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The Protective Effect of Teprenone on Aspirin-Related Gastric Mucosal Injuries. Gastroenterol Res Pract 2019; 2019:6532876. [PMID: 31316561 PMCID: PMC6604287 DOI: 10.1155/2019/6532876] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 11/28/2018] [Indexed: 02/06/2023] Open
Abstract
Objective Aspirin usage is associated with increased risk of gastrointestinal bleeding. The present study explored the potential of teprenone, an antiulcerative, in preventing aspirin-related gastric mucosal injuries. Methods 280 patients with coronary diseases, naïve to aspirin medication, were admitted between 2011 and 2013 at the First Affiliated Hospital of Zhejiang Chinese Medical University and randomized into two groups (n = 140). The aspirin group received aspirin enteric-coated tablets 100 mg/day, while the aspirin+teprenone group received teprenone 50 mg 3 times/day along with aspirin. The patients were recorded for gastrointestinal symptoms and gastric mucosal injuries during a follow-up period of 12 months with 3-month intervals. Results During the 3-month follow-up, no significant difference was observed in the incidence rate of gastrointestinal symptoms between the two groups (P = 0.498). However, the incidence rate of gastrointestinal symptoms was significantly lower in the aspirin+teprenone group than in the aspirin group during the follow-ups at 6 months (P = 0.036) and 12 months (P = 0.036). The incidence rate of gastric mucosal injuries in the aspirin group was significantly increased at 12 months compared to that at 3 months (P = 0.016). The incidence rates at 12 months and cumulative for the entire follow-up period in the aspirin+teprenone group were both significantly lower than those of the aspirin group (P = 0.049 and P = 0.001, respectively). Conclusion Long-term use of low-dose aspirin causes varying degrees of gastric mucosal damages and gastrointestinal symptoms; the severity will increase within a certain range with the extension of medication duration. Teprenone mitigates the gastrointestinal symptoms caused by low-dose aspirin, lowering both the incidence and severity of gastric mucosal injuries and exerting a positive protective effect.
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Dimmitt SB, Floyd CN, Ferner RE. Antithrombotic dose: Some observations from published clinical trials. Br J Clin Pharmacol 2019; 85:2194-2197. [PMID: 31050833 DOI: 10.1111/bcp.13968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/31/2019] [Accepted: 04/03/2019] [Indexed: 12/12/2022] Open
Abstract
The clinical doses of antithrombotics-antiplatelet and anticoagulant agents-need to balance efficacy and safety. It is not clear from the published literature how the doses currently used in clinical practice have been derived from preclinical and clinical data. There are few large randomised controlled trials (RCTs) that compare outcomes with different doses vs placebo. For newer antithrombotics, RCT doses appear to have been chosen to maximise the probability of demonstrating noninferiority when compared to established agents such as warfarin or clopidogrel. Data from RCTs show that aspirin is an effective antithrombotic at doses below 75 mg daily, and that direct oral anticoagulants reduce the risk of stroke in patients with coronary disease at doses 1/4 of those recommended in atrial fibrillation. Lower doses than those currently recommended are safer and still maintain substantial efficacy.
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Affiliation(s)
- Simon B Dimmitt
- Division of Internal Medicine, Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Crawley, Australia.,School of Medicine & Public Health, University of Newcastle, UK
| | - Christopher N Floyd
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology School of Cardiovascular Medicine and Sciences, King's College London British Heart Foundation Centre, London, UK.,Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Robin E Ferner
- West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham, UK.,Institute of Clinical Sciences, University of Birmingham, UK
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53
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Bleeding risk assessment for stroke patients on antithrombotic therapy. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2019; 31:282-288. [PMID: 31005341 DOI: 10.1016/j.arteri.2019.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/04/2019] [Accepted: 01/27/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION After an ischemic cerebrovascular event the risk of new ischemic events is high, therefore antithrombotic therapy are indicated to prevent stroke recurrence. DISCUSSION Despite its clear benefit, these therapies increase the risk of bleeding. Therefore, it is essential to identify high hemorrhagic risk patients. There are different predictive models of hemorrhage, in particular of intracranial hemorrhage, associated with the use of antiaggregants in patients who have presented an ischemic stroke or TIA, such as the CCSC, intracranial scales -B2LEED3S score or S2TOP-BLEED. However, though main international guidelines recommend the use of scales, in particular, the HAS-BLED score, to assess the risk of bleeding in anticoagulated patients, there is no specific recommendation in the case of the use of antiplatelet drugs. CONCLUSIONS In this review we present the main models currently available for the prediction of bleeding of antithrombotic therapy in patients who have had a stroke or TIA.
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Selak V, Jackson R, Poppe K, Wu B, Harwood M, Grey C, Pylypchuk R, Mehta S, Kerr A, Wells S. Predicting Bleeding Risk to Guide Aspirin Use for the Primary Prevention of Cardiovascular Disease: A Cohort Study. Ann Intern Med 2019; 170:357-368. [PMID: 30802900 DOI: 10.7326/m18-2808] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many prognostic models for cardiovascular risk can be used to estimate aspirin's absolute benefits, but few bleeding risk models are available to estimate its likely harms. OBJECTIVE To develop prognostic bleeding risk models among persons in whom aspirin might be considered for the primary prevention of cardiovascular disease (CVD). DESIGN Prospective cohort study. SETTING New Zealand primary care. PARTICIPANTS The study cohort comprised 385 191 persons aged 30 to 79 years whose CVD risk was assessed between 2007 and 2016. Those with indications for or contraindications to aspirin and those who were already receiving antiplatelet or anticoagulant therapy were excluded. MEASUREMENTS For each sex, Cox proportional hazards models were developed to predict major bleeding risk; participants were censored at the earliest of the date on which they first met an exclusion criterion, date of death, or study end date (30 June 2017). The main models included the following predictors: demographic characteristics (age, ethnicity, and socioeconomic deprivation), clinical measurements (systolic blood pressure and ratio of total-high-density lipoprotein cholesterol), family history of premature CVD, medical history (smoking, diabetes, bleeding, peptic ulcer disease, cancer, chronic liver disease, chronic pancreatitis, or alcohol-related conditions), and medication use (nonsteroidal anti-inflammatory agents, corticosteroids, and selective serotonin reuptake inhibitors). RESULTS During 1 619 846 person-years of follow-up, 4442 persons had major bleeding events (of which 313 [7%] were fatal). The main models predicted a median 5-year bleeding risk of 1.0% (interquartile range, 0.8% to 1.5%) in women and 1.1% (interquartile range, 0.7% to 1.6%) in men. Plots of predicted-against-observed event rates showed good calibration throughout the risk range. LIMITATION Hemoglobin level, platelet count, and body mass index were excluded from the main models because of high numbers of missing values, and the models were not externally validated in non-New Zealand populations. CONCLUSION Prognostic bleeding risk models were developed that can be used to estimate the absolute bleeding harms of aspirin among persons in whom aspirin is being considered for the primary prevention of CVD. PRIMARY FUNDING SOURCE The Health Research Council of New Zealand.
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Affiliation(s)
- Vanessa Selak
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., S.W.)
| | - Rod Jackson
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., S.W.)
| | - Katrina Poppe
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., S.W.)
| | - Billy Wu
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., S.W.)
| | - Matire Harwood
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., S.W.)
| | - Corina Grey
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., S.W.)
| | - Romana Pylypchuk
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., S.W.)
| | - Suneela Mehta
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., S.W.)
| | - Andrew Kerr
- University of Auckland and Middlemore Hospital, Auckland, New Zealand (A.K.)
| | - Sue Wells
- University of Auckland, Auckland, New Zealand (V.S., R.J., K.P., B.W., M.H., C.G., R.P., S.M., S.W.)
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Roses SM, Christianson T, Dombrowski K. Acute Respiratory Distress Syndrome Associated With Clopidogrel in a Young Male Patient. Front Med (Lausanne) 2019; 6:38. [PMID: 30906739 PMCID: PMC6419477 DOI: 10.3389/fmed.2019.00038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 02/11/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Clopidogrel is a commonly prescribed antiplatelet drug in patients with stents and histories of arterial vascular disease. It generally has a favorable side effect profile with increasing bleeding risk as the main concern as an adverse event. Case Presentation: A 19-year-old previously healthy male presented to the neurological intensive care unit with a subarachnoid hemorrhage requiring a flow diverting stent to secure the aneurysm. The patient was stable for 2 weeks and had no changes to management or medication within 48 h of antiplatelet therapy. Within hours of first-time dosing of clopidogrel, the patient experienced a syncopal episode and dyspnea. He was difficult to arouse and using accessory muscles to breath with an otherwise benign exam. He was hypoxic with bibasilar crackles requiring bilevel positive airway pressure (BiPap). Imaging showed bilateral pulmonary edema and he was diagnosed with moderate acute respiratory distress syndrome (ARDS). Infectious, cardiogenic, and contrast-induced ARDS were ruled out. Upon cessation of clopidogrel, his pulmonary function and mental status improved. Conclusions: This is the first reported case of a young and immunocompetent patient's severe pulmonary edema leading to acute respiratory distress syndrome in association with first- time dosing of clopidogrel.
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Affiliation(s)
| | | | - Keith Dombrowski
- Department of Neurology, Duke University, Durham, NC, United States
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56
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Shenvi CL, Platts-Mills TF. Managing the Elderly Emergency Department Patient. Ann Emerg Med 2019; 73:302-307. [DOI: 10.1016/j.annemergmed.2018.08.426] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Indexed: 01/06/2023]
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Ge L, Ouyang X, Ban C, Yu H, Wu Q, Wu H, Liang J. Cerebral microbleeds in patients with ischemic cerebrovascular disease taking aspirin or clopidogrel. Medicine (Baltimore) 2019; 98:e14685. [PMID: 30817601 PMCID: PMC6831427 DOI: 10.1097/md.0000000000014685] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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
Cerebral microbleeds (CMBs) may be markers of intracerebral bleeding risk in patients receiving antithrombotic drugs. This study aimed to analyze CMBs and white matter hyperintensities (WMHs) in patients taking aspirin or clopidogrel.This retrospective study included patients with ischemic cardiovascular disease administered 75 mg/day aspirin (n = 150) or clopidogrel (n = 150, matched for age and gender) for >1 year (Affiliated Hospital of Inner Mongolia Medical University, China, from July, 2010 to July, 2015). Patients underwent T2-weighted imaging, T1-weighted imaging, diffusion-weighted imaging (DWI) and enhanced T2*-weighted angiography (ESWAN) imaging (3.0-Tesla scanner). Baseline vascular risk factors for CMBs and macroscopic bleeding (MB) were evaluated using univariate and multivariate analyses.The aspirin and clopidogrel groups did not differ significantly in baseline characteristics or prevalences of CMBs or MB. The odds of MB were higher in patients with CMBs than in patients without CMBs in both the aspirin (odds ratio, 95% confidence interval: 4.09, 1.93-8.68; P < .001) and clopidogrel (6.42, 2.83-14.57; P < .001) groups. The odds of WMHs were also higher in patients with CMBs in both the aspirin (3.28, 1.60-6.71; P = .001) and clopidogrel (4.09, 1.91-8.75; P < .001) groups. Patients receiving treatment for >5 years showed elevated risk of CMBs in the aspirin (0.17; 0.09-0.36; P < .001) and clopidogrel (0.15, 0.07-0.33; P < .001) groups as well as higher odds of MB in the aspirin (0.34, 0.16-0.71; P = .004) and clopidogrel (0.37, 0.17-0.80; P = .010) groups.The WMHs and MB were associated with CMBs in patients taking aspirin or clopidogrel for >1 year, and long-term use increased the risks of CMB and bleeding.
