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Turnbull RE, Hafeez A, Sander KN, Barrett DA, Murphy GJ, Goodall AH. Unfractionated heparin reverses aspirin inhibition of platelets during coronary artery bypass graft surgery. Sci Rep 2024; 14:8572. [PMID: 38609431 PMCID: PMC11015001 DOI: 10.1038/s41598-024-58005-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Unfractionated heparin (UFH) is an effective antithrombotic during surgery but has known adverse effects, in particular on platelets. A marked increase in platelet responsiveness has previously been observed in patients within minutes of receiving UFH, despite adequate inhibition by aspirin prior to heparin. We studied this phenomenon in patients undergoing cardiac artery bypass grafting (n = 17) to determine whether the effects of heparin were systemic or platelet-specific. All patients' platelets were fully inhibited by aspirin prior to surgery, but within 3 min of receiving heparin spontaneous aggregation and responses to arachidonic acid (AA) and ADP increased significantly (p ≥ 0.0002), and activated platelets were found in the circulation. While there was no rise in thromboxane in the plasma following heparin, levels of the major platelet 12-lipoxygenase product, 12-HETE, rose significantly. Mixing experiments demonstrated that the changes caused by heparin resided primarily in the platelets, while addition of AA pathway inhibitors, and analysis of oxylipins provided evidence that, following heparin, aggregating platelets regained their ability to synthesise thromboxane. These findings highlight potentially unrecognised pro-thrombotic and pro-inflammatory changes during CABG surgery, and provide further evidence of adverse effects associated with UFH.
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Affiliation(s)
- Robert E Turnbull
- Department of Cardiovascular Sciences, University of Leicester and NIHR Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK.
- The Leicester Institute of Structural and Chemical Biology and Department of Molecular and Cell Biology, University of Leicester, Lancaster Road, Leicester, LE1 7HB, UK.
| | - Azhar Hafeez
- Department of Cardiovascular Sciences, University of Leicester and NIHR Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, S10 2HQ, UK
| | - Katrin N Sander
- Centre for Analytical Bioscience, Advanced Materials and Healthcare Division, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - David A Barrett
- Centre for Analytical Bioscience, Advanced Materials and Healthcare Division, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester and NIHR Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Alison H Goodall
- Department of Cardiovascular Sciences, University of Leicester and NIHR Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
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2
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Subramanian A, Delaney S, Murphy SJX, Smith DR, Offiah C, McMahon J, de Borst GJ, Naylor AR, Hamilton G, Kinsella JA, McCabe DJH. Platelet Biomarkers in Patients with Atherosclerotic Extracranial Carotid Artery Stenosis: A Systematic Review. Eur J Vasc Endovasc Surg 2022; 63:379-389. [PMID: 35181225 DOI: 10.1016/j.ejvs.2021.10.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 10/12/2021] [Accepted: 10/16/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim was to enhance understanding of the role of platelet biomarkers in the pathogenesis of vascular events and risk stratifying patients with asymptomatic or symptomatic atherosclerotic carotid stenosis. DATA SOURCES Systematic review conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. REVIEW METHODS A systematic review collated data from 1975 to 2020 on ex vivo platelet activation and platelet function/reactivity in patients with atherosclerotic carotid stenosis. RESULTS Forty-three studies met the inclusion criteria; the majority included patients on antiplatelet therapy. Five studies showed increased platelet biomarkers in patients with ≥ 30% asymptomatic carotid stenosis (ACS) vs. controls, with one neutral study. Preliminary data from one study suggested that quantification of "coated platelets" in combination with stenosis severity may aid risk stratification in patients with ≥ 50% - 99% ACS. Platelets were excessively activated in patients with ≥ 30% symptomatic carotid stenosis (SCS) vs. controls (≥ 11 positive studies and one neutral study). Antiplatelet-High on Treatment Platelet Reactivity (HTPR), previously called "antiplatelet resistance", was observed in 23% - 57% of patients on aspirin, with clopidogrel-HTPR in 25% - 100% of patients with ≥ 50% - 99% ACS. Aspirin-HTPR was noted in 9.5% - 64% and clopidogrel-HTPR in 0 - 83% of patients with ≥ 50% SCS. However, the data do not currently support the use of ex vivo platelet function/reactivity testing to tailor antiplatelet therapy outside of a research setting. Platelets are excessively activated (n = 5), with increased platelet counts (n = 3) in recently symptomatic vs. asymptomatic patients, including those without micro-emboli on transcranial Doppler (TCD) monitoring (n = 2). Most available studies (n = 7) showed that platelets become more reactive or activated following carotid endarterectomy or stenting, either as an acute phase response to intervention or peri-procedural treatment. CONCLUSION Platelets are excessively activated in patients with carotid stenosis vs. controls, in recently symptomatic vs. asymptomatic patients, and may become activated/hyper-reactive following carotid interventions despite commonly prescribed antiplatelet regimens. Further prospective multicentre studies are required to determine whether models combining clinical, neurovascular imaging, and platelet biomarker data can facilitate optimised antiplatelet therapy in individual patients with carotid stenosis.
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Affiliation(s)
- Arun Subramanian
- Department of Neurology, Tallaght University Hospital/Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital (AMNCH), Tallaght, Dublin, Ireland; Stroke Service, Tallaght University Hospital/Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital (AMNCH), Tallaght, Dublin, Ireland
| | - Siobhan Delaney
- Department of Neurology, Tallaght University Hospital/Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital (AMNCH), Tallaght, Dublin, Ireland; Stroke Service, Tallaght University Hospital/Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital (AMNCH), Tallaght, Dublin, Ireland
| | - Stephen J X Murphy
- Department of Neurology, Tallaght University Hospital/Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital (AMNCH), Tallaght, Dublin, Ireland; Stroke Service, Tallaght University Hospital/Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital (AMNCH), Tallaght, Dublin, Ireland
| | - Deirdre R Smith
- Department of Neurology, Tallaght University Hospital/Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital (AMNCH), Tallaght, Dublin, Ireland; Vascular Neurology Research Foundation, Tallaght University Hospital/ Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital (AMNCH), Tallaght, Dublin, Ireland
| | - Chika Offiah
- Department of Neurology, Tallaght University Hospital/Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital (AMNCH), Tallaght, Dublin, Ireland; Stroke Service, Tallaght University Hospital/Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital (AMNCH), Tallaght, Dublin, Ireland
| | - Jean McMahon
- Tallaght University Hospital Library, Tallaght University Hospital/ Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital (AMNCH), Tallaght, Dublin, Ireland
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Netherlands
| | - A Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK
| | - George Hamilton
- Department of Vascular Surgery, University Department of Surgery, Royal Free Hampstead NHS Trust, London, UK
| | - Justin A Kinsella
- Department of Neurology, St Vincent's University Hospital/University College Dublin, Ireland
| | - Dominick J H McCabe
- Department of Neurology, Tallaght University Hospital/Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital (AMNCH), Tallaght, Dublin, Ireland; Stroke Service, Tallaght University Hospital/Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital (AMNCH), Tallaght, Dublin, Ireland; Vascular Neurology Research Foundation, Tallaght University Hospital/ Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital (AMNCH), Tallaght, Dublin, Ireland; Department of Clinical Neurosciences, Royal Free Campus, UCL Queen Square Institute of Neurology, London, UK; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Dublin, Ireland.
