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Kobata H, Sugie A, Kawakami M, Tanaka S, Sarapuddin G, Tucker A. Treatment strategies for patients with out-of-hospital cardiac arrest associated with traumatic brain injury: A case series. Am J Emerg Med 2024; 82:8-14. [PMID: 38749373 DOI: 10.1016/j.ajem.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/04/2024] [Accepted: 05/06/2024] [Indexed: 07/19/2024] Open
Abstract
INTRODUCTION Collapse after out-of-hospital cardiac arrest (OHCA) can cause severe traumatic brain injury (TBI). We aimed to investigate the clinical characteristics and treatment strategies for patients with OHCA and TBI. METHODS We analyzed a consecutive cohort of patients with intrinsic OHCA retrospectively treated between January 2011 and December 2021 at a single critical care center, and presented a case series of seven patients. Patients with collapse-related TBI were examined for the causes and situations of cardiac arrest, laboratory data, radiological images, targeted temperature management (TTM), coronary angiography (CAG), percutaneous coronary intervention (PCI), and extracorporeal cardiopulmonary resuscitation (ECPR). RESULTS Of the 197 patients with intrinsic OHCA, 7 (3.6%) had TBI (age range: 49-70 years; 6 men). All seven patients presented with ventricular fibrillation in the initial electrocardiograms, with four refractory cases treated with ECPR. All patients underwent CAG under heparinization, and four underwent PCI with antiplatelet administration. Initial head computed tomography indicated an intracranial hemorrhage (ICH) in three patients. ICH appeared or was exacerbated in six patients after CAG with or without PCI, except in one who underwent delayed PCI. All patients displayed elevated plasma D-dimer levels, and four underwent neurosurgical procedures. Four patients survived (three with cerebral performance category [CPC] 2, one with CPC 3) and three died; two had hypoxic-ischemic brain injury and one had severe TBI. CONCLUSION Delayed ICH occurred frequently. Individualized management is required based on the extent of brain and cardiac damage, including optimal TTM, PCI procedures, and antiplatelet medications. Early detection of ICH and emergency treatment are critical for multi-disciplinary collaboration.
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Affiliation(s)
- Hitoshi Kobata
- Osaka Mishima Emergency Critical Center, 11-1 Minami-akutagawacho, Takatsuki, Osaka 569-1124, Japan; Department of Neurosurgery, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan; Deparment of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan.
| | - Akira Sugie
- Osaka Mishima Emergency Critical Center, 11-1 Minami-akutagawacho, Takatsuki, Osaka 569-1124, Japan; Emergency Medical Center, Ijinkai Takeda General Hospital, 28-1 Isidamoriminamicho, Fushimiku, Kyoto, 601-1495, Japan.
| | - Makiko Kawakami
- Osaka Mishima Emergency Critical Center, 11-1 Minami-akutagawacho, Takatsuki, Osaka 569-1124, Japan; Department of Anesthesiology, Osaka Saiseikai Suita Hospital, 1-2 Kawazonocho, Suita, Suita, Osaka 564-0013, Japan.
| | - Suguru Tanaka
- Osaka Mishima Emergency Critical Center, 11-1 Minami-akutagawacho, Takatsuki, Osaka 569-1124, Japan; Deparment of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan.
| | - Gemmalynn Sarapuddin
- Osaka Mishima Emergency Critical Center, 11-1 Minami-akutagawacho, Takatsuki, Osaka 569-1124, Japan; Neurology Department, Institute of Neurosciences, The Medical City, Ortigas Avenue, Pasig, Metro Manila, Philippines.
| | - Adam Tucker
- Osaka Mishima Emergency Critical Center, 11-1 Minami-akutagawacho, Takatsuki, Osaka 569-1124, Japan; Department of Neurosurgery, Japanese Red Cross Kitami Hospital, 2-1 Kita 6-jo, higashi, Kitami, Hokkaido 090-8666, Japan.
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Matsuoka T, Fujikawa T, Kawamura Y, Hasegawa S. Impact of Preoperative Continued Aspirin Therapy on Perioperative Bleeding Complications in Patients Undergoing Gastrectomy for Malignancy. Cureus 2024; 16:e65303. [PMID: 39184653 PMCID: PMC11343640 DOI: 10.7759/cureus.65303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2024] [Indexed: 08/27/2024] Open
Abstract
Background The question of whether antiplatelet therapy (APT) should be discontinued prior to gastrectomy is controversial. In this study, we investigated the impact of continuing aspirin preoperatively on perioperative bleeding and thromboembolic complications in patients receiving gastrectomy for malignancy. Methods The study cohort comprised 1001 patients with malignant gastric tumors who had undergone gastrectomy between 2005 and 2021. This study excludes emergency surgery. The patients were allocated to the following three groups: those who continued aspirin monotherapy prior to surgery (cAPT group), those who stopped receiving it seven days prior to surgery (dAPT group), and those who did not take APT at any stage (non-APT group). The differences between the groups in intraoperative and postoperative complications, such as bleeding and thromboembolism, were examined. Results The non-APT group comprised 682 patients, the dAPT group had 164, and the cAPT group had 155. There were 22 bleeding events (2.2%) in the whole cohort, 11 (1.1%) of which occurred in the non-APT group, six (3.7%) in the dAPT group, and five (3.2%) in the cAPT group. The differences between the three groups were not significant in terms of bleeding complications. There were 10 (1.0%) thromboembolic events in the whole cohort, five (0.7%) of which occurred in the non-APT group, four (2.4%) in the dAPT group, and one (0.6%) in the cAPT group. The differences between the three groups were not significant in terms of thromboembolic complications. In a multivariate analysis of the whole cohort, intraoperative blood loss (≥1000 mL) (p < 0.001, odds ratio (OR) = 11.8) and multidrug APT (p < 0.001, OR = 7.8) were both independent predictors of bleeding complications. However, continuing to take aspirin before surgery was not a risk factor for bleeding complications. Conclusions In patients with malignant gastric tumors, preoperative continuation of aspirin monotherapy has no impact on either intraoperative or postoperative bleeding. Gastrectomy can be performed safely, even in patients who continue aspirin treatment.
