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Lizana J, Aliaga N, Basurco A. Hematoma subdural crónico: Una patología común de manejo complejo. Surg Neurol Int 2021. [DOI: 10.25259/sni_676_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Antecedentes:
El hematoma subdural crónico (HSDC) es una patología ampliamente estudiada, muy frecuente, sobre todo en adultos mayores; su cuadro clínico tiene una apariencia benigna y suele ir acompañado de múltiples comorbilidades asociadas a la edad, lo que resulta en un aumento de las complicaciones e incluso la muerte. Con el incremento de la expectativa de vida a nivel mundial, el uso de medicamentos antitrombóticos es cada vez más frecuente. El papel de estos fármacos en la evolución de la enfermedad como en la recurrencia, sigue siendo motivo de discusión.
Métodos:
Los autores revisaron la fisiopatología y características clínicas del HSDC. El presente artículo discute acerca de las terapéuticas actuales y las nuevas opciones de tratamiento que podrían mejorar los resultados. Este manuscrito es susceptible de cambios en el tiempo, con el desarrollo científico y tecnológico.
Resultados:
El HSDC puede ser abordado por vía quirúrgica y farmacológica; no obstante, un manejo individualizado requiere la consideracion cuidadosa de diversos factores. A pesar de los avances en el campo de la neurocirugía, la clásica trepanación craneal sigue siendo el Gold estándar en el HSDC y sobre todo en pacientes con síntomas graves. Se debe resaltar que aún hay aspectos de este procedimiento (como la localización del dren, número de drenajes, el efecto de la irrigación, la temperatura de la solución con que se irriga, etc.) que siguen siendo materia de estudio.
Conclusiones:
Entender el mecanismo de la enfermedad ha permitido explicar su historia natural y a su vez proponer nuevas alternativas de tratamiento. El manejo médico (atorvastatina, corticoides) ha generado gran interés por sus alentadores resultados preliminares. Recientemente, se ha reportado la terapia endovascular como una alternativa segura y existe gran expectativa por confirmar su efecto en estudios más grandes.
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Affiliation(s)
- Jafeth Lizana
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara, Lima, Peru,
| | - Nelida Aliaga
- Department of Medicine, School of Biomedical Sciences, Austral University, Mariano Acosta, Buenos Aires, Argentina
| | - Alfonso Basurco
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara, Lima, Peru,
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Hang G, Chen JY, Yew AKS, Pang HN, Jin DTK, Chia SL, Lo NN, Yeo SJ. Effects of continuing use of aspirin on blood loss in patients who underwent unilateral total knee arthroplasty. J Orthop Surg (Hong Kong) 2020; 28:2309499019894390. [PMID: 31916487 DOI: 10.1177/2309499019894390] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Concerning the ongoing debate on the effects of continuing aspirin therapy on blood loss in knee arthroplasty, we conducted a retrospective investigation to test the hypothesis that continuation of aspirin prior total knee arthroplasty (TKA) will not cause more blood loss. METHODS From a database of patients who underwent unilateral TKA between 2011 and 2016, we identified two groups: the aspirin group (patients continued aspirin during perioperative period) and the nonaspirin group (patients had no current or recent history of aspirin usage). We extracted and compared patient demographic information, comorbidity index, baseline serum hemoglobin (Hb), and creatinine level between the two groups. We also compared our primary outcomes, including the total blood loss, transfusion requirement, and length of hospitalization between the two groups. A multivariate logistic regression for analyzing the risk factors of requiring transfusion was performed. RESULTS We found that apart from preoperative serum creatinine level, there was no difference in the baseline Hb level, perioperative change in Hb, total blood loss, or length of hospitalization between the two groups. The percentage of transfusion utilization was also comparable between the two groups. Our regression analysis shows that the risk of requiring transfusion after TKA is not significantly associated with patients taking aspirin therapy before operation. CONCLUSION Patients who underwent TKA with continuation of low-dose aspirin did not result in more blood loss. Current blood loss management has provided sufficient reduction of blood loss to accommodate aspirin therapy perioperatively. We suggest that it is safe to continue aspirin prior to TKA.
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Affiliation(s)
- Guanqi Hang
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | | | - Andy Khye Soon Yew
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Hee-Nee Pang
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | | | - Shi-Lu Chia
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Ngai Nung Lo
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Seng Jin Yeo
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Al-Ansari A. Acquired bleeding disorders through antithrombotic therapy: the implications for dental practitioners. Br Dent J 2020; 229:729-734. [PMID: 33311678 DOI: 10.1038/s41415-020-2399-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/28/2020] [Indexed: 11/09/2022]
Abstract
Antithrombotic medications are one of the most common causes of an acquired bleeding disorder. The majority of these medications are administered orally for a variety of clinical indications. It is important that dental surgeons are aware of these medications, their mechanisms of action and how they can influence the dental management of patients, particularly when undertaking procedures which carry a risk of bleeding.
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Affiliation(s)
- Anmar Al-Ansari
- Dental Core Trainee 1 in Oral and Maxillofacial Surgery, Forth Valley Royal Hospital, Stirling Rd, Larbert, FK5 4WR, UK.
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Chia PY, Htun HL, Leo YS, Lye DC. Safety of temporary interruption of antiplatelet therapy in dengue fever with thrombocytopenia. J Infect 2020; 82:270-275. [PMID: 33271172 DOI: 10.1016/j.jinf.2020.10.038] [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: 12/21/2019] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 10/22/2022]
Abstract
Thrombocytopenia commonly occurs in dengue and may be complicated by bleeding. Dengue can occur in adults who may be on long term antiplatelet therapy for ischemic heart disease or stroke. In these cases, clinicians may temporarily discontinue antiplatelet therapy to minimize the risk of bleeding in the absence of clear guidelines. We conducted a retrospective cohort study of laboratory-confirmed adult dengue patients on antiplatelet therapy and evaluated participants whose antiplatelet therapy was continued versus discontinued. Primary outcome was a composite outcome of major adverse cardiac and cerebrovascular events (MACCE), and all-cause mortality in-hospital and for 1-year post discharge. Secondary outcomes were platelet and blood transfusion, and occurrence of dengue haemorrhagic fever (DHF), dengue shock syndrome, dengue with warning signs and severe dengue according to World Health Organization criteria. Discontinuation of antiplatelet therapy did not result in higher composite outcome (p=0.192). Continuation of antiplatelet therapy did not result in more platelet or blood transfusion (p=0.489 and p=0.567 respectively), DHF (p=0.923). Our results suggest that discontinuation or continuation of antiplatelet therapy based on clinical judgement in dengue with thrombocytopenia, is largely safe but further studies are needed.
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Affiliation(s)
- Po Ying Chia
- National Centre for Infectious Diseases, 16 Jalan Tan Tock Seng, 308422, Singapore; Department of Infectious Diseases, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433, Singapore; Lee Kong Chian School of Medicine, 11 Mandalay Road, 308232, Singapore.
| | - Htet Lin Htun
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics and Knowledge (OCEAN), Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433, Singapore.
| | - Yee Sin Leo
- National Centre for Infectious Diseases, 16 Jalan Tan Tock Seng, 308422, Singapore; Department of Infectious Diseases, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433, Singapore; Lee Kong Chian School of Medicine, 11 Mandalay Road, 308232, Singapore; Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, 117549, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 11, 119228, Singapore.
| | - David Chien Lye
- National Centre for Infectious Diseases, 16 Jalan Tan Tock Seng, 308422, Singapore; Department of Infectious Diseases, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433, Singapore; Lee Kong Chian School of Medicine, 11 Mandalay Road, 308232, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 11, 119228, Singapore.
