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Alhazzani A, Alajlan FS, Alkhathaami AM, Al-Senani FM, Muayqil TA, Alghamdi SA, AlKawi A, AlZahrani S, Bakheet M, Aljohani M, Taher N, Almutairi A, AlQarni M, Alsalman S, Alqahtani SA, Almansour N, Abukhamsin L, Mouminah A, Almodarra N, Mohamed G, Almodhy M, Albogumi E, Alzawahmah M, Alreshaid A, Akhtar N, Hussain MS, Albers GW, Shuaib A. Stroke and high-risk TIA outcomes with reduction of treatment duration when treatment initiated in emergency rooms (SHORTER-study). Int J Stroke 2024:17474930241237120. [PMID: 38395748 DOI: 10.1177/17474930241237120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
BACKGROUND Following transient ischemic attack (TIA) and minor stroke, the risk of recurrent stroke can be significantly reduced with short-duration dual antiplatelet therapy (DAPT). We wish to investigate whether 10 days of DAPT is as effective as 21 days' treatment. STUDY DESIGN This is an open-label, randomized, parallel-group study comparing whether 10 days of DAPT treatment (ASA + clopidogrel) is non-inferior to 21 days of DAPT in patients with acute ischemic stroke (AIS) or high-risk TIA. In both groups, DAPT is started within 24 hours of symptom onset. This study is being conducted in approximately 15 study sites in the Kingdom of Saudi Arabia. The planned sample size is 1932. OUTCOMES Non-inferiority of 10 days compared to 21 days of DAPT in the prevention of the composite endpoint of stroke and death at 90 days in AIS/TIA patients. The primary safety outcome is major intra-cranial and systemic hemorrhage. STUDY PERIOD Enrolment started in the second quarter of 2023, and the completion of the study is expected in the fourth quarter of 2025. DISCUSSION The trial is expected to show that 10 days of DAPT is non-inferior for the prevention of early recurrence of vascular events in patients with high-risk TIAs and minor strokes.
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Affiliation(s)
- Adel Alhazzani
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Fahad S Alajlan
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Ali M Alkhathaami
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Taim A Muayqil
- Neurology Unit, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Saeed A Alghamdi
- King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia
| | - Ammar AlKawi
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Saeed AlZahrani
- King Fahad General Hospital, Ministry of Health, Jeddah, Saudi Arabia
| | | | | | - Nouran Taher
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Mustafa AlQarni
- King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Sadiq Alsalman
- King Fahad Hospital Hofuf, Al-Ahsa, Riyadh, Saudi Arabia
| | | | | | | | - Amr Mouminah
- King Abdullah Medical Complex, Jeddah, Saudi Arabia
| | - Nehal Almodarra
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Gamal Mohamed
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Meshal Almodhy
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Eid Albogumi
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
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Mikulík R, Eckstein J, Pearce LA, Mundl H, Rudilosso S, Olavarría VV, Shoamanesh A, Chamorro Á, Martí-Fàbregas J, Veltkamp R, Öztürk Ş, Tatlisumak T, Peacock WF, Berkowitz SD, Connolly SJ, Hart RG. Frequency and Predictors of Major Bleeding in Patients With Embolic Strokes of Undetermined Source: NAVIGATE-ESUS Trial. Stroke 2020; 51:2139-2147. [PMID: 32517582 DOI: 10.1161/strokeaha.119.027995] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Risks, sites, and predictors of major bleeding during antithrombotic therapies have not been well defined for patients with recent embolic stroke of undetermined source. METHODS Exploratory analysis of major bleeds defined by International Society of Thrombosis and Hemostasis criteria occurring among 7213 participants in international NAVIGATE (New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial) embolic stroke of undetermined source randomized trial comparing rivaroxaban 15 mg daily with aspirin 100 mg daily. RESULTS During a median follow-up of 11 months, 85 major bleeds occurred. The most frequent site was gastrointestinal (38%), followed by intracranial (29%). Assignment to rivaroxaban (hazard ratio [HR], 2.7 [95% CI, 1.7-4.3]), East Asia region (HR, 2.5 [95% CI, 1.6-3.9]), systolic blood pressure ≥160 mm Hg (HR, 2.2 [95% CI, 1.2-3.8]), and reduced estimated glomerular filtration rate (HR, 1.2 per 10 mL/min per 1.73 m2 decrease, [95% CI, 1.0-1.3]) were independently associated with presence of major bleeds. Five (6%) were fatal. Among 15 patients with intracerebral hemorrhage, 2 (13%) were fatal. There was no evidence of an early high-risk period following initiation of rivaroxaban. The annualized rate of intracerebral hemorrhage was 6-fold higher among East Asian participants (0.67%) versus all other regions (0.11%; HR, 6.3 [95% CI, 2.2-18.0]). Distribution of bleeding sites was similar for rivaroxaban and aspirin. CONCLUSIONS Among embolic stroke of undetermined source patients participating in an international randomized trial, independent predictors of major bleeding were assignment to rivaroxaban, East Asia region, increased systolic blood pressure, and impaired renal function. East Asia as a region was strongly associated with risk of intracerebral hemorrhage. Estimated glomerular filtration rate should be a consideration for stratifying bleeding risk. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02313909.
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Affiliation(s)
- Robert Mikulík
- International Clinical Research Center and Neurology Department, St. Anne's University Hospital and Masaryk University Brno, Czech Republic (R.M.)
| | - Jens Eckstein
- Department of Internal Medicine, University Hospital Basel, Switzerland (J.E.)
| | | | | | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neuroscience (S.R.), Hospital Clinic, Barcelona, Spain
| | - Veroníca V Olavarría
- Department of Neurology and Psychiatry, Faculty of Medicine, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile (V.V.O.)
| | - Ashkan Shoamanesh
- McMaster University/Population Health Research Institute, Hamilton Health Sciences, ON, Canada (A.S., S.J.C., R.G.H.)
| | - Ángel Chamorro
- Comprehensive Stroke Center, Department of Neuroscience (A.C.), Hospital Clinic, Barcelona, Spain
| | | | | | - Şerefnur Öztürk
- Department of Neurology, Selcuk University Faculty of Medicine, Turkey (S.O.)
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.).,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.)
| | | | - Scott D Berkowitz
- Pharmaceuticals Clinical Development Thrombosis, Bayer U.S. LLC, Whippany, NJ (S.D.B.)
| | - Stuart J Connolly
- McMaster University/Population Health Research Institute, Hamilton Health Sciences, ON, Canada (A.S., S.J.C., R.G.H.)
| | - Robert G Hart
- McMaster University/Population Health Research Institute, Hamilton Health Sciences, ON, Canada (A.S., S.J.C., R.G.H.)
