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Bindal P, Kumar V, Kapil L, Singh C, Singh A. Therapeutic management of ischemic stroke. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:2651-2679. [PMID: 37966570 DOI: 10.1007/s00210-023-02804-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 10/19/2023] [Indexed: 11/16/2023]
Abstract
Stroke is the third leading cause of years lost due to disability and the second-largest cause of mortality worldwide. Most occurrences of stroke are brought on by the sudden occlusion of an artery (ischemic stroke), but sometimes they are brought on by bleeding into brain tissue after a blood vessel has ruptured (hemorrhagic stroke). Alteplase is the only therapy the American Food and Drug Administration has approved for ischemic stroke under the thrombolysis category. Current views as well as relevant clinical research on the diagnosis, assessment, and management of stroke are reviewed to suggest appropriate treatment strategies. We searched PubMed and Google Scholar for the available therapeutic regimes in the past, present, and future. With the advent of endovascular therapy in 2015 and intravenous thrombolysis in 1995, the therapeutic options for ischemic stroke have expanded significantly. A novel approach such as vagus nerve stimulation could be life-changing for many stroke patients. Therapeutic hypothermia, the process of cooling the body or brain to preserve organ integrity, is one of the most potent neuroprotectants in both clinical and preclinical contexts. The rapid intervention has been linked to more favorable clinical results. This study focuses on the pathogenesis of stroke, as well as its recent advancements, future prospects, and potential therapeutic targets in stroke therapy.
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Affiliation(s)
- Priya Bindal
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India
| | - Vishal Kumar
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India
| | - Lakshay Kapil
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India
| | - Charan Singh
- Department of Pharmaceutical Sciences, HNB Garhwal University (A Central University), Chauras Campus, Distt. Tehri Garhwal, Uttarakhand, 246174, India
| | - Arti Singh
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India.
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Duke AJ, Bowen S, Baig S, Cohen D, Komatsu DE, Nicholson J. Thirty day low-dose versus regular-dose aspirin for venous thromboembolism prophylaxis in primary total joint arthroplasty. J Orthop Surg (Hong Kong) 2023; 31:10225536231173329. [PMID: 37137821 DOI: 10.1177/10225536231173329] [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] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND The optimal dosing of aspirin (ASA) monotherapy for prophylaxis after total joint arthroplasty is debatable. The objective of this study was to compare two ASA regimens with regards to symptomatic deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding, and infection 90 days after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS We retrospectively identified 625 primary THA and TKA surgeries in 483 patients who received ASA for 4 weeks post-op. 301 patients received 325 mg once daily (QD) and 324 patients received 81 mg twice daily (BID). Patients were excluded if they were minors, had a prior venous thromboembolism (VTE), had ASA allergy, or received other VTE prophylaxis drugs. RESULTS There was a significant difference in rate of bleeding and suture reactions between the two groups. Bleeding was 7.6% for 325 mg QD and 2.5% for 81 mg BID (p = .0029 Χ2, p = .004 on multivariate logistic regression analysis). Suture reactions were 3.3% for 325 mg QD and 1.2% for 81 mg BID (p = .010 Χ2, p = .027 on multivariate logistic regression analysis). Rates of VTE, symptomatic DVT, and PE were not significantly different. The incidence of VTE was 2.7% for 325 mg QD and 1.5% for 81 mg BID (p = .4056). Symptomatic DVT rates were 1.6% for 325 mg QD and 0.9% for 81 mg BID (p = .4139). Deep infection was 1.0% for 325 mg QD and 0.31% for 81 mg BID (p = .3564). CONCLUSION Low-dose ASA in patients with limited comorbidities undergoing primary THA and TKA is associated with significant lower rates of bleeding and suture reactions than high dose ASA. Low-dose ASA was not inferior to higher dose ASA for the prevention of VTE, wound complications, and infection 90 days postoperatively.
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Affiliation(s)
- Alexander J Duke
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
| | - Stephen Bowen
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
| | - Samir Baig
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
| | - Dorian Cohen
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
| | - David E Komatsu
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
| | - James Nicholson
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
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Twine CP, Kakkos SK, Aboyans V, Baumgartner I, Behrendt CA, Bellmunt-Montoya S, Jilma B, Nordanstig J, Saratzis A, Reekers JA, Zlatanovic P, Antoniou GA, de Borst GJ, Bastos Gonçalves F, Chakfé N, Coscas R, Dias NV, Hinchliffe RJ, Kolh P, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Vermassen FEG, Wanhainen A, Koncar I, Fitridge R, Matsagkas M, Valgimigli M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases. Eur J Vasc Endovasc Surg 2023; 65:627-689. [PMID: 37019274 DOI: 10.1016/j.ejvs.2023.03.042] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 04/05/2023]
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Canonico ME, Piccolo R, Avvedimento M, Leone A, Esposito S, Franzone A, Giugliano G, Gargiulo G, Hess CN, Berkowitz SD, Hsia J, Cirillo P, Esposito G, Bonaca MP. Antithrombotic Therapy in Peripheral Artery Disease: Current Evidence and Future Directions. J Cardiovasc Dev Dis 2023; 10:164. [PMID: 37103043 PMCID: PMC10144744 DOI: 10.3390/jcdd10040164] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/07/2023] [Accepted: 04/08/2023] [Indexed: 04/28/2023] Open
Abstract
Patients with peripheral artery disease (PAD) are at an increased risk of major adverse cardiovascular events, and those with disease in the lower extremities are at risk of major adverse limb events primarily driven by atherothrombosis. Traditionally, PAD refers to diseases of the arteries outside of the coronary circulation, including carotid, visceral and lower extremity peripheral artery disease, and the heterogeneity of PAD patients is represented by different atherothrombotic pathophysiology, clinical features and related antithrombotic strategies. The risk in this diverse population includes systemic risk of cardiovascular events as well as risk related to the diseased territory (e.g., artery to artery embolic stroke for patients with carotid disease, lower extremity artery to artery embolism and atherothrombosis in patients with lower extremity disease). Moreover, until the last decade, clinical data on antithrombotic management of PAD patients have been drawn from subanalyses of randomized clinical trials addressing patients affected by coronary artery disease. The high prevalence and related poor prognosis in PAD patients highlight the pivotal role of tailored antithrombotic therapy in patients affected by cerebrovascular, aortic and lower extremity peripheral artery disease. Thus, the proper assessment of thrombotic and hemorrhagic risk in patients with PAD represents a key clinical challenge that must be met to permit the optimal antithrombotic prescription for the various clinical settings in daily practice. The aim of this updated review is to analyze different features of atherothrombotic disease as well as current evidence of antithrombotic management in asymptomatic and secondary prevention in PAD patients according to each arterial bed.
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Affiliation(s)
- Mario Enrico Canonico
- CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Marisa Avvedimento
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC G1V0A6, Canada
| | - Attilio Leone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Salvatore Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Giuseppe Giugliano
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Connie N. Hess
- CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Scott D. Berkowitz
- CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Judith Hsia
- CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Marc P. Bonaca
- CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA
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Li Y, Liu X, Chen S, Wang J, Pan C, Li G, Tang Z. Effect of antiplatelet therapy on the incidence, prognosis, and rebleeding of intracerebral hemorrhage. CNS Neurosci Ther 2023; 29:1484-1496. [PMID: 36942509 PMCID: PMC10173719 DOI: 10.1111/cns.14175] [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: 02/02/2023] [Revised: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 03/23/2023] Open
Abstract
OBJECTIVE Antiplatelet medications are increasingly being used for primary and secondary prevention of ischemic attacks owing to the increasing prevalence of ischemic stroke occurrences. Currently, many patients receive antiplatelet therapy (APT) to prevent thromboembolic events. However, long-term use of APT might also lead to an increased occurrence of intracerebral hemorrhage (ICH) and affect the prognosis of patients with ICH. Furthermore, some research suggest that restarting APT for patients who have previously experienced ICH may result in rebleeding events. The precise relationship between APT and ICH remains unknown. METHODS We searched PubMed for the most recent related literature and summarized the findings from various studies. The search terms included "antiplatelet," "intracerebral hemorrhage," "cerebral microbleeds," "hematoma expansion," "recurrent," and "reinitiate." Clinical studies involving human subjects were ultimately included and interpreted in this review, and animal studies were not discussed. RESULTS When individuals are administered APT, the risk of thrombotic events should be weighted against the risk of bleeding. In general, for some patients' concomitant with risk factors of thrombotic events, the advantages of antiplatelet medication may outweigh the inherent risk of rebleeding. However, the use of antiplatelet medications for other patients with a higher risk of bleeding should be carefully evaluated and closely monitored. In the future, a quantifiable system for assessing thrombotic risk and bleeding risk will be necessary. After evaluation, the appropriate time to restart APT for ICH patients should be determined to prevent underlying ischemic stroke events. According to the present study results and expert experience, most patients now restart APT at around 1 week following the onset of ICH. Nevertheless, the precise time to restart APT should be chosen on a case-by-case basis as per the patient's risk of embolic events and recurrent bleeding. More compelling evidence-based medicine evidence is needed in the future. CONCLUSION This review thoroughly discusses the relationship between APT and the development of ICH, the impact of APT on the course and prognosis of ICH patients, and the factors influencing the decision to restart APT after ICH. However, different studies' conclusions are inconsistent due to the differences in quality control. To support future clinical decisions, more large-scale randomized controlled trials are required.
