BS, Barton BM, Kandil E, Friedlander PL. Association of Continued Preoperative Aspirin Use and Bleeding Complications in Patients Undergoing Thyroid Surgery. JAMA Otolaryngol Head Neck Surg 2019; 144:335-341. [PMID: 29494736 DOI: 10.1001/jamaoto.2017.3262] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance No evidence exists to direct the management of preoperative aspirin (acetylsalicylic acid) use in patients undergoing thyroid surgery. Nevertheless, a considerable number of patients interrupt receiving aspirin therapy during the preoperative period to minimize bleeding complications despite the increased risk of experiencing major adverse cardiac events. Objective To determine whether aspirin therapy continued preoperatively increases bleeding complications in patients undergoing thyroid surgery. Design, Setting, and Participants Retrospective analysis of a consecutive sample of 570 patients, aged 18 to 100 years, who underwent thyroid surgery for benign and malignant disease from January 1, 2010, to December 31, 2015, by a single surgeon at a tertiary referral hospital center in New Orleans, Louisiana. Exposures Patients receiving aspirin therapy and patients not receiving aspirin therapy (aspirin naive) preoperatively. Main Outcomes and Measures Comparison of estimated blood loss, substantial blood loss, operative hematoma, nonoperative hematoma, and recurrent laryngeal nerve injury. Results Of 570 patients who underwent thyroid surgery, 106 (18.6%) were performed in patients receiving aspirin; of these, 23 (21.7%) were men and 105 (99.1%) were older than 45 years. Those receiving aspirin therapy displayed a 14.4-year difference in age (95% CI, 11.6-17.1). The aspirin group displayed a 20.3% absolute increase (95% CI, 9.3-30.7) in African American patients. Aspirin therapy was not associated with a statistically significant or clinically meaningful increase in intraoperative blood loss (2.5 mL; 95% CI, -0.4 to 5.3). Aspirin therapy was associated with a statistically significant increase in total hematoma formation (3.3%; 95% CI, 0.4-9.0), but the results were inconclusive. Aspirin therapy was not associated with a statistically significant increase in recurrent laryngeal nerve injury (2.6%; 95% CI, -1.1 to 8.6), but the results were inconclusive. Conclusions and Relevance These results suggest that aspirin therapy can be maintained prior to thyroid surgery without increased intraoperative bleeding. Further research with a larger sample size and more outcome events are required to make definitive conclusions regarding the association between aspirin use and complications, including hematoma and recurrent laryngeal nerve injury.
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Affiliation(s)
- Blake S Raggio
- Department of Otolaryngology, Tulane University Medical Center, New Orleans, Louisiana
| | - Blair M Barton
- Department of Otolaryngology, Tulane University Medical Center, New Orleans, Louisiana
| | - Emad Kandil
- Department of Otolaryngology, Tulane University Medical Center, New Orleans, Louisiana
| | - Paul L Friedlander
- Department of Otolaryngology, Tulane University Medical Center, New Orleans, Louisiana
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Bhattad VB, Gaddam S, Lassiter MA, Jagadish PS, Ardeshna D, Cave B, Khouzam RN. Intravenous cangrelor as a peri-procedural bridge with applied uses in ischemic events. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:408. [PMID: 31660307 PMCID: PMC6787394 DOI: 10.21037/atm.2019.07.64] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/15/2019] [Indexed: 11/06/2022]
Abstract
Cangrelor is a relatively new antiplatelet drug that has been approved for use as an adjunct therapy to percutaneous coronary intervention (PCI) to decrease peri-procedural myocardial infarction (MI), coronary revascularization, and stent thrombosis. Cangrelor is an adenosine triphosphate analogue with a pharmacokinetic mechanism based on a reversible, dose-dependent inhibition adenosine diphosphate (ADP)-induced platelet aggregation. This drug has lately been in the spotlight as a possible bridge therapy for anti-platelet medication prior to cardiac and non-cardiac surgeries. Platelet function is usually restored within sixty minutes of cessation of therapy, thereby decreasing the risk of bleeding while providing adequate pre-procedural coverage to reduce ischemic events. This manuscript reviews the literature on cangrelor and summarizes its role as a peri-procedural bridge.
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Affiliation(s)
- Venugopal B. Bhattad
- Department of Internal Medicine, Division of Cardiovascular Diseases, East Tennessee State University, Johnson City, TN, USA
| | - Sathvika Gaddam
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Margaret A. Lassiter
- Cardiovascular Clinical Pharmacy Department, Johnson City Medical Center, Johnson City, TN, USA
| | | | - Devarshi Ardeshna
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Brandon Cave
- Department of Pharmacy, Methodist University Hospital, Memphis, TN, USA
| | - Rami N. Khouzam
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN, USA
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Plazak ME, Mouradjian MT, Watson K, Reed BN, Noel ZR, Devabhakthuni S, Gale SE. An aspirin a day? Clinical utility of aspirin therapy for the primary prevention of cardiovascular disease. Expert Rev Cardiovasc Ther 2019; 17:561-573. [PMID: 31305180 DOI: 10.1080/14779072.2019.1642108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction: Cardiovascular disease remains a leading cause of morbidity and mortality. Since the description of its therapeutic potential, aspirin has been a cornerstone of therapy following vascular events. However, aspirin in the primary prevention setting is controversial and major guideline groups provide inconsistent recommendations. Thus, there is variability in practice as providers are faced with a balance of therapeutic benefit and drug-induced harm. Areas covered: This article provides a critical appraisal of both past and present data for aspirin in the primary prevention setting. PubMed and Cochrane Central Register databases were searched from inception to May 1st, 2019. Expert opinion: The decision to initiate or withdraw aspirin for primary prevention requires an understanding of the equilibrium between efficacy and safety. In adults greater than 70 years of age, low to moderate cardiovascular risk, controlled diabetes, or at high risk of bleeding, initiation of aspirin for primary prevention should generally be avoided. Instead, risk factor modification should be prioritized. The net benefit of aspirin in those at high risk for cardiovascular disease and in those with uncontrolled diabetes is largely unknown. Ultimately, initiation or withdrawal of aspirin therapy must involve discussion of the patient's wishes and treatment expectations.
