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Wang X, Han L, Yang J. Evaluation of efficacy and safety of aspirin combination treatment in treating patients with coronary heart disease: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e28848. [PMID: 35363182 PMCID: PMC9281913 DOI: 10.1097/md.0000000000028848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 01/28/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Coronary heart disease (CHD) has a high incidence rate as a cardiovascular condition, primarily affecting the elderly and middle-aged individuals. CHD has debilitating effects on the standard of life of the elderly, and affecting their physical and psychological health. Reportedly, using aspirin alone is less effective as a first line of treatment for CHD. Therefore, this systematic review and meta-analysis will synthesize evidence on the effectiveness and safeness of aspirin combination treatment in treating patients with CHD. METHODS A comprehensive meta-analysis is to be performed to evaluate the effectiveness and safety of aspirin combination treatment for CHD patients. A search will be performed on PubMed, EMBASE, Cochrane Central, WanFang, and Chinese National Knowledge Infrastructure till December 25, 2021 to identify randomized controlled trials, assess all related studies on the aspirin combination treatment in treating patients with CHD. In this systematic review, we will adopt the second version of Cochrane risk of bias assessment tool to assess the bias risk in all studies that fulfil the eligibility conditions. Two authors will separately conduct the study selection process, risk of bias assessment, and data extraction. Moreover, a random-effects meta-analysis will be conducted to synthesize evidence for all outcomes. Provided there is sufficient homogeneity among the studies, we will perform meta-analysis. I2 test will be employed to assess the heterogeneity of the outcomes. OSF REGISTRATION NUMBER 10.17605/OSF.IO/MDTCA.
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Affiliation(s)
- Xueling Wang
- Department of Cardiovascular Medicine, Beijing Hospital of Integrated Traditional Chinese and Western Medicine, Beijing, China
| | - Lin Han
- Department of Cardiology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jiyuan Yang
- Department of Cardiovascular Medicine, Beijing Hospital of Integrated Traditional Chinese and Western Medicine, Beijing, China
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2
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Calderaro D, Bichuette LD, Maciel PC, Cardozo FAM, Ribeiro HB, Gualandro DM, Baracioli LM, Soeiro ADM, Serrano CV, Costa RAD, Caramelli B. Update of the Brazilian Society of Cardiology's Perioperative Cardiovascular Assessment Guideline: Focus on Managing Patients with Percutaneous Coronary Intervention - 2022. Arq Bras Cardiol 2022; 118:536-547. [PMID: 35262593 PMCID: PMC8856674 DOI: 10.36660/abc.20220039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Daniela Calderaro
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luciana Dornfeld Bichuette
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Pamela Camara Maciel
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Francisco Akira Malta Cardozo
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Henrique Barbosa Ribeiro
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Danielle Menosi Gualandro
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel - Suíça
| | - Luciano Moreira Baracioli
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Hospital Sírio Libanês, São Paulo, SP - Brasil
| | - Alexandre de Matos Soeiro
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Hospital BP Mirante, São Paulo, SP - Brasil
| | - Carlos Vicente Serrano
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Bruno Caramelli
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
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3
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Parikh PB. Dual Antiplatelet Duration After DES: Is it Time to Say Goodbye to 1-Year DAPT? J Am Coll Cardiol 2021; 78:1987-1989. [PMID: 34763775 DOI: 10.1016/j.jacc.2021.08.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Puja B Parikh
- Division of Cardiovascular Medicine, Department of Medicine, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA.
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4
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Lee S, Guthrie DB, Epstein RH. Kawasaki Disease and General Anesthesia for Dental Treatment: A Case Report. Anesth Prog 2021; 68:146-153. [PMID: 34606572 DOI: 10.2344/anpr-68-01-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 11/15/2020] [Indexed: 11/11/2022] Open
Abstract
Kawasaki disease (KD) is an acute vasculitis of childhood and is the leading cause of acquired heart disease in children in developed countries. Failure to quickly diagnose and treat patients with KD can result in severe cardiac sequelae, especially coronary artery aneurysms (CAAs). Patients with a prior diagnosis of KD who require general anesthesia (GA) may present unique challenges depending on the severity of any cardiovascular sequelae. This case report describes the perioperative management of a 5-year-old male patient previously diagnosed with incomplete KD approximately 1 year before presenting to Stony Brook University Hospital for full mouth dental rehabilitation under GA. Most uniquely, the patient was at high risk for coronary artery thrombosis due to a giant CAA of his right coronary artery and a small CAA of his left anterior descending artery. The discussion also includes the implications of dental treatment under GA for patients with a history of KD.
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Affiliation(s)
- Sarah Lee
- Department of Oral and Maxillofacial Surgery, Stony Brook School of Dental Medicine, Stony Brook, New York.,Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - David B Guthrie
- Department of Oral and Maxillofacial Surgery, Stony Brook School of Dental Medicine, Stony Brook, New York.,Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Ralph H Epstein
- Department of Oral and Maxillofacial Surgery, Stony Brook School of Dental Medicine, Stony Brook, New York.,Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
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5
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Fukui M, Takamochi K, Suzuki K, Ando K, Matsunaga T, Hattori A, Oh S, Suzuki K. Outcomes of lung cancer surgery for patients with interstitial pneumonia and coronary disease. Surg Today 2021; 52:137-143. [PMID: 34136963 DOI: 10.1007/s00595-021-02319-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/22/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate the surgical outcomes of lung cancer patients with idiopathic interstitial pneumonia (IIP) and/or coronary artery disease (CAD). METHODS The subjects of this retrospective study were 2830 patients who underwent surgical resection for lung cancer between 2009 and 2018. Seventy-one patients (2.6%) had both IIP and CAD (FC group). The remaining patients were divided into those with IIP only (group F), those with CAD only (group C), and those without IIP or CAD (group N). We compared mortality and overall survival (OS) among the groups. RESULTS The 90-day mortality and OS were poorer in group FC than in groups C and N, but equivalent to those in group F. Multivariate analyses revealed that IIP (odds ratio [OR] 3.163; p = 0.001) and emphysema (2.588; p = 0.009) were predictors of 90-day mortality. IIP (OR 2.991, p < 0.001), diabetes (OR 1.241, p = 0.043), and a history of other cancers (OR 1.347, p = 0.011) were all predictors of OS. CONCLUSIONS Short-term and long-term mortality after lung cancer surgery were not dependent on coexistent CAD but were related to IIP. Thus, computed tomography (CT) should be done preoperatively to check for IIP, which is a risk factor for surgical mortality.
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Affiliation(s)
- Mariko Fukui
- Departments of General Thoracic Surgery, Juntendo University School of Medicine, 1-3, Hongo 3-chome, Bunkyo-ku, Tokyo, 113-8431, Japan.
| | - Kazuya Takamochi
- Departments of General Thoracic Surgery, Juntendo University School of Medicine, 1-3, Hongo 3-chome, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Kazuhiro Suzuki
- Departments of Radiology, Juntendo University School of Medicine, Tokyo, Japan
| | - Katsutoshi Ando
- Departments of Respiratory Medicine, Juntendo University School of Medicine, Tokyo, Japan
| | - Takeshi Matsunaga
- Departments of General Thoracic Surgery, Juntendo University School of Medicine, 1-3, Hongo 3-chome, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Aritoshi Hattori
- Departments of General Thoracic Surgery, Juntendo University School of Medicine, 1-3, Hongo 3-chome, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Shiaki Oh
- Departments of General Thoracic Surgery, Juntendo University School of Medicine, 1-3, Hongo 3-chome, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Kenji Suzuki
- Departments of General Thoracic Surgery, Juntendo University School of Medicine, 1-3, Hongo 3-chome, Bunkyo-ku, Tokyo, 113-8431, Japan
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Partow-Navid R, Prasitlumkum N, Mukherjee A, Varadarajan P, Pai RG. Management of ST Elevation Myocardial Infarction (STEMI) in Different Settings. Int J Angiol 2021; 30:67-75. [PMID: 34025097 DOI: 10.1055/s-0041-1723944] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
ST-segment elevation myocardial infarction (STEMI) is a life-threatening condition that requires emergent, complex, well-coordinated treatment. Although the primary goal of treatment is simple to describe-reperfusion as quickly as possible-the management process is complicated and is affected by multiple factors including location, patient, and practitioner characteristics. Hence, this narrative review will discuss the recommended management and treatment strategies of STEMI in the circumstances.