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Affiliation(s)
- Yunjie Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xia Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiling Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jingyi Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chao Pan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gaigai Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 184] [Impact Index Per Article: 184.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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Patrono C. Fifty years with aspirin and platelets. Br J Pharmacol 2023; 180:25-43. [PMID: 36189951 PMCID: PMC10099789 DOI: 10.1111/bph.15966] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 12/14/2022] Open
Abstract
In 2021, we reached the 50th anniversary of the publication of Sir John Vane's seminal paper in Nature New Biology describing the experiments supporting his mechanistic hypothesis that inhibition of prostaglandin synthesis might explain the main pharmacological effects of aspirin and aspirin-like drugs, that is, reduction in pain, fever and inflammation. Bengt Samuelsson's subsequent discoveries elucidating the cyclooxygenase pathway of platelet arachidonic acid metabolism motivated my research interest towards measuring platelet thromboxane A2 biosynthesis as a tool to investigate the clinical pharmacology of cyclooxygenase inhibition by aspirin in health and disease. What followed was a long, winding road of clinical research leading to the characterization of low-dose aspirin as a life-saving antiplatelet drug that still represents the cornerstone of antithrombotic therapy. Having witnessed and participated in these 50 years of aspirin research, I thought of providing a personal testimony of how things developed and eventually led to a remarkable success story of independent research.
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Affiliation(s)
- Carlo Patrono
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
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Habib S, Hafeez MS, Yuo TH, Subramaniam K. The Unstable Carotid Plaque. Anesthesiol Clin 2022; 40:737-749. [PMID: 36328626 DOI: 10.1016/j.anclin.2022.08.015] [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] [Indexed: 06/16/2023]
Abstract
Carotid revascularization is performed to prevent cerebrovascular events in patients with symptomatic (>50%) and asymptomatic high degree (>70%) carotid stenosis. As this operation carries significant risks for perioperative stroke, careful selection of patients who will benefit from the procedure is essential. Certain plaque characteristics, including texture, are associated with increased tendency for rupture and can be used to identify high-risk patients. Medical therapy, carotid endarterectomy, and carotid stenting are the mainstays for patient management. With careful selection of patients, all anesthesia techniques (general anesthesia, monitored anesthesia care, and regional anesthesia) can be used safely for these revascularization procedures.
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Affiliation(s)
- Salim Habib
- Department of Vascular Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA; Division of Vascular Surgery, Department of Surgery, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA 15143, USA
| | - Muhammad Saad Hafeez
- Department of Vascular Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA; Division of Vascular Surgery, Department of Surgery, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA 15143, USA
| | - Theodore H Yuo
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA 15143, USA
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, 3471 5th Avenue Ste 402, Pittsburgh, PA 15213, USA.
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Lee C, Columbo JA, Stone DH, Creager MA, Henkin S. Preoperative evaluation and perioperative management of patients undergoing major vascular surgery. Vasc Med 2022; 27:496-512. [PMID: 36214163 PMCID: PMC9551317 DOI: 10.1177/1358863x221122552] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients undergoing major vascular surgery have an increased risk of perioperative major adverse cardiovascular events (MACE). Accordingly, in this population, it is of particular importance to appropriately risk stratify patients' risk for these complications and optimize risk factors prior to surgical intervention. Comorbidities that portend a higher risk of perioperative MACE include coronary artery disease, heart failure, left-sided valvular heart disease, and significant arrhythmic burden. In this review, we provide a current approach to risk stratification prior to major vascular surgery and describe the strengths and weaknesses of different cardiac risk indices; discuss the role of noninvasive and invasive cardiac testing; and review perioperative pharmacotherapies.
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Affiliation(s)
| | | | | | | | - Stanislav Henkin
- Stanislav Henkin, Heart and Vascular
Center, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at
Dartmouth, Lebanon, NH 03756, USA.
Twitter: @stanhenkin
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Perioperative Medical Management for Symptomatic Carotid Artery Interventions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022. [DOI: 10.1007/s11936-022-00966-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Howard TA, Judd CS, Snowden GT, Lambert RJ, Clement ND. Incidence and risk factors associated with venous thromboembolism following primary total hip arthroplasty in low-risk patients when using aspirin for prophylaxis. Hip Int 2022; 32:562-567. [PMID: 33594900 DOI: 10.1177/1120700021994530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIMS The primary aim was to assess the incidence of venous thromboembolism (VTE) following total hip replacements (THR) in a low-risk patient group when using 150 mg aspirin as the pharmacological component of VTE prophylaxis on discharge. The secondary aim was to identify factors associated with an increased risk of a VTE event in this low-risk group. PATIENTS AND METHODS Retrospective review of a consecutive cohort of patients undergoing THR during a 63-month period. Patient demographics, socio-economic status, ASA grade, type of anaesthetic, length of surgery and BMI were recorded. A diagnosis of VTE was assigned to symptomatic patients with positive imaging for a deep vein thrombosis (DVT) and/or a pulmonary embolism (PE) within 8 weeks of surgery. Multivariate logistic regression modeling was used to identify factors associated with VTE after THR. RESULTS 3880 patients underwent THR during the study period, of which 2740 (71%) were low risk and prescribed aspirin for VTE prophylaxis. There were 34 VTE events, of which 15 were DVTs and 18 were PEs, with 1 patient diagnosed with both. The incidence of VTE was 1.2%, with no VTE-related deaths. Patients incurring a VTE postoperatively were more likely to be male (odds ratio [OR] 2.06, p = 0.022), of older age (OR 0.43, p = 0.047) and were more likely to be socially deprived (OR 0.32, p = 0.006). There was no significant difference with patients given low-molecular-weight heparin (LMWH) as an inpatient prior to discharge on aspirin (p = 0.806), nor any difference with the type of anaesthetic used during surgery (p = 0.719). CONCLUSIONS Aspirin is a relatively safe and effective choice for VTE prophylaxis in low-risk patients undergoing THR. Male sex and age >70 years were twice as likely to sustain a VTE and patients from the most deprived socio-economic background are 3 times as likely.
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Affiliation(s)
- Thomas A Howard
- Department of Trauma and Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Caitlin S Judd
- Division of Medical and Radiological Sciences - Orthopaedics, The University of Edinburgh, Edinburgh, UK
| | - Gordon T Snowden
- Department of Trauma and Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Robert J Lambert
- Department of Trauma and Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nick D Clement
- Department of Trauma and Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, UK
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Li B, Eisenberg N, Howe KL, Forbes TL, Roche-Nagle G. The impact of sex on outcomes following carotid endarterectomy. Ann Vasc Surg 2022; 88:210-217. [PMID: 36029946 DOI: 10.1016/j.avsg.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/29/2022] [Accepted: 08/04/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Previous studies have demonstrated significant sex differences in vascular surgery outcomes. We assessed stroke or death rates following carotid endarterectomy (CEA) in women vs. men. METHODS The Vascular Quality Initiative (VQI) was used to identify all patients who underwent CEA between 2010-2019. Demographic, clinical, and procedural characteristics were recorded and differences between women vs. men were assessed using independent t-test and chi-square test. The primary outcomes were 30-day and 1-year stroke or death. Associations between sex and outcomes were assessed using univariate/multivariate logistic regression and Cox proportional hazards analysis. RESULTS 52,137 women and 79,974 men underwent CEA in VQI sites during the study period. Women were younger (70.3 vs. 70.5 years, p < 0.001) and more likely to have hypertension (89.2% vs. 88.9%, p < 0.05) and diabetes (36.2% vs. 35.8%, p < 0.001), but less likely to be diagnosed with coronary artery disease (23.2% vs. 31.0%, p < 0.001). A greater proportion of men were receiving cardiovascular risk reduction medications and had symptomatic carotid stenosis (28.5% vs. 26.7%, p < 0.001). Women had shorter procedure times (113 vs. 122 minutes, p < 0.001) and were less likely to receive electroencephalography neuromonitoring (27.9% vs. 28.8%, p < 0.001), drain (35.9% vs. 37.3%, p < 0.001), and protamine (67.4% vs. 68.0%, p < 0.01). Stroke or death at 30 days (1.9% vs. 1.8%, p = 0.60) and 1 year (HR 0.98 [95% CI 0.94 - 1.01], p = 0.20) were similar between groups, which persisted in asymptomatic patients (HR 0.97 [95% CI 0.93 - 1.01], p = 0.17) and symptomatic patients (HR 0.99 [95% CI 0.93 - 1.05], p = 0.71). The similarities in 1-year stroke or death rates existed in both the US (HR 0.96 [95% CI 0.92 - 1.01], p = 0.09) and Canada (HR 1.21 [95% CI 0.47 - 3.11], p = 0.70). CONCLUSIONS Despite sex differences in clinical and procedural characteristics, women and men have similar 30-day and 1-year outcomes following carotid endarterectomy.
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Affiliation(s)
- Ben Li
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn L Howe
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Inoue T, Mizutamari M, Hatake K. Safety of Continuous Low-Dose Aspirin Therapy for Cervical Laminoplasty. Spine Surg Relat Res 2022; 6:240-246. [PMID: 35800625 PMCID: PMC9200418 DOI: 10.22603/ssrr.2021-0081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/25/2021] [Indexed: 01/25/2023] Open
Abstract
Introduction Methods Results Conclusions
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Affiliation(s)
- Tetsuji Inoue
- Department of Orthopedic Surgery, Kumamoto Chuo Hospital
| | | | - Kuniaki Hatake
- Department of Orthopedic Surgery, Kumamoto Chuo Hospital
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Shah J, Liu S, Yu W. Contemporary antiplatelet therapy for secondary stroke prevention: a narrative review of current literature and guidelines. Stroke Vasc Neurol 2022; 7:406-414. [PMID: 35393359 DOI: 10.1136/svn-2021-001166] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 02/16/2022] [Indexed: 11/04/2022] Open
Abstract
Antiplatelet therapy is one of the mainstays for secondary stroke prevention. This narrative review aimed to highlight the current evidence and recommendations of antiplatelet therapy for stroke prevention.We conducted advanced literature search for antiplatelet therapy. Landmark studies and randomised controlled trials evaluating antiplatelet therapy for secondary stroke prevention are reviewed. Results from Cochrane systematic review, pooled data analysis and meta-analysis are discussed.Single-antiplatelet therapy (SAPT) with aspirin, aspirin/extended-release dipyridamole or clopidogrel reduces the risk of recurrent ischaemic stroke in patients with non-cardioembolic ischaemic stroke or transient ischaemic attack (TIA). Dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel or ticagrelor for 21-30 days is more effective than SAPT in patients with minor acute noncardioembolic ischaemic stroke or high-risk TIA. Prolonged use of DAPT is associated with higher risk of haemorrhage without reduction in stroke recurrence than SAPT. Compared with placebo, aspirin reduces the relative risk of recurrent stroke by approximately 22%. Aspirin/dipyridamole and cilostazol are superior to aspirin but associated with significant side effects. Cilostazol or ticagrelor might be more effective than aspirin or clopidogrel in patients with intracranial stenosis.SAPT is indicated for secondary stroke prevention in patients with non-cardioembolic ischaemic stroke or TIA. DAPT with aspirin and clopidogrel or ticagrelor for 21-30 days followed by SAPT is recommended for patients with minor acute noncardioembolic stroke or high-risk TIA. Selection of appropriate antiplatelet therapy should also be based on compliance, drug tolerance or resistance.
