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Hensley NB, Ariyo PT, Holmes SD, Williams MS, Joseph Robert Whitman G, Ad N, Metkus TS. Center Variation in Use of Preoperative Dual Antiplatelet Therapy and Platelet Function Testing at the Time of Coronary Artery Bypass Grafting in Maryland. Anesth Analg 2022; 135:567-575. [PMID: 35426835 DOI: 10.1213/ane.0000000000005964] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patients presenting with acute coronary syndrome are administered a P2Y12 inhibitor and aspirin before coronary catheterization to prevent further myocardial injury from thrombosis. Guidelines recommend a standard waiting period between the time patients are administered dual antiplatelet therapy (DAPT) and elective cardiac surgery. Since 25% to 30% of the population may be considered nonresponders to clopidogrel, platelet function testing can be utilized for timing of surgery and to assess bleeding risks. The extent to which a standard waiting period or platelet function testing is used across centers is not established, representing an important opportunity to standardize practice. METHODS We conducted a retrospective cohort study from 2011 to 2020 using data from the Maryland Cardiac Surgical Quality Initiative, a consortium of all 10 hospitals in the state performing cardiac surgery. The proportion of patients administered DAPT within 5 days of surgery was examined by hospital over the time period. Mixed-effects multivariable logistic regressions were used to examine the association of preoperative DAPT with ischemic and bleeding outcomes. Centers were surveyed on use or nonuse of preoperative platelet function testing, and bleeding outcomes were compared. RESULTS There was significant heterogeneity of preoperative DAPT usage across centers ranging from 2% to 54% (P < .001). DAPT within 5 days of isolated coronary artery bypass grafting (CABG) was associated with higher odds of reoperation for bleeding (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.19-2.01; P = .001), >2 units of red blood cells (RBCs) transfused (OR, 1.62; 95% CI, 1.44-1.81; P < .001), and >2 units of non-RBCs transfused (OR, 1.79; 95% CI, 1.60-2.00; P < .001). In the 5 hospitals using preoperative platelet function testing to guide timing of surgery, there were greater odds for DAPT within 5 days (OR, 1.33; 95% CI, 1.22-1.45; P < .001), fewer RBCs >2 units transfusions (22% vs 33%; P < .001), and non-RBCs >2 units (17% vs 28%; P < .001) transfusions within DAPT patients. CONCLUSIONS There is significant variability in DAPT usage within 5 days of CABG between hospital centers. Preoperative platelet function testing may allow for earlier timing of surgery for those on DAPT without increased bleeding risks.
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Affiliation(s)
- Nadia B Hensley
- From the Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Promise T Ariyo
- From the Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sari D Holmes
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Marlene S Williams
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn Joseph Robert Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Niv Ad
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland.,Division of Cardiac Surgery, Adventist Health Care White Oak Medical Center, Silver Spring, Maryland
| | - Thomas Stephen Metkus
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Oral Antiplatelet Therapy Administered Upstream to Patients With NSTEMI. Crit Pathw Cardiol 2020; 19:166-172. [PMID: 32947379 PMCID: PMC7664955 DOI: 10.1097/hpc.0000000000000243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To describe from a noninterventional registry (Utilization of Ticagrelor in the Upstream Setting for Non-ST-Segment Elevation Acute Coronary Syndrome), the short-term ischemic and hemorrhagic outcomes in patients with non-ST elevation myocardial infarction (MI) are managed with a loading dose (LD) of a P2Y12 inhibitor (P2Y12i) given at least 4 hours before diagnostic angiography and delineation of coronary anatomy. Prior data on the effects of such “upstream loading” have been inconsistent.