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Affiliation(s)
- Rod Partow-Navid
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Narut Prasitlumkum
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Ashish Mukherjee
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Padmini Varadarajan
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Ramdas G Pai
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
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Hishikari K, Hikita H, Abe F, Ito N, Kanno Y, Iiya M, Murai T, Takahashi A, Yonetsu T, Sasano T. Risk factors and prognostic impact of post-discharge bleeding after endovascular therapy for peripheral artery disease. Vasc Med 2021; 26:281-287. [PMID: 33645340 DOI: 10.1177/1358863x21992863] [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: 12/24/2022]
Abstract
This study evaluated the incidence, predictors, and impact of bleeding requiring hospitalization following successful endovascular therapy (EVT) for peripheral artery disease. Platelet inhibition after EVT reduces the risk of major adverse limb events but increases the risk of bleeding. The incidence of post-discharge bleeding after EVT, its independent predictors, and its prognostic importance in clinical practice have not been fully addressed. We evaluated 779 consecutive patients who underwent EVT. We found that 77 patients (9.9%) were hospitalized for major bleeding during follow-up after EVT (median 39 months, range 22-66 months), with almost half (48.1%) of the bleeding categorized as gastrointestinal bleeding. Significant predictors of post-discharge bleeding were hemodialysis (hazard ratio (HR), 3.12; 95% CI: 1.93 to 5.05; p < 0.001) and dual antiplatelet therapy (DAPT) use (HR, 1.87; 95% CI: 1.03 to 3.41; p = 0.041). During follow-up, the all-cause mortality-free survival rate was significantly worse in patients who had experienced major bleeding than in those who had not (log-rank test χ2 = 54.6; p < 0.001). Cox proportional hazards analysis showed that major bleeding (HR, 2.78; 95% CI: 1.90 to 4.06; p < 0.001) was an independent predictor of all-cause death after EVT. Hospitalization for post-discharge bleeding after EVT is associated with a substantially increased risk of death, even after successful EVT. We concluded that patients' predicted bleeding risk should be considered when selecting patients likely to benefit from EVT, and that the risk should be considered especially thoroughly in hemodialysis patients.
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Affiliation(s)
- Keiichi Hishikari
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan.,Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Hikita
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Fumichika Abe
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Naruhiko Ito
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Yoshinori Kanno
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Munehiro Iiya
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Tadashi Murai
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | | | - Taishi Yonetsu
- Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuo Sasano
- Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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8
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Lee Y, Lim YH, Park Y, Shin J. Real-World Bleeding and Ischemic Events in Asian Patients on P2Y12-Inhibitors After Percutaneous Coronary Intervention: A National Claims Data Analysis. Adv Ther 2021; 38:562-578. [PMID: 33179207 PMCID: PMC7854396 DOI: 10.1007/s12325-020-01526-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/06/2020] [Indexed: 12/11/2022]
Abstract
Introduction The safety and effectiveness of potent P2Y12 inhibitors in East Asians have been questioned because of the higher bleeding tendency and lower thrombotic risk in this population. We comparatively evaluated the safety, effectiveness and treatment persistence of the dual antiplatelet therapies (DAPT) with clopidogrel (CDAPT), ticagrelor (TDAPT) and prasugrel (PDAPT) after percutaneous coronary intervention (PCI) in the Korean population. Methods A retrospective cohort study was conducted using Korean National Health Insurance claims data. In 57,197 patients treated with DAPT after PCI, the risk of bleeding events, risk of major adverse cardiac and cerebral events (MACCE: a composite of all-cause death, myocardial infarction [MI], stroke and revascularization), risk of net adverse clinical events (NACE) and persistence and adherence rates were assessed with stabilized inverse probability of treatment weighting. Results TDAPT was associated with higher risks of bleeding (1 year: hazard ratio [HR], 1.37; 95% confidence interval [CI] 1.28–1.46; prolonged: HR 1.39, 95% CI 1.31–1.47), MACCE (1 year: HR 1.10, 95% CI 1.03–1.18; prolonged: HR 1.24, 95% CI 1.16–1.31) and NACE (1 year: HR 1.23, 95% CI 1.18–1.29; prolonged: HR 1.31, 95% CI 1.25–1.36) than CDAPT both at 1 year and in the prolonged periods, whereas there were no significant differences between PDAPT and CDAPT. Similar results were also observed in a subgroup analysis of patients with baseline MI. CDAPT was associated with higher persistence and adherence rates than TDAPT and PDAPT. Conclusions CDAPT was associated with clinical outcomes that were more favorable than those in TDAPT and comparable to those in PDAPT and drug persistence and adherence that were higher than in TDAPT or PDAPT. Clopidogrel may remain a viable first option for post-PCI DAPT in East Asian patients with a low thrombotic risk and a high bleeding tendency. Electronic Supplementary Material The online version of this article (10.1007/s12325-020-01526-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yonggu Lee
- Division of Cardiology, College of Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Young-Hyo Lim
- Division of Cardiology, College of Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Yongwhi Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Jinho Shin
- Division of Cardiology, College of Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea.
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Li Y, Ming JE, Kong F, Yin H, Zhang L, Bai H, Liu H, Qi L, Wang Y, Xie F, Yang N, Ping C, Li Y, Chen L, Han C, Liu J, Wang X. Bioequivalence Study Comparing Fixed-Dose Combination of Clopidogrel and Aspirin with Coadministration of Individual Formulations in Chinese Subjects Under Fed Conditions: A Phase I, Open-Label, Randomized, Crossover Study. Adv Ther 2020; 37:4660-4674. [PMID: 32970315 PMCID: PMC7547973 DOI: 10.1007/s12325-020-01486-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Indexed: 11/28/2022]
Abstract
Introduction Simultaneous administration of acetylsalicylic acid (ASA) and clopidogrel has demonstrated efficacy in the treatment of acute coronary syndrome. Clopidogrel + ASA in a fixed-dose combination (FDC) provides a pharmaceutical option to enhance adherence to the coadministration of dual antiplatelet therapy (DAPT). Herein, we evaluate the bioequivalence of enteric ASA and clopidogrel in an FDC compared with simultaneous administration of the individual formulations. Methods This study is a randomized, single-center, open-label, three-sequence, three-period, two-treatment, crossover study conducted in healthy Chinese male and female subjects under fed conditions. Subjects were randomized to receive, in each period, a single dose of (1) a combination tablet containing 75-mg clopidogrel and 100-mg enteric ASA (test formulation) or (2) coadministration of one 75-mg clopidogrel tablet and one 100-mg enteric-coated ASA tablet (reference formulations) under fed conditions. Plasma samples were analyzed for ASA, salicylic acid, clopidogrel, and the clopidogrel metabolite SR26334. For ASA, the reference-scaled average bioequivalence (RSABE) analysis was conducted for Cmax of ASA because within-subject standard deviation (SDW) was ≥ 0.294 for log-transformed Cmax. Results The point estimate (test/reference geometric mean ratio) was between 0.80 and 1.25, and the upper one-sided 95% confidence interval (CI) for the scaled average bioequivalence metric was ≤ 0 (-0.08). AUC of ASA as SDW was < 0.294 for log-transformed AUClast and AUC. Estimates of 90% CIs for log-transformed AUClast and AUC ratios were within the bioequivalence range of 0.80 to 1.25 (0.98–1.08 and 1.00–1.10, respectively). For clopidogrel, the 90% CIs for the ratios comparing log-transformed Cmax, AUClast, and AUC ratios of clopidogrel following administration of test versus reference formulation were calculated using the ABE method and were well within the acceptable range of 0.80 to 1.25 (1.02–1.12, 0.92–0.99, and 0.92–0.98, respectively). Conclusion FDC of ASA and clopidogrel was bioequivalent to the simultaneous administration of the individual formulations in healthy Chinese subjects under fed conditions. Trial registration CTR20190376. Electronic Supplementary Material The online version of this article (10.1007/s12325-020-01486-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yan Li
- Phase I Clinical Trial Center, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | | | | | | | | | - Haihong Bai
- Phase I Clinical Trial Center, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Huijuan Liu
- Phase I Clinical Trial Center, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Lu Qi
- Phase I Clinical Trial Center, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | | | - Fang Xie
- Medical, Sanofi, Shanghai, China
| | - Na Yang
- Research and Development, Sanofi, Beijing, China
| | - Chuan Ping
- Research and Development, Sanofi, Beijing, China
| | - Yi Li
- Research and Development, Sanofi, Beijing, China
| | - Liu Chen
- Phase I Clinical Trial Center, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Chunyu Han
- Phase I Clinical Trial Center, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Ju Liu
- Phase I Clinical Trial Center, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Xinghe Wang
- Phase I Clinical Trial Center, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China.