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Affiliation(s)
- Jay Shah
- Neurology, University of California, Irvine, California, USA
| | - Shimeng Liu
- Neurology, University of California, Irvine, California, USA.,Neurology, Tiantan Hospital, Beijing, China
| | - Wengui Yu
- Neurology, University of California, Irvine, California, USA
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Hassani S, Fisher M. Management of Atherosclerotic Carotid Artery Disease: A Brief Overview and Update. Am J Med 2022; 135:430-434. [PMID: 34732352 DOI: 10.1016/j.amjmed.2021.09.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 09/22/2021] [Accepted: 09/28/2021] [Indexed: 11/01/2022]
Abstract
Extracranial carotid atherosclerotic disease has been associated with approximately 15%-20% of ischemic stroke cases and is a leading cause of mortality and disability worldwide. Medical, surgical, and endovascular therapies for the prevention of stroke from carotid disease have advanced considerably over the past quarter century. The objective of this review is to outline the clinical presentation of symptomatic carotid artery stenosis and the risk factors associated with development of carotid artery stenosis and then summarize the current evidence-based medical treatment modalities, along with available surgical and endovascular therapies.
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Affiliation(s)
- Sara Hassani
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
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16
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Tang A, Zak SG, Waren D, Iorio R, Slover JD, Bosco JA, Schwarzkopf R. Low-Dose Aspirin is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Knee Arthroplasty: A Retrospective Cohort Study. J Knee Surg 2022; 35:553-559. [PMID: 32898907 DOI: 10.1055/s-0040-1716377] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Venous thromboembolism (VTE) events are rare, but serious complications of total joint replacement affect patients and health care systems due to the morbidity, mortality, and associated cost of its complications. There is currently no established universal standard of care for prophylaxis against VTE in patients undergoing revision total knee arthroplasty (rTKA). The aim of this study was to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or sufficient in preventing VTE in patients undergoing rTKAs versus 325-mg ASA BID. In 2017, our institution adopted a new protocol for VTE prophylaxis for arthroplasty patients. Patients initially received 325-mg ASA BID for 1 month and then changed to a lower dose of 81-mg BID. A retrospective review from 2011 to 2019 was conducted identifying 1,438 consecutive rTKA patients and 90-day postoperative outcomes including VTE, gastrointestinal, and wound bleeding complications, acute periprosthetic joint infection, and mortality. In the 74 months prior to protocol implementation, 1,003 rTKAs were performed and nine VTE cases were diagnosed (0.90%). After 26 months of the protocol change, 435 rTKAs were performed with one VTE case identified (0.23%). There was no significant difference in rates or odds in postoperative pulmonary embolism (PE; p = 0.27), DVT (p = 0.35), and total VTE rates (p = 0.16) among patients using either protocol. There were also no differences in bleeding complications (p = 0.15) or infection rate (p = 0.36). No mortalities were observed. In the conclusion, 81-mg ASA BID is noninferior to 325-mg ASA BID in maintaining low rates of VTE and may be safe for use in patients undergoing rTKA.
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Affiliation(s)
- Alex Tang
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Stephen G Zak
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Daniel Waren
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Richard Iorio
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - James D Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joseph A Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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17
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Ho-Yan Lee M, Li PY, Li B, Shakespeare A, Samarasinghe Y, Feridooni T, Cuen-Ojeda C, Alshabanah L, Kishibe T, Al-Omran M. A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery. J Vasc Surg 2022; 76:581-594.e25. [DOI: 10.1016/j.jvs.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
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18
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Martinez-Gutierrez JC, Roy AT, D'Amato S, Berkman JM, Montes D, Kimball CA, Rordorf GA, Chibnik LB, Romero JM, Silverman SB. Preoperative antithrombotic treatment in acutely symptomatic carotid artery stenosis. J Stroke Cerebrovasc Dis 2022; 31:106396. [PMID: 35219972 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES Early recurrence of cerebral ischemia in acutely symptomatic carotid artery stenosis can precede revascularization. The optimal antithrombotic regimen for this high-risk population is not well established. Although antiplatelet agents are commonly used, there is limited evidence for the use of anticoagulants. We sought to understand the safety and efficacy of short-term preoperative anticoagulants in secondary prevention of recurrent cerebral ischemic events from acutely symptomatic carotid stenosis in patients awaiting carotid endarterectomy (CEA). MATERIALS AND METHODS A retrospective query of a prospective single institution registry of carotid revascularization was performed. Patients who presented with acute ischemic stroke or transient ischemic attack (TIA) attributable to an ipsilateral internal carotid artery stenosis (ICA) were included. Antiplatelet (AP) only and anticoagulation (AC) treatment arms were compared. The primary outcome was a composite of preoperative recurrent ischemic stroke or TIA. The primary safety outcome was symptomatic intracranial hemorrhage. RESULTS Out of 443 CEA patients, 342 were in the AC group and 101 in the AP group. Baseline characteristics between groups (AC vs AP) were similar apart from age (71±10.5 vs 73±9.5, p=0.04), premorbid modified Rankin scale (mRS) score (1.0±1.2 vs 1.4±1.3, p=0.03) and stroke as presenting symptom (65.8 vs 53.5%, p=0.02). Patients in the AC group had a lower incidence of recurrent stroke/TIA (3.8 vs 10.9%, p=0.006). One patient had symptomatic intracranial hemorrhage in the AC group, and none in the AP group. In multivariate analysis controlling for age, premorbid mRS, stroke severity, degree of stenosis, presence of intraluminal thrombus (ILT) and time to surgery, AC was protective (OR 0.30, p=0.007). This effect persisted in the cohort exclusively without ILT (OR 0.23, p=0.002). CONCLUSIONS Short term preoperative anticoagulation in patients with acutely symptomatic carotid stenosis appears safe and effective compared to antiplatelet agents alone in the prevention of recurrent cerebral ischemic events while awaiting CEA.
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Affiliation(s)
- Juan Carlos Martinez-Gutierrez
- Department of Neurosurgery, UTHealth McGovern Medical School, 6400 Fannin ST, Houston, TX 77030, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States.
| | - Alexis T Roy
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Salvatore D'Amato
- Department of Neurosurgery, UTHealth McGovern Medical School, 6400 Fannin ST, Houston, TX 77030, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Jillian M Berkman
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Daniel Montes
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Cheryl A Kimball
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Guy A Rordorf
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Lori B Chibnik
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Javier M Romero
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Scott B Silverman
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States.
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Abstract
The goal of the current review is to examine the hazards and benefits of carotid interventions in women and to provide recommendations for the indications for carotid intervention in female patients. Stroke and cerebrovascular disease are prevalent in women. There are inherent biological and other differences in men and women, which affect the manifestations and outcome of stroke, with women experiencing worse disability and higher mortality following ischemic stroke than men. Due to the underrepresentation of female patients in most clinical trials, the ability to make firm but alternative recommendations for women specifically on the management of carotid stenosis is challenging. Although some data suggest that women might have worse periprocedural outcomes as compared to men following all carotid revascularization procedures, there is also an abundance of data to support a similar risk for carotid procedures in men and women, especially with carotid endarterectomy and transcarotid artery revascularization. Therefore, the indications for carotid revascularization are the same in women as they are in men. The choice of a carotid revascularization procedure in women is based upon the same factors as in men and requires careful evaluation of a particular patient's risk profile, anatomic criteria, plaque morphology, and medical comorbidities that might favor one technique over the other. When performing carotid revascularization procedures in women, tailored techniques and procedures to address the small diameter of the female artery are warranted.
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Affiliation(s)
- Caron Rockman
- Division of Vascular Surgery, NYU Grossman School of Medicine, New York, NY (C.R.)
| | - Valeria Caso
- Department of Cardiovascular Medicine, Santa Maria Della Misericordia Hospital, University of Perugia, Italy (V.C.)
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California San Francisco (P.A.S.)