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Affiliation(s)
| | | | | | - Suguru Hasegawa
- Gastroenterological Surgery, Fukuoka University Hospital, Fukuoka, JPN
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Yang S, Shi L. Efficacy and safety of proton pump inhibitors on cardiovascular events and inflammatory factors in patients with upper gastrointestinal bleeding undergoing dual antiplatelet therapy. Inflammopharmacology 2024; 32:1999-2006. [PMID: 38642222 DOI: 10.1007/s10787-024-01467-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 03/22/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND This work evaluated the effects of proton pump inhibitors (PPIs) on cardiovascular events (CVEs) and inflammatory factors in patients with upper gastrointestinal bleeding (UGIB) undergoing dual antiplatelet therapy (DAPT) after percutaneous coronary intervention. Clinical data from these patients were analysis, intending to provide relevant theoretical evidence for clinical practice. MATERIALS AND METHODS Data of 166 patients who underwent percutaneous coronary intervention and developed UGIB while on DAPT at The First People' Hospital of Linping District from April 2021 to April 2023 were retrospectively analyzed. The patients were rolled into two groups: those who received PPI treatment and those who did not, namely, PPI and non-PPI group, respectively. Furthermore, occurrence of CVEs and the levels of inflammatory factors of patients in all groups were statistically analyzed. RESULTS In patients with UGIB, melena is a common presentation. The incidence of CVE in the PPI group showed no statistically significant difference compared to the control group, and there was no significant variance observed in the distribution of CVE incidence among different PPIs. However, levels of C-reactive protein (CRP) and tumor necrosis factor-alpha (TNF-α) were significantly lower in the PPI group compared to the non-PPI group (P < 0.05). CONCLUSION Melena was the most frequent clinical manifestation in UGIB patients. The use of PPIs did not increase the risk of CVEs, and different PPI drugs did not affect the occurrence of CVEs. Furthermore, PPIs lowered CRP and TNF-α levels in serum of these patients.
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Affiliation(s)
- Shuting Yang
- Department of Emergency, The First People' Hospital of Linping Dstrict, Zhejiang Province, Hangzhou, 311199, China
| | - Linni Shi
- Department of Gastroenterology, Xinchang People's Hospital, Zhejiang Province, Shaoxing, 312500, China.
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Cortese B, Sanchez-Jimenez E, Lazar L. Coronary stent failure: role of a blended approach with drug-coated balloons for complex lesions. Minerva Cardiol Angiol 2024; 72:266-280. [PMID: 36939731 DOI: 10.23736/s2724-5683.22.06172-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
The management of coronary artery disease by means of percutaneous approach have been focused initially to overcome the recoil and acute occlusion after vessel ballooning; therefore, to develop and improve metallic stent platforms, and later drug-eluting technologies. Contemporarily, the necessity emerged to optimize interventional procedures using functional physiologic tests and intravascular imaging guidance, but still stent failures, especially in the complex lesion setting, continue to be not negligible. This comprehensive review is focused on the technology of drug-coated balloons as a tool to treat coronary artery disease without the need for metal implantation but still eluting antirestenotic drugs such as paclitaxel or sirolimus. We delve into these technologies, the drugs, the technical aspects of the deployment and the most updated evidence also proposing a dedicated interventional algorithm. There is solid data to support the use of drug-coated balloons in patients with in-stent restenosis and de-novo small coronary artery disease but also new evidence with promising results from recent studies indicate the feasibility of this approach in complex coronary interventions, bifurcation lesions and larger coronary vessels. In this state-of-the-art review, we also propose a blended approach based on the combination of drug-eluting stents and drug-coated balloons, keeping in mind the necessity to reduce the total stent length in order to reduce the long-term risk of complications.
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Affiliation(s)
- Bernardo Cortese
- Fondazione Ricerca e Innovazione Cardiovascolare, Milan, Italy -
| | | | - Leontin Lazar
- Fondazione Ricerca e Innovazione Cardiovascolare, Milan, Italy
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Shahzad F, Ahmed U, Muhammad A, Shahzad F, Naufil SI, Sukkari MW, Kamran AB, Murtaza S, Khalid MB, Shabbir H, Saeed S. Safety and efficacy of desmopressin (DDAVP) in preventing hematoma expansion in intracranial hemorrhage associated with antiplatelet drugs use: A systematic review and metaanalysis. Brain Behav 2024; 14:e3540. [PMID: 38778788 PMCID: PMC11112402 DOI: 10.1002/brb3.3540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 02/18/2024] [Accepted: 02/22/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION One of the most serious complications associated with antiplatelet agents is antiplatelet-associated intracranial hemorrhage (AA-ICH). Desmopressin is a synthetic antidiuretic hormone (ADH) analog. It has been linked to improving patient outcomes in antiplatelet-induced intracranial hemorrhage. The secondary outcomes included the incidence of thrombotic complications and neurological outcomes. METHODS A systematic search was conducted on three databases (PubMed, Cochrane, and ClinicalTrials.gov) to find eligible literature that compares desmopressin (DDAVP) versus controls in patients with AA-ICH. The Mantel-Haenszel statistic was used to determine an overall effect estimate for each outcome by calculating the risk ratios and 95% confidence intervals (CI). Heterogeneity was measured using the I2 test. The risk of bias in studies was calculated using the New Castle Ottowa Scale. RESULTS Five studies were included in the analysis with a total of 598 patients. DDAVP was associated with a nonsignificant decrease in the risk of hematoma expansion (RR = .8, 95% CI,.51-1.24; p = .31, I2 = 44%). It was also associated with a non-significant decrease in the risk of thrombotic events (RR,.83; 95% CI,.25-2.76; p = .76, I2 = 30%). However, patients in the DDAVP group demonstrated a significant increase in the risk of poor neurological outcomes (RR, 1.31; 95% CI, 1.07-1.61; p = .01, I2 = 0%). The risk of bias assessment showed a moderate to low level of risk. CONCLUSION DDAVP was associated with a nonsignificant decrease in hematoma expansion and thrombotic events. However, it was also associated with a significantly poor neurological outcome in the patients. Thus, until more robust clinical trials are conducted, the use of DDAVP should be considered on a case-to-case basis.