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Singh S, Mandal S, Chugh A, Deora S, Jain G, Khan MA, Chugh VK. Clinical Post-operative Bleeding During Minor Oral Surgical Procedure and In Vitro Platelet Aggregation in Patients on Aspirin Therapy: Are they Coherent? J Maxillofac Oral Surg 2020; 20:132-137. [PMID: 33584054 DOI: 10.1007/s12663-020-01438-4] [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: 06/08/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022] Open
Abstract
Aim The risk of excessive bleeding prompts physicians to discontinue aspirin in patients on low-dose, long-term therapy which in turn puts them at the risk from adverse cardiovascular and thrombotic events. Effect of low-dose aspirin therapy on platelet function was assessed using platelet aggregation method. The aim was to correlate the laboratory platelet function with cutaneous and clinical oral bleeding time (BT). Materials and Methods One hundred one patients were enrolled in this prospective trial and were allocated into two groups. Interventional or test group consisted of patients who were on aspirin therapy (75 mg/100 mg) for primary or secondary prevention of angina, myocardial infarction and stroke. Minor oral surgical procedure was performed in this group without discontinuing aspirin therapy. Control group consisted of healthy patients (under no medication) undergoing minor oral surgical procedure. Cutaneous and clinical oral BT were recorded in both the groups. Venous blood sample was drawn, and percentage platelet aggregation function was analysed using adenosine diphosphate (ADP) and arachidonic acid (AA) reagents. The percentage of platelet aggregation was then correlated with cutaneous and clinical oral BT. Results A significant decrease in percentage platelet aggregation using ADP (aspirin-74.7 21.39; control-89.2 13.70) and AA (aspirin-47.6 23.11; control-82.3 20.17) was observed. However, there were no significant difference in mean cutaneous BT (aspirin-1.5 0.65 min; control-1.6 0.71 min) and clinical oral BT (aspirin-5.0 2.48 min; control-4.8 2.60 min) in aspirin and control groups. Conclusion Majority of the minor oral surgical procedures can be carried out safely without discontinuing aspirin in patients on low-dose long-term therapy. This is possible because despite significant platelet aggregation evident in laboratory evaluation there is lack of its clinical corroboration owing to aspirin resistance. Clinical Trial Registration CTRI/2018/02/012055.
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Affiliation(s)
- Surjit Singh
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Jodhpur, India
| | - Saptarshi Mandal
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Jodhpur, Jodhpur, India
| | - Ankita Chugh
- Department of Dentistry, All India Institute of Medical Sciences, Jodhpur, Jodhpur, India
| | - Surender Deora
- Department of Cardiology, All India Institute of Medical Sciences, Jodhpur, Jodhpur, India
| | - Gaurav Jain
- Department of Dentistry, All India Institute of Medical Sciences, Jodhpur, Jodhpur, India
| | - Md Atik Khan
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Jodhpur, Jodhpur, India
| | - Vinay Kumar Chugh
- Department of Dentistry, All India Institute of Medical Sciences, Jodhpur, Jodhpur, India
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Periprocedural Major Bleeding Risk of Image-Guided Percutaneous Chest Tube Placement in Patients with an Elevated International Normalized Ratio. J Vasc Interv Radiol 2019; 30:1765-1768. [PMID: 31587947 DOI: 10.1016/j.jvir.2019.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To evaluate the incidence of major hemorrhage after image-guided percutaneous chest tube placement in patients with an abnormal international normalized ratio (INR) measured before the procedure. MATERIALS AND METHODS Between January 2013 and September 2017, 49 image-guided percutaneous chest tubes were placed in 45 adult patients who had an elevated INR of greater than 1.6. Data collected included routine serum pre-procedure coagulation studies, indication for chest tube placement, insertion technique, size of chest tube, and presence of complications after drain placement. Major bleeding complications were defined using the Society of Interventional Radiology classification system. RESULTS Mean patient age was 62 years (range, 22-94 years), with median American Society of Anesthesiologists score of 4. Mean INR was 2.1 (range, 1.7-3), with 21 (43%) procedures with an INR between 1.7 and 1.9, 20 (41%) procedures with an INR between 2.0 and 2.4, and 8 (16%) procedures with an INR between 2.5 and 3.0. Computed tomography guidance was used for 27 (55%) procedures; ultrasound guidance was used for 22 (45%) procedures. Median size of chest tube was 10 Fr (range, 8-14 Fr) used in 27 (55%) procedures. No major bleeding complications were observed. There was a small, significant decrease in mean hemoglobin after the procedure (mean = 0.9g/dL; P < .0001), which correlated to increasing chest tube size (P = .0269). CONCLUSIONS No major bleeding complications were observed after image-guided percutaneous chest tube placement in patients with an elevated INR. Major bleeding complications in these patients may be safer than initially considered, and this study encourages the conduct of larger trials for further evaluation.
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Stamenovic D, Schneider T, Messerschmidt A. Aspirin for patients undergoing major lung resections: hazardous or harmless?†. Interact Cardiovasc Thorac Surg 2019; 28:535-541. [PMID: 30346533 DOI: 10.1093/icvts/ivy255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 07/05/2018] [Accepted: 07/11/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Acetylsalicylic acid (ASA, aspirin) is a medication widely used for primary and secondary prevention of cardiovascular diseases, which are the leading cause of morbidity and mortality worldwide. Whether aspirin should be continued or paused in the perioperative period remains controversial, especially in thoracic surgical settings. METHODS A single-centred retrospective study comprised 486 patients. Of these, 329 patients did not use aspirin (group ASA-0) and 157 did (group ASA-1) during the perioperative period after anatomical lung resection at our hospital from January 2013 to December 2016. Major outcome measures were the amount of blood loss during the operation and during the first 5 days postoperatively (per Mercuriali's formula), as well as the amount and proportion of the blood transfusion (packed red cells) received. The need for reoperation due to a postoperative haemothorax and/or bleeding was recorded. The groups were also compared according to their rates of morbidity and mortality. Inferential statistical methods with bootstrap analysis using 1000 samples and the Mersenne Twister, a random number generator, were used. RESULTS There were no significant differences between the 2 groups in intraoperative bleeding [ASA-0M = 418.69 ml, standard deviation (SD) ± 364.87; ASA-1M = 399.8 ml, SD ± 323.84; P = 0.58] or in total blood loss according to Mercuriali's formula (ASA-0M = 1111.62 ml, SD ± 816.69; ASA-1M = 1115.08 ml, SD ± 682.12; P = 0.95). A total of 104 patients received transfusions up to postoperative day 5: 71 patients in the ASA-0 group received 151 blood transfusions, whereas 33 patients in the ASA-1 group received 65 blood transfusions (P = 0.66). The indication for reoperation due to bleeding (ASA-1 = 3, ASA-0 = 4; P = 0.69) was similar between the groups. There was a trend towards higher rates of postoperative complications in the ASA-1 group (risk ratio (RR) = 1.28; P = 0.055); neither cardiovascular complications nor deaths were more frequent in either of the 2 groups (P = 0.73). CONCLUSIONS Patients taking aspirin therapy and undergoing anatomical lung resection seem not to be at any disadvantage regarding bleeding. However, a trend towards a higher rate of postoperative complications indicates a basically increased risk for operations due to comorbidities in these patients.
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Affiliation(s)
- Davor Stamenovic
- Department of Thoracic Surgery, ViDia Kliniken, Karlsruhe, Germany
| | - Thomas Schneider
- Department of Thoracic Surgery, ViDia Kliniken, Karlsruhe, Germany
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8
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Tang M, Yu C, Hu P, Wang C, Sheng J, Ma S. Risk factors for bleeding after dental extractions in patients over 60 years of age who are taking antiplatelet drugs. Br J Oral Maxillofac Surg 2018; 56:854-858. [DOI: 10.1016/j.bjoms.2018.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 09/17/2018] [Indexed: 12/18/2022]
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Management of dental extractions in patients on warfarin and antiplatelet therapy. J Formos Med Assoc 2018; 117:979-986. [PMID: 30195969 DOI: 10.1016/j.jfma.2018.08.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 08/14/2018] [Accepted: 08/20/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND/PURPOSE Planning dental extractions for Taiwanese patients on antithrombotic therapy remains controversial. This study aimed to examine management of dental extraction in patients on warfarin and antiplatelet therapy. METHODS Subjects comprised 1331 patients, with (1) 60 on warfarin with intentional normalized ratio (INR) below 4.0 (warfarin continued: 28 patients/33 occasions; warfarin stopped and switched to heparin under hospitalization: 32 patients/37 occasions); (2) 183 on antiplatelet therapy (aspirin: 125 patients/185 occasions; clopidogrel: 42 patients/65 occasions; dual therapy: 16 patients/24 occasions); and (3) a control group of 1088 patients/1472 occasions without any antithrombotic therapy. The patient's clinico-demographic parameters, warfarin effectiveness (dose and INR levels) and antiplatelet therapy, number and type of dental extraction and incidence of postoperative bleeding were investigated. RESULTS Incidence of postoperative bleeding in the warfarinized group (warfarin continued: 9.1%; warfarin stopped: 8.1%) was higher than in the antiplatelet group (aspirin: 1.1%; clopidogrel: 3.1%; dual antiplatelet: 4.2%), and the control group (0.7%), but these differences were not significant and unrelated to INR or number and type of dental extraction. Postoperative hemorrhage was managed successfully by repacking with Gelfoam impregnated with tranexamic acid powder in most patients. CONCLUSION The study indicated that there is no need to interrupt warfarin (INR<4.0) and antiplatelet therapy before dental extractions in Taiwanese patients. A sufficient hemostasis could be obtained using local measures. This approach can save these individuals from becoming exposed to the risk of thromboembolism and the inconvenience of bridging anticoagulation with heparin.
