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Rojanaworarit C, Limsawan S. Risk of Hemorrhage Attributed to Underlying Chronic Diseases and Uninterrupted Aspirin Therapy of Patients Undergoing Minor Oral Surgical Procedures: A Retrospective Cohort Study. J Prev Med Public Health 2017; 50:165-176. [PMID: 28605890 PMCID: PMC5495684 DOI: 10.3961/jpmph.16.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 03/31/2017] [Indexed: 11/18/2022] Open
Abstract
Objectives This study aimed to estimate the risk of bleeding following minor oral surgical procedures and uninterrupted aspirin therapy in high-risk patients or patients with existing chronic diseases compared to patients who did not use aspirin during minor oral surgery at a public hospital. Methods This retrospective cohort study analyzed the data of 2912 patients, aged 20 years or older, who underwent 5251 minor oral surgical procedures at a district hospital in Thailand. The aspirin group was comprised of patients continuing aspirin therapy during oral surgery. The non-aspirin group (reference) included all those who did not use aspirin during surgery. Immediate and late-onset bleeding was evaluated in each procedure. The risk ratio of bleeding was estimated using a multilevel Poisson regression. Results The overall cumulative incidence of immediate bleeding was 1.3% of total procedures. No late-onset bleeding was found. A significantly greater incidence of bleeding was found in the aspirin group (5.8% of procedures, p<0.001). After adjusting for covariates, a multilevel Poisson regression model estimated that the bleeding risk in the aspirin group was 4.5 times higher than that of the non-aspirin group (95% confidence interval, 2.0 to 10.0; p<0.001). However, all bleeding events were controlled by simple hemostatic measures. Conclusions High-risk patients or patients with existing chronic diseases who continued aspirin therapy following minor oral surgery were at a higher risk of hemorrhage than general patients who had not used aspirin. Nonetheless, bleeding complications were not life-threatening and could be promptly managed by simple hemostatic measures. The procedures could therefore be provided with an awareness of increased bleeding risk, prepared hemostatic measures, and postoperative monitoring, without the need for discontinuing aspirin, which could lead to more serious complications.
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Affiliation(s)
| | - Soontaree Limsawan
- Department of Epidemiology, Faculty of Public Health, Mahidol University, Bangkok, Thailand
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Khan NI, Siddiqui FM, Goldstein JN, Cox M, Xian Y, Matsouaka RA, Heidenreich PA, Peterson ED, Bhatt DL, Fonarow GC, Schwamm LH, Smith EE. Association Between Previous Use of Antiplatelet Therapy and Intracerebral Hemorrhage Outcomes. Stroke 2017; 48:1810-1817. [PMID: 28596454 DOI: 10.1161/strokeaha.117.016290] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 04/24/2017] [Accepted: 05/05/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Although the use of antiplatelet therapy (APT) is associated with the risk of intracerebral hemorrhage (ICH), there are limited data on prestroke APT and outcomes, particularly among patients on combination APT (CAPT). We hypothesized that the previous use of antiplatelet agents is associated with increased mortality in ICH. METHODS We analyzed data of 82 576 patients with ICH who were not on oral anticoagulant therapy from 1574 Get with the Guidelines-Stroke hospitals between October 2012 and March 2016. Patients were categorized as not on APT, on single-APT (SAPT), and CAPT before hospital presentation with ICH. We described baseline characteristics, comorbidities, hospital characteristics and outcomes, overall and stratified by APT use. RESULTS Before the diagnosis of ICH, 65.8% patients were not on APT, 29.5% patients were on SAPT, and 4.8% patients were on CAPT. There was an overall modest increased in-hospital mortality in the APT group versus no APT group (24% versus 23%; adjusted odds ratio, 1.05; 95% confidence interval, 1.01-1.10). Although patients on SAPT and CAPT were older and had higher risk profiles in terms of comorbidities, there was no significant difference in the in-hospital mortality among patients on SAPT versus those not on any APT (23% versus 23%; adjusted odds ratio, 1.01; 95% confidence interval, 0.97-1.05). However, in-hospital mortality was higher among those on CAPT versus those not on APT (30% versus 23%; adjusted odds ratio, 1.50; 95% confidence interval, 1.39-1.63). CONCLUSIONS Our study suggests that among patients with ICH, previous use of CAPT, but not SAPT, was associated with higher risk for in-hospital mortality.
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Affiliation(s)
- Nadeem I Khan
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (N.I.K., F.M.S.); Department of Emergency Medicine (J.N.G.), Department of Neurology (L.H.S.), Massachusetts General Hospital, and Brigham and Women's Hospital Heart and Vascular Center (D.L.B.), Harvard Medical School, Boston; Duke Clinical Research Institute, Durham, NC (M.C., Y.X., R.A.M., E.D.P.); Department of Medicine (E.D.P.), and Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.A.M.); Department of Medicine, Stanford University School of Medicine, CA (P.A.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center (G.C.F.); and Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.).
| | - Fazeel M Siddiqui
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (N.I.K., F.M.S.); Department of Emergency Medicine (J.N.G.), Department of Neurology (L.H.S.), Massachusetts General Hospital, and Brigham and Women's Hospital Heart and Vascular Center (D.L.B.), Harvard Medical School, Boston; Duke Clinical Research Institute, Durham, NC (M.C., Y.X., R.A.M., E.D.P.); Department of Medicine (E.D.P.), and Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.A.M.); Department of Medicine, Stanford University School of Medicine, CA (P.A.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center (G.C.F.); and Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Joshua N Goldstein
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (N.I.K., F.M.S.); Department of Emergency Medicine (J.N.G.), Department of Neurology (L.H.S.), Massachusetts General Hospital, and Brigham and Women's Hospital Heart and Vascular Center (D.L.B.), Harvard Medical School, Boston; Duke Clinical Research Institute, Durham, NC (M.C., Y.X., R.A.M., E.D.P.); Department of Medicine (E.D.P.), and Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.A.M.); Department of Medicine, Stanford University School of Medicine, CA (P.A.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center (G.C.F.); and Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Margueritte Cox
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (N.I.K., F.M.S.); Department of Emergency Medicine (J.N.G.), Department of Neurology (L.H.S.), Massachusetts General Hospital, and Brigham and Women's Hospital Heart and Vascular Center (D.L.B.), Harvard Medical School, Boston; Duke Clinical Research Institute, Durham, NC (M.C., Y.X., R.A.M., E.D.P.); Department of Medicine (E.D.P.), and Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.A.M.); Department of Medicine, Stanford University School of Medicine, CA (P.A.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center (G.C.F.); and Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Ying Xian
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (N.I.K., F.M.S.); Department of Emergency Medicine (J.N.G.), Department of Neurology (L.H.S.), Massachusetts General Hospital, and Brigham and Women's Hospital Heart and Vascular Center (D.L.B.), Harvard Medical School, Boston; Duke Clinical Research Institute, Durham, NC (M.C., Y.X., R.A.M., E.D.P.); Department of Medicine (E.D.P.), and Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.A.M.); Department of Medicine, Stanford University School of Medicine, CA (P.A.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center (G.C.F.); and Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Roland A Matsouaka
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (N.I.K., F.M.S.); Department of Emergency Medicine (J.N.G.), Department of Neurology (L.H.S.), Massachusetts General Hospital, and Brigham and Women's Hospital Heart and Vascular Center (D.L.B.), Harvard Medical School, Boston; Duke Clinical Research Institute, Durham, NC (M.C., Y.X., R.A.M., E.D.P.); Department of Medicine (E.D.P.), and Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.A.M.); Department of Medicine, Stanford University School of Medicine, CA (P.A.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center (G.C.F.); and Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Paul A Heidenreich
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (N.I.K., F.M.S.); Department of Emergency Medicine (J.N.G.), Department of Neurology (L.H.S.), Massachusetts General Hospital, and Brigham and Women's Hospital Heart and Vascular Center (D.L.B.), Harvard Medical School, Boston; Duke Clinical Research Institute, Durham, NC (M.C., Y.X., R.A.M., E.D.P.); Department of Medicine (E.D.P.), and Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.A.M.); Department of Medicine, Stanford University School of Medicine, CA (P.A.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center (G.C.F.); and Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Eric D Peterson
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (N.I.K., F.M.S.); Department of Emergency Medicine (J.N.G.), Department of Neurology (L.H.S.), Massachusetts General Hospital, and Brigham and Women's Hospital Heart and Vascular Center (D.L.B.), Harvard Medical School, Boston; Duke Clinical Research Institute, Durham, NC (M.C., Y.X., R.A.M., E.D.P.); Department of Medicine (E.D.P.), and Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.A.M.); Department of Medicine, Stanford University School of Medicine, CA (P.A.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center (G.C.F.); and Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Deepak L Bhatt
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (N.I.K., F.M.S.); Department of Emergency Medicine (J.N.G.), Department of Neurology (L.H.S.), Massachusetts General Hospital, and Brigham and Women's Hospital Heart and Vascular Center (D.L.B.), Harvard Medical School, Boston; Duke Clinical Research Institute, Durham, NC (M.C., Y.X., R.A.M., E.D.P.); Department of Medicine (E.D.P.), and Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.A.M.); Department of Medicine, Stanford University School of Medicine, CA (P.A.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center (G.C.F.); and Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Gregg C Fonarow
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (N.I.K., F.M.S.); Department of Emergency Medicine (J.N.G.), Department of Neurology (L.H.S.), Massachusetts General Hospital, and Brigham and Women's Hospital Heart and Vascular Center (D.L.B.), Harvard Medical School, Boston; Duke Clinical Research Institute, Durham, NC (M.C., Y.X., R.A.M., E.D.P.); Department of Medicine (E.D.P.), and Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.A.M.); Department of Medicine, Stanford University School of Medicine, CA (P.A.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center (G.C.F.); and Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Lee H Schwamm
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (N.I.K., F.M.S.); Department of Emergency Medicine (J.N.G.), Department of Neurology (L.H.S.), Massachusetts General Hospital, and Brigham and Women's Hospital Heart and Vascular Center (D.L.B.), Harvard Medical School, Boston; Duke Clinical Research Institute, Durham, NC (M.C., Y.X., R.A.M., E.D.P.); Department of Medicine (E.D.P.), and Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.A.M.); Department of Medicine, Stanford University School of Medicine, CA (P.A.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center (G.C.F.); and Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
| | - Eric E Smith
- From the Department of Neurology, Southern Illinois University School of Medicine, Springfield (N.I.K., F.M.S.); Department of Emergency Medicine (J.N.G.), Department of Neurology (L.H.S.), Massachusetts General Hospital, and Brigham and Women's Hospital Heart and Vascular Center (D.L.B.), Harvard Medical School, Boston; Duke Clinical Research Institute, Durham, NC (M.C., Y.X., R.A.M., E.D.P.); Department of Medicine (E.D.P.), and Department of Neurology (Y.X.), Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.A.M.); Department of Medicine, Stanford University School of Medicine, CA (P.A.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center (G.C.F.); and Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (E.E.S.)