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3
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Kazimi AU, Weber CF, Keese M, Miesbach W. The Pre- and Postoperative Prevalence and Risk Factors of ASA Nonresponse in Vascular Surgery. Clin Appl Thromb Hemost 2021; 27:10760296211044723. [PMID: 34609920 PMCID: PMC8642110 DOI: 10.1177/10760296211044723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background An antiplatelet therapy with acetylsalicylic acid (ASA) is prescribed in the
prevention of cardiovascular events, but around 24% of ASA takers are
resistant to the treatment. Aim In this prospective, observational cohort study, we aimed to identify the
prevalence and risk factors of ASA nonresponse in patients who underwent
vascular surgery. Methods The study was conducted in the University hospital in Frankfurt am Main. In
total, 70 patients were pre-treated with 100 mg of ASA per day and underwent
either elective carotid thromboendarterectomy, femoral thromboendarterectomy
or endovascular aneurysm repair of the abdominal aorta. The platelet
function was measured on the first preoperative and the second or fourth
postoperative day with the multiple electrode aggregometry by in-vitro
stimulation with arachidonic acid (ASPItest) and thrombin receptor
activating peptide 6 (TRAPtest). The primary end point was the in-vitro
induced platelet aggregation in the ASPItest. If the ASPItest amounted ≥400
AU × min, the patients were categorized as ASA nonresponders. Results The total prevalence of ASA nonresponse in our study was 20% preoperatively
and 35.7% postoperatively (p = 0.005). As significant predictors for ASA
nonresponse, we demonstrated the area under the aggregation curve in the
TRAPtest preoperatively (p = 0.04) and postoperatively (p = 0.02), and the
two comorbidities arterial hypertension (P < .001; rho
0.44) and diabetes mellitus (p = 0.04; rho 0.39), which are already well
known to be associated with ASA nonresponse. Conclusion In conclusion, data of the study indicate a high incidence of perioperative,
laboratory ASA nonresponse in patients undergoing vascular surgery.
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Affiliation(s)
- Alia Uzra Kazimi
- Sana Klinikum Offenbach, Medical Clinic I, 9206Internal Intensive Care Medicine and General Medicine, Offenbach, Germany
| | | | | | - Wolfgang Miesbach
- Hemophilia Centre, 14984University Hospital Frankfurt, Medical Clinic II, Institute of Transfusion Medicine and Immunhematology, Frankfurt, Germany
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Beaulieu RJ, Sutzko DC, Albright J, Jeruzal E, Osborne NH, Henke PK. Association of High Mortality With Postoperative Myocardial Infarction After Major Vascular Surgery Despite Use of Evidence-Based Therapies. JAMA Surg 2020; 155:131-137. [PMID: 31800003 DOI: 10.1001/jamasurg.2019.4908] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Patients undergoing vascular surgery are at high risk of postoperative myocardial infarction (POMI). Postoperative myocardial infarction is independently associated with significant risk of in-hospital mortality. Objective To examine the association of patient and procedural characteristics with the risk of POMI after vascular surgery and determine the association of evidence-based therapies with longer-term outcomes. Design, Setting, and Participants A retrospective cohort study of prospectively collected data within a statewide quality improvement collaborative database between January 2012 and December 2017. Patient demographics, comorbid conditions, and perioperative medications were captured. Patients were grouped according to occurrence of POMI. Univariate analysis and logistic regression were used to identify factors associated with POMI. The collaborative collects data from private and academic hospitals in Michigan. Patients undergoing major vascular surgery, defined as endovascular aortic aneurysm repair, open abdominal aortic aneurysm, peripheral bypass, carotid endarterectomy, or carotid artery stenting were included. Analysis began December 2018. Main Outcomes and Measures The presence of a POMI and 1-year mortality. Results Of 26 231 patients identified, 16 989 (65.8%) were men and the overall mean (SD) age was 69.35 (9.89) years. A total of 410 individuals (1.6%) experienced a POMI. Factors associated with higher rates of POMI were age (odds ratio [OR], 1.032 [95% CI, 1.019-1.045]; P < .001), diabetes (OR, 1.514 [95% CI, 1.201-1.907]; P < .001), congestive heart failure (OR, 1.519 [95% CI, 1.163-1.983]; P = .002), valvular disease (OR, 1.447 [95% CI, 1.024-2.046]; P = .04), coronary artery disease (OR, 1.381 [95% CI, 1.058-1.803]; P = .02), and preoperative P2Y12 antagonist use (OR, 1.37 [95% CI, 1.08-1.725]; P = .009). Procedurally, open abdominal aortic aneurysm (OR, 4.53 [95% CI, 2.73-7.517]; P < .001) and peripheral bypass (OR, 2.375 [95% CI, 1.818-3.102]; P < .001) were associated with the highest risk of POMI. After POMI, patients were discharged and received evidence-based therapy with high fidelity, including β-blockade (296 [82.7%]) and antiplatelet therapy (336 [95.7%]). A high portion of patients with POMI were dead at 1 year compared with patients without POMI (113 [37.42%] vs 993 [5.05%]; χ2 = 589.3; P < .001). Conclusions and Relevance Despite high rates of discharge with evidence-based therapies, the long-term burden of POMI is substantial, with a high mortality rate in the following year. Patients with diabetes mellitus, coronary artery disease, congestive heart failure, and valvular disease warrant additional consideration in the preoperative period. Further, aggressive strategies to treat patients who experience a POMI are needed to reduce the risk of postoperative mortality.
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Affiliation(s)
- Robert J Beaulieu
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Danielle C Sutzko
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Jeremy Albright
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Erin Jeruzal
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Nicholas H Osborne
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor
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5
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Murphy SJX, Lim ST, Kinsella JA, Tierney S, Egan B, Feeley TM, Murphy SM, Walsh RA, Collins DR, Coughlan T, O'Neill D, Harbison JA, Madhavan P, O'Neill SM, Colgan MP, Cox D, Moran N, Hamilton G, Meaney JF, McCabe DJH. Relationship between 'on-treatment platelet reactivity', shear stress, and micro-embolic signals in asymptomatic and symptomatic carotid stenosis. J Neurol 2019; 267:168-184. [PMID: 31606758 DOI: 10.1007/s00415-019-09550-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 09/17/2019] [Accepted: 09/19/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Assessment of 'high on-treatment platelet reactivity (HTPR)' could enhance understanding of the pathophysiology of first or recurrent vascular events in carotid stenosis patients on antiplatelet therapy. METHODS This prospective, multi-centre study assessed antiplatelet-HTPR status and its relationship with micro-emboli signals (MES) in asymptomatic vs. symptomatic ≥ 50-99% carotid stenosis. Platelet function/reactivity was assessed under 'moderately high shear stress' with the PFA-100® and 'low shear stress' with VerifyNow® and Multiplate® analysers. Bilateral 1-h transcranial Doppler ultrasound of the middle cerebral arteries classified patients as MES + ve or MES - ve. RESULTS Data from 34 asymptomatic patients were compared with 43 symptomatic patients in the 'early phase' (≤ 4 weeks) and 37 patients in the 'late phase' (≥ 3 months) after TIA/ischaemic stroke. Median daily aspirin doses were higher in early symptomatic (225 mg; P < 0.001), but not late symptomatic (75 mg; P = 0.62) vs. asymptomatic patients (75 mg). There was a lower prevalence of aspirin-HTPR in early (28.6%; P = 0.028), but not late symptomatic (38.9%; P = 0.22) compared with asymptomatic patients (56.7%) on the PFA-100®, but not on the VerifyNow® or Multiplate® (P ≤ 0.53). Early symptomatic patients had a higher prevalence of aspirin-HTPR on the PFA-100® (28.6%) vs. VerifyNow® (9.5%; P = 0.049), but not Multiplate® assays (11.9%, P = 0.10). There was no difference in aspirin-HTPR prevalence between any symptomatic vs. asymptomatic MES + ve or MES - ve subgroup. DISCUSSION Recently symptomatic moderate-severe carotid stenosis patients had a lower prevalence of aspirin-HTPR than their asymptomatic counterparts on the PFA-100®, likely related to higher aspirin doses. The prevalence of antiplatelet-HTPR was positively influenced by higher shear stress levels, but not MES status.