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Perioperative aspirin therapy in non-cardiac surgery: A systematic review and meta-analysis of randomized controlled trials. Int J Cardiol 2018; 258:59-67. [DOI: 10.1016/j.ijcard.2017.12.088] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 12/09/2017] [Accepted: 12/21/2017] [Indexed: 01/18/2023]
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Perioperative Platelet Inhibition in Elective Inguinal Hernia Surgery—Increased Rate of Postoperative Bleeding and Hematomas? Int Surg 2018. [DOI: 10.9738/intsurg-d-16-00041.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
In patients on oral antiplatelet therapy secondary to critical vascular diseases, the risk of interrupting antiplatelet therapy has to be weighed against the risk of postoperative hematoma or bleeding when surgery is planned. The goal of this study was to determine the risk of postoperative hematoma and postoperative bleeding in elective inguinal hernia surgery during continuous platelet inhibition. Patients receiving either elective total extraperitoneal hernioplasty or Lichtenstein repair for inguinal hernia were included. Patients with mere suture repair, emergency hernia repair, combination of different simultaneous operations, and patients under therapeutic anticoagulation with heparin were excluded. Postoperative bleeding/hematoma was determined by physical examination and graded according to the Clavien-Dindo classification. Between January 2006 and December 2013, 561 patients with elective surgical repair of an inguinal hernia were included. A total of 29 patients were under continuous perioperative platelet inhibition (PI) with either aspirin or clopidogrel in addition to perioperative antithrombotic prophylaxis with subcutaneous dalteparin injections (PI group). A total of 532 patients received perioperative antithrombotic prophylaxis only (control group). The number of patients under antiplatelet therapy increased from 1.3% (Jan. 2006–Dec. 2009) to 10.0% (Jan. 2010–Dec. 2013; P < 0.0001). Postoperative hematoma/bleeding occurred in 5 PI patients (17.2%) versus 38 control patients (7.1%, P = 0.062). Rate of postoperative bleeding or hematoma is not higher under mono antiplatelet therapy for elective inguinal hernia repair. Since the majority of hematomas can be treated conservatively, it seems unnecessary to stop mono platelet inhibition perioperatively.
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Foëx P. Innovations in management of cardiac disease: drugs, treatment strategies and technology. Br J Anaesth 2017; 119:i23-i33. [DOI: 10.1093/bja/aex327] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2017] [Indexed: 01/15/2023] Open
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Murphy L, Brown C, Smith A, Cranfield F, Sharp L, Visvanathan K, Bennett K, Barron TI. End-of-life prescribing of aspirin in patients with breast or colorectal cancer. BMJ Support Palliat Care 2017; 9:e6. [PMID: 28838931 DOI: 10.1136/bmjspcare-2017-001370] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the influence of an approaching cancer death on end-of-life aspirin use, a frequently prescribed medication for cardiovascular disease prevention. METHODS This study was conducted using linked cancer registry and prescribing data. Breast (n=1151) and colorectal (n=1859) cancer decedents were matched to cancer survivors and the probability of either initiating aspirin, or continuing established aspirin use, was estimated in consecutive periods over the 5 years approaching a cancer-specific death (decedents) or matched index date (survivors). RESULTS Using the linked data sets, we identified patients who died of their cancer (decedents) between 1 January 2001 and 31 December 2009. In the 5 years prior to death, we compared (1) the probability of initiating aspirin use for the first time, and (2) the probability of continuing aspirin use. In comparison to matched cancer survivors, an approaching cancer death was not associated with a reduction in aspirin initiation by breast or colorectal cancer decedents. However, the probability of continuing established aspirin use declined considerably in the 24 months approaching death and at the time of a death was significantly lower for breast (risk difference (RD) -0.26, 95% CI -0.33 to -0.20) and colorectal (RD -0.38, 95% CI -0.46 to -0.30) cancer decedents versus matched survivors. CONCLUSION A significant proportion of patients discontinue their aspirin in the time approaching a breast or colorectal cancer-specific death. The safety and benefits of this are unclear and empirical data are needed to guide decisions about aspirin use in the end of life.
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Affiliation(s)
- Laura Murphy
- Division of Population Health Science, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Amelia Smith
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, Trinity College, University of Dublin, Dublin, Ireland
| | | | - Linda Sharp
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Kala Visvanathan
- Sidney Kimmel Comprehensive Cancer Centre, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kathleen Bennett
- Division of Population Health Science, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Thomas Ian Barron
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, Trinity College, University of Dublin, Dublin, Ireland.,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Schwab PE, Lavand'homme P, Yombi J, Thienpont E. Aspirin mono-therapy continuation does not result in more bleeding after knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2017; 25:2586-2593. [PMID: 26515774 DOI: 10.1007/s00167-015-3824-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 09/25/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Current clinical practice guidelines sometimes still recommend stopping aspirin five to seven days before knee arthroplasty surgery. Literature regarding multimodal blood management and continuation of anti-platelet therapy in this type of surgery is scant. The study hypothesis was that knee arthroplasty under low-dose aspirin mono-therapy continuation does not cause more total blood loss than knee arthroplasty performed without aspirin. Blood loss would be measured by haemoglobin (Hb) and haematocrit (HTC) levels drop at day 2 or day 4 for patients who benefit from multimodal bleeding control measures. METHODS A database of all patients undergoing knee arthroplasty between 2006 and 2014 was analysed. Demographic, surgical and complete blood workup data were collected. A retrospective comparison study analysed both groups in terms of blood loss, by mean calculated blood loss as haemoglobin or haematocrit drop between the preoperative Nadir value and the postoperative day 2 and 4 value. A group of 198 (44 UKA and 154 TKA) patients underwent surgery without interrupting their aspirin therapy for cardiovascular prevention. Mean (SD) age was 71 (8) and the mean (SD) BMI was 29 (5.5) kg/m2. The control group consisted of 403 (102 UKA and 301 TKA) patients who were not under aspirin, or any other anti-platelet agent. Mean (SD) age was 65 (10) (p < 0.05) and the mean (SD) BMI was 29 (5.0) kg/m2 (n.s.). All patients in the control group were randomly selected. RESULTS There were no differences in terms of visible (early) or hidden (late) blood loss as measured by Hb drop in between both groups. There is no difference in transfusion rates. CONCLUSIONS Modern multimodal blood management provides sufficient blood loss prevention during and after knee arthroplasty to allow physicians to continue low-dose aspirin mono-therapy for cardiovascular prevention. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | | | - JeanCyr Yombi
- University hospital Saint Luc, Av. Hippocrate 10, 1200, Brussels, Belgium
| | - Emmanuel Thienpont
- University hospital Saint Luc, Av. Hippocrate 10, 1200, Brussels, Belgium.