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Affiliation(s)
- Faizan Shahzad
- Medical StudentRawalpindi Medical UniversityRawalpindiPakistan
| | - Usman Ahmed
- Department of MedicineHoly Family HospitalRawalpindiPakistan
| | - Ayesha Muhammad
- Medical StudentRawalpindi Medical UniversityRawalpindiPakistan
| | - Farhan Shahzad
- Medical StudentRawalpindi Medical UniversityRawalpindiPakistan
| | | | | | | | - Sara Murtaza
- Department of MedicineHoly Family HospitalRawalpindiPakistan
| | | | - Haroon Shabbir
- Medical StudentRawalpindi Medical UniversityRawalpindiPakistan
| | - Sajeel Saeed
- Department of MedicineHoly Family HospitalRawalpindiPakistan
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Aslam F, Naeem A, Munir E, Ashraf HJ, Ali B, Qammar B, Farooq M, Ullah S, Jawad S. Effects of Proton Pump Inhibitors on Cardiovascular Events and Inflammatory Factors in Patients With Upper Gastrointestinal Bleeding Undergoing Dual Antiplatelet Therapy. Cureus 2024; 16:e59925. [PMID: 38854272 PMCID: PMC11161665 DOI: 10.7759/cureus.59925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 06/11/2024] Open
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT), vital post-percutaneous coronary intervention (PCI) to prevent cardiovascular events (CVEs) via aspirin and P2Y12 receptor antagonists, faces controversy when combined with proton pump inhibitors (PPIs) due to potential impacts on bleeding risk and antiplatelet efficacy, prompting the need for further research to determine optimal co-administration practices. This work evaluated the effects of PPIs on CVEs and inflammatory factors in patients with upper gastrointestinal bleeding (UGIB) undergoing DAPT after PCI. MATERIALS AND METHODS The data of 166 patients who underwent PCI and developed UGIB while on DAPT from April 2021 to April 2023 were retrospectively analyzed. The patients were rolled into two groups: those who received PPI treatment and those who did not, namely, the PPI and non-PPI group, respectively. Clinical data from these patients was analyzed, intending to provide relevant theoretical evidence for clinical practice. Furthermore, the occurrence of CVEs and the levels of inflammatory factors of patients in all groups were statistically analyzed. RESULTS Melena was the most common clinical symptom observed in all UGIB patients. The incidence of CVEs in the PPI group was not greatly different from that in the non-PPI group (P>0.05). The distribution of CVEs occurrence among different PPI drugs also exhibited no obvious difference (P>0.05). The PPI group exhibited greatly lower C-reactive protein (CRP) and tumor necrosis factor α (TNF-α) based on the non-PPI group (P<0.05). CONCLUSION Melena was the most frequent clinical manifestation in UGIB patients. The use of PPIs did not increase the risk of CVEs, and different PPI drugs did not affect the occurrence of CVEs. Furthermore, PPIs lowered CRP and TNF-α levels in serum of these patients.
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Affiliation(s)
- Farhan Aslam
- Orthopedics, Sir Ganga Ram Hospital, Lahore, PAK
| | - Afaq Naeem
- Internal Medicine, Shalamar Hospital, Lahore, PAK
| | - Emad Munir
- Cardiology, Shalamar Hospital, Lahore, PAK
| | | | - Bilawal Ali
- Internal Medicine, DHQ Teaching Hospital, Dera Ghazi Khan, PAK
| | - Bilal Qammar
- Internal Medicine, Shalamar Hospital, Lahore, PAK
| | - Maham Farooq
- Public Health Practices and Administration, Institute of Public Health, Lahore, PAK
| | - Sami Ullah
- Internal Medicine, Shalamar Hospital, Lahore, PAK
| | - Sumbal Jawad
- Medicine, DHQ Teaching Hospital, Gujranwala, PAK
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Bertolini G, Belli L, Mazza S, Ugolotti PT, Tadonio I, Ceccarelli P, Rossi S, Ippolito S. Feasibility and Safety of Bridging Antiplatelet Therapy with Cangrelor in Neuro-Oncology: A Preliminary Experience. J Neurol Surg A Cent Eur Neurosurg 2024. [PMID: 38621711 DOI: 10.1055/s-0044-1785649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Antiplatelet therapy is mandatory for prevention of thrombotic events in patients with a recent history of acute coronary syndromes and/or percutaneous coronary interventions. However, if an urgent surgery is required during antiplatelet therapy, a compromise between the ischemic/thrombotic and hemorrhagic risk has to be reached. Different bridging schemes are reported in the literature, but there is no clear consensus on the optimal treatment strategy in terms of efficacy and safety. Although some indications about the perioperative management of antiplatelet therapy regarding specific surgical specializations are available, balancing the thrombotic and hemorrhagic risk on an individual basis, no evidence referring to neurosurgical or neuro-oncologic procedures is reported. Herein, we present our preliminary experience in the perioperative management of a patient who underwent a neurosurgical procedure for the resection of a primary malignant brain tumor using an intravenous P2Y12 inhibitor (cangrelor) as bridging therapy after a recent acute myocardial infarction treated with primary percutaneous coronary intervention and stenting. The oral P2Y12 inhibitor (clopidogrel) was withdrawn 5 days prior to the surgical procedure and continuous infusion of cangrelor was started 3 days before the surgery at a dose of 0.75 μg/kg/min. Cangrelor was discontinued 2 hours before surgery and resumed 72 hours after tumor resection for further 60 hours. Neither cangrelor-related bleeding nor cardiac ischemic events were observed in the perioperative period and the following 90 days, supporting data regarding the feasibility and safety of this bridging scheme. Further studies are needed to confirm our promising results.
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Affiliation(s)
- Giacomo Bertolini
- Neurosurgery Unit, Head and Neck Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Laura Belli
- Neurosurgery Unit, Head and Neck Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Stefania Mazza
- Neurosurgery Unit, Head and Neck Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Pietro Tito Ugolotti
- Department of Surgery, Cardiology Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Iacopo Tadonio
- Department of Surgery, Cardiology Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Patrizia Ceccarelli
- Department of Anesthesiology and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Sandra Rossi
- Department of Anesthesiology and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Salvatore Ippolito
- Neurosurgery Unit, Head and Neck Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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Abukalam N, Kannan Sudha R, Al Marzooqi M. Traumatic Brain Injury With Concomitant Myocardial Infarction: A Clinical Dilemma. Cureus 2023; 15:e50898. [PMID: 38249258 PMCID: PMC10799652 DOI: 10.7759/cureus.50898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 01/23/2024] Open
Abstract
A 51-year-old male patient was brought to the emergency department (ED) by paramedics after an unwitnessed fall from a height while he was working. He sustained a severe head injury with a low Glasgow Coma Scale (GCS). After securing his airway and stabilizing the patient, a CT scan of the brain was done that revealed bilateral subdural hematomas, and an electrocardiogram (EKG) revealed an ST elevation inferior wall myocardial infarction (MI), which was suggested to be the cause of his fall. With the presence of two concomitant life-threatening medical conditions, it was a predicament which of the two pathologies to target first in treatment. Ultimately, a management plan was decided following a multidisciplinary urgent meeting in the ED, which was attended by all respective teams. Initial conservative management with close neurological and cardiovascular monitoring in the intensive care unit (ICU) was deemed the safest option in this case.