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Wang XL, Deng HF, Tan CY, Xiao ZH, Liu MD, Liu K, Zhang HL, Xiao XZ. The role of PSGL-1 in pathogenesis of systemic inflammatory response and coagulopathy in endotoxemic mice. Thromb Res 2019; 182:56-63. [PMID: 31450009 DOI: 10.1016/j.thromres.2019.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/14/2019] [Accepted: 08/17/2019] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Endotoxemia often results in systemic inflammatory response syndrome (SIRS), coagulation disturbance and acute lung injury (ALI), and such a condition is associated with the activation of platelets, leukocytes and vascular endothelial cells (VECs). P-selectin glycoprotein ligand 1 (PSGL-1) is a key regulatory molecule in the activation of platelets, leukocytes and VECs. However, it still remains largely unexplored whether PSGL-1 plays an important role in SIRS, coagulation dysfunction and ALI of endotoxemia. In the present study, we aimed to study the role of PSGL-1 in above-mentioned situations using endotoxemic mice. MATERIALS AND METHODS An endotoxemia model was established in BALB/c mice via lipopolysaccharide (LPS) administration. Moreover, the mice were simultaneously injected with PSGL-1 antibody for intervention. The survival rate, morphologic changes of lung tissues, platelet-leukocyte adhesion, tissue factor expression on leukocytes, fibrinogen deposition in lung tissues, serum levels of inflammatory factors and the activation of VECs were determined. RESULTS The results showed that the aggregation and recruitment of platelets and leukocytes in lung tissues, the expression of tissue factor on leukocytes, the serum levels of inflammatory factors, the activation of VECs, and the fibrinogen deposition in lung tissues were increased in endotoxemic mice, which were significantly alleviated by administration of PSGL-1 antibody. Moreover, blockade of PSGL-1 markedly increased survival rate, and alleviated coagulation disturbance and lung injury in endotoxemic mice. CONCLUSIONS Taken together, PSGL-1 played an important role in pathogenesis of SIRS and coagulation dysfunction and ALI in endotoxemic mice.
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Affiliation(s)
- Xiao-Li Wang
- Key Laboratory of Sepsis Translation Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan 410078, PR China; Medical College of Jishou University, Jishou, Hunan 416000, PR China
| | - Hua-Fei Deng
- Key Laboratory of Sepsis Translation Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan 410078, PR China
| | - Chu-Yi Tan
- Key Laboratory of Sepsis Translation Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan 410078, PR China
| | - Zi-Hui Xiao
- Key Laboratory of Sepsis Translation Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan 410078, PR China.
| | - Mei-Dong Liu
- Key Laboratory of Sepsis Translation Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan 410078, PR China
| | - Ke Liu
- Key Laboratory of Sepsis Translation Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan 410078, PR China
| | - Hua-Li Zhang
- Key Laboratory of Sepsis Translation Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan 410078, PR China
| | - Xian-Zhong Xiao
- Key Laboratory of Sepsis Translation Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan 410078, PR China.
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Wang XL, Deng HF, Li T, Miao SY, Xiao ZH, Liu MD, Liu K, Xiao XZ. Clopidogrel reduces lipopolysaccharide-induced inflammation and neutrophil-platelet aggregates in an experimental endotoxemic model. J Biochem Mol Toxicol 2018; 33:e22279. [PMID: 30537341 DOI: 10.1002/jbt.22279] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 09/11/2018] [Accepted: 11/08/2018] [Indexed: 12/11/2022]
Abstract
Platelet activation contributes to organs failure in inflammation and plays an important role in endotoxemia. Clopidogrel inhibits platelet aggregation and activation. However, the role of clopidogrel in modulating inflammatory progression of endotoxemia remains largely unexplored. Therefore, we investigated the role of clopidogrel on the activation of platelet and leukocytes in lipopolysaccharide (LPS)-induced inflammation in mice. Animals were treated with clopidogrel or vehicle before LPS induction. The expression of neutrophil-platelet aggregates and platelet activation and tissue factor was determined. Immunofluorescence was used to analyze platelet-leukocyte interactions and tissue factor (TF) expression on leukocytes. Clopidogrel pretreatment markedly decreased lung damage, inhibited platelet-neutrophil aggregates and TF expression. In addition, clopidogrel reduced thrombocytopenia and affected the number of circulating white blood cell in endotoxemia mice. Moreover, clopidogrel also reduced platelet shedding of CD40L and CD62P in endotoxemic mice. Taken together, clopidogrel played an important role through reducing platelet activation and inflammatory process in endotoxemia.
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Affiliation(s)
- Xiao-Li Wang
- Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, China.,Department of Pathophysiology, Medical College of Jishou University, Jishou, Human, China
| | - Hua-Fei Deng
- Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, China
| | - Ting Li
- Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, China
| | - Shu-Ying Miao
- Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, China
| | - Zi-Hui Xiao
- Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, China
| | - Mei-Dong Liu
- Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, China
| | - Ke Liu
- Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, China
| | - Xian-Zhong Xiao
- Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, China
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