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Additive antithrombotic effect of ASP6537, a selective cyclooxygenase (COX)-1 inhibitor, in combination with clopidogrel in guinea pigs. Eur J Pharmacol 2017; 798:72-76. [PMID: 28095326 DOI: 10.1016/j.ejphar.2017.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 01/13/2017] [Accepted: 01/13/2017] [Indexed: 11/21/2022]
Abstract
Clopidogrel (Plavix®, Sanofi-Aventis), the adenosine diphosphate P2Y12 receptor antagonist, is reported to be effective in the prevention of cardiovascular events and is often used in combination with aspirin, particularly in high-risk patients. ASP6537 is a reversible cyclooxygenase (COX)-1 inhibitor that is under investigation as an anti-platelet agent. First, we investigated the reversibility of the antiplatelet effect of ASP6537 and its interaction with ibuprofen to compare the usability of ASP6537 with that of aspirin. We then evaluated the antithrombotic effect of ASP6537 in combination with clopidogrel using a FeCl3-induced thrombosis model in guinea pigs. ASP6537 exerted reversible antiplatelet activity, and no pharmacodynamic interaction with ibuprofen was noted. When administered as monotherapy, ASP6537 exerted a significant antithrombotic effect at ≥3mg/kg, while aspirin inhibited thrombosis at 100mg/kg. ASP6537 exerted significant additive effects in combination with clopidogrel, and the minimum antithrombotic dose was reduced by concomitant administration of clopidogrel. Our study showed that ASP6537 did not interact with ibuprofen and has clear additive effects in combination with clopidogrel. ASP6537 may therefore represent a promising antiplatelet agent for use in clinical settings in combination with clopidogrel.
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Elbadawi A, Saad M, Nairooz R. Aspirin Use Prior to Coronary Artery Bypass Grafting Surgery: a Systematic Review. Curr Cardiol Rep 2017; 19:18. [DOI: 10.1007/s11886-017-0822-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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González-Pérez A, Sáez ME, Johansson S, Nagy P, García Rodríguez LA. Mortality in patients who discontinue low-dose acetylsalicylic acid therapy after upper gastrointestinal bleeding. Pharmacoepidemiol Drug Saf 2016; 26:215-222. [DOI: 10.1002/pds.4140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 09/13/2016] [Accepted: 11/03/2016] [Indexed: 01/10/2023]
Affiliation(s)
- Antonio González-Pérez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE); Madrid Spain
- Andalusian Bioinformatics Research Centre (CAEBi); Seville Spain
| | - María Eugenia Sáez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE); Madrid Spain
- Andalusian Bioinformatics Research Centre (CAEBi); Seville Spain
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Amour J, Garnier M, Szymezak J, Le Manach Y, Helley D, Bertil S, Ouattara A, Riou B, Gaussem P. Prospective observational study of the effect of dual antiplatelet therapy with tranexamic acid treatment on platelet function and bleeding after cardiac surgery. Br J Anaesth 2016; 117:749-757. [DOI: 10.1093/bja/aew357] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2016] [Indexed: 12/20/2022] Open
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Chello M, Nenna A. Continuing aspirin before coronary artery bypass grafting surgery: old fears challenged by new evidences. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:S34. [PMID: 27868002 DOI: 10.21037/atm.2016.09.39] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Massimo Chello
- Department of Cardiovascular Sciences, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Antonio Nenna
- Department of Cardiovascular Sciences, Università Campus Bio-Medico di Roma, Rome, Italy
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Kayse R, Becker RC. The case for preoperative aspirin administration in patients undergoing elective CABG: is it open or closed? ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:S26. [PMID: 27867994 DOI: 10.21037/atm.2016.10.31] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Regina Kayse
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Hwang JY, Oh S, Kim CS, Chang JE, Min SW. Perioperative complications following preoperative cessation of antithrombotic agents for total knee arthroplasty: A retrospective study. Medicine (Baltimore) 2016; 95:e5487. [PMID: 27902607 PMCID: PMC5134780 DOI: 10.1097/md.0000000000005487] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The number of elderly patients undergoing total knee arthroplasty (TKA) has steadily increased. Elderly patients undergoing TKA usually have underlying diseases, and some of them take antithrombotic agents for the prevention or treatment of these co-morbidities, including cardiovascular, cerebrovascular, or thromboembolic diseases. When these patients are scheduled to undergo TKA, preoperative cessation of antithrombotic agents is considered on the basis of its risks and benefits. This study was aimed to evaluate the impact of discontinuing antithrombotic agents for primary total knee arthroplasty (TKA) on perioperative complications.Patients who underwent primary TKA between 2008 and 2012 were identified, and classified into two groups: group A, in whom antithrombotic agents were ceased preoperatively, and group B, in which patients did not receive antithrombotic therapy. Patient characteristics, history of antithrombotic therapy, intraoperative blood loss, perioperative blood transfusion, postoperative 30-day complications, and postoperative hospital stay were recorded.Of 885 patients undergoing primary TKA, 218 (24.6%) patients were included in group A, and 667 (75.4%) in group B. Group A received transfusion more frequently than group B (P < 0.001). However, there was no difference between the two groups in terms of intraoperative blood loss, postoperative 30-day complications, and postoperative hospital stay.Patients who discontinued antithrombotic drugs before primary TKA do not have a higher incidence of postoperative 30-day complications, including cardiovascular, cerebrovascular, or thromboembolic events. Moreover, the estimated intraoperative blood loss was not different compared with patients not receiving antithrombotic agents preoperatively. Larger prospective studies of this issue are required.
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Affiliation(s)
| | - Sohee Oh
- Department of Biostatistics, SMG-SNU Boramae Medical Center, Boramae-ro, Dongjak-gu, Seoul, Republic of Korea
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Dual anti-platelet therapy and dento-alveolar surgery. How do we manage patients on anti-platelet medication? Br Dent J 2016; 217:E24. [PMID: 25476660 DOI: 10.1038/sj.bdj.2014.1055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The optimum management of dual anti-platelet therapy (DAPT) in patients undergoing dentoalveolar surgery is controversial. The lack of guidelines has meant clinicians have been left to manage these cases from specialist advice or past experience. In view of this the British Association of Oral Surgeons (BAOS) membership was surveyed to assess current practice. DESIGN An electronic survey consisting of nine closed multiple-choice questions was circulated to all 435 registered BAOS members. A section for open comments was also included. The data was transcribed, organised and reduced to themes by hand and finally analysed. RESULTS One hundred and eighty members completed the questionnaire giving a response rate of 41%. Ninety-two percent of clinicians had direct involvement in managing patients on DAPT and of these 80% had not encountered a bleeding complication. DAPT was continued for simple dental extraction under local anaesthetic by 83% of respondents and 73% for surgical extractions. Two thirds of the respondents did not follow any guidelines but for those that did the most common was the UK Medicines Information protocols. Only 10% of respondents reported a significant post-operative bleeding complication following surgery in patients on DAPT. CONCLUSION This survey confirmed the continued variable management of patients on DAPT undergoing dentoalveolar surgery. Reported bleeding rates were low with over 75% of patients not having their DAPT treatment interrupted.