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Affiliation(s)
| | - Xuehui Ouyang
- Department of Magnetic Resonance, Inner Mongolia Autonomous Region People's Hospital, Hohhot, China
| | - Chao Ban
- Department of Magnetic Resonance
| | | | - Qiong Wu
- Department of Magnetic Resonance
| | - Hui Wu
- Department of Magnetic Resonance
| | - Junguo Liang
- Department of Thoracic Surgery, the Affiliated Hospital of Inner Mongolia Medical University
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58
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Handoyo V, Pertiwi GAR, Prabawa IPY, Manuaba IBAP, Bhargah A, Budiana IPG. Management of ST-elevation myocardial infarction in the setting of anterior epistaxis: focused on antiplatelet and antithrombotic therapies. Int Med Case Rep J 2019; 12:33-38. [PMID: 30804689 PMCID: PMC6371948 DOI: 10.2147/imcrj.s189370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Antiplatelet and antithrombotic therapies are part of standard core treatments for ST-elevation myocardial infarction (STEMI). Effectiveness of these therapies, however, is often offset by the resultant hemorrhagic complications, which in turn possess significantly worse prognosis. Acute myocardial infarction (AMI) accompanied by acute bleeding, such as anterior epistaxis, is common and arise potential dilemma in deciding appropriate management as a standard medical strategy that may put patients in immediate threat as it increases the ongoing bleeding event. Case description A 46-year-old male patient with late-onset infero-posterolateral STEMI and anterior epistaxis was admitted to the emergency ward of Mangusada Regional Hospital. The patient had long-standing history of uncontrolled hypertension and previously been treated with tranexamic acid to stop nasal bleeding. Neither percutaneous coronary intervention nor fibrinolysis was performed due to financial issue, and patient only managed conservatively with adequate medications including dual antiplatelet with aspirin and clopidogrel and anticoagulant with unfractionated heparin. No active bleeding was observed during in-hospital treatment and the patient was then discharged after 8 days with complete improvement of symptoms and ST-segment elevation resolution. Conclusion This case report highlights the treatment strategy for patients with myocardial infarction in the setting of acute bleeding focusing on antiplatelet and anticoagulant therapies. We also discussed the potential association between tranexamic acid and arterial thromboembolic complication resulting in AMI.
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Affiliation(s)
- Victoria Handoyo
- Department of Cardiovascular Medicine, Mangusada Regional Hospital, Badung, Bali, Indonesia,
| | - Gusti Ayu Riska Pertiwi
- Department of Cardiovascular Medicine, Mangusada Regional Hospital, Badung, Bali, Indonesia,
| | - I Putu Yuda Prabawa
- Master Program in Biomedicine, Faculty of Medicine, Udayana University, Bali, Indonesia.,Department of Clinical Pathology, Faculty of Medicine, Udayana University, Sanglah General Hospital, Bali, Indonesia
| | - Ida Bagus Amertha Putra Manuaba
- International Program of Medicine, Taipei Medical University, Taipei, Taiwan.,Medical and Health Education, Faculty of Medicine, Udayana University, Bali, Indonesia
| | - Agha Bhargah
- Faculty of Medicine, Udayana University, Bali, Indonesia
| | - I Putu Gede Budiana
- Department of Cardiovascular Medicine, Mangusada Regional Hospital, Badung, Bali, Indonesia,
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Jabri MA, Marzouki L, Sebai H. Ethnobotanical, phytochemical and therapeutic effects of Myrtus communis L. berries seeds on gastrointestinal tract diseases: a review. Arch Physiol Biochem 2018; 124:390-396. [PMID: 29303617 DOI: 10.1080/13813455.2017.1423504] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Medicinal plants have always had an important place in the therapeutic arsenal of humanity and particularly in the treatment of gastrointestinal tract diseases. Myrtus communis L., known as common myrtle, is native to Southern Europe, North Africa, and Western Asia. The different parts of this plant are used as antiinflammatory, antiulcer, antidiabetic, urinary antiseptic, and to treat the respiratory and digestive systems diseases. For the first time, an exhaustive bibliographic research of the seeds of myrtle berries has been carried out. As a result, it has been found that this plant is very rich in biologically active compounds such as phospholipids, polyunsaturated fatty acids, and phenolic compounds. This has made it effective in the treatment of digestive diseases. In order to emphasize the importance of myrtle berries seeds, this review has been established by discussing its botanical, morphological, phytochemical, ethnomedicinal studies as well as its effect on digestive tract diseases.
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Affiliation(s)
- Mohamed-Amine Jabri
- a Laboratoire de Physiologie Fonctionnelle et Valorisation des Bio-Ressources - Institut Supérieur de Biotechnologie de Béja , Université de Jendouba , Béja , Tunisia
| | - Lamjed Marzouki
- a Laboratoire de Physiologie Fonctionnelle et Valorisation des Bio-Ressources - Institut Supérieur de Biotechnologie de Béja , Université de Jendouba , Béja , Tunisia
| | - Hichem Sebai
- a Laboratoire de Physiologie Fonctionnelle et Valorisation des Bio-Ressources - Institut Supérieur de Biotechnologie de Béja , Université de Jendouba , Béja , Tunisia
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60
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Larson EA, German DM, Shatzel J, DeLoughery TG. Anticoagulation in the cardiac patient: A concise review. Eur J Haematol 2018; 102:3-19. [PMID: 30203452 DOI: 10.1111/ejh.13171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 08/28/2018] [Accepted: 08/30/2018] [Indexed: 01/12/2023]
Abstract
Anticoagulation has multiple roles in the treatment of cardiovascular disease, including in management of acute myocardial infarction, during percutaneous coronary intervention, as stroke prophylaxis in patients with atrial arrhythmias, and in patients with mechanical heart valves. Clinical anticoagulation choices in the aforementioned diseases vary widely, due to conflicting data to support established agents and the rapid evolution of evidence-based practice that parallels more widespread use of novel oral anticoagulants. This review concisely summarizes evidence-based guidelines for anticoagulant use in cardiovascular disease, and highlights new data specific to direct oral anticoagulants.
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Affiliation(s)
- Elise A Larson
- The Division of Hematology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
| | - David M German
- The Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Joseph Shatzel
- The Division of Hematology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
| | - Thomas G DeLoughery
- The Division of Hematology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
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61
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AlMutairi H, O'Dwyer M, McCarron M, McCallion P, Henman MC. The use of proton pump inhibitors among older adults with intellectual disability: A cross sectional observational study. Saudi Pharm J 2018; 26:1012-1021. [PMID: 30416357 PMCID: PMC6218847 DOI: 10.1016/j.jsps.2018.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 05/21/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Older people with Intellectual Disability (ID) have a high prevalence of gastrointestinal conditions such as Gastro-Oesophageal Reflux Disease (GORD). However, despite this, information about treatment, in particular the use of Proton Pump Inhibitors (PPIs), in this population is sparse and limited. OBJECTIVE To investigate the prevalence and pattern of PPI use among older people with ID. METHOD Data on PPI use and key demographics was analysed from Wave 2 (2013/2014) of IDS-TILDA, a nationally representative longitudinal study of 677 participants aged 40 years and above in Ireland. Descriptive statistics, bivariate analyses and binary logistic regression were carried out. RESULTS Just over a quarter, 27.9% (n = 189), of participants reported use of PPIs, and 53.4% (n = 101) were female. The largest proportion of PPI users (53.4%) were aged between 50 and 64 yrs. Most of the PPIs were used in maximum doses (66.7%). However only 43.9% of PPI users had an indication for PPI use (GORD, stomach ulcer or/and an NSAID use), and further 13.2% were also taking an antiplatelet agent. Use among those in residential care homes (54.3%) was much higher than for those living independently or with family (7%). PPI use among those who have severe/profound ID was 25% higher than those with mild ID. Information about the length of PPI use was missing for 31.2%, but of those with data, just over half recorded using the PPIs for more than a year. Apart from an indication, the factors associated with PPI use were older ages (≥50 years), severe/profound level of ID. CONCLUSION PPI use among older people with intellectual disability is prevalent and frequently long term, often without a clear indication. PPI use especially among those with severe/profound ID and those who live in residential care homes, could predispose these individuals to additional comorbidities and in order to avoid inappropriate long term of use regular review is required.
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Affiliation(s)
- Hadiah AlMutairi
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Máire O'Dwyer
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Mary McCarron
- Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland
| | | | - Martin C. Henman
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
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62
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Bali SK, Madaiah H, Dharmapalan J, Janarthanam S, Tarannum F. Effect of systemic long-term, low-dose aspirin on periodontal status and soluble CD14 in gingival crevicular fluid: a case-control study. JOURNAL OF INVESTIGATIVE AND CLINICAL DENTISTRY 2018; 9:e12353. [PMID: 30062853 DOI: 10.1111/jicd.12353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/18/2018] [Indexed: 06/08/2023]
Abstract
AIM In the present study, we evaluated the effect of systemic long-term, low-dose aspirin on the periodontal status and gingival crevicular fluid (GCF) concentrations of aspirin-triggered lipoxins (ATL) and soluble CD14 (sCD14). METHODS The study group consisted of 45 patients who were on long-term, low-dose aspirin therapy, and the control group included patients not on aspirin therapy. Mean bleeding index, plaque index (PI), probing depth (PD), and clinical attachment loss (CAL) were recorded. GCF samples were analyzed for concentrations of ATL, and sCD14 using enzyme-linked immunosorbent assay method. RESULTS The means of PI, PD, and CAL were higher for the control group compared to the study group. The mean concentration of ATL was significantly higher for the study group (49.13 ± 37.39 ng/mL). The mean concentration of sCD14 was higher in the control group (5.75 ± 3.91 μg/mL). There was a negative correlation in the study group between concentrations of ATL with PD (r = -0.54) and CAL (r = -0.123). There was a positive correlation between sCD14 and CAL (r = 0.047) in the study group. A negative correlation was also observed between concentrations of sCD14 and ATL (r = -0.134) in the study group. CONCLUSION The results indicate better periodontal status among long-term aspirin users compared to non-aspirin users.