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10
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Ureteroscopy in Patients Taking Anticoagulant or Antiplatelet Therapy: Practice Patterns and Outcomes in a Surgical Collaborative. J Urol 2020; 205:833-840. [PMID: 33035142 DOI: 10.1097/ju.0000000000001416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE AUA guidelines recommend ureteroscopy as first line therapy for patients on anticoagulant or antiplatelet therapy and advocate using a ureteral access sheath. We examined practice patterns and unplanned health care use for these patients in Michigan. MATERIALS AND METHODS Using the Michigan Urological Surgery Improvement Collaborative (MUSIC) clinical registry we identified ureteroscopy cases from 2016 to 2019. We assessed outcomes and adherence to guidelines based on therapy at time of ureteroscopy: 1) anticoagulant: continuous warfarin or novel oral agent therapy; 2) antiplatelet: continuous clopidogrel or aspirin therapy; 3) control: not on anticoagulant/antiplatelet therapy. We fit multivariate models to assess anticoagulant or antiplatelet therapy association with emergency department visits, hospitalization and ureteral access sheath use. RESULTS In total, 9,982 ureteroscopies were performed across 31 practices with 3.1% and 7.8% on anticoagulant and antiplatelet therapy, respectively. There were practice (0% to 21%) and surgeon (0% to 35%) variations in performing ureteroscopy on patients on anticoagulant/antiplatelet therapy regardless of volume. After adjusting for risk factors, anticoagulant or antiplatelet therapy was not associated with emergency department visits. Hospitalization rates in anticoagulant, antiplatelet and control groups were 4.3%, 5.5% and 3.2%, respectively, and significantly increased with antiplatelet therapy (OR 1.48, 95% CI 1.02-2.14). Practice-level ureteral access sheath use varied (23% to 100%) and was not associated with anticoagulant/antiplatelet therapy. Limitations include inability to risk stratify between type/dosage of anticoagulant/antiplatelet therapy. CONCLUSIONS We found practice-level and surgeon-level variation in performing ureteroscopy while on anticoagulant/antiplatelet therapy. Ureteroscopy on anticoagulant is safe. However, antiplatelet therapy increases the risk of hospitalization. Despite guideline recommendations, ureteral access sheath use is not associated with anticoagulant/antiplatelet therapy.
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11
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Saba ES, Higgins MK, Heyes R, Lott DG. Is Continued Perioperative Antithrombotic Therapy Safe When Performing Direct Microlaryngoscopy? Laryngoscope 2020; 130:2853-2858. [PMID: 32134121 DOI: 10.1002/lary.28600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 01/20/2020] [Accepted: 01/29/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate whether antithrombotic status impacts the incidence of perioperative or postoperative bleeding in direct microlaryngoscopy (DML). STUDY DESIGN Retrospective chart review. METHODS Patients undergoing DML in a single surgeon's practice from September 2012 to September 2017 were studied. Included patients underwent DML with or without biopsy, balloon dilation, microsurgery, laser ablation, or vocal fold injection. Patients were stratified based on perioperative antithrombotic status and assessed for rates of peri- and postoperative bleeding and other complications. RESULTS Of the 581 patients meeting inclusion criteria, 179 patients (31%) had a history of baseline antithrombotic therapy. Of these patients, 124 had perioperative continuation of their therapy. Medicated patients were older (P < .01), predominately male (P < .01), and increasingly comorbid (P < .01). Perioperative complications unrelated to bleeding occurred in 22 patients (4%), minor perioperative bleeding occurred in four patients (0.7%), and minor postoperative bleeding occurred in 12 of the 479 patients with recorded follow-up (2.5%). There were no postoperative bleeds requiring intervention or readmission, and no recorded thrombotic events during the peri- and postoperative period. There was no difference in perioperative bleeding based on baseline antithrombotic status (P = .81). Patients on baseline antithrombotic therapy were more likely to have a postoperative bleed in comparison to patients without history of antithrombotic use (P < .01). However, there were no significant differences in postoperative bleeding between patients on baseline anticoagulation who continued or ceased their medication perioperatively (P = .45). CONCLUSIONS Perioperative continuation of antithrombotic medications appears to be safe when performing routine DML. LEVEL OF EVIDENCE 4 Laryngoscope, 2020.
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Affiliation(s)
- Elias S Saba
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michelle K Higgins
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona, U.S.A
| | - Richard Heyes
- Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, U.S.A
| | - David G Lott
- Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, U.S.A
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Abstract
Many patients undergoing ophthalmic surgery are elderly with comorbidities requiring antiplatelet therapy to prevent thromboembolic or atherothrombotic events. The use of antiplatelet therapy has expanded over the years, predisposing these patients to hemorrhagic complications perioperatively. The risk of hemorrhagic complications must be weighed against the risk of thromboembolic events with cessation of antiplatelet therapy. The decision to continue or interrupt antiplatelet therapy in the setting of ophthalmic surgery is based upon various factors, including the type of surgery and each patient’s comorbidities. This review examines the risks of thrombotic complications versus hemorrhagic complications in different types of ophthalmic surgeries with the use of antiplatelet medications and provides evidence-based recommendations regarding perioperative management of antiplatelet therapy
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Affiliation(s)
- Sana Idrees
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Jayanth Sridhar
- Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
| | - Ajay E. Kuriyan
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY, USA
- Retina Service, Wills Eye Hospital, Philadelphia, PA, USA
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13
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Ratcliffe FM, Kharbanda R, Foëx P. Perioperative ST-elevation myocardial infarction: with time of the essence, is there a case for guidelines? Br J Anaesth 2019; 123:548-554. [PMID: 31543267 DOI: 10.1016/j.bja.2019.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/02/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- Fiona M Ratcliffe
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK.
| | | | - Pierre Foëx
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
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14
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Winter MP, von Lewinski D, Wallner M, Prüller F, Kolesnik E, Hengstenberg C, Siller-Matula JM. Incidence, predictors, and prognosis of premature discontinuation or switch of prasugrel or ticagrelor: the ATLANTIS - SWITCH study. Sci Rep 2019; 9:8194. [PMID: 31160687 PMCID: PMC6547711 DOI: 10.1038/s41598-019-44673-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 05/13/2019] [Indexed: 02/06/2023] Open
Abstract
Aim of the present study was to investigate the frequency and predictors of premature discontinuation or switch of ADP receptor blockers and its association with serious adverse events. For this purpose 571 consecutive ACS patients receiving ticagrelor (n = 258, 45%) or prasugrel (n = 313, 55%) undergoing PCI were enrolled in this prospective, observational, multicenter ATLANTIS-SWITCH substudy. Predictors of premature discontinuation or switch of antiplatelet therapy and their association with major adverse cardiovascular events and TIMI bleeding events were evaluated. Premature stop/switch was found in 72 (12.6%) patients: 34 (5.9%) stopped and 38 (6.7%) switched the ADP blocker. Ticagrelor treated patients were significantly more likely to stop/switch therapy as compared to prasugrel (15.9% vs. 9.2%, p = 0.016). We identified 4 independent predictors for stop/switch of ADP blocker: major surgery, need for oral anticoagulation (OAC), TIMI major bleeding and drug intolerance. TIMI major bleeding was a driver of stop/switch actions and occurred in 4.3% vs 0.2% in patients with vs without stop/switch (p = 0.001). The majority of stop/switch actions (75%) were physicians driven decisions. Importantly, stop/switch of therapy was not associated with increased risk of MACE (p = 0.936). In conclusion premature switch/stop of ADP blockers appears to be safe when mainly driven by physician’s decision and clinical indication.
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Affiliation(s)
- Max-Paul Winter
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | - Markus Wallner
- Department of Cardiology, Medical University of Graz, Graz, Austria.,Lewis Katz School of Medicine, Temple University, Cardiovascular Research Center, Philadelphia, PA, USA
| | - Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Ewald Kolesnik
- Department of Cardiology, Medical University of Graz, Graz, Austria
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15
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Akonjom M, Battenberg A, Beverland D, Choi JH, Fillingham Y, Gallagher N, Han SB, Jang WY, Jiranek W, Manrique J, Mihov K, Molloy R, Mont MA, Nandi S, Parvizi J, Peel T, Pulido L, Sarungi M, Sodhi N, Alberdi MT, Olivan RT, Wallace D, Weng X, Wynn-Jones H, Yeo SJ. General Assembly, Prevention, Blood Conservation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S147-S155. [PMID: 30348569 DOI: 10.1016/j.arth.2018.09.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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16
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Di Mario C, Mugelli A, Perrone Filardi P, Rosano G, Rossi F. Long-term dual antiplatelet therapy: pharmacological and clinical implications. J Cardiovasc Med (Hagerstown) 2019; 19:399-410. [PMID: 29894353 DOI: 10.2459/jcm.0000000000000677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
: Patients experiencing an acute coronary syndrome are exposed to an increased residual risk of recurrent coronary events. Dual antiplatelet therapy (DAPT) is highly effective in preventing atherothrombotic complications in patients with previous myocardial infarction and current guidelines recommend the prescription of DAPT for at least 12 months in all patients experiencing an acute event. However, recent findings demonstrated that long-term DAPT (over 12 months) is related to a better outcome in patients at high risk, suggesting the use of a long-term DAPT to achieve a better clinical outcome. The choice of DAPT duration is still a difficult issue and a personalized approach to the patients is mandatory to manage both the residual ischemic risk and the risk of bleeding events.The aim of this review is to analyze the pharmacological characteristics of available antiplatelet agents and to revise the use of DAPT in clinical practice, focusing on the benefits of a long-term approach.
