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Premji AM, Blegen MB, Corley AM, Ulloa J, Booth MS, Begashaw M, Larkin J, Shekelle P, Girgis MD, Maggard-Gibbons M. Dual antiplatelet management in the perioperative period: updated and expanded systematic review. Syst Rev 2023; 12:197. [PMID: 37838696 PMCID: PMC10576385 DOI: 10.1186/s13643-023-02360-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 09/25/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND Antiplatelet agents are central in the management of vascular disease. The use of dual antiplatelet therapy (DAPT) for the management of thromboembolic complications must be weighed against bleeding risk in the perioperative setting. This balance is critical in patients undergoing cardiac or non-cardiac surgery. The management of patients on DAPT for any indication (including stents) is not clear and there is limited evidence to guide decision-making. This review summarizes current evidence since 2015 regarding the occurrence of major adverse events associated with continuing, suspending, or varying DAPT in the perioperative period. METHODS A research librarian searched PubMed and Cochrane from November 30, 2015 to May 17, 2022, for relevant terms regarding adult patients on DAPT for any reason undergoing surgery, with a perioperative variation in DAPT strategy. Outcomes of interest included the occurrence of major adverse cardiac events, major adverse limb events, all-cause death, major bleeding, and reoperation. We considered withdrawal or discontinuation of DAPT as stopping either aspirin or a P2Y12 inhibitor or both agents; continuation of DAPT indicates that both drugs were given in the specified timeframe. RESULTS Eighteen observational studies met the inclusion criteria. No RCTs were identified, and no studies were judged to be at low risk of bias. Twelve studies reported on CABG. Withholding DAPT therapy for more than 2 days was associated with less blood loss and a slight trend favoring less transfusion and surgical re-exploration. Among five observational CABG studies, there were no statistically significant differences in patient death across DAPT management strategies. Few studies reported cardiac outcomes. The remaining studies, which were about procedures other than exclusively CABG, demonstrated mixed findings with respect to DAPT strategy, bleeding, and ischemic outcomes. CONCLUSION The evidence base on the benefits and risks of different perioperative DAPT strategies for patients with stents is extremely limited. The strongest signal, which was still judged as low certainty evidence, is that suspension of DAPT for greater than 2 days prior to CABG surgery is associated with less bleeding, transfusions, and re-explorations. Different DAPT strategies' association with other outcomes of interest, such as MACE, remains uncertain. SYSTEMATIC REVIEW REGISTRATION A preregistered protocol for this review can be found on the PROSPERO International Prospective Register of systematic reviews ( http://www.crd.york.ac.uk/PROSPERO/ ; registration number: CRD42022371032).
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Affiliation(s)
- Alykhan M Premji
- Veterans Health Administration, Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA, 90073, USA.
| | - Mariah B Blegen
- Veterans Health Administration, Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA, 90073, USA
- National Clinician Scholars Program, University of California, Los Angeles, 1100 Glendon Ave., Suite 900, Los Angeles, CA, 90024, USA
| | - Alyssa M Corley
- Duke University School of Medicine, DUMC Box 104002, Durham, NC, 27710, USA
| | - Jesus Ulloa
- Veterans Health Administration, Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA, 90073, USA
- David Geffen School of Medicine at University of California, Los Angeles, 885 Tiverton Dr., Los Angeles, CA, 90095, USA
| | - Marika S Booth
- Southern California Evidence-Based Practice Center, RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA
| | - Meron Begashaw
- Veterans Health Administration, Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA, 90073, USA
| | - Jody Larkin
- Southern California Evidence-Based Practice Center, RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA
| | - Paul Shekelle
- Veterans Health Administration, Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA, 90073, USA
| | - Mark D Girgis
- Veterans Health Administration, Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA, 90073, USA
- David Geffen School of Medicine at University of California, Los Angeles, 885 Tiverton Dr., Los Angeles, CA, 90095, USA
| | - Melinda Maggard-Gibbons
- Veterans Health Administration, Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA, 90073, USA
- David Geffen School of Medicine at University of California, Los Angeles, 885 Tiverton Dr., Los Angeles, CA, 90095, USA
