Prasugrel Versus Clopidogrel: A Comparative Examination of Local Bleeding After Dental Extraction in Patients Receiving Dual Antiplatelet Therapy

The prevalence of bleeding after percutaneous coronary interventions: A systematic review and meta-analysis

BACKGROUND

Bleeding is a common complication associated with percutaneous coronary intervention (PCI). The aim of this study was to determine the prevalence of bleeding after PCI through a systematic review and meta-analysis.

METHODS

The systematic review and meta-analysis covered the period from 1989 to 2023. Multiple databases, including Embase, PubMed, Scopus, Web of Sciences (WoS), MagIran, Scientific Information Database (SID), and Google Scholar, were searched using validated keywords with MeSH and Emtree. The I2 index was used to check for heterogeneity among studies.

RESULTS

The review of 8 studies, with a sample size of 397,298 participants, showed high heterogeneity (I2: 97.8 %). Therefore, the random effects method was used to analyze the results. The prevalence of bleeding after intervention in percutaneous coronary arteries was reported to be 4.4 % (95%CI: 2-9.1).

CONCLUSION

This meta-analysis showed a significant prevalence of bleeding after PCI, highlighting the need for health policymakers to pay more attention to the complications associated with PCI. Interventional cardiologists should consider the effective factors in these bleeding and how to treat and control them due to the importance of this complication.

Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery: Part 2

Part 1 of "Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery" covered the physiological process of hemostasis and the pharmacology of both traditional and novel oral antiplatelets and anticoagulants. Part 2 of this review discusses various factors that are considered when developing a perioperative management plan for patients on oral antithrombotic therapy in consultation with dental professionals and managing physicians. Additionally included are how thrombotic and thromboembolic risks are assessed as well as how patient- and procedure-specific bleeding risks are evaluated. Special attention is given to the bleeding risks associated with procedures encountered when providing sedation and general anesthesia within the office-based dental environment.

Should we stop dual anti-platelet therapy for dental extractions? An umbrella review for this dental dilemma

OBJECTIVES

Dual Anti-platelet Therapy (DAPT) are prescribed to patients who had or are at risk of cerebrovascular or cardiovascular ischemic events. This umbrella review appraises existing systematic reviews on the risk of bleeding related complications during and after dental extractions for patients on DAPT.

STUDY DATA AND SOURCES

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered to the PROSPERO (International prospective register of systematic reviews) database. A systematic electronic literature search was conducted according to the PRISMA guidelines, via PubMed, Ovid, Cochrane and Embase.

STUDY SELECTION

Four systematic reviews met the inclusion criteria and were included the analysis. They show DAPT increases the risk of bleeding related complications after dental extractions, but the differences may not be clinically significant as local haemostatic measures were adequate in controlling bleeding.

CONCLUSION

Despite the increased risk of bleeding after dental extractions in patients on DAPT, it may not be necessary to interrupt the anti-platelet therapy. Local haemostatic agents may be sufficient in controlling both the primary or secondary bleeding. On the other hand, the complications of discontinuing DAPT may be more severe and fatal.

Assessment of Postoperative Bleeding after Dental Extractions in Patients Who Are On Antiplatelet Therapy: A Prospective Study

Introduction:

Patients with ischemic heart disease are placed on antiplatelet therapy (APT). This study allows a definite protocol to be set which will allow us the make the right judgment when it comes to extractions in patients on APT.

Materials and Methods:

For this study, 100 patients were taken up for dental extraction after obtaining a thorough case history. Bleeding time was assessed preoperatively for all the patients and patients with normal bleeding time were taken up for surgery under local anesthesia. Local haemostatic measures were employed after the extraction. Patients were monitored for first 30 minutes at the clinic and a telephonic review of all the patients was done at 24 h–48 h interval after the procedure. If there was an active ooze from the surgical site at any point, haemostatic measures with local haemostatic agents were carried out.

Results:

In patients with mono antiplatelet therapy, bleeding was noted in 16 patients after the 1 h time interval and was absent after 24h–48 h time intervals. The q = 32 and the P < 0.001, making it statistically significant. Regarding patients on dual APT, bleeding was noted in ten patients after 1 h, and in one patient after 24 h with no patients presenting with bleeding at the 48 h time interval. The q = 16.545 and P < 0.001, making it statistically significant.

Discussion:

The benefits of continuing APT for patients who require dental extraction outweighs the risks of postoperative bleeding.

Conclusion:

Antiplatelets are used for the prevention of myocardial infarction, ischemic stroke, and vascular death among patients who are at high risk of these events. Antiplatelets have minimal impact on the amount and duration of bleeding following routine dental extractions.