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Affiliation(s)
- S J X Murphy
- Department of Neurology, AMNCH/Tallaght University Hospital, Dublin, Ireland.,Stroke Service, AMNCH/Tallaght University Hospital, Dublin, Ireland
| | - S T Lim
- Department of Neurology, AMNCH/Tallaght University Hospital, Dublin, Ireland.,Stroke Service, AMNCH/Tallaght University Hospital, Dublin, Ireland
| | - J A Kinsella
- Department of Neurology, St Vincent's University Hospital, University College Dublin, Dublin, Ireland
| | - S Tierney
- Department of Vascular Surgery, AMNCH/Tallaght University Hospital, Dublin, Ireland
| | - B Egan
- Department of Vascular Surgery, AMNCH/Tallaght University Hospital, Dublin, Ireland
| | - T M Feeley
- Department of Vascular Surgery, AMNCH/Tallaght University Hospital, Dublin, Ireland.,Dublin Midlands Hospital Group, Dublin, Ireland
| | - S M Murphy
- Department of Neurology, AMNCH/Tallaght University Hospital, Dublin, Ireland.,Stroke Service, AMNCH/Tallaght University Hospital, Dublin, Ireland.,Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - R A Walsh
- Department of Neurology, AMNCH/Tallaght University Hospital, Dublin, Ireland.,Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - D R Collins
- Age-Related Health Care Department, AMNCH/Tallaght University Hospital, Dublin, Ireland.,Stroke Service, AMNCH/Tallaght University Hospital, Dublin, Ireland
| | - T Coughlan
- Age-Related Health Care Department, AMNCH/Tallaght University Hospital, Dublin, Ireland.,Stroke Service, AMNCH/Tallaght University Hospital, Dublin, Ireland
| | - D O'Neill
- Age-Related Health Care Department, AMNCH/Tallaght University Hospital, Dublin, Ireland.,Stroke Service, AMNCH/Tallaght University Hospital, Dublin, Ireland
| | - J A Harbison
- Department of Medicine for the Elderly/Stroke Service, St. James's Hospital/Trinity College Dublin, Dublin, Ireland
| | - P Madhavan
- Department of Vascular Surgery, St. James's Hospital/Trinity College Dublin, Dublin, Ireland
| | - S M O'Neill
- Department of Vascular Surgery, St. James's Hospital/Trinity College Dublin, Dublin, Ireland
| | - M P Colgan
- Department of Vascular Surgery, St. James's Hospital/Trinity College Dublin, Dublin, Ireland
| | - D Cox
- Department of Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland.,Irish Centre for Vascular Biology, Dublin, Ireland
| | - N Moran
- Department of Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland.,Irish Centre for Vascular Biology, Dublin, Ireland
| | - G Hamilton
- Department of Vascular Surgery, University Department of Surgery, Royal Free Hampstead NHS Trust, London, UK
| | - J F Meaney
- Department of Radiology, Centre for Advanced Medical Imaging, St. James's Hospital/Trinity College Dublin, Dublin, Ireland
| | - D J H McCabe
- Vascular Neurology Research Foundation, C/O Department of Neurology, The Adelaide and Meath Hospital, Dublin, Incorporating the National Children's Hospital (AMNCH)/Tallaght University Hospital, Tallaght, Dublin 24, Ireland. .,Department of Neurology, AMNCH/Tallaght University Hospital, Dublin, Ireland. .,Stroke Service, AMNCH/Tallaght University Hospital, Dublin, Ireland. .,Department of Clinical Neurosciences, Royal Free Campus, UCL Queen Square Institute of Neurology, London, UK. .,Irish Centre for Vascular Biology, Dublin, Ireland. .,Stroke Clinical Trials Network Ireland, Dublin, Ireland. .,Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Dublin, Ireland.
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6
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Naylor AR. Medical treatment strategies to reduce perioperative morbidity and mortality after carotid surgery. Semin Vasc Surg 2017; 30:17-24. [DOI: 10.1053/j.semvascsurg.2017.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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7
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Brenner T, Schmitt FC, Demirel S, Salgado E, Celi de la Torre JA, Göring M, Bruckner T, Böckler D, Weigand MA, Hofer S, Attigah N. The role of unfractionated heparin for the antiaggregatory effect of aspirin in patients undergoing carotid endarterectomy: Results of an observational clinical study. Vascular 2016; 25:19-27. [PMID: 26993144 DOI: 10.1177/1708538116638961] [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] [Indexed: 11/16/2022]
Abstract
The aims of the present study were to examine the influence of a low-dose unfractionated heparin regime on platelet aggregation and to additionally assess the prevalence of primary aspirin resistance in patients undergoing carotid endarterectomy. Therefore, 50 patients undergoing carotid endarterectomy were enrolled. A bolus of 3000 IU unfractionated heparin was administered 2 min before carotid cross-clamping additionally to standard antiaggregatory therapy. Haemostaseological point of care testing was performed twice, prior to surgery and 10 min after unfractionated heparin administration by the use of aggregometric and viscoelastic point of care testing. Following unfractionated heparin administration, the activated partial thromboplastin time increased significantly and clotting time in viscoelastic INTEM test was shown to be significantly prolonged. In contrast, the antiaggregatory effect of aspirin was not diminished in aggregometric ASPI test. A low-dose unfractionated heparin regime during carotid endarterectomy was therefore considered to be safe, without diminishing the antiplatelet effect of aspirin. Moreover, aggregometric point of care testing was identified to be a suitable tool for the identification of patients with primary aspirin resistance ( n = 3).