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Smith CC, Schneider B, McCormick ZL, Gill J, Loomba V, Engel AJ, Duszynski B, King W. Risks and Benefits of Ceasing or Continuing Anticoagulant Medication for Image-Guided Procedures for Spine Pain: A Systematic Review. PAIN MEDICINE 2017; 19:438-448. [DOI: 10.1093/pm/pnx152] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Clark C Smith
- Columbia University College of Physicians and Surgeons, New York, New York
| | | | | | - Jatinder Gill
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | - Wade King
- Manning Pain Management, Mayo Private Hospital, Taree, New South Wales, Australia
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Hashad MM, Abdeldaeim HM, Moussa A, Assem A, Youssif TMA. Bipolar vs monopolar resection of bladder tumours of >3 cm in patients maintained on low-dose aspirin: A randomised clinical trial. Arab J Urol 2017; 15:223-227. [PMID: 29071156 PMCID: PMC5651943 DOI: 10.1016/j.aju.2017.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 04/04/2017] [Accepted: 04/23/2017] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVE To compare the safety and efficacy of bipolar vs monopolar transurethral resection of bladder tumour (TURBT) in patients maintained on low-dose aspirin with tumours >3 cm. PATIENTS AND METHODS A prospective randomised single-centre study was performed including 200 patients with bladder tumours of >3 cm, as measured by ultrasonography. All patients were using low-dose aspirin (81 mg/day), which was not stopped in the perioperative period. Patients were randomised into two groups: Group A, monopolar TURBT (M-TURBT); Group B, bipolar TURBT (B-TURBT). The primary endpoint of the study was the decrease in postoperative haemoglobin (Hb) concentration measured using an automated cell counter. The secondary endpoints of the study were intraoperative blood transfusion or the occurrence of urethral trauma during cystoscopy and the need for re-coagulation. RESULTS The postoperative reduction in Hb concentration, was significantly lower in the B-TURBT group [mean (SD) 0.55 (0.26) g/dL] compared with the M-TURBT group [mean (SD) 1.24 (0.61) g/dL] (P < 0.001). There was also a significant difference (in favour of B-TURBT) between the groups in the mean postoperative reduction in haematocrit and the mean postoperative hospital stay. There was no significant difference between the groups for the occurrence of obturator jerk, bladder perforation, and the need for blood transfusion. CONCLUSION B-TURBT in patients maintained on low-dose aspirin is better than M-TURBT for minimising postoperative drop in Hb concentration.
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Affiliation(s)
| | | | - Ahmed Moussa
- Urology Department, Alexandria University, Alexandria, Egypt
| | - Akram Assem
- Urology Department, Alexandria University, Alexandria, Egypt
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Atwell TD, Wennberg PW, McMenomy BP, Murthy NS, Anderson JR, Kriegshauser JS, McKinney JM. Peri-procedural use of anticoagulants in radiology: an evidence-based review. Abdom Radiol (NY) 2017; 42:1556-1565. [PMID: 28070656 DOI: 10.1007/s00261-016-1027-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Peri-procedural anticoagulant management hinges on the balance of hemorrhagic and thrombotic complications. The radiologist is tasked with accurately assessing the hemorrhagic risk for patients undergoing procedures, taking into account procedural bleeding rates, underlying coagulopathy based on lab tests, and use of anticoagulants. The purpose of this article is to provide a contemporary review of commonly used anticoagulants and, incorporating published evidence, review their management related to image-guided procedures.
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Kamenova M, Croci D, Guzman R, Mariani L, Soleman J. Low-dose acetylsalicylic acid and bleeding risks with ventriculoperitoneal shunt placement. Neurosurg Focus 2017; 41:E4. [PMID: 27581316 DOI: 10.3171/2016.6.focus16173] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ventriculoperitoneal (VP) shunt placement is a common procedure for the treatment of hydrocephalus following diverse neurosurgical conditions. Most of the patients present with other comorbidities and receive antiplatelet therapy, usually acetylsalicylic acid (ASA). Despite its clinical relevance, the perioperative management of these patients has not been sufficiently investigated. The aim of this study was to compare the peri- and postoperative bleeding complication rates associated with ASA intake in patients undergoing VP shunt placement. METHODS Of 172 consecutive patients undergoing VP shunt placement between June 2009 and December 2015, 40 (23.3%) patients were receiving low-dose ASA treatment. The primary outcome measure was bleeding events in ASA users versus nonusers, whereas secondary outcome measures were postoperative cardiovascular events, hematological findings, morbidity, and mortality. A subgroup analysis was conducted in patients who discontinued ASA treatment for < 7 days (n = 4, ASA Group 1) and for ≥ 7 days (n = 36, ASA Group 2). RESULTS No statistically significant difference for bleeding events was observed between ASA users and nonusers (p = 0.30). Cardiovascular complications, surgical morbidity, and mortality did not differ significantly between the groups either. Moreover, there was no association between ASA discontinuation regimens (< 7 days and ≥ 7 days) and hemorrhagic events. CONCLUSIONS Given the lack of guidelines regarding perioperative management of neurosurgical patients with antiplatelet therapy, these findings elucidate one issue, showing comparable bleeding rates in ASA users and nonusers undergoing VP shunt placement.
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Affiliation(s)
- Maria Kamenova
- Department of Neurosurgery, University Hospital of Basel, Switzerland
| | - Davide Croci
- Department of Neurosurgery, University Hospital of Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Switzerland
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Burr-Hole Drainage for Chronic Subdural Hematoma Under Low-Dose Acetylsalicylic Acid: A Comparative Risk Analysis Study. World Neurosurg 2017; 100:594-600. [PMID: 28137546 DOI: 10.1016/j.wneu.2017.01.065] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 01/13/2017] [Accepted: 01/16/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Chronic subdural hematoma (cSDH) is one of the most common neurosurgical diseases typically affecting older people. Many of these patients have coronary artery disease and receive antiplatelet therapy, usually acetylsalicylic acid (ASA). Despite growing clinical relevance, there is still a lack of data focusing on the perioperative management of such patients. OBJECTIVE The aim of this study is to compare the perioperative and postoperative bleeding and cardiovascular complication rates of patients undergoing burr-hole drainage for cSDH with and without discontinuation of low-dose ASA. METHODS Of 963 consecutive patients undergoing burr-hole drainage for cSDH, 198 (20.5%) patients were receiving low-dose ASA treatment. In 26 patients (13.1%), ASA was not discontinued (ASA group; ASA discontinuation ≤7 days); in the remaining patients (n = 172; 86.9%), ASA was discontinued at least for 7 days (control group). The primary outcome measure was recurrent cSDH that required revision surgery owing to clinical symptoms, whereas secondary outcome measures were postoperative cardiovascular and thromboembolic events, other complications, operation and hospitalization time, morbidity, and mortality. RESULTS No statistically significant difference was observed between the 2 groups regarding recurrence of cSDH (P = 1). Cardiovascular event rates, surgical morbidity, and mortality did not significantly differ between patients with and without discontinuation of low-dose ASA. CONCLUSION Given the lack of guidelines regarding perioperative management with antiplatelet therapy, our findings elucidate one issue, showing comparable recurrence rates with and without discontinuation of low-dose ASA in patients undergoing burr-hole drainage for cSDH.
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Lu SY, Tsai CY, Lin LH, Lu SN. Dental extraction without stopping single or dual antiplatelet therapy: results of a retrospective cohort study. Int J Oral Maxillofac Surg 2016; 45:1293-8. [PMID: 26972159 DOI: 10.1016/j.ijom.2016.02.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 02/07/2016] [Accepted: 02/18/2016] [Indexed: 11/18/2022]
Abstract
The aim of this study was to investigate the incidence of bleeding after dental extraction without stopping antiplatelet therapy. Postoperative bleeding was assessed in a total of 1271 patients who were divided into two groups: a study group comprising 183 patients on antiplatelet therapy (aspirin 125 patients/185 occasions; clopidogrel 42 patients/65 occasions; dual therapy 16 patients/24 occasions) who underwent 548 dental extractions on 274 occasions, and a control group comprising 1088 patients who were not receiving any antiplatelet or anticoagulant therapy and underwent 2487 dental extractions on 1472 occasions. The incidence of postoperative bleeding was higher in the study group (5/274, 1.8%) than in the control group (10/1472, 0.7%), and also in the dual antiplatelet subgroup (1/24, 4.2%) than in the single antiplatelet subgroups (clopidogrel: 2/65, 3.1%; aspirin: 2/185, 1.1%); however, these differences were not significant. Postoperative bleeding was managed successfully by repacking with Gelfoam impregnated with tranexamic acid powder in 12 patients and by resuturing in three of the control patients undergoing extraction of impacted teeth with flap elevation. These findings indicate that there is no need to interrupt antiplatelet drugs before dental extraction.
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Affiliation(s)
- S-Y Lu
- Oral Pathology and Family Dentistry Section, Department of Dentistry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - C-Y Tsai
- Oral Pathology and Family Dentistry Section, Department of Dentistry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - L-H Lin
- Oral Pathology and Family Dentistry Section, Department of Dentistry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - S-N Lu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Thiele T, Kaftan H, Hosemann W, Greinacher A. Hemostatic management of patients undergoing ear-nose-throat surgery. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 14:Doc07. [PMID: 26770281 PMCID: PMC4702056 DOI: 10.3205/cto000122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Perioperative hemostatic management is increasingly important in the field of otolaryngology. This review summarizes the key elements of perioperative risk stratification, thromboprophylaxis and therapies for bridging of antithrombotic treatment. It gives practical advice based on the current literature with focus on patients undergoing ENT surgery.