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Affiliation(s)
- Sumeet K Bali
- Department of Periodontics, M.R. Ambedkar Dental College and Hospital, Bangalore, Karnataka, India
| | - Hemalata Madaiah
- Department of Periodontics, M.R. Ambedkar Dental College and Hospital, Bangalore, Karnataka, India
| | - Jayanthi Dharmapalan
- Department of Periodontics, M.R. Ambedkar Dental College and Hospital, Bangalore, Karnataka, India
| | - Sanghamitra Janarthanam
- Department of Periodontics, M.R. Ambedkar Dental College and Hospital, Bangalore, Karnataka, India
| | - Fouzia Tarannum
- Department of Periodontics, M.R. Ambedkar Dental College and Hospital, Bangalore, Karnataka, India
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63
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Barlas RS, Loke YK, Mamas MA, Bettencourt-Silva JH, Ford I, Clark AB, Bowles KM, Metcalf AK, Potter JF, Myint PK. Effect of Antiplatelet Therapy (Aspirin + Dipyridamole Versus Clopidogrel) on Mortality Outcome in Ischemic Stroke. Am J Cardiol 2018; 122:1085-1090. [PMID: 30072125 DOI: 10.1016/j.amjcard.2018.05.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 05/23/2018] [Accepted: 05/23/2018] [Indexed: 10/28/2022]
Abstract
The optimal regimen of antiplatelet therapy for secondary prevention in noncardioembolic ischemic stroke remains controversial. We aimed to determine which regimen was associated with the greatest reduction in adverse outcomes. We analysed prospectively collected data from the Norfolk and Norwich University Hospital Stroke Register. The sample population consisted of 3,572 participants (mean age 74.96 ± 12.67) with ischemic stroke, who were consecutively admitted between 2003 and 2015. Patients were placed on one of three antiplatelet regimens at hospital discharge; aspirin monotherapy, aspirin plus dipyridamole and clopidogrel. Clopidogrel and aspirin plus dipyridamole were compared to aspirin. A direct comparison between clopidogrel and aspirin plus dipyridamole was also performed. Outcomes included all-cause mortality and a combined end point of all-cause mortality and incidence of major adverse cardiac events (stroke or myocardial infarction). Cox-regression models adjusted for potential confounders at the following time periods after discharge; 0 to 90 days, 91 to 365 days, and 1 to 3 years. Aspirin plus dipyridamole was associated with a lower risk of mortality at 0 to 90 days; hazard ratio (HR) 0.62 (0.43 to 0.91). Clopidogrel was associated with a lower risk of mortality at 1 to 3 years; HR of 0.39 (0.26 to 0.60). Similar HRs were observed for the corresponding time points in the composite outcome. In conclusion, patients with noncardioembolic stroke may gain maximum benefits from aspirin plus dipyridamole initially (≤1 year) with a subsequent switch to clopidogrel, with regard to mortality and major adverse cardiac eventsoutcomes.
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Selak V, Kerr A, Poppe K, Wu B, Harwood M, Grey C, Jackson R, Wells S. Annual Risk of Major Bleeding Among Persons Without Cardiovascular Disease Not Receiving Antiplatelet Therapy. JAMA 2018; 319:2507-2520. [PMID: 29946729 PMCID: PMC6583689 DOI: 10.1001/jama.2018.8194] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE A decision to initiate aspirin therapy for primary prevention of cardiovascular disease (CVD) requires consideration of both treatment benefits and harms. The most significant harm associated with aspirin is major bleeding, yet there is a paucity of data on bleeding risk in suitable community populations. OBJECTIVE To determine the risk of major bleeding among people without CVD who are not receiving antiplatelet therapy. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study of 359 166 individuals aged 30 to 79 years receiving primary care in New Zealand who had CVD risk assessment between 2002 and 2015. Participants were censored at the earliest date on which they had a first major bleeding event, died, or met any baseline cohort exclusion criteria or the study end date of December 31, 2015. Analyses were repeated after excluding people with medical conditions associated with increased bleeding risk (non-high-risk cohort; n=305 057) and after further excluding people receiving other medications associated with increased bleeding risk (nonmedication cohort; n=240 254). EXPOSURES Sex and age group in 10-year bands from 30 to 79 years. MAIN OUTCOMES AND MEASURES Risk of a major bleeding event (hospitalization or death associated with bleeding); nonfatal gastrointestinal tract bleeding; and gastrointestinal tract bleeding-related case fatality. RESULTS Mean participant age was 54 years (SD, 10 years), 44% were women, and 57% were European. Among the 359 166 individuals in the baseline cohort, 3976 had a major bleeding event during 1 281 896 person-years of follow-up. Most had gastrointestinal (GI) bleeding (n=2910 [73%]). There were 274 fatal bleeding events (7%), of which 153 were intracerebral. The risk of a nonfatal GI bleeding event per 1000 person-years was 2.19 (95% CI, 2.11-2.27), 1.77 (95% CI, 1.69-1.85) and 1.61 (95% CI, 1.52-1.69), in the baseline, non-high-risk, and nonmedication cohorts, respectively. Case fatality associated with GI bleeding was 3.4% (95% CI, 2.2%-4.1%), 4.0% (95% CI, 3.2%-5.1%), and 4.6% (95% CI, 3.6%-6.0%) in the baseline, non-high-risk, and nonmedication cohorts, respectively. CONCLUSIONS AND RELEVANCE In a population not receiving antiplatelet therapy, the annual risk of major bleeding events and nonfatal major bleeding was estimated. These findings could inform population-level guidelines for primary prevention of CVD.
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Affiliation(s)
- Vanessa Selak
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Andrew Kerr
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
- Middlemore Hospital, Auckland, New Zealand
| | - Katrina Poppe
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Billy Wu
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Matire Harwood
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
- Te Kupenga Hauora Māori, University of Auckland, Auckland, New Zealand
| | - Corina Grey
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Rod Jackson
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Sue Wells
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
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Ebi M, Inoue S, Sugiyama T, Yamamoto K, Adachi K, Yoshimine T, Yamaguchi Y, Tamura Y, Izawa S, Hijikata Y, Funaki Y, Ogasawara N, Sasaki M, Kasugai K. A Small Bowel Ulcer due to Clopidogrel with Cytomegalovirus Enteritis Diagnosed by Capsule and Double-Balloon Endoscopy. Case Rep Gastroenterol 2018; 12:303-310. [PMID: 30022920 PMCID: PMC6047549 DOI: 10.1159/000490096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/07/2018] [Indexed: 12/17/2022] Open
Abstract
We report the first case of small bowel ulcers due to clopidogrel in a 74-year-old man. He presented with diarrhea and melena after having been taking low-dose aspirin (LDA) and clopidogrel. There was no evidence of bleeding in the stomach, duodenum, or colon. Capsule endoscopy showed multiple ulcers and erosions in the small intestine. Double-balloon endoscopy revealed multiple ulcers throughout the ileum. Examination of the biopsy specimen showed cytomegalovirus infection. His LDA was discontinued and he was prescribed ganciclovir. However, the small bowel ulcers were aggravated. Therefore, clopidogrel was discontinued. The small bowel ulcers subsequently healed completely, forming scars.
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Affiliation(s)
- Masahide Ebi
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Satoshi Inoue
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Tomoya Sugiyama
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kazuhiro Yamamoto
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kazunori Adachi
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Takashi Yoshimine
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Yoshiharu Yamaguchi
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Yasuhiro Tamura
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Shinya Izawa
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Yasutaka Hijikata
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Yasushi Funaki
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Naotaka Ogasawara
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Makoto Sasaki
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kunio Kasugai
- Department of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
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Ueki N, Futagami S, Akimoto T, Maruki Y, Yamawaki H, Kodaka Y, Nagoya H, Shindo T, Kusunoki M, Kawagoe T, Gudis K, Miyake K, Iwakiri K. Effect of Antithrombotic Therapy and Long Endoscopic Submucosal Dissection Procedure Time on Early and Delayed Postoperative Bleeding. Digestion 2018; 96:21-28. [PMID: 28609771 DOI: 10.1159/000475924] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 04/21/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recent updated guidelines of the Japanese Society of Gastroenterology recommend the use of a single dose of antiplatelet agents in patients undergoing endoscopic submucosal dissection (ESD). However, the postoperative bleeding risk after gastric ESD associated with the continuation or interruption of antithrombotic therapy remains controversial. We aimed to evaluate whether certain factors including interrupted antithrombotic therapy could affect early and delayed post-ESD bleeding risk. METHODS Three hundred sixty-four patients with gastric neoplasms were treated with ESD at our hospital between October 2005 and December 2012. Seventy-four patients with interrupted antithrombotic therapy were undertaken with ESD. Early and delayed postoperative bleeding patterns were estimated. Various clinical characteristics such as gender, age, tumor location, tumor size, ESD procedure time, platelet count, and comorbidity were evaluated. RESULTS There was a significant difference (p = 0.042) in the ESD procedure time between the patients with postoperative bleeding and those without it. There was no significant difference in postoperative bleeding between the patients on antithrombotic therapy and not on it. Moreover, interrupted antithrombotic therapy and platelet count were significantly (p = 0.0461 and p = 0.0059, respectively) associated with early postoperative bleeding in multivariate analysis. In addition, in univariate analysis, ESD procedure time was significantly (p = 0.041) associated with delayed postoperative bleeding. CONCLUSIONS Antithrombotic therapy and prolonged ESD procedure time were significantly associated with early and delayed postoperative bleeding, respectively.
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Affiliation(s)
- Nobue Ueki
- Department of Internal Medicine, Division of Gastroenterology, Nippon Medical School, Tokyo, Japan
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Abstract
Non-variceal upper gastrointestinal bleeding continues to be an important cause of morbidity and mortality. The most common causes include peptic ulcer disease, Mallory-Weiss syndrome, erosive gastritis, duodenitis, esophagitis, malignancy, angiodysplasias and Dieulafoy's lesion. Initial assessment and early aggressive resuscitation significantly improves outcomes. Upper gastrointestinal endoscopy continues to be the gold standard for diagnosis and treatment. We present a comprehensive review of literature for the evaluation and management of non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Ronald Samuel
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551.
| | - Obada Tayyem
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Praveen Guturu
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551
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Al-Shahi Salman R, Dennis MS, Murray GD, Innes K, Drever J, Dinsmore L, Williams C, White PM, Whiteley WN, Sandercock PAG, Sudlow CLM, Newby DE, Sprigg N, Werring DJ. The REstart or STop Antithrombotics Randomised Trial (RESTART) after stroke due to intracerebral haemorrhage: study protocol for a randomised controlled trial. Trials 2018; 19:162. [PMID: 29506580 PMCID: PMC5838871 DOI: 10.1186/s13063-018-2542-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/12/2018] [Indexed: 01/08/2023] Open
Abstract
Background For adults surviving stroke due to spontaneous (non-traumatic) intracerebral haemorrhage (ICH) who had taken an antithrombotic (i.e. anticoagulant or antiplatelet) drug for the prevention of vaso-occlusive disease before the ICH, it is unclear whether starting antiplatelet drugs results in an increase in the risk of recurrent ICH or a beneficial net reduction of all serious vascular events compared to avoiding antiplatelet drugs. Methods/design The REstart or STop Antithrombotics Randomised Trial (RESTART) is an investigator-led, randomised, open, assessor-blind, parallel-group, randomised trial comparing starting versus avoiding antiplatelet drugs for adults surviving antithrombotic-associated ICH at 122 hospital sites in the United Kingdom. RESTART uses a central, web-based randomisation system using a minimisation algorithm, with 1:1 treatment allocation to which central research staff are masked. Central follow-up includes annual postal or telephone questionnaires to participants and their general (family) practitioners, with local provision of information about adverse events and outcome events. The primary outcome is recurrent symptomatic ICH. The secondary outcomes are: symptomatic haemorrhagic events; symptomatic vaso-occlusive events; symptomatic stroke of uncertain type; other fatal events; modified Rankin Scale score; adherence to antiplatelet drug(s). The magnetic resonance imaging (MRI) sub-study involves the conduct of brain MRI according to a standardised imaging protocol before randomisation to investigate heterogeneity of treatment effect according to the presence of brain microbleeds. Recruitment began on 22 May 2013. The target sample size is at least 720 participants in the main trial (at least 550 in the MRI sub-study). Discussion Final results of RESTART will be analysed and disseminated in 2019. Trial registration ISRCTN71907627 (www.isrctn.com/ISRCTN71907627). Prospectively registered on 25 April 2013. Electronic supplementary material The online version of this article (10.1186/s13063-018-2542-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
| | - Martin S Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Gordon D Murray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Karen Innes
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Jonathan Drever
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Lynn Dinsmore
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Carol Williams
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Philip M White
- Institute of Neuroscience and Newcastle University Institute for Ageing, Newcastle-upon-Tyne, UK
| | - William N Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Peter A G Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Cathie L M Sudlow
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Nikola Sprigg
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - David J Werring
- Institute of Neurology, University College London, London, UK
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Platelet Count Does Not Predict Bleeding in Cirrhotic Patients: Results from the PRO-LIVER Study. Am J Gastroenterol 2018; 113:368-375. [PMID: 29257146 DOI: 10.1038/ajg.2017.457] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 11/06/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Thrombocytopenia is a hallmark for patients with cirrhosis and it is perceived as a risk factor for bleeding events. However, the relationship between platelet count and bleeding is still unclear. METHODS We investigated the relationship between platelet count and major or clinical relevant nonmajor bleedings during a follow-up of ∼4 years. RESULTS A total of 280 cirrhotic patients with different degrees of liver disease (67% males; age 64±37 years; 47% Child-Pugh B and C) were followed up for a median of 1,129 (interquartile range: 800-1,498) days yielding 953.12 patient-year of observation. The annual rate of any significant bleeding was 5.45%/year (3.57%/year and 1.89%/year for major and minor bleeding, respectively). Fifty-two (18.6%) patients experienced a major (n=34) or minor (n=18) bleeding event, predominantly from gastrointestinal origin. Platelet counts progressively decreased with the worsening of liver disease and were similar in patients with or without major or minor bleeding: a platelet count ≤50 × 103/μl was detected in 3 (6%) patients with and in 20 (9%) patients without any bleeding event. Conversely, prothrombin time-international normalized ratio was slightly higher in patients with overall or major bleeding. On Cox proportional hazard analysis, only a previous gastrointestinal bleeding (hazard ratio (HR): 1.96; 95% confidence interval: 1.11-3.47; P=0.020) and encephalopathy (HR: 2.05; 95% confidence interval: 1.16-3.62; P=0.013) independently predicted overall bleeding events. CONCLUSIONS Platelet count does not predict unprovoked major or minor bleeding in cirrhotic patients.