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3
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Ye MB, Chen YL, Wang Q, An J, Ye F, Jing P. Aspirin plus clopidogrel versus aspirin mono-therapy for ischemic stroke: a meta-analysis. SCAND CARDIOVASC J 2019; 53:169-175. [PMID: 31112048 DOI: 10.1080/14017431.2019.1620962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objectives. Stroke is a common condition after a transient ischemic attack (TIA) or minor ischemic stroke (IS). Adding clopidogrel to aspirin may yield more beneficial outcomes than aspirin mono-therapy; meanwhile, the risk of bleeding in the acute phase remains poorly understood. Therefore, there is increasing emphasis on the risks and benefits of clopidogrel with aspirin compared with aspirin mono-therapy in an effort to treat TIA/IS. Design. We searched several electronic databases, including PubMed, Cochrane, and Embase, to identify eligible randomized controlled trials (RCTs) based on the index words comparing dual-antiplatelet therapy to aspirin mono-therapy for secondary stroke prevention updated to December, 2018. Results. A total of 11 RCTs met our inclusion criteria. The pooled analysis showed that clopidogrel plus aspirin was associated with a trend toward a reduction in recurrent IS (RR = 0.72, 95%CI = 0.65-0.81, p < .001), but not the recurrent stroke rate (RR = 0.81, 95% CI = 0.63-1.03, p = .09) than aspirin mono-therapy. There were differences in bleeding episodes (RR = 1.81, 95%CI = 1.65-1.99, p < .001), moderate-severe major bleeding (RR = 1.64, 95% CI = 1.24-2.16, p = .0005), or mild bleeding (RR = 2.25, 95%CI = 1.54-3.31, p < .001) between the study groups. Meanwhile, no benefit of reducing the risk of intracranial hemorrhage with dual-antiplatelet therapy was found in TIA/IS patients (RR = 1.44, 95% CI = 0.95-2.19, p = .09). Conclusions. The addition of clopidogrel to aspirin for patients with TIA or IS appeared to significantly reduce the risk of IS recurrence with a possible increase in the risk of bleeding compared with aspirin alone.
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Affiliation(s)
- Mao-Bin Ye
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Yan-Lin Chen
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Qin Wang
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Jun An
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Fei Ye
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Ping Jing
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
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Ögren J, Irewall AL, Söderström L, Mooe T. Serious hemorrhages after ischemic stroke or TIA - Incidence, mortality, and predictors. PLoS One 2018; 13:e0195324. [PMID: 29621285 PMCID: PMC5886551 DOI: 10.1371/journal.pone.0195324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 03/20/2018] [Indexed: 11/26/2022] Open
Abstract
Background Data are lacking on the risk and impact of a serious hemorrhage on the prognosis after ischemic stroke (IS) or transient ischemic attack (TIA). We aimed to estimate the incidence of serious hemorrhage, analyze the impact on mortality, and identify predictors of hemorrhage after discharge from IS or TIA. Methods and findings All patients admitted to Östersund Hospital for an IS or TIA in 2010–2013 were included (n = 1528, mean age: 75.1 years). Serious hemorrhages were identified until 31st December 2015. Incidence rates were calculated. The impact on mortality (stratified by functional level) was determined with Kaplan-Meier analysis. Non-parametric estimation under the assumption of competing risk was performed to assess the cumulative incidence and predictors of serious hemorrhages. The incidence rates of serious (n = 113) and intracranial hemorrhages (n = 45) after discharge from IS and TIA were 2.48% and 0.96% per year at risk, respectively. Patients with modified Rankin Scale (mRS) scores of 3–5 exhibited 58.9% mortality during follow-up and those with mRS scores of 0–2 exhibited 18.4% mortality. A serious hemorrhage did not affect mortality in patients with impaired functional status, but it increased the risk of death in patients with mRS scores of 0–2. Hypertension was associated with increased risk of serious hemorrhage. Conclusions We found that, after discharge from an IS or TIA, serious hemorrhages were fairly common. Impairments in function were associated with high mortality, but serious hemorrhages only increased the risk of mortality in patients with no or slight disability. Improved hypertension treatment may decrease the risk of serious hemorrhage, but in patients with low functional status, poor survival makes secondary prevention challenging.
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Affiliation(s)
- Joachim Ögren
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden
- * E-mail:
| | - Anna-Lotta Irewall
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden
| | - Lars Söderström
- Unit of Research, Development and Education, Östersund, Sweden
| | - Thomas Mooe
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden
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Wei D, Xie D, Li H, Chen Y, Qi D, Wang Y, Zhang Y, Chen K, Li C, Zhang Z. The positive effects of Xueshuan Xinmai tablets on brain functional connectivity in acute ischemic stroke: a placebo controlled randomized trial. Sci Rep 2017; 7:15244. [PMID: 29127417 PMCID: PMC5681502 DOI: 10.1038/s41598-017-15456-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 10/25/2017] [Indexed: 11/09/2022] Open
Abstract
Through a placebo controlled randomized study, the purpose of this report was to investigate the effects of Xueshuan Xinmai tablets (XXMT) on neurologic deficits, quality of life and brain functional connectivity in acute ischemic stroke patients and to explore the mechanism of action of XXMT. In total, 44 acute ischemic stroke patients were randomly divided to the XXMT treatment group (n = 22) or the placebo group (n = 22) in a 2-week trial. Before and after the treatment, the neurological assessment and functional magnetic resonance imaging examinations were carried out. Compared to the placebo group, the scores of the National Institutes of Health Stroke Scale (NIHSS) and Stroke-Specific Quality of Life Scale (SSQOL) significantly improved in the treatment group. In addition, XXMT-treated patients demonstrated significantly enhanced functional connectivity within the default mode, frontal-parietal, and motor control networks. Furthermore, the changed connectivity in the left precuneus was positively correlated to the improvement of NIHSS and SSQOL scores. The present study indicated that XXMT treatment significantly improved the neurologic deficit and quality of life of acute ischemic stroke patients and that the therapeutic effect may be based on the modulation of XXMT on the functional connectivity of brain networks.