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Sirvinskas E, Veikutiene A, Grybauskas P, Cimbolaityte J, Mongirdiene A, Veikutis V, Raliene L. Influence of aspirin or heparin on platelet function and postoperative blood loss after coronary artery bypass surgery. Perfusion 2016; 21:61-6. [PMID: 16485701 DOI: 10.1191/0267659106pf845oa] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of the study was to assess the effect of aspirin or heparin pretreatment on platelet function and bleeding in the early postoperative period after coronary artery bypass grafting (CABG) surgery. Seventy-five male patients with coronary artery disease who underwent CABG with cardiopulmonary bypass (CPB) were studied. The patients were divided into three groups: Group 1 ( n = 25) included patients receiving aspirin pretreatment, Group 2 ( n = 22) received heparin pretreatment, and Group 3 ( n = 28) included patients who received no antiplatelet or anticoagulant pretreatment. Twenty-four hours after surgery, all patients were administered aspirin therapy that was continued throughout their hospitalization period. We assessed the following preoperative blood coagulation indices: activated partial thromboplastin time (aPTT), international normalized ratio (INR), and fibrinogen. We compared platelet count and platelet aggregation induced by adenosinediphosphate (ADP) before surgery, 1 h after surgery, 20 h after surgery and on the seventh postoperative day. We assessed drained blood loss within 20 postoperative hours. Preoperative blood coagulation indices did not differ among the groups. Platelet count was also similar. One hour after surgery, platelet count significantly decreased in all groups ( p <0.001), after 20 postoperative hours it did not undergo any marked changes, and on the seventh postoperative day, it significantly increased in all groups ( p <0.001). Before surgery, the lowest index of ADP-induced platelet aggregation was found in Group 1 ( p <0.05). One hour after surgery, platelet aggregation significantly decreased in all groups, most markedly in Group 3 ( p <0.001), yet after 20 h, its restitution tendency and a significant increase in all groups was noted. On the seventh day, a further increase in the statistical mean platelet aggregation value was noted in Groups 2 and 3. Comparison of platelet aggregation after 20 postoperative hours and on the seventh day after surgery revealed a significantly higher than 10% increase of the index in 32% of patients in Group 1 ( p <0.05), 27.3% of patients in Group 2 ( p <0.05) and in 35.7% of patients in Group 3 ( p <0.001). The lowest statistically significant value of postoperative blood loss was noted in Group 2 ( p <0.01). Our study has shown that aspirin or heparin pretreatment had no impact on the dynamics of platelet function in the early postoperative period after CABG. The lowest postoperative blood loss was noted in patients pretreated with heparin.
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Affiliation(s)
- Edmundas Sirvinskas
- Institute for Biomedical Research, Kaunas University of Medicine, Kaunas, Lithuania.
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De Servi S, Morici N, Boschetti E, Rossini R, Martina P, Musumeci G, D'Urbano M, Lazzari L, La Vecchia C, Senni M, Klugmann S, Savonitto S. Bridge therapy or standard treatment for urgent surgery after coronary stent implantation: Analysis of 314 patients. Vascul Pharmacol 2016; 80:85-90. [DOI: 10.1016/j.vph.2015.11.085] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 11/02/2015] [Accepted: 11/27/2015] [Indexed: 11/30/2022]
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Williams DJP. The great ESCAPE - a clinical pharmacologist's journey in stroke research. Br J Clin Pharmacol 2016; 82:334-9. [PMID: 27062549 DOI: 10.1111/bcp.12966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 04/04/2016] [Accepted: 04/04/2016] [Indexed: 11/30/2022] Open
Affiliation(s)
- David J P Williams
- Royal College of Surgeons in Ireland (RCSI) and Beaumont Hospital Dublin, Dublin, Ireland
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Lu SY, Tsai CY, Lin LH, Lu SN. Dental extraction without stopping single or dual antiplatelet therapy: results of a retrospective cohort study. Int J Oral Maxillofac Surg 2016; 45:1293-8. [PMID: 26972159 DOI: 10.1016/j.ijom.2016.02.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 02/07/2016] [Accepted: 02/18/2016] [Indexed: 11/18/2022]
Abstract
The aim of this study was to investigate the incidence of bleeding after dental extraction without stopping antiplatelet therapy. Postoperative bleeding was assessed in a total of 1271 patients who were divided into two groups: a study group comprising 183 patients on antiplatelet therapy (aspirin 125 patients/185 occasions; clopidogrel 42 patients/65 occasions; dual therapy 16 patients/24 occasions) who underwent 548 dental extractions on 274 occasions, and a control group comprising 1088 patients who were not receiving any antiplatelet or anticoagulant therapy and underwent 2487 dental extractions on 1472 occasions. The incidence of postoperative bleeding was higher in the study group (5/274, 1.8%) than in the control group (10/1472, 0.7%), and also in the dual antiplatelet subgroup (1/24, 4.2%) than in the single antiplatelet subgroups (clopidogrel: 2/65, 3.1%; aspirin: 2/185, 1.1%); however, these differences were not significant. Postoperative bleeding was managed successfully by repacking with Gelfoam impregnated with tranexamic acid powder in 12 patients and by resuturing in three of the control patients undergoing extraction of impacted teeth with flap elevation. These findings indicate that there is no need to interrupt antiplatelet drugs before dental extraction.
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Affiliation(s)
- S-Y Lu
- Oral Pathology and Family Dentistry Section, Department of Dentistry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - C-Y Tsai
- Oral Pathology and Family Dentistry Section, Department of Dentistry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - L-H Lin
- Oral Pathology and Family Dentistry Section, Department of Dentistry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - S-N Lu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Myles PS, Smith JA, Forbes A, Silbert B, Jayarajah M, Painter T, Cooper DJ, Marasco S, McNeil J, Bussières JS, Wallace S. Stopping vs. Continuing Aspirin before Coronary Artery Surgery. N Engl J Med 2016; 374:728-37. [PMID: 26933848 DOI: 10.1056/nejmoa1507688] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Most patients with coronary artery disease receive aspirin for primary or secondary prevention of myocardial infarction, stroke, and death. Aspirin poses a risk of bleeding in patients undergoing surgery, but it is unclear whether aspirin should be stopped before coronary artery surgery. METHODS We used a 2-by-2 factorial trial design to randomly assign patients who were scheduled to undergo coronary artery surgery and were at risk for perioperative complications to receive aspirin or placebo and tranexamic acid or placebo. The results of the aspirin trial are reported here. Patients were randomly assigned to receive 100 mg of aspirin or matched placebo preoperatively. The primary outcome was a composite of death and thrombotic complications (nonfatal myocardial infarction, stroke, pulmonary embolism, renal failure, or bowel infarction) within 30 days after surgery. RESULTS Among 5784 eligible patients, 2100 were enrolled; 1047 were randomly assigned to receive aspirin and 1053 to receive placebo. A primary outcome event occurred in 202 patients in the aspirin group (19.3%) and in 215 patients in the placebo group (20.4%) (relative risk, 0.94; 95% confidence interval, 0.80 to 1.12; P=0.55). Major hemorrhage leading to reoperation occurred in 1.8% of patients in the aspirin group and in 2.1% of patients in the placebo group (P=0.75), and cardiac tamponade occurred at rates of 1.1% and 0.4%, respectively (P=0.08). CONCLUSIONS Among patients undergoing coronary artery surgery, the administration of preoperative aspirin resulted in neither a lower risk of death or thrombotic complications nor a higher risk of bleeding than that with placebo. (Funded by the Australian National Health and Medical Research Council and others; Australia New Zealand Clinical Trials Registry number, ACTRN12605000557639.).
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Affiliation(s)
- Paul S Myles
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Julian A Smith
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Andrew Forbes
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Brendan Silbert
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Mohandas Jayarajah
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Thomas Painter
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - D James Cooper
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Silvana Marasco
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - John McNeil
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Jean S Bussières
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Sophie Wallace
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
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Nenna A, Spadaccio C, Prestipino F, Lusini M, Sutherland FW, Beattie GW, Petitti T, Nappi F, Chello M. Effect of Preoperative Aspirin Replacement With Enoxaparin in Patients Undergoing Primary Isolated On-Pump Coronary Artery Bypass Grafting. Am J Cardiol 2016; 117:563-570. [PMID: 26721653 DOI: 10.1016/j.amjcard.2015.11.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 11/19/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
Abstract
Management of preoperative antiplatelet therapy in coronary artery bypass grafting (CABG) is variable among surgeons: guidelines collide with prejudices because replacement of aspirin with low-molecular-weight heparin is still performed because of a presumed minor bleeding risk. This study aims to analyze postoperative bleedings and complications in patients scheduled for elective primary isolated on-pump CABG, depending on preoperative aspirin treatment or its replacement with enoxaparin. In this cohort study, we propensity score matched 200 patients in whom aspirin was stopped at least 5 days before CABG and replaced with enoxaparin and 200 patients who continued aspirin therapy until the day before surgery. Postoperative bleedings and complications were monitored during hospitalization. Among patients who continued aspirin treatment, mean overall bleeding was 701.0 ± 334.6 ml, whereas in the matched enoxaparin group, it was significantly greater (882.6 ± 64.6 ml, p value <0.001); this was associated with reduced postoperative complications, lower values of postoperative C-reactive protein in aspirin takers, and a presumed protective effect for statins. After propensity score adjustment, aspirin treatment carried a protective effect against major postoperative bleeding (odds ratio 0.312, p = 0.001). In conclusion, postoperative bleeding is reduced in patients who continued aspirin, likely due to a reduction in postoperative inflammation. The practice of empirically discontinuing aspirin and replacing it with enoxaparin before CABG should be abandoned. Patients with coronary artery disease referred to CABG should continue antiplatelet medications until the surgical procedure. Those results might be extended to patients under oral anticoagulant therapy requiring CABG.