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Affiliation(s)
- Carlo Di Mario
- Department of Cardiology, Careggi University Hospital, Florence
| | - Alessandro Mugelli
- Department of Neurosciences, Drug Research and Child's Health, University of Florence
| | | | - Giuseppe Rosano
- Cardiovascular Clinical Academic Group, St George's Hospitals NHS Trust University of London, London, UK.,Department of Medical Sciences, IRCCS San Raffaele, Rome
| | - Francesco Rossi
- Department of Experimental Medicine, Section of Pharmacology 'L. Donatelli,' University of Campania 'Luigi Vanvitelli,' Naples, Italy
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17
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Savage MP, Fischman DL. Clopidogrel Hypersensitivity: Overview of the Problem. Curr Vasc Pharmacol 2019; 17:108-109. [DOI: 10.2174/1570161116666180820123041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 08/06/2018] [Accepted: 08/13/2018] [Indexed: 11/22/2022]
Affiliation(s)
- Michael P. Savage
- Department of Cardiology Sidney Kimmel Medical College at Thomas Jefferson University Director, Cardiac Catheterization Laboratory Thomas Jefferson University Hospital Philadelphia, PA, United States
| | - David L. Fischman
- Department of Medicine Sidney Kimmel Medical College at Thomas Jefferson University Co-Director, Cardiac Catheterization Laboratory Director, Interventional Cardiology Fellowship Program Thomas Jefferson University Hospital Philadelphia, PA, United States
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18
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Incidence, predictors, and outcomes of DAPT disruption due to non-compliance vs. bleeding after PCI: insights from the PARIS Registry. Clin Res Cardiol 2019; 108:643-650. [DOI: 10.1007/s00392-018-1392-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/05/2018] [Indexed: 12/20/2022]
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19
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Sahar-Helft S, Chackartchi T, Polak D, Findler M. Dental treatment in the era of new anti-thrombotic agents. Int Dent J 2018; 68:131-137. [DOI: 10.1111/idj.12322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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20
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Chandrasekhar J, Baber U, Sartori S, Aquino M, Tomey M, Kruckoff M, Moliterno D, Henry TD, Weisz G, Gibson CM, Iakovou I, Kini A, Faggioni M, Vogel B, Farhan S, Colombo A, Steg PG, Witzenbichler B, Chieffo A, Cohen D, Stuckey T, Ariti C, Pocock S, Dangas G, Mehran R. Patterns and associations between DAPT cessation and 2-year clinical outcomes in left main/proximal LAD versus other PCI: Results from the Patterns of Non-Adherence to Dual Antiplatelet Therapy in Stented Patients (PARIS) registry. Int J Cardiol 2017; 243:132-139. [DOI: 10.1016/j.ijcard.2017.05.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/22/2017] [Accepted: 05/10/2017] [Indexed: 11/28/2022]
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21
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Stefanini G, Byrne R, Windecker S, Kastrati A. State of the art: coronary artery stents – past, present and future. EUROINTERVENTION 2017; 13:706-716. [DOI: 10.4244/eij-d-17-00557] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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22
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Akhlaghi F, Khaheshi I, Amirhassani S, Tabrizi R. Do antiplatelet drugs increase the risk of bleeding after tooth extraction? A case-crossover study. Int J Oral Maxillofac Surg 2017; 46:1475-1478. [PMID: 28663019 DOI: 10.1016/j.ijom.2017.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/25/2017] [Accepted: 06/05/2017] [Indexed: 10/19/2022]
Abstract
The aim of this study was to assess the risk of bleeding after tooth extraction in patients taking aspirin or clopidogrel. This case-crossover study evaluated patients taking aspirin (80mg/day) or clopidogrel (75mg/day) and undergoing tooth extraction. In the first session, extraction was performed without discontinuing aspirin (group 1) or clopidogrel (group 2). In the second session, patients ceased using antiplatelet drugs 5days prior to tooth extraction. Bleeding was evaluated using a visual analogue scale (VAS) for 72h after tooth extraction. The platelet function assay (PFA) was performed for group 1 and flow cytometry assessment of vasodilator-stimulated phosphoprotein (VASP) was performed for group 2, in both sessions. Thirty-eight patients were studied: 20 in group 1 and 18 in group 2. Analysis of the data did not demonstrate any difference in bleeding severity between sessions 1 and 2 in either group (P>0.05). There was a significant difference between sessions 1 and 2 in group 1 for the mean collagen/epinephrine membrane closure time (PFA) (P=0.001). A significant difference in platelet reactivity index (flow cytometry for VASP) was noted between sessions 1 and 2 in group 2 (P=0.001). According to this case-crossover study, dental extraction can be performed safely without withdrawal of aspirin or clopidogrel.
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Affiliation(s)
- F Akhlaghi
- Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - I Khaheshi
- Cardiovascular Research Centre, Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - S Amirhassani
- Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - R Tabrizi
- Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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23
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Chung MJ, Hansen JD, Schulteis RD, Boggan JC, Jones WS, Povsic TJ, Roberts S, Krucoff MW, Rao SV. Understanding operator stent choice in the catheterization laboratory using a pre-procedure survey: Opportunities for quality improvement. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:588-591. [PMID: 28529095 DOI: 10.1016/j.carrev.2017.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/27/2017] [Accepted: 05/03/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES We sought to characterize how the perceived risk of early dual antiplatelet therapy (DAPT) discontinuation is incorporated into operator decision-making regarding stent choice, using a simple pre-procedure survey screening for clinical variables that may lead to early DAPT discontinuation. BACKGROUND Understanding which factors influence operator decision-making regarding stent choice during percutaneous coronary intervention (PCI) could help identify areas for quality improvement. METHODS We retrospectively identified 1202 patients who underwent PCI from July 2008 to January 2013 at the Durham Veterans Affairs Medical Center. We excluded patients without a complete pre-procedure survey within 14days of PCI, repeat procedures on the same patient and those who received both drug-eluting stents (DES) and bare-metal stents (BMS) or no stent during PCI, leaving 864 patients. The primary outcome was the independent association of "yes" responses to survey items with the odds of DES use during PCI. RESULTS Of 864 patients, 661 received DES and 203 received BMS. A "yes" response to "planned major surgery or dental work in the next year" (OR 0.20, 95% CI 0.11-0.36, p<0.001), "recent bleeding event or bleeding diathesis" (OR 0.31, 95% CI 0.14-0.68, p=0.003) or "currently taking Coumadin" (OR 0.39, 95% CI 0.19-0.78, p=0.007) was independently associated with lower odds of DES use. CONCLUSIONS Responses to 3 items on a simple pre-procedure survey screening for clinical variables that may lead to early DAPT discontinuation were independently associated with stent type used during PCI, suggesting the importance of these factors in an operator's stent choice.
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Affiliation(s)
- Matthew J Chung
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, USA.
| | - Jonathan D Hansen
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Ryan D Schulteis
- Department of Medicine, Duke University Medical Center, Durham, NC, USA; Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Joel C Boggan
- Department of Medicine, Duke University Medical Center, Durham, NC, USA; Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - W Schuyler Jones
- Department of Medicine, Duke University Medical Center, Durham, NC, USA; Durham Veterans Affairs Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Thomas J Povsic
- Department of Medicine, Duke University Medical Center, Durham, NC, USA; Durham Veterans Affairs Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Susan Roberts
- Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Mitchell W Krucoff
- Department of Medicine, Duke University Medical Center, Durham, NC, USA; Durham Veterans Affairs Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Sunil V Rao
- Department of Medicine, Duke University Medical Center, Durham, NC, USA; Durham Veterans Affairs Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
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24
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Tian M, Zhu L, Lin H, Lin Q, Huang P, Yu X, Jing Y. Hsp-27 levels and thrombus burden relate to clinical outcomes in patients with ST-segment elevation myocardial infarction. Oncotarget 2017; 8:73733-73744. [PMID: 29088740 PMCID: PMC5650295 DOI: 10.18632/oncotarget.17852] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/26/2017] [Indexed: 12/11/2022] Open
Abstract
High thrombus burden, subsequent distal embolization, and myocardial no-reflow remain a large obstacle that may negate the benefits of urgent coronary revascularization in patients with ST-segment elevation myocardial infarction (STEMI). However, the biological function and clinical association of Hsp-27 with thrombus burden and clinical outcomes in patients with STEMI is not clear. Consecutive patients (n = 146) having STEMI undergoing primary percutaneous coronary intervention (pPCI) within 12 hours from the onset of symptoms were enrolled in this prospective study in the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shangdong, P.R. China. Patients were divided into low thrombus burden and high thrombus burden groups. The present study demonstrated that patients with high-thrombus burden had higher plasma Hsp-27 levels ([32.0 ± 8.6 vs. 58.0 ± 12.3] ng/mL, P < 0.001). The median value of Hsp-27 levels in all patients with STEMI was 45 ng/mL. Using the receiver operating characteristic (ROC) curve analysis, plasma Hsp-27 levels were of significant diagnostic value for high thrombus burden (AUC, 0.847; 95% CI, 0.775–0.918; P < 0.01). The multivariate cox regression analysis demonstrated that Hsp-27 > 45 ng/mL (HR 2.801, 95% CI 1.296–4.789, P = 0.001), were positively correlated with the incidence of major adverse cardiovascular events (MACE). Kaplan-Meier survival analysis demonstrated that MACE-free survival at 180-day follow-up was significantly lower in patients with Hsp-27 > 45 ng/mL (log rank = 10.28, P < 0.001). Our data demonstrate that plasma Hsp-27 was positively correlated with high thrombus burden and the incidence of MACE in patients with STEMI who underwent pPCI.
