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Boorman S, Douglas H, Driessen B, Gillespie MJ, Schaer TP. Fatal Ovarian Hemorrhage Associated With Anticoagulation Therapy in a Yucatan Mini-Pig Following Venous Stent Implantation. Front Vet Sci 2020; 7:18. [PMID: 32083102 PMCID: PMC7002391 DOI: 10.3389/fvets.2020.00018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 01/10/2020] [Indexed: 01/10/2023] Open
Abstract
Swine models are commonly utilized in endovascular research for development of intravascular interventions and medical device development. As part of a pilot study for a venous vascular stent device, a 5-year-old female Yucatan mini-pig underwent bilateral external iliac vein stent placement under general anesthesia. To reduce thrombotic complications by reduction of thrombus formation on wires, sheaths, and catheters, the pig was heparinized with a total of 300 IU/kg of heparin, establishing an activated clotting time (ACT) of 436 s. The ACT had returned to below 200 s by the end of the procedure. To prevent postoperative thrombosis, the pig received an anticoagulation therapy protocol consisting of enoxaparin, clopidogrel, and aspirin. There were no complications during the immediate postoperative period. However, the pig died 4 days after surgery. Necropsy established the cause of death as abdominal exsanguination due to severe, acute, intra-ovarian hemorrhage, most likely related to ovulation. Life-threatening ovarian hemorrhage is occasionally seen in women with congenital or acquired bleeding disorders; to our knowledge this is the first report of fatal ovarian hemorrhage in an animal enrolled in a pre-clinical research trial.
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Affiliation(s)
- Sophie Boorman
- Department of Clinical Sciences, College of Veterinary Medicine, JT Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, United States
| | - Hope Douglas
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Bernd Driessen
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Matthew J Gillespie
- Department of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Thomas P Schaer
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Karan V, Vyas D, Bohra V, Huded V. Ticagrelor Use in Indian Patients Undergoing Neuroendovascular Procedures: A Single Center Experience. Neurointervention 2019; 14:125-130. [PMID: 31387163 PMCID: PMC6736500 DOI: 10.5469/neuroint.2019.00087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/27/2019] [Indexed: 12/21/2022] Open
Abstract
PURPOSE A safe and efficacious antiplatelet drug is needed for patients with clopidogrel resistance who undergo neuroendovascular procedures. Ticagrelor is a new reversibly binding, oral, direct-acting P2Y receptor antagonist with no known resistance. We describe our clinical experience using ticagrelor for neuroendovascular procedures in Indian patients with clopidogrel resistance at the NH Institute of Neurosciences, Narayana Health City, Bangalore. MATERIALS AND METHODS We retrospectively reviewed our endovascular procedure database for all patients with predefined clopidogrel resistance. Clopidogrel resistance was defined as P2Y12 inhibition <40%. Patients were administered ticagrelor along with aspirin prior to the procedure. RESULTS Of 127 patients, 32 (25%) were non-responders to clopidogrel (22 [69%] males, 10 [31%] females; median age, 54 years [range, 20-75]). All patients were treated with a 180-mg loading dose of ticagrelor, followed by 90 mg twice daily. Twenty patients (63%) underwent endovascular intervention for intracranial aneurysm, two (6%) for dissecting aneurysms, nine (28%) for stenotic lesions, and one (3%) for carotico-cavernous fistula. No patient experienced any adverse effects related to the use of Ticagrelor in the postoperative period. CONCLUSION Ticagrelor is an effective alternative to clopidogrel for use in conjunction with aspirin in patients with clopidogrel resistance. None of our patients had adverse effects from ticagrelor. Drug cost, twice-daily dosing, and risk of faster platelet aggregation activation after discontinuation should be taken into consideration prior to its use in such patients.