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21
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Neira JA, Connolly ES. Indications for Carotid Endarterectomy in Patients With Asymptomatic and Symptomatic Carotid Stenosis. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00076-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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22
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Symptom Status of Patients Undergoing Carotid Endarterectomy in Canada and United States. Ann Vasc Surg 2021; 81:183-195. [PMID: 34780953 DOI: 10.1016/j.avsg.2021.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Previous studies have demonstrated significant geographic variations in the management of carotid artery stenosis despite standard guidelines. To further characterize these practice variations, we assessed differences in patient selection, operative technique, and outcomes for carotid endarterectomy (CEA) in Canada vs. United States. METHODS The Vascular Quality Initiative (VQI) was used to identify all patients who underwent CEA between 2010 and 2019 in Canada and United States. Demographic, clinical, and procedural characteristics were recorded and differences between countries were assessed using independent t-test and chi-square test. The primary outcome was the percentage of CEA performed for asymptomatic versus symptomatic disease. The secondary outcomes were 30-day and long-term stroke or death. Associations between country and outcomes were assessed using univariate/multivariate logistic regression and Cox proportional hazards analysis. RESULTS During the study period, 131,411 US patients and 701 Canadian patients underwent CEA in VQI sites. Patients from the US were older with more comorbidities including hypertension, diabetes, congestive heart failure, and chronic kidney disease. The use of a shunt, patch, drain, or protamine was less common in the US. Most patients had 70 - 99% stenosis, with no difference between regions. The percentage of CEA performed for asymptomatic disease was significantly higher in the US even after adjusting for demographic, clinical, and procedural characteristics (72.4% vs. 30.7%, adjusted OR 3.91 [95% CI 3.21 - 4.78], p < 0.001). Thirty-day stroke/death was low (1.8% vs. 1.9%) and 1-year stroke/death was similar between groups (HR 0.98 [95% CI 0.69 - 1.39], P = 0.89). The similarities in 1-year stroke/death persisted in asymptomatic patients (HR 0.70 [95% CI 0.37 - 1.30], P = 0.26) and symptomatic patients (HR 1.14 [95% CI 0.74 - 1.73], P = 0.56). CONCLUSIONS There are significant variations in CEA practice between Canada and US. In particular, most US patients are treated for asymptomatic disease, whereas most Canadian patients are treated for symptomatic disease. Furthermore, adjunctive procedures including shunting, patch use, and protamine administration are performed less commonly in the US. Despite these differences, perioperative and 1-year stroke/death rates are similar between countries. Future studies should investigate reasons for these variations and quality improvement projects are needed to standardize care.
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23
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Aboyans V, Bauersachs R, Mazzolai L, Brodmann M, Palomares JFR, Debus S, Collet JP, Drexel H, Espinola-Klein C, Lewis BS, Roffi M, Sibbing D, Sillesen H, Stabile E, Schlager O, De Carlo M. Antithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy. Eur Heart J 2021; 42:4013-4024. [PMID: 34279602 DOI: 10.1093/eurheartj/ehab390] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/27/2021] [Accepted: 06/03/2021] [Indexed: 12/24/2022] Open
Abstract
The aim of this collaborative document is to provide an update for clinicians on best antithrombotic strategies in patients with aortic and/or peripheral arterial diseases. Antithrombotic therapy is a pillar of optimal medical treatment for these patients at very high cardiovascular risk. While the number of trials on antithrombotic therapies in patients with aortic or peripheral arterial diseases is substantially smaller than for those with coronary artery disease, recent evidence deserves to be incorporated into clinical practice. In the absence of specific indications for chronic oral anticoagulation due to concomitant cardiovascular disease, a single antiplatelet agent is the basis for long-term antithrombotic treatment in patients with aortic or peripheral arterial diseases. Its association with another antiplatelet agent or low-dose anticoagulants will be discussed, based on patient's ischaemic and bleeding risk as well therapeutic paths (e.g. endovascular therapy). This consensus document aims to provide a guidance for antithrombotic therapy according to arterial disease localizations and clinical presentation. However, it cannot substitute multidisciplinary team discussions, which are particularly important in patients with uncertain ischaemic/bleeding balance. Importantly, since this balance evolves over time in an individual patient, a regular reassessment of the antithrombotic therapy is of paramount importance.
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Affiliation(s)
- Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and INSERM 1094 & IRD, University of Limoges, 2, Martin Luther King ave, 87042, Limoges, France
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt Germany, and Center for Thrombosis and Hemostasis, University of Mainz, Mainz, Germany
| | - Lucia Mazzolai
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - José F Rodriguez Palomares
- Department of Cardiology, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en RedCV, CIBER CV, Barcelona, Spain
| | - Sebastian Debus
- Department of Vascular Medicine, University Heart Centre Hamburg, University Medical Centre HamburgEppendorf, Hamburg, Germany
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group (www.actioncoeur.org), INSERM UMRS 1166, Institut de Cardiologie, Hôpital PitiéSalpêtrière (APHP), Paris, France
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Landeskrankenhaus Feldkirch, Austria
| | - Christine Espinola-Klein
- Section Angiology, Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, TechnionIsrael Institute of Technology, Haifa, Israel
| | - Marco Roffi
- Division of Cardiology, University Hospitals, Geneva, Switzerland
| | - Dirk Sibbing
- Ludwig Maximilians Universität München and Privatklinik Lauterbacher Mühle am Ostersee, Munich, Germany
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Eugenio Stabile
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples 'Federico II', Naples, Italy
| | - Oliver Schlager
- Division of Angiology, 2nd Department of Medicine, Medical University of Vienna, Austria
| | - Marco De Carlo
- Cardiothoracic and Vascular Department, Azienda OspedalieroUniversitaria Pisana, Pisa, Italy
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24
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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Merkow DB, Tang A, Iorio R, Slover JD, Bosco JA, Schwarzkopf R. Low dose aspirin is effective in preventing venous thromboembolism in patients undergoing primary total knee arthroplasty. J Orthop 2021; 24:26-28. [PMID: 33679024 DOI: 10.1016/j.jor.2021.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/03/2021] [Indexed: 10/22/2022] Open
Abstract
Introduction Venous thromboembolism (VTE) is a known complication after total knee arthroplasty (TKA) with well-established morbidity, mortality, and significant healthcare expenditure. However, no standard form of prophylaxis against VTE currently exists. Methods A retrospective review was performed identifying 12,866 TKA cases and post-operative VTE events using either 325 mg aspirin or 81 mg aspirin twice daily (BID). Results 133 VTE cases were diagnosed of the 9413 TKA on 325 mg aspirin BID compared to 8 VTE cases out of 3453 TKA on 81 mg aspirin BID (1.41% vs. 0.23%, p < 0.001). Conclusion 81 mg aspirin BID significantly improved post-operative VTE rates over 325 mg aspirin BID.
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Affiliation(s)
- David B Merkow
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Alex Tang
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | | | - James D Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Joseph A Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
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Comparable efficacy of 100 mg aspirin twice daily and rivaroxaban for venous thromboembolism prophylaxis following primary total hip arthroplasty: a randomized controlled trial. Chin Med J (Engl) 2021; 134:164-172. [PMID: 33410616 PMCID: PMC7817327 DOI: 10.1097/cm9.0000000000001305] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Aspirin has demonstrated safety and efficacy for venous thromboembolism (VTE) prophylaxis following total hip arthroplasty (THA); however, inconsistent dose regimens have been reported in the literature. This study aimed to evaluate and compare the safety and efficacy of 100 mg aspirin twice daily with rivaroxaban in VTE prophylaxis following THA. Methods: Patients undergoing elective unilateral primary THA between January 2019 and January 2020 were prospectively enrolled in the study and randomly allocated to receive 5 weeks of VTE prophylaxis with either oral enteric-coated aspirin (100 mg twice daily) or rivaroxaban (10 mg once daily). Medication safety and efficacy were comprehensively evaluated through symptomatic VTE incidence, deep vein thrombosis (DVT) on Doppler ultrasonography, total blood loss (TBL), laboratory bloodwork, Harris hip score (HHS), post-operative recovery, and the incidence of other complications. Results: We included 70 patients in this study; 34 and 36 were allocated to receive aspirin and rivaroxaban prophylaxis, respectively. No cases of symptomatic VTE occurred in this study. The DVT rate on Doppler ultrasonography in the aspirin group was not significantly different from that in the rivaroxaban group (8.8% vs. 8.3%, χ2 = 0.01, P = 0.91), confirming the non-inferiority of aspirin for DVT prophylaxis (χ2 = 2.29, P = 0.01). The calculated TBL in the aspirin group (944.9 mL [658.5–1137.8 mL]) was similar to that in the rivaroxaban group (978.3 mL [747.4–1740.6mL]) (χ2 = 1.55, P = 0.12). However, there were no significant inter-group differences in HHS at post-operative day (POD) 30 (Aspirin: 81.0 [78.8–83.0], Rivaroxaban: 81.0 [79.3–83.0], χ2 = 0.43, P = 0.67) and POD 90 (Aspirin: 90.0 [89.0–92.0], Rivaroxaban: 91.5 [88.3–92.8], χ2 = 0.77, P = 0.44), the incidence of bleeding events (2.9% vs. 8.3%, χ2 = 0.96, P = 0.33), or gastrointestinal complications (2.9% vs. 5.6%, χ2 = 1.13, P = 0.29). Conclusion: In terms of safety and efficacy, the prophylactic use of 100 mg aspirin twice daily was not statistically different from that of rivaroxaban in preventing VTE and reducing the risk of blood loss following elective primary THA. This supports the use of aspirin chemoprophylaxis following THA as a less expensive and more widely available option for future THAs. Trial Registration: Chictr.org, ChiCTR18000202894; http://www.chictr.org.cn/showproj.aspx?proj=33284
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27
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Messas E, Goudot G, Halliday A, Sitruk J, Mirault T, Khider L, Saldmann F, Mazzolai L, Aboyans V. Management of carotid stenosis for primary and secondary prevention of stroke: state-of-the-art 2020: a critical review. Eur Heart J Suppl 2020; 22:M35-M42. [PMID: 33664638 PMCID: PMC7916422 DOI: 10.1093/eurheartj/suaa162] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Carotid atherosclerotic plaque is encountered frequently in patients at high cardiovascular risk, especially in the elderly. When plaque reaches 50% of carotid lumen, it induces haemodynamically significant carotid stenosis, for which management is currently at a turning point. Improved control of blood pressure, smoking ban campaigns, and the widespread use of statins have reduced the risk of cerebral infarction to <1% per year. However, about 15% of strokes are still secondary to a carotid stenosis, which can potentially be detected by effective imaging techniques. For symptomatic carotid stenosis, current ESC guidelines put a threshold of 70% for formal indication for revascularization. A revascularization should be discussed for symptomatic stenosis over 50% and for asymptomatic carotid stenosis over 60%. This evaluation should be performed by ultrasound as a first-line examination. As a complement, computed tomography angiography (CTA) and/or magnetic resonance angiography are recommended for evaluating the extent and severity of extracranial carotid stenosis. In perspective, new high-risk markers are currently being developed using markers of plaque neovascularization, plaque inflammation, or plaque tissue stiffness. Medical management of patient with carotid stenosis is always warranted and applied to any patient with atheromatous lesions. Best medical therapy is based on cardiovascular risk factors correction, including lifestyle intervention and a pharmacological treatment. It is based on the tri-therapy strategy with antiplatelet, statins, and ACE inhibitors. The indications for carotid endarterectomy (CEA) and carotid artery stenting (CAS) are similar: for symptomatic patients (recent stroke or transient ischaemic attack ) if stenosis >50%; for asymptomatic patients: tight stenosis (>60%) and a perceived high long-term risk of stroke (determined mainly by imaging criteria). Choice of procedure may be influenced by anatomy (high stenosis, difficult CAS or CEA access, incomplete circle of Willis), prior illness or treatment (radiotherapy, other neck surgery), or patient risk (unable to lie flat, poor AHA assessment). In conclusion, neither systematic nor abandoned, the place of carotid revascularization must necessarily be limited to the plaques at highest risk, leaving a large place for optimized medical treatment as first line management. An evaluation of the value of performing endarterectomy on plaques considered to be at high risk is currently underway in the ACTRIS and CREST 2 studies. These studies, along with the next result of ACST-2 trial, will provide us a more precise strategy in case of carotid stenosis.