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67
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Bacquelin R, Oger E, Filippi E, Hacot JP, Auffret V, Le Guellec M, Coudert I, Castellant P, Moquet B, Druelles P, Rialan A, Rouault G, Boulanger B, Treuil J, Leurent G, Bedossa M, Boulmier D, Avez B, Gilard M, Le Breton H. Safety of prasugrel in real-world patients with ST-segment elevation myocardial infarction: 1-year results from a prospective observational study (Bleeding and Myocardial Infarction Study). Arch Cardiovasc Dis 2015; 109:31-8. [PMID: 26514325 DOI: 10.1016/j.acvd.2015.08.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 06/19/2015] [Accepted: 08/29/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Antiplatelet therapies, including prasugrel, are a cornerstone in the treatment of ST-segment elevation myocardial infarction (STEMI), but are associated with a bleeding risk. This risk has been evaluated in randomized trials, but few data on real-world patients are available. AIM To evaluate prasugrel safety in real-world patients with STEMI. METHODS Consecutive patients with STEMI were recruited over 1 year. Follow-up was done at 3 months and 1 year to evaluate prasugrel safety from hospital discharge to the STEMI anniversary date. The primary outcome was occurrence of any major bleeding according to the Bleeding Academic Research Consortium (BARC) 3 or 5 definitions, or minor bleeding according to the BARC 2 definition. RESULTS Overall, 1083 patients were recruited. Compared to patients treated with aspirin+clopidogrel, patients treated with aspirin+prasugrel had fewer BARC 3 or 5 bleedings (two [0.4%] patients vs. nine [1.8%] patients; P=0.04), but more BARC 2 bleedings (45 [9.3%] patients vs. 20 [4.0%] patients; P<0.001). The baseline characteristics of prasugrel- and clopidogrel-treated patients differed because the former were carefully selected (younger, higher body mass index, less frequent history of stroke). In the overall population, rates of in-hospital and out-of-hospital major bleeding were 2.6% (n=28) and 1.3% (n=13), respectively. CONCLUSION The rate of major bleeding, particularly out-of-hospital bleeding, in patients treated with prasugrel is low within 1 year after a STEMI. Accurate selection of patient candidates for prasugrel is likely to have reduced the risk of bleeding.
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Affiliation(s)
- Raoul Bacquelin
- Department of Cardiology, Rennes University Hospital, 35000 Rennes, France; Rennes 1 University, LTSI, 35000 Rennes, France.
| | - Emmanuel Oger
- Rennes 1 University, LTSI, 35000 Rennes, France; Centre d'investigation clinique, INSERM CIC 0203, 35000 Rennes, France
| | | | | | - Vincent Auffret
- Department of Cardiology, Rennes University Hospital, 35000 Rennes, France; Rennes 1 University, LTSI, 35000 Rennes, France
| | | | - Isabelle Coudert
- Emergency Service, Rennes University Hospital, 35000 Rennes, France
| | | | - Benoît Moquet
- Centre hospitalier Yves-Le-Foll, 22000 Saint-Brieuc, France
| | - Philippe Druelles
- Department of Cardiology, clinique Saint-Laurent, 35000 Rennes, France
| | - Antoine Rialan
- Centre hospitalier de Saint-Malo, 35400 Saint-Malo, France
| | - Gilles Rouault
- Centre hospitalier de Cornouaille, 29000 Quimper, France
| | | | - Josiane Treuil
- Emergency Service, Brest University Hospital, 29200 Brest, France
| | - Guillaume Leurent
- Department of Cardiology, Rennes University Hospital, 35000 Rennes, France; Rennes 1 University, LTSI, 35000 Rennes, France
| | - Marc Bedossa
- Department of Cardiology, Rennes University Hospital, 35000 Rennes, France; Rennes 1 University, LTSI, 35000 Rennes, France
| | - Dominique Boulmier
- Department of Cardiology, Rennes University Hospital, 35000 Rennes, France; Rennes 1 University, LTSI, 35000 Rennes, France
| | - Bertrand Avez
- Centre hospitalier Yves-Le-Foll, 22000 Saint-Brieuc, France
| | - Martine Gilard
- Department of Cardiology, Brest University Hospital, 29200 Brest, France
| | - Hervé Le Breton
- Department of Cardiology, Rennes University Hospital, 35000 Rennes, France; Rennes 1 University, LTSI, 35000 Rennes, France; INSERM U1099, 35000 Rennes, France
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Dundon JM, Trimba R, Bree KJ, Woods CJ, Laughlin RT. Recommendations for Perioperative Management of Patients on Existing Anticoagulation Therapy. JBJS Rev 2015; 3:01874474-201509000-00002. [PMID: 27490669 DOI: 10.2106/jbjs.rvw.n.00105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- John M Dundon
- Department of Orthopaedic Surgery, Sports Medicine & Rehabilitation, Boonshoft School of Medicine, Wright State University, 30 East Apple Street, Suite 2200, Dayton, OH 45409
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Mishra PK, Thekkudan J, Sahajanandan R, Gravenor M, Lakshmanan S, Fayaz KM, Luckraz H. The role of point-of-care assessment of platelet function in predicting postoperative bleeding and transfusion requirements after coronary artery bypass grafting. Ann Card Anaesth 2015; 18:45-51. [PMID: 25566711 PMCID: PMC4900327 DOI: 10.4103/0971-9784.148321] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE OBJECTIVE platelet function assessment after cardiac surgery can predict postoperative blood loss, guide transfusion requirements and discriminate the need for surgical re-exploration. We conducted this study to assess the predictive value of point-of-care testing platelet function using the Multiplate® device. METHODS Patients undergoing isolated coronary artery bypass grafting were prospectively recruited ( n = 84). Group A ( n = 42) patients were on anti-platelet therapy until surgery; patients in Group B ( n = 42) stopped anti-platelet treatment at least 5 days preoperatively. Multiplate® and thromboelastography (TEG) tests were performed in the perioperative period. Primary end-point was excessive bleeding (>2.5 ml/kg/h) within first 3 h postoperative. Secondary end-points included transfusion requirements, re-exploration rates, intensive care unit and in-hospital stays. RESULTS Patients in Group A had excessive bleeding (59% vs. 33%, P = 0.02), higher re-exploration rates (14% vs. 0%, P < 0.01) and higher rate of blood (41% vs. 14%, P < 0.01) and platelet (14% vs. 2%, P = 0.05) transfusions. On multivariate analysis, preoperative platelet function testing was the most significant predictor of excessive bleeding (odds ratio [OR]: 2.3, P = 0.08), need for blood (OR: 5.5, P < 0.01) and platelet transfusion (OR: 15.1, P < 0.01). Postoperative "ASPI test" best predicted the need for transfusion (sensitivity - 0.86) and excessive blood loss (sensitivity - 0.81). TEG results did not correlate well with any of these outcome measures. CONCLUSIONS Peri-operative platelet functional assessment with Multiplate® was the strongest predictor for bleeding and transfusion requirements in patients on anti-platelet therapy until the time of surgery.
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Affiliation(s)
- Pankaj Kumar Mishra
- Department of Cardiothoracic Surgery, Heart and Lung Centre, Wolverhampton, United Kingdom WV10 0QP,
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70
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Becker RC, Helmy T. Are at least 12 months of dual antiplatelet therapy needed for all patients with drug-eluting stents? Not all patients with drug-eluting stents need at least 12 months of dual antiplatelet therapy. Circulation 2015; 131:2010-9; discussion 2019. [PMID: 26034083 DOI: 10.1161/circulationaha.114.013281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Richard C Becker
- From Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, OH.
| | - Tarek Helmy
- From Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, OH
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Leavitt DA, Theckumparampil N, Moreira DM, Elsamra SE, Waingankar N, Hoenig DM, Smith AD, Okeke Z. Continuing aspirin therapy during percutaneous nephrolithotomy: unsafe or under-utilized? J Endourol 2015; 28:1399-403. [PMID: 25393457 DOI: 10.1089/end.2014.0235] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Aspirin, as an inhibitor of platelets, is traditionally discontinued prior to percutaneous nephrolithotomy (PCNL) given the concern for increased surgical hemorrhage. However, this practice is based on expert opinion only, and mounting evidence suggests holding aspirin perioperatively can be more harmful than once thought. We sought to compared PCNL outcomes and complications in patients continuing aspirin to those stopping aspirin perioperatively. METHODS A retrospective review was performed of 321 consecutive PCNLs done between July 2012 and March 2014. Patients were separated into two groups. The on-aspirin group consisted of patients continuing aspirin throughout the perioperative period. The off-aspirin group had aspirin held temporarily pre- and postoperatively. Surgical outcomes and complications were compared between groups. RESULTS Of the 321 PCNLs, 60 (18.7%) occurred in patients chronically taking aspirin. The on-aspirin group included 17 PCNLs (5.2%), while the off-aspirin group included 43 PCNLs (13.4%). There were no differences between groups in terms of operative time (77 minutes vs 74 minutes, p=0.212), hemoglobin change (p=0.522), stone size (21 mm vs 22 mm, p=1.0), stone-free rate (p=0.314), median length of hospitalization (p=0.642), transfusion rate (p=0.703), or total complications (p=1.0). No patient experienced a thromboembolic event. CONCLUSIONS PCNL is safe in patients continuing aspirin perioperatively and does not result in more blood transfusions, angioembolization procedures, or complications. Patients with large stone burdens who are at high risk for thromboembolic events appear to be able to safely undergo PCNL without discontinuing aspirin.