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70
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Khan AA, Lip GYH. Resumption of antiplatelet therapy in patients with primary intracranial haemorrhage: Balancing benefits and risks. J Neurol Sci 2018; 384:139-140. [PMID: 29221666 DOI: 10.1016/j.jns.2017.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 11/29/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Ahsan A Khan
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.
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71
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Aspirin use and endometrial cancer risk and survival. Gynecol Oncol 2017; 148:222-232. [PMID: 29132875 DOI: 10.1016/j.ygyno.2017.10.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/20/2017] [Accepted: 10/23/2017] [Indexed: 02/06/2023]
Abstract
The role of acetylsalicylic acid (aspirin) as a chemo-preventive and adjuvant therapeutic agent for cancers is generating attention. Mounting evidence indicates that aspirin reduces the incidence and mortality of certain obesity-related cancers, particularly colorectal cancer. In endometrial cancer, previous studies examining the effect of aspirin remain inconsistent as to the reduction in the risk of endometrial cancer. While some evidence indicates protective effects in obese women, other studies have showed a potential deleterious effect of these medications on endometrial cancer outcomes. However, exposure measurement across studies has been inconsistent in recording dose, duration, and frequency of use; thus making comparisons difficult. In this article, we review the evidence for the association between endometrial cancer and obesity, the pharmacological differences between regular- and low-dose aspirin, as well as the potential anti-tumor mechanism of aspirin, supporting a possible therapeutic effect on endometrial cancer. A proposed mechanism behind decreased cancer mortality in endometrial cancer may be a result of inhibition of metastasis via platelet inactivation and possible prostaglandin E2 suppression by aspirin. Additionally, aspirin use in particular may have a secondary benefit for obesity-related comorbidities including cardiovascular disease in women with endometrial cancer. Although aspirin-related bleeding needs to be considered as a possible adverse effect, the benefits of aspirin therapy may exceed the potential risk in women with endometrial cancer. The current evidence reviewed herein has resulted in conflicting findings regarding the potential effect on endometrial cancer outcomes, thus indicating that future studies in this area are needed to resolve the effects of aspirin on endometrial cancer survival, particularly to identify specific populations that might benefit from aspirin use.
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72
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Aspirin Use in Secondary Cardiovascular Protection and the Development of Aspirin-Associated Erosions and Ulcers. J Cardiovasc Pharmacol 2017; 68:121-6. [PMID: 27002280 DOI: 10.1097/fjc.0000000000000387] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Aspirin for secondary cardiovascular disease prevention is well established, but treatment discontinuation, often because of gastrointestinal mucosal injury or symptoms, can lead to increased risk for cardiovascular events. Proton pump inhibitor therapy is recommended for aspirin-treated patients at gastrointestinal risk. PA32540 [enteric-coated aspirin (EC-ASA) 325 mg + immediate-release omeprazole 40 mg] was compared with EC-ASA 325 mg alone once daily for 6 months in 2 duplicate, randomized double-blind trials in gastrointestinal-risk patients taking aspirin for ≥3 months for secondary prevention. In this post hoc analysis, we determined the prevalence of endoscopic upper gastrointestinal ulcers at screening and whether baseline endoscopic gastric erosions impacted subsequent ulcer development. At the screening endoscopy, 6% of subjects had upper gastrointestinal ulcers (not eligible for randomization) and 40% had gastric erosions. Conditional logistic regression modeling showed that baseline gastric erosions are significantly associated with endoscopic gastric ulcer development (OR = 2.12, 95% confidence interval, 1.26-3.57). In subjects with baseline gastric erosion, 4.2% of PA32540-treated versus 13.0% of EC-ASA-treated subjects (P = 0.001) subsequently developed endoscopic gastric ulcers. These data suggest that gastric injury predisposes to gastric ulcer development when taking EC-ASA, and exposure to immediate-release omeprazole in the presence of aspirin therapy significantly reduces the likelihood of progressing to gastric ulcers.
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73
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Cea Soriano L, Gaist D, Soriano-Gabarró M, Bromley S, García Rodríguez LA. Low-dose aspirin and risk of intracranial bleeds. Neurology 2017; 89:2280-2287. [DOI: 10.1212/wnl.0000000000004694] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 09/07/2017] [Indexed: 11/15/2022] Open
Abstract
Objective:To quantify the risk of intracranial bleeds (ICBs) associated with new use of prophylactic low-dose aspirin using a population-based primary care database in the United Kingdom.Methods:A cohort of new users of low-dose aspirin (75–300 mg; n = 199,079) aged 40–84 years and a 1:1 matched cohort of nonusers of low-dose aspirin at baseline were followed (maximum 14 years, median 5.4 years) to identify incident cases of ICB, with validation by manual review of patient records or linkage to hospitalization data. Using 10,000 frequency-matched controls, adjusted rate ratios (RRs) with 95% confidence intervals (CIs) were calculated for current low-dose aspirin use (0–7 days before the index date [ICB date for cases, random date for controls]); reference group was never used.Results:There were 1,611 cases of ICB (n = 743 for intracerebral hemorrhage [ICH], n = 483 for subdural hematoma [SDH], and n = 385 for subarachnoid hemorrhage [SAH]). RRs (95% CI) were 0.98 (0.84–1.13) for all ICB, 0.98 (0.80–1.20) for ICH, 1.23 (0.95–1.59) for SDH, and 0.77 (0.58–1.01) for SAH. No duration of use or dose–response association was apparent. RRs (95% CI) for ≥1 year of low-dose aspirin use were 0.90 (0.72–1.13) for ICH, 1.20 (0.91–1.57) for SDH, and 0.69 (0.50–0.94) for SAH.Conclusion:Low-dose aspirin is not associated with an increased risk of any type of ICB and is associated with a significantly decreased risk of SAH when used for ≥1 year.
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Abstract
Significant advances in our understanding of transient ischemic attack (TIA) have taken place since it was first recognized as a major risk factor for stroke during the late 1950's. Recently, numerous studies have consistently shown that patients who have experienced a TIA constitute a heterogeneous population, with multiple causative factors as well as an average 5–10% risk of suffering a stroke during the 30 days that follow the index event. These two attributes have driven the most important changes in the management of TIA patients over the last decade, with particular attention paid to effective stroke risk stratification, efficient and comprehensive diagnostic assessment, and a sound therapeutic approach, destined to reduce the risk of subsequent ischemic stroke. This review is an outline of these changes, including a discussion of their advantages and disadvantages, and references to how new trends are likely to influence the future care of these patients.
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Affiliation(s)
- Camilo R Gomez
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| | - Michael J Schneck
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| | - Jose Biller
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
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Lemmens R, Al-Shahi Salman R. Individualized risk prediction of major bleeding in secondary stroke prevention: Are we there yet? Neurology 2017; 89:882-883. [PMID: 28768843 DOI: 10.1212/wnl.0000000000004303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Robin Lemmens
- From the Department of Neurosciences (R.L.), Experimental Neurology and Leuven Institute for Neuroscience and Disease (LIND), KU Leuven-University of Leuven; Laboratory of Neurobiology (R.L.), Center for Brain & Disease Research, VIB, Leuven; Department of Neurology (R.L.), University Hospitals Leuven, Belgium; and Centre for Clinical Brain Sciences (R.A.S.), University of Edinburgh, UK.
| | - Rustam Al-Shahi Salman
- From the Department of Neurosciences (R.L.), Experimental Neurology and Leuven Institute for Neuroscience and Disease (LIND), KU Leuven-University of Leuven; Laboratory of Neurobiology (R.L.), Center for Brain & Disease Research, VIB, Leuven; Department of Neurology (R.L.), University Hospitals Leuven, Belgium; and Centre for Clinical Brain Sciences (R.A.S.), University of Edinburgh, UK
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Li JJ, Wu XY, Chen JL, Chen GR, Xu J, Gu Y, Song HP. Antiplatelet drug ticagrelor delays gastric ulcer healing in rats. Exp Ther Med 2017; 14:3774-3779. [PMID: 29042978 DOI: 10.3892/etm.2017.4955] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 03/24/2017] [Indexed: 02/07/2023] Open
Abstract
Adenosine diphosphate P2Y12 receptor antagonist clopidogrel is not sufficiently safe for the gastric mucosa in patients with high risk of peptic ulcer, since it may impair healing of gastric erosions. However, the safety of the novel P2Y12 receptor antagonist ticagrelor in the gastric mucosa has not been elucidated to date. The present study aimed to examine whether ticagrelor delays gastric ulcer healing and to elucidate the involved mechanisms. Gastric kissing ulcers were produced in rats by luminal application of acetic acid solution, and ticagrelor was administered at dose of 10 or 20 mg/kg/day orally for 7 days. On day 8 after ulcer induction, the ulcer size, mucosal epithelial cell proliferation of the ulcer margin, expression levels of epidermal growth factor (EGF) and vascular endothelial growth factor (VEGF), and signal transduction pathways for cell proliferation and angiogenesis were measured and compared between the ticagrelor-treated and untreated model groups. The results revealed that the ulcer size was significantly greater in the ticagrelor-treated group compared with the model group, while the mucosal epithelial cell proliferation of the ulcer margin was significantly decreased in the ticagrelor-treated group. In addition, ticagrelor significantly decreased the ulcer-stimulated expression levels of EGF, VEGF, phosphorylated extracellular signal-regulated kinase (ERK), phosphorylated P38 mitogen-activated protein kinase and nuclear factor-κB P65 at the ulcer margin (P<0.05). These findings suggested that ticagrelor delayed gastric ulcer healing. Furthermore, the possible mechanisms underlying the effect of ticagrelor were associated with its functions of attenuating the expression levels of VEGF and EGF, as well as suppressing the phosphorylation activation of ERK1/2, P38 and nuclear factor-κB P65. Finally, the gastric epithelial cell proliferation and angiogenesis were also inhibited.