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Affiliation(s)
- Vivek Karan
- Division of Stroke and Interventional Neurology, NH Institute of Neurosciences, Bangalore, India
| | - Devashish Vyas
- Division of Stroke and Interventional Neurology, NH Institute of Neurosciences, Bangalore, India
| | - Vikram Bohra
- Division of Stroke and Interventional Neurology, NH Institute of Neurosciences, Bangalore, India
| | - Vikram Huded
- Division of Stroke and Interventional Neurology, NH Institute of Neurosciences, Bangalore, India
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Yang QY, Ouyang J, Yang JD. Sepsis as an important risk factor for gastrointestinal bleeding in acute coronary syndrome patients: Two case reports. Medicine (Baltimore) 2018; 97:e12273. [PMID: 30200168 PMCID: PMC6133616 DOI: 10.1097/md.0000000000012273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Sepsis is a common stressor that may decrease microcirculation in the gastrointestinal tract in patients and increase the gastrointestinal bleeding risk of stress-related mucosal disease. However, the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines) bleeding risk score, recommended by authoritative guidelines for acute coronary syndrome (ACS), does not include sepsis as a bleeding risk factor. PATIENT CONCERNS The 2 cases were about ACS with hemorrhagic complications. The first patient was an 88-year-old man with hypertension, gallstones, hepatic cysts, and chest pain; the second one was a 79-year-old man with chest pain and hypertension. These 2 ACS patients had no bleeding on admission; however, both patients suffered apparent gastrointestinal bleeding immediately after the development of sepsis or severe sepsis. DIAGNOSES Both patients were diagnosed as ACS with sepsis. INTERVENTIONS The first ACS patient had no use of proton pump inhibitors (PPIs) for prophylaxis prior to the diagnosis of sepsis. The second one was administered PPIs at standard oral doses. OUTCOMES The first patient suffered from gastrointestinal bleeding immediately after the onset of sepsis. And oral PPIs failed to prevent upper gastrointestinal bleeding for the second patient, when severe sepsis developed. However, the second patient's gastrointestinal hemorrhage gradually stopped immediately after high doses of PPIs were administered intravenously, rather than orally. When sepsis developed again, the second patient also had no recurrent gastrointestinal bleeding under the protection of PPIs at standard oral doses. LESSONS Our report suggests that sepsis may be an important bleeding risk factor for ACS patients, and the reasonable use of PPIs to prevent gastrointestinal bleeding could be vital for ACS patients complicated with sepsis.
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Affiliation(s)
- Qi-Yu Yang
- Department of Thoracic Oncology, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Jing Ouyang
- Department of Pharmacy, Chongqing Public Health Medical Center
| | - Jia-Dan Yang
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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He L, Zhang J, Zhang S. Risk factors of in-hospital mortality among patients with upper gastrointestinal bleeding and acute myocardial infarction. Saudi J Gastroenterol 2018; 24:177-182. [PMID: 29652028 PMCID: PMC5985637 DOI: 10.4103/sjg.sjg_492_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background/Aims Patients with simultaneous upper gastrointestinal bleeding (UGIB) and acute myocardial infarction (AMI) have higher mortality than patients with either GIB or AMI. We aimed to assess the incidence and risk factors of in-hospital mortality in patients with UGIB and AMI. Patients and Methods A total of 243 patients with UGIB and AMI were enrolled during 2012-2017. Clinical and laboratory data were collected and analyzed for clinical characteristics and potential risk factors of in-hospital mortality. Results Among the 243 patients, 60 in-hospital deaths were observed (in-hospital mortality rate of 24.7%). Patients who died were older than the survivors (78.7 ± 6.6 vs. 72.6 ± 10.5 years, P < 0.001). Compared with survivors, patients who died showed increased peak white blood cell (WBC) count (9.74 ± 4.72 vs. 7.60 ± 2.91 × 109/L, P= 0.002), serum creatinine levels [134 (106, 190) vs. 97 (79, 125) mmol/L, P= 0.014], peak blood urine nitrogen levels (16.31 ± 8.48 mmol/L vs. 9.86 ± 6.33 mmol/L, P < 0.001), and peak brain natriuretic peptide (BNP) amounts [13,250 (6071, 30,000) vs. 3598 (728, 12,842) pg/mL, P < 0.001]. Meanwhile, patients who died also displayed lower minimum hemoglobin levels (78.3 ± 21.1 vs. 86.3 ± 22.3 g/L, P= 0.018) and minimum platelet counts (184.3 ± 79.1 vs. 214.6 ± 80.1 × 109/L, P= 0.013). In multivariable logistic analysis, age [OR (95% CI) =1.118 (1.053-1.186), P < 0.001], peak WBC count [OR (95% CI) =1.252 (1.113-1.407), P < 0.001], minimum platelet count [OR (95% CI) = 0.994 (0.989-1.000), P= 0.032], and peak BNP levels [OR (95% CI) =3.880 (1.761-8.550), P= 0.001] were independent predictors of in-hospital mortality. Conclusions Patients with UGIB and AMI had a high in-hospital mortality, which was independently associated with age, peak WBC count, minimum platelet count, and peak BNP levels.