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Wu F, Ma K, Xiang R, Han B, Chang J, Zuo Z, Luo Y, Mao M. Efficacy and safety of a bridging strategy that uses intravenous platelet glycoprotein receptor inhibitors for patients undergoing surgery after coronary stent implantation: a meta-analysis. BMC Cardiovasc Disord 2022; 22:125. [PMID: 35331138 PMCID: PMC8953042 DOI: 10.1186/s12872-022-02563-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 03/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Current guidelines indicate we can consider a bridging strategy that uses intravenous, reversible glycoprotein inhibitors for patients that required surgery following recent stent implantation. However, no strong clinical evidence exists that demonstrates the efficacy and safety of this treatment. Therefore, in this study, the efficacy and safety of a bridging strategy that uses intravenous platelet glycoprotein receptor inhibitors will be evaluated. METHODS A meta-analysis was performed on preoperative bridging studies in patients undergoing coronary stent surgery. The primary outcome was the success rate of no major adverse cardiovascular events (MACE). The secondary outcomes were the success rate of no reoperations to stop bleeding. RESULTS A total of 10 studies that included 382 patients were used in this meta-analysis. For the primary endpoint, the success rate was 97.7% (95% CI 94.4-98.0%) for glycoprotein IIb/IIIa inhibitors, 98.8% (95% CI 96.0-100%) for tirofiban (6 studies) and 95.8% (95% CI 90.4-99.4%) for eptifibatide (4 studies). For secondary endpoints, the success rate was 98.0% (95% CI 94.8-99.9%) for glycoprotein IIb/IIIa inhibitors, 99.7% (95% CI 97.1-100%) for tirofiban (5 studies), and 95.3% (95% CI 88.5-99.4%) for eptifibatide (4 studies). CONCLUSION The results of this study showed that the use of intravenous platelet glycoprotein IIb/IIIa inhibitors as a bridging strategy might be safe and effective for patients undergoing coronary stent implantation that require surgery soon after.
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Affiliation(s)
- Fan Wu
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Kanghua Ma
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Rui Xiang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Baoru Han
- College of Medical Informatics, Chongqing Medical University, Chongqing, 401135, China
| | - Jing Chang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Zhong Zuo
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Yue Luo
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Min Mao
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China.
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3
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Sirolimus Release from Biodegradable Polymers for Coronary Stent Application: A Review. Pharmaceutics 2022; 14:pharmaceutics14030492. [PMID: 35335869 PMCID: PMC8949664 DOI: 10.3390/pharmaceutics14030492] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 02/02/2023] Open
Abstract
Drug-eluting stents (DESs) are commonly used for the treatment of coronary artery disease. The evolution of the drug-eluting layer on the surface of the metal stent plays an important role in DES functionality. Here, the use of biodegradable polymers has emerged as an attractive strategy because it minimizes the occurrence of late thrombosis after stent implantation. Furthermore, understanding the drug-release behavior of DESs is also important for improving the safety and efficacy of stent treatments. Drug release from biodegradable polymers has attracted extensive research attention because biodegradable polymers with different properties show different drug-release behaviors. Molecular weight, composition, glass transition temperature, crystallinity, and the degradation rate are important properties affecting the behavior of polymers. Sirolimus is a conventional anti-proliferation drug and is the most widely used drug in DESs. Sirolimus-release behavior affects endothelialization and thrombosis formation after DES implantation. In this review, we focus on sirolimus release from biodegradable polymers, including synthetic and natural polymers widely used in the medical field. We hope this review will provide valuable up-to-date information on this subject and contribute to the further development of safe and efficient DESs.
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Jourdi G, Godier A, Lordkipanidzé M, Marquis-Gravel G, Gaussem P. Antiplatelet Therapy for Atherothrombotic Disease in 2022—From Population to Patient-Centered Approaches. Front Cardiovasc Med 2022; 9:805525. [PMID: 35155631 PMCID: PMC8832164 DOI: 10.3389/fcvm.2022.805525] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/06/2022] [Indexed: 12/20/2022] Open
Abstract
Antiplatelet agents, with aspirin and P2Y12 receptor antagonists as major key molecules, are currently the cornerstone of pharmacological treatment of atherothrombotic events including a variety of cardio- and cerebro-vascular as well as peripheral artery diseases. Over the last decades, significant changes have been made to antiplatelet therapeutic and prophylactic strategies. The shift from a population-based approach to patient-centered precision medicine requires greater awareness of individual risks and benefits associated with the different antiplatelet strategies, so that the right patient gets the right therapy at the right time. In this review, we present the currently available antiplatelet agents, outline different management strategies, particularly in case of bleeding or in perioperative setting, and develop the concept of high on-treatment platelet reactivity and the steps toward person-centered precision medicine aiming to optimize patient care.