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Affiliation(s)
- Dongfeng Wei
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, 100700, P.R. China.,BABRI Centre, Beijing Normal University, Beijing, 100875, P.R. China
| | - Daojun Xie
- The First Affiliated Hospital of Anhui University of traditional Chinese Medicine, Hefei, 230031, P.R. China
| | - He Li
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, 100700, P.R. China.,BABRI Centre, Beijing Normal University, Beijing, 100875, P.R. China
| | - Yaojing Chen
- State Key Laboratory of Cognitive Neuroscience and Learning & IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing, 100875, P.R. China.,BABRI Centre, Beijing Normal University, Beijing, 100875, P.R. China
| | - Di Qi
- State Key Laboratory of Cognitive Neuroscience and Learning & IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing, 100875, P.R. China.,BABRI Centre, Beijing Normal University, Beijing, 100875, P.R. China
| | - Yujiao Wang
- Graduate School of Anhui University of traditional Chinese Medicine, Hefei, 230038, P.R. China
| | - Yangjun Zhang
- State Key Laboratory of Cognitive Neuroscience and Learning & IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing, 100875, P.R. China.,BABRI Centre, Beijing Normal University, Beijing, 100875, P.R. China
| | - Kewei Chen
- BABRI Centre, Beijing Normal University, Beijing, 100875, P.R. China.,Banner Alzheimer's Institute, Phoenix, Arizona, 85006, USA
| | - Chuanfu Li
- The First Affiliated Hospital of Anhui University of traditional Chinese Medicine, Hefei, 230031, P.R. China.
| | - Zhanjun Zhang
- State Key Laboratory of Cognitive Neuroscience and Learning & IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing, 100875, P.R. China. .,BABRI Centre, Beijing Normal University, Beijing, 100875, P.R. China.
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6
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Hart RG, Sharma M, Mundl H, Shoamanesh A, Kasner SE, Berkowitz SD, Pare G, Kirsch B, Pogue J, Pater C, Peters G, Davalos A, Lang W, Wang Y, Wang Y, Cunha L, Eckstein J, Tatlisumak T, Shamalov N, Mikulik R, Lavados P, Hankey GJ, Czlonkowska A, Toni D, Ameriso SF, Gagliardi RJ, Amarenco P, Bereczki D, Uchiyama S, Lindgren A, Endres M, Brouns R, Yoon BW, Ntaios G, Veltkamp R, Muir KW, Ozturk S, Arauz A, Bornstein N, Bryer A, O’Donnell MJ, Weitz J, Peacock F, Themeles E, Connolly SJ. Rivaroxaban for secondary stroke prevention in patients with embolic strokes of undetermined source: Design of the NAVIGATE ESUS randomized trial. Eur Stroke J 2016; 1:146-154. [PMID: 31008276 PMCID: PMC6301240 DOI: 10.1177/2396987316663049] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 07/13/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Embolic strokes of undetermined source comprise up to 20% of ischemic strokes. The stroke recurrence rate is substantial with aspirin, widely used for secondary prevention. The New Approach riVaroxaban Inhibition of Factor Xa in a Global trial versus ASA to prevenT Embolism in Embolic Stroke of Undetermined Source international trial will compare the efficacy and safety of rivaroxaban, an oral factor Xa inhibitor, versus aspirin for secondary prevention in patients with recent embolic strokes of undetermined source. MAIN HYPOTHESIS In patients with recent embolic strokes of undetermined source, rivaroxaban 15 mg once daily will reduce the risk of recurrent stroke (both ischemic and hemorrhagic) and systemic embolism (primary efficacy outcome) compared with aspirin 100 mg once daily. DESIGN Double-blind, randomized trial in patients with embolic strokes of undetermined source, defined as nonlacunar cryptogenic ischemic stroke, enrolled between seven days and six months from the qualifying stroke. The planned sample size of 7000 participants will be recruited from approximately 480 sites in 31 countries between 2014 and 2017 and followed for a mean of about two years until at least 450 primary efficacy outcome events have occurred. The primary safety outcome is major bleeding. Two substudies assess (1) the relative effect of treatments on MRI-determined covert brain infarcts and (2) the biological underpinnings of embolic strokes of undetermined source using genomic and biomarker approaches. SUMMARY The New Approach riVaroxaban Inhibition of Factor Xa in a Global trial versus ASA to prevenT Embolism in Embolic Stroke of Undetermined Source trial is evaluating the benefits and risks of rivaroxaban for secondary stroke prevention in embolic strokes of undetermined source patients. Main results are anticipated in 2018.
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Affiliation(s)
- Robert G Hart
- Department of Medicine (Neurology),
Population Health Research Institute, McMaster University, Hamilton Health Sciences,
Hamilton, Canada
| | - Mukul Sharma
- Department of Medicine (Neurology),
Population Health Research Institute, McMaster University, Hamilton Health Sciences,
Hamilton, Canada
| | | | - Ashkan Shoamanesh
- Department of Medicine (Neurology),
Population Health Research Institute, McMaster University, Hamilton Health Sciences,
Hamilton, Canada
| | - Scott E Kasner
- Department of Neurology, University of
Pennsylvania, Philadelphia, USA
| | | | - Guillaume Pare
- Department of Medicine (Neurology),
Population Health Research Institute, McMaster University, Hamilton Health Sciences,
Hamilton, Canada
| | | | - Janice Pogue
- Department of Clinical Epidemiology and
Biostatistics, Department of Medicine, Population Health Research Institute,
McMaster University, Hamilton Health Sciences, Hamilton, Canada
| | | | - Gary Peters
- Janssen Research and Development, LLC,
Spring House, Pennsylvania, USA
| | - Antoni Davalos
- Department of Neurosciences, Hospital
Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Wilfried Lang
- Hospital St. John of God, Medical
Faculty, Sigmund Freud University, Vienna, Austria
| | - Yongjun Wang
- Department of Neurology, Beijing
Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing
Tiantan Hospital, Capital Medical University, Beijing, China
| | - Luis Cunha
- Centro Hospitalar e Universitário de
Coimbra, Coimbra, Portugal
| | - Jens Eckstein
- Department of Innere Medizin,
Universitätsspital Basel, Basel, Switzerland
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki
University Central Hospital, Helsinki, Finland
| | - Nikolay Shamalov
- Pirogov Russian National Research
Medical University, Moscow, Russia
| | - Robert Mikulik
- International Clinical Research Center
and Neurology Department, St. Anne’s University Hospital, Brno, Czech Republic
| | - Pablo Lavados
- Clinica Alemana de Santiago,
Universidad del Desarrollo, Universidad de Chile, Santiago, Chile
| | - Graeme J Hankey
- School of Medicine and Pharmacology,
University of Western Australia, Sir Charles Gairdner Hospital, Perth,
Australia
| | - Anna Czlonkowska
- 2nd Department of Neurology, Institute
of Psychiatry and Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Danilo Toni
- Department of Neurology and
Psychiatry, “Sapienza” University of Rome, Rome, Italy
| | - Sebastian F Ameriso
- Institute for Neurological Research,
Fundacion para la Lucha contra las Enfermedades Neurologicas de la Infancia (FLENI),
Buenos Aires, Argentina
| | | | | | - Daniel Bereczki
- Department of Neurology, Semmelweis
University, Budapest, Hungary
| | | | - Arne Lindgren
- Department of Clinical Sciences
(Neurology), Department of Neurology and Rehabilitation Medicine, Skane University
Hospital, Lund University, Lund, Sweden
| | - Matthias Endres
- Klinik und Hochschulambulanz für
Neurologie, Center for Stroke Research Berlin, Charité-Universitätsmedizin, Berlin,
Germany
| | - Raf Brouns
- Universitair Ziekenhuis Brussel,
Brussels, Belgium
| | - Byung-Woo Yoon
- Department of Neurology, Seoul
National University Hospital, Seoul, Korea
| | - George Ntaios
- Department of Medicine, University of
Thessaly, Larissa, Greece
| | | | - Keith W Muir
- Institute of Neuroscience and
Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow,
UK
| | | | - Antonio Arauz
- Instituto Nacional de Neurologia y
Neurocirugia, Mexico D.F., Mexico
| | | | - Alan Bryer
- Groote Schuur Hospital, University of
Cape Town, Cape Town, South Africa
| | | | - Jeffrey Weitz