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Affiliation(s)
- Lingjie He
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, China
| | - Jianwei Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-related Cardiovascular Disease, Ministry of Education, Beijing, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, China
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Lucenteforte E, Lombardi N, Vetrano DL, La Carpia D, Mitrova Z, Kirchmayer U, Corrao G, Lapi F, Mugelli A, Vannacci A. Inappropriate pharmacological treatment in older adults affected by cardiovascular disease and other chronic comorbidities: a systematic literature review to identify potentially inappropriate prescription indicators. Clin Interv Aging 2017; 12:1761-1778. [PMID: 29089750 PMCID: PMC5656349 DOI: 10.2147/cia.s137403] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Avoiding medications in which the risks outweigh the benefits in the elderly patient is a challenge for physicians, and different criteria to identify inappropriate prescription (IP) exist to aid prescribers. Definition of IP indicators in the Italian geriatric population affected by cardiovascular disease and chronic comorbidities could be extremely useful for prescribers and could offer advantages from a public health perspective. The purpose of the present study was to identify IP indicators by means of a systematic literature review coupled with consensus criteria. A systematic search of PubMed, EMBASE, and CENTRAL databases was conducted, with the search structured around four themes and combining each with the Boolean operator “and”. The first regarded “prescriptions”, the second “adverse events”, the third “cardiovascular conditions”, and the last was planned to identify studies on “older people”. Two investigators independently reviewed titles, abstracts, full texts, and selected articles addressing IP in the elderly affected by cardiovascular condition using the following inclusion criteria: studies on people aged ≥65 years; studies on patients with no restriction on age but with data on subjects aged ≥65 years; and observational effectiveness studies. The database searches produced 5,742 citations. After removing duplicates, titles and abstracts of 3,880 records were reviewed, and 374 full texts were retrieved that met inclusion criteria. Thus, 49 studies reporting 32 potential IP indicators were included in the study. IP indicators regarded mainly drug–drug interactions, cardio- and cerebrovascular risk, bleeding risk, and gastrointestinal risk; among them, only 19 included at least one study that showed significant results, triggering a potential warning for a specific drug or class of drugs in a specific context. This systematic review demonstrates that both cardiovascular and non-cardiovascular drugs increase the risk of adverse drug reactions in older adults with cardiovascular diseases.
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Affiliation(s)
- Ersilia Lucenteforte
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Niccolò Lombardi
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | | | | | | | | | - Giovanni Corrao
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | | | - Alessandro Mugelli
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Alfredo Vannacci
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
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Hsieh MJ, Wang CC, Chen CC, Wang CL, Wu LS, Hsieh IC. HAS-BLED score predicts risk of in-hospital major bleeding in patients with acute non-ST segment elevation myocardial infarction. Thromb Res 2015; 136:775-80. [PMID: 26337931 DOI: 10.1016/j.thromres.2015.08.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 08/03/2015] [Accepted: 08/22/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND The role of the Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs or alcohol use (HAS-BLED) score in the prediction of in-hospital bleeding in non-ST segment elevation myocardial infarction (NSTEMI) patients receiving dual anti-platelet therapy plus heparin was unknown. In this study, we compared the HAS-BLED score with the Can Rapid Risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) and Acute Catheterization and Urgent Intervention Triage strategY and the Harmonizing Outcomes with RevascularIZatiON and Stents in acute myocardial infarction (ACUITY-HORIZONS) bleeding risk scores for in-hospital major bleeding risk stratification in NSTEMI patients. METHODS A real world population of 617 NSTEMI patients receiving dual anti-platelet plus heparin as initial therapy were enrolled. CRUSADE, ACUITY-HORIZONS and HAS-BLED risk scores were calculated for each patient. RESULTS This cohort had a 6.5% incidence of in-hospital major bleeding. For the prediction of in-hospital major bleeding, the discriminations between CRUSADE, ACUITY-HORIZONS and HAS-BLED were good (C-statistic 0.81, 0.82 and 0.80, respectively). There was no significant difference between these three risk scores (HAS-BLED vs. CRUSADE: z=-0.08, p=0.27; HAS-BLED vs. ACUITY-HORIZONS: z=-0.06, p=0.26; CRUSADE vs. ACUITY-HORIZONS: z=-0.15, p=0.28). CONCLUSION The CRUSADE, ACUITY-HORIZONS and HAS-BLED scores were useful tools for risk stratification of in-hospital major bleeding in NSTEMI patients. The HAS-BLED score had a simpler calculation and a similar accuracy for risk assessment as the other two scores evaluated.