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Affiliation(s)
- Michael E Plazak
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy , Baltimore , MD , USA
| | - Mallory T Mouradjian
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy , Baltimore , MD , USA
| | - Kristin Watson
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy , Baltimore , MD , USA
| | - Brent N Reed
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy , Baltimore , MD , USA
| | - Zachary R Noel
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy , Baltimore , MD , USA
| | - Sandeep Devabhakthuni
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy , Baltimore , MD , USA
| | - Stormi E Gale
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy , Baltimore , MD , USA
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Li J, Wang M, Cheng T. The safe and risk assessment of perioperative antiplatelet and anticoagulation therapy in inguinal hernia repair, a systematic review. Surg Endosc 2019; 33:3165-3176. [DOI: 10.1007/s00464-019-06956-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 07/01/2019] [Indexed: 01/30/2023]
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Bogunovic L, Haas AK, Brophy RH, Matava MJ, Smith MV, Wright RW. The Perioperative Continuation of Aspirin in Patients Undergoing Arthroscopic Surgery of the Knee. Am J Sports Med 2019; 47:2138-2142. [PMID: 31226002 DOI: 10.1177/0363546519855643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The perioperative withdrawal of aspirin increases the risk of cardiac, neurologic, and vascular thromboembolic events. The safety of continuing aspirin in patients undergoing knee arthroscopy is unknown. HYPOTHESIS Perioperative continuation of aspirin does not increase surgical complications or worsen outcomes in patients 50 years of age and older undergoing knee arthroscopy. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS This is a single-center, institutional review board-approved, prospective matched dual-cohort study comparing the surgical complication rates and postoperative outcomes of patients taking daily aspirin with those of unmedicated controls. Ninety patients who were 50 years of age or older and taking 81 mg or 325 mg daily aspirin were matched to 90 controls. Patients were matched on age, surgery type, and the use of a tourniquet. A complication was defined as bleeding, wound dehiscence, or wound infection requiring reoperation. Postoperative outcome measures including hematoma formation, extent of ecchymosis (mm), visual analog scale (VAS) scores for pain and swelling, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were collected preoperatively and postoperatively (10-14 days and 4-6 weeks). RESULTS There were no complications (0%) in either cohort. There was no difference in hematoma formation (aspirin, 1.8%; controls, 2.4%; P = .79), incidence of ecchymosis (aspirin, 17%; controls, 21%; P = .70), or the average extent of ecchymosis (aspirin, 124.6 mm; controls, 80.3 mm; P = .36) between patients taking aspirin and controls. There was no significant difference in pre- or postoperative knee range of motion between controls and patients taking aspirin. The KOOS subscores and VAS pain scores were similar between patients taking aspirin and controls at baseline and at follow-up. CONCLUSION The perioperative continuation of daily aspirin in patients 50 years of age and older undergoing arthroscopic procedures of the knee is safe and does not result in an increased rate of bleeding or wound complications requiring reoperation. Continued aspirin use in patients 50 years of age and older had no significant effect on postoperative physical examination measures or patient-rated outcome scores.