- Thrombosis and Atherosclerosis
Research Institute, McMaster University, Hamilton, Canada
| | | | | | - Stuart J Connolly
- Department of Medicine (Cardiology),
Population Health Research Institute, McMaster University, Hamilton Health Sciences,
Hamilton, Canada
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7
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Role of needle core biopsy in patients presenting with a breast lump associated with trauma. Eur Surg 2016. [DOI: 10.1007/s10353-016-0425-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Mijalski C, Silver B. TIA Management: Should TIA Patients be Admitted? Should TIA Patients Get Combination Antiplatelet Therapy? Neurohospitalist 2015; 5:151-60. [PMID: 26288673 DOI: 10.1177/1941874415580598] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Transient ischemic attack (TIA) has gained increasing attention over the last 2 decades with the realization that the condition is common, portends potentially serious consequences, and, when identified early, can be evaluated and treated to modify future risk. In this review, we examine the issues of whether all TIA patients need admission and whether such patients should receive short-term dual antiplatelet therapy. Not all patients require admission if evaluation and treatment are done promptly. There may be a role for dual antiplatelet therapy, but the results of further clinical trials will help provide better clarity on which patients are the best candidates for this treatment.
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Affiliation(s)
- Christina Mijalski
- Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Brian Silver
- Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
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9
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Abstract
Stroke is a major public health issue, and stroke recurrence accounts for a quarter of all events. Antiplatelet therapy has been extensively studied for secondary stroke prevention and is established as effective in this high-risk population. Several agents have been evaluated in this setting, both in isolation and combination. The most widely used antiplatelet medications are aspirin, clopidogrel, and aspirin plus extended-release dipyridamole. However, new agents and combinations continue to be evaluated. A detailed review of the evidence supporting various antiplatelet regimens for secondary stroke prevention is outlined with special focus on recent developments that may impact clinical management of patients with stroke or TIA.
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10
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Block RC, Abdolahi A, Tu X, Georas SN, Brenna JT, Phipps RP, Lawrence P, Mousa SA. The effects of aspirin on platelet function and lysophosphatidic acids depend on plasma concentrations of EPA and DHA. Prostaglandins Leukot Essent Fatty Acids 2015; 96:17-24. [PMID: 25555354 PMCID: PMC4395522 DOI: 10.1016/j.plefa.2014.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 12/11/2014] [Accepted: 12/14/2014] [Indexed: 12/21/2022]
Abstract
Aspirin's prevention of cardiovascular disease (CVD) events in individuals with type 2 diabetes mellitus is controversial. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and aspirin all affect the cyclooxygenase enzyme. The relationship between plasma EPA and DHA and aspirin's effects has not been determined. Thirty adults with type 2 diabetes mellitus ingested aspirin (81 mg/day) for 7 days, then EPA+DHA (2.6g/day) for 28 days, then both for another 7 days. Lysophosphatidic acid (LPA) species and more classic platelet function outcomes were determined. Plasma concentrations of total EPA+DHA were associated with 7-day aspirin reduction effects on these outcomes in a "V"-shaped manner for all 11 LPA species and ADP-induced platelet aggregation. This EPA+DHA concentration was quite consistent for each of the LPA species and ADP. These results support aspirin effects on lysolipid metabolism and platelet aggregation depending on plasma EPA+DHA concentrations in individuals with a disturbed lipid milieu.
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Affiliation(s)
- Robert C Block
- Department of Public Health Sciences, University of Rochester, School of Medicine and Dentistry, 265 Crittenden Boulevard, Box CU 420644, Rochester, NY 14642, USA.
| | - Amir Abdolahi
- Department of Public Health Sciences, University of Rochester, School of Medicine and Dentistry, 265 Crittenden Boulevard, Box CU 420644, Rochester, NY 14642, USA
| | - Xin Tu
- Department of Biostatistics and Computational Biology, University of Rochester, School of Medicine and Dentistry, 265 Crittenden Boulevard, Box CU 420644, Rochester, NY 14642 USA
| | - Steve N Georas
- Pulmonary and Critical Care Division, Department of Medicine, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA
| | - J Thomas Brenna
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Richard P Phipps
- Department of Environmental Medicine, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA
| | - Peter Lawrence
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Shaker A Mousa
- Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
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Gandhi CD, Bulsara KR, Fifi J, Kass-Hout T, Grant RA, Delgado Almandoz JE, English J, Meyers PM, Abruzzo T, Prestigiacomo CJ, Powers CJ, Lee SK, Albani B, Do HM, Eskey CJ, Patsalides A, Hetts S, Hussain MS, Ansari SA, Hirsch JA, Kelly M, Rasmussen P, Mack W, Pride GL, Alexander MJ, Jayaraman MV. Platelet function inhibitors and platelet function testing in neurointerventional procedures: Table 1. J Neurointerv Surg 2014; 6:567-77. [DOI: 10.1136/neurintsurg-2014-011357] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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12
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Eissa A, Krass I, Bajorek BV. Use of medications for secondary prevention in stroke patients at hospital discharge in Australia. Int J Clin Pharm 2014; 36:384-93. [DOI: 10.1007/s11096-013-9908-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Accepted: 12/26/2013] [Indexed: 10/25/2022]
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13
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Salvi F, Marchetti A, D'Angelo F, Boemi M, Lattanzio F, Cherubini A. Adverse drug events as a cause of hospitalization in older adults. Drug Saf 2013; 35 Suppl 1:29-45. [PMID: 23446784 DOI: 10.1007/bf03319101] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Older adults are about four to seven times more likely than younger persons to experience adverse drug events (ADEs) that cause hospitalization, especially if they are women and take multiple medications. The prevalence of drug-related hospitalizations has been reported to be as high as 31%, with large heterogeneity between different studies, depending on study setting (all hospital admissions or only acute hospital admissions), study population (entire hospital, specific wards, selected population and/or age groups), type of drug-related problem measured (adverse drug reaction or ADE), method of data collection (chart review, spontaneous reporting or database research) and method and definition used to detect ADEs. The higher risk of drug-related hospitalizations in older adults is mainly caused by age-related pharmacokinetic and pharmacodynamic changes, a higher number of chronic conditions and polypharmacy, which is often associated with the use of potentially inappropriate drugs. Other factors that have been involved are errors related to prescription or administration of drugs, medication non-adherence and inadequate monitoring of pharmacological therapies. A few commonly used drugs are responsible for the majority of emergency hospitalizations in older subjects, i.e. warfarin, oral antiplatelet agents, insulin and oral hypoglycaemic agents, central nervous system agents. The aims of the present review are to summarize recent evidence concerning drug-related hospitalization in older adults, to assess the contribution of specific medications, and to identify potential interventions able to reduce the occurrence of these drug-related events, as they are, at least partly, potentially preventable.