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Affiliation(s)
- David A Leavitt
- The Smith Institute for Urology , Hofstra North Shore Long Island Jewish School of Medicine, New Hyde Park, New York
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Madhavan MV, Généreux P, Kirtane AJ, Xu K, Witzenbichler B, Mehran R, Stone GW. Is routine post-procedural anticoagulation warranted after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction? Insights from the HORIZONS-AMI trial. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 6:650-658. [DOI: 10.1177/2048872615592246] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Mahesh V Madhavan
- Columbia University Medical Center, New York-Presbyterian Hospital, USA
| | - Philippe Généreux
- Columbia University Medical Center, New York-Presbyterian Hospital, USA
- Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Canada
| | - Ajay J Kirtane
- Columbia University Medical Center, New York-Presbyterian Hospital, USA
- Cardiovascular Research Foundation, USA
| | - Ke Xu
- Cardiovascular Research Foundation, USA
| | | | - Roxana Mehran
- Cardiovascular Research Foundation, USA
- Icahn School of Medicine at Mount Sinai, USA
| | - Gregg W Stone
- Columbia University Medical Center, New York-Presbyterian Hospital, USA
- Cardiovascular Research Foundation, USA
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Kristensen SD, Grove EL, Maeng M. Coronary stents and non-cardiac surgery: to bridge or not to bridge? Thromb Haemost 2015; 114:211-3. [PMID: 26018636 DOI: 10.1160/th15-04-0305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 04/13/2015] [Indexed: 11/05/2022]
Affiliation(s)
- S D Kristensen
- Prof. Steen Dalby Kristensen, Department of Cardiology, Aarhus University Hospital, DK-8200 Aarhus N, Denmark, E-mail:
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Does aspirin administration increase perioperative morbidity in patients with cardiac stents undergoing spinal surgery? Spine (Phila Pa 1976) 2015; 40:629-35. [PMID: 26030214 DOI: 10.1097/brs.0000000000000695] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cohort. OBJECTIVE To compare the perioperative morbidity of patients with cardiac stents after spine surgery who continue to take aspirin before and after the operation with a similar group of patients who preoperatively discontinued aspirin. SUMMARY OF BACKGROUND DATA The preoperative discontinuation of anticoagulant therapy has been the standard of care for orthopedic surgical procedures. However, recent literature has demonstrated significant cardiac risk associated with aspirin withdrawal in patients with cardiac stents. Although it has recently been demonstrated that performing orthopedic surgery while continuing low-dose aspirin therapy seems to be safe, studies focused on spinal surgery have not yet been performed. Because of the risk of intraspinal bleeding and the serious consequences of subsequent epidural hematoma with associated spinal cord compression, spinal surgeons have been reluctant to operate on patients taking aspirin. METHODS This institutional review board-approved study included 200 patients. Preoperative parameters and postoperative outcome measures were analyzed for 100 patients who underwent spinal surgery after the discontinuation of anticoagulation therapy and 100 patients who continued to take daily aspirin through the perioperative period. The primary outcome measure was serious bleeding-related postoperative complications such as spinal epidural hematoma. The operative time, intraoperative estimated blood loss, hospital length of stay, transfusion of blood products, and 30-day hospital readmission rates were also recorded and compared. RESULTS The patients who continued taking aspirin in the perioperative period had a shorter hospital length of stay on average (4.1 ± 2.7 vs. 6.2 ± 5.8; P < 0.005), as well as a reduced operative time (210 ± 136 vs. 266 ± 143; P < 0.01), whereas there was no significant difference in the estimated blood loss (642 ± 905 vs. 697 ± 1187), the amount of blood products transfused, overall intra- and postoperative complication rate (8% vs. 11%), or 30-day hospital readmission rate (5% vs. 5%). No clinically significant spinal epidural hematomas were observed in either of the study groups. CONCLUSION The current study has observed no appreciable increase in bleeding-related complication rates in patients with cardiac stents undergoing spine surgery while continuing to take aspirin compared with patients who discontinued aspirin prior to surgery. Although very large studies will be needed to determine whether aspirin administration results in a small complication rate increase, the current study provides evidence that perioperative aspirin therapy is relatively safe in patients undergoing spinal surgery. LEVEL OF EVIDENCE 2.
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Palamaras I, Semkova K. Perioperative management of and recommendations for antithrombotic medications in dermatological surgery. Br J Dermatol 2015; 172:597-605. [DOI: 10.1111/bjd.13362] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2014] [Indexed: 12/30/2022]
Affiliation(s)
- I. Palamaras
- Department of Dermatology; Barnet General Hospital; Royal Free Foundation Trust; Wellhouse Lane Barnet EN5 3DJ London U.K
| | - K. Semkova
- Department of Dermatology and Venereology; Medical University-Sofia; Sofia Bulgaria
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Franchitti J, Desmaizières M, Reuter PG, Galinski M, Adnet F, Lapostolle F. [Patient knowledge about their treatment according to the therapeutic class: misplaced antiplatelet]. Presse Med 2015; 44:354-6. [PMID: 25559660 DOI: 10.1016/j.lpm.2014.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 10/01/2014] [Accepted: 10/08/2014] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jessica Franchitti
- SAMU 93 - UF Recherche-Enseignement-Qualité, université Paris 13, Sorbonne Cité, EA 3509, Bobigny, France
| | - Michel Desmaizières
- SAMU 93 - UF Recherche-Enseignement-Qualité, université Paris 13, Sorbonne Cité, EA 3509, Bobigny, France
| | - Paul-Georges Reuter
- SAMU 93 - UF Recherche-Enseignement-Qualité, université Paris 13, Sorbonne Cité, EA 3509, Bobigny, France
| | - Michel Galinski
- SAMU 93 - UF Recherche-Enseignement-Qualité, université Paris 13, Sorbonne Cité, EA 3509, Bobigny, France
| | - Frédéric Adnet
- SAMU 93 - UF Recherche-Enseignement-Qualité, université Paris 13, Sorbonne Cité, EA 3509, Bobigny, France
| | - Frédéric Lapostolle
- SAMU 93 - UF Recherche-Enseignement-Qualité, université Paris 13, Sorbonne Cité, EA 3509, Bobigny, France.
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Sáez ME, González-Pérez A, Johansson S, Nagy P, Rodríguez LAG. Patterns of Antiplatelet Therapy in Patients Who Have Experienced an Acute Coronary Event: A Descriptive Study in UK Primary Care. J Cardiovasc Pharmacol Ther 2014; 20:378-86. [PMID: 25501499 DOI: 10.1177/1074248414562910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 11/05/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Antiplatelet (AP) therapy is well established for the secondary prevention of acute coronary events. However, patients may discontinue treatment, often owing to gastrointestinal (GI) complications, leaving them at elevated risk of recurrent cardiovascular events. OBJECTIVES This descriptive retrospective study assessed trends in prescription of AP agents and coprescription of gastroprotective therapy, after an acute coronary event. Discontinuation of AP therapy within 2 years of an event and factors predicting discontinuation were investigated. METHODS The study was conducted in a UK primary care setting from 2000 to 2008; a total of 27, 351 patients aged 50 to 84 years were included in the analysis. Main outcome measures were exposures to low-dose acetylsalicylic acid (ASA), clopidogrel, and proton pump inhibitors (PPIs). RESULTS At 90 days after an acute coronary event, 85.9% of patients had been prescribed some form of AP therapy and 33.6% of patients who were issued at least 1 ASA prescription in this period were also issued a PPI prescription. The use of dual antiplatelet therapy (DAT) 90 days after an event increased from 2% in 2000 to over 50% in 2008. An estimated 15.1% of patients on ASA monotherapy and 37.5% on DAT discontinued treatment within 1 year. A bleeding event during follow-up, including upper GI bleeding or hemorrhagic stroke, was the strongest predictor of discontinuation. CONCLUSION Although most patients were prescribed AP therapy in the 90 days following an acute coronary event, a substantial proportion discontinued DAT or ASA monotherapy within 1 year. It is essential that physicians consider strategies to reduce the risk of discontinuation of AP therapy.