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Affiliation(s)
- Ljiljana Bogunovic
- Department of Orthopaedics, Washington University, Chesterfield, Missouri, USA
| | - Amanda K Haas
- Department of Orthopaedics, Washington University, Chesterfield, Missouri, USA
| | - Robert H Brophy
- Department of Orthopaedics, Washington University, Chesterfield, Missouri, USA
| | - Matthew J Matava
- Department of Orthopaedics, Washington University, Chesterfield, Missouri, USA
| | - Matthew V Smith
- Department of Orthopaedics, Washington University, Chesterfield, Missouri, USA
| | - Rick W Wright
- Department of Orthopaedics, Washington University, Chesterfield, Missouri, USA
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Briet C, Blanchart K, Lemaître A, Roux I, Lavergne K, Rocamora A, Bignon M, Ardouin P, Sabatier R, Roule V, Beygui F. Bedside mental status and outcome in elderly patients admitted for acute coronary syndromes. Heart 2019; 105:1635-1641. [DOI: 10.1136/heartjnl-2019-314978] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/27/2019] [Accepted: 05/09/2019] [Indexed: 11/04/2022] Open
Abstract
ObjectiveWe investigated whether mental status assessed by simple bedside tests in elderly patients admitted for acute coronary syndromes (ACS) was associated with higher risk of mortality.MethodsWe used the data from a prospective, open, ongoing cohort of patients≥75 years old admitted for ACS to a tertiary centre. Cognitive impairment (CogI) was defined by delirium detected by the Confusion Assessment Method or an abnormal Mini Mental State Examination score. A Cox model adjusted on predefined correlates of mortality was used to assess the relationship between CogI and 1-year mortality.ResultsSix-hundred consecutive patients with mental status assessment within 48 hours after admission were included. CogI was identified in 172 (29%) patients among whom 153 (25.5%) had an abnormal Mini Mental State Evaluation and 19 (3.2%) delirium. Death occurred in 49 (28.6%) patients with and 43 (10.5%) patients without CogI at 1 year. There was a significant association between CogI and 1-year mortality (adjusted-HR 2.4, 95% CI 1.53 to 3.62), p<0.001) independent of other covariables. CogI was also independently associated with higher rates of in-hospital bleeding and mortality as well as 3-month rates of all-cause, cardiovascular-related and heart failure-related rehospitalisation.ConclusionsCogI detected by simple bedside tests in patients≥75 admitted for ACS is associated with an increased risk of 1-year mortality and 3 month rehospitalisation independent of other correlates of poor outcome.
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Stamenovic D, Schneider T, Messerschmidt A. Aspirin for patients undergoing major lung resections: hazardous or harmless?†. Interact Cardiovasc Thorac Surg 2019; 28:535-541. [PMID: 30346533 DOI: 10.1093/icvts/ivy255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 07/05/2018] [Accepted: 07/11/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Acetylsalicylic acid (ASA, aspirin) is a medication widely used for primary and secondary prevention of cardiovascular diseases, which are the leading cause of morbidity and mortality worldwide. Whether aspirin should be continued or paused in the perioperative period remains controversial, especially in thoracic surgical settings. METHODS A single-centred retrospective study comprised 486 patients. Of these, 329 patients did not use aspirin (group ASA-0) and 157 did (group ASA-1) during the perioperative period after anatomical lung resection at our hospital from January 2013 to December 2016. Major outcome measures were the amount of blood loss during the operation and during the first 5 days postoperatively (per Mercuriali's formula), as well as the amount and proportion of the blood transfusion (packed red cells) received. The need for reoperation due to a postoperative haemothorax and/or bleeding was recorded. The groups were also compared according to their rates of morbidity and mortality. Inferential statistical methods with bootstrap analysis using 1000 samples and the Mersenne Twister, a random number generator, were used. RESULTS There were no significant differences between the 2 groups in intraoperative bleeding [ASA-0M = 418.69 ml, standard deviation (SD) ± 364.87; ASA-1M = 399.8 ml, SD ± 323.84; P = 0.58] or in total blood loss according to Mercuriali's formula (ASA-0M = 1111.62 ml, SD ± 816.69; ASA-1M = 1115.08 ml, SD ± 682.12; P = 0.95). A total of 104 patients received transfusions up to postoperative day 5: 71 patients in the ASA-0 group received 151 blood transfusions, whereas 33 patients in the ASA-1 group received 65 blood transfusions (P = 0.66). The indication for reoperation due to bleeding (ASA-1 = 3, ASA-0 = 4; P = 0.69) was similar between the groups. There was a trend towards higher rates of postoperative complications in the ASA-1 group (risk ratio (RR) = 1.28; P = 0.055); neither cardiovascular complications nor deaths were more frequent in either of the 2 groups (P = 0.73). CONCLUSIONS Patients taking aspirin therapy and undergoing anatomical lung resection seem not to be at any disadvantage regarding bleeding. However, a trend towards a higher rate of postoperative complications indicates a basically increased risk for operations due to comorbidities in these patients.
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Affiliation(s)
- Davor Stamenovic
- Department of Thoracic Surgery, ViDia Kliniken, Karlsruhe, Germany
| | - Thomas Schneider
- Department of Thoracic Surgery, ViDia Kliniken, Karlsruhe, Germany
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Song PS, Kim MJ, Jeon KH, Lim S, Park JS, Choi RK, Kim JS, Lee HJ, Kim TH, Choi YJ, Lim DS, Yu CW. Efficacy of postprocedural anticoagulation after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: A post-hoc analysis of the randomized INNOVATION trial. Medicine (Baltimore) 2019; 98:e15277. [PMID: 31027084 PMCID: PMC6831338 DOI: 10.1097/md.0000000000015277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
There exists controversy on whether and for how long anticoagulation is necessary after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).We aimed to study the impact of prolonged (>24 h) or brief (<24 h) postprocedural anticoagulation on infarct size assessed by cardiac magnetic resonance (CMR) after 30 days as well as on left ventricular ejection fraction (LVEF) and left ventricular (LV) remodeling evaluated by 2D-echocardiography after 9 months from the INNOVATION trial (Clinical Trial Registration: NCT02324348).Of the 114 patients (mean age: 59.5 years) enrolled, 76 (66.7%) received prolonged anticoagulation therapy (median duration: 72.6 h) and 38 (33.3%) patients received brief anticoagulation therapy (median duration: 5 h) after primary PCI. There was no significant difference in infarct size (mean size: 15.6% after prolonged anticoagulation versus 19.8% after brief anticoagulation, P = .100) and the incidence of microvascular obstruction (50.7% versus 52.9%, P = .830) between the groups. Even after adjusting, prolonged anticoagulation therapy could not reduce larger infarct (defined as >75 percentile of infarct size; 19.7% versus 35.3%; adjusted odd ratio [OR]: 0.435; 95% confidence interval [CI]: 0.120-1.57; P = .204). Similar results were observed in subanalyses of major high-risk subgroups. Moreover, follow-up LVEF <35% (3.2% versus 7.4%; adjusted OR: 0.383; 95% CI: 0.051-2.884; P = .352) and LV remodeling (defined as >20% increase in LV end-diastolic volume; 37.1% versus 18.5%; adjusted OR: 2.249; 95% CI: 0.593-8.535; P = .234) were similar between groups.These data suggest that prolonged postprocedural anticoagulation may not provide much benefit after successful primary PCI in patients with STEMI. However, further studies are needed.