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Trombara F, Cosentino N, Marenzi G. Intracranial haemorrhage in acute myocardial infarction: A rare but dramatic complication. Int J Cardiol 2023; 391:131300. [PMID: 37657670 DOI: 10.1016/j.ijcard.2023.131300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 08/27/2023] [Indexed: 09/03/2023]
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Mousa A, Hassan A, Oudah B, Arslan KI, Parang P. Acute Spontaneous Subdural Hematoma in a Patient With an End-Stage Renal Disease After Starting Dual Antiplatelet Therapy Post Drug-Eluting Stent Insertion: A Case Report. Cureus 2023; 15:e41761. [PMID: 37575833 PMCID: PMC10416268 DOI: 10.7759/cureus.41761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 08/15/2023] Open
Abstract
Dual antiplatelet therapy (DAPT) has been widely utilized for secondary prevention in patients with cardiovascular diseases, such as post-drug eluting stent insertion, stroke, and peripheral vascular disease. The occurrence of bleeding complications, including intracranial hemorrhage, has been extensively studied in relation to DAPT. However, the occurrence of acute spontaneous subdural hematomas in this context is relatively rare. These hematomas can manifest through various symptoms, including altered mental status (AMS) and confusion. The risk of intracranial hemorrhage is particularly higher in patients receiving aspirin with ticagrelor, especially in those with reduced estimated glomerular filtration rate (eGFR) and liver disease. In this case report, we present the case of a patient with end-stage renal disease undergoing peritoneal hemodialysis and a remote history of liver transplant. The patient presented to the hospital with chest pain, subsequently underwent drug-eluting stent placement, and was initiated on DAPT. Following the initiation of DAPT, the patient developed confusion and was diagnosed with an acute spontaneous subdural hematoma. The patient underwent middle meningeal artery embolization to manage the hematoma.
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Affiliation(s)
- Aliaa Mousa
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Ahmed Hassan
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Bashar Oudah
- Internal Medicine, Eisenhower Medical Center, Rancho Mirage, USA
| | | | - Pirouz Parang
- Cardiology, Capital Health Regional Medical Center, Trenton, USA
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Gosavi S, Krishnan G, Acharya RV. Aspirin vs Clopidogrel: Antiplatelet Agent of Choice for Those With Recent Bleeding or at Risk for Gastrointestinal Bleed. Cureus 2023; 15:e37890. [PMID: 37213942 PMCID: PMC10199733 DOI: 10.7759/cureus.37890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2023] [Indexed: 05/23/2023] Open
Abstract
Antiplatelet agents are used worldwide mainly for primary and secondary prevention of cardiovascular events on a long-term basis for mortality benefit. Gastrointestinal bleeding is a well-known adverse effect. Various factors are to be considered while choosing antiplatelet agents to prevent the risk of bleed and rebleed incidents. These range from deciding on the agent, timing of therapy, underlying indications, coadministration of proton pump inhibitor, etc. At the same time, one must weigh the risks of cardiovascular events secondary to the stoppage of antiplatelet therapy. With this review, we have tried to guide the clinician on decision-making regarding the care of patients on management of acute upper and lower gastrointestinal bleeding, stoppage, restarting of agents, and measures to prevent a recurrence. We have focused on aspirin and clopidogrel as they are among the most widely used antiplatelet agents.
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Affiliation(s)
- Siddharth Gosavi
- Department of Internal Medicine, Kasturba Medical College Manipal, Manipal, IND
| | - Gokul Krishnan
- Department of Internal Medicine, Kasturba Medical College Manipal, Manipal, IND
| | - Raviraja V Acharya
- Department of Internal Medicine, Kasturba Medical College Manipal, Manipal, IND
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12
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Cirillo P, DI Serafino L, Gamra H, Zimarino M, Barbato E, Briguori C, Amat-Santos IJ, Chieffo A, Erglis A, Gil RJ, Kedev SA, Petrov I, Radico F, Niglio T, Nakamura S, Costa RA, Kanic V, Perfetti M, Pellicano M, Maric K, Tesorio T, Vukcevic V, Esposito G, Stankovic G. Impact of dual antiplatelet therapy duration on clinical outcome after coronary bifurcation stenting: results from the EuroBifurcation Club registry. Panminerva Med 2023; 65:1-12. [PMID: 35546730 DOI: 10.23736/s0031-0808.22.04604-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Optimal duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) of a bifurcation stenosis is still debated. We evaluated the impact of DAPT duration on clinical outcomes in all-comers patients undergoing bifurcation PCI included in the European Bifurcation Club (EBC) registry. METHODS We enrolled 2284 consecutive patients who completed at least 18 months follow-up. The cumulative occurrence of major adverse cardiac and cardiovascular events (MACCE), defined as a composite of overall-death, non-fatal myocardial infarction (MI), target vessel revascularization (TVR) and stroke were evaluated. Bleedings classified as Bleeding Academic Research Consortium (BARC) ≥3 were evaluated too. RESULTS Patients were divided into 3 groups: short DAPT (<6-months, N.=375); standard DAPT (≥6-months but ≤12-months, N.=636); prolonged DAPT (>12-months, N.=1273). At 24 months follow-up MACCE-free survival was significantly lower in short DAPT patients (Log-Rank: 45.23, P for trend <0.001). MACCE occurred less frequently in the prolonged DAPT group (148 [11.6%]) as compared with both the short (83 [22.1%] HR: 0.48 [0.37-0.63], P<0.001) and standard DAPT groups (137 [21.5%] HR:0.51 [0.41-0.65], P<0.001). These differences remain after propensity score adjustment (respectively, HR: 0.27 [0.20-0.36] and HR: 0.44 [0.34-0.57]). Such finding was consistent in patients presenting with both acute and chronic coronary syndromes. BARC≥3 bleedings were 0.3% in the standard DAPT, 1.6% in short and 1.9% in prolonged DAPT groups. CONCLUSIONS In the "real-world" EBC registry of patients undergoing PCI of coronary artery bifurcation stenosis, a prolonged DAPT duration was associated with a significantly lower risk of MACCE and a potential increased risk of major bleedings.