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Affiliation(s)
- María E Sáez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain Andalusian Bioinformatics Research Centre (CAEBi), Seville, Spain
| | - Antonio González-Pérez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain Andalusian Bioinformatics Research Centre (CAEBi), Seville, Spain
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78
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Kong KL, Khan J. Ophthalmic patients on antithrombotic drugs: a review and guide to perioperative management. Br J Ophthalmol 2014; 99:1025-30. [DOI: 10.1136/bjophthalmol-2014-306036] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 11/09/2014] [Indexed: 12/14/2022]
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79
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Brachemi S, Bollée G. Renal biopsy practice: What is the gold standard? World J Nephrol 2014; 3:287-294. [PMID: 25374824 PMCID: PMC4220363 DOI: 10.5527/wjn.v3.i4.287] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 07/22/2014] [Accepted: 09/10/2014] [Indexed: 02/06/2023] Open
Abstract
Renal biopsy (RB) is useful for diagnosis and therapy guidance of renal diseases but incurs a risk of bleeding complications of variable severity, from transitory haematuria or asymptomatic hematoma to life-threatening hemorrhage. Several risk factors for complications after RB have been identified, including high blood pressure, age, decreased renal function, obesity, anemia, low platelet count and hemostasis disorders. These should be carefully assessed and, whenever possible, corrected before the procedure. The incidence of serious complications has become low with the use of automated biopsy devices and ultrasound guidance, which is currently the “gold standard” procedure for percutaneous RB. An outpatient biopsy may be considered in a carefully selected population with no risk factor for bleeding. However, controversies persist on the duration of observation after biopsy, especially for native kidney biopsy. Transjugular RB and laparoscopic RB represent reliable alternatives to conventional percutaneous biopsy in patients at high risk of bleeding, although some factors limit their use. This aim of this review is to summarize the issues of complications after RB, assessment of hemorrhagic risk factors, optimal biopsy procedure and strategies aimed to minimize the risk of bleeding.
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80
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The use of perioperative antithrombotics in posterior segment ocular surgery. Am J Ophthalmol 2014; 158:858-9. [PMID: 25437829 DOI: 10.1016/j.ajo.2014.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 08/02/2014] [Accepted: 08/04/2014] [Indexed: 11/20/2022]
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81
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Madhavan MV, Généreux P, Kirtane AJ, Xu K, Witzenbichler B, Mehran R, Stone GW. Postprocedural anticoagulation for specific therapeutic indications after revascularization for ST-segment elevation myocardial infarction (from the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction Trial). Am J Cardiol 2014; 114:1322-8. [PMID: 25239828 DOI: 10.1016/j.amjcard.2014.07.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 07/30/2014] [Accepted: 07/30/2014] [Indexed: 11/19/2022]
Abstract
Postprocedural anticoagulation (AC) after primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) may be administered for a number of specific therapeutic indications (e.g. atrial fibrillation or left ventricular thrombus). However, the safety and effectiveness of such post-PCI AC for specific indications are not well defined. Thus, we sought to study outcomes after postprocedural AC for specific indications in patients undergoing primary PCI for STEMI in the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial. Patients who underwent primary PCI for STEMI in the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial were grouped according to whether they received specific indication AC. Adverse outcomes were assessed using propensity-adjusted multivariate analyses. After excluding patients who received post-PCI AC solely for routine prophylaxis, 410 patients (16.6%) received postprocedural AC for specific indications and 2,063 patients (83.4%) received no post-PCI AC. After propensity adjustment, use of postprocedural AC for specific indications was associated with higher rates of cardiac mortality, reinfarction, stent thrombosis, and major bleeding at 30 days compared with patients who received no AC post-PCI. In conclusion, in this large prospective study, use of postprocedural AC for specific indications after primary PCI for STEMI was independently associated with early rates of adverse ischemic and hemorrhagic outcomes. Post-PCI AC for specific indications was also associated with worse outcomes from 30 days to 3 years. Further studies are warranted to determine the optimal use of postprocedural AC after primary PCI in STEMI.
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Affiliation(s)
- Mahesh V Madhavan
- Department of Medicine, Division of Cardiology, New York-Presbyterian Hospital and the Columbia University Medical Center, New York, New York
| | - Philippe Généreux
- Department of Medicine, Division of Cardiology, New York-Presbyterian Hospital and the Columbia University Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York; Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Quebec, Canada
| | - Ajay J Kirtane
- Department of Medicine, Division of Cardiology, New York-Presbyterian Hospital and the Columbia University Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Ke Xu
- Cardiovascular Research Foundation, New York, New York
| | | | - Roxana Mehran
- Cardiovascular Research Foundation, New York, New York; Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gregg W Stone
- Department of Medicine, Division of Cardiology, New York-Presbyterian Hospital and the Columbia University Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York.
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82
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Leavitt DA, Theckumparampil N, Moreira DM, Elsamra SE, Morganstern B, Hoenig DM, Smith AD, Okeke Z. Percutaneous nephrolithotomy during uninterrupted aspirin therapy in high-cardiovascular risk patients: preliminary report. Urology 2014; 84:1034-8. [PMID: 25443896 DOI: 10.1016/j.urology.2014.06.076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 04/11/2014] [Accepted: 06/02/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine the feasibility and safety of performing percutaneous nephrolithotomy (PCNL) in high-cardiovascular risk patients remaining on aspirin therapy. METHODS We retrospectively reviewed all PCNLs performed by 3 fellowship-trained endourologists at a single institution between July 2012 and January 2014. All patients remaining on aspirin for imperative indications through the day of surgery were evaluated for surgical outcomes and thromboembolic events. RESULTS Of 281 PCNL procedures performed during the study period, 16 (5.7%) were performed in 14 patients taking aspirin, uninterrupted, through surgery. Mean surgery time was 66 minutes, mean estimated blood loss was 161 mL, and mean length of hospital stay was 2.8 days. All patients were stone free. There were no intraoperative complications. A total of 5 patients experienced a postoperative complication (n = 4, Clavien grade II; n = 1, Clavien grade IIIa). No patient experienced a perioperative thromboembolic or cardiac event. Three patients required a blood transfusion postoperatively, and none experienced delayed renal bleeding. CONCLUSION PCNL can be performed safely and effectively in high-cardiovascular risk patients continuing aspirin perioperatively. Compared with the potential sequelae of a thromboembolic or cardiac event, PCNL is associated with an acceptably low transfusion rate, and should be considered a viable treatment option for large renal stones in this population.
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Affiliation(s)
- David A Leavitt
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY.
| | - Nithin Theckumparampil
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY
| | - Daniel M Moreira
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY
| | - Sammy E Elsamra
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY
| | - Bradley Morganstern
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY
| | - David M Hoenig
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY
| | - Arthur D Smith
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY
| | - Zeph Okeke
- The Arthur Smith Institute for Urology, Hofstra North Shore-Long Island Jewish School of Medicine, New Hyde Park, NY
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83
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Abstract
The rising use of antiplatelet therapy for primary prevention and secondary prevention of cardiovascular and cerebrovascular events poses a dilemma for physicians in the perioperative period. The proven benefits of aspirin in preventing further thrombotic events in patients with prior ACS or stroke make it difficult to withdraw this therapy. The risk of hypercoagulability associated with surgery is also independent of antiplatelet withdrawal, but adds to the rebound effect of platelet responsiveness. Therefore, aspirin should be continued whenever feasible. Similarly, the use of thienopyridines such as clopidogrel, especially for the prevention of stent thrombosis, should be maintained for at least the recommended time frame, if not longer. It is recognized that maintaining antiplatelet therapy is also not without risk, as bleeding complications have been well documented. Unfortunately, current perioperative guidelines do not often provide a simple solution for management. Therefore, the risk of bleeding has to be weighed against the risk of thrombosis, and decisions should be made with all providers caring for the patient on an individual basis.
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84
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Leavitt DA, Theckumparampil N, Moreira DM, Elsamra S, Waingankar N, Hoenig DM, Smith A, Okeke Z. Continuing Aspirin Therapy During Percutaneous Nephrolithotomy: Unsafe or Under-utilized? J Endourol 2014. [DOI: 10.1089/end.2014.0235.ecc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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85
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Hamon M, Lemesle G, Tricot O, Meurice T, Deneve M, Dujardin X, Brufau JM, Bera J, Lamblin N, Bauters C. Incidence, Source, Determinants, and Prognostic Impact of Major Bleeding in Outpatients With Stable Coronary Artery Disease. J Am Coll Cardiol 2014; 64:1430-6. [DOI: 10.1016/j.jacc.2014.07.957] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 06/21/2014] [Accepted: 07/01/2014] [Indexed: 11/25/2022]
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86
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Kammerer T, Beiras-Fernandez A, Rehm M, Stangl M, Guba M, Kupatt-Jeremias C, Weis F. Use of drug-eluting balloon coronary intervention prior to living donor kidney transplantation. BMC Cardiovasc Disord 2014; 14:112. [PMID: 25179749 PMCID: PMC4162970 DOI: 10.1186/1471-2261-14-112] [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: 01/30/2014] [Accepted: 08/19/2014] [Indexed: 11/11/2022] Open
Abstract
Background Kidney transplantation is the gold standard of therapy in patients with terminal renal insufficiency. Living donor transplantation is a well-established option in this field. Enlarging the donor’s pool implicates the acceptance of an increased rate of comorbidities. Among them, coronary artery disease is a growing problem. An increasing number of patients, undergoing living donation, receive antiplatelet therapies due to coronary disease. Case presentation Here we report about the perioperative treatment with a drug-eluting balloon in a patient with major cardiac risk factors who underwent kidney transplantation. Conclusion At the current time no recommendation can be given for the routine use of drug-eluting balloons.