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Affiliation(s)
- Pil Sang Song
- Division of Cardiology, Cardiovascular Center, Mediplex Sejong General Hospital, Incheon
| | - Min Jeong Kim
- Division of Cardiology, Cardiovascular Center, Mediplex Sejong General Hospital, Incheon
| | - Ki-Hyun Jeon
- Division of Cardiology, Cardiovascular Center, Mediplex Sejong General Hospital, Incheon
| | - Sungmin Lim
- Division of Cardiology, Cardiovascular Center, Mediplex Sejong General Hospital, Incheon
| | - Jin-Sik Park
- Division of Cardiology, Cardiovascular Center, Mediplex Sejong General Hospital, Incheon
| | - Rak Kyeong Choi
- Division of Cardiology, Cardiovascular Center, Mediplex Sejong General Hospital, Incheon
| | - Je Sang Kim
- Division of Cardiology, Department of Internal Medicine, Sejong General Hospital, Bucheon
| | - Hyun Jong Lee
- Division of Cardiology, Department of Internal Medicine, Sejong General Hospital, Bucheon
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Sejong General Hospital, Bucheon
| | - Young Jin Choi
- Division of Cardiology, Department of Internal Medicine, Sejong General Hospital, Bucheon
| | - Do-Sun Lim
- Cardiovascular Center, Anam Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Cheol Woong Yu
- Cardiovascular Center, Anam Hospital, Korea University Medical Center, Seoul, Republic of Korea
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Akonjom M, Battenberg A, Beverland D, Choi JH, Fillingham Y, Gallagher N, Han SB, Jang WY, Jiranek W, Manrique J, Mihov K, Molloy R, Mont MA, Nandi S, Parvizi J, Peel T, Pulido L, Sarungi M, Sodhi N, Alberdi MT, Olivan RT, Wallace D, Weng X, Wynn-Jones H, Yeo SJ. General Assembly, Prevention, Blood Conservation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S147-S155. [PMID: 30348569 DOI: 10.1016/j.arth.2018.09.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Abstract
Colonoscopy with polypectomy is the means by which the incidence of colon cancer may be reduced; however, polypectomy is not without risk. Physicians must carefully weigh the risks and benefits of colonoscopy, particularly when patients are given prescriptions for antiplatelet agents and anticoagulants. This article discusses the risks of colonoscopy and polypectomy and reviews the most recent data for managing antiplatelet agents and anticoagulants in the periendoscopic period.
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Affiliation(s)
- Linda Anne Feagins
- Division of Gastroenterology and Hepatology, University of Texas Southwestern Medical Center, VA North Texas Healthcare System, Dallas VA Medical Center, 4500 South Lancaster Road (111B1), Dallas, TX 75216, USA.
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Hasselgren M, Runer T, Janson P, Ekström M. Antithrombotic treatment and risk of complications after head and neck full thickness skin graft surgery. J Plast Surg Hand Surg 2018; 52:333-337. [PMID: 30178690 DOI: 10.1080/2000656x.2018.1498789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Head and neck skin cancer surgery using a full thickness skin graft is a common procedure. Evidence concerning the effects of perioperative antithrombotic treatment on complications is limited. The aim of this study was to evaluate whether perioperative antithrombotic treatment is associated with risk of necrosis, bleeding or infection after full thickness skin graft surgery. Retrospective single-center cohort study with medical records review. Patients operated with a head and neck full thickness skin graft in 2010 and 2013-2015 had available data and were included. Any antithrombotic treatment was continued and all patients were routinely followed-up on days 7-10 after surgery. Data on demographics, concurrent disease, clinical characteristics, antithrombotic medications and postoperative necrosis, bleeding and infection were collected from electronic medical records. Associations with complications were examined using multivariate logistic regression adjusted for age, sex, reoperation, size of excision, site of surgery and concurrent disease. In total, 302 patients (53% women) were included. Antithrombotic treatment (n = 125 patients) was not associated with higher adjusted risk of total complications in multivariate analysis (OR 0.70; 95% CI: 0.34-1.46). In subgroup analyses, the total risk was not increased in patients on aspirin (OR 0.76; 95% CI: 0.39-1.48) or warfarin (OR 1.20; 95% CI: 0.47-3.10). In the warfarin subgroup (N = 26), there was a statistically non-significant trend towards increased risk of graft necrosis. This study supports that aspirin and warfarin should not be discontinued prior to head and neck full thickness skin graft surgery.
