Peri-Operative Outcomes of Carotid Endarterectomy are Not Improved on Dual Antiplatelet Therapy vs. Aspirin Monotherapy: A Systematic Review and Meta-Analysis

Efficacy and safety of proton pump inhibitors on cardiovascular events and inflammatory factors in patients with upper gastrointestinal bleeding undergoing dual antiplatelet therapy

BACKGROUND

This work evaluated the effects of proton pump inhibitors (PPIs) on cardiovascular events (CVEs) and inflammatory factors in patients with upper gastrointestinal bleeding (UGIB) undergoing dual antiplatelet therapy (DAPT) after percutaneous coronary intervention. Clinical data from these patients were analysis, intending to provide relevant theoretical evidence for clinical practice.

MATERIALS AND METHODS

Data of 166 patients who underwent percutaneous coronary intervention and developed UGIB while on DAPT at The First People' Hospital of Linping District from April 2021 to April 2023 were retrospectively analyzed. The patients were rolled into two groups: those who received PPI treatment and those who did not, namely, PPI and non-PPI group, respectively. Furthermore, occurrence of CVEs and the levels of inflammatory factors of patients in all groups were statistically analyzed.

RESULTS

In patients with UGIB, melena is a common presentation. The incidence of CVE in the PPI group showed no statistically significant difference compared to the control group, and there was no significant variance observed in the distribution of CVE incidence among different PPIs. However, levels of C-reactive protein (CRP) and tumor necrosis factor-alpha (TNF-α) were significantly lower in the PPI group compared to the non-PPI group (P < 0.05).

CONCLUSION

Melena was the most frequent clinical manifestation in UGIB patients. The use of PPIs did not increase the risk of CVEs, and different PPI drugs did not affect the occurrence of CVEs. Furthermore, PPIs lowered CRP and TNF-α levels in serum of these patients.

Effects of Proton Pump Inhibitors on Cardiovascular Events and Inflammatory Factors in Patients With Upper Gastrointestinal Bleeding Undergoing Dual Antiplatelet Therapy

INTRODUCTION

Dual antiplatelet therapy (DAPT), vital post-percutaneous coronary intervention (PCI) to prevent cardiovascular events (CVEs) via aspirin and P2Y12 receptor antagonists, faces controversy when combined with proton pump inhibitors (PPIs) due to potential impacts on bleeding risk and antiplatelet efficacy, prompting the need for further research to determine optimal co-administration practices. This work evaluated the effects of PPIs on CVEs and inflammatory factors in patients with upper gastrointestinal bleeding (UGIB) undergoing DAPT after PCI.

MATERIALS AND METHODS

The data of 166 patients who underwent PCI and developed UGIB while on DAPT from April 2021 to April 2023 were retrospectively analyzed. The patients were rolled into two groups: those who received PPI treatment and those who did not, namely, the PPI and non-PPI group, respectively. Clinical data from these patients was analyzed, intending to provide relevant theoretical evidence for clinical practice. Furthermore, the occurrence of CVEs and the levels of inflammatory factors of patients in all groups were statistically analyzed.

RESULTS

Melena was the most common clinical symptom observed in all UGIB patients. The incidence of CVEs in the PPI group was not greatly different from that in the non-PPI group (P>0.05). The distribution of CVEs occurrence among different PPI drugs also exhibited no obvious difference (P>0.05). The PPI group exhibited greatly lower C-reactive protein (CRP) and tumor necrosis factor α (TNF-α) based on the non-PPI group (P<0.05).

CONCLUSION

Melena was the most frequent clinical manifestation in UGIB patients. The use of PPIs did not increase the risk of CVEs, and different PPI drugs did not affect the occurrence of CVEs. Furthermore, PPIs lowered CRP and TNF-α levels in serum of these patients.

Association of Impedance Aggregometry-Measured Platelet Aggregation With Thromboembolic Events in Patients Who Undergo Carotid Endarterectomy: A Pilot Study

OBJECTIVES

The aim of the current study was to assess the relationship among thrombin receptor activator peptide 6 (TRAP test), adenosine-5'-diphosphate (ADP test), arachidonic acid (ASPI test), and stroke/transient ischemic attack (TIA), using the multiple electrode aggregometry (Multiplate) in patients undergoing carotid thromboendarterectomy (CEA).

DESIGN

A retrospective study.

SETTING

Vascular surgery operating rooms of a university hospital.

PARTICIPANTS

One hundred thirty-one out of 474 patients undergoing CEA between November 2020 and October 2022.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A preoperative blood sample of all enrolled patients was analyzed using the Multiplate analyzer. Receiver operating characteristics curves, were generated to test the ability of TRAP, ADP, and ASPI in discriminating perioperative thromboembolic stroke/TIA. A logistic LASSO regression model was used to identify factors independently associated with stroke/TIA. Eight patients experienced a perioperative stroke/TIA. Although all the platelet functional assays showed excellent predictive performance, an ADP value exceeding 72 U showed the highest specificity (87%) and sensitivity (68%) in discriminating patients who had a perioperative thromboembolic stroke/TIA, with a negative predictive value of 99% and a positive predictive value of 15%. After LASSO regression, an ADP >72 U and the need for a shunt during CEA were the only 2 variables independently associated with perioperative stroke/TIA.

CONCLUSION

Because the ADP test was independently associated with perioperative stroke/TIA, the assessment of platelet reactivity using Multiplate may offer potential utility in monitoring patients undergoing CEA.

An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis

OBJECTIVE

Despite the publication of various national/international guidelines, several questions concerning the management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis remain unanswered. The aim of this international, multi-specialty, expert-based Delphi Consensus document was to address these issues to help clinicians make decisions when guidelines are unclear.