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Affiliation(s)
- Thorsten Brenner
- 1 Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix Cf Schmitt
- 1 Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Serdar Demirel
- 2 Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Eduardo Salgado
- 1 Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Martin Göring
- 1 Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Bruckner
- 3 Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Dittmar Böckler
- 2 Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Weigand
- 1 Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Hofer
- 1 Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Nicolas Attigah
- 2 Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
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8
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Wąsowicz M, Syed S, Wijeysundera DN, Starzyk Ł, Grewal D, Ragoonanan T, Harsha P, Travis G, Carroll J, Karkouti K, Beattie WS. Effectiveness of platelet inhibition on major adverse cardiac events in non-cardiac surgery after percutaneous coronary intervention: a prospective cohort study. Br J Anaesth 2016; 116:493-500. [PMID: 26888800 DOI: 10.1093/bja/aev556] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Platelet inhibition is mandatory therapy after percutaneous coronary intervention (PCI). Withdrawal of oral antiplatelet agents has been linked to increased incidence of postoperative adverse cardiac events in post-PCI patients having non-cardiac surgery (NCS). There is limited knowledge of temporal changes in platelet inhibition in this high-risk surgical population. We therefore performed a multicentre prospective cohort study evaluating perioperative platelet function and its association with postoperative major adverse cardiac events (MACE). METHODS In 201 post-PCI patients having NCS, we assessed the association between platelet function and postoperative MACE. We performed perioperative platelet function testing using a platelet mapping assay (PMA). Troponin-I was measured every 8 h for 2 days, then daily until day 5. Myocardial infarction was assessed using the third universal definition. We used multivariable logistic regression to assess the association between platelet inhibition and MACE. RESULTS Major adverse cardiac events occurred in 40 patients within 30 days of surgery. Thirty-two of these events were non-ST-elevation myocardial infarction, four ST-elevation myocardial infarction, and four exacerbation of congestive heart failure. We were unable to show an association between platelet inhibition and MACE. The PMA showed declining levels of platelet inhibition the longer the antiplatelet therapy was withheld before surgery. Logistic regression did not show an association between preoperative platelet function or the type of stent and MACE. We found an increased cardiac risk of MACE after surgery within 6 weeks of PCI. CONCLUSIONS The incidence of MACE in patients undergoing NCS after previous PCI is high in spite of adequate perioperative antiplatelet therapy. CLINICAL TRIAL REGISTRATION NCT 01707459 (registered at http://www.clinicaltrials.gov).
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Affiliation(s)
- M Wąsowicz
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 The Peter Munk Cardiac Centre, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 Department of Anesthesia, University of Toronto, 12 Floor, 123 Edward Street, Toronto, ON Canada M5G 1E2
| | - S Syed
- Department of Anesthesia Hamilton Health Sciences Corporation, McMaster University, 237 Barton Street East, Hamilton, ON, Canada L8L 2X2
| | - D N Wijeysundera
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 Department of Anesthesia, University of Toronto, 12 Floor, 123 Edward Street, Toronto, ON Canada M5G 1E2 Li Ka Shing Knowledge Institute of St Michael's Hospital, 209 Victoria Street, Toronto, ON, Canada M5B 1T8 Institute of Health Policy Management and Evaluation, 155 College Street, Toronto, ON, Canada M5T 3M6
| | - Ł Starzyk
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4
| | - D Grewal
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4
| | - T Ragoonanan
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4
| | - P Harsha
- Department of Anesthesia Hamilton Health Sciences Corporation, McMaster University, 237 Barton Street East, Hamilton, ON, Canada L8L 2X2
| | - G Travis
- Department of Anesthesia Hamilton Health Sciences Corporation, McMaster University, 237 Barton Street East, Hamilton, ON, Canada L8L 2X2
| | - J Carroll
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 The Peter Munk Cardiac Centre, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 Department of Anesthesia, University of Toronto, 12 Floor, 123 Edward Street, Toronto, ON Canada M5G 1E2 Institute of Health Policy Management and Evaluation, 155 College Street, Toronto, ON, Canada M5T 3M6
| | - W S Beattie
- Department of Anesthesia and Pain Management, Toronto General Hospital/University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 The Peter Munk Cardiac Centre, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 Department of Anesthesia, University of Toronto, 12 Floor, 123 Edward Street, Toronto, ON Canada M5G 1E2
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9
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Duncan D, Wijeysundera DN. Preoperative Cardiac Evaluation and Management of the Patient Undergoing Major Vascular Surgery. Int Anesthesiol Clin 2016; 54:1-32. [PMID: 26967800 PMCID: PMC5087846 DOI: 10.1097/aia.0000000000000091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Dallas Duncan
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Duminda N. Wijeysundera
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, ON, Canada
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10
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Tzoran I, Brenner B, Sakharov G, Trujillo-Santos J, Lorenzo A, Madridano O, López-Sáez JB, Monreal M. Clinical outcome in patients with venous thromboembolism receiving concomitant anticoagulant and antiplatelet therapy. Eur J Intern Med 2014; 25:821-5. [PMID: 25287697 DOI: 10.1016/j.ejim.2014.09.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 09/11/2014] [Accepted: 09/12/2014] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Patients with arterial disease receiving antiplatelet agents may develop venous thromboembolism (VTE) and need anticoagulant therapy, although concomitant use of these drugs may increase bleeding risk. We analyzed RIETE data and compared clinical outcomes depending on decision to discontinue or maintain antiplatelet therapy at VTE diagnosis. METHODS Consecutive patients with acute VTE were enrolled in RIETE. Only patients receiving antiplatelet therapy at baseline were included in this analysis. Primary outcomes were: rate of subsequent ischemic events, major bleeding or death during anticoagulation course. RESULTS 1178 patients who received antiplatelet drugs at VTE diagnosis were included. Antiplatelet therapy was discontinued in 62% of patients. During anticoagulation course, patients also receiving antiplatelet therapy had higher rates of lower limb amputations (2.28 vs. 0.21 events per 100 patients-years; p<0.01), any ischemic events (5.7 vs. 2.28 events per 100 patients-years; p<0.05) or death (23.6 vs. 13.9 deaths per 100 patients-years; p<0.01). No differences in the rate of major bleeding or recurrent VTE were revealed. In matched analysis, patients on antiplatelet therapy were found to have a significantly higher rate of limb amputations (odds ratio: 15.3; 95% CI: 1.02-229) and an increased number of composite outcomes including all-cause deaths, arterial and VTE events (odds ratio: 1.46; CI: 1.03-2.06), with no differences in major bleeding rate. CONCLUSION Concomitant anticoagulant and antiplatelet therapy in patients with VTE and arterial disease is not associated with increased risk for bleeding, recurrent VTE or death. The worse outcome observed in patients who continued antiplatelet therapy requires further investigations.
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Affiliation(s)
- Inna Tzoran
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Israel.
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Israel; Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Gleb Sakharov
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Israel
| | - Javier Trujillo-Santos
- Department of Internal Medicine, Hospital Universitario de Santa Lucía, Cartagena, Spain
| | - Alicia Lorenzo
- Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
| | - Olga Madridano
- Department of Internal Medicine, Hospital Infanta Sofía, Madrid, Spain
| | | | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
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11
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Fong R, Sweitzer BJ. Preoperative Optimization of Patients Undergoing Ambulatory Surgery. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0082-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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12
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Roberts JD, Sweitzer B. Perioperative evaluation and management of cardiac disease in the ambulatory surgery setting. Anesthesiol Clin 2014; 32:309-320. [PMID: 24882119 DOI: 10.1016/j.anclin.2014.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Preoperative cardiac evaluation focuses on risk assessment and reduction. Diagnostic testing and interventions are used only when the risk of adverse outcomes is high and intervention will lower the risk. The evaluation is performed in a stepwise fashion according to guidelines in the literature.