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Affiliation(s)
- Martin Hasselgren
- a Department of Otolaryngology Head & Neck Surgery , Blekinge Hospital , Karlskrona , Sweden
| | - Thomas Runer
- a Department of Otolaryngology Head & Neck Surgery , Blekinge Hospital , Karlskrona , Sweden
| | - Peter Janson
- a Department of Otolaryngology Head & Neck Surgery , Blekinge Hospital , Karlskrona , Sweden
| | - Magnus Ekström
- b Division of Respiratory Medicine and Allergology, Department of Clinical Sciences , Lund University , Lund , Sweden
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Otto BJ, Terry RS, Lutfi FG, Syed JS, Hamann HC, Gupta M, Bird VG. The Effect of Continued Low Dose Aspirin Therapy in Patients Undergoing Percutaneous Nephrolithotomy. J Urol 2018; 199:748-753. [DOI: 10.1016/j.juro.2017.10.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2017] [Indexed: 12/23/2022]
Affiliation(s)
- Brandon J. Otto
- Department of Urology, University of Florida College of Medicine, Gainesville, Florida
| | - Russell S. Terry
- Department of Urology, University of Florida College of Medicine, Gainesville, Florida
| | - Forat G. Lutfi
- University of Florida College of Medicine, Gainesville, Florida
| | - Jamil S. Syed
- University of Florida College of Medicine, Gainesville, Florida
| | | | - Mohit Gupta
- Department of Urology, University of Florida College of Medicine, Gainesville, Florida
| | - Vincent G. Bird
- Department of Urology, University of Florida College of Medicine, Gainesville, Florida
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The Rate of Epistaxis Incidence in New-Generation Anticoagulants and Perioperative Approach in Otorhinolaryngological Practices. J Craniofac Surg 2018; 28:e178-e182. [PMID: 27755410 DOI: 10.1097/scs.0000000000003135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Nose bleeding is a common situation seen in otorhinolaryngological practices. One of the greatest risk factors in nose bleeding is the use of anticoagulant medicine. With the medicine developed in recent years, the risk of nose bleeding due to the frequent use of anticoagulant and antiagregant is gradually increasing.The purpose of this study is to determine the effects of especially new-generation anticoagulants on nose bleeding. In addition, the use and complications of new-generation anticoagulants and antiagregants have been compiled in light of information obtained from the literature.Three hundred forty patients whose follow-up is conducted by the cardiology department and who use oral antithrombocytic medicine have been included in the study. It has been determined that 15% of these patients use new-generation oral anticoagulants (Rivaroksaban, apiksaban, dabigatran, danaparoid) and the other patients are treated with conventional antithrombocytic treatment (Aspirin, Warfarin, Enoksaparin sodium). The rate of nose bleeding in patients who use classical anticoagulants has been observed to be 28%. In 30 of these patients who had nose bleeding, while cauterization and buffering by otorhinolaryngology specialists, major intervention has not been necessary for any of the patients. While bleeding has been observed in 26% of the patients who use new-generation anticoagulants, bleeding that required operational intervention has taken place in 2 patients. Bleedings have been stopped surgically through a large number of cauterization and buffering.While the new-generation anticoagulants cause lower rate of bleeding, it has been observed that controlling these bleedings is more difficult.
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Larsen S, Grove E, Kristensen S, Neergaard-Petersen S, Hvas AM. Increased platelet aggregation and serum thromboxane levels in aspirin-treated patients with prior myocardial infarction. Thromb Haemost 2017; 108:140-7. [DOI: 10.1160/th12-01-0026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 04/11/2012] [Indexed: 11/05/2022]
Abstract
SummaryThe antiplatelet effect of aspirin displays considerable inter-individual variability. We investigated the antiplatelet effect of aspirin in patients with coronary artery disease on aspirin mono-therapy with and without prior myocardial infarction (MI). Further, we investigated whether the effect of aspirin differed between patients with and without aspirin use at the time of MI onset. We performed a study on 231 patients, including 171 with prior MI. Among patients with only one prior MI (116 patients), 59 patients were on aspirin at the time of MI onset. All patients received 75 mg aspirin as mono-therapy. Platelet aggregation was assessed by multiple electrode aggregometry (Multiplate®) and Verify -Now®, and platelet activation was evaluated by soluble P-selectin. Furthermore, we measured serum thromboxane B2. MI patients had higher median platelet aggregation levels than patients without prior MI when evaluated by Multiplate® (parachidonic acid<0.0001, pcollagen=0.20). This was not supported by VerifyNow®. Furthermore, MI patients had higher median serum thromboxane B2 levels than patients without prior MI (p=0.01). Patients on aspirin before MI onset had significantly higher median aggregation levels compared with MI patients not on aspirin when evaluated by Multiplate® (pcollagen=0.02) and VerifyNow® (p<0.0001). In conclusion, patients with prior MI had higher platelet aggregation levels than patients without prior MI when evaluated by Multiplate®, despite same aspirin dose and optimal compliance. Serum thromboxane B2 levels were higher in MI patients than in patients without prior MI. Finally, patients on aspirin before MI onset had higher aggregation levels compared with patients not on aspirin.