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Affiliation(s)
- Thomas Thiele
- Institute for Immunology and Transfusion Medicine, Section of Transfusion Medicine, University Medicine of Greifswald, Germany
| | - Holger Kaftan
- Department of Otolaryngology, Head & Neck Surgery, University Medicine of Greifswald, Germany
| | - Werner Hosemann
- Department of Otolaryngology, Head & Neck Surgery, University Medicine of Greifswald, Germany
| | - Andreas Greinacher
- Institute for Immunology and Transfusion Medicine, Section of Transfusion Medicine, University Medicine of Greifswald, Germany
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Multicenter Study Assessing Physician Recommendations Regarding the Continuation of Aspirin and/or NSAIDs Prior to Gastrointestinal Endoscopy. Dig Dis Sci 2015; 60:3234-41. [PMID: 26123839 DOI: 10.1007/s10620-015-3781-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 06/20/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND In 2009 the American Society for Gastrointestinal Endoscopy (ASGE) guidelines advised that both aspirin and NSAIDs be continued prior to low-risk gastrointestinal endoscopic procedures. We sought to determine physician knowledge regarding these guidelines. METHODS A survey questionnaire was developed based on the ASGE guidelines. Physicians were queried about whether they would continue/stop aspirin in a patient with cardiac disease and in a patient taking NSAIDs for arthritis whether they would continue/stop NSAIDs prior to endoscopy. The survey was administered at three academic medical centers. Demographic information: level of training, board certification, teaching trainees, percentage of time in clinical practice, year of medical school graduation, and location of medical school were all reviewed. The primary outcome was number of questions answered correctly and predictors of correct responses. RESULTS The survey was administered to 941 participants with 12 declining to participate, while 80% (740/929) of the subjects completed the survey; 20% (150/740) respondents answered both questions correctly and 42% (310/740) answered one question correctly. There was no significant difference between institutions (p = 0.6) or between attendings and trainees (p = 0.75). Multivariate predictors of correct answers were self-reported familiarity with the guideline (-0.029; 95% CI -0.003 to -0.056, p < 0.031), level of training (0.050; 95% CI 0.012-0.088, p = 0.010), and specialty (0.108; 95% CI 0.058-0.159, p < 0.0001). Finally, there was an inverse, linear relationship between postgraduate year and percent questions correct. CONCLUSION Physician knowledge of guidelines regarding the use of aspirin and NSAIDs prior to endoscopy is suboptimal. Interventions are necessary to improve knowledge of the current pre-procedure guidelines.
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS guidelines on myocardial revascularization. EUROINTERVENTION 2015; 10:1024-94. [PMID: 25187201 DOI: 10.4244/eijy14m09_01] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Stephan Windecker
- Cardiology, Bern University Hospital, Freiburgstrasse 4, CH-3010 Bern, Switzerland
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Mima Y, Yasaka M, Wakugawa Y, Okada Y. Safety and Management of Antithrombotic Therapy with Intra-Arterial Catheter Procedures. Intern Med 2015; 54:2115-20. [PMID: 26328634 DOI: 10.2169/internalmedicine.54.4071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Intravascular catheter procedures are often performed in patients undergoing antithrombotic therapy. However, methods for the management of antithrombotic agents in the perioperative period are currently unclear. Therefore, the safety and management of antithrombotic agents in these patients were investigated. METHODS A prospective, multicenter, observational study [Management of Antithrombotic Agents During Surgery or Medical Procedures with Bleeding (MARK study)] at 58 National Hospital Organization institutions in Japan was performed. 1,040 patients were enrolled in the MARK study and underwent an intravascular catheter procedure. For all participants, the details of the procedure, method of perioperative management of antithrombotic agents, and occurrence of thrombosis, embolism, and bleeding complications during the study period were investigated. RESULTS The use of antithrombotic agents was continued in 1,017 patients (98%, continuation group) and discontinued in the other 23 (2%, discontinuation group). Continuation of the antithrombotic agents did not have a significant effect on the overall occurrence of thromboembolism [hazard ratio (HR), 0.15; p=0.08] or bleeding events (HR, 0.19; p=0.12). However, the overall adverse event risk was significantly lower in the continuation group than in the discontinuation group (HR, 0.18; p=0.03). CONCLUSION It is both safe and appropriate to perform intravascular catheter procedures in patients continuing with antithrombotic therapy.
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Affiliation(s)
- Yohei Mima
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Japan
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25
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541-619. [PMID: 25173339 DOI: 10.1093/eurheartj/ehu278] [Citation(s) in RCA: 3291] [Impact Index Per Article: 329.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Rai R, Mohan B, Babbar V, Dang N. Practices and Perceptions of Doctors for Patients on Anti-platelets During Dental Surgery: A National Survey. J Maxillofac Oral Surg 2014; 13:249-52. [PMID: 25018596 PMCID: PMC4082559 DOI: 10.1007/s12663-013-0523-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 04/13/2013] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Marked variations are noticed in the practices about anti-platelet therapy during dental surgery due to fear of thrombotic events versus bleeding. The main aim of this survey was to study the prevalent practices and perceptions amongst dentists, physicians and cardiologists for stopping anti-platelet agents (APA) in patients undergoing dental extractions. MATERIALS AND METHODS A questionnaire consisting of 5 questions was distributed to 800 doctors. Questions were related to their perception about increased bleeding complications versus thrombotic risks in cardiac patient on anti-platelet agents undergoing dental surgery. The data was analyzed using Chi-square test and Z-test. RESULTS Total number of responders was 428 from a total of 800 doctors. It consisted of two groups, group I (325) included physicians and group II (103) included dentists. 82.5 % of dentists believed that bleeding increased if APA are continued whereas 42.77 % of physicians felt the opposite (p = 0.0000035). When asked about stopping APA in patients of stable angina and stroke, both groups had similar answers (63.1 vs. 60.92 %). For patients with medicated stents 70.76 % of physicians were not in favor of stopping APA but 49.51 % dentists believed that it should be stopped (p = 0.0001). However, regarding their attitude towards stopping APA in patients with bare metal stents or post CABG, most of the doctors felt that it should be stopped (48.61 vs. 42.71 %). Discrepancy regarding the number of days for which APA should be withdrawn was found among both the groups. CONCLUSION Marked variation was found amongst participants in this survey despite international guidelines on APA being used during dental surgery. There is a need for national guidelines to be laid on this issue and dissemination of knowledge among the practicing doctors.
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Affiliation(s)
- Rita Rai
- />Department of Dentistry, Dayanand Medical College and Hospital, Ludhiana, 141001 India
| | - B. Mohan
- />Department of Cardiology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Vibha Babbar
- />Department of Dentistry, Dayanand Medical College and Hospital, Ludhiana, 141001 India
| | - Namita Dang
- />Department of Dentistry, Dayanand Medical College and Hospital, Ludhiana, 141001 India
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Martín-Merino E, Johansson S, Nagy P, García Rodríguez LA. Represcription of low-dose acetylsalicylic acid after discontinuation in patients receiving treatment for secondary cardiovascular disease prevention in the UK. Am J Cardiovasc Drugs 2014; 14:319-26. [PMID: 25027353 DOI: 10.1007/s40256-014-0079-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In this retrospective database study, carried out using The Health Improvement Network, a UK primary care database, we followed up patients who were prescribed low-dose acetylsalicylic acid (ASA) (75-300 mg/day) for the secondary prevention of cardiovascular disease in 2000-2007, and who discontinued therapy for a period of at least 90 days during that time (n = 11,565). We assessed the incidence of, and factors associated with, ASA represcription. Patients were followed up from the first day after their initial 90-day period of discontinuation (start date) until ASA represcription, death, or the end of the study period (31 December 2010). Hazard ratios for factors associated with represcription were calculated using Cox regression models. The cumulative incidence of ASA represcription was 85.2% over the entire follow-up period, and 63.5% of all represcriptions were received in the first 6 months after patients' start dates. Factors significantly associated with a reduced likelihood of ASA represcription included being aged 75-84 years, cardiovascular and gastrointestinal comorbidities (in particular, atrial fibrillation and high overall gastrointestinal risk), adverse drug reactions experienced during therapy, and use of gastroprotective or cardiovascular medications (most notably warfarin). Factors significantly associated with an increased likelihood of ASA represcription included obesity, diabetes mellitus, stable angina, depression, and use of non-steroidal anti-inflammatory drugs. In conclusion, approximately 85% of patients who discontinued low-dose ASA therapy were subsequently represcribed ASA during the study period. Comorbidities and comedication use affected represcription rates.