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Affiliation(s)
- Maozhou Tian
- Department of Cardiac Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shangdong 264000, P.R. China
| | - Lingmin Zhu
- Department of Cardiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shangdong 264000, P.R. China
| | - Hongyang Lin
- Emergency Centre, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shangdong 264000, P.R. China
| | - Qiaoyan Lin
- Department of Cardiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shangdong 264000, P.R. China
| | - Peng Huang
- Department of Cardiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shangdong 264000, P.R. China
| | - Xiao Yu
- Department of Endocrinology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shangdong 264000, P.R. China
| | - Yanyan Jing
- Department of Cardiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shangdong 264000, P.R. China
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25
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Domingues R, Bruniera G, Brunale F, Mangueira C, Senne C. Lumbar puncture in patients using anticoagulants and antiplatelet agents. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 74:679-86. [PMID: 27556380 DOI: 10.1590/0004-282x20160098] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 05/25/2016] [Indexed: 12/26/2022]
Abstract
The use of anticoagulants and antiplatelet agents has largely increased. Diagnostic lumbar puncture in patients taking these drugs represents a challenge considering the opposing risks of bleeding and thrombotic complications. To date there are no controlled trials, specific guidelines, nor clear recommendations in this area. In the present review we make some recommendations about lumbar puncture in patients using these drugs. Our recommendations take into consideration the pharmacology of these drugs, the thrombotic risk according to the underlying disease, and the urgency in cerebrospinal fluid analysis. Evaluating such information and a rigorous monitoring of neurological symptoms after lumbar puncture are crucial to minimize the risk of hemorrhage associated neurological deficits. An individualized patient decision-making and an effective communication between the assistant physician and the responsible for conducting the lumbar puncture are essential to minimize potential risks.
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Affiliation(s)
| | - Gustavo Bruniera
- Senne Líquor Diagnóstico, São Paulo SP, Brasil;,Hospital Israelita Albert Einstein, Laboratório de Patologia Clínica, São Paulo SP, Brasil
| | - Fernando Brunale
- Senne Líquor Diagnóstico, São Paulo SP, Brasil;,Hospital Israelita Albert Einstein, Laboratório de Patologia Clínica, São Paulo SP, Brasil
| | - Cristóvão Mangueira
- Hospital Israelita Albert Einstein, Laboratório de Patologia Clínica, São Paulo SP, Brasil
| | - Carlos Senne
- Senne Líquor Diagnóstico, São Paulo SP, Brasil;,Hospital Israelita Albert Einstein, Laboratório de Patologia Clínica, São Paulo SP, Brasil
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26
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Barillà F, Pelliccia F, Borzi M, Camici P, Cas LD, Di Biase M, Indolfi C, Mercuro G, Montemurro V, Padeletti L, Filardi PP, Vizza CD, Romeo F. Optimal duration of dual anti-platelet therapy after percutaneous coronary intervention: 2016 consensus position of the Italian Society of Cardiology. J Cardiovasc Med (Hagerstown) 2017; 18:1-9. [PMID: 27635937 DOI: 10.2459/jcm.0000000000000434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Definition of the optimal duration of dual anti-platelet therapy (DAPT) is an important clinical issue, given the large number of patients having percutaneous coronary intervention (PCI), the costs and risks of pharmacologic therapy, the consequences of stent thrombosis, and the potential benefits of DAPT in preventing ischaemic outcomes beyond stent thrombosis. Nowadays, the rationale for a prolonged duration of DAPT should be not only the prevention of stent thrombosis, but also the prevention of ischaemic events unrelated to the coronary stenosis treated with index PCI. A higher predisposition to athero-thrombosis may persist for years after an acute myocardial infarction, and even stable patients with a history of prior myocardial infarction are at high risk for major adverse cardiovascular events. Recently, results of pre-specified post-hoc analyses of randomized clinical trials, including the PEGASUS-TIMI 54 trial, have shed light on strategies of DAPT in various clinical situations, and should impact the next rounds of international guidelines, and also routine practice. Accordingly, the 2015 to 2016 the Board of the Italian Society of Cardiology addressed newer recommendations on duration of DAPT based on most recent scientific information. The document states that physicians should decide duration of DAPT on an individual basis, taking into account ischaemic and bleeding risks of any given patient. Indeed, current controversy surrounding optimal duration of DAPT clearly reflects the fact that, nowadays, a one size fits all strategy cannot be reliably applied to patients treated with PCI. Indeed, patients usually have factors for both increased ischaemic and bleeding risks that must be carefully evaluated to assess the benefit/risk ratio of prolonged DAPT. Personalized management of DAPT must be seen as a dynamic prescription with regular re-evaluations of the risk/benefit to the patient according to changes in his/her clinical profile. Also, in order to derive more benefit than harm from new treatments, a multi-parametric approach using several risk scores of the ischaemic and bleeding risks might improve the process of risk factor characterization. In patients with high ischaemic risk, particularly those with a history of myocardial infarction, the benefits of extended DAPT (particularly with ticagrelor up to 3 years) are likely to outweigh the risks.
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Affiliation(s)
- Francesco Barillà
- aDepartment of Cardiovascular Sciences, Sapienza University bDepartment of Cardiovascular Disease, Tor Vergata University of Rome, Rome cCardiothoracic and Vascular Department, Vita-Salute University, Milan dDepartment of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia eDepartment of Medical & Surgical Sciences, University of Foggia, Foggia fDivision of Cardiology, Department of Medical and Surgical Sciences, 'Magna Graecia' University, Catanzaro gDepartment of Medical Sciences 'Mario Aresu', University of Cagliari, Cagliari hHeart and Vessels Department, University of Florence, Florence iDepartment of Advanced Biomedical Sciences, Federico II University, Naples, Italy
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Von Keudell AG, Thornhill TS, Katz JN, Losina E. Mortality Risk Assessment of Total Knee Arthroplasty and Related Surgery After Percutaneous Coronary Intervention. Open Orthop J 2017; 10:706-716. [PMID: 28144380 PMCID: PMC5220172 DOI: 10.2174/1874325001610010706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 09/30/2016] [Accepted: 10/05/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The optimal antiplatelet therapy (APT) treatment strategy after Coronary Artery Stenting (CAS) in non-cardiac surgery, such as total knee arthroplasty (TKA) or urgent TKA-related surgery remains unknown. METHODS We built a decision tree model to examine the mortality outcomes of two alternative strategies for APT after CAS use in the perioperative period namely, continuous use and discontinuation. RESULTS If surgery was performed in the first month after CAS placement, discontinuing APT led to an estimated 30-day post TKA mortality of 10.5%, compared to 1.0% in a strategy with continuous APT use. Mortality with both strategies decreased with longer intervals. CONCLUSION Our model demonstrated that APT discontinuation in patients undergoing TKA or urgent TKA related surgery after CAS placement might lead to greater 30-day mortality up to one year.