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Patrono C, Morais J, Baigent C, Collet JP, Fitzgerald D, Halvorsen S, Rocca B, Siegbahn A, Storey RF, Vilahur G. Antiplatelet Agents for the Treatment and Prevention of Coronary Atherothrombosis. J Am Coll Cardiol 2017; 70:1760-1776. [PMID: 28958334 DOI: 10.1016/j.jacc.2017.08.037] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 08/08/2017] [Accepted: 08/09/2017] [Indexed: 01/06/2023]
Abstract
Antiplatelet drugs provide first-line antithrombotic therapy for the management of acute ischemic syndromes (both coronary and cerebrovascular) and for the prevention of their recurrence. Their role in the primary prevention of atherothrombosis remains controversial because of the uncertain balance of the potential benefits and risks when combined with other preventive strategies. The aim of this consensus document is to review the evidence for the efficacy and safety of antiplatelet drugs, and to provide practicing cardiologists with an updated instrument to guide their choice of the most appropriate antiplatelet strategy for the individual patient presenting with different clinical manifestations of coronary atherothrombosis, in light of comorbidities and/or interventional procedures.
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Affiliation(s)
- Carlo Patrono
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy.
| | - Joao Morais
- Division of Cardiology, Santo Andre's Hospital, Leiria, Portugal
| | - Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jean-Philippe Collet
- Sorbonne Université Paris 6, ACTION Study Group, Institut de Cardiologie Hôpital Pitié-Salpêtrière (APHP), INSERM UMRS 1166, Paris, France
| | | | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevål, and University of Oslo, Oslo, Norway
| | - Bianca Rocca
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Agneta Siegbahn
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Gemma Vilahur
- Cardiovascular Science Institute-ICCC IIB-Sant Pau, CiberCV, Hospital de Sant Pau, Barcelona, Spain
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Sundström J, Hedberg J, Thuresson M, Aarskog P, Johannesen KM, Oldgren J. Low-Dose Aspirin Discontinuation and Risk of Cardiovascular Events. Circulation 2017; 136:1183-1192. [DOI: 10.1161/circulationaha.117.028321] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 07/06/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Johan Sundström
- From Department of Medical Sciences (J.S., J.O.), Uppsala Clinical Research Center (J.S., J.O.), and Department of Surgical Sciences (J.H), Uppsala University, Sweden; Statisticon AB, Uppsala, Sweden (M.T.); AstraZeneca Nordic Baltic, Södertälje, Sweden (P.A.); and Linköping University, Sweden (K.M.J.)
| | - Jakob Hedberg
- From Department of Medical Sciences (J.S., J.O.), Uppsala Clinical Research Center (J.S., J.O.), and Department of Surgical Sciences (J.H), Uppsala University, Sweden; Statisticon AB, Uppsala, Sweden (M.T.); AstraZeneca Nordic Baltic, Södertälje, Sweden (P.A.); and Linköping University, Sweden (K.M.J.)
| | - Marcus Thuresson
- From Department of Medical Sciences (J.S., J.O.), Uppsala Clinical Research Center (J.S., J.O.), and Department of Surgical Sciences (J.H), Uppsala University, Sweden; Statisticon AB, Uppsala, Sweden (M.T.); AstraZeneca Nordic Baltic, Södertälje, Sweden (P.A.); and Linköping University, Sweden (K.M.J.)
| | - Pernilla Aarskog
- From Department of Medical Sciences (J.S., J.O.), Uppsala Clinical Research Center (J.S., J.O.), and Department of Surgical Sciences (J.H), Uppsala University, Sweden; Statisticon AB, Uppsala, Sweden (M.T.); AstraZeneca Nordic Baltic, Södertälje, Sweden (P.A.); and Linköping University, Sweden (K.M.J.)
| | - Kasper Munk Johannesen
- From Department of Medical Sciences (J.S., J.O.), Uppsala Clinical Research Center (J.S., J.O.), and Department of Surgical Sciences (J.H), Uppsala University, Sweden; Statisticon AB, Uppsala, Sweden (M.T.); AstraZeneca Nordic Baltic, Södertälje, Sweden (P.A.); and Linköping University, Sweden (K.M.J.)
| | - Jonas Oldgren
- From Department of Medical Sciences (J.S., J.O.), Uppsala Clinical Research Center (J.S., J.O.), and Department of Surgical Sciences (J.H), Uppsala University, Sweden; Statisticon AB, Uppsala, Sweden (M.T.); AstraZeneca Nordic Baltic, Södertälje, Sweden (P.A.); and Linköping University, Sweden (K.M.J.)