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Affiliation(s)
| | - Andres Beiras-Fernandez
- Department of Thoracic and Cardiovascular Surgery, University Hospital, JW Goethe-University, Theodor-Stern-Kai 7, 61590 Frankfurt, Germany.
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87
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Omar HR, Sprenker C, Karlnoski R, Camporesi EM, Mangar D. Late and very late drug-eluting stent thrombosis in the immediate postoperative period after antiplatelet withdrawal: a retrospective study. Ther Adv Cardiovasc Dis 2014; 8:185-92. [DOI: 10.1177/1753944714542592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: Late (31–360 days after deployment) and very late (>360 days after deployment) stent thrombosis is a feared complication after drug-eluting stent (DES) deployment. The American College of Cardiology/American Heart Association guidelines recommend dual antiplatelet therapy for 12 months due to the lack of protection beyond this period in randomized trials. The perioperative period is a unique state of generalized hypercoagulability which can predispose people to DES thrombosis when combined with the rebound hypercoagulable effect of antiplatelet withdrawal. Methods: A retrospective chart review was performed to detect incidences of late and very late postoperative DES thrombosis after elective noncardiac surgery. Only definite and probable cases of stent thrombosis were included. All cases were analyzed for patient demographics, comorbidities, type of surgery, intervention history, preoperative antiplatelets management, postoperative course and outcome. Results: A total of six patients with prior DES deployment (10–42 months earlier, average 30 months) developed DES thrombosis (five very late and one late) in the immediate postoperative period. All patients had stable coronary artery disease and were cleared for surgery (intermediate cardiac risk surgery) by their cardiologist. In all patients, antiplatelets were discontinued 4–7 days (average 5.6 days) prior to surgery to minimize operative bleeding. Five of six patients developed ST-segment elevation myocardial infarction. Half of the patients had simultaneous two-vessel DES thrombosis and two cases had single vessel thrombosis. Three patients developed ventricular fibrillation and cardiac arrest. One-third of the patients died during the index hospitalization. Coronary thrombectomy and angioplasty was successful in the remaining four cases. The incidence of postoperative late and very late DES thrombosis among all patients undergoing noncardiac surgery who were older than 40 years was 0.006%. Conclusion: Caution should be exercised when attempting to withdraw antiplatelets preoperatively in patients with DES even when the recommended 12-month period of dual antiplatelet therapy (DAPT) has elapsed. The significant morbidity and mortality of this complication warrants further research to study the ideal perioperative management of antiplatelets in patients with prior DES deployment over 1 year who are still receiving DAPT.
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Affiliation(s)
- Hesham R. Omar
- Internal Medicine Department, Mercy Medical Center, Clinton, IA 52732, USA
| | - Collin Sprenker
- Florida Gulf to Bay Anesthesiology Associates LLC, Tampa, FL, USA
| | - Rachel Karlnoski
- Florida Gulf to Bay Anesthesiology Associates LLC, Tampa, FL, USA
| | - Enrico M. Camporesi
- Department of Surgery/Anesthesiology, Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, FL, USA
| | - Devanand Mangar
- Tampa General Hospital and Florida Gulf to Bay Anesthesiology Associates LLC, Tampa, FL, USA
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88
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Fischer C, Lümmen G. [ASA and clopidogrel for urological operations. Perioperative management]. Urologe A 2014; 52:1597-605. [PMID: 24121474 DOI: 10.1007/s00120-013-3263-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In a systematic overview and meta-analysis among more than 50,000 patients at risk for coronary artery disease, not adhering to or discontinuing aspirin (acetylsalicylic acid, ASA) was associated with a significantly increased risk of non-fatal myocardial infarction or death. Withdrawal of low dose aspirin was correlated with a threefold increase in the risk of adverse cardiovascular events. This risk is present irrespective of the length of time patients had been taking low dose aspirin. Therefore, in patients on chronic low dose aspirin for secondary prevention of cardiovascular disease, aspirin should never be discontinued. In the few available studies in urological surgery the increase in bleeding does not translate into a significant increase in specific morbidity. This seems to be also true for the additional administration of clopidogrel to aspirin. Nevertheless, in patients with drug-eluting stents and dual antiplatelet therapy, urologists should ensure a multidisciplinary management of the perioperative course.
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89
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Manaqibwala MI, Butler KA, Sagebien CA. Complications of hip fracture surgery on patients receiving clopidogrel therapy. Arch Orthop Trauma Surg 2014; 134:747-53. [PMID: 24682494 DOI: 10.1007/s00402-014-1981-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Clopidogrel (Plavix(®)) may influence patient safety during fracture surgery. Our study examines the incidence of complications for patients undergoing hemiarthroplasty on clopidogrel therapy. MATERIALS AND METHODS All patients, who underwent hemiarthroplasty between 2005 and 2011 were retrospectively reviewed. Patients were placed in two comparative groups based on the use of clopidogrel antiplatelet therapy. Records were reviewed for patient demographics, ASA score, pre and postoperative hemoglobin, time to surgery, length of stay, bleeding events, transfusions and complications. Comparative statistical analysis was performed using Fisher's exact test and Student's t test, using P < 0.05 to identify statistical significance. RESULTS A total of 203 charts were reviewed, of which 162 patients met inclusion/exclusion criteria. One hundred and twelve females and 50 males with mean age of 84 years were identified. The clopidogrel group consisted of 15 (9.3 %) patients and the nonclopidogrel group 147 (90.7 %). The clopidogrel group had more comorbidities resulting in a significantly higher ASA score (3.9 vs. 2.9), and lower preoperative hemoglobin (11.3 vs. 12.0). There was no significant difference identified in time to surgery, intraoperative blood loss, hemoglobin on days 1-3, or number of transfusions received between groups. Patients on clopidogrel were seen to have significantly longer hospital stays (10.6 vs. 7.4 days). However, a similar rate of wound and bleeding related complications (6.7 vs. 6.1 %) was seen. CONCLUSIONS The optimal treatment for hip fracture patients on antiplatelet therapy is unclear. However, in this study there appears to be no significant difference with regards to bleeding and bleeding related wound complications, suggesting it is safe to proceed with hemiarthroplasty for patients receiving clopidogrel.
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Affiliation(s)
- Moiz I Manaqibwala
- Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, New Brunswick, NJ, 08901, USA,
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90
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Bleeding complications in patients with coronary stents during non-cardiac surgery. Thromb Res 2014; 134:268-72. [PMID: 24913999 DOI: 10.1016/j.thromres.2014.05.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 05/12/2014] [Accepted: 05/12/2014] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Patients with coronary stents often undergo non-cardiac invasive procedures. These are often associated with thrombotic and/or hemorrhagic complications. The type of procedure, perioperative antiplatelet therapy, and other patient-related factors influence the risk of postoperative haemorrhage. Our objective was to analyze the postoperative risk factors for hemorrhagic complications and to determine the impact of antiplatelet and anticoagulant therapy strategies on postoperative bleeding risk in patients with coronary stents undergoing non-cardiac surgery. PATIENTS AND METHODS Prospective, multicentre observational cohort study of 1134 consecutive patients with coronary stents undergoing non-cardiac surgery between April 2007 and April 2009. The primary outcome measure was the occurrence of an hemorrhagic complication during the first 30days following the surgery or intervention. RESULTS Among the 1134 patients evaluated, 108 (9.5%) experienced a postoperative hemorrhagic complication (with a median time to occurrence of 5.3days). These complications were considered major, involved the operative site, and required reoperation in 92 (85.2%), 92 (85.2%), and 20 (18.5%) of patients, respectively. Mortality in patients with a haemorrhagic complication was 12% (n=13). Independent postoperative factors associated with haemorrhagic complications were identified as a high and intermediate bleeding risk procedure and the use and dose of anticoagulants. When interrupted before the procedure, resumption of antiplatelet treatment was delayed in patients developing early postoperative hemorrhagic complications. CONCLUSION Patients with coronary stents who undergo surgery are at high risk for hemorrhagic complications.