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Affiliation(s)
- Jing-Jing Li
- Department of Pharmacy, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, P.R. China
| | - Xin-Ying Wu
- Department of Cardiology, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, P.R. China
| | - Jing-Lou Chen
- Department of Pharmacy, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, P.R. China
| | - Guan-Rong Chen
- Department of Pharmacy, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, P.R. China
| | - Jun Xu
- Department of Pharmacy, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, P.R. China
| | - Ye Gu
- Department of Cardiology, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, P.R. China
| | - Hong-Ping Song
- Department of Pharmacy, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, P.R. China
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Hilkens NA, Algra A, Diener HC, Reitsma JB, Bath PM, Csiba L, Hacke W, Kappelle LJ, Koudstaal PJ, Leys D, Mas JL, Sacco RL, Amarenco P, Sissani L, Greving JP. Predicting major bleeding in patients with noncardioembolic stroke on antiplatelets: S 2TOP-BLEED. Neurology 2017; 89:936-943. [PMID: 28768848 DOI: 10.1212/wnl.0000000000004289] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 05/01/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To develop and externally validate a prediction model for major bleeding in patients with a TIA or ischemic stroke on antiplatelet agents. METHODS We combined individual patient data from 6 randomized clinical trials (CAPRIE, ESPS-2, MATCH, CHARISMA, ESPRIT, and PRoFESS) investigating antiplatelet therapy after TIA or ischemic stroke. Cox regression analyses stratified by trial were performed to study the association between predictors and major bleeding. A risk prediction model was derived and validated in the PERFORM trial. Performance was assessed with the c statistic and calibration plots. RESULTS Major bleeding occurred in 1,530 of the 43,112 patients during 94,833 person-years of follow-up. The observed 3-year risk of major bleeding was 4.6% (95% confidence interval [CI] 4.4%-4.9%). Predictors were male sex, smoking, type of antiplatelet agents (aspirin-clopidogrel), outcome on modified Rankin Scale ≥3, prior stroke, high blood pressure, lower body mass index, elderly, Asian ethnicity, and diabetes (S2TOP-BLEED). The S2TOP-BLEED score had a c statistic of 0.63 (95% CI 0.60-0.64) and showed good calibration in the development data. Major bleeding risk ranged from 2% in patients aged 45-54 years without additional risk factors to more than 10% in patients aged 75-84 years with multiple risk factors. In external validation, the model had a c statistic of 0.61 (95% CI 0.59-0.63) and slightly underestimated major bleeding risk. CONCLUSIONS The S2TOP-BLEED score can be used to estimate 3-year major bleeding risk in patients with a TIA or ischemic stroke who use antiplatelet agents, based on readily available characteristics. The discriminatory performance may be improved by identifying stronger predictors of major bleeding.
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Affiliation(s)
- Nina A Hilkens
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France.
| | - Ale Algra
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Hans-Christoph Diener
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Johannes B Reitsma
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Philip M Bath
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Laszlo Csiba
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Werner Hacke
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - L Jaap Kappelle
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Peter J Koudstaal
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Didier Leys
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Jean-Louis Mas
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Ralph L Sacco
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Pierre Amarenco
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Leila Sissani
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Jacoba P Greving
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
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Lee AT, Gagnidze A, Pan SR, Sookplung P, Nair B, Newman SF, Ben-Ari A, Zaky A, Cain K, Vavilala MS, Rozet I. Preoperative Low-Dose Aspirin Exposure and Outcomes After Emergency Neurosurgery for Traumatic Intracranial Hemorrhage in Elderly Patients. Anesth Analg 2017; 125:514-520. [DOI: 10.1213/ane.0000000000002053] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Li L, Geraghty OC, Mehta Z, Rothwell PM. Age-specific risks, severity, time course, and outcome of bleeding on long-term antiplatelet treatment after vascular events: a population-based cohort study. Lancet 2017; 390. [PMID: 28622955 PMCID: PMC5537194 DOI: 10.1016/s0140-6736(17)30770-5] [Citation(s) in RCA: 247] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Lifelong antiplatelet treatment is recommended after ischaemic vascular events, on the basis of trials done mainly in patients younger than 75 years. Upper gastrointestinal bleeding is a serious complication, but had low case fatality in trials of aspirin and is not generally thought to cause long-term disability. Consequently, although co-prescription of proton-pump inhibitors (PPIs) reduces upper gastrointestinal bleeds by 70-90%, uptake is low and guidelines are conflicting. We aimed to assess the risk, time course, and outcomes of bleeding on antiplatelet treatment for secondary prevention in patients of all ages. METHODS We did a prospective population-based cohort study in patients with a first transient ischaemic attack, ischaemic stroke, or myocardial infarction treated with antiplatelet drugs (mainly aspirin based, without routine PPI use) after the event in the Oxford Vascular Study from 2002 to 2012, with follow-up until 2013. We determined type, severity, outcome (disability or death), and time course of bleeding requiring medical attention by face-to-face follow-up for 10 years. We estimated age-specific numbers needed to treat (NNT) to prevent upper gastrointestinal bleeding with routine PPI co-prescription on the basis of Kaplan-Meier risk estimates and relative risk reduction estimates from previous trials. FINDINGS 3166 patients (1582 [50%] aged ≥75 years) had 405 first bleeding events (n=218 gastrointestinal, n=45 intracranial, and n=142 other) during 13 509 patient-years of follow-up. Of the 314 patients (78%) with bleeds admitted to hospital, 117 (37%) were missed by administrative coding. Risk of non-major bleeding was unrelated to age, but major bleeding increased steeply with age (≥75 years hazard ratio [HR] 3·10, 95% CI 2·27-4·24; p<0·0001), particularly for fatal bleeds (5·53, 2·65-11·54; p<0·0001), and was sustained during long-term follow-up. The same was true of major upper gastrointestinal bleeds (≥75 years HR 4·13, 2·60-6·57; p<0·0001), particularly if disabling or fatal (10·26, 4·37-24·13; p<0·0001). At age 75 years or older, major upper gastrointestinal bleeds were mostly disabling or fatal (45 [62%] of 73 patients vs 101 [47%] of 213 patients with recurrent ischaemic stroke), and outnumbered disabling or fatal intracerebral haemorrhage (n=45 vs n=18), with an absolute risk of 9·15 (95% CI 6·67-12·24) per 1000 patient-years. The estimated NNT for routine PPI use to prevent one disabling or fatal upper gastrointestinal bleed over 5 years fell from 338 for individuals younger than 65 years, to 25 for individuals aged 85 years or older. INTERPRETATION In patients receiving aspirin-based antiplatelet treatment without routine PPI use, the long-term risk of major bleeding is higher and more sustained in older patients in practice than in the younger patients in previous trials, with a substantial risk of disabling or fatal upper gastrointestinal bleeding. Given that half of the major bleeds in patients aged 75 years or older were upper gastrointestinal, the estimated NNT for routine PPI use to prevent such bleeds is low, and co-prescription should be encouraged. FUNDING Wellcome Trust, Wolfson Foundation, British Heart Foundation, Dunhill Medical Trust, National Institute of Health Research (NIHR), and the NIHR Oxford Biomedical Research Centre.
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Affiliation(s)
- Linxin Li
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Olivia C Geraghty
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Ziyah Mehta
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Peter M Rothwell
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.
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Park SM, Jeong H, Jung MH, Hong KS, Hong MK, Bang CS, Kim CY. Rationale and Design for a Randomized Comparison of Efficacy and Safety between Aspirin and Clopidogrel in Atrial Fibrillation Patients with Low Stroke Risk: CESAC-AF trial. Contemp Clin Trials 2017. [PMID: 28642210 DOI: 10.1016/j.cct.2017.06.011] [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: 11/30/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) increases the risk of thromboembolic stroke. An oral anticoagulant should be administrated to prevent stroke in patients with moderate stroke risk (ie, CHA2DS2-VASc score>2). If the stroke risk is low (i.e. the score=1), however, antiplatelet agent such as aspirin is widely used. Aspirin can cause peptic ulcer disease (PUD) while its alternative, clopidogrel, theoretically does not. OBJECTIVE To elucidate the efficacy and safety between aspirin and clopidogrel, a multicenter randomized controlled trial was designed in AF patients with low stroke risk. METHODS According to sample size estimation based on previous literature, a total of 1560 AF patients with low stroke risk will be randomly assigned into 4 different groups dependent upon initial esophagogastroduodenoscopy (EGD) results: two mono-antiplatelet treatment groups with either aspirin 100mg or clopidogrel 75mg for 1year; two antiplatelet agent and proton pump inhibitor (PPI) combination groups. Follow-up EGD will be performed at 1year. RESULTS The clinical follow-up will be performed for 1year after enrollment. The primary efficacy endpoint is to compare the annual stroke rate between aspirin and clopidogrel treatment groups. The primary safety endpoint is to compare the prevalence of drug-induced gastrointestinal (GI) and intracranial hemorrhage and upper-GI response including PUD based on EGD after 1year. CONCLUSIONS This trial will determine whether clopidogrel is noninferior in stroke prevention and superior in reduction of GI events including PUD to aspirin in AF patients with low stroke risk. (ClinicalTrials.gov: NCT02960126).
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Affiliation(s)
- Sang Min Park
- Cardiovascular Center, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea; Department of Medicine, the Graduate School of Yonsei University, Seoul, Republic of Korea.
| | - Haemin Jeong
- Cardiovascular Center, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Mi-Hyang Jung
- Cardiovascular Center, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Kyung Soon Hong
- Cardiovascular Center, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Myeong-Ki Hong
- Division of Cardiology, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chang Seok Bang
- Division of Gastroenterology, Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
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81
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García-Rayado G, Sostres C, Lanas A. Aspirin and omeprazole for secondary prevention of cardiovascular disease in patients at risk for aspirin-associated gastric ulcers. Expert Rev Clin Pharmacol 2017; 10:875-888. [PMID: 28463532 DOI: 10.1080/17512433.2017.1324782] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Cardiovascular disease is the most important cause of morbidity and mortality in the world and low-dose aspirin is considered the cornerstone of the cardiovascular disease prevention. However, low-dose aspirin use is associated with gastrointestinal adverse effects in the whole gastrointestinal tract. In this setting, co-therapy with a proton pump inhibitor is the most accepted strategy to reduce aspirin related upper gastrointestinal damage. In addition, some adverse effects have been described with proton pump inhibitors long term use. Areas covered: Low-dose aspirin related beneficial and adverse effects in cardiovascular system and gastrointestinal tract are reviewed. In addition, this manuscript summarizes current data on upper gastrointestinal damage prevention and adverse events with proton pump inhibition. Finally, we discuss the benefit/risk ratio of proton pump inhibitor use in patients at risk of gastrointestinal damage taking low-dose aspirin. Expert commentary: Nowadays, with the current available evidence, the combination of low-dose aspirin with proton pump inhibitor is the most effective therapy for cardiovascular prevention in patients at high gastrointestinal risk. However, further studies are needed to discover new effective strategies with less related adverse events.