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Affiliation(s)
- Emmanuel Messas
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Guillaume Goudot
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Level 6 John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Jonas Sitruk
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Tristan Mirault
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Lina Khider
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Frederic Saldmann
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Lucia Mazzolai
- Angiology Division, CHUV University Hospital, Lausanne, Switzerland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, INSERM 1094 & IRD, Limoges, France
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28
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Gerstein NS, Albrechtsen CL, Mercado N, Cigarroa JE, Schulman PM. A Comprehensive Update on Aspirin Management During Noncardiac Surgery. Anesth Analg 2020; 131:1111-1123. [PMID: 32925332 DOI: 10.1213/ane.0000000000005064] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aspirin is considered critical lifelong therapy for patients with established cardiovascular (CV) disease (including coronary artery, cerebrovascular, and peripheral arterial diseases) and is consequently one of the most widely used medications worldwide. However, the indications for aspirin use continue to evolve and recent trials question its efficacy for primary prevention. Although one third of patients undergoing noncardiac surgery and at risk for a major adverse CV event receive aspirin perioperatively, uncertainty still exists about how aspirin should be optimally managed in this context, and significant practice variability remains. Recent trials suggest that the risks of continuing aspirin during the perioperative period outweigh the benefits in many cases, but data on patients with high CV risk remain limited. We performed a comprehensive PubMed and Medline literature search using the following keywords: aspirin, aspirin withdrawal, perioperative, coronary artery disease, cerebrovascular disease, peripheral artery disease, and CV disease; we manually reviewed all relevant citations for inclusion. Patients taking aspirin for the primary prevention of CV disease should likely discontinue it during the perioperative period, especially when there is a high risk of bleeding. Patients with established CV disease but without a coronary stent should likely continue aspirin during the perioperative period unless undergoing closed-space surgery. Patients with a history of coronary stenting also likely need aspirin continuation throughout the perioperative period for nonclosed space procedures. Perioperative clinicians need to balance the risks of ceasing aspirin before surgery against its continuation during the perioperative interval using a patient-specific strategy. The guidance on decision-making with regard to perioperative aspirin cessation or continuation using currently available clinical data from studies in high-risk patients along with nonclinical aspirin studies is conflicting and does not enable a simplified or unified answer. However, pertinent guidelines on CV disease management provide a basic framework for aspirin management, and large trial findings provide some insight into the safety of perioperative aspirin cessation in some contexts, although uncertainty on perioperative aspirin still exists. This review provides an evidence-based update on perioperative aspirin management in patients undergoing noncardiac surgery with a focus on recommendations for perioperative clinicians on continuing versus holding aspirin during this context.
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Affiliation(s)
- Neal S Gerstein
- From the Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | - Nestor Mercado
- Division of Cardiology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | - Peter M Schulman
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
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29
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O'Brien AJ, Donlan J, Vrazas JI. Prevalence of internal carotid artery stenosis in ambulatory patients presenting for non-emergent percutaneous coronary angiogram in a single Australian centre. Australas J Ultrasound Med 2020; 24:31-36. [PMID: 34760609 DOI: 10.1002/ajum.12220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 06/12/2020] [Accepted: 06/22/2020] [Indexed: 11/06/2022] Open
Abstract
Introduction Association between coronary artery disease (CAD) and internal carotid artery stenosis (ICAS) could prove clinically relevant. However, evidence defining this association is currently inconclusive. Our study investigates the prevalence of ICAS in non-emergent, ambulatory patients presenting for PCA with suspected CAD in an Australian context. Methods Between February 2019 and June 2019, 121 consecutive participants were verbally consented and enrolled in our study. The data were analysed retrospectively. PCA and CUS were performed within 24 h of each other. Multinomial logistic regression assessed independent predictors for ICAS, with statistical significance set at P value < 0.05. Linear regression analysis correlated CAD and ICAS severity, with significance of a P-value < 0.05. Analysis was conducted using IBM SPSS 26 software (Chicago, Illinois). Results The final study included 121 patients (age 73 ± 9 years, 76.9% male). ICAS on CUS was present in 55.4% of participants for PCA. CAD was an independent risk factor for ICAS on multinomial logistic regression odds ratio 3.87 (P = 0.023). CAD severity (multi vessel disease) showed significant correlation with ICAS r = 0.22 (P = 0.014) using linear regression analysis. Conclusion CAD is an independent predictor of ICAS, and severity of ICAS is correlated with CAD disease. However, most participants had only minor ICAS (16-49% diameter stenosis). Our findings are consistent with internationally published studies, suggesting their data are generalisable to the Australian population. Larger studies are needed to address the applicability of CUS screening in patients with advanced CAD.
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Affiliation(s)
- Andrew J O'Brien
- Department of Medicine University of Melbourne Parkville Victoria 3010 Australia.,St. Vincent's Private Hospital 59-61 Victoria Parade Fitzroy Victoria 3065 Australia.,Melbourne Institute of Vascular and Interventional Radiology 59-61 Victoria Parade Fitzroy Victoria 3065 Australia
| | - John Donlan
- St. Vincent's Private Hospital 59-61 Victoria Parade Fitzroy Victoria 3065 Australia.,Melbourne Institute of Vascular and Interventional Radiology 59-61 Victoria Parade Fitzroy Victoria 3065 Australia
| | - John I Vrazas
- Department of Medicine University of Melbourne Parkville Victoria 3010 Australia.,St. Vincent's Private Hospital 59-61 Victoria Parade Fitzroy Victoria 3065 Australia.,Melbourne Institute of Vascular and Interventional Radiology 59-61 Victoria Parade Fitzroy Victoria 3065 Australia
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30
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Tang A, Zak S, Iorio R, Slover J, Bosco J, Schwarzkopf R. Low-Dose Aspirin Is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Hip Arthroplasty: A Retrospective Cohort Study. J Arthroplasty 2020; 35:2182-2187. [PMID: 32334898 DOI: 10.1016/j.arth.2020.03.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/22/2020] [Accepted: 03/24/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Currently, there is no established universal standard of care for prophylaxis against venous thromboembolism (VTE) in orthopedic patients undergoing revision total hip arthroplasty (rTHA). The aim of this study is to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or effective in preventing VTE in patients undergoing rTHAs vs 325-mg ASA BID. METHODS In 2017, a large academic medical center adopted a new protocol for VTE prophylaxis in arthroplasty patients at standard risk. Initially, patients received 325-mg ASA BID but switched to 81-mg ASA BID. A retrospective review (2011-2019) was performed to identify 1361 consecutive rTHA patients and their associated 90-day postoperative complications such as VTE, including pulmonary embolism (PE) and/or deep vein thrombosis (DVT), as the primary outcome; and gastrointestinal and wound bleeding, acute periprosthetic joint infection, and mortality as the secondary outcome. RESULTS From 2011 to 2017, 973 rTHAs were performed and 13 total VTE cases were diagnosed (1.34%). From 2017 to 2019, 388 rTHAs were performed with 3 total VTE cases identified (0.77%). Chi-squared analyses and logistic regression models showed no differences in rates or odds in postoperative PE (P = .09), DVT (P = .79), PE and DVT (P = .85), and total VTE (P = .38) using either dose. There were also no differences between bleeding complications (P = .14), infection rate (P = .46), and mortality (P = .53). CONCLUSION Using a protocol of 81-mg of ASA BID is noninferior to 325-mg ASA BID and may be safe and effective in maintaining low rates of VTE in patients undergoing rTHA.