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Affiliation(s)
- Fabio Salvi
- Geriatrics and Geriatric Emergency Care, Italian National Research Centres on Aging (INRCA), Via della Montagnola n. 81, 60127, Ancona, Italy
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Block RC, Abdolahi A, Smith B, Meednu N, Thevenet-Morrison K, Cai X, Cui H, Mousa S, Brenna JT, Georas S. Effects of low-dose aspirin and fish oil on platelet function and NF-kappaB in adults with diabetes mellitus. Prostaglandins Leukot Essent Fatty Acids 2013; 89:9-18. [PMID: 23664596 PMCID: PMC3683095 DOI: 10.1016/j.plefa.2013.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 03/10/2013] [Accepted: 03/11/2013] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Many diabetics are insensitive to aspirin's platelet anti-aggregation effects. The possible modulating effects of co-administration of aspirin and fish oil in subjects with diabetes are poorly characterized. PARTICIPANTS AND METHODS Thirty adults with type 2 diabetes mellitus were treated with aspirin 81 mg/d for 7 days, then with fish oil 4 g/day for 28 days, then the combination of fish oil and aspirin for another 7 days. RESULTS Aspirin alone and in combination with fish oil reduced platelet aggregation in most participants. Five of 7 participants classified as aspirin insensitive 1 week after daily aspirin ingestion were sensitive after the combination. Although some platelet aggregation measures correlated positively after aspirin and fish oil ingestion alone and (in combination) in all individuals, correlation was only observed in those who were aspirin insensitive after ingestion of the combination. CONCLUSIONS Co-administration of aspirin and fish oil may reduce platelet aggregation more than aspirin alone in adults with diabetes mellitus.
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Affiliation(s)
- Robert C Block
- Department of Public Health Sciences, The University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
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15
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Baron TH, Kamath PS, McBane RD. Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl J Med 2013; 368:2113-24. [PMID: 23718166 DOI: 10.1056/nejmra1206531] [Citation(s) in RCA: 278] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Todd H Baron
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.
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16
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Lau AY, Zhao Y, Chen C, Leung TW, Fu J, Huang Y, Suwanwela NC, Han Z, Tan KS, Ratanakorn D, Markus HS, Wong KS. Dual antiplatelets reduce microembolic signals in patients with transient ischemic attack and minor stroke: subgroup analysis of CLAIR study. Int J Stroke 2013; 9 Suppl A100:127-32. [PMID: 23489888 DOI: 10.1111/ijs.12003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 08/02/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Short course of dual antiplatelet therapy for early secondary prevention is a promising treatment for patients with minor stroke or transient ischemic attack at high risk of recurrence. METHODS We examined the efficacy and safety of dual antiplatelets in patients with transient ischemic attack or minor stroke, defined as National Institute of Health Stroke Scale scores 0-3, in a subgroup analysis of Clopidogrel plus aspirin versus Aspirin alone for Reducing embolization in patients with acute symptomatic cerebral or carotid artery stenosis (CLAIR) study. Microembolic signals on transcranial Doppler monitoring was used as surrogate marker for recurrent stroke risk. Patients with ≥1 microembolic signals at baseline were randomized to receive dual therapy (aspirin 75-160 mg daily and clopidogrel 300 mg day 1 then 75 mg daily) or monotherapy (aspirin 75-160 mg daily) for seven-days. RESULTS Sixty-five of 100 patients recruited had transient ischemic attack or minor stroke: 30 received dual therapy and 35 received monotherapy. Mean onset-to-randomization was 2·3 days in dual therapy group and 3·2 days in monotherapy group (P = 0·03). At day 7, the proportion of patients with ≥1 microembolic signals was 9 of 29 patients in dual therapy group and 18 of 34 patients in monotherapy group (adjusted relative risk reduction 41·4%, 95% CI 29·8-51·1, P < 0·001). The median number of microembolic signals on day 7 was 0 in dual therapy group and 1·0 in monotherapy group (P = 0·046). No patients had intracranial or severe systemic hemorrhage. CONCLUSIONS Early dual therapy with clopidogrel and aspirin reduces microembolic signals in patients with minor ischemic stroke or transient ischemic attack, without causing significant bleeding complications.
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Affiliation(s)
- Alexander Y Lau
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong
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17
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Diener HC, Weber R. Clopidogrel added to aspirin adds no benefit but bleeding risk in patients with recent lacunar stroke. Stroke 2013; 44:861-3. [PMID: 23339960 DOI: 10.1161/strokeaha.112.680751] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hans-Christoph Diener
- Department of Neurology and Stroke Center, University Hospital Essen, Essen, Germany.