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Affiliation(s)
- Elisa Martín-Merino
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Almirante 28-2, 28004, Madrid, Spain
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Wahl MJ. Dental surgery and antiplatelet agents: bleed or die. Am J Med 2014; 127:260-7. [PMID: 24333202 DOI: 10.1016/j.amjmed.2013.11.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 11/02/2013] [Accepted: 11/13/2013] [Indexed: 01/14/2023]
Abstract
In patients taking antiplatelet medications who are undergoing dental surgery, physicians and dentists must weigh the bleeding risks in continuing antiplatelet medications versus the thrombotic risks in interrupting antiplatelet medications. Bleeding complications requiring more than local measures for hemostasis are rare after dental surgery in patients taking antiplatelet medications. Conversely, the risk for thrombotic complications after interruption of antiplatelet therapy for dental procedures apparently is significant, although small. When a clinician is faced with a decision to continue or interrupt antiplatelet therapy for a dental surgical patient, the decision comes down to "bleed or die." That is, there is a remote chance that continuing antiplatelet therapy will result in a (nonfatal) bleeding problem requiring more than local measures for hemostasis versus a small but significant chance that interrupting antiplatelet therapy will result in a (possibly fatal) thromboembolic complication. The decision is simple: It is time to stop interrupting antiplatelet therapy for dental surgery.
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Dental extraction can be performed safely in patients on aspirin therapy: a timely reminder. ISRN DENTISTRY 2014; 2014:463684. [PMID: 25093121 PMCID: PMC4004018 DOI: 10.1155/2014/463684] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 03/16/2014] [Indexed: 12/01/2022]
Abstract
Cardiac patients on aspirin therapy may require extractions for their diseased teeth. It is a common practice among physicians and treating surgeons to stop aspirin prior to tooth extraction because of fear of bleeding complications. This practice often predisposes the patient to adverse thromboembolic events. This practice is based on theoretical risk of bleeding and on isolated case reports of excessive bleeding with aspirin therapy. The current consensus and recommendations are in favor of continuing aspirin therapy during simple tooth extraction as the bleeding complication incidence is very less and if it occurs can be controlled efficiently with local hemostasis measures.
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Zuckerman SL, Seder DB, Tsujiura C, Cushing D, Gallup H, Mocco J, Hanel RA, Ecker RD. Aspirin allergy desensitization in cerebrovascular disease. A report of two cases, literature review and management guide for the neurointerventionalist. Interv Neuroradiol 2014; 20:5-11. [PMID: 24556294 DOI: 10.15274/inr-2014-10002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 08/10/2013] [Indexed: 01/23/2023] Open
Abstract
Aspirin (ASA) is the mainstay of treatment in cerebrovascular and systemic vascular disease. ASA hypersensitivity can pose a challenge to achieving optimum medical management prior to and after neurointerventional treatment. Desensitization to ASA is well described in the allergy and cardiovascular literature, but there are no similar discussions specific to neurointervention. The purpose of our study was to describe our experience with ASA hypersensitivity management and review the relevant literature. Two cases of patients with symptomatic cerebrovascular disease requiring neurointervention who were successfully desensitized to their ASA hypersensitivity prior to treatment are described. The subsequent literature is reviewed. Several ASA desensitization protocols exist and have been proven to successfully treat ASA hypersensitivity and allow for ASA therapy to be safely initiated. We describe several previously published protocols. ASA desensitization is a safe and simple way to manage ASA hypersensitivity. We provide comprehensive management guidelines for the neurointerventionalist engaging in ASA desensitization.
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Affiliation(s)
- Scott L Zuckerman
- Department of Neurosurgery, Vanderbilt University Medical Center; Nashville, TN, USA -
| | - David B Seder
- Department of Neurosurgery, Vanderbilt University Medical Center; Nashville, TN, USA
| | - Crystiana Tsujiura
- Department of Neurosurgery, Vanderbilt University Medical Center; Nashville, TN, USA
| | - Deborah Cushing
- Department of Neurosurgery, Vanderbilt University Medical Center; Nashville, TN, USA
| | - Holly Gallup
- Department of Neurosurgery, Vanderbilt University Medical Center; Nashville, TN, USA
| | - J Mocco
- Department of Neurosurgery, Vanderbilt University Medical Center; Nashville, TN, USA
| | - Richard A Hanel
- Department of Neurosurgery, Vanderbilt University Medical Center; Nashville, TN, USA
| | - Robert D Ecker
- Department of Neurosurgery, Vanderbilt University Medical Center; Nashville, TN, USA
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Doutremepuich C, Aguejouf O, Desplat V, Eizayaga FX. Aspirin discontinuation syndromes: clinical implications of basic research studies. Am J Cardiovasc Drugs 2013; 13:377-84. [PMID: 24045958 DOI: 10.1007/s40256-013-0044-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Abrupt discontinuation of many drugs used in medicine causes withdrawal syndromes, some of which can be fatal. Discontinuation of a number of cardiovascular drugs can increase the risk of cardiovascular events. Whereas aspirin administration is known to decrease the risk of vascular ischemic problems, aspirin withdrawal may temporarily increase the risk of thrombotic events. Indeed, aspirin withdrawal has been associated with an increased risk of thrombosis both in clinical and fundamental research studies. Such complications occur within the first month after interrupting aspirin therapy and their mechanism remains unexplained. We have previously demonstrated that aspirin, when injected as a single high dose (100 mg/kg), induces a prothrombotic state in the rat, similar to that described above, 8 and 10 days after administration. This effect in the rat may be reproduced 1 hour after a single injection of ultra-low-dose aspirin. Caution is therefore required regarding the possibility of drug discontinuation effects within the framework of drug safety evaluation.
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Abstract
UNLABELLED Although special care dentistry (SCD) is a fairly recent specialty, the principles and practice of SCD have been developed since the 1980s. Shared care of these patients with general dental practitioners remains vital to ensure that comprehensive care is provided. This article aims to discuss some of the patient groups commonly seen in SCD clinics and give an insight into the varied complex medical and social aspects of care which are managed as part of providing appropriate, safe and holistic care. CLINICAL RELEVANCE Many patients who currently fall under the remit of special care dentistry could be treated safely in general dental practice. This article acts as an introduction to special care dentistry for general dental practitioners.
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Does Antiplatelet Therapy Increase the Risk of Hemoptysis During Percutaneous Transthoracic Needle Biopsy of a Pulmonary Lesion? AJR Am J Roentgenol 2013; 200:1014-9. [DOI: 10.2214/ajr.12.8931] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Napeñas JJ, Oost FC, deGroot A, Loven B, Hong CH, Brennan MT, Lockhart PB, van Diermen DE. Review of postoperative bleeding risk in dental patients on antiplatelet therapy. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 115:491-9. [DOI: 10.1016/j.oooo.2012.11.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 09/29/2012] [Accepted: 10/22/2012] [Indexed: 10/27/2022]
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Omar HR, Mangar D, Karlnoski R, Abdelmalak HD, Camporesi EM. Simultaneous left anterior descending and right coronary stent thrombosis after aspirin withdrawal. Am J Emerg Med 2012; 30:2093.e5-8. [DOI: 10.1016/j.ajem.2011.12.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2011] [Accepted: 12/21/2011] [Indexed: 10/28/2022] Open
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Abstract
PURPOSE OF REVIEW : This review summarizes the systematic approaches that can be used to optimize secondary stroke prevention. Systematic secondary stroke prevention involves not only prescribing stroke patients the appropriate medications to manage risk factors, but also optimizing the effectiveness of those drugs by focusing on medication adherence. Medication adherence is defined as the extent to which patients take their medications as prescribed by their providers. RECENT FINDINGS : Many potential barriers to adherence exist, including relationships among patient, provider, and the health system. Medication reconciliation at discharge and early follow-up are steps that may increase medication adherence, decrease medication errors, and improve the transition to home. In addition, inclusion of the primary provider or stroke specialist in decisions regarding the management of antithrombotic therapy for procedures is important, as discontinuing these medications is often associated with recurrent ischemic events. SUMMARY : Prevention of recurrent stroke should be a priority for patients, caregivers, providers, and health systems. Medication-taking behavior should be considered from all of these perspectives in order to optimize adherence.