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Affiliation(s)
- Alex Tang
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Stephen Zak
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Richard Iorio
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - James Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Joseph Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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31
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Velz J, Esposito G, Wegener S, Kulcsar Z, Luft A, Regli L. [Diagnostic and Therapeutic Management of Carotid Artery Disease]. PRAXIS 2020; 109:705-723. [PMID: 32635848 DOI: 10.1024/1661-8157/a003475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Diagnostic and Therapeutic Management of Carotid Artery Disease Abstract. A quarter of all ischemic strokes is caused by atherosclerotic obliterations of the extra- and intracranial brain-supplying vessels. The prevalence of atherosclerotic extracranial carotid stenosis rises up to 6-15 % from the age of 65. The risk of stroke in symptomatic carotid stenosis, i.e. after stroke or transient ischemic attack (TIA), is very high at 25 % within 14 days. Conservative therapy is the cornerstone of treatment by controlling the risk factors, treatment with platelet aggregation inhibitors and antihypertensive and lipid-lowering medication. Carotid endarterectomy (CEA) is the first line treatment for symptomatic patients with a >50 % and asymptomatic patients with a >60 % carotid stenosis. In order to ensure the best possible treatment of patients with asymptomatic and symptomatic carotid stenosis, interdisciplinary cooperation in diagnostics, therapy and aftercare in a neuromedical centre of maximum care is necessary.
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Affiliation(s)
- Julia Velz
- Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
- Universität Zürich
| | - Giuseppe Esposito
- Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
- Universität Zürich
| | - Susanne Wegener
- Universität Zürich
- Klinik für Neurologie, Klinisches Neurozentrum, Universitätsspital Zürich
| | - Zsolt Kulcsar
- Universität Zürich
- Klinik für Neuroradiologie, Klinisches Neurozentrum, Universitätsspital Zürich
| | - Andreas Luft
- Universität Zürich
- Klinik für Neurologie, Klinisches Neurozentrum, Universitätsspital Zürich
- Cereneo Zentrum für Neurologie und Rehabilitation, Vitznau
| | - Luca Regli
- Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
- Universität Zürich
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32
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Papanikolaou P, Antonopoulos AS, Mastorakou I, Angelopoulos A, Kostoula E, Mystakidi XV, Simantiris S, Galiatsatos N, Oikonomou E, Tousoulis D. Antithrombotic Therapy in Carotid Artery Disease. Curr Pharm Des 2020; 26:2725-2734. [PMID: 32418521 DOI: 10.2174/1381612826666200518111359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/08/2020] [Indexed: 12/19/2022]
Abstract
The management of asymptomatic atherosclerotic carotid artery disease and the role of antithrombotic therapy is of increasing importance for stroke prevention. Non-invasive imaging of carotid plaques can identify high-risk plaque features that are associated with the risk of plaque rupture. Carotid plaque necrosis, hemorrhage, fibrous cap thinning, and the presence of foam cells have all been correlated with the risk of rupture and onset of neurological symptoms in patients with carotid stenosis. Antiplatelets are currently recommended for patients with a history of ischemic stroke and/or significant carotid artery stenosis, with aspirin and clopidogrel being the most widely used and studied agents. The role of dual antiplatelet therapy remains controversial. Moreover, there is scarce evidence on the role of newer anticoagulant agents in stable patients with carotid artery stenosis. In this review article, we discuss the pathophysiology of carotid atherosclerosis, the use of non-invasive imaging for detecting the vulnerable carotid plaque and summarize the existing clinical evidence on the use of antiplatelet and antithrombotic agents in carotid artery disease.
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Affiliation(s)
- Paraskevi Papanikolaou
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Alexios S Antonopoulos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Irene Mastorakou
- Imaging Department - Onassis Cardiac Surgery Centre, Athens, Greece
| | - Andreas Angelopoulos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | | | - Xara-Vasiliki Mystakidi
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Spyros Simantiris
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Nikolaos Galiatsatos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Evangelos Oikonomou
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
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33
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Del Brutto VJ, Chaturvedi S, Diener HC, Romano JG, Sacco RL. Antithrombotic Therapy to Prevent Recurrent Strokes in Ischemic Cerebrovascular Disease: JACC Scientific Expert Panel. J Am Coll Cardiol 2020; 74:786-803. [PMID: 31395130 DOI: 10.1016/j.jacc.2019.06.039] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/11/2019] [Accepted: 06/24/2019] [Indexed: 01/02/2023]
Abstract
Stroke survivors carry a high risk of recurrence. Antithrombotic medications are paramount for secondary prevention and thus crucial to reduce the overall stroke burden. Appropriate antithrombotic agent selection should be based on the best understanding of the physiopathological mechanism that led to the initial ischemic injury. Antiplatelet therapy is preferred for lesions characterized by atherosclerosis and endothelial injury, whereas anticoagulant agents are favored for cardiogenic embolism and highly thrombophilic conditions. Large randomized controlled trials have provided new data to support recommendations for the evidence-based use of antiplatelet agents and anticoagulant agents after stroke. In this review, the authors cover recent trials that have altered clinical practice, cite systematic reviews and meta-analyses, review evidence-based recommendations based on older landmark trials, and indicate where there are still evidence-gaps and new trials being conducted.
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Affiliation(s)
- Victor J Del Brutto
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida.
| | | | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Jose G Romano
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida
| | - Ralph L Sacco
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida.
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34
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Azboy I, Groff H, Goswami K, Vahedian M, Parvizi J. Low-Dose Aspirin Is Adequate for Venous Thromboembolism Prevention Following Total Joint Arthroplasty: A Systematic Review. J Arthroplasty 2020; 35:886-892. [PMID: 31733981 DOI: 10.1016/j.arth.2019.09.043] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/09/2019] [Accepted: 09/26/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patients undergoing total joint arthroplasty (TJA) are at risk of developing venous thromboembolism (VTE) without adequate prophylaxis. Since the American Academy of Orthopedic Surgeons issued guidelines in 2007 recommending aspirin 325 mg bis in die for 6 weeks, aspirin has been favored as the main VTE prophylaxis. However, the appropriate dose and duration of aspirin are not well-studied. This systematic review aims to identify any differences between high and low dose as well as duration for aspirin thromboprophylaxis after TJA as outlined by previous studies. METHODS A search was performed using Ovid MEDLINE, EMBASE, and PubMed, including articles up to July 2016. Studies were included if they contained at least 1 cohort that underwent TJA with aspirin as the sole chemoprophylaxis and reported either (1) symptomatic VTE or (2) secondary outcomes such as major bleeding or 90-day mortality. RESULTS Forty-five papers were included. There were no significant differences in symptomatic pulmonary embolism, symptomatic deep vein thrombosis, 90-day mortality, or major bleeding between patients receiving low-dose or high-dose aspirin. Patients treated with aspirin for <4 weeks had a higher risk of major bleeding (1.59%) vs patients treated for 4 weeks (0.15%), which may be attributed to premature cessation or differential reporting. Patients treated with aspirin for <4 weeks had a statistically higher 90-day mortality (1.95%) vs patients treated for 4 weeks (0.07%). There was no significant difference between incidence of pulmonary embolism or deep vein thrombosis and the durations of aspirin treatment. CONCLUSION This review suggests that low-dose aspirin is not inferior to high-dose aspirin for VTE thromboprophylaxis in TJA patients. Additionally, patients treated with aspirin for less than 4 weeks may have a higher risk of major bleeding and 90-day mortality compared to patients treated for a longer duration.
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Affiliation(s)
- Ibrahim Azboy
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Department of Orthopaedics and Traumatology, Istanbul Medipol University School of Medicine, Istanbul, Turkey
| | - Hannah Groff
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Karan Goswami
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Mohammed Vahedian
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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35
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Abstract
PURPOSE OF REVIEW Ischemic stroke describes a condition in which inadequate blood flow leads to lack of oxygenation to the brain tissue and ensuing neuronal death. There are multiple causes of ischemic stroke, each of which may indicate different antithrombotic management strategies. The goal of this review is to provide information about antithrombotic therapies for secondary stroke prevention based on etiology of stroke. RECENT FINDINGS New studies of existing antiplatelet and antithrombotic therapies have demonstrated varied efficacies of treatments based on the underlying risk factor of ischemic stroke. Understanding the optimal therapies for secondary stroke prevention can enhance care of stroke patients and lower the incidence of recurrent cerebrovascular ischemia.
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36
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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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No Difference Between Low- and Regular-dose Aspirin for Venous Thromboembolism Prophylaxis After THA. Clin Orthop Relat Res 2019; 477:396-402. [PMID: 30624322 PMCID: PMC6370078 DOI: 10.1097/corr.0000000000000613] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Aspirin is established as an effective prophylaxis for venous thromboembolism (VTE) after THA; however, there is no consensus as to whether low- or regular-dose aspirin is more effective at preventing VTE. QUESTIONS/PURPOSES (1) Is there a difference in the incidence of symptomatic VTE within 90 days of elective THA using low-dose aspirin compared with regular-dose aspirin? (2) Is there a difference in the risk of significant bleeding (gastrointestinal and wound bleeding) and mortality between low- and standard-dose aspirin within 90 days after surgery? METHODS We retrospectively evaluated 7488 patients in our database who underwent THA between September 2012 and December 2016. A total of 3936 (53%) patients received aspirin alone for VTE prophylaxis after THA. During the study period, aspirin was prescribed as a monotherapy for VTE prophylaxis after surgery in low-risk patients (no history of VTE, recent orthopaedic surgery, hypercoagulable state, history of cardiac arrhythmia requiring anticoagulation, or receiving anticoagulation for any other medical conditions before surgery). Patients were excluded if aspirin use was contraindicated because of peptic ulcer disease, intolerance, or other reasons. Patients received aspirin twice daily (BID) for 4 to 6 weeks after surgery and were grouped into two cohorts: a low-dose (81 mg BID) aspirin group (n = 1033) and a standard-dose (325 mg BID) aspirin group (n = 2903). The primary endpoint was symptomatic VTE (deep vein thrombosis [DVT] and pulmonary embolism [PE]). Secondary endpoints included significant bleeding (gastrointestinal [GI] and wound) and mortality. Exploratory univariate analyses were used to compare confounders between the study groups. Multivariate regression was used to control for confounding variables (including age, sex, body mass index, comorbidities, and surgeon) as we compared the study groups with respect to the proportion of patients who developed symptomatic VTE, bleeding (GI or wound), and mortality within 90 days of surgery. RESULTS The 90-day incidence of symptomatic VTE was 1.0% in the 325-mg group and 0.6% in the 81-mg group (p = 0.35). Symptomatic DVT incidence was 0.8% in the 325-mg group and 0.5% in the 81-mg group (p = 0.49), and the incidence of symptomatic PE was 0.3% in the 325-mg group and 0.2% in the 81-mg group (p = 0.45). Furthermore, bleeding was observed in 0.8% of the 325-mg group and 0.5% of the 81-mg group (p = 0.75), and 90-day mortality was not different (0.1%) between the groups (p = 0.75). After accounting for confounders, regression analyses showed no difference between aspirin doses and the 90-day incidence of symptomatic VTE (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.29-2.85; p = 0.85) or symptomatic DVT (OR, 0.96; 95% CI, 0.26-3.59; p = 0.95). CONCLUSIONS We found no difference in the incidence of symptomatic VTE after THA with low-dose compared with standard-dose aspirin. In the absence of compelling evidence to the contrary, low-dose aspirin appears to be a reasonable option for VTE prophylaxis in otherwise healthy patients undergoing elective THA. LEVEL OF EVIDENCE Level III, therapeutic study.