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Clinical outcomes after craniotomy for unruptured intracranial aneurysm in patients with coronary artery disease. J Clin Neurosci 2017; 46:113-117. [PMID: 28887082 DOI: 10.1016/j.jocn.2017.08.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/14/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) patients receiving antiplatelet agents occasionally undergo craniotomy. We aimed to clarify clinical outcomes after craniotomy for unruptured intracranial aneurysm (UIA) in patients with CAD. We also aimed to identify the possible predictive factors for morbidity and surgical complications in patients on antiplatelet treatment. METHODS We retrospectively analyzed 401 consecutive patients who had undergone craniotomy for UIA at our institution between January 2006 and December 2016. Forty-three patients (10.7%) received antiplatelet agents during the perioperative period. The underlying reasons for antiplatelet treatment were CAD in 12 patients and other diseases in 31 patients. RESULTS Severe morbidity and intracranial hemorrhage occurred more commonly and symptomatic brain infarction occurred less frequently in patients with CAD compared to patients with other underlying diseases (16.7% versus 3.2%, 16.7% versus 9.7%, and 8.3% versus 16.1%, respectively), though differences between the two groups were not significant. Univariate analysis revealed that a low preoperative baseline platelet count was significantly correlated with the occurrence of intracranial hemorrhage (cutoff value, 16.5×104/µL; odds ratio (OR), 46.67; 95% confidence interval (CI), 3.88-561.95; p=0.0005), and a high baseline platelet count tended to correlate with severe morbidity (cutoff value, 29.8×104/µL; OR, 11.33; 95% CI, 0.88-145.52; p=0.0550). CONCLUSIONS Our results suggest that surgical complications and clinical outcomes after craniotomy may depend on the underlying reason for antiplatelet treatment. Moreover, a preoperative platelet count can be useful in predicting the occurrence of intracranial hemorrhage and severe morbidity after craniotomy in patients receiving antiplatelet agents.
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Sánchez-Martínez M, Flores-Blanco PJ, López-Cuenca ÁA, Sánchez-Galián MJ, Gómez-Molina M, Cambronero-Sánchez F, Guerrero-Pérez E, Valdés M, Januzzi JL, Manzano-Fernández S. Evaluation of the CRUSADE Risk Score for Predicting Major Bleeding in Patients with Concomitant Kidney Dysfunction and Acute Coronary Syndromes. Cardiorenal Med 2017; 7:179-187. [PMID: 28736558 DOI: 10.1159/000455102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 12/05/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Kidney dysfunction (KD) has been associated with increased risk for major bleeding (MB) in patients with acute coronary syndromes (ACS) and may be in part related to an underuse of evidence-based therapies. Our aim was to assess the predictive ability of the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) risk score in patients with concomitant ACS and chronic kidney disease. METHODS We conducted a retrospective analysis of a prospective registry including 1,587 ACS patients. In-hospital MB was prospectively recorded according to the CRUSADE and Bleeding Academic Research Consortium (BARC) criteria. KD was defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2. RESULTS The predictive ability of the CRUSADE risk score was assessed by discrimination and calibration analyses. A total of 465 (29%) subjects had KD. In multivariate logistic regression analyses, we found high CRUSADE risk score values to be associated with a higher rate of in-hospital MB; however, among patients with KD, it was not associated with BARC MB. Regardless of the MB definition, the predictive ability of the CRUSADE score in patients with KD was lower: area under the curve (AUC) 0.71 versus 0.79, p = 0.03 for CRUSADE MB and AUC 0.65 versus 0.75, p = 0.02 for BARC MB. Hosmer-Lemeshow analyses showed a good calibration in all renal function subgroups for both MB definitions (all p values >0.3). CONCLUSIONS The CRUSADE risk score shows a lower accuracy for predicting in-hospital MB in KD patients compared to those without KD.
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Affiliation(s)
| | - Pedro J Flores-Blanco
- Division of Cardiology, University Hospital Virgen de la Arrixaca, School of Medicine, Murcia, Spain
| | | | - María J Sánchez-Galián
- Division of Cardiology, University Hospital Virgen de la Arrixaca, School of Medicine, Murcia, Spain
| | - Miriam Gómez-Molina
- Division of Cardiology, University Hospital Virgen de la Arrixaca, School of Medicine, Murcia, Spain
| | | | - Esther Guerrero-Pérez
- Division of Cardiology, University Hospital Virgen de la Arrixaca, School of Medicine, Murcia, Spain
| | - Mariano Valdés
- Division of Cardiology, University Hospital Virgen de la Arrixaca, School of Medicine, Murcia, Spain.,University of Murcia, Murcia, Spain
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sergio Manzano-Fernández
- Division of Cardiology, University Hospital Virgen de la Arrixaca, School of Medicine, Murcia, Spain.,University of Murcia, Murcia, Spain
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Lee J, Jung CW, Jeon Y, Kim TK, Cho YJ, Koo CH, Choi YH, Kim KB, Hwang HY, Kim HR, Park JY. Effects of preoperative aspirin on perioperative platelet activation and dysfunction in patients undergoing off-pump coronary artery bypass graft surgery: A prospective randomized study. PLoS One 2017; 12:e0180466. [PMID: 28715503 PMCID: PMC5513419 DOI: 10.1371/journal.pone.0180466] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 06/13/2017] [Indexed: 11/18/2022] Open
Abstract
The benefit of aspirin use after coronary artery bypass graft surgery has been well proven. However, the effect of preoperative aspirin use in patients undergoing off-pump coronary artery bypass graft surgery (OPCAB) has not been evaluated sufficiently. To evaluate platelet function changes during OPCAB due to preoperative aspirin use, we conducted a randomized controlled trial using flow cytometry and the Multiplate® analyzer. Forty-eight patients scheduled for elective OPCAB were randomized to the aspirin continuation (100 mg/day until operative day) and discontinuation (4 days before the operative day) groups. Platelet function was measured using the platelet activation markers CD62P, CD63, and PAC-1 by flow cytometry, and platelet aggregation was measured using the Multiplate® analyzer, after the induction of anesthesia (baseline), at the end of the operation, and 24 and 48 h postoperatively. Findings of conventional coagulation assays, thromboelastography by ROTEM® assays, and postoperative bleeding—related clinical outcomes were compared between groups. No significant change in CD62P, CD63, or PAC-1 was observed at the end of the operation or 24 or 48 h postoperatively compared with baseline in either group. The area under the curve for arachidonic acid—stimulated platelet aggregation, measured by the Multiplate® analyzer, was significantly smaller in the aspirin continuation group (P < 0.01). However, chest tube drainage and intraoperative and postoperative transfusion requirements did not differ between groups. Our study showed that preoperative use of aspirin for OPCAB did not affect perioperative platelet activation, but it impaired platelet aggregation, which did not affect postoperative bleeding, by arachidonic acid.