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18
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Block RC, Kakinami L, Jonovich M, Antonetti I, Lawrence P, Meednu N, CalderonArtero P, Mousa SA, Brenna JT, Georas S. The combination of EPA+DHA and low-dose aspirin ingestion reduces platelet function acutely whereas each alone may not in healthy humans. Prostaglandins Leukot Essent Fatty Acids 2012; 87:143-51. [PMID: 23017325 PMCID: PMC3589139 DOI: 10.1016/j.plefa.2012.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Revised: 08/21/2012] [Accepted: 08/22/2012] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Aspirin's effectiveness in reducing cardiovascular disease events is inadequate in some individuals, a phenomenon termed aspirin "resistance". The hypothesis that combining low dose aspirin with eicosapentaenoic acid and docosahexaenoic acid (EPA+DHA) reduces platelet function in the acute setting has not been investigated. PATIENTS AND METHODS We conducted a clinical trial of EPA+DHA and aspirin ingestion in healthy adults. Fasting blood samples were drawn at baseline and 4 h after supplementation with EPA/DHA (3.4 g/d), aspirin (81 mg), and both. Platelet function was measured using the Platelet Function Analyzer-100 (PFA-100). Plasma lysophosphatidylcholine (LPC), lysophosphatidic acid (LPA), autotaxin, angiogenesis activators, and cytokines were measured. RESULTS Platelet function decreased with the combination of aspirin+EPA/DHA (p=0.03) but not with either alone (p>0.05). EPA-LPC increased (p=0.002). DISCUSSION AND CONCLUSIONS Our results demonstrate that a potentially beneficial effect on platelet function occurred within 4h after ingestion of low-dose aspirin and EPA+DHA in healthy adults.
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Affiliation(s)
- Robert C Block
- Department of Community and Preventive Medicine, The University of Rochester School of Medicine and Dentistry, Box 644, Rochester, NY 14642, USA.
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Benavente OR, Hart RG, McClure LA, Szychowski JM, Coffey CS, Pearce LA. Effects of clopidogrel added to aspirin in patients with recent lacunar stroke. N Engl J Med 2012; 367:817-25. [PMID: 22931315 PMCID: PMC4067036 DOI: 10.1056/nejmoa1204133] [Citation(s) in RCA: 475] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Lacunar infarcts are a frequent type of stroke caused mainly by cerebral small-vessel disease. The effectiveness of antiplatelet therapy for secondary prevention has not been defined. METHODS We conducted a double-blind, multicenter trial involving 3020 patients with recent symptomatic lacunar infarcts identified by magnetic resonance imaging. Patients were randomly assigned to receive 75 mg of clopidogrel or placebo daily; patients in both groups received 325 mg of aspirin daily. The primary outcome was any recurrent stroke, including ischemic stroke and intracranial hemorrhage. RESULTS The participants had a mean age of 63 years, and 63% were men. After a mean follow-up of 3.4 years, the risk of recurrent stroke was not significantly reduced with aspirin and clopidogrel (dual antiplatelet therapy) (125 strokes; rate, 2.5% per year) as compared with aspirin alone (138 strokes, 2.7% per year) (hazard ratio, 0.92; 95% confidence interval [CI], 0.72 to 1.16), nor was the risk of recurrent ischemic stroke (hazard ratio, 0.82; 95% CI, 0.63 to 1.09) or disabling or fatal stroke (hazard ratio, 1.06; 95% CI, 0.69 to 1.64). The risk of major hemorrhage was almost doubled with dual antiplatelet therapy (105 hemorrhages, 2.1% per year) as compared with aspirin alone (56, 1.1% per year) (hazard ratio, 1.97; 95% CI, 1.41 to 2.71; P<0.001). Among classifiable recurrent ischemic strokes, 71% (133 of 187) were lacunar strokes. All-cause mortality was increased among patients assigned to receive dual antiplatelet therapy (77 deaths in the group receiving aspirin alone vs. 113 in the group receiving dual antiplatelet therapy) (hazard ratio, 1.52; 95% CI, 1.14 to 2.04; P=0.004); this difference was not accounted for by fatal hemorrhages (9 in the group receiving dual antiplatelet therapy vs. 4 in the group receiving aspirin alone). CONCLUSIONS Among patients with recent lacunar strokes, the addition of clopidogrel to aspirin did not significantly reduce the risk of recurrent stroke and did significantly increase the risk of bleeding and death. (Funded by the National Institute of Neurological Disorders and Stroke and others; SPS3 ClinicalTrials.gov number, NCT00059306.).
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Parvaiz MA, Korwar V, McArthur D, Claxton A, Dyer J, Isgar B. Large retroperitoneal haematoma: an unexpected complication of ilioinguinal nerve block for inguinal hernia repair. Anaesthesia 2012; 67:80-81. [PMID: 22150494 DOI: 10.1111/j.1365-2044.2011.06971.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - V Korwar
- New Cross Hospital, Wolverhampton, UK
| | | | - A Claxton
- New Cross Hospital, Wolverhampton, UK
| | - J Dyer
- New Cross Hospital, Wolverhampton, UK
| | - B Isgar
- New Cross Hospital, Wolverhampton, UK
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Acelajado MC, Oparil S. Antiplatelet Therapy for Transient Ischemic Attack. J Clin Hypertens (Greenwich) 2012; 14:103-111. [DOI: 10.1111/j.1751-7176.2011.00571.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Åsberg S, Henriksson KM, Farahmand B, Terént A. Hemorrhage after ischemic stroke - relation to age and previous hemorrhage in a nationwide cohort of 58,868 patients. Int J Stroke 2011; 8:80-6. [PMID: 22168375 DOI: 10.1111/j.1747-4949.2011.00718.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND In randomized controlled trials of secondary prevention after stroke, the risk of hemorrhage varies between 1% and 5% per year in patients with antithrombotic therapy, i.e. anticoagulants and antiplatelets. AIM To explore the rate and the risk of hemorrhage after stroke in a nationwide cohort. METHODS We identified 58 868 first ever ischemic stroke patients in the Swedish Stroke Register during 2001 to 2005 (=index stroke) and followed them by record linkage to the National Patient Register. Rates of hemorrhage and hazard ratios, for comparisons of rates between subgroups, were calculated. RESULTS Of the 58 586 ischemic stroke patients identified, 5527 (9·4%) had a history of hemorrhage. During follow-up (mean 2·0 years), 2876 patients endured a hemorrhage, giving an average hemorrhage rate of 2·6 (95% confidence interval 2·5-2·7) per 100 person-years. After index stroke, 11% of the patients were discharged with anticoagulants, and 79% with antiplatelets. Given the differences in baseline characteristics, the hemorrhage rates (per 100 person-years) were 2·5 (95% confidence interval 2·2-2·8), 2·4 (95% confidence interval 2·3-2·5), and 3·8 (95% confidence interval 3·5-4·2) in patients prescribed anticoagulants, antiplatelets, and no antithrombotics, respectively. There was an increased risk of hemorrhage in patients ≥75 years compared with those <75 years (hazard ratio = 1·61, 95% confidence interval 1·49-1·73) and in patients with previous hemorrhages compared with those without (hazard ratio = 1·82, 95% confidence interval 1·64-2·02). CONCLUSIONS When antithrombotics were used in large-scale clinical practice, the observed rates of hemorrhage were similar with anticoagulant therapy but increased with antiplatelet therapy compared with rates reported in randomized controlled trials. Old age and previous hemorrhage were associated with an increased risk of hemorrhage after an ischemic stroke.