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38
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Abstract
Carotid endarterectomy (CEA) is a surgical intervention that may prevent stroke in asymptomatic and symptomatic patients. Our aim was to examine the microsurgical anatomy of carotid artery and other related neurovascular structures to summarize the CEA that is currently applied in ideal conditions. The upper necks of 2 adult cadavers (4 sides) were dissected using ×3 to ×40 magnification. The common carotid artery, external carotid artery (ECA), and internal carotid artery were exposed and examined. The surgical steps of CEA were described using 3-D cadaveric photos and computed tomography angiographic pictures obtained with help of OsiriX imaging software program. Segregating certain neurovascular and muscular structures in the course of CEA significantly increased the exposure. The division of facial vein allowed for internal jugular vein to be mobilized more laterally and dividing the posterior belly of digastric muscle resulted in an additional dorsal exposure of almost 2 cm. Isolating the ansa cervicalis that pulls hypoglossal nerve inferiorly allowed hypoglossal nerve to be released safely medially. The locations of the ECA branches alter depending on their anatomical variations. The hypoglossal nerve, glossopharyngeal nerve, and accessory nerve pierce the fascia of the upper part of the carotid sheath and they are vulnerable to injury because of their distinct courses along the surgical route. Surgical exposure in CEA requires meticulous dissection and detailed knowledge of microsurgical anatomy of the neck region to avoid neurovascular injuries and to determine the necessary surgical maneuvers in cases with neurovascular variations.
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Laboratory Monitoring of Antiplatelet Therapy. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00036-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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40
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Antiplatelet Drugs in the Management of Cerebral Ischemia. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00057-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Murphy SJX, Naylor AR, Ricco JB, Sillesen H, Kakkos S, Halliday A, de Borst GJ, Vega de Ceniga M, Hamilton G, McCabe DJH. Optimal Antiplatelet Therapy in Moderate to Severe Asymptomatic and Symptomatic Carotid Stenosis: A Comprehensive Review of the Literature. Eur J Vasc Endovasc Surg 2018; 57:199-211. [PMID: 30414802 DOI: 10.1016/j.ejvs.2018.09.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/11/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Carotid stenosis patients are at risk of vascular events despite antiplatelet therapy. Data on prescribed antiplatelet regimens have not been comprehensively collated from trials to guide optimal therapy in this population. METHODS This review was conducted in line with the current Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Medline, Ovid, Embase, Web of Science, and Google Scholar from 1988 to 2018 were searched using the search terms "carotid stenosis", "asymptomatic", "symptomatic", "antiplatelet", and "anti-platelet" to identify randomised trials in patients with asymptomatic or symptomatic extracranial moderate-severe carotid stenosis on any form of antiplatelet therapy in which vascular events and pre specified composite outcome events were reported. RESULTS Twenty-five studies were judged eligible for inclusion. Data from one randomised controlled trial showed no significant difference in benefit with aspirin versus placebo in asymptomatic carotid stenosis, but it is still reasonable to recommend aspirin (81-325 mg daily) for prevention of vascular events in these patients. Low to medium dose aspirin (81-325 mg daily) is superior to higher doses (>650 mg daily) at preventing recurrent vascular events in patients undergoing endarterectomy. Data from endovascular treatment (EVT) trials support peri-procedural treatment of asymptomatic and symptomatic patients with 81-325 mg of aspirin daily. The use of peri-procedural aspirin-clopidogrel in patients undergoing EVT is based on one pilot trial, but appears safe. Short-term aspirin-dipyridamole or aspirin-clopidogrel treatments are equally effective at reducing micro-embolic signals on transcranial Doppler ultrasound in patients with ≥50% symptomatic carotid stenosis. There is insufficient evidence to recommend routine aspirin-clopidogrel combination therapy to reduce the risk of recurrent clinical ischaemic events in patients with symptomatic moderate-severe carotid stenosis. CONCLUSIONS This comprehensive review outlines an evidence based approach to antiplatelet therapy in carotid stenosis patients. Future trials should randomise such patients to receive different antiplatelet regimens to assess their efficacy and safety and to optimise peri-procedural and long-term preventive treatment in this patient cohort.
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Affiliation(s)
- Stephen J X Murphy
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH)/Tallaght University Hospital, Dublin, Ireland; Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH)/Tallaght University Hospital, Dublin, Ireland
| | - A Ross Naylor
- Department of Vascular Surgery, Glenfield Hospital, Leicester, UK
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery, University of Strasbourg, Strasbourg, France
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Denmark
| | - Stavros Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Alison Halliday
- Nuffield Dept. of Surgical Sciences, University of Oxford, Oxford, UK
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, The Netherlands
| | - Melina Vega de Ceniga
- Department of Angiology and Vascular Surgery, Hospital de Galdakao-Usansolo, Bizkaia, Spain
| | - George Hamilton
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, University College London Medical School, London, UK
| | - Dominick J H McCabe
- Vascular Neurology Research Foundation, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH)/Tallaght University Hospital, Dublin, Ireland; Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH)/Tallaght University Hospital, Dublin, Ireland; Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH)/Tallaght University Hospital, Dublin, Ireland; Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, UK; Irish Centre for Vascular Biology, Dublin, Ireland; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland.
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Abstract
Atherosclerotic cardiovascular (CV) disease represents one of leading cause of mortality and morbidity in Western countries. An increased risk of CV events was identified in patients with peripheral arterial diseases (PADs), which include all arterial diseases, other than coronary arteries and the aorta. In particular, lower extremity artery disease (LEAD) and/or carotid artery disease present growing incidence in general population and a consequent increase in mortality and morbidity. Medical treatment, including antiplatelet therapy, is a cornerstone in management of these patients, even when they are treated with endovascular or surgical procedures. Despite their clinical relevance, data on optimal antiplatelet treatment in this clinical setting are lacking and often derived from clinical trials on coronary artery disease and by subgroups analysis. The purpose of this review is to examine the available data from registries, randomized trials and meta-analysis on antiplatelet treatment in patients with LEAD and carotid stenosis with the aim to provide evidence to support clinical decision making.
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Affiliation(s)
- Rosetta Melfi
- Unit of Cardiovascular Sciences, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
| | - Elisabetta Ricottini
- Unit of Cardiovascular Sciences, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
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Is Management of Central Retinal Artery Occlusion the Next Frontier in Cerebrovascular Diseases? J Stroke Cerebrovasc Dis 2018; 27:2781-2791. [PMID: 30060907 DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 05/30/2018] [Accepted: 06/05/2018] [Indexed: 01/19/2023] Open
Abstract
Central retinal artery occlusion (CRAO) is a medical emergency that, if not treated, may result in irreversible loss of vision. It continues to be an important cause for acute painless loss of vision. Amaurosis fugax or "transient CRAO" has long been considered an equivalent of transient cerebral ischemic event. Animal models, in addition to data from retrospective and randomized clinical studies, provide valuable insights into the time interval for irreversible retinal ischemia. Subset analyses from 2 large studies of patients with CRAO show benefit from treatment with thrombolysis within 6 hours from symptoms onset. Significant workflow improvements after the intra-arterial therapy trials for acute ischemic stroke have occurred world over in last 5 years. Patients with CRAO are uniquely suited to receive maximum benefits from the changes in workflow for treatment of patient's acute ischemic stroke. Just as in clinical triage of acute ischemic stroke, correct and timely diagnosis of patients with CRAO may help in preventing visual loss. The approach to acute ocular ischemia should mimic that used for acute brain ischemia. Comprehensive stroke centers would be ideal triage centers for these patients in view of availability of multidisciplinary participation from vascular neurology, neuroendovascular surgery, and ophthalmology. Time is Retina!