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Affiliation(s)
- J Devin Roberts
- Department of Anesthesia and Critical Care, University of Chicago, 5841 South Maryland Ave MC4028, Chicago, IL 60637, USA.
| | - BobbieJean Sweitzer
- Departments of Anesthesia and Critical Care, Anesthesia Perioperative Medicine Clinic, University of Chicago, 5841 South Maryland Ave MC4028, Chicago, IL 60637, USA
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13
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McMahon GS, Jones CI, Hayes PD, Naylor AR, Goodall AH. Transient heparin-induced platelet activation linked to generation of platelet 12-lipoxygenase. Findings from a randomised controlled trial. Thromb Haemost 2013; 109:1099-107. [PMID: 23494053 DOI: 10.1160/th12-11-0793] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 01/31/2013] [Indexed: 11/05/2022]
Abstract
Previously we demonstrated that heparin administration during carotid endarterectomy (CEA) caused a marked, but transient increase in platelet aggregation to arachidonic acid (AA) and adenosine diphosphate (ADP), despite effective platelet cyclo-oxygenase-1 (COX-1) inhibition with aspirin. Here we investigated the metabolism of AA via platelet 12-lipoxygenase (12-LOX) as a possible mediator of the observed transient aspirin resistance, and compared the effects of unfractionated (UFH) and low-molecular-weight (LMWH) heparin. A total of 43 aspirinated patients undergoing CEA were randomised in the trial to 5,000 IU UFH (n=22) or 2,500 IU LMWH (dalteparin, n=21). Platelet aggregation to AA (4x10⁻³) and ADP (3x10⁻⁶) was determined, and the products of the COX-1 and 12-LOX pathways; thromboxane B₂ (TXB₂) and 12-hydroxyeicosatretraenoic acid (12-HETE) were measured in plasma, and in material released from aggregating platelets.Aggregation to AA increased significantly (~10-fold) following heparinisation (p<0.0001), irrespective of heparin type (p=0.33). Significant, but smaller (~2-fold) increases in aggregation to ADP were also seen, which were significantly lower in the platelets of patients randomised to LMWH (p<0.0001). Plasma levels of TxB2 did not rise following heparinisation (p=0.93), but 12-HETE increased significantly in the patients' plasma, and released from platelets stimulated in vitro withADP, with both heparin types (p<0.0001). The magnitude of aggregation to ADP correlated with 12-HETE generation (p=0.03). Heparin administration during CEA generates AA that is metabolised to 12-HETE via the 12-LOX pathway, possibly explaining the phenomenon of transient heparin-induced platelet activation. LMWH has less effect on aggregation and 12-HETE generation than UFH when the platelets are stimulated with ADP.
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Affiliation(s)
- Greg S McMahon
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield Hospital, Leicester, LE3 9QP, UK
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14
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Grosser T, Fries S, Lawson JA, Kapoor SC, Grant GR, FitzGerald GA. Drug resistance and pseudoresistance: an unintended consequence of enteric coating aspirin. Circulation 2012; 127:377-85. [PMID: 23212718 DOI: 10.1161/circulationaha.112.117283] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Low dose aspirin reduces the secondary incidence of myocardial infarction and stroke. Drug resistance to aspirin might result in treatment failure. Despite this concern, no clear definition of aspirin resistance has emerged, and estimates of its incidence have varied remarkably. We aimed to determine the commonality of a mechanistically consistent, stable, and specific phenotype of true pharmacological resistance to aspirin-such as might be explained by genetic causes. METHODS AND RESULTS Healthy volunteers (n=400) were screened for their response to a single oral dose of 325-mg immediate release or enteric coated aspirin. Response parameters reflected the activity of the molecular target of aspirin, cyclooxygenase-1. Individuals who appeared aspirin resistant on 1 occasion underwent repeat testing, and if still resistant were exposed to low-dose enteric coated aspirin (81 mg) and clopidogrel (75 mg) for 1 week each. Variable absorption caused a high frequency of apparent resistance to a single dose of 325-mg enteric coated aspirin (up to 49%) but not to immediate release aspirin (0%). All individuals responded to aspirin on repeated exposure, extension of the postdosing interval, or addition of aspirin to their platelets ex vivo. CONCLUSIONS Pharmacological resistance to aspirin is rare; this study failed to identify a single case of true drug resistance. Pseudoresistance, reflecting delayed and reduced drug absorption, complicates enteric coated but not immediate release aspirin administration. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00948987.
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Affiliation(s)
- Tilo Grosser
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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15
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Kinsella JA, Tobin WO, Hamilton G, McCabe DJH. Platelet activation, function, and reactivity in atherosclerotic carotid artery stenosis: a systematic review of the literature. Int J Stroke 2012; 8:451-64. [PMID: 23013536 DOI: 10.1111/j.1747-4949.2012.00866.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
An important proportion of transient ischemic attack or ischemic stroke is attributable to moderate or severe (50-99%) atherosclerotic carotid stenosis or occlusion. Platelet biomarkers have the potential to improve our understanding of the pathogenesis of vascular events in this patient population. A detailed systematic review was performed to collate all available data on ex vivo platelet activation and platelet function/reactivity in patients with carotid stenosis. Two hundred thirteen potentially relevant articles were initially identified; 26 manuscripts met criteria for inclusion in this systematic review. There was no consistent evidence of clinically informative data from urinary or soluble blood markers of platelet activation in patients with symptomatic moderate or severe carotid stenosis who might be considered suitable for carotid intervention. Data from flow cytometry studies revealed evidence of excessive platelet activation in patients in the early, sub-acute, or late phases after transient ischemic attack or stroke in association with moderate or severe carotid stenosis and in asymptomatic moderate or severe carotid stenosis compared with controls. Furthermore, pilot data suggest that platelet activation may be increased in recently symptomatic than in asymptomatic severe carotid stenosis. Excessive platelet activation and platelet hyperreactivity may play a role in the pathogenesis of first or subsequent transient ischemic attack or stroke in patients with moderate or severe carotid stenosis. Larger longitudinal studies assessing platelet activation status with flow cytometry and platelet function/reactivity in symptomatic vs. asymptomatic carotid stenosis are warranted to improve our understanding of the mechanisms responsible for transient ischemic attack or stroke.
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Affiliation(s)
- J A Kinsella
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, Ireland
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16
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Halawani SHM, Williams DJP, Adefurin A, Webster J, Greaves M, Ford I. Aspirin failure in patients presenting with acute cerebrovascular ischaemia. Thromb Haemost 2011; 106:240-7. [PMID: 21544317 DOI: 10.1160/th11-01-0045] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Accepted: 04/08/2011] [Indexed: 11/05/2022]
Abstract
Aspirin is the most commonly used antiplatelet drug for prevention of ischaemic stroke. In order to determine the prevalence and nature of aspirin failure, we studied 51 adults admitted with suspected ischaemic stroke and already prescribed daily aspirin. Within 48 hours (h) of onset, blood and urine samples were collected to assess platelet aggregation, activation and aspirin response by a range of methods. All tests were then repeated on a second sample taken 24 h after witnessed administration of 75 mg or 150 mg aspirin. At entry to the study, incomplete response to aspirin, measured by arachidonic acid (AA)-stimulated platelet aggregation, was found in 43% of patients. Following in-hospital aspirin administration, there was a significant decrease in AA-aggregation (p=0.001) suggesting poor adherence to therapy prior to admission. However, residual aggregation (10-15%) persisted in 11 subjects - suggesting alternative causes. In incomplete responders on admission, platelet aggregation with adenosine diphosphate (ADP) was significantly higher compared with responders (p<0.05) but there were no significant differences in collagen aggregation, platelet fibrinogen binding or P-selectin expression, plasma von Willebrand factor, fibrinogen, high-sensitivity C-reactive protein, or the urinary metabolite, 11-dehydro-TxB2. Incomplete platelet inhibition is common around the time of acute cerebrovascular ischaemic events in patients prescribed aspirin. Up to 50% of these observations appear due to incomplete adherence to aspirin therapy. Intervention studies are required to determine the clinical relevance of measured platelet response to aspirin in terms of outcome, and the effectiveness of improved pharmacotherapy for stroke prevention.