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Affiliation(s)
- Arvind G Von Keudell
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, JNK), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, JNK), Department of Orthopedic Surgery (AGvK, TST, JNK, EL), Brigham and Women's Hospital, Boston, MA, Massachusetts; Harvard Medical School, Boston, MA, Massachusetts (TST, JNK, EL); Department of Epidemiology, Harvard School of Public Health (JNK), Department of Biostatistics, Boston University School of Public Health, Boston, MA, Massachusetts (EL), USA
| | - Thomas S Thornhill
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, JNK), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, JNK), Department of Orthopedic Surgery (AGvK, TST, JNK, EL), Brigham and Women's Hospital, Boston, MA, Massachusetts; Harvard Medical School, Boston, MA, Massachusetts (TST, JNK, EL); Department of Epidemiology, Harvard School of Public Health (JNK), Department of Biostatistics, Boston University School of Public Health, Boston, MA, Massachusetts (EL), USA
| | - Jeffrey N Katz
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, JNK), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, JNK), Department of Orthopedic Surgery (AGvK, TST, JNK, EL), Brigham and Women's Hospital, Boston, MA, Massachusetts; Harvard Medical School, Boston, MA, Massachusetts (TST, JNK, EL); Department of Epidemiology, Harvard School of Public Health (JNK), Department of Biostatistics, Boston University School of Public Health, Boston, MA, Massachusetts (EL), USA
| | - Elena Losina
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, JNK), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, JNK), Department of Orthopedic Surgery (AGvK, TST, JNK, EL), Brigham and Women's Hospital, Boston, MA, Massachusetts; Harvard Medical School, Boston, MA, Massachusetts (TST, JNK, EL); Department of Epidemiology, Harvard School of Public Health (JNK), Department of Biostatistics, Boston University School of Public Health, Boston, MA, Massachusetts (EL), USA
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28
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Kaw R. Cardiac Risk Stratification Among Ambulatory Patients Undergoing Non-Cardiac Surgery. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0188-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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29
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Eisen A, Bhatt DL. Optimal duration of dual antiplatelet therapy after acute coronary syndromes and coronary stenting. Heart 2016; 103:871-884. [PMID: 27888209 DOI: 10.1136/heartjnl-2015-309022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Alon Eisen
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
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31
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Siu H, Kaliyadan A, Fischman DL, Nardone E, Poll D, Savage MP. Use of prasugrel in the setting of clopidogrel hypersensitivity: Case report and systematic review of the literature. Platelets 2016; 27:824-827. [DOI: 10.1080/09537104.2016.1203402] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Henry Siu
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Antony Kaliyadan
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - David L. Fischman
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Evan Nardone
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - David Poll
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Michael P. Savage
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Duration of dual antiplatelet therapy after various drug-eluting stent implantation. Int J Cardiol 2016; 215:157-66. [DOI: 10.1016/j.ijcard.2016.04.118] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 04/11/2016] [Indexed: 11/17/2022]
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Tantry US, Navarese EP, Gurbel PA. What is the Optimal Duration of Dual Antiplatelet Therapy After Stenting? CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2016. [DOI: 10.15212/cvia.2016.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Triple antithrombotic therapy versus dual antiplatelet therapy in patients with atrial fibrillation undergoing drug-eluting stent implantation. Coron Artery Dis 2016; 26:372-80. [PMID: 25768244 DOI: 10.1097/mca.0000000000000242] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The optimal antithrombotic regimen in patients with atrial fibrillation (AF) undergoing drug-eluting stent (DES) implantation for complex coronary artery disease is unclear. We compared the net clinical outcomes of triple antithrombotic therapy (TAT; aspirin, thienopyridine, and warfarin) and dual antiplatelet therapy (DAPT; aspirin and thienopyridine) in AF patients who had undergone DES implantation. METHODS A total of 367 patients were enrolled and analyzed retrospectively; 131 patients (35.7%) received TAT and 236 patients (64.3%) received DAPT. DAPT and warfarin were maintained for a minimum of 12 and 24 months, respectively. The primary endpoint was the 2-year net clinical outcomes, a composite of major bleeding and major adverse cardiac and cerebral events (MACCE). Propensity score-matching analysis was carried out in 99 patient pairs. RESULTS The 2-year net clinical outcomes of the TAT group were worse than those of the DAPT group (34.3 vs. 21.1%, P=0.006), which was mainly due to the higher incidence of major bleeding (16.7 vs. 4.6%, P<0.001), without any significant increase in MACCE (22.1 vs. 17.7%, P=0.313). In the multivariate analysis, TAT was an independent predictor of worse net clinical outcomes (odds ratio 1.63, 95% confidence interval 1.06-2.50) and major bleeding (odds ratio 3.54, 95% confidence interval 1.65-7.58). After propensity score matching, the TAT group still had worse net clinical outcomes and a higher incidence of major bleeding compared with the DAPT group. CONCLUSION In AF patients undergoing DES implantation, prolonged administration of TAT may be harmful due to the substantial increase in the risk for major bleeding without any reduction in MACCE.
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Hiller KN. Clinically relevant exaggerated pharmacodynamic response to dual antiplatelet therapy detected by Thromboelastogram(®) Platelet Mapping™. J Anaesthesiol Clin Pharmacol 2016; 32:112-4. [PMID: 27006555 PMCID: PMC4784190 DOI: 10.4103/0970-9185.173347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) is the standard of care for primary and secondary prevention strategies in patients with coronary artery disease after stenting. Current guidelines recommend that DAPT be continued for 12 months in patients after receiving drug eluting stents. Approximately 5% of these patients will present within this 12-month period for noncardiac surgery. This case report describes a clinically relevant exaggerated pharmacodynamic response to DAPT detected by preoperative assessment of platelet function. Based on the clinical history and physical exam and subsequent lab results, a general anesthetic was performed rather than a spinal anesthetic and the surgical procedure was changed. An exaggerated pharmacodynamic response to DAPT poses its own set of risks (unexpected uncontrolled bleeding, epidural hematoma following neuraxial block placement) that point-of-care aggregation testing may decrease or mitigate by altering clinical decision making. If the clinical history and physical exam reveal possible platelet dysfunction in patients receiving DAPT, preoperative platelet function testing should be considered.
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Affiliation(s)
- Kenneth N Hiller
- Department of Anesthesiology, University of Texas Medical School at Houston, Houston, TX 77030, USA
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Fang X, Baillargeon JG, Jupiter DC. Continued Antiplatelet Therapy and Risk of Bleeding in Gastrointestinal Procedures: A Systematic Review. J Am Coll Surg 2016; 222:890-905.e11. [PMID: 27016908 DOI: 10.1016/j.jamcollsurg.2016.01.053] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 01/13/2016] [Accepted: 01/13/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Management of perioperative antiplatelet medications in gastrointestinal (GI) surgery is challenging. The risk of intraoperative and postoperative bleeding is associated with perioperative use of antiplatelet medication. However, cessation of these drugs may be unsafe for patients who are required to maintain antiplatelet use due to cardiovascular conditions. The objective of this systematic review was to compare the risk of intraoperative or postoperative bleeding among patients who had GI surgery while on continuous antiplatelet therapy (aspirin, clopidogrel, or dual therapy) with the risk among those not taking continuous antiplatelet medication. STUDY DESIGN We reviewed articles published between January 2000 and July 2015 from the Medline Ovid and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Studies involving any GI procedures were included if the articles met our inclusion criteria (listed in Methods). The following key words were used for the search: clopidogrel, Plavix, aspirin, antiplatelet, bleeding, hemorrhage, and digestive system surgical procedures. Quality of the studies was assessed, depending on their study design, using the Newcastle-Ottawa score or the Cochrane Collaboration's tool for assessing risk of bias. RESULTS Twenty-two studies were eligible for inclusion in the systematic review. Five showed that the risk of intraoperative bleeding or postoperative bleeding among patients who had GI surgery while on continuous antiplatelet therapy was higher compared that for those not on continuous therapy. The remaining 17 studies reported that there was no statistically significant difference in the risks of bleeding between the continuous antiplatelet therapy group and the group without continuous antiplatelet therapy. CONCLUSIONS The risk of bleeding associated with GI procedures in patients receiving antiplatelet therapy was not significantly higher than in patients with no antiplatelet or interrupted antiplatelet therapy.
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Affiliation(s)
- Xiao Fang
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX.
| | - Jacques G Baillargeon
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - Daniel C Jupiter
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
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Schulman-Marcus J, Pashun RA, Feldman DN, Swaminathan RV. Coronary Angiography and Revascularization Prior to Noncardiac Surgery. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:3. [PMID: 26728404 DOI: 10.1007/s11936-015-0427-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OPINION STATEMENT The role of coronary angiography and revascularization, including percutaneous coronary intervention (PCI) prior to noncardiac surgery remains poorly defined. The goal of preoperative angiography and PCI is improved risk stratification and ideally risk reduction of postoperative cardiovascular events, such as myocardial infarction (MI). By current guidelines, these procedures should be performed sparingly in high-risk stable coronary artery disease (CAD) patients and routinely in patients with acute coronary syndrome (ACS). Anatomic assessment of CAD by routine invasive angiography is discouraged, although noninvasive assessment may soon be possible. As prior trials have failed to show a clear benefit in outcomes, PCI should only be considered in patients with high-risk anatomic features. The ideal management of other anatomic disease discovered by angiography is currently unknown. Limited registry data suggest that PCI is used more frequently than recommended, although the features of these procedures remain poorly elaborated. In patients who do undergo preoperative PCI, careful attention must be paid to patient-specific factors including the nature and urgency of surgery and duration of dual antiplatelet therapy. In summary, substantial evidence gaps warrant further research in this important area.