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91
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Sousa-Uva M, Storey R, Huber K, Falk V, Leite-Moreira AF, Amour J, Al-Attar N, Ascione R, Taggart D, Collet JP. Expert position paper on the management of antiplatelet therapy in patients undergoing coronary artery bypass graft surgery. Eur Heart J 2014; 35:1510-4. [PMID: 24748565 PMCID: PMC4057644 DOI: 10.1093/eurheartj/ehu158] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Miguel Sousa-Uva
- Department of Cardiac Surgery, Hospital Cruz Vermelha, Lisbon, Portugal Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research Center, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Robert Storey
- Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Emergency Medicine, Wilhelminenhospital, Vienna, Austria
| | - Volkmar Falk
- Cardivascular Surgery Address University Hospital Zurich, Zurich, Switzeland
| | - Adelino F Leite-Moreira
- Department of Cardiothoracic Surgery, Hospital São João, Porto, Portugal Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research Center, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Julien Amour
- Institut de Cardiologie, UMRS 1166, Pitié-Salpêtrière Hospital (AP-HP), Université, Pierre et Marie Curie, 47-83 Bvd de l'Hôpital, Paris 75013, France
| | - Nawwar Al-Attar
- Cardiac Surgery and Transplantation, Golden Jubilee National Hospital, Agamemnon Street, Clydebank G81 4DY, UK
| | - Raimondo Ascione
- Cardiac Surgery & Translational Research, Bristol Royal Infirmary, UK
| | - David Taggart
- Cardiovascular Surgery, University of Oxford, Oxford, UK
| | - Jean-Philippe Collet
- Institut de Cardiologie, UMRS 1166, Pitié-Salpêtrière Hospital (AP-HP), Université, Pierre et Marie Curie, 47-83 Bvd de l'Hôpital, Paris 75013, France
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92
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Wendl-Soeldner M, Moll C, Kammerlander C, Gosch M, Roth T. Algorithm for anticoagulation management in geriatric hip fracture patients—Surgeons save Blood. Z Gerontol Geriatr 2014; 47:95-104. [DOI: 10.1007/s00391-013-0595-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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93
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Casado-Arroyo R, Sostres C, Lanas A. Optimizing the use of aspirin for cardiovascular prevention. Drugs 2014; 73:803-14. [PMID: 23677803 DOI: 10.1007/s40265-013-0061-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This article describes the mechanism of action, pharmacokinetics, and pharmacodynamics of aspirin at doses used for cardiovascular prevention and provides specific management recommendations for optimal use in clinical practice. The paper highlights practical aspects related to antiplatelet therapy, including the optimal dose of aspirin, concomitant treatment with other NSAIDs, and strategies for the prevention of gastrointestinal toxicity. Specifically, we revise the benefits and hazards in different clinical settings to help the clinician in the decision-making process for individuals who have different risks for cardiovascular and gastrointestinal bleeding events.
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Affiliation(s)
- Rubén Casado-Arroyo
- Heart Rhythm Management Center, Cardiovascular Division, Cardiovascular Center, Free University of Brussels (UZ Brussels) VUB, Laarbeeklaan 101, Brussels, Belgium.
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Firstenberg MS, Dyke CM, Angiolillo DJ, Ramaiahm C, Price M, Brtko M, Welsby I, Chandna H, Holmes DR, Voeltz M, Tummala P, Hutyra M, Manoukian SV, Prats J, Todd M, Liu T, Chronos N, Dietrich M, Montalescot G, Cannon LA, Topo EJ. Safety and efficacy of cangrelor, an intravenous, short-acting platelet inhibitor in patients requiring coronary artery bypass surgery. Heart Surg Forum 2014; 16:E60-9. [PMID: 23625478 DOI: 10.1532/hsf98.20121103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Oral P2Y₁₂ platelet receptor inhibitors are a cornerstone of reducing complications in patients with acute coronary syndromes or coronary stents. Guidelines advocate discontinuing treatment with P2Y₁₂ platelet receptor inhibitors before surgery. Cangrelor, a short-acting, reversible, intravenously administered P2Y₁₂ platelet inhibitor is effective in achieving appropriate platelet inhibition in patients who are awaiting coronary artery bypass grafting (CABG) and require P2Y₁₂ inhibition. The objective of this study was to assess the effects of preoperative cangrelor on the incidence of perioperative complications, which are currently unknown. METHODS Patients (n = 210) requiring preoperative clinical administration of thienopyridine therapy were randomized in a multicenter, double-blinded study to receive cangrelor or placebo while awaiting CABG after discontinuation of the thienopyridine. Optimal platelet reactivity, which was defined as <240 P2Y₁₂ platelet reaction units, was measured with serial point-of-care testing (VerifyNow). Pre- and postoperative outcomes, bleeding values, and transfusion rates were compared. To quantify potential risk factors for bleeding, we developed a multivariate logistic model. RESULTS The differences between the groups in bleeding and perioperative transfusion rates were not significantly different. The rate of CABG-related bleeding was 11.8% (12/102) in cangrelor-treated patients and 10.4% (10/96) in the placebo group (P = .763). Transfusion rates for the groups were similar. Serious postoperative adverse events for the cangrelor and placebo groups were 7.8% (8/102) and 5.2% (5/96), respectively (P = .454). CONCLUSIONS Compared with placebo, bridging patients with cangrelor prior to CABG effectively maintains platelet inhibition without increasing post-CABG complications, including bleeding and the need for transfusions. These data suggest cangrelor treatment is a potential strategy for bridging patients requiring P2Y₁₂ receptor inhibition while they await surgery.
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Affiliation(s)
- Michael S Firstenberg
- Department of Surgery (Cardiothoracic), Akron City Hospital, Northeast Ohio Medical University, Akron, OH 44309, USA.
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95
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Martins Fonseca N, Rodrigues Alves R, Pontes JPJ. Recomendações da SBA para segurança na anestesia regional em uso de anticoagulantes. Rev Bras Anestesiol 2014. [DOI: 10.1016/j.bjan.2013.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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96
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Fonseca NM, Alves RR, Pontes JPJ. SBA recommendations for regional anesthesia safety in patients taking anticoagulants. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2014; 64:1-15. [PMID: 24565383 DOI: 10.1016/j.bjane.2013.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 04/28/2013] [Indexed: 06/03/2023]
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97
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Omar HR, Mangar D, Sullebarger JT, Sprenker C, Camporesi EM. Post-operative simultaneous very late two-vessel drug eluting stent thrombosis with sparing of bare metal stent in a Jehovah's witness after clopidogrel withdrawal. J Cardiol Cases 2013; 9:57-60. [PMID: 30534296 DOI: 10.1016/j.jccase.2013.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 09/18/2013] [Accepted: 10/02/2013] [Indexed: 01/21/2023] Open
Abstract
Very late stent thrombosis is a feared complication after drug-eluting stent (DES) implantation. Several factors related to the patient, generation and type of the deployed stent, procedure, and premature antiplatelet withdrawal are known to contribute to this complication. Herein, we describe a case of a Jehovah's witness patient who developed simultaneous two-vessel 1st generation DES thrombosis 5.4 and 3.5 years after deployment [with sparing of the bare metal stent (BMS)] in the immediate post-operative period secondary to clopidogrel withdrawal. The case was complicated by ST-segment elevation myocardial infarction, cardiogenic shock, and a ventricular fibrillation cardiac arrest requiring urgent percutaneous coronary intervention. The acute thrombosis of DESs with sparing of the BMS exemplify how they are more prone to this complication due to delayed endothelialization of stent struts and neoinitimal coverage. <Learning objective: Extreme caution should be excercised when attempting to withdraw antiplatelets immediately before surgery in patients with drug eluting stents even if the recomended 12-month period of dual antiplatelet therapy has elapsed because of the risk of very late stent thrombosis.>.
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Affiliation(s)
- Hesham R Omar
- Internal Medicine Department, Mercy Hospital and Medical Center, Chicago, IL, USA
| | - Devanand Mangar
- Department of Anesthesiology, Tampa General Hospital, Tampa, FL, USA
| | | | | | - Enrico M Camporesi
- Department of Surgery/Anesthesiology, University of South Florida, Tampa, FL, USA
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98
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Doutremepuich C, Aguejouf O, Desplat V, Eizayaga FX. Aspirin discontinuation syndromes: clinical implications of basic research studies. Am J Cardiovasc Drugs 2013; 13:377-84. [PMID: 24045958 DOI: 10.1007/s40256-013-0044-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Abrupt discontinuation of many drugs used in medicine causes withdrawal syndromes, some of which can be fatal. Discontinuation of a number of cardiovascular drugs can increase the risk of cardiovascular events. Whereas aspirin administration is known to decrease the risk of vascular ischemic problems, aspirin withdrawal may temporarily increase the risk of thrombotic events. Indeed, aspirin withdrawal has been associated with an increased risk of thrombosis both in clinical and fundamental research studies. Such complications occur within the first month after interrupting aspirin therapy and their mechanism remains unexplained. We have previously demonstrated that aspirin, when injected as a single high dose (100 mg/kg), induces a prothrombotic state in the rat, similar to that described above, 8 and 10 days after administration. This effect in the rat may be reproduced 1 hour after a single injection of ultra-low-dose aspirin. Caution is therefore required regarding the possibility of drug discontinuation effects within the framework of drug safety evaluation.
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99
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Capodanno D, Angiolillo DJ. Management of Antiplatelet Therapy in Patients With Coronary Artery Disease Requiring Cardiac and Noncardiac Surgery. Circulation 2013; 128:2785-98. [DOI: 10.1161/circulationaha.113.003675] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Davide Capodanno
- From the Ferrarotto Hospital, University of Catania, Catania, Italy (D.C.); and University of Florida College of Medicine-Jacksonville, Jacksonville, FL (D.C., D.J.A.)
| | - Dominick J. Angiolillo
- From the Ferrarotto Hospital, University of Catania, Catania, Italy (D.C.); and University of Florida College of Medicine-Jacksonville, Jacksonville, FL (D.C., D.J.A.)
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100
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Capodanno D, Tamburino C. Bridging antiplatelet therapy in patients requiring cardiac and non-cardiac surgery: from bench to bedside. J Cardiovasc Transl Res 2013; 7:82-90. [DOI: 10.1007/s12265-013-9517-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 10/23/2013] [Indexed: 11/29/2022]
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