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Affiliation(s)
- Ming-Jer Hsieh
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Chun-Chieh Wang
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Chun-Chi Chen
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Chun-Li Wang
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - Lung-Sheng Wu
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan
| | - I-Chang Hsieh
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 5, Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan.
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Jung JA, Kim TE, Kim JR, Kim MJ, Huh W, Park KM, Lee SY, Ko JW. The Pharmacokinetics and Safety of a Fixed-Dose Combination of Acetylsalicylic Acid and Clopidogrel Compared With the Concurrent Administration of Acetylsalicylic Acid and Clopidogrel in Healthy Subjects: A Randomized, Open-Label, 2-Sequence, 2-Period, Single-Dose Crossover Study. Clin Ther 2013; 35:985-94. [DOI: 10.1016/j.clinthera.2013.05.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 05/07/2013] [Accepted: 05/21/2013] [Indexed: 11/29/2022]
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Hanel RA, Taussky P, Dixon T, Miller DA, Sapin M, Nordeen JD, Tawk RG, Navarro R, Johns G, Freeman WD. Safety and efficacy of ticagrelor for neuroendovascular procedures. A single center initial experience. J Neurointerv Surg 2013; 6:320-2. [DOI: 10.1136/neurintsurg-2013-010699] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Rahman MS, Soo L, Qasim A. An unusual case of massive subcutaneous chest wall haemorrhage with enoxaparin. ACUTE CARDIAC CARE 2011; 13:199-201. [PMID: 21877880 DOI: 10.3109/17482941.2011.606474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Enoxaparin is used in the treatment of acute coronary syndromes and offers improved outcome in the composite endpoint of death, myocardial infarction and major bleeding when compared with unfractionated heparin (UFH). Our report describes a rare case of massive life-threatening subcutaneous chest wall haemorrhage, distant to the injection site. Clinicians should be aware of atypical presentations of haemorrhage when using combination antiplatelet and antithrombotic therapy.
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Bossaert L, O'Connor RE, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Hoek TLV, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e175-212. [PMID: 20959169 DOI: 10.1016/j.resuscitation.2010.09.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Samama MM. Use of Low-Molecular-Weight Heparins and New Anticoagulants in Elderly Patients with Renal Impairment. Drugs Aging 2011; 28:177-93. [DOI: 10.2165/11586730-000000000-00000] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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O'Connor RE, Bossaert L, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Vanden Hoek TL, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S422-65. [PMID: 20956257 DOI: 10.1161/circulationaha.110.985549] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Abstract
Objective The aim of this review was to examine aspirin utilization, cardiovascular risk estimation, and clinical evidence for aspirin prophylaxis in Asian versus Western countries. Methods A literature search was performed using PubMed and the key terms “aspirin” and “Asia” or “Western”. Results Despite the growing burden of cardiovascular disease (CVD), aspirin is underutilized in high-risk patients in both Asian and Western countries. A number of risk estimation scores are available; however, validation is needed in countries such as Japan, India, and in South Asia. Underutilization of aspirin in Asia may be linked to an overestimation of bleeding risks. It is possible that a higher prevalence of Helicobacter pylori infection and genetic differences may make Asians more susceptible to gastrointestinal bleeding. Very low aspirin doses and even the wider use of gastroprotective agents may be the optimal approach to high-risk patients in Asia. Conclusions Based on the current evidence, aspirin should be used for CVD prevention when the risk:benefit ratio is favorable. A number of trials are underway, including the Diabetic Atherosclerosis Prevention by Cilostazol and Japanese Primary Prevention Project, which will provide key data on the benefits of aspirin in Asian patients at risk of CVD, and may improve aspirin utilization and risk estimation.
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Affiliation(s)
- Runlin Gao
- Department of Cardiology, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, PR China.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2010. [DOI: 10.1002/pds.1849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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