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Affiliation(s)
- Signild Åsberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
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Jung KH, Chu K, Lee ST, Yoon HJ, Chang JY, Nam WS, Yoon SH, Cho JY, Yu KS, Jang IJ, Kim M, Lee SK, Roh JK. Prolonged Use of Aspirin Alters Human and Rat Intestinal Cells and Thereby Limits the Absorption of Clopidogrel. Clin Pharmacol Ther 2011; 90:612-9. [DOI: 10.1038/clpt.2011.163] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Altenburg A, Haage P. Antiplatelet and Anticoagulant Drugs in Interventional Radiology. Cardiovasc Intervent Radiol 2011; 35:30-42. [DOI: 10.1007/s00270-011-0204-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 05/22/2011] [Indexed: 01/16/2023]
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Saeed F, Kousar N, Sinnakirouchenan R, Ramalingam VS, Johnson PB, Holley JL. Blood Loss through AV Fistula: A Case Report and Literature Review. Int J Nephrol 2011; 2011:350870. [PMID: 21716705 PMCID: PMC3118665 DOI: 10.4061/2011/350870] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Revised: 03/10/2011] [Accepted: 03/24/2011] [Indexed: 11/20/2022] Open
Abstract
Little has been written about acute blood loss from hemodialysis vascular access. We describe a 57-year-old Caucasian male with an approximately 7 gm/dL drop in hemoglobin due to bleeding from a ruptured aneurysm in his right brachiocephalic arteriovenous fistula (AVF). There was no evidence of fistula infection. The patient was successfully managed by blood transfusions and insertion of a tunneled dialysis catheter for dialysis access. Later, the fistula was ligated and a new fistula was constructed in the opposite arm. Aneurysm should be considered in cases of acute vascular access bleeding in chronic dialysis patients.
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Affiliation(s)
- Fahad Saeed
- College of Medicine at Urbana-Champaign, University of Illinois, 611 W Park Street, Urbana, IL 61801, USA
| | - Nadia Kousar
- College of Medicine at Urbana-Champaign, University of Illinois, 611 W Park Street, Urbana, IL 61801, USA
| | - Ramapriya Sinnakirouchenan
- College of Medicine at Urbana-Champaign, University of Illinois, 611 W Park Street, Urbana, IL 61801, USA
| | - Vijaya S. Ramalingam
- College of Medicine at Urbana-Champaign, University of Illinois, 611 W Park Street, Urbana, IL 61801, USA
| | - Philip B. Johnson
- College of Medicine at Urbana-Champaign, University of Illinois, 611 W Park Street, Urbana, IL 61801, USA
| | - Jean L. Holley
- College of Medicine at Urbana-Champaign, University of Illinois, 611 W Park Street, Urbana, IL 61801, USA
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Weber R, Diener HC. Controversies and future perspectives of antiplatelet therapy in secondary stroke prevention. J Cell Mol Med 2011; 14:2371-80. [PMID: 20738445 PMCID: PMC3823155 DOI: 10.1111/j.1582-4934.2010.01162.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Antiplatelet agents are a cornerstone in the treatment of acute arterial thrombotic events and in the prevention of thrombus formation. However, existing antiplatelet agents (mainly aspirin, the combination of aspirin and dipyridamole and clopidogrel) reduce the risk of vascular events only by about one quarter compared with placebo. As a consequence, more efficacious antiplatelet therapies with a reduced bleeding risk are needed. We give an overview of several new antiplatelet agents that are currently investigated in secondary stroke prevention: adenosine 5'-diphosphonate receptor antagonists, cilostazol, sarpogrelate, terutroban and SCH 530348. There are unique features in secondary stroke prevention that have to be taken into account: ischaemic stroke is a heterogeneous disease caused by multiple aetiologies and the blood-brain barrier is disturbed after stroke which may result in a higher intracerebral bleeding risk. Several small randomized trials indicated that the combination of aspirin and clopidogrel might be superior to antiplatelet monotherapy in the acute and early post-ischaemic phase. There is an ongoing debate about antiplatelet resistance. Decreasing response to aspirin is correlated independently with an increased risk of cardiovascular events. However, there is still no evidence from randomized trials linking aspirin resistance and recurrent ischaemic events. Similarly, randomized trials have not demonstrated a clinical significantly decreased antiplatelet effect by the concomitant use of clopidogrel and proton pump inhibitors. Nevertheless, a routine use of this drug combination is not recommended.
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Affiliation(s)
- Ralph Weber
- Department of Neurology and Stroke Center, University Duisburg-Essen, Essen, Germany
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Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, Creager MA, Culebras A, Eckel RH, Hart RG, Hinchey JA, Howard VJ, Jauch EC, Levine SR, Meschia JF, Moore WS, Nixon JVI, Pearson TA. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2010; 42:517-84. [PMID: 21127304 DOI: 10.1161/str.0b013e3181fcb238] [Citation(s) in RCA: 1030] [Impact Index Per Article: 73.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE This guideline provides an overview of the evidence on established and emerging risk factors for stroke to provide evidence-based recommendations for the reduction of risk of a first stroke. METHODS Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council Scientific Statement Oversight Committee and the AHA Manuscript Oversight Committee. The writing group used systematic literature reviews (covering the time since the last review was published in 2006 up to April 2009), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations using standard AHA criteria (Tables 1 and 2). All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive peer review by the Stroke Council leadership and the AHA scientific statements oversight committees before consideration and approval by the AHA Science Advisory and Coordinating Committee. RESULTS Schemes for assessing a person's risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic predisposition. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, excessive alcohol consumption, drug abuse, use of oral contraceptives, sleep-disordered breathing, migraine, hyperhomocysteinemia, elevated lipoprotein(a), hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed. CONCLUSIONS Extensive evidence identifies a variety of specific factors that increase the risk of a first stroke and that provide strategies for reducing that risk.