Incidence of bleeding after minor oral surgery in patients on dual antiplatelet therapy: a systematic review and meta-analysis

Bleeding is a feared complication of minor oral surgery in patients on treatment with antiplatelet agents and there is no agreed strategy regarding the cessation or not of antiplatelet treatment. The aim of this systematic review was to evaluate bleeding with minor oral surgery in patients on dual antiplatelet therapy (DAPT), single antiplatelet therapy (SAPT), or no antiplatelet therapy (no APT). The PubMed, Embase, Web of Science, and Cochrane Library databases were screened. Sixteen studies were included. DAPT was continued in all studies. The perioperative bleeding risk was significantly higher for DAPT than for SAPT (risk ratio (RR) 10.16, P= 0.010; risk difference (RD) 0.35, P= 0.269), but not higher compared to no APT (RR 6.50, P= 0.057; RD 0.19, P= 0.060). The postoperative bleeding risk was significantly elevated for DAPT compared to SAPT (RR 2.61, P= 0.010) and no APT (RR 3.63, P= 0.035), but only by 1% (RD 0.01, P= 0.103) and 1% (RD 0.01, P= 0.421), respectively. Clinically, this may be considered quite similar. Additionally, local haemostatic measures could control all reported bleeding and no lethal events occurred. Therefore, DAPT interruption is not advised before minor oral surgery.

Safety of dental extractions in patients on dual antiplatelet therapy - a meta-analysis

Introduction

Safety of dental extractions in patients on chronic antiplatelet therapy either with only acetylsalicylic acid (ASA) or clopidogrel or with both combined has been a matter of debate, with no clearly conclusive studies published.

Aim

To perform a meta-analysis of published observational studies in order to study the effect of single and double antiplatelet therapy in comparison to controls on the occurrence of immediate local bleeding complications during dental extractions.

Material and methods

PubMed/Scopus/Embase database search revealed 22 papers (13 original and 9 review), 3 of which were finally included in the meta-analysis. Phrases searched: dual[All Fields] AND antiplatelet[All Fields] AND (“therapy”[Subheading] OR “therapy”[All Fields] OR “therapeutics”[MeSH Terms] OR “therapeutics”[All Fields]) AND (“tooth extraction”[MeSH Terms] OR (“tooth”[All Fields] AND “extraction”[All Fields]) OR “tooth extraction”[All Fields]).

Results

The overall event incidence (bleeding complication after extraction) in the entire population was 1.59% (42 events in 2637 patients). As compared to the control group, the use of double antiplatelet therapy DAPT was associated with on odd ratio OR of 40.23 (95% CI: 4.37–370.36) increase in risk of bleeding events occurrence (p = 0.0011). Significant heterogeneity was observed (p < 0.001; I² of 76.7%).

Conclusions

Dental extractions following strict procedural protocols in patients on double antiplatelet therapy with clopidogrel and ASA are associated with an additional risk of immediate local bleeding complications.

Antiplatelet therapy in patients undergoing oral surgery: A systematic review and meta-analysis

Background

The number of patients under antiplatelet therapy (APT) continues to raise as current recommendations foster this practice. Although some recommendations to manage this treatment during oral surgery procedures exist, these have methodological shortcomings that preclude them from being conclusive.

Material and Methods

A systematic review and meta-analysis of the best current evidence was carried out; The Cochrane Library, EMBASE and MEDLINE databases were searched for Randomized Controlled Trials (RCT) concerning patients undergoing oral surgery with APT, other relevant sources were searched manually.

Results

5 RCTs met the Inclusion criteria. No clear tendency was observed (RR= 0.97 CI 95%: 0,41–2,34; p=0,09; I2= 51%), moreover, they weren’t clinically significant.

Conclusions

According to these findings and as bleeding is a manageable complication it seems unreasonable to undermine the APT, putting the patient in danger of a thrombotic event and its high inherent morbidity, which isn’t comparable in severity and manageability to the former.”

Key words:Antiplatelet therapy, aspirin, oral surgery, platelet aggregation inhibitors, oral surgical procedures, systematic reviews.

Management of dental patients receiving antiplatelet therapy or chronic oral anticoagulation: A review of the latest evidence

The perioperative management of patients treated with antithrombotic medications who undergo surgical procedures represents a common clinical problem. Dental interventions are usually associated with a low risk of bleeding; however, the dental implications of new antithrombotic agents are not yet fully understood. The present review is based on the latest evidence and recommendations published on the periprocedural management of dental patients treated with single or dual antiplatelet therapy, vitamin K antagonists, or direct oral anticoagulants for a variety of indications.

Dental management in patients with antiplatelet therapy: A systematic review

INTRODUCTION

Cardiovascular diseases are the most frequent cause of death in the Western world. Its treatment frequently needs therapy with antiplatelet agents, which increases the haemorrhage risk after oral surgical procedures. The aim of this study is to present a review on the dental management of the patients under antiplatelet treatment.

MATERIAL AND METHODS

A systematic review was carried out following PRISMA recommendations including studies searched in Pubmed-Medline, Embase and Cochrane databases.