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Affiliation(s)
- Plinio Cirillo
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy -
| | - Luigi DI Serafino
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Habib Gamra
- Department of Cardiology, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia
| | - Marco Zimarino
- Institute of Cardiology, G. D'Annunzio University, Chieti, Italy.,Interventional Cath Lab, ASL 2 Abruzzo, Chieti, Italy
| | - Emanuele Barbato
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.,CIBERCV, University Clinical Hospital of Valladolid, Valladolid, Spain
| | | | | | - Alaide Chieffo
- Unit of Interventional Cardiology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Andrejs Erglis
- Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Robert J Gil
- Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior, Warsaw, Poland
| | - Sasko A Kedev
- University Clinic of Cardiology Skopje, Skopje, Macedonia
| | | | - Francesco Radico
- Institute of Cardiology, G. D'Annunzio University, Chieti, Italy
| | - Tullio Niglio
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Sunao Nakamura
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | | | - Vojko Kanic
- Department of Cardiology and Angiology, University Medical Centre, Maribor, Slovenia
| | | | - Mariano Pellicano
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.,CIBERCV, University Clinical Hospital of Valladolid, Valladolid, Spain.,Laboratory of Invasive Cardiology, Montevergine Clinic, Mercogliano, Avellino, Italy
| | - Kristina Maric
- Department of Cardiovascular Medicine, University Hospital Centre, Zagreb, Croatia
| | - Tullio Tesorio
- Laboratory of Invasive Cardiology, Montevergine Clinic, Mercogliano, Avellino, Italy
| | - Vladan Vukcevic
- Department of Cardiology, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Giovanni Esposito
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Goran Stankovic
- Department of Cardiology, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
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13
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Beccari S, Sierra-Torre V, Valero J, Pereira-Iglesias M, García-Zaballa M, Soria FN, De Las Heras-Garcia L, Carretero-Guillen A, Capetillo-Zarate E, Domercq M, Huguet PR, Ramonet D, Osman A, Han W, Dominguez C, Faust TE, Touzani O, Pampliega O, Boya P, Schafer D, Mariño G, Canet-Soulas E, Blomgren K, Plaza-Zabala A, Sierra A. Microglial phagocytosis dysfunction in stroke is driven by energy depletion and induction of autophagy. Autophagy 2023:1-30. [PMID: 36622892 DOI: 10.1080/15548627.2023.2165313] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Microglial phagocytosis of apoptotic debris prevents buildup damage of neighbor neurons and inflammatory responses. Whereas microglia are very competent phagocytes under physiological conditions, we report their dysfunction in mouse and preclinical monkey models of stroke (macaques and marmosets) by transient occlusion of the medial cerebral artery (tMCAo). By analyzing recently published bulk and single cell RNA sequencing databases, we show that the phagocytosis dysfunction was not explained by transcriptional changes. In contrast, we demonstrate that the impairment of both engulfment and degradation was related to energy depletion triggered by oxygen and nutrient deprivation (OND), which led to reduced process motility, lysosomal exhaustion, and the induction of a protective macroautophagy/autophagy response in microglia. Basal autophagy, in charge of removing and recycling intracellular elements, was critical to maintain microglial physiology, including survival and phagocytosis, as we determined both in vivo and in vitro using pharmacological and transgenic approaches. Notably, the autophagy inducer rapamycin partially prevented the phagocytosis impairment induced by tMCAo in vivo but not by OND in vitro, where it even had a detrimental effect on microglia, suggesting that modulating microglial autophagy to optimal levels may be a hard to achieve goal. Nonetheless, our results show that pharmacological interventions, acting directly on microglia or indirectly on the brain environment, have the potential to recover phagocytosis efficiency in the diseased brain. We propose that phagocytosis is a therapeutic target yet to be explored in stroke and other brain disorders and provide evidence that it can be modulated in vivo using rapamycin.Abbreviations: AIF1/IBA1: allograft inflammatory factor 1; AMBRA1: autophagy/beclin 1 regulator 1; ATG4B: autophagy related 4B, cysteine peptidase; ATP: adenosine triphosphate; BECN1: beclin 1, autophagy related; CASP3: caspase 3; CBF: cerebral blood flow; CCA: common carotid artery; CCR2: chemokine (C-C motif) receptor 2; CIR: cranial irradiation; Csf1r/v-fms: colony stimulating factor 1 receptor; CX3CR1: chemokine (C-X3-C motif) receptor 1; DAPI: 4',6-diamidino-2-phenylindole; DG: dentate gyrus; GO: Gene Ontology; HBSS: Hanks' balanced salt solution; HI: hypoxia-ischemia; LAMP1: lysosomal-associated membrane protein 1; MAP1LC3/LC3: microtubule-associated protein 1 light chain 3; MCA: medial cerebral artery; MTOR: mechanistic target of rapamycin kinase; OND: oxygen and nutrient deprivation; Ph/A coupling: phagocytosis-apoptosis coupling; Ph capacity: phagocytic capacity; Ph index: phagocytic index; SQSTM1: sequestosome 1; RNA-Seq: RNA sequencing; TEM: transmission electron microscopy; tMCAo: transient medial cerebral artery occlusion; ULK1: unc-51 like kinase 1.
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Affiliation(s)
- Sol Beccari
- Glial Cell Biology Labb, Department of Biochemistry and Molecular Biology, Achucarro Basque Center for Neuroscience, 48940, Leioa, Bizkaia, Spain.,Department of Neuroscience, University of the Basque Country UPV/EHU, 48940, Leioa, Bizkaia, Spain
| | - Virginia Sierra-Torre
- Glial Cell Biology Labb, Department of Biochemistry and Molecular Biology, Achucarro Basque Center for Neuroscience, 48940, Leioa, Bizkaia, Spain.,Department of Neuroscience, University of the Basque Country UPV/EHU, 48940, Leioa, Bizkaia, Spain
| | - Jorge Valero
- Glial Cell Biology Labb, Department of Biochemistry and Molecular Biology, Achucarro Basque Center for Neuroscience, 48940, Leioa, Bizkaia, Spain.,Department of Neuroscience, University of the Basque Country UPV/EHU, 48940, Leioa, Bizkaia, Spain.,Neural Plasticity and Neurorepair Group, Laboratory of Neuronal Plasticity and Neurorepair, Institute for Neuroscience of Castilla y León (INCyL), and Institute for Biomedical Research of Salamanca, University of Salamanca, 37007, Salamanca, Spain
| | - Marta Pereira-Iglesias
- Glial Cell Biology Labb, Department of Biochemistry and Molecular Biology, Achucarro Basque Center for Neuroscience, 48940, Leioa, Bizkaia, Spain.,Department of Neuroscience, University of the Basque Country UPV/EHU, 48940, Leioa, Bizkaia, Spain