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Affiliation(s)
- Saeed H M Halawani
- School of Medicine and Dentistry, University of Aberdeen, and Acute Stroke Unit, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK
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17
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Kasotakis G, Pipinos II, Lynch TG. Current evidence and clinical implications of aspirin resistance. J Vasc Surg 2009; 50:1500-10. [PMID: 19679423 DOI: 10.1016/j.jvs.2009.06.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Revised: 06/11/2009] [Accepted: 06/14/2009] [Indexed: 10/20/2022]
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18
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Collins P, Ford I, Greaves M, Macaulay E, Brittenden J. Surgical revascularisation in patients with severe limb ischaemia induces a pro-thrombotic state. Platelets 2009; 17:311-7. [PMID: 16928603 DOI: 10.1080/09537100600746540] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Platelet and coagulation activation are implicated in the increased incidence of ischaemic events seen in patients with peripheral arterial disease. This study aimed to assess the effect of surgical revascularisation on platelet aggregation and coagulation in patients with severe limb ischaemia (SLI). Twenty-two patients had blood samples taken: prior to surgery, on reperfusion, 2, 24 and 48 h post-surgery. Platelet aggregation through COX-mediated and thrombin receptor activator peptide (TRAP)-stimulated GPIIb/IIIa pathways was measured by the Ultegra point of care system. Thrombin-antithrombin III Complex (TAT) and D-dimer were measured by ELISA. COX-mediated aggregation increased significantly at reperfusion and remained elevated at 24 h [median increase from baseline of 9% (range -16 to 33%) P = 0.011]. TRAP-stimulated aggregation increased significantly at reperfusion and remained elevated at 2 h post-surgery [median increase 18% (range -71 to 45%); P = 0.007]. TAT levels were significantly elevated from reperfusion and remained so at 48 h (P < 0.003), whereas D-dimer only increased at 24 h (P = 0.014). For the first time, we have demonstrated that in patients with SLI, platelet aggregation is increased following surgery and there is a mismatch in the balance between the coagulation and fibrinolytic pathways despite the use of aspirin and heparin. Thus in the early post-operative these patients exhibit a pro-thrombotic state.
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Affiliation(s)
- P Collins
- Department of Vascular Surgery, University of Aberdeen, Scotland, UK
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19
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McMahon GS, Webster SE, Hayes PD, Jones CI, Goodall AH, Naylor AR. Low molecular weight heparin significantly reduces embolisation after carotid endarterectomy--a randomised controlled trial. Eur J Vasc Endovasc Surg 2009; 37:633-9. [PMID: 19328023 DOI: 10.1016/j.ejvs.2009.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2008] [Accepted: 02/22/2009] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The administration of unfractionated heparin (UFH) prior to carotid clamping during carotid endarterectomy (CEA) transiently increases the platelet aggregation response to arachidonic acid (AA) despite the use of aspirin. We hypothesized that this phenomenon might be reduced by using low molecular weight heparin (LMWH) resulting in fewer emboli in the early post-operative period. METHODS 183 aspirinated patients undergoing CEA were randomised to 5000 IU UFH (n=91) or 2500 IU LMWH (dalteparin, n=92) prior to carotid clamping. End-points were: transcranial Doppler (TCD) measurement of embolisation, effect on bleeding and platelet aggregation to AA and adenosine 5'-diphosphate (ADP). RESULTS Patients randomised to UFH had twice the odds of experiencing a higher number of emboli in the first 3h after CEA, than those randomised to LMWH (p=0.04). This was not associated with increased bleeding (mean time from flow restoration to operation end: 23 min (UFH) vs. 24 min (LMWH), p=0.18). Platelet aggregation to AA increased significantly following heparinisation, but was unaffected by heparin type (p=0.90). The platelets of patients randomised to LMWH exhibited significantly lower aggregation to ADP compared to UFH (p<0.0001). CONCLUSIONS Intravenous LMWH is associated with a significant reduction in post-operative embolisation without increased bleeding. The higher rate of embolisation seen with UFH may be mediated by increased platelet aggregation to ADP, rather than to AA.
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Affiliation(s)
- G S McMahon
- Department of Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, Leicester, UK.
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20
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Bowden D, Hayes N, London N, Bell P, Naylor AR, Hayes P. Carotid endarterectomy performed in the morning is associated with increased cerebral microembolization. J Vasc Surg 2009; 50:48-53. [PMID: 19223147 DOI: 10.1016/j.jvs.2009.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Revised: 12/22/2008] [Accepted: 01/03/2009] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Platelet function exhibits circadian variation with highest levels of activity in the morning and plays a central role in arterial thrombotic events, including thrombotic stroke following carotid endarterectomy (CEA). Prior to the platelet-rich thrombus occluding the carotid artery, multiple embolic signals are detected in the middle cerebral artery using transcranial Doppler ultrasound. We hypothesized that patients undergoing CEA early in the day may be at an increased stroke risk and this would manifest as an increased postoperative embolic count. METHODS Data were collected prospectively on 235 patients undergoing primary CEA. Accurate start and finish times were recorded in addition to the number of postoperative emboli detected in the first three hours after CEA using transcranial Doppler (TCD) monitoring. RESULTS For operations finishing before midday, there was a 3.6-fold increase in the number of emboli detected relative to afternoon finishes (53.2 vs 14.8, P = .002) with similar results for starts before 10:30 AM (48.1 vs 14.7, P =.002). There was also a significant correlation between start time and emboli count (P = .02). Of the 55 patients with no postoperative emboli, only 19 had a morning start (relative risk 0.63, P = .011). Patients were 6.9 times more likely to require treatment with Dextran-40 to prevent progression onto a thrombotic stroke if their CEA finished before midday (P = .008). CONCLUSION There is a significantly increased rate of postoperative embolization for operations begun earlier in the day. Carotid endarterectomies performed in the afternoon may be at less risk of developing postoperative thrombotic stroke.