RESULTS

The current trend is to maintain the treatment during the surgical procedure, assuring a good control of the haemorrhage with local haemostatic measures. However, new antiplatelet drugs protocols are not firmly established.

CONCLUSIONS

In spite of the existing recommendations, it is always advisable to consult with the internist or cardiologist of every patient before any intervention. Key words:Antiplatelet, Oral Surgery, Exodontia, Dental Management.

Antithrombotic treatment in anticoagulated atrial fibrillation patients undergoing percutaneous coronary intervention

Coronary artery disease coexists in a clinically relevant number of patients with atrial fibrillation and it often requires percutaneous coronary intervention. These patients represent a particular challenge for clinicians in terms of antithrombotic management. They require combined antiplatelet-anticoagulant therapy to reduce the risk of recurrent ischemic cardiac events and stroke; however, this antithrombotic strategy is associated with an increased risk of bleeding complications. In the absence of randomized, controlled clinical trials, the majority of current recommendations rely on the results of cohort studies, meta-analyses, post-hoc analyses and subgroup analyses of large, phase III studies. Based on the available evidence, the present review discusses the optimal antithrombotic strategy for patients receiving chronic anticoagulant therapy due to atrial fibrillation who require antiplatelet treatment after acute coronary syndrome and/or percutaneous coronary intervention, and discusses the issue of dental procedures. The correct planning of therapy significantly reduces the risk of bleeding complications and thromboembolic events.

KEY MESSAGES

In order to reduce the occurrence of recurrent cardiac ischemic events and stroke, anticoagulated patients with acute coronary syndrome and/or percutaneous coronary intervention require a combination of therapies including anticoagulants and antiplatelet drugs. Using the newest optimal combination of therapeutic strategies reduces the risk of haemorrhagic complications.

Exodontia in dual antiplatelet therapy: the evidence

BACKGROUND

Haemostasis is crucial for the success of oral surgical treatment as bleeding problems can cause complications both pre- and post-operatively. Patients on antiplatelet drugs present a challenge due to their increased risk of bleeding.

AIMS

To identify a protocol for the management of oral surgery patients on dual antiplatelet therapy (aspirin and clopidogrel).

METHODS

A literature review was conducted in January 2016 of free-text and MESH searches (keywords: aspirin, clopidogrel and dental extractions) in the Cochrane Library, PubMed and CINAHL. Trial registers, professional bodies for guidelines and OpenGrey for unpublished literature were also searched. Studies were selected for appraisal after limits were applied (adult, human and English only studies) and inclusion/exclusion criteria imposed.

RESULTS

Eight studies were identified for critical appraisal using the CASP tools. These were a combination of retrospective, prospective, cohort and case control studies. Napenas et al. and Park et al. found no statistically significant risk of postoperative bleeding complications in patients on dual antiplatelet therapy. Girotra et al., Lillis et al., Omar et al. and Olmos-Carrasco et al., however, found statistically significant risk of postoperative bleeding in this group of patients, all of which can be controlled with local measures.

CONCLUSION

Patients on dual antiplatelet therapy - although at an increased risk of postoperative bleeding complications - can be managed safely with local haemostatic measures and without the need to discontinue antiplatelet therapy.

Assessment of platelet function in patients receiving tirofiban early after primary coronary intervention

Background

Following percutaneous coronary intervention, combined antiplatelet therapy is necessary. Platelet function testing (PFT) has prognostic value and may be applied in the risk assessment of acute coronary syndrome. In case of combined antiplatelet therapy, PFT may require special laboratory methods, as different antiplatelet agents may influence test results.

Materials and methods

Platelet functions were measured in stent thrombosis-segment elevation myocardial infarction patients receiving aspirin, clopidogrel, and tirofiban. The first sampling was obtained immediately after the termination of administration of tirofiban. The second sample was drawn at a randomly assigned time between 1 and 6 h. The third sampling was done after a minimum of 24 h of tirofiban cessation. Adenosine diphosphate (ADP)- and thrombin receptor-activating peptide (TRAP)-induced aggregations were measured.

Results

Thirty-seven patients were included. Both TRAP- and ADP-induced aggregation values were significantly lower immediately after tirofiban termination, than after 24 h [TRAP: 26.41 ± 25.00 units (U) vs. 109.86 ± 23.69 U, p < 0.0001; ADP: 17.43 ± 10.10 U vs. 43.92 ± 23.35 U, p ≤ 0.0001]. Elimination half-life of tirofiban and clopidogrel were 1.34 ± 0.49 and 1.269 ± 0.78, respectively.

Conclusion

ADP-induced residual platelet reactivity is significantly influenced by the presence of concurrent glycoprotein IIb/IIIa inhibitor. In patients receiving combined antiplatelet treatment, ADP-receptor-specific efficiency measurements are valid only after total elimination of GPIIb/IIIa inhibitors.