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Affiliation(s)
- Guillermo García-Rayado
- a Service of Digestive Diseases , University Clinic Hospital Lozano Blesa , Zaragoza , Spain.,b Aragón Health Research Institute (IIS Aragón) , Zaragoza , Spain
| | - Carlos Sostres
- a Service of Digestive Diseases , University Clinic Hospital Lozano Blesa , Zaragoza , Spain.,b Aragón Health Research Institute (IIS Aragón) , Zaragoza , Spain.,c CIBERehd , Madrid , Spain.,d University of Zaragoza , Zaragoza , Spain
| | - Angel Lanas
- a Service of Digestive Diseases , University Clinic Hospital Lozano Blesa , Zaragoza , Spain.,b Aragón Health Research Institute (IIS Aragón) , Zaragoza , Spain.,c CIBERehd , Madrid , Spain.,d University of Zaragoza , Zaragoza , Spain
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82
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Shan J, Lei H, Shi W, Sun X, Tang Y, Ren C. High Serum Pepsinogen I and beta Helicobacter pylori Infection Are Risk Factors for Aspirin-Induced Gastroduodenal Injury. Dig Dis 2017; 36:66-71. [PMID: 28595197 DOI: 10.1159/000477203] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 04/21/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Whether gastric hyperchlorhydria and Helicobacter pylori infection contribute to aspirin-induced gastroduodenal injury still lacks evidence. Because serum pepsinogens (PGs) and gastrin-17 (G17) can reflect gastric acid secretion, this study intended to elucidate whether serum PGs, serum G17, and H. pylori infection are associated with aspirin-induced gastrointestinal injury. SUMMARY A total of 60 patients taking low-dose aspirin for more than 1 month were enrolled in this study. Serum PG I, PG II, and G17 were determined using ELISA. A 14C-urea breath test was used for the detection of an H. pylori infection. The modified Lanza score was used to evaluate the degree of gastroduodenal injury under endoscopy. The median serum PG I level was significantly higher in the intensive gastroduodenal injury (IGI) group compared to that in the mild gastroduodenal injury group (155.0 vs. 116.6 ng/mL, p = 0.006). The H. pylori infection rate was significantly higher in the IGI group (73 vs. 40%, p = 0.037). Receiver operator characteristic curves analysis revealed that the cutoff value of PG I was 123 ng/mL, with 80% sensitivity and 61.4% specificity. H. pylori infection combined with PG I at >123 ng/mL had an OR (95% CI) of 15.8 (2.4 ± 104.5) for the prediction of aspirin-induced gastroduodenal injury. Key Messages: Serum PG I and H. pylori infection could be used to identify potential high-risk aspirin-induced gastroduodenal injury patients.
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Affiliation(s)
- Jing Shan
- Department of Gastroenterology, The 3rd People's Hospital of Chengdu, The Second Affiliated Hospital of Chengdu, Chongqing Medical University, Chengdu, China
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83
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Barton BM, Riley CA, Fitzpatrick JC, Hasney CP, Moore BA, McCoul ED. Postoperative anticoagulation after free flap reconstruction for head and neck cancer: A systematic review. Laryngoscope 2017; 128:412-421. [PMID: 28581030 DOI: 10.1002/lary.26703] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Postoperative use of anticoagulation after free tissue transfer in head and neck ablative procedures is common practice, but a clear protocol has not been well established. The outcome measures including total flap failure, thrombosis, and hematoma formation for different anticoagulation regimens in free tissue transfer in the head and neck were reviewed. DATA SOURCES PubMed, Ovid, and Cochrane databases were examined for patients who underwent free tissue transfer following head and neck ablative procedures. REVIEW METHODS Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were utilized to identify English-language studies reporting anticoagulation regimens following free tissue transfer in head and neck ablative procedures. Outcomes included total flap failure, thrombosis, and hematoma formation. Two independent reviewers assessed the quality of the articles by using the Methodological Index for Non-Randomized Studies. RESULTS A total of 368 articles were identified. An additional 36 articles were identified through screening of reference lists. Twenty-one of these studies met final inclusion criteria for qualitative analysis. Outcome data on total flap failure, thrombosis, and hematoma formation were extracted and analyzed for comparison against all anticoagulation regimens. Total flap failure, thrombosis, and hematoma formation rates were 4.4%, 4.5%, and 2.2%, respectively. Individual study rates ranged from 0.0% to 10.7%, 0.0% to 10.4%, and 0.6% to 7.2%, respectively. CONCLUSIONS There is not adequate evidence to develop a standardized anticoagulation protocol for head and neck free flap procedures. Comparable flap complications were reported between all the employed anticoagulation methods studied, though significant variability in study design among articles existed. Prospective, randomized studies are warranted to determine the optimal postoperative anticoagulation regimen following free tissue transfer of the head and neck. Laryngoscope, 128:412-421, 2018.
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Affiliation(s)
- Blair M Barton
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Christian P Hasney
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, U.S.A
| | - Brian A Moore
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, U.S.A
| | - Edward D McCoul
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, U.S.A
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84
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85
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Martin AC, Houssany-Pissot S, Zlotnik D, Taylor G, Godier A. [Management of the bleeding risk associated with antiplatelet agents]. Rev Med Interne 2017; 38:467-473. [PMID: 28528236 DOI: 10.1016/j.revmed.2017.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 01/09/2017] [Accepted: 01/23/2017] [Indexed: 10/19/2022]
Abstract
Like all antithrombotic drugs, antiplatelet agents expose to a risk of bleeding complications. Clinical research has extensively focused on the efficacy of these drugs to reduce ischemic events. The bleeding risk associated with them was solely considered as an inevitable and acceptable complication. When two new potent P2Y12-receptor inhibitors, prasugrel and ticagrelor, were marketed, the risk of major bleeding increased. These new agents have modified the balance between the absolute risk reduction in ischemic events and the absolute risk increase in bleeding events. This paper is an update on the bleeding risk assessment associated with antiplatelet agents. It discusses the place of platelet function monitoring, and the optimal management of bleeding complications. It addresses the challenging issue of reversal of antiplatelet therapy, focusing especially on ticagrelor, which pharmacodynamics complicate bleeding management.
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Affiliation(s)
- A-C Martin
- Service de cardiologie, hôpital d'instruction des armées Percy, 92140 Clamart, France; Inserm UMRS 1140, faculté de pharmacie, université Paris Descartes, 75006 Paris, France.
| | - S Houssany-Pissot
- Service de cardiologie, hôpital d'instruction des armées Percy, 92140 Clamart, France
| | - D Zlotnik
- Inserm UMRS 1140, faculté de pharmacie, université Paris Descartes, 75006 Paris, France
| | - G Taylor
- Service d'anesthésie réanimation, fondation Adolphe-de-Rothschild, 75019 Paris, France
| | - A Godier
- Inserm UMRS 1140, faculté de pharmacie, université Paris Descartes, 75006 Paris, France; Service d'anesthésie réanimation, fondation Adolphe-de-Rothschild, 75019 Paris, France
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86
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Hisazumi J, Kleinebudde P. In-line monitoring of multi-layered film-coating on pellets using Raman spectroscopy by MCR and PLS analyses. Eur J Pharm Biopharm 2017; 114:194-201. [DOI: 10.1016/j.ejpb.2017.01.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 01/16/2017] [Accepted: 01/16/2017] [Indexed: 10/20/2022]
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87
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Sharma R, Roy A, Ramos C, Rosenberg R, Garcia-Carrasquillo R, Lebwohl B. Low adherence to national guidelines for proton-pump inhibitor prescription in patients receiving combination aspirin and anticoagulation. Therap Adv Gastroenterol 2017; 10:387-396. [PMID: 28507597 PMCID: PMC5415095 DOI: 10.1177/1756283x17694807] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 01/11/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Aspirin, when used with concurrent anticoagulation, increases the risk of gastrointestinal bleeding (GIB). Therefore, multisociety guidelines recommend prophylactic proton-pump inhibitors (PPIs) for patients receiving aspirin and anticoagulation. We aimed to determine rates and predictors of adherence to these recommendations. METHODS All adult inpatients discharged from the hospital on aspirin and anticoagulation from July 2009 to June 2014 were retrospectively evaluated for PPI prescription on discharge instructions. We used univariate and multivariate logistic regression to test for predictors of PPI prescription. RESULTS A total of 2422 patients were discharged on aspirin and anticoagulation; the mean age was 68 years and 53.2% were male; 42.2% were prescribed a PPI at discharge. On univariate analysis, factors associated with discharge PPI prescription included increased age (47.1% versus 37.9%), white race (47.3% versus 37.1-40.2%), higher aspirin dose (55.1% versus 39.4%), being married (46.2% versus 39.4%) and preadmission PPI use (96.6% versus 23.4%). On multivariate analysis, significant predictors of discharge PPI prescription were age 60-69 years [odds ratio (OR) 1.61] and 70-79 years (OR 1.48), and preadmission PPI use (OR 120.03). Lower odds of discharge PPI prescription included Medicaid (OR 0.55) or Medicare (OR 0.71) insurance, Spanish language (OR 0.63), and lower dose aspirin (81 mg) (OR 0.40). CONCLUSIONS A total of 42.2% of patients discharged on aspirin and anticoagulation were prescribed PPIs. Older age and preadmission PPI use were predictive of PPI prescription, while Medicaid/Medicare insurance, Spanish language, and lower dose aspirin decreased the likelihood of discharge PPI prescription. This creates an opportunity to improve primary GIB prevention through quality improvement interventions.
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Affiliation(s)
- Rajani Sharma
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Abhik Roy
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Christopher Ramos
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Richard Rosenberg
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Reuben Garcia-Carrasquillo
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY, USA
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88
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Amirsadri M, Sedighi MJ. Cost-effectiveness evaluation of aspirin in primary prevention of myocardial infarction amongst males with average cardiovascular risk in Iran. Res Pharm Sci 2017; 12:144-153. [PMID: 28515767 PMCID: PMC5385729 DOI: 10.4103/1735-5362.202453] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Aspirin is one of the certified medicines commonly used for the secondary prevention of myocardial infarction (MI). Aspirin side effects and gastrointestinal bleeding, in particular, have arisen debates on its use for the primary prevention of MI. The present research evaluates the cost-effectiveness of the use of aspirin in the primary prevention of MI among Iranian men with average cardiovascular disease (CVD) risk, using Markov modeling technique. The incremental cost-effectiveness ratios (ICERs) estimated to be 864 USA dollars (USD) per quality-adjusted life years (QALY) gained and 782 USD per life years gained (LYG) for each patient in the base-case scenario (public tariffs and no discounting). This research proves cost-effectiveness of the use of aspirin in the primary prevention of MI in targeted population, since the assessed ICERs are quite under the recommended threshold by WHO which is one gross domestic product (GDP) per capita ($5315.1 for Iran in 2015).
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Affiliation(s)
- Mohammadreza Amirsadri
- Department of Clinical Pharmacy and Pharmacy Practice and Isfahan Pharmaceutical Sciences Research Center, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, I.R. Iran
| | - Mohammad Javad Sedighi
- Department of Clinical Pharmacy and Pharmacy Practice and Isfahan Pharmaceutical Sciences Research Center, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, I.R. Iran
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89
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Scott MJ, Veitch A, Thachil J. Reintroduction of anti-thrombotic therapy after a gastrointestinal haemorrhage: if and when? Br J Haematol 2017; 177:185-197. [PMID: 28272736 DOI: 10.1111/bjh.14599] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 12/20/2016] [Indexed: 12/11/2022]
Abstract
Gastrointestinal haemorrhage is a common clinical scenario and, in those using antithrombotic agents, the risk is significantly increased. Management of these patients, in terms of initial resuscitation is well established and numerous guidelines exist in this area. However, few studies have addressed the subsequent dilemma of if and when antithrombotic agents should be reintroduced. Consequently, practice is variable and not necessarily evidenced-based. Overall, for patients that are either anticoagulated or using antiplatelet drugs for secondary prophylaxis, there is a clear benefit to restarting these agents. However, there is limited data to guide when this should occur. For individuals at low risk of re-bleeding, current guidelines suggest single agent aspirin can be continued without interruption, assuming haemostatic control has been confirmed endoscopically. For those at higher bleeding risk, aspirin should be withheld, but reintroduced early (within 3 days of index endoscopy). However, randomised evidence is lacking, as are studies including more modern agents or combined anticoagulant/ antiplatelet regimens. As such, guidance statements are limited and management suggestions must be extrapolated from clinical trials, retrospective studies and data relating specifically to warfarin and aspirin. The intention of this review is to summarise what evidence is available and, where this is lacking, suggest pragmatic management options based on a risk-benefit assessment of thromboembolism and recurrent bleeding.