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Abstract
BACKGROUND AND PURPOSE The aim of the study was to search for differences between clinical characteristics of recurrent ischaemic stroke which occurred within the fifth year after the first event or later, and early recurrence, i.e. within the first year after first-ever ischaemic stroke. We also tried to determine prognostic factors of late recurrent ischaemic episodes. MATERIAL AND METHODS The patients were divided into two groups: group I comprised 124 individuals with recurrence within the first year, and group II - 98 individuals in whom the recurrent episode appeared within the fifth year or later. RESULTS A significantly higher percentage of patients in group I demonstrated evident stenosis (70% or more) of internal carotid artery ipsilateral to stroke (p = 0.023). In this group more cardioembolic strokes were found compared to group II, while in the latter, predominantly lacunar strokes appeared (p = 0.046 and 0.0002, respectively). Group II patients significantly more frequently reported acetylsalicylic acid application, including systematic drug use (p = 0.001). No evident differences were found between groups considering other important non-modifiable and modifiable risk factors of stroke. CONCLUSIONS Small differences between risk factors of ischaemic stroke profiles in patients with early and late recurrent episodes do not allow us to distinguish unequivocally a group of patients with better prognosis regarding the time of recurrent stroke. Use of antiplatelet drugs, either systematic or non-systematic, and lacunar stroke are independent, positive prognostic factors of delay of potential recurrent stroke.
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Clopidogrel application: beyond coronary artery disease. Clin Sci (Lond) 2009; 118:459-61. [PMID: 19888916 DOI: 10.1042/cs20090546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Revised: 11/02/2009] [Accepted: 11/04/2009] [Indexed: 11/17/2022]
Abstract
Dual antiplatelet therapy with aspirin and clopidogrel, a P2Y12 antagonist, is a cornerstone for treatment of patients with stroke, peripheral arterial disease, and acute coronary artery disease followed with or without percutaneous coronary intervention. Giachini and colleagues found that clopidogrel could normalize the increased phenylephrine-induced vascular contraction and impaired acetylcholine-induced vasodilatation in mesenteric arteries from angiotensin II-infused Sprague-Dawley rats. This might develop a new area for clopidogrel application. However, whether clopidogrel can improve the arterial function in patients with hypertension or diabetes, or whether clopidogrel outweighs the beneficial effect aspirin in those patients, remains an open field for future inquiry.
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Pisters R, Dinh T, Crijns HJ. Clopidogrel plus aspirin in atrial fibrillation. N Engl J Med 2009; 361:1312; author reply 1314-5. [PMID: 19776416 DOI: 10.1056/nejmc091230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Waksman R. Definition, incidence, correlates, and clinical impact of "nuisance" bleeding in patients undergoing drug-eluting stent implantation. Am J Cardiol 2009; 104:30C-3C. [PMID: 19695358 DOI: 10.1016/j.amjcard.2009.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
"Nuisance" bleeding, or superficial bleeding, after antiplatelet therapy is not well characterized despite its potential to affect patient compliance and premature cessation of oral antiplatelet therapy, which can lead to clinical events, such as stent thrombosis. In contrast to major, moderate, or minor bleeding, nuisance bleeding has never been included in the primary or secondary end points of antiplatelet and antithrombin trials and was not reported as an in-hospital or follow-up event in the pivotal pharmacology or device trials associated with percutaneous coronary intervention. Currently, the incidence and impact of these bleeds are not officially recorded and remain unknown. Indeed, there are challenges in the definition, in the acquisition of consistent phenomenon characteristics, and its attribution to major clinical adverse events. Nuisance bleeding is commonly seen in patients on dual antiplatelet therapy. It may be the cause of premature cessation of oral antiplatelet therapy, which is detrimental to prognosis after drug-eluting stent implantation. This article discusses the various definitions, incidence, correlates, and clinical impact of this phenomenon.
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Affiliation(s)
- Ron Waksman
- Division of Cardiology, Washington Hospital Center, 110 Irving Street NW, Washington, DC 20010, USA.
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Abstract
Abstract
This article discusses how we approach medical decision making in the treatment of the various facets of the antiphospholipid syndrome (APS), including secondary prophylaxis in the setting of venous and arterial thrombosis, as well as treatment for the prevention of recurrent miscarriages and fetal death. The role of primary thromboprophylaxis is also discussed in depth. Great emphasis is given to incorporating the most up-to-date and relevant evidence base both from the APS literature, and from large, recent, randomized controlled trials (RCTs) of primary and secondary thrombotic prophylaxis in the general population setting (ie, the population that has not been specifically investigated for APS).
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Notaro LA, Usman MH, Burke JF, Siddiqui A, Superdock KR, Ezekowitz MD. Secondary Prevention in Concurrent Coronary Artery, Cerebrovascular, and Chronic Kidney Disease: Focus on Pharmacological Therapy. Cardiovasc Ther 2009; 27:199-215. [DOI: 10.1111/j.1755-5922.2009.00087.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Bibliography current world literature. Coron Artery Dis 2009; 20:428-9. [PMID: 19696599 DOI: 10.1097/mca.0b013e3283315984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hermann A, Dzialowski I, Koch R, Gahn G. Combined anti-platelet therapy with aspirin and clopidogrel: risk factor for thrombolysis-related intracerebral hemorrhage in acute ischemic stroke? J Neurol Sci 2009; 284:155-7. [PMID: 19473668 DOI: 10.1016/j.jns.2009.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Revised: 05/04/2009] [Accepted: 05/06/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE To date, pre-treatment with anti-platelet agents does not constitute a contraindication for thrombolysis in acute ischemic stroke. We tested the hypothesis that combined pre-treatment with aspirin and clopidogrel is a risk factor for thrombolysis-related symptomatic intracerebral hemorrhage (sICH). METHODS We retrospectively studied patients with acute ischemic stroke receiving standard i.v. thrombolytic therapy with rt-PA in our institution. Exclusion criteria were thrombolysis initiated later than 3 h from symptom onset or with non-tPA-agents, no follow-up imaging was performed and data on prior medication was missing. We recorded clinical baseline variables including known risk factors for ICH. Our outcome measure was the incidence of ICH defined as parenchymal hematoma type 2 with > or = 4 points deterioration on the National Institute of Health Stroke Scale score. We performed univariate analysis to determine risk factors for sICH. RESULTS We identified 102 patients receiving any thrombolysis of which 63 fulfilled the inclusion criteria. Mean age was 69 years, onset-to-treatment-time 138 min, 56% male, median NIHSS score was 10, and 3 patients received additional intra-arterial interventions. A total of 3 patients had received combined aspirin and clopidogrel treatment before thrombolysis. SICH occurred in 3/63 (4.7%) of patients. Out of these, 2 patients had received the combined anti-platelet treatment. In univariate analysis, only combined pre-treatment with aspirin and clopidogrel treatment were associated with the occurrence of sICH. CONCLUSION In our retrospective study, only pre-treatment with aspirin and clopidogrel was associated with thrombolysis-related intracerebral hemorrhage. This finding should be further validated in large prospective databases like the SITS-MOST registry.
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Affiliation(s)
- Andreas Hermann
- Department of Neurology, University of Technology Dresden, Fetscherstrabetae 74, 01307, Dresden, Germany
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