METHODS

Fourteen controversial topics were identified. A three-round Delphi Consensus process was performed including 61 experts. The aim of Round 1 was to investigate the differing views and opinions regarding these unresolved topics. In Round 2, clarifications were asked from each participant. In Round 3, the questionnaire was resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response.

RESULTS

Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) the time threshold for a patient being considered "recently symptomatic" should be reduced from the current definition of "6 months" to 3 months or less; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) shunting should be used selectively, rather than always or never. Consensus could not be reached on the remaining topics due to conflicting, inadequate, or controversial evidence.

CONCLUSIONS

The present international, multi-specialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues. However, consensus could not be achieved on some topics, highlighting areas requiring future research.

Dual Antiplatelet Therapy for the Acute Management and Long-term Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack, An Updated Review

To improve the efficacy over antiplatelet monotherapy, dual antiplatelet therapy (DAPT) has been increasingly adopted in the management of non-cardioembolic stroke. For minor ischemic stroke and high-risk transient ischemic attack, the aspirin-clopidogrel combination is now recommended for acute short-term treatment, whereas aspirin-ticagrelor combination may be considered in selected patients, especially those with resistance to clopidogrel. For long-term stroke prevention, aspirin-dipyridamole combination has been used as an alternative to antiplatelet monotherapy, and aspirin or clopidogrel combined with cilostazole may be prescribed for added protection in high-risk patients. In this paper, we review the development of DAPT from a historical perspective and describe the findings from major clinical trials published up until the end of 2023. Using the 2021 American Heart Association guideline for secondary stroke prevention as a basis for our recommendations, we further discuss areas of controversy and more recent developments to provide an updated review for clinicians to consider in their daily practice.

Medical Management of Cardiovascular Disease

We offer an overview of lipid lowering, antiplatelet, antihypertensive, and glucose-lowering therapies for vascular surgeons and their respective medical teams. Further reviews should offer additional guidance on smoking cessation, exercise therapy, and nutritional optimization.

Carotid Artery Stenosis: A Look Into the Diagnostic and Management Strategies, and Related Complications

Carotid stenosis (CS) is a buildup of atherosclerotic plaque within the artery leading to a wide range of symptoms, from mild symptoms, including blurred vision and confusion, to much more life-threatening presentations, including paralysis due to stroke. The presentation is insidious, with symptoms exhibiting predominantly at severe stenosis; hence the emphasis is placed on the importance of early diagnosis, treatment, and lifestyle modifications. CS is seen undergoing almost the same pathogenesis of any atherosclerotic plaque formation, from endothelial damage of the artery lumen to the formation of a fibrous cap with a foam cell, lipid-filled core. The findings of our review article were consistent with the recent literature, depicting that comorbid hypertension, diabetes, and chronic kidney disease (CKD), and lifestyle aspects, including smoking and diet, played the most salient role in plaque development. Among several imaging modalities, duplex ultrasound (DUS) imaging is the widely preferred method in clinical practice. Carotid endarterectomy (CEA) and carotid stenting are the primarily advocated procedures for symptomatic severe stenosis, with similar long-term outcomes. Although, earlier clinical trials showed promising results in mitigating the risk of stroke among asymptomatic severe CS with surgical intervention. However, recent advancements have shifted the focus to medical management alone due to comparable results among the asymptomatic population. Both surgical and medical regimens are beneficial in treating patients, but it is still an ongoing debate as to which is predominantly superior. The currently advancing trials and research will help elucidate definitive guidelines. However, the massive impact of lifestyle modifications advocates some degree of individualized multidisciplinary management strategies.

Editor's Choice - Risk of Bleeding Complications With Different Peri-Operative Antithrombotic Regimens During Carotid Endarterectomy: a National Registry Analysis

OBJECTIVE

Antithrombotic therapy is one of the cornerstones of the prevention of (recurrent) ocular or cerebral ischaemic events in patients with carotid artery stenosis. Randomised controlled trials on antithrombotic therapy for patients with minor ischaemic stroke and transient ischaemic attack (TIA) have recommended dual antiplatelet therapy (DAPT) in the three weeks following the index event. However, these trials excluded patients undergoing carotid revascularisation. To date, the optimal antithrombotic therapy during the peri-operative period of carotid endarterectomy (CEA) remains unclear.

METHODS

Symptomatic and asymptomatic patients with carotid artery stenosis undergoing primary CEA from the Dutch Audit for Carotid Interventions registry between June 2013 and December 2020 were eligible for inclusion. The primary outcome was defined as post-operative cervical bleeding needing re-intervention or intracranial haemorrhage during the first 30 days following CEA. The secondary outcomes were ischaemic stroke or TIA or all cause mortality during the first 30 days following CEA. Descriptive statistics and multiple logistic regressions analyses were applied, with acetylsalicylic acid (ASA) as the reference value.

RESULTS

A total of 12 317 patients were included. In the peri-operative phase, 31.0% of patients were treated with ASA, 32.4% with clopidogrel, 11.1% with ASA plus clopidogrel, 10.4% with ASA plus dipyridamole, 10.3% with vitamin K antagonist, and 4.8% with direct acting oral anticoagulants therapy. After multiple logistic regression analysis, no association was seen with the primary outcome in ASA plus clopidogrel (odds ratio [OR] 0.81; confidence interval [CI] 0.58 - 1.13; p = .23), and ASA plus dipyridamole (OR 0.69; CI 0.47 - 1.00; p = .059). Both the DAPT therapies were not associated with the secondary outcome.

CONCLUSION

The effectiveness and safety of DAPT did not differ from single antiplatelet therapy (SAPT) in patients undergoing CEA and further evaluation is needed in prospective studies. Considering additional data from the literature and guideline recommendations, DAPT should be started immediately after stroke until 30 days after CEA followed by SAPT, due to a possible reduction in the risk of recurrence.