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Affiliation(s)
- Martin J Scott
- Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Andrew Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Jecko Thachil
- Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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90
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No Benefit From Platelet Transfusion for Gastrointestinal Bleeding in Patients Taking Antiplatelet Agents. Clin Gastroenterol Hepatol 2017; 15:46-52. [PMID: 27464591 DOI: 10.1016/j.cgh.2016.07.017] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 07/07/2016] [Accepted: 07/08/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Antiplatelet agents decrease cardiovascular events but increase gastrointestinal bleeding (GIB). Guidelines propose platelet transfusion for patients who take antiplatelet agents and have serious GIB. We investigated whether such patients are at decreased risk for rebleeding or increased risk for cardiovascular events after platelet transfusion. METHODS We performed a retrospective cohort study of patients with GIB admitted to Yale-New Haven Hospital from 2008 to 2013 who were taking antiplatelet agents and had platelet counts higher than 100 × 109/L. Cases (patients who received platelet transfusion, n = 204) were matched with controls (no platelet transfusions, n = 204) for sex, age, and GIB location. The primary outcome was recurrent GIB. Multivariable regression analyses were performed to adjust for differences in baseline characteristics. RESULTS Cases and controls had similar proportions of GIB due to non-variceal upper GIB (117 of 204, 57% vs 115 of 204, 56%) and colonic GIB (80 of 204, 39% vs 81 of 204, 40%). Cases had more severe GIB than controls, which was based on lower blood pressure and hemoglobin levels and higher heart rates and the proportion admitted to intensive care. Univariate analyses showed that higher proportions of cases had major cardiovascular events (23% vs 13% for controls), died (7% vs 1% for controls), or had hospital stay longer than 4 days (47% vs 33% for controls). However, multivariable analyses showed a significant difference between cases and controls in only risk of death (odds ratio, 5.57; 95% confidence interval, 1.52-27.1). The adjusted odds ratio for recurrent bleeding was 1.47 (95% confidence interval, 0.73-3.05) for cases vs controls. CONCLUSIONS The use of platelet transfusions in patients with GIB who are taking antiplatelet agents without thrombocytopenia did not reduce rebleeding but was associated with higher mortality. At least some of the increase in mortality could be due to the residual bias of an observational study, but because of the lack of benefit, we do not support the use of platelet transfusions in patients with GIB who are taking antiplatelet agents.
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91
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Kumar NL, Saltzman JR. Does Transfusion Effectively Counter Antiplatelet Agents in Patients With Gastrointestinal Bleeding? Clin Gastroenterol Hepatol 2017; 15:53-55. [PMID: 27639331 DOI: 10.1016/j.cgh.2016.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 09/06/2016] [Accepted: 09/07/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Navin L Kumar
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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92
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Sharma T, Bliden K, Chaudhary R, Tantry U, Gurbel PA. Efficacy of aspirin (325 mg) + omeprazole (40 mg) in treating coronary artery disease. Expert Opin Pharmacother 2016; 18:123-131. [DOI: 10.1080/14656566.2016.1269747] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Tushar Sharma
- Department of Medicine, Sinai Hospital, Baltimore, MD, USA
| | - Kevin Bliden
- Director of Cardiovascular Research, Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA, USA
| | | | - Udaya Tantry
- Director of Cardiovascular Research, Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA, USA
| | - Paul A. Gurbel
- Director of Cardiovascular Research, Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA, USA
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93
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Agus DB, Gaudette É, Goldman DP, Messali A. The Long-Term Benefits of Increased Aspirin Use by At-Risk Americans Aged 50 and Older. PLoS One 2016; 11:e0166103. [PMID: 27902693 PMCID: PMC5130201 DOI: 10.1371/journal.pone.0166103] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 10/07/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The usefulness of aspirin to defend against cardiovascular disease in both primary and secondary settings is well recognized by the medical profession. Multiple studies also have found that daily aspirin significantly reduces cancer incidence and mortality. Despite these proven health benefits, aspirin use remains low among populations targeted by cardiovascular prevention guidelines. This article seeks to determine the long-term economic and population-health impact of broader use of aspirin by older Americans at higher risk for cardiovascular disease. METHODS AND FINDINGS We employ the Future Elderly Model, a dynamic microsimulation that follows Americans aged 50 and older, to project their lifetime health and spending under the status quo and in various scenarios of expanded aspirin use. The model is based primarily on data from the Health and Retirement Study, a large, representative, national survey that has been ongoing for more than two decades. Outcomes are chosen to provide a broad perspective of the individual and societal impacts of the interventions and include: heart disease, stroke, cancer, life expectancy, quality-adjusted life expectancy, disability-free life expectancy, and medical costs. Eligibility for increased aspirin use in simulations is based on the 2011-2012 questionnaire on preventive aspirin use of the National Health and Nutrition Examination Survey. These data reveal a large unmet need for daily aspirin, with over 40% of men and 10% of women aged 50 to 79 presenting high cardiovascular risk but not taking aspirin. We estimate that increased use by high-risk older Americans would improve national life expectancy at age 50 by 0.28 years (95% CI 0.08-0.50) and would add 900,000 people (95% CI 300,000-1,400,000) to the American population by 2036. After valuing the quality-adjusted life-years appropriately, Americans could expect $692 billion (95% CI 345-975) in net health benefits over that period. CONCLUSIONS Expanded use of aspirin by older Americans with elevated risk of cardiovascular disease could generate substantial population health benefits over the next twenty years and do so very cost-effectively.
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Affiliation(s)
- David B. Agus
- Lawrence J. Ellison Institute for Transformative Medicine, University of Southern California Keck School of Medicine and Viterbi School of Engineering, Beverly Hills, California, United States of America
- * E-mail:
| | - Étienne Gaudette
- Schaeffer Center for Health Policy and Economics, University of Southern California Price School and School of Pharmacy, Los Angeles, California, United States of America
| | - Dana P. Goldman
- Schaeffer Center for Health Policy and Economics, University of Southern California Price School and School of Pharmacy, Los Angeles, California, United States of America
| | - Andrew Messali
- Analysis Group, Inc. Boston, Massachusetts, United States of America
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Elwood PC, Morgan G, Galante J, Chia JWK, Dolwani S, Graziano JM, Kelson M, Lanas A, Longley M, Phillips CJ, Pickering J, Roberts SE, Soon SS, Steward W, Morris D, Weightman AL. Systematic Review and Meta-Analysis of Randomised Trials to Ascertain Fatal Gastrointestinal Bleeding Events Attributable to Preventive Low-Dose Aspirin: No Evidence of Increased Risk. PLoS One 2016; 11:e0166166. [PMID: 27846246 PMCID: PMC5113022 DOI: 10.1371/journal.pone.0166166] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/19/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Aspirin has been shown to lower the incidence and the mortality of vascular disease and cancer but its wider adoption appears to be seriously impeded by concerns about gastrointestinal (GI) bleeding. Unlike heart attacks, stroke and cancer, GI bleeding is an acute event, usually followed by complete recovery. We propose therefore that a more appropriate evaluation of the risk-benefit balance would be based on fatal adverse events, rather than on the incidence of bleeding. We therefore present a literature search and meta-analysis to ascertain fatal events attributable to low-dose aspirin. METHODS In a systematic literature review we identified reports of randomised controlled trials of aspirin in which both total GI bleeding events and bleeds that led to death had been reported. Principal investigators of studies in which fatal events had not been adequately described were contacted via email and asked for further details. A meta-analyses was then performed to estimate the risk of fatal gastrointestinal bleeding attributable to low-dose aspirin. RESULTS Eleven randomised trials were identified in the literature search. In these the relative risk (RR) of 'major' incident GI bleeding in subjects who had been randomised to low-dose aspirin was 1.55 (95% CI 1.33, 1.83), and the risk of a bleed attributable to aspirin being fatal was 0.45 (95% CI 0.25, 0.80). In all the subjects randomised to aspirin, compared with those randomised not to receive aspirin, there was no significant increase in the risk of a fatal bleed (RR 0.77; 95% CI 0.41, 1.43). CONCLUSIONS The majority of the adverse events caused by aspirin are GI bleeds, and there appears to be no valid evidence that the overall frequency of fatal GI bleeds is increased by aspirin. The substantive risk for prophylactic aspirin is therefore cerebral haemorrhage which can be fatal or severely disabling, with an estimated risk of one death and one disabling stroke for every 1,000 people taking aspirin for ten years. These adverse effects of aspirin should be weighed against the reductions in vascular disease and cancer.
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Affiliation(s)
- Peter C. Elwood
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
| | - Gareth Morgan
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
- Hywel Dda University Health Board, Llanelli, United Kingdom
| | - Julieta Galante
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - John W. K. Chia
- Division of Medical Oncology, National Cancer Centre, Singapore, Singapore
| | - Sunil Dolwani
- Institute of Cancer & Genetics Cardiff University, Cardiff, United Kingdom
| | | | - Mark Kelson
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
| | - Angel Lanas
- University Clinic Hospital, University of Zaragoza, IIS Aragón, CIBEReshd, Zaragoza, Spain
| | - Marcus Longley
- Welsh Institute for Health and Social Care, University of South Wales, Cardiff, United Kingdom
| | - Ceri J. Phillips
- Swansea Centre for Health Economics, Swansea University, Swansea, United Kingdom
| | - Janet Pickering
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
| | | | - Swee S. Soon
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Will Steward
- Department of Cancer Studies, University of Leicester, Leicester, United Kingdom
| | - Delyth Morris
- University Library Services, Cardiff University, Cardiff, United Kingdom
| | - Alison L. Weightman
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
- Specialist Unit for Review Evidence (SURE), Cardiff University, Cardiff, United Kingdom
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95
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Karlsson WK, Jensen JS, Jakobsen JC. Antiplatelet therapy for preventing stroke in people with atrial fibrillation. Hippokratia 2016. [DOI: 10.1002/14651858.cd012428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- William K Karlsson
- Rigshospitalet; Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812; Blegdamsvej 9 Copenhagen Denmark 2100
- Herlev Hospital; Department of Neurology; Herlev Ringvej 75 Copenhagen Denmark 2730
| | - Jakob S Jensen
- Rigshospitalet; Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Sjaelland Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
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96
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Mammadova-Bach E, Zigrino P, Brucker C, Bourdon C, Freund M, De Arcangelis A, Abrams SI, Orend G, Gachet C, Mangin PH. Platelet integrin α6 β1 controls lung metastasis through direct binding to cancer cell-derived ADAM9. JCI Insight 2016; 1:e88245. [PMID: 27699237 DOI: 10.1172/jci.insight.88245] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Metastatic dissemination of cancer cells, which accounts for 90% of cancer mortality, is the ultimate hallmark of malignancy. Growing evidence suggests that blood platelets have a predominant role in tumor metastasis; however, the molecular mechanisms involved remain elusive. Here, we demonstrate that genetic deficiency of integrin α6β1 on platelets markedly decreases experimental and spontaneous lung metastasis. In vitro and in vivo assays reveal that human and mouse platelet α6β1 supports platelet adhesion to various types of cancer cells. Using a knockdown approach, we identified ADAM9 as the major counter receptor of α6β1 on both human and mouse tumor cells. Static and flow-based adhesion assays of platelets binding to DC-9, a recombinant protein covering the disintegrin-cysteine domain of ADAM9, demonstrated that this receptor directly binds to platelet α6β1. In vivo studies showed that the interplay between platelet α6β1 and tumor cell-expressed ADAM9 promotes efficient lung metastasis. The integrin α6β1-dependent platelet-tumor cell interaction induces platelet activation and favors the extravasation process of tumor cells. Finally, we demonstrate that a pharmacological approach targeting α6β1 efficiently impairs tumor metastasis through a platelet-dependent mechanism. Our study reveals a mechanism by which platelets promote tumor metastasis and suggests that integrin α6β1 represents a promising target for antimetastatic therapies.