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Affiliation(s)
- Jiwon Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
- * E-mail:
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Tae Kyong Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chang-Hoon Koo
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yoon Hyeong Choi
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ki-Bong Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hang-Rae Kim
- Department of Anatomy and Cell Biology, Department of Biomedical Sciences, BK21 Plus Biomedical Science Project, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-Young Park
- FACS Core Facility, Seoul National University College of Medicine, Seoul, Korea
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Perioperative changes in platelet count and function in patients undergoing cardiac surgery. Med J Islam Repub Iran 2017; 31:37. [PMID: 29445666 PMCID: PMC5804419 DOI: 10.14196/mjiri.31.37] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Indexed: 11/18/2022] Open
Abstract
Background: Patients undergoing cardiac surgery are at increased risk of bleeding due to multifactorial coagulopathies. In the present
study, we aimed at investigating the changes in platelet count and function during and after surgery as well as determining the
association of the platelet dysfunction with bleeding and transfusion requirements in these patients.
Methods: A total of 40 adult patients scheduled for elective valve coronary cardiac surgery were included in this prospective observational
study. Changes in platelet count and function with ADP, acid arachidonic, and collagen (light transmission aggregometry)
were analyzed at three time points: before CPB, after CPB, and 24 hours after end of surgery. Postoperative bleeding and intraoperative
transfusion requirements were recorded.
Results: There were a significant reverse correlation between CPB time and ADP-induced aggregation, particularly after CPB and
postoperative AA-induced aggregation. There was not any significant correlation between platelet count and function at all-time
points. Both platelet count and platelet aggregation significantly reduced during CPB. While platelet aggregation increased on postoperative
Day 1, platelet count reduced by about 40% after CPB, and remained at this level postoperatively. Patients with abnormal
ADP-induced aggregation had significant increased postoperative bleeding and transfusion requirements.
Conclusion: The results of this study demonstrate that platelet count and platelet aggregation are reduced during CPB. Our results
emphasized the effect of platelet dysfunction on increased postoperative bleeding and transfusion requirements. Perioperative monitoring
of platelet function can be considered as a bleeding management strategy for implantation of PBM programs.
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Feagins LA. Management of Anticoagulants and Antiplatelet Agents During Colonoscopy. Am J Med 2017; 130:786-795. [PMID: 28344132 DOI: 10.1016/j.amjmed.2017.01.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 01/14/2023]
Abstract
Colonoscopy frequently is performed for patients who are taking aspirin, nonsteroidal anti-inflammatory drugs, antiplatelet agents, and other anticoagulants. These colonoscopies often involve polypectomy, which can be complicated by bleeding. The risks of precipitating thromboembolic complications if anticoagulants are stopped must be weighed against the risk of postpolypectomy bleeding if these agents are continued. This article systematically reviews the management of anticoagulation during elective and emergency colonoscopy. For patients undergoing colonoscopic polypectomy, the overall risk of postpolypectomy bleeding is <0.5%. Risk factors for postpolypectomy bleeding include large polyp size and anticoagulant use, especially warfarin and thienopyridines. For patients who do not stop aspirin or other nonsteroidal anti-inflammatory drugs prior to colonoscopy, the rate of postpolypectomy bleeding is not significantly different from that for patients who do not take those medications. For patients who continue thienopyridines and undergo polypectomy, the risk of delayed postpolypectomy bleeding is approximately 2.4%. Even for patients who interrupt warfarin, the risk of postpolypectomy bleeding is increased. The direct oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) have a rapid onset and offset of action, and periprocedural bridging generally is not necessary. For the thienopyridines, warfarin, and the direct oral anticoagulants, the decision to interrupt or continue these agents for endoscopy will involve considerable exercise of clinical judgment.
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Affiliation(s)
- Linda Anne Feagins
- Divisions of Gastroenterology and Hepatology, VA North Texas Health Care System, Dallas and the University of Texas Southwestern Medical Center at Dallas.
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