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Affiliation(s)
- David Bowden
- Addenbrooke's Hospital, Cambridge, United Kingdom
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21
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Assadian A, Senekowitsch C, Hagmüller GW, Lax J, Hübl W. Effects of enoxaparin and unfractionated heparin on platelet activity and reactivity during carotid endarterectomy. Vascular 2008; 16:161-6. [PMID: 18674465 DOI: 10.2310/6670.2008.00028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to determine platelet activity and reactivity and the effects of unfractionated heparin (UFH) and enoxaparin on platelet function during carotid eversion endarterectomy under local anesthesia. Twenty symptomatic patients undergoing carotid endarterectomy were randomly assigned to either 5,000 units of UFH or body weight-adjusted enoxaparin (0.5 mg/kg body weight) as an intraoperative intravenous bolus. The activity of platelets was assessed by measuring the expression of CD62p and CD41 with flow cytometry. Additionally, platelet-leukocyte aggregates (PLAs) were enumerated. The reactivity of platelets was evaluated by measuring the expression of the same antigens after stimulation. In addition, platelet reactivity was also analyzed using a PFA-100 analyzer. A significant increase in platelet activity was observed during surgery for CD41 and CD62p (p = .002 and < .001, respectively). The number of PLAs showed no significant changes during surgery. Yet there was a significant difference between patients treated with UFH and patients treated with enoxaparin. No difference for platelet activity or reactivity for patients receiving either UFH or enoxaparin prior to cross-clamping of the carotid arteries was seen. The formation of PLAs after endarterectomy was significantly higher in the UFH group; thus, PLAs are probably a useful surrogate parameter for measuring platelet activity.
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Affiliation(s)
- Afshin Assadian
- Department of General and Vascular Surgery, Wilhelminenspital Vienna, Austria.
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22
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Newsome LT, Weller RS, Gerancher JC, Kutcher MA, Royster RL. Coronary Artery Stents: II. Perioperative Considerations and Management. Anesth Analg 2008; 107:570-90. [DOI: 10.1213/ane.0b013e3181731e95] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Vogten JM, Gerritsen WB, Ackerstaff RG, van Dongen EP, de Vries JPP. Perioperative Microemboli and Platelet Aggregation in Patients Undergoing Carotid Endarterectomy. Vascular 2008; 16:154-60. [DOI: 10.2310/6670.2008.00027] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In carotid endarterectomy (CEA) patients, platelet aggregation is increased despite heparinization. We investigated whether this phenomenon correlates with the occurrence of perioperative microemboli. Of 27 CEA patients, 18 (67%) used aspirin and 9 also used clopidogrel. Blood was collected at multiple time points before, during, and after CEA. Platelet aggregation and P-selectin expression were determined. Transcranial Doppler monitoring was used to measure microemboli. Platelet aggregation showed a significant increase 5 minutes postheparinization compared with preheparinization (19.7 ± 2.8% vs 8.9 ± 0.9% in the aspirin group and 22.5 ± 4.4% vs 8.7 ± 1.2% in the clopidogrel group; p < .01 and p < .05, respectively). P-selectin expression showed a tendency to increase postheparinization in both groups ( p = .07 and p = .09, respectively). The number of microemboli ranged from 0 to 50. Clopidogrel patients displayed fewer microemboli than aspirin patients (4.1 ± 2.3 vs 17.6 ± 18.2; p < .01). Patients with a high number of microemboli displayed had a tendency toward higher baseline platelet aggregation than patients with a low number of microemboli ( p = .08). In conclusion, platelet aggregation is transiently increased during CEA despite the administration of antiplatelet agents. Clopidogrel is associated with a decreased number of perioperative microemboli. The exact relationships between these findings, postoperative microemboli formation, and the risk for thromboembolic complications after CEA remain to be determined.
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Affiliation(s)
- J. Mathys Vogten
- Departments of *Vascular Surgery, †Clinical Chemistry, ‡Clinical Neurophysiology, and §Anesthesiology and Intensive Care, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Wim B.M. Gerritsen
- Departments of *Vascular Surgery, †Clinical Chemistry, ‡Clinical Neurophysiology, and §Anesthesiology and Intensive Care, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Rob G.A. Ackerstaff
- Departments of *Vascular Surgery, †Clinical Chemistry, ‡Clinical Neurophysiology, and §Anesthesiology and Intensive Care, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Eric P. van Dongen
- Departments of *Vascular Surgery, †Clinical Chemistry, ‡Clinical Neurophysiology, and §Anesthesiology and Intensive Care, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Jean-Paul P.M. de Vries
- Departments of *Vascular Surgery, †Clinical Chemistry, ‡Clinical Neurophysiology, and §Anesthesiology and Intensive Care, St Antonius Hospital, Nieuwegein, The Netherlands
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Macdonald S. Influence of Antiplatelet Therapy on Cerebral Micro-emboli After Carotid Endarterectomy Using Postoperative Transcranial Doppler Monitoring. Eur J Vasc Endovasc Surg 2007; 34:143-4. [PMID: 17588786 DOI: 10.1016/j.ejvs.2007.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Accepted: 05/18/2007] [Indexed: 10/23/2022]
Affiliation(s)
- S Macdonald
- Consultant Vascular Radiologist & Honorary Clinical Senior Lecturer, Freeman Hospital, Newcastle-upon-Tyne, NE7 7DN, UK
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25
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Abstract
Carotid endarterectomy (CEA) is performed to prevent embolic stroke in patients with atheromatous disease at the carotid bifurcation. There is now substantial evidence to support early operation in symptomatic patients, ideally within 2 weeks of the last neurological symptoms. Thus, the anaesthetist may be faced with a high risk patient in whom there has been limited time for preoperative preparation. The operation may be performed under local or general anaesthesia. The advantages and disadvantages of both are explored in this review. Carotid shunting may offer a degree of cerebral protection, but carries its own risks and has not been proved to reduce morbidity and mortality. The use of carotid shunts is based on clinical judgement, awake neurological monitoring, and the use of monitors of cerebral perfusion. There is no ideal monitor of cerebral perfusion in the patient receiving general anaesthesia. Both the intraoperative and postoperative periods may be witness to dramatic haemodynamic changes that may compromise the cerebral or myocardial circulations. In particular, postoperative hypotension may compromise both myocardial and cerebral perfusion, and severe hypertension can cause cerebral hyperperfusion. There is as yet limited evidence to guide the management of these problems. In summary, CEA can yield significant benefit, but those with the most to gain from the operation also present the greatest challenge to the anaesthetist.
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Affiliation(s)
- S J Howell
- Academic Unit of Anaesthesia, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK.
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26
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Assadian A, Lax J, Meixner-Loicht U, Hagmüller GW, Bayer PM, Hübl W. Aspirin resistance among long-term aspirin users after carotid endarterectomy and controls: Flow cytometric measurement of aspirin-induced platelet inhibition. J Vasc Surg 2007; 45:1142-7; discussion 1147. [PMID: 17543677 DOI: 10.1016/j.jvs.2007.01.064] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2006] [Accepted: 01/24/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Numerous studies have indicated that some patient subpopulations do not respond to the antithrombotic effects of aspirin. The objective of this study was to evaluate aspirin-induced inhibition of platelet cyclooxygenase (COX) using a flow cytometric technique in long-term aspirin users after carotid endarterectomy (CEA) and controls with newly diagnosed carotid stenosis not taking aspirin and to compare these results with platelet function analyzer measurements. METHODS The study included 86 patients with a history of CEA on long-term aspirin therapy (100 mg daily) and 29 age-matched patients with newly diagnosed carotid artery stenosis not taking aspirin. Platelet-rich plasma diluted with phosphate-buffered saline was incubated with arachidonic acid (ARA) at a final concentration of 80 micromol/L. After staining with phycoerythrin-labeled anti-P-selectin (CD62p) antibody, platelet CD62p-antigen expression was measured on a flow cytometer. RESULTS Flow cytometric measurement of ARA-induced platelet activation showed an inhibition of ARA-induced platelet stimulation in all patients on aspirin therapy, whereas all but two controls (95%) showed expected platelet reactivity. In contrast, results of the platelet function analyzer measurements were normal in 16% of aspirin-treated patients. CONCLUSIONS Flow cytometric measurement of CD62p expression on platelets after incubation with ARA proved to be a practicable tool to monitor aspirin-induced inhibition of platelet COX. Results in patients on long-term low-dose aspirin therapy show that the inability of aspirin to inhibit platelet COX for both symptomatic and asymptomatic patients with high-grade internal carotid artery stenosis is a very rare event. So-called aspirin resistance detected quite frequently by platelet function analyzer measurement is most likely from COX-independent mechanisms.