| | - Mikel García-Zaballa
- Glial Cell Biology Labb, Department of Biochemistry and Molecular Biology, Achucarro Basque Center for Neuroscience, 48940, Leioa, Bizkaia, Spain.,Department of Neuroscience, University of the Basque Country UPV/EHU, 48940, Leioa, Bizkaia, Spain
| | - Federico N Soria
- Glial Cell Biology Labb, Department of Biochemistry and Molecular Biology, Achucarro Basque Center for Neuroscience, 48940, Leioa, Bizkaia, Spain.,Department of Neuroscience, University of the Basque Country UPV/EHU, 48940, Leioa, Bizkaia, Spain.,Ikerbasque Foundation, 48009, Bilbao, Bizkaia, Spain
| | - Laura De Las Heras-Garcia
- Glial Cell Biology Labb, Department of Biochemistry and Molecular Biology, Achucarro Basque Center for Neuroscience, 48940, Leioa, Bizkaia, Spain.,Department of Neuroscience, University of the Basque Country UPV/EHU, 48940, Leioa, Bizkaia, Spain
| | - Alejandro Carretero-Guillen
- Glial Cell Biology Labb, Department of Biochemistry and Molecular Biology, Achucarro Basque Center for Neuroscience, 48940, Leioa, Bizkaia, Spain
| | - Estibaliz Capetillo-Zarate
- Glial Cell Biology Labb, Department of Biochemistry and Molecular Biology, Achucarro Basque Center for Neuroscience, 48940, Leioa, Bizkaia, Spain.,Department of Neuroscience, University of the Basque Country UPV/EHU, 48940, Leioa, Bizkaia, Spain.,Ikerbasque Foundation, 48009, Bilbao, Bizkaia, Spain.,Centro de Investigación en Red de Enfermedades Neurodegenerativas (CIBERNED), Spain
| | - Maria Domercq
- Glial Cell Biology Labb, Department of Biochemistry and Molecular Biology, Achucarro Basque Center for Neuroscience, 48940, Leioa, Bizkaia, Spain.,Department of Neuroscience, University of the Basque Country UPV/EHU, 48940, Leioa, Bizkaia, Spain
| | - Paloma R Huguet
- Glial Cell Biology Labb, Department of Biochemistry and Molecular Biology, Achucarro Basque Center for Neuroscience, 48940, Leioa, Bizkaia, Spain.,Department of Neuroscience, University of the Basque Country UPV/EHU, 48940, Leioa, Bizkaia, Spain
| | - David Ramonet
- INSERM U1060 CarMeN, Université Claude Bernard Lyon 1 - IRIS team, CarMeN, bat. B13, gpt hosp. Est, 59 bld Pinel, 69500, Bron, Auvergne-Rhône-Alpes, France
| | - Ahmed Osman
- Department of Women and Children´s Health, Karolisnka Institute, 17164, Stockholm, Södermanland and Uppland, Sweden
| | - Wei Han
- Department of Women and Children´s Health, Karolisnka Institute, 17164, Stockholm, Södermanland and Uppland, Sweden
| | - Cecilia Dominguez
- Department of Women and Children´s Health, Karolisnka Institute, 17164, Stockholm, Södermanland and Uppland, Sweden
| | - Travis E Faust
- Department of Neurobiology, University of Massachusetts Medical School, 01605, Worcester, MA, USA
| | - Omar Touzani
- Normandie-Univ, UNICAEN, CEA, CNRS, ISTCT/CERVOxy Group, 14000, Caen, Normandie, France
| | - Olatz Pampliega
- Glial Cell Biology Labb, Department of Biochemistry and Molecular Biology, Achucarro Basque Center for Neuroscience, 48940, Leioa, Bizkaia, Spain.,Department of Neuroscience, University of the Basque Country UPV/EHU, 48940, Leioa, Bizkaia, Spain
| | - Patricia Boya
- Laboratory of Autophagy, Centro de Investigaciones Biológicas Margarita Salas, Madrid 28040, Spain.,Department of Medicine, University of Fribourg, 1700, Freiburg, Switzerland
| | - Dorothy Schafer
- Department of Neurobiology, University of Massachusetts Medical School, 01605, Worcester, MA, USA
| | - Guillermo Mariño
- Department of Medicine, University of Fribourg, 1700, Freiburg, Switzerland.,Department of Functional Biology, University of Oviedo, 33003, Oviedo, Asturias, Spain
| | - Emmanuelle Canet-Soulas
- INSERM U1060 CarMeN, Université Claude Bernard Lyon 1 - IRIS team, CarMeN, bat. B13, gpt hosp. Est, 59 bld Pinel, 69500, Bron, Auvergne-Rhône-Alpes, France
| | - Klas Blomgren
- Department of Women and Children´s Health, Karolisnka Institute, 17164, Stockholm, Södermanland and Uppland, Sweden.,Department of Pediatric Oncology, Karolinska University Hospital, 171 64, Stockholm, Södermanland and Uppland, Sweden
| | - Ainhoa Plaza-Zabala
- Glial Cell Biology Labb, Department of Biochemistry and Molecular Biology, Achucarro Basque Center for Neuroscience, 48940, Leioa, Bizkaia, Spain.,Department of Pharmacology, University of the Basque Country UPV/EHU, 48940, Leioa, Bizkaia, Spain
| | - Amanda Sierra
- Glial Cell Biology Labb, Department of Biochemistry and Molecular Biology, Achucarro Basque Center for Neuroscience, 48940, Leioa, Bizkaia, Spain.,Department of Neuroscience, University of the Basque Country UPV/EHU, 48940, Leioa, Bizkaia, Spain.,Ikerbasque Foundation, 48009, Bilbao, Bizkaia, Spain
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14
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Boudihi A, El-azrak M, Tahani I, Ismaili N, Ouafi NE. Hemorrhagic stroke during the acute phase of myocardial infarction: a rare and difficult situation to manage. Radiol Case Rep 2023; 18:1133-1139. [PMID: 36660577 PMCID: PMC9842540 DOI: 10.1016/j.radcr.2022.10.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/20/2022] [Accepted: 10/23/2022] [Indexed: 01/09/2023] Open
Abstract
Given the ischemic risk due to the hypercoagulability associated with acute coronary syndromes, the administration of antiplatelet and antithrombotic agents is necessary to prevent intracoronary and postprocedural thrombosis during percutaneous coronary interventions. However, the risk of bleeding, hemorrhagic stroke included, is real, although it has a lower prevalence, and it complicates the management of the coronary event if it happens. We report the case of a 66 years old patient with no prior pathological history who was initially admitted for acute coronary syndromes, complicated by paroxysmal atrial fibrillation that was successfully thrombolysed. Subsequently, the patient benefited from a drug-eluting stent angioplasty of the proximal circumflex artery, performed within 24 hours after the symptomatology onset. Following angioplasty, the patient presented with a left parietal intraparenchymal hematoma not indicating surgery. The double antiplatelet therapy was consequently withdrawn. Two days later, the patient presented with an ST-segment elevation infarction recurrence, inciting the resumption of the dual antiplatelet aggregation therapy. On evolution, the neurological state was still stable with a stationary aspect of the hematoma on cerebral imagery but without angina recurrence or electrocardiographic modifications. Hemorrhagic complications' occurrence following thrombolysis or angioplasty for ST-segment elevation infarction challenges the short and long-term management of the disease and must push practitioners to better weigh the risks and benefits before any medication administration decision.