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Affiliation(s)
- Elmina Mammadova-Bach
- UMR-S949, INSERM, Etablissement Français du Sang-Alsace, Université de Strasbourg, Strasbourg, France. Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
| | - Paola Zigrino
- Department of Dermatology and Venerology, University of Cologne, Cologne, Germany
| | - Camille Brucker
- UMR-S949, INSERM, Etablissement Français du Sang-Alsace, Université de Strasbourg, Strasbourg, France. Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
| | - Catherine Bourdon
- UMR-S949, INSERM, Etablissement Français du Sang-Alsace, Université de Strasbourg, Strasbourg, France. Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
| | - Monique Freund
- UMR-S949, INSERM, Etablissement Français du Sang-Alsace, Université de Strasbourg, Strasbourg, France. Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
| | - Adèle De Arcangelis
- U964, INSERM, UMR 7104, CNRS, Université de Strasbourg, Institut de Génétique et de Biologie Moléculaire et Cellulaire, Illkirch, Strasbourg, France
| | - Scott I Abrams
- Department of Immunology, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Gertaud Orend
- INSERM U1109, The Microenvironmental Niche in Tumorigenesis and Targeted Therapy, Université de Strasbourg, Fédération de Médecine Translationnelle de Strasbourg, LabEx Medalis, Strasbourg, France
| | - Christian Gachet
- UMR-S949, INSERM, Etablissement Français du Sang-Alsace, Université de Strasbourg, Strasbourg, France. Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
| | - Pierre Henri Mangin
- UMR-S949, INSERM, Etablissement Français du Sang-Alsace, Université de Strasbourg, Strasbourg, France. Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
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97
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Risk of bleeding after hospitalization for a serious coronary event: a retrospective cohort study with nested case-control analyses. BMC Cardiovasc Disord 2016; 16:164. [PMID: 27577589 PMCID: PMC5006362 DOI: 10.1186/s12872-016-0348-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 08/19/2016] [Indexed: 01/19/2023] Open
Abstract
Background Bleeding events have been associated with the use of antiplatelet agents. This study estimated the incidence of bleeding events in patients previously hospitalized for a serious coronary event and determined the risks of bleeding associated with the use of acetylsalicylic acid (ASA) and/or clopidogrel. Methods A UK primary care database was used to identify 27,707 patients aged 50 to 84 years, hospitalized for a serious coronary event during 2000 to 2007 and who were alive 30 days later (start date). Patients were followed up until they reached an endpoint (hemorrhagic stroke, upper or lower gastrointestinal bleeding [UGIB/LGIB]), death or end of study [June 30, 2011]) or met an exclusion criterion. Risk factors for bleeding were determined in a nested case-control analysis. Results Incidences of hemorrhagic stroke, UGIB, and LGIB were 5.0, 11.9, and 25.5 events per 10,000 person-years, respectively, and increased with age. UGIB and LGIB led to hospitalization in 73 and 23 % of patients, respectively. Non-users of ASA, who were mostly discontinuers, and current users of ASA had similar risks of hemorrhagic stroke, UGIB, and LGIB. Users of combined antithrombotic therapy (warfarin and antiplatelets) experienced an increased risk of hemorrhagic stroke (odds ratio [OR], 6.36; 95 % confidence interval [CI], 1.34–30.16), whereas users of combined antiplatelet therapy (clopidogrel and ASA) experienced an increased risk of UGIB (OR, 2.42; 95 % CI, 1.09–5.36). An increased risk of LGIB (OR, 1.86; 95 % CI, 1.34–2.57) was also observed in users of clopidogrel. Conclusions In patients previously hospitalized for a serious coronary event, combined antithrombotic therapy was associated with an increased risk of hemorrhagic stroke, whereas combined antiplatelet therapy was associated with an increased risk of UGIB.Non-use of ASA was rare in this population and use of ASA was not associated with a significantly increased risk of hemorrhagic stroke, UGIB, or LGIB. Electronic supplementary material The online version of this article (doi:10.1186/s12872-016-0348-6) contains supplementary material, which is available to authorized users.
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98
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Lee PC, Yeh CM, Hu YW, Chen CC, Liu CJ, Su CW, Huo TI, Huang YH, Chao Y, Chen TJ, Lin HC, Wu JC. Antiplatelet Therapy is Associated with a Better Prognosis for Patients with Hepatitis B Virus-Related Hepatocellular Carcinoma after Liver Resection. Ann Surg Oncol 2016; 23:874-883. [PMID: 27541812 DOI: 10.1245/s10434-016-5520-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recurrence of hepatocellular carcinoma (HCC) with unsatisfactory survival is common after surgical resection. Antiplatelet therapy with aspirin or clopidogrel was recently shown to prevent hepatic carcinogenesis in a murine model, but its effect in humans had not been clarified. This study aimed to investigate the association between antiplatelet therapy and the outcomes for patients with hepatitis B virus (HBV)-related HCC after liver resection. METHODS By analyzing data from the Taiwan National Health Insurance Research Database, 9461 HBV-related HCC patients who had undergone liver resection between January 1997 and December 2011 were identified. After one-to-four matching by sex, age, and propensity score, 442 patients with antiplatelet therapy and 1768 patients without antiplatelet therapy were enrolled for the analysis. The Kaplan-Meier method and modified Cox proportional hazards models were used for survival and multivariable, stratified analyses. RESULTS Recurrence-free survival and overall survival after resection surgery were significantly better after 5 years in the treated cohort than in the untreated cohort (52.8 vs 47.9 %; p = 0.021 and 80.3 vs 65.4 %; p < 0.001, respectively). Besides, antiplatelet therapy reduced the risk of HCC recurrence (hazard ratio [HR] 0.73; p < 0.001) and overall mortality (HR 0.57; p < 0.001) in the multivariable analysis. However, antiplatelet use significantly increased the risk of upper gastrointestinal bleeding (odds ratio [OR] 1.91; p < 0.001). CONCLUSIONS Use of aspirin or clopidogrel was associated with better recurrence-free survival and overall survival among patients with HBV-related HCC after liver resection. However, these agents should be used with caution due to the adverse effects of upper gastrointestinal bleeding.
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Affiliation(s)
- Pei-Chang Lee
- Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Yuanshan Branch, Taipei Veterans General Hospital, Yilan, Taiwan
| | - Chiu-Mei Yeh
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Wen Hu
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Chun-Chia Chen
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Jen Liu
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan. .,Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
| | - Chien-Wei Su
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
| | - Teh-Ia Huo
- Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yee Chao
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Han-Chieh Lin
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jaw-Ching Wu
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
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99
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Fanaroff AC, Roe MT. Contemporary Reflections on the Safety of Long-Term Aspirin Treatment for the Secondary Prevention of Cardiovascular Disease. Drug Saf 2016; 39:715-27. [PMID: 27028617 PMCID: PMC5778440 DOI: 10.1007/s40264-016-0421-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Aspirin has been the cornerstone of therapy for the secondary prevention treatment of patients with cardiovascular disease since landmark trials were completed in the late 1970s and early 1980s that demonstrated the efficacy of aspirin for reducing the risk of ischemic events. Notwithstanding the consistent benefits demonstrated with aspirin for both acute and chronic cardiovascular disease, there are a number of toxicities associated with aspirin that have been showcased by recent long-term clinical trials that have included an aspirin monotherapy arm. As an inhibitor of cyclooxygenase (COX), aspirin impairs gastric mucosal protective mechanisms. Previous trials have shown that up to 15-20 % of patients developed gastrointestinal symptoms with aspirin monotherapy, and approximately 1 % of patients per year had a clinically significant bleeding event, including 1 in 1000 patients who suffered an intracranial or fatal bleed. These risks have been shown to be compounded for patients with acute coronary syndromes (ACS) and those undergoing percutaneous coronary intervention (PCI) who are also treated with other antithrombotic agents during the acute care/procedural period, as well as for an extended time period afterwards. Given observations of substantial increases in bleeding rates from many prior long-term clinical trials that have evaluated aspirin together with other oral platelet inhibitors or oral anticoagulants, the focus of contemporary research has pivoted towards tailored antithrombotic regimens that attempt to either shorten the duration of exposure to aspirin or replace aspirin with an alternative antithrombotic agent. While these shifts are occurring, the safety profile of aspirin when used for the secondary prevention treatment of patients with established cardiovascular disease deserves further consideration.
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Affiliation(s)
- Alexander C Fanaroff
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Room 7035, Durham, NC, 27705, USA
| | - Matthew T Roe
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Room 7035, Durham, NC, 27705, USA.
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100
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Li T, Liu M, Ben H, Xu Z, Zhong H, Wu B. Clopidogrel versus aspirin in patients with recent ischemic stroke and established peripheral artery disease: an economic evaluation in a Chinese setting. Clin Drug Investig 2016; 35:365-74. [PMID: 25985838 DOI: 10.1007/s40261-015-0290-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Clopidogrel or aspirin are indicated for patients with recent ischemic stroke (IS) or established peripheral artery disease (PAD). We compared the cost effectiveness of clopidogrel with that of aspirin in Chinese patients with recent IS or established PAD. METHODS A discrete-event simulation was developed to evaluate the economic implications of secondary prevention with clopidogrel versus aspirin. All available evidence was derived from clinical studies. Costs from a Chinese healthcare perspective in 2013 US dollars and quality-adjusted life-years (QALYs) were projected over patients' lifetimes. Uncertainties were addressed using sensitivity analyses. RESULTS Compared with aspirin, clopidogrel yielded a marginally increased life expectancy by 0.46 and 0.21 QALYs at an incremental cost-effectiveness ratio of $US5246 and $US9890 per QALY in patients with recent IS and established PAD, respectively. One-way sensitivity analyses showed that the evaluation of patients with PAD and recent IS was robust except for the parameter of patient age. Given a willingness-to-pay of $US19,877 per QALY gained, clopidogrel had a probability of 90 and 68% of being cost effective in the recent IS or established PAD subgroups compared with aspirin, respectively. CONCLUSIONS The analysis suggests that clopidogrel for secondary prevention is cost effective for patients with either PAD or recent IS in a Chinese setting in comparison with aspirin.
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Affiliation(s)
- Te Li
- Department of Pharmacy, Yuxi People's Hospital, affiliated with the Kunming Medical College, Yuxi, China,
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