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Affiliation(s)
- Afshin Assadian
- Department of General and Vascular Surgery, Wilhelminenspital Vienna, Vienna, Austria.
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Gopalan D, Thomas SM. Pharmacotherapy for patients undergoing carotid stenting. Eur J Radiol 2006; 60:14-9. [PMID: 16891083 DOI: 10.1016/j.ejrad.2006.05.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2006] [Accepted: 05/29/2006] [Indexed: 11/19/2022]
Abstract
Stroke is the second most common cause of death worldwide [Murray CJ, Lopez AD. Mortality by cause for eight regions of the World: Global Burden of Disease Study, Lancet 1997;349:1269-76. [1]] and remains one of the most common and disabling neurological disorders, particularly in the elderly. Survivors of stroke remain at high risk for developing further vascular events including recurrent strokes, myocardial infarction and vascular deaths. Treatment modalities for such patients include life style modifications, drug therapy and where applicable, surgical or endovascular intervention. Carotid artery disease is implicated in 20-30% of the population as the aetiology for stroke [De Bakey ME. Carotid endarterectomy revisited, J Endovasc Surg 1996;3:4. [2]]. This article examines the pharmacotherapy for patients undergoing carotid stenting. This will be divided into best medical therapy for these patients, and is the same as that that should be given to all patients following transient ischaemic attack (TIA) or stroke. It will provide a concise description of the safety profile, dosage, indications and contraindications of the various drugs that are currently available to reduce the risk of further TIA or stroke. Then the specific drugs used in the peri-procedural period during carotid stenting will be described, along with the evidence supporting their use.
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Affiliation(s)
- Deepa Gopalan
- Sheffield Vascular Institute, Northern General Hospital, Sheffield, UK
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Huang R, Patel RB, Ma H, Taylor K, Abela GS. Aspirin reduces platelet aggregation during high-energy excimer laser. Lasers Surg Med 2006; 38:875-9. [PMID: 16964625 DOI: 10.1002/lsm.20381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Excimer laser is used clinically in arterial revascularization procedures. This study evaluated the efficacy of aspirin in reducing platelet aggregation during high-energy excimer lasing. STUDY DESIGN/MATERIALS AND METHODS Platelet rich plasma (PRP) from seven rabbits was circulated in a dual organ chamber with aspirin added to one and the other was control. PRP was irradiated using an excimer laser (308 nm; 45 mJ/mm(2); 25 Hz; 5 minutes) via a 2.0 mm laser catheter. Platelet aggregation (particle volume) was measured by laser-light scattering. Morphology was evaluated by phase contrast and electron microscopy. RESULTS Baseline platelet volume was 3.4 microm(3) for both control and aspirin groups. Following lasing, platelet volume peaked at 102.2 +/- 18.5 microm(3) for control compared to 43.1 +/- 49.2 microm(3) for aspirin-treated PRP (P < 0.0001). CONCLUSION Aspirin reduces large platelet aggregates but not small aggregates by 58% during lasing of PRP.
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Affiliation(s)
- Ruiping Huang
- Division of Cardiology, Department of Medicine, Michigan State, University, East Lansing, Michigan 48824, USA
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Lordkipanidzé M, Pharand C, Palisaitis DA, Diodati JG. Aspirin resistance: truth or dare. Pharmacol Ther 2006; 112:733-43. [PMID: 16919334 DOI: 10.1016/j.pharmthera.2006.05.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2006] [Accepted: 05/30/2006] [Indexed: 02/02/2023]
Abstract
Acetylsalicylic acid, or aspirin (ASA), is widely used in patients with cardiovascular disease to prevent acute ischemic events. However, platelet response to ASA is not equal in all individuals, and a high variability in the prevalence of ASA resistance is reported in the literature (0.4-83%). Actually, ASA resistance is poorly understood; this stems from the fact that its definition is unclear, its presence can be evaluated by a number of assays that are not equivalent, and its prevalence may vary widely based on the population studied. This article (1) exposes the difficulties in defining ASA resistance; (2) discusses the mechanisms by which ASA resistance may occur; (3) presents the characteristics that may put patients at greater risk of exhibiting ASA resistance; and (4) discusses the clinical impact of ASA resistance in patients requiring chronic therapy.
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Williams PC, Coffey MJ, Coles B, Sanchez S, Morrow JD, Cockcroft JR, Lewis MJ, O'Donnell VB. In vivo aspirin supplementation inhibits nitric oxide consumption by human platelets. Blood 2005; 106:2737-43. [PMID: 15972451 DOI: 10.1182/blood-2005-02-0664] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Antiplatelet therapies improve endothelial function in atherosclerosis, suggesting that platelets regulate vascular nitric oxide (NO) bioactivity in vivo. Herein, washed platelets consumed NO on activation in an aspirin-sensitive manner, and aspirin enhanced platelet NO responses in vitro. To examine whether in vivo aspirin can inhibit platelet NO consumption, a double-blind placebo-controlled study was conducted. After a 2-week nonsteroidal anti-inflammatory drug (NSAID)-free period, healthy men were randomly assigned and administered aspirin (75 mg/d orally) or identical placebo for 14 days, then crossed over to the opposite arm. Following in vivo aspirin, NO consumption by platelets was inhibited 91%. Rate of onset and recovery following aspirin withdrawal was consistent with cyclooxygenase 1 (COX-1) inhibition. In a small substudy, NO consumption by platelets from postmenopausal women was faster in hypercholesterolemics and less sensitive to aspirin (ie, 39% versus 76% inhibition for hypercholesterolemics or normocholesterolemics, respectively). However, 150 mg aspirin/day increased inhibition of NO consumption by platelets of hypercholesterolemics to 80%. Comparisons of platelet COX-1 or -2 expression and urinary 11-dehydro-thromboxane B2 excretion suggested that aspirin was less able to block platelet activation in vivo in hypercholesterolemia. In conclusion, aspirin inhibits NO consumption by platelets from healthy subjects, but its beneficial effects on NO bioactivity may be compromised in some hypercholesterolemic patients.
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Affiliation(s)
- P Claire Williams
- Department of Medical Biochemistry and Immunology, University of Wales College of Medicine, Heath Park, Cardiff, CF14 4XN, United Kingdom
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