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Biccard BM, Sigamani A, Chan MTV, Sessler DI, Kurz A, Tittley JG, Rapanos T, Harlock J, Szalay D, Tiboni ME, Popova E, Vásquez SM, Kabon B, Amir M, Mrkobrada M, Mehra BR, El Beheiry H, Mata E, Tena B, Sabaté S, Zainal Abidin MK, Shah VR, Balasubramanian K, Devereaux PJ. Effect of aspirin in vascular surgery in patients from a randomized clinical trial (POISE-2). Br J Surg 2018; 105:1591-1597. [PMID: 30019751 DOI: 10.1002/bjs.10925] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/13/2018] [Accepted: 05/31/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND In the POISE-2 (PeriOperative ISchemic Evaluation 2) trial, perioperative aspirin did not reduce cardiovascular events, but increased major bleeding. There remains uncertainty regarding the effect of perioperative aspirin in patients undergoing vascular surgery. The aim of this substudy was to determine whether there is a subgroup effect of initiating or continuing aspirin in patients undergoing vascular surgery. METHODS POISE-2 was a blinded, randomized trial of patients having non-cardiac surgery. Patients were assigned to perioperative aspirin or placebo. The primary outcome was a composite of death or myocardial infarction at 30 days. Secondary outcomes included: vascular occlusive complications (a composite of amputation and peripheral arterial thrombosis) and major or life-threatening bleeding. RESULTS Of 10 010 patients in POISE-2, 603 underwent vascular surgery, 319 in the continuation and 284 in the initiation stratum. Some 272 patients had vascular surgery for occlusive disease and 265 had aneurysm surgery. The primary outcome occurred in 13·7 per cent of patients having aneurysm repair allocated to aspirin and 9·0 per cent who had placebo (hazard ratio (HR) 1·48, 95 per cent c.i. 0·71 to 3·09). Among patients who had surgery for occlusive vascular disease, 15·8 per cent allocated to aspirin and 13·6 per cent on placebo had the primary outcome (HR 1·16, 0·62 to 2·17). There was no interaction with the primary outcome for type of surgery (P = 0·294) or aspirin stratum (P = 0·623). There was no interaction for vascular occlusive complications (P = 0·413) or bleeding (P = 0·900) for vascular compared with non-vascular surgery. CONCLUSION This study suggests that the overall POISE-2 results apply to vascular surgery. Perioperative withdrawal of chronic aspirin therapy did not increase cardiovascular or vascular occlusive complications. Registration number: NCT01082874 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- B M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - A Sigamani
- Narayana Hrudayalaya Limited, Bangalore, India
| | - M T V Chan
- Department of Anaesthetics, Chinese University of Hong Kong, Hong Kong, China
| | - D I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - A Kurz
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - J G Tittley
- Division of Vascular Surgery, McMaster University, Hamilton, Ontario, Canada
| | - T Rapanos
- Division of Vascular Surgery, McMaster University, Hamilton, Ontario, Canada
| | - J Harlock
- Division of Vascular Surgery, McMaster University, Hamilton, Ontario, Canada
| | - D Szalay
- Division of Vascular Surgery, McMaster University, Hamilton, Ontario, Canada
| | - M E Tiboni
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - E Popova
- Biomedical Research Institute (IIB - Sant Pau), Barcelona, Spain
| | - S M Vásquez
- Grupo de Cardiología Preventiva Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia
| | - B Kabon
- Department of Anaesthesiology, Medical University of Vienna, Vienna, Austria
| | - M Amir
- Department of Surgery, Shifa International Hospital/Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - M Mrkobrada
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - B R Mehra
- Mahatma Gandhi Institute of Medical Sciences, Sevagram, India
| | - H El Beheiry
- University of Toronto, Trillium Health Partners, Toronto, Ontario, Canada
| | - E Mata
- Hospital Universitario La Princesa, Madrid, Spain
| | - B Tena
- Department of Anaesthesiology, Hospital Clinic, Barcelona, Spain
| | - S Sabaté
- Department of Anaesthesiology, Fundació Puigvert (IUNA), Barcelona, Spain
| | - M K Zainal Abidin
- Department of Anaesthesiology and Intensive Care, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | | | | | - P J Devereaux
- Population Health Research Institute, Hamilton, Ontario, Canada
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Low-Dose Aspirin Is Safe and Effective for Venous Thromboembolism Prophylaxis Following Total Knee Arthroplasty. J Arthroplasty 2018; 33:S131-S135. [PMID: 29656974 DOI: 10.1016/j.arth.2018.03.001] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/02/2018] [Accepted: 03/03/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Aspirin is an effective prophylaxis for venous thromboembolism (VTE) after total knee arthroplasty (TKA). The optimal prophylactic aspirin dose has not been established. The study aims to compare 2 aspirin regimens with regard to the incidence of (1) symptomatic deep venous thrombosis (DVT), (2) pulmonary embolism (PE), (3) bleeding, and (4) mortality within 90 days after TKA. METHODS We retrospectively identified 5666 patients who received aspirin twice daily for 4 to 6 weeks after TKA. A total of 1327 patients received 81-mg BID and 4339 patients received 325-mg BID aspirin. Postoperative complications collected were VTEs (DVT and PE), bleeding (gastrointestinal or wound bleeding), and mortality. RESULTS The incidence of VTE was 1.5% in the 325-mg group and 0.7% in the 81-mg group (P = .02). Symptomatic DVT was 1.4% in the 325-mg aspirin compared with 0.3% for the 81-mg aspirin (P = .0009). Regression model showed no correlation between aspirin dose and VTE incidence (odds ratio [OR] = 1.03; 95% confidence interval [95% CI], 0.45-2.36; P = .94) or DVT (OR = 0.50; 95% CI, 0.16-1.55; P = .20). The incidence of PE was 0.2% in the high-aspirin group compared with 0.4% in the low-aspirin group (P = .13). Bleeding was 0.2% in the 325-mg aspirin group and 0.2% in the 81-mg aspirin group (P = .62), and 90-day mortality was similar (0.1%) between the groups (P = .56). CONCLUSION Low-dose aspirin was not inferior to high-dose aspirin for the prevention of VTE after TKA. Low-dose aspirin can be considered a safe and effective agent in the prevention of VTE after TKA.
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Spence JD. Cardioembolic stroke: everything has changed. Stroke Vasc Neurol 2018; 3:76-83. [PMID: 30022801 PMCID: PMC6047338 DOI: 10.1136/svn-2018-000143] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/07/2018] [Accepted: 02/24/2018] [Indexed: 02/03/2023] Open
Abstract
Historically, because of the difficulty of using warfarin safely and effectively, many patients with cardioembolic stroke who should have been anticoagulated were instead given ineffective antiplatelet therapy (or no antithrombotic therapy). With the arrival of new oral anticoagulants that are not significantly more likely than aspirin to cause severe haemorrhage, everything has changed. Because antiplatelet agents are much less effective in preventing cardioembolic stroke, it is now more prudent to anticoagulate patients in whom cardioembolic stroke is strongly suspected. Recent advances include the recognition that intermittent atrial fibrillation is better detected with more prolonged monitoring of the cardiac rhythm, and that percutaneous closure of patent foramen ovale (PFO) may reduce the risk of stroke. However, because in most patients with stroke and PFO the PFO is incidental, this should be reserved for patients in whom paradoxical embolism is likely. A high shunt grade on transcranial Doppler saline studies, and clinical clues to paradoxical embolism, can help in appropriate selection of patients for percutaneous closure. For patients with atrial fibrillation who cannot be anticoagulated, ablation of the left atrial appendage is an emerging option. It is also increasingly recognised that high levels of homocysteine, often due to undiagnosed metabolic deficiency of vitamin B12, markedly increase the risk of stroke in atrial fibrillation, and that B vitamins (folic acid and B12) do prevent stroke by lowering homocysteine. However, with regard to B12, methylcobalamin should probably be used instead of cyanocobalamin. Many important considerations for judicious application of therapies to prevent cardioembolic stroke are discussed.
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Affiliation(s)
- J David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
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47
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Kisilevsky A, Gelb AW, Bustillo M, Flexman AM. Anaemia and red blood cell transfusion in intracranial neurosurgery: a comprehensive review. Br J Anaesth 2018; 120:988-998. [PMID: 29661416 DOI: 10.1016/j.bja.2017.11.108] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 11/08/2017] [Accepted: 11/30/2017] [Indexed: 01/04/2023] Open
Abstract
Both anaemia and blood transfusion are associated with poor outcomes in the neurosurgical population. Based on the available literature, the optimal haemoglobin concentration for neurologically injured patients appears to be in the range of 9.0-10.0 g dl-1, although the individual risks and benefits should be weighed. Several perioperative blood conservation strategies have been used successfully in neurosurgery, including correction of anaemia and coagulopathy, use of antifibrinolytics, and intraoperative cell salvage. Avoidance of non-steroidal anti-inflammatory drugs and starch-containing solutions is recommended given the potential for platelet dysfunction.
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Affiliation(s)
- A Kisilevsky
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
| | - A W Gelb
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - M Bustillo
- Department of Anesthesiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - A M Flexman
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada.
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Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Markus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Archie J, Bellmunt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M. Editor's Choice - Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:3-81. [PMID: 28851594 DOI: 10.1016/j.ejvs.2017.06.021] [Citation(s) in RCA: 794] [Impact Index Per Article: 132.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Spence JD. Letter by Spence Regarding Article, "Antiplatelet Regimen for Patients With Breakthrough Strokes While on Aspirin: A Systematic Review and Meta-Analysis". Stroke 2017; 48:e311. [PMID: 28887397 DOI: 10.1161/strokeaha.117.018919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- J David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
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50
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How I use laboratory monitoring of antiplatelet therapy. Blood 2017; 130:713-721. [DOI: 10.1182/blood-2017-03-742338] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 05/24/2017] [Indexed: 12/11/2022] Open
Abstract
Abstract
Antiplatelet therapy is of proven benefit in coronary artery disease and a number of other clinical settings. This article reviews platelet function, molecular targets of antiplatelet agents, and clinical indications for antiplatelet therapy before focusing on a frequent question to hematologists about the 2 most commonly used antiplatelet therapies: Could the patient be aspirin “resistant” or clopidogrel “resistant”? If so, should results of a platelet function test be used to guide the dose or type of antiplatelet therapy? Whether such guided therapy is of clinical benefit to patients has been a source of controversy. The present article reviews this subject in the context of 2 prototypical clinical cases. Available evidence does not support the use of laboratory tests to guide the dose of aspirin or clopidogrel in patients with so-called aspirin or clopidogrel “resistance.”
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