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Affiliation(s)
- Abdelaziz Boudihi
- Department of Cardiology, Mohammed VI University Hospital of Oujda, First Mohammed University of Oujda, Morocco,Faculty of Medicine and Pharmacy, Oujda University Mohammed I, Morocco,Corresponding author.
| | - Mohammed El-azrak
- Department of Cardiology, Mohammed VI University Hospital of Oujda, First Mohammed University of Oujda, Morocco,Faculty of Medicine and Pharmacy, Oujda University Mohammed I, Morocco
| | - Ikram Tahani
- Department of Cardiology, Mohammed VI University Hospital of Oujda, First Mohammed University of Oujda, Morocco,Faculty of Medicine and Pharmacy, Oujda University Mohammed I, Morocco
| | - Nabila Ismaili
- Department of Cardiology, Mohammed VI University Hospital of Oujda, First Mohammed University of Oujda, Morocco,Faculty of Medicine and Pharmacy, Oujda University Mohammed I, Morocco
| | - Noha El Ouafi
- Department of Cardiology, Mohammed VI University Hospital of Oujda, First Mohammed University of Oujda, Morocco,Faculty of Medicine and Pharmacy, Oujda University Mohammed I, Morocco
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15
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Dai L, Zhang Y, Jiang Y, Chen K. Panax notoginseng preparation plus aspirin versus aspirin alone on platelet aggregation and coagulation in patients with coronary heart disease or ischemic stroke: A meta-analysis of randomized controlled trials. Front Pharmacol 2022; 13:1015048. [PMID: 36569332 PMCID: PMC9768032 DOI: 10.3389/fphar.2022.1015048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
Purpose: We aimed to evaluate the effects of Panax notoginseng preparations (PNP) containing Panax Notoginseng Saponins (PNS) or Panaxatriol Saponin (PTS) on platelet aggregation and coagulation in the adjuvant treatment of coronary heart disease (CHD) and ischemic stroke (IS). Methods: Randomized controlled trials (RCTs) comparing the combination of PNP and aspirin (ASA) versus ASA alone for CHD or IS were searched in eight databases. Subgroup analysis was performed according to saponin category. When statistical heterogeneity was significant, sensitivity analysis was performed using the leave-one-out approach. Funnel plot, Egger' test, and Begg' test was adopted to detect publication bias. Results: Twenty RCTs involving 2216 patients were analyzed. Compared with ASA alone, PNP plus ASA had a stronger inhibitory effect on in PAgR [PNS, WMD = -6.10 (-7.25, -4.95), p < 0.00001; PTS, WMD = -3.53 (-4.68, -2.38), p < 0.00001]; PNS plus ASA better reduced FIB [WMD = -0.43 (-0.49, -0.36)] and DD [WMD = -0.59 (-0.67, -0.51), p < 0.00001], while PLT (p = 0.07) and PT (p = 0.34) were not significantly different; PTS plus ASA better prolonged PT [WMD = 1.90 (1.47, 2.32), p < 0.00001] and PT-INR [WMD = 0.22 (0.11, 0.32), p < 0.0001], whereas no significant difference in DD (p = 0.1) and bleeding-related events (positive fecal occult blood, p = 0.96; upper gastrointestinal bleeding, p = 0.67; subcutaneous hemorrhage, p = 0.51; bulbar conjunctival hemorrhage, p = 0.51; hematuria, p = 0.58). There was no significant difference between PNP plus ASA and ASA alone in terms of gastrointestinal side effect (PNS, p = 0.65; PTS, p = 0.56) and urticaria (PNS, p = 0.57; PTS, p = 0.55). Conclusion: PNP combined with ASA might produce stronger antiplatelet aggregation and anticoagulation effects without increasing bleeding risk, gastrointestinal side effects, and urticaria compared with ASA alone. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier CRD42022339234.
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Affiliation(s)
| | | | | | - Keji Chen
- *Correspondence: Keji Chen, ; Yuerong Jiang,
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16
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Tritschler T, Patel A, Kraaijpoel N, Bhatt DL, De Luca G, Di Santo P, Feres F, Costa RA, Hibbert B, Isshiki T, Le Gal G, Castellucci LA. Case-fatality rate of major bleeding events in patients on dual antiplatelet therapy after percutaneous coronary intervention: A systematic review and meta-analysis. Res Pract Thromb Haemost 2022; 6:e12834. [PMID: 36349260 PMCID: PMC9634492 DOI: 10.1002/rth2.12834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022] Open
Abstract
Background Assessment of the case-fatality rate (CFR) of major bleeding on dual antiplatelet therapy (DAPT) may improve balancing risks and benefits of different durations of DAPT following percutaneous coronary intervention (PCI). Objectives To determine the CFR of major bleeding in patients on DAPT after PCI and to compare rates among different durations of DAPT. Methods Medline, Embase, and CENTRAL were searched from inception to August 2021 for randomized trials that reported fatal bleeding among patients who were randomized to ≥1 month of DAPT following PCI. Summary estimates for CFRs of major bleeding were calculated using the random-effects inverse-variance method. Statistical heterogeneity was evaluated using the I 2 statistic. Results Of 2777 citations obtained by the search, 15 (48%) of 31 potentially eligible studies were excluded because fatal bleeding was not reported, leaving 16 studies that were included in the analysis. Overall, there were 823 major bleeding events including 91 fatal events in 48,884 patients who were assigned to receive DAPT during study follow-up. The CFR of major bleeding was 10.8% (95% confidence interval [CI], 7.1-16.2; I 2 = 50%) in the entire study population, and 13.8% (95% CI, 6.5-27.1; I 2 = 28%), 11.2% (95% CI, 6.7-18.0; I 2 = 0%), and 5.8% (95% CI, 3.0-11.1; I 2 = 0%) in those on short-term (≤6 months; n = 16,553), standard-term (12 months; n = 19,453), and long-term DAPT (>12 months; n = 10,238), respectively. Conclusion Fatal bleeding is not reported in many studies evaluating DAPT after PCI. The CFR of major bleeding on DAPT is substantial and may be higher in the first 12 months of DAPT than during long-term DAPT.