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Affiliation(s)
- Joshua Schulman-Marcus
- Departments of Medicine and Radiology, Weill Cornell Medical College, 1305 York Ave, 8th Avenue, New York, NY, 10021, USA.
| | - Raymond A Pashun
- Department of Medicine, New York Presbyterian Hospital, 505 E 70th St, Suite 450, New York, NY, 10021, USA.
| | - Dmitriy N Feldman
- Greenberg Division of Cardiology, Weill Cornell Medical College, 520 E 70th St, New York, NY, 10021, USA.
| | - Rajesh V Swaminathan
- Greenberg Division of Cardiology, Weill Cornell Medical College, 520 E 70th St, New York, NY, 10021, USA.
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Optimal duration of dual antiplatelet therapy after coronary stent implantation. Am J Cardiol 2015; 116:1631-6. [PMID: 26456206 DOI: 10.1016/j.amjcard.2015.08.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Revised: 08/18/2015] [Accepted: 08/18/2015] [Indexed: 10/23/2022]
Abstract
Dual antiplatelet pharmacotherapy reduces ischemic events at the cost of excess bleeding in patients who underwent coronary stenting. The currently recommended treatment period is based on trials held some 20 years ago and not relevant to current clinical practice. In recent years, numerous clinical trials have tried to answer the question of what is the optimal duration of therapy to maximize clinical benefit. These trials showed 2 seemingly conflicting answers-on one hand, shorter treatment duration seems to be safer in reducing bleeding while not increasing ischemic events, and on the other hand, longer duration is superior in terms of preventing ischemic events albeit at the cost of increased bleeding rates. In this review, we summarize the evidence favoring each approach, highlight the limitations of the various pivotal clinical trials in this field, review future directions of research and changes in practice that may influence the duration of antiplatelet therapy, and attempt to propose a personalized approach to achieve maximal benefit for the individual patient.
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Vela Vásquez R, Peláez Romero R. Aspirin and spinal haematoma after neuraxial anaesthesia: Myth or reality? Br J Anaesth 2015; 115:688-98. [DOI: 10.1093/bja/aev348] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Patil RK, Swaminathan RV, Feldman DN. Continuation of Dual-Antiplatelet Therapy Following Percutaneous Revascularization with a Drug-Eluting Stent: What Duration Is Optimal? Curr Atheroscler Rep 2015; 17:63. [PMID: 26399876 DOI: 10.1007/s11883-015-0543-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Dual-antiplatelet therapy (DAPT) is required after percutaneous coronary intervention with drug-eluting stents (DESs) to prevent thrombotic complications, particularly stent thrombosis (ST). However, there is still disagreement regarding the optimal duration of DAPT post-DES placement. Compared to bare metal stents, DESs are known to reduce restenosis and target vessel revascularization but may be more prone to late and very late ST due to delayed endothelialization. Several trials have suggested that longer (>12 months) DAPT reduces ischemic events but does so at the cost of increased bleeding. Other trials have demonstrated non-inferiority of shorter (3 to 6 months) DAPT compared to long-term DAPT, with fewer bleeding events. The clinical challenge is how to balance the reduced ischemic risk with increased bleeding associated with longer DAPT. Furthermore, ST is associated with multiple patient- and procedure-specific factors, thereby limiting a "one-size-fits-all" approach to determining optimal duration of DAPT. The evaluation of DAPT duration should therefore be tailored individually. We will review the data supporting current recommendations for DAPT and recent clinical trials comparing varying DAPT durations and discuss patient- and procedure-specific factors affecting the "optimal" DAPT duration.
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Affiliation(s)
- Rupa K Patil
- Department of Medicine, Greenberg Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, 520 East 70th Street, Starr-434 Pavilion, New York, NY, 10021, USA
| | - Rajesh V Swaminathan
- Department of Medicine, Greenberg Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, 520 East 70th Street, Starr-434 Pavilion, New York, NY, 10021, USA
| | - Dmitriy N Feldman
- Department of Medicine, Greenberg Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, 520 East 70th Street, Starr-434 Pavilion, New York, NY, 10021, USA.
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Dundon JM, Trimba R, Bree KJ, Woods CJ, Laughlin RT. Recommendations for Perioperative Management of Patients on Existing Anticoagulation Therapy. JBJS Rev 2015; 3:01874474-201509000-00002. [PMID: 27490669 DOI: 10.2106/jbjs.rvw.n.00105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- John M Dundon
- Department of Orthopaedic Surgery, Sports Medicine & Rehabilitation, Boonshoft School of Medicine, Wright State University, 30 East Apple Street, Suite 2200, Dayton, OH 45409
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Ziada KM, Abdel-Latif AK, Charnigo R, Moliterno DJ. Safety of an abbreviated duration of dual antiplatelet therapy (≤6 months) following second-generation drug-eluting stents for coronary artery disease: A systematic review and meta-analysis of randomized trials. Catheter Cardiovasc Interv 2015; 87:722-732. [PMID: 26309050 DOI: 10.1002/ccd.26110] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 06/27/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) is recommended for ≥12 months following coronary drug-eluting stents (DES) to reduce risk of major adverse ischemic events. Randomized trials suggest an abbreviated DAPT duration (≤6 months) is adequately protective. However, these trials are individually underpowered to detect differences in rare but serious events such as stent thrombosis (ST). OBJECTIVES We performed a meta-analysis of published randomized trials to define the impact of abbreviated DAPT (≤6 months) on death, myocardial infarction (MI), stent thrombosis (ST), and bleeding complications compared to standard-duration DAPT (≥12 months). METHODS Seven randomized controlled trials comparing abbreviated vs. standard DAPT regimens following DES use were identified by two independent investigators. Study characteristics were reviewed and clinical endpoint data were abstracted and analyzed in aggregate using fixed and random-effects models. RESULTS The seven trials included 15,874 randomized patients. Second-generation DES were used in most patients. Compared to standard-duration DAPT, abbreviated DAPT was not associated with an increase in mortality (OR 0.93; CI: 0.73 to 1.17; P = 0.52), MI (OR 1.14; CI: 0.89 to 1.45; P = 0.30) or ST (OR 1.25; CI: 0.81 to 1.93; P = 0.31). Abbreviated DAPT was associated with significantly fewer major bleeding complications (OR 0.52; CI: 0.34 to 0.82; P = 0.005). The results were consistent between fixed and random-effects models, with no heterogeneity. Sensitivity analyses adjusting for inclusion of bare metal stents, 1st generation DES and/or abbreviated DAPT regimens of 3 months resulted in similar conclusions. CONCLUSIONS In a meta-analysis of >15,000 patients primarily treated with second-generation DES, abbreviated-duration DAPT (≤6 months) was associated with a significant reduction in major bleeding complications with no evidence of a significant increase in risk of death, MI or ST. Accordingly, abbreviated DAPT should be strongly considered for patients receiving second generation DES.
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Affiliation(s)
- Khaled M Ziada
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky and the Lexington VA Medical Center, Lexington, KY
| | - Ahmed K Abdel-Latif
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky and the Lexington VA Medical Center, Lexington, KY
| | - Richard Charnigo
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky and the Lexington VA Medical Center, Lexington, KY
| | - David J Moliterno
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky and the Lexington VA Medical Center, Lexington, KY
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Hsueh WD, Hwang PH, Abuzeid WM. Perioperative Management of Antithrombotic Therapy in Common Otolaryngologic Surgical Procedures: State of the Art Review. Otolaryngol Head Neck Surg 2015; 153:493-503. [PMID: 26307580 DOI: 10.1177/0194599815600409] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 07/23/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The perioperative management of patients undergoing otolaryngologic procedures is increasingly complicated by the use of newer antithrombotic agents. Furthermore, with advances in anesthesia and surgical technique, otolaryngologists are presented with the challenge of operating on patients with advanced comorbid diseases. The objective of this review is to provide evidence-based recommendations on perioperative antithrombotic management for common otolaryngologic procedures. DATA SOURCES PubMed/MEDLINE. REVIEW METHODS Selected literature on patient-specific thromboembolic risk, rate of bleeding complications in otolaryngologic procedures, and the interruption of antithrombotic therapy is reviewed and interpreted by expert opinion. CONCLUSIONS By stratifying patients into either low thromboembolic risk (≤ 5%) or high thromboembolic risk (> 5%) and interpreting this in the context of procedural bleed risk and potential clinical consequences in the event of a bleed, otolaryngologists can make evidence-based decisions to determine the appropriate perioperative management of antithrombotic therapy. IMPLICATIONS FOR PRACTICE When the perioperative management of antithrombotic therapy is being decided, 3 critical factors must be considered systematically: the patient's inherent thromboembolic risk, the risk and potential consequences of bleeding related to the procedure, and the timing of interruption of thromboembolic therapy.