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Samama CM. Gestion péri-opératoire des antiplaquettaires. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2012. [DOI: 10.1016/s1878-6480(12)70837-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Lan Y, Lu GT. Preventive and therapeutic strategies for gastrointestinal injury associated with antiplatelet therapy. Shijie Huaren Xiaohua Zazhi 2012; 20:1489-1494. [DOI: 10.11569/wcjd.v20.i17.1489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Antiplatelet therapy is the basic therapy for cardiovascular diseases and is widely used in clinical practice. It can cause damage to the gastrointestinal tract and induce severe events such as gastrointestinal bleeding. It is very important for clinicians to prevent and treat this side effect in patients taking low-dose aspirin and clopidogrel. In this paper we discuss the mechanism, prevention and treament of gastrointestinal injury caused by aspirin and clopidogrel, and introduce the consensus recommendations on reducing the gastrointestinal risk of antiplatelet therapy.
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Should more patients continue aspirin therapy perioperatively?: clinical impact of aspirin withdrawal syndrome. Ann Surg 2012; 255:811-9. [PMID: 22470078 DOI: 10.1097/sla.0b013e318250504e] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To provide an evidence-based focused review of aspirin use in the perioperative period along with an in-depth discussion of the considerations and risks associated with its preoperative withdrawal. BACKGROUND For patients with established cardiovascular disease, taking aspirin is considered a critical therapy. The cessation of aspirin can cause a platelet rebound phenomenon and prothrombotic state leading to major adverse cardiovascular events. Despite the risks of aspirin withdrawal, which are exacerbated during the perioperative period, standard practice has been to stop aspirin before elective surgery for fear of excessive bleeding. Mounting evidence suggests that this practice should be abandoned. METHODS We performed a PubMed and Medline literature search using the keywords aspirin, withdrawal, and perioperative. We manually reviewed relevant citations for inclusion. RESULTS/CONCLUSIONS Clinicians should employ a patient-specific strategy for perioperative aspirin management that weighs the risks of stopping aspirin with those associated with its continuation. Most patients, especially those taking aspirin for secondary cardiovascular prevention, should have their aspirin continued throughout the perioperative period. When aspirin is held preoperatively, the aspirin withdrawal syndrome may significantly increase the risk of a major thromboembolic complication. For many operative procedures, the risk of perioperative bleeding while continuing aspirin is minimal, as compared with the concomitant thromboembolic risks associated with aspirin withdrawal. Those cases where aspirin should be stopped include patients undergoing intracranial, middle ear, posterior eye, intramedullary spine, and possibly transurethral prostatectomy surgery.
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Nowfar S, Kopp R, Palazzi-Churas K, Derweesh IH, Kane CJ. Initial Experience with Aspirin Use During Robotic Radical Prostatectomy. J Laparoendosc Adv Surg Tech A 2012; 22:225-9. [DOI: 10.1089/lap.2011.0388] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sepehr Nowfar
- Department of Surgery/Urology, University of California San Diego, La Jolla, California
| | - Ryan Kopp
- Department of Surgery/Urology, University of California San Diego, La Jolla, California
| | - Kerrin Palazzi-Churas
- Department of Surgery/Urology, University of California San Diego, La Jolla, California
| | - Ithaar H. Derweesh
- Department of Surgery/Urology, University of California San Diego, La Jolla, California
- Moores UCSD Cancer Center, La Jolla, California
- VA San Diego Medical Center, La Jolla, California
| | - Christopher J. Kane
- Department of Surgery/Urology, University of California San Diego, La Jolla, California
- Moores UCSD Cancer Center, La Jolla, California
- VA San Diego Medical Center, La Jolla, California
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Cea Soriano L, Bueno H, Johansson S, García Rodríguez LA. Predictors and time trends in clopidogrel and proton pump inhibitor coprescription with low-dose acetylsalicylic acid. Pharmacoepidemiol Drug Saf 2012; 21:463-9. [DOI: 10.1002/pds.3195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 11/14/2011] [Accepted: 11/28/2011] [Indexed: 12/23/2022]
Affiliation(s)
- Lucía Cea Soriano
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE); Madrid Spain
| | - Héctor Bueno
- Department of Cardiology; Hospital General Universitario Gregorio Marañón; Madrid Spain
| | - Saga Johansson
- AstraZeneca R&D; Mölndal Sweden
- Institute of Medicine, Sahlgrenska Academy; Gothenburg University; Gothenburg Sweden
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Park MW, Her SH, Kwon JB, Lee JB, Choi MS, Cho JS, Kim DB, Chung WS, Seung KB, Kim KY. Safety of dental extractions in coronary drug-eluting stenting patients without stopping multiple antiplatelet agents. Clin Cardiol 2012; 35:225-30. [PMID: 22278596 DOI: 10.1002/clc.21960] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 11/22/2011] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The risk of excessive bleeding prompts physicians to stop multiple antiplatelet agents before minor surgery, which puts coronary stenting patients at risk for adverse thrombotic events. HYPOTHESIS We hypothesized that most dental extractions can be carried out safely without stopping multiple antiplatelet agents. METHODS All dental extraction patients who had undergone coronary stenting and who were also on oral multiple antiplatelet agents therapy were enrolled. One hundred patients underwent dental procedures without stopping antiplatelet agents. All wounds were sutured and followed up at 24 hours, 1 week, and 1 month after the procedure. There were 2233 patients who had not taken oral antiplatelet agents from a health promotion center and had teeth extracted by the same method. After performing propensity-score matching for the entire population, a total of 100 matched pairs of patients were created. The primary outcome was a composite of excessive intraextraction blood loss, transfusion, and rehospitalization for bleeding, and the secondary outcome was a composite of death, nonfatal myocardial infarction, target lesion revascularization, and stent thrombosis within 1 month after the procedure. RESULTS There were 2 excessive intraextraction bleeding cases that continued at the extraction site for 4 and 5 hours, respectively, in the coronary stenting patients, and 1 excessive intraextraction bleeding case that continued for 3 hours in the control patients. There were no cases of transfusion, rehospitalization for bleeding, or major cardiovascular events for the 2 propensity-matched groups. CONCLUSIONS We found that most dental extractions in coronary stenting patients can be carried out safely without stopping multiple antiplatelet agents.
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Affiliation(s)
- Mahn-Won Park
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, South Korea
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Complications of cutaneous surgery in patients taking clopidogrel-containing anticoagulation. J Am Acad Dermatol 2011; 65:584-591. [DOI: 10.1016/j.jaad.2011.02.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Revised: 11/10/2010] [Accepted: 02/23/2011] [Indexed: 11/22/2022]
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Reidenberg MM. Drug discontinuation effects are part of the pharmacology of a drug. J Pharmacol Exp Ther 2011; 339:324-8. [PMID: 21849624 DOI: 10.1124/jpet.111.183285] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Most reviews of drug withdrawal effects focus on drugs of potential abuse such as opioids, benzodiazepines, etc. Abrupt discontinuation of many other drugs used in medicine cause withdrawal syndromes, some of which can be fatal. Discontinuation of a number of cardiovascular drugs can increase risk of cardiovascular events above that of people not taking these drugs. These include β-adrenergic receptor antagonists, aspirin, HMG-CoA reductase inhibitors (statins), and heparin. Rebound hypertension occurs after abrupt cessation of many antihypertensive drugs. The possibility of discontinuation syndromes has usually been neglected until adverse clinical events force them to be noticed. Attention to the possibility of drug discontinuation effects is an important part of drug safety evaluation.
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Ferrandis R, Llau JV, Mugarra A. Perioperative management of antiplatelet-drugs in cardiac surgery. Curr Cardiol Rev 2011; 5:125-32. [PMID: 20436853 PMCID: PMC2805815 DOI: 10.2174/157340309788166688] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Revised: 08/11/2008] [Accepted: 08/11/2008] [Indexed: 11/30/2022] Open
Abstract
The management of coronary patients scheduled for a coronary artery bypass grafting (CABG), who are receiving one or more antiplatelet drugs, is plenty of controversies. It has been shown that withdrawal of antiplatelet drugs is associated with an increased risk of a thrombotic event, but surgery under an altered platelet function also means an increased risk of bleeding in the perioperative period. Because of the conflict recommendations, this review article tries to evaluate the outcome of different perioperative antiplatelet protocols in patients with coronary artery disease undergoing CABG.