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Affiliation(s)
- Tobias Tritschler
- Department of General Internal MedicineInselspital, Bern University Hospital, University of BernBernSwitzerland
- Department of MedicineOttawa Hospital Research Institute, University of OttawaOttawaOntarioCanada
| | - Anuj Patel
- Department of MedicineOttawa Hospital Research Institute, University of OttawaOttawaOntarioCanada
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Deepak L. Bhatt
- Brigham and Women's Hospital Heart and Vascular CenterHarvard Medical School, BostonBostonMassachusettsUSA
| | - Giuseppe De Luca
- Division of CardiologyAzienda Ospedaliera‐Universitaria “Maggiore della Carità”, Eastern Piedmont UniversityNovaraItaly
| | | | - Fausto Feres
- Department of Invasive CardiologyInstituto Dante Pazzanese de CardiologiaSao PauloBrazil
| | - Ricardo A. Costa
- Department of Invasive CardiologyInstituto Dante Pazzanese de CardiologiaSao PauloBrazil
| | | | | | - Grégoire Le Gal
- Department of MedicineOttawa Hospital Research Institute, University of OttawaOttawaOntarioCanada
| | - Lana A. Castellucci
- Department of MedicineOttawa Hospital Research Institute, University of OttawaOttawaOntarioCanada
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17
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Kuszynski DS, Lauver DA. Pleiotropic effects of clopidogrel. Purinergic Signal 2022; 18:253-265. [PMID: 35678974 DOI: 10.1007/s11302-022-09876-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/26/2022] [Indexed: 01/04/2023] Open
Abstract
Clopidogrel is a widely prescribed prodrug with anti-thrombotic activity through irreversible inhibition of the P2Y12 receptor on platelets. It is FDA-approved for the clinical management of thrombotic diseases like unstable angina, myocardial infarction, stroke, and during percutaneous coronary interventions. Hepatic clopidogrel metabolism generates several distinct metabolites. Only one of these metabolites is responsible for inhibiting the platelet P2Y12 receptor. Importantly, various non-hemostatic effects of clopidogrel therapy have been described. These non-hemostatic effects are perhaps unsurprising, as P2Y12 receptor expression has been reported in multiple tissues, including osteoblasts, leukocytes, as well as vascular endothelium and smooth muscle. While the "inactive" metabolites have been commonly thought to be biologically inert, recent findings have uncovered P2Y12 receptor-independent effects of clopidogrel treatment that may be mediated by understudied metabolites. In this review, we summarize both the P2Y12 receptor-mediated and non-P2Y12 receptor-mediated effects of clopidogrel and its metabolites in various tissues.
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Affiliation(s)
- Dawn S Kuszynski
- Department of Pharmacology and Toxicology, College of Veterinary Medicine, Michigan State University, 1355 Bogue Street, B336 Life Science, East Lansing, MI, USA.,Institute of Integrative Toxicology, Michigan State University, East Lansing, MI, USA
| | - D Adam Lauver
- Department of Pharmacology and Toxicology, College of Veterinary Medicine, Michigan State University, 1355 Bogue Street, B336 Life Science, East Lansing, MI, USA.
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18
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Magid-Bernstein J, Girard R, Polster S, Srinath A, Romanos S, Awad IA, Sansing LH. Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions. Circ Res 2022; 130:1204-1229. [PMID: 35420918 PMCID: PMC10032582 DOI: 10.1161/circresaha.121.319949] [Citation(s) in RCA: 135] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intracerebral hemorrhage (ICH) is a devastating form of stroke with high morbidity and mortality. This review article focuses on the epidemiology, cause, mechanisms of injury, current treatment strategies, and future research directions of ICH. Incidence of hemorrhagic stroke has increased worldwide over the past 40 years, with shifts in the cause over time as hypertension management has improved and anticoagulant use has increased. Preclinical and clinical trials have elucidated the underlying ICH cause and mechanisms of injury from ICH including the complex interaction between edema, inflammation, iron-induced injury, and oxidative stress. Several trials have investigated optimal medical and surgical management of ICH without clear improvement in survival and functional outcomes. Ongoing research into novel approaches for ICH management provide hope for reducing the devastating effect of this disease in the future. Areas of promise in ICH therapy include prognostic biomarkers and primary prevention based on disease pathobiology, ultra-early hemostatic therapy, minimally invasive surgery, and perihematomal protection against inflammatory brain injury.
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Affiliation(s)
| | - Romuald Girard
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sean Polster
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Abhinav Srinath
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sharbel Romanos
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Issam A. Awad
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Lauren H. Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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19
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Bhatt DL, Pollack CV, Mazer CD, Angiolillo DJ, Steg PG, James SK, Weitz JI, Ramnath R, Arnold SE, Mays MC, Umstead BR, White B, Hickey LL, Jennings LK, Curry BJ, Lee JS, Verma S. Bentracimab for Ticagrelor Reversal in Patients Undergoing Urgent Surgery. NEJM EVIDENCE 2022; 1:EVIDoa2100047. [PMID: 38319214 DOI: 10.1056/evidoa2100047] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND: Ticagrelor is a reversible oral P2Y12 platelet inhibitor used to treat patients with acute coronary syndromes, prior myocardial infarction, high-risk coronary artery disease, transient ischemic attack, or ischemic stroke. A healthy volunteer study showed that the intravenous monoclonal antibody bentracimab rapidly reverses ticagrelor, but the effect in patients was unknown. METHODS: In a prespecified interim analysis of a single-arm, prospective study, bentracimab was evaluated in ticagrelor-treated patients who required urgent surgery or had major hemorrhage. The extent of reversal was determined using the VerifyNow P2Y12 assay. Clinical hemostasis was assessed by central adjudication using validated criteria. Treatment-emergent safety events were evaluated. The trial is ongoing and will enroll approximately 200 patients with evaluable data. RESULTS: Of 150 enrolled patients, 142 required urgent surgery and 8 had major hemorrhage. For the end-point analysis, 129 patients had analyzable platelet data; 122 had data on adjudicated hemostasis. Bentracimab provided a rapid reversal of ticagrelor’s antiplatelet effects within 5 to 10 minutes. The reversal was sustained for more than 24 hours, as measured with the VerifyNow P2Y12 and vasodilator-stimulated phosphoprotein phosphorylation assays (P<0.001, with both assays and in all subgroups). Adjudicated hemostasis was achieved for more than 90% of patients (P<0.001); approximately 5% of patients had thrombotic events. No allergic or infusion-related reactions were reported. CONCLUSIONS: Bentracimab provided immediate and sustained reversal of the antiplatelet effects of ticagrelor in patients undergoing surgical procedures. (Funded by PhaseBio Pharmaceuticals, Inc.; ClinicalTrials.gov number, NCT04286438.)
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Affiliation(s)
- Deepak L Bhatt
- Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Charles V Pollack
- Department of Emergency Medicine, University of Mississippi School of Medicine, Jackson
| | | | | | - Ph Gabriel Steg
- INSERM UMR1148, University of Paris, Paris
- Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris
| | - Stefan K James
- Cardiology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | | | | | | | | | - John S Lee
- PhaseBio Pharmaceuticals, Inc., Malvern, PA
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