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Affiliation(s)
- Wayne D Hsueh
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Waleed M Abuzeid
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
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Ford I. Coming safely to a stop: a review of platelet activity after cessation of antiplatelet drugs. Ther Adv Drug Saf 2015; 6:141-50. [PMID: 26301068 PMCID: PMC4530348 DOI: 10.1177/2042098615588085] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The platelet P2Y12 antagonists are widely used, usually in combination with aspirin, to prevent atherothrombotic events in patients with acute coronary syndromes during percutaneous coronary intervention and after placement of arterial stents. Inhibition by clopidogrel or prasugrel lasts for the lifetime of the affected platelets and platelet haemostatic function gradually recovers after stopping the drug, as new unaffected platelets are formed. The optimal durations for dual antiplatelet therapy are prescribed by clinical guidelines. Continuation beyond the recommended duration is associated with an increased mortality, mainly associated with major bleeding. Fear of a 'rebound' of prothrombotic platelet activity on stopping the drug has provoked much discussion and many studies. However, review of the available literature reveals no evidence for production of hyper-reactive platelets after cessation of clopidogrel in patients who are stable. Any increase in acute coronary and other vascular events after stopping seems most likely therefore to be due to premature discontinuation or disruption of treatment while thrombotic risk is still high. No difference in rebound was found with the newer P2Y12 inhibitors, although ticagrelor and prasugrel are more potent platelet inhibitors than clopidogrel. Recent randomized controlled trials confirm it is safe to stop the thienopyridine and continue with aspirin alone in most patients after the duration of treatment recommended by the guidelines. Decisions on when to stop therapy in individuals, however, remain challenging and there is a growing rationale for platelet testing to assist clinical judgement in certain situations such as patients stopping dual antiplatelet therapy before surgery or in individuals at highest bleeding or thrombotic risk.
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Affiliation(s)
- Isobel Ford
- Division of Applied Medicine, School of Medicine and Dentistry, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, Scotland, AB25 2ZD, UK
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Antithrombotic therapy in the anticoagulated patient undergoing percutaneous coronary intervention with coronary stenting. Curr Opin Cardiol 2015; 30:319-24. [PMID: 26049376 DOI: 10.1097/hco.0000000000000181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Despite being the subject of extensive research, the optimal antithrombotic therapy for patients on chronic oral anticoagulation (OAC) undergoing percutaneous coronary intervention (PCI) with stent implantation is still unknown. This review presents the latest data regarding this much-debated topic. RECENT FINDINGS Dual therapy, with clopidogrel (a P2Y12 inhibitor) and OAC, may be an alternative to triple therapy, which usually consists of aspirin and clopidogrel in addition to OAC, in terms of improving clinical outcomes in patients on chronic OAC following PCI with stent implantation. With the arrival of new, safer nonvitamin K antagonists oral anticoagulants (NOACs), the combination of NOAC and clopidogrel may also be an option for replacing triple therapy. In contrast to clopidogrel, combining the more potent P2Y12 inhibitors (prasugrel and ticagrelor) with OAC may only be considered in certain specific circumstances. SUMMARY Patients on chronic OAC undergoing PCI with stent implantation require triple therapy. However, triple therapy is controversial, because it increases the risk of bleeding. With the introduction of prasugrel, ticagrelor and NOACs, the question arises which P2Y12 inhibitor to choose as part of the triple therapy regime and how NOACs combine with antiplatelet agents when treating patients undergoing PCI.
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Nozari Y, Vosooghi S, Boroumand M, Poorhosseini H, Nematipour E, Salarifar M, Kassaian SE, Amirzadegan A, Alidoosti M, Haji-Zeinali AM, Saroukhani S. The impact of cytochrome P450 2C19 polymorphism on the occurrence of one-year in-stent restenosis in patients who underwent percutaneous coronary intervention: A case-match study. Anatol J Cardiol 2015; 15:348-53. [PMID: 25993709 PMCID: PMC5779167 DOI: 10.5152/akd.2014.5418] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE In this case-match study, we evaluated the impact of the CYP2C19*2 polymorphism in the occurrence of in-stent restenosis during a 1-year follow-up period despite adequate dual anti-platelet therapy in Iranian patients having undergone percutaneous coronary intervention (PCI). METHODS This study, conducted at a tertiary referral heart center in Tehran, recruited 100 patients: 50 patients had in-stent restenosis after PCI during a 1-year follow-up and were compared to another 50 patients without in-stent restenosis who were individually matched according to sex. In order to evaluate the impact of the CYP2C19*2 polymorphism, case frequency matching was performed with respect to variables previously shown to be predictors of in-stent restenosis. The CYP2C19*2 polymorphism evaluated using real-time PCR methods. RESULTS Among all 100 patients (mean age=60.09 ± 10.29: 72.0% male), 89 (89%) patients had wild (CYP2C19*1/CYP2C19*1) and 11% had a heterozygous (CYP2C19*1/CYP2C19*2) genotypes, and there was no patient with a completely mutant genotype (CYP2C19*2/CYP2C19*2). Conditional logistic regression analysis showed that there was no significant association between genotype CYP2C19*1/CYP2C19*2 and the occurrence of in-stent restenosis after PCI (OR=2.5, p value=0.273). CONCLUSION Our findings indicated that carrying a CYP2C19*2 allele with a functional CYP2C19*1 allele had no significant association with in-stent restenosis 1 year after PCI. The antiplatelet treatment strategy for non-functional allele carriers is still a matter of controversy. Further studies with larger sample sizes are necessary to determine the prevalence of non-functional alleles in various populations and to achieve a consensus about the effective treatment strategy.
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Affiliation(s)
- Younes Nozari
- Department of Interventional Cardiology, University of Medical Sciences, Tehran Heart Center; Tehran-Iran.
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Sabouret P, Rushton-Smith SK, Kerneis M, Silvain J, Collet JP, Montalescot G. Dual antiplatelet therapy: optimal timing, management, and duration. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 1:198-204. [PMID: 27533996 DOI: 10.1093/ehjcvp/pvv015] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 03/18/2015] [Indexed: 12/27/2022]
Abstract
Platelet activation and aggregability play a key role in the genesis of arterial thrombus secondary to plaque rupture. For coronary patients, inhibition of platelet function is crucial to decrease the rate of major adverse cardiac events but may expose them to excess bleeding risk. Switching P2Y12 inhibitors is common, yet the clinical consequences are unknown. The aim of this review is to provide an overview of the evidence from randomized, clinical trials and epidemiological studies, with a focus on the optimal duration of dual antiplatelet therapy (DAPT) and appropriate agent and dose selection. The report discusses the latest evidence regarding switching therapies during DAPT, the potential benefits of a personalized strategy, management of the preoperative period, and other clinical perspectives in this complex and rapidly changing field. Ongoing trials will be useful to answer to some important unresolved questions.
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Affiliation(s)
- Pierre Sabouret
- Institut du Cœur, Pitié-Salpêtrière Hospital (AP-HP), Pierre and Marie Curie University, 47-83, boulevard de l'Hôpital, Paris 75013, France, ACTION Group, www.action-coeur.org
| | | | - Mathieu Kerneis
- Institut du Cœur, Pitié-Salpêtrière Hospital (AP-HP), Pierre and Marie Curie University, 47-83, boulevard de l'Hôpital, Paris 75013, France, ACTION Group, www.action-coeur.org
| | - Johanne Silvain
- Institut du Cœur, Pitié-Salpêtrière Hospital (AP-HP), Pierre and Marie Curie University, 47-83, boulevard de l'Hôpital, Paris 75013, France, ACTION Group, www.action-coeur.org
| | - Jean-Philippe Collet
- Institut du Cœur, Pitié-Salpêtrière Hospital (AP-HP), Pierre and Marie Curie University, 47-83, boulevard de l'Hôpital, Paris 75013, France, ACTION Group, www.action-coeur.org
| | - Gilles Montalescot
- Institut du Cœur, Pitié-Salpêtrière Hospital (AP-HP), Pierre and Marie Curie University, 47-83, boulevard de l'Hôpital, Paris 75013, France, ACTION Group, www.action-coeur.org
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Toth PP. The Potential Role of Prasugrel in Secondary Prevention of Ischemic Events in Patients with Acute Coronary Syndromes. Postgrad Med 2015; 121:59-72. [DOI: 10.3810/pgm.2009.01.1955] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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50
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Clark MG, Beavers C, Osborne J. Managing the acute coronary syndrome patient: Evidence based recommendations for anti-platelet therapy. Heart Lung 2015; 44:141-9. [DOI: 10.1016/j.hrtlng.2014.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 11/18/2014] [Accepted: 11/20/2014] [Indexed: 12/01/2022]
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