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Affiliation(s)
- Raquel Ferrandis
- Department of Anaesthesiology and Critical Care Medicine, Hospital Clínic Universitari, València, Spain
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46
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Richter JA, Patrie JT, Richter RP, Henry ZH, Pop GH, Regan KA, Peura DA, Sawyer RG, Northup PG, Wang AY. Bleeding after percutaneous endoscopic gastrostomy is linked to serotonin reuptake inhibitors, not aspirin or clopidogrel. Gastrointest Endosc 2011; 74:22-34.e1. [PMID: 21704806 DOI: 10.1016/j.gie.2011.03.1258] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 03/29/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is an invasive procedure that can result in bleeding. Guidelines recommend discontinuing clopidogrel for 7 to 10 days, but not withholding aspirin, before PEG. Serotonin reuptake inhibitors (SRIs) have been associated with an increased risk of GI bleeding. OBJECTIVE To determine whether there is an association between periprocedural aspirin, clopidogrel, or SRI use and bleeding in patients who underwent PEG tube placement. DESIGN Retrospective cohort study. SETTING Large quaternary-care academic medical center. PATIENTS A total of 990 patients (525 men) with a median age of 69.8 years who underwent PEG from January 1999 to April 2009. INTERVENTIONS PEG tube placement. MAIN OUTCOME MEASUREMENTS GI bleeding. RESULTS Sixteen patients (1.6%) had evidence of bleeding during the first 48 hours after PEG, and 12 patients (1.2%) had evidence of bleeding between 48 hours and 14 days after PEG. Thirty-six patients (3.6%) received high-dose aspirin (>325 mg), 27 patients (2.7%) received clopidogrel (75 mg), and 99 patients (10%) received an SRI before PEG. Twenty-four patients (2.4%) received high-dose aspirin, 25 patients (2.5%) received clopidogrel, and 130 patients (13.1%) received an SRI after PEG. Multivariate analysis demonstrated no association between periprocedural use of aspirin (at any dose) or clopidogrel and post-PEG bleeding. However, SRIs administered 24 hours or less before PEG were associated with a significantly higher odds of post-PEG bleeding (adjusted odds ratio 4.1; 95% CI, 1.1-13.4; P = .04). LIMITATIONS Retrospective, single-center study with limited statistical power despite a relatively large cohort of patients. CONCLUSIONS Use of aspirin or clopidogrel before or after PEG was not associated with procedure-related bleeding. SRI use in the 24 hours before PEG was associated with an increased risk of bleeding.
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Saini SD, Fendrick AM, Scheiman JM. Cost-effectiveness analysis: cardiovascular benefits of proton pump inhibitor co-therapy in patients using aspirin for secondary prevention. Aliment Pharmacol Ther 2011; 34:243-51. [PMID: 21615437 DOI: 10.1111/j.1365-2036.2011.04707.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Many patients with cardiovascular (CV) disease will stop aspirin (ASA) because of ASA-related dyspepsia. Proton pump inhibitor (PPI) co-therapy may reduce ASA-related dyspepsia, enhancing ASA adherence and improving CV outcomes. AIM To explore the impact of PPI co-therapy on CV outcomes in long-term, low-dose ASA users. METHODS We modified a previously published Markov model to assess the long-term impact of PPI co-therapy on CV and upper gastrointestinal bleeding (UGIB) outcomes among patients using ASA for secondary CV prevention. UGIB events, recurrent myocardial infarctions (MIs) and incremental cost-effectiveness ratios (ICERs) were measured. The perspective taken was that of a long-term payer. RESULTS Compared with ASA alone, ASA plus PPI resulted in fewer lifetime UGIB events (3.4% vs. 7.2%) and increased ASA adherence (74% vs. 71%). Increased ASA adherence resulted in fewer recurrent MIs (26 fewer events per 10000 patients). On average, the ASA plus PPI strategy resulted in 38 additional days of life per patient, with the majority of this benefit (61%) because of a reduction in CV mortality (rather than UGIB-related mortality). ASA plus PPI was also more costly than ASA alone, with an ICER of $19000 per life-year saved. Results were sensitive to cost of PPI and impact of PPI on ASA adherence. CONCLUSIONS Proton pump inhibitor co-therapy has the potential to impact not only GI, but also CV outcomes in patients with CV disease using ASA and such co-therapy is likely to be cost-effective. Future studies should better quantify the CV benefits of PPI co-therapy.
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Affiliation(s)
- S D Saini
- Center for Clinical Management Research, Ann Arbor VA HSR&D Center of Excellence, Ann Arbor, MI 48105, USA.
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48
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Moberg C, Naesdal J, Svedberg LE, Duchateau D, Harte N. Impact of Gastrointestinal Problems on Adherence to Low-Dose Acetylsalicylic Acid. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2011; 4:103-13. [DOI: 10.2165/11589200-000000000-00000] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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49
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Václavík J, Táborský M. Antiplatelet therapy in the perioperative period. Eur J Intern Med 2011; 22:26-31. [PMID: 21238889 DOI: 10.1016/j.ejim.2010.10.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 10/01/2010] [Accepted: 10/25/2010] [Indexed: 12/22/2022]
Abstract
The current practice of withdrawing aspirin 7-10 days preoperatively may be dangerous in certain groups of patients. The risk of cardiovascular events increases 3-fold after aspirin withdrawal. The average time between aspirin withdrawal and the manifestation of acute coronary syndrome is 8 to 11 days. The withdrawal of clopidogrel earlier than 4-6 weeks after bare metal stent implantation or less than 12 months after drug-eluting stent implantation is very risky and poses a high risk of stent thrombosis and high perioperative mortality. Continuing aspirin perioperatively leads to a 1.5-fold increase in perioperative bleeding complications but it does not lead to a higher severity of bleeding complications or higher mortality. The article analyzes current European and American guidelines for perioperative antiplatelet treatment and suggests an algorithm based on the guidelines to help make clinical decisions.
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Affiliation(s)
- Jan Václavík
- Department of Internal Medicine I-Cardiology, University Hospital Olomouc and Palacký University Faculty of Medicine, I. P. Pavlova 6, 775 20, Olomouc, Czech Republic.
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50
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Frelinger AL, Barnard MR, Fox ML, Michelson AD. The Platelet Activity After Clopidogrel Termination (PACT) study. Circ Cardiovasc Interv 2010; 3:442-9. [PMID: 20736449 DOI: 10.1161/circinterventions.110.937961] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND "Rebound" platelet hyperreactivity after discontinuation of clopidogrel has been proposed to lead to increased thrombotic risk, including late stent thrombosis. However the hypothesis that discontinuation of clopidogrel results in platelet hyperreactivity has never been rigorously tested. We therefore performed a randomized, double-blind, placebo-controlled, crossover study: the Platelet Activity after Clopidogrel Termination (PACT) study. METHODS AND RESULTS Platelet reactivity in 15 healthy subjects was measured at baseline, during clopidogrel 75 mg or placebo daily for 14 days, and on days 1, 4, 8, 11, 15, and 45 after discontinuation of clopidogrel or placebo. Platelet reactivity was assessed by (1) platelet surface activated GPIIb-IIIa and surface P-selectin (by whole blood flow cytometry) in response to ADP 0.5, 1, and 20 μmol/L; thrombin receptor activating peptide (TRAP) 1 and 20 μmol/L; and collagen/epinephrine 5 μg/mL/5 μmol/L, (2) light transmission aggregation with ADP 2.5, 5, and 20 μmol/L; TRAP 2 and 20 μmol/L; and collagen 6 μg/mL, (3) whole blood impedance aggregation with ADP 1.6 and 6.5 μmol/L; TRAP 4 and 32 μmol/L; and collagen 3.2 μg/mL, and (4) plasma soluble CD40 ligand (by ELISA). Immature platelet fraction was measured in the Sysmex XE-2100. At no time point after discontinuation of clopidogrel was platelet reactivity, as determined by any assay end point, or the immature platelet fraction significantly greater than after discontinuation of placebo. CONCLUSIONS This randomized, double-blind, placebo-controlled, crossover study demonstrates that discontinuation of clopidogrel does not result in "rebound" platelet hyperreactivity, as determined by multiple time points, assays, agonists, and agonist concentrations. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00619073.
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Affiliation(s)
- Andrew L Frelinger
- Center for Platelet Research Studies, Division of Hematology/Oncology, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115-5737, USA.
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