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Affiliation(s)
- Georges Jourdi
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- *Correspondence: Georges Jourdi
| | - Anne Godier
- Université de Paris, Innovative Therapies in Haemostasis, INSERM UMR_S1140, Paris, France
- Department of Anesthesiology and Critical Care, AP-HP, Université de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Marie Lordkipanidzé
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Guillaume Marquis-Gravel
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Pascale Gaussem
- Université de Paris, Innovative Therapies in Haemostasis, INSERM UMR_S1140, Paris, France
- Service d'Hématologie Biologique, AP-HP, Université de Paris, Hôpital Européen Georges Pompidou, Paris, France
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Riscado LVS, de Pinho JHS, Lobato ADC. Efficacy and safety of tirofiban bridge as an alternative to suspension of dual antiplatelet therapy in patients undergoing surgery: a systematic review. J Vasc Bras 2021; 20:e20210113. [PMID: 34925474 PMCID: PMC8668084 DOI: 10.1590/1677-5449.210113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/08/2021] [Indexed: 11/22/2022] Open
Abstract
Use of a tirofiban bridge is an alternative to simply withdrawing dual antiplatelet therapy prior to operating on patients at high risk of stent thrombosis and bleeding. We aimed to evaluate the efficacy and safety of this protocol in patients undergoing surgery within 12 months of a percutaneous coronary intervention involving stenting. We performed a systematic review based on searches of the PubMed, Web of Science, Cochrane, Embase, Lilacs, and Scielo databases and of the references of relevant articles on the topic. Five of the 107 studies identified were included after application of eligibility criteria and analysis of methodological quality, totaling 422 patients, 227 in control groups. Notwithstanding the limitations reported, four of the five studies included indicate that the tirofiban bridge technique is effective for reducing adverse cardiac events and is safe in terms of not interfering with the risk of hemorrhagic events or bleeding. However, randomized clinical trials are needed to provide robust evidence.
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Jourdi G, Lordkipanidzé M, Philippe A, Bachelot-Loza C, Gaussem P. Current and Novel Antiplatelet Therapies for the Treatment of Cardiovascular Diseases. Int J Mol Sci 2021; 22:ijms222313079. [PMID: 34884884 PMCID: PMC8658271 DOI: 10.3390/ijms222313079] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 12/14/2022] Open
Abstract
Over the last decades, antiplatelet agents, mainly aspirin and P2Y12 receptor antagonists, have significantly reduced morbidity and mortality associated with arterial thrombosis. Their pharmacological characteristics, including pharmacokinetic/pharmacodynamics profiles, have been extensively studied, and a significant number of clinical trials assessing their efficacy and safety in various clinical settings have established antithrombotic efficacy. Notwithstanding, antiplatelet agents carry an inherent risk of bleeding. Given that bleeding is associated with adverse cardiovascular outcomes and mortality, there is an unmet clinical need to develop novel antiplatelet therapies that inhibit thrombosis while maintaining hemostasis. In this review, we present the currently available antiplatelet agents, with a particular focus on their targets, pharmacological characteristics, and patterns of use. We will further discuss the novel antiplatelet therapies in the pipeline, with the goal of improved clinical outcomes among patients with atherothrombotic diseases.
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Affiliation(s)
- Georges Jourdi
- Research Center, Montreal Heart Institute, Montreal, QC H1T 1C8, Canada;
- Faculty of Pharmacy, Université de Montréal, Montreal, QC H3T 1J4, Canada
- Correspondence: (G.J.); (P.G.)
| | - Marie Lordkipanidzé
- Research Center, Montreal Heart Institute, Montreal, QC H1T 1C8, Canada;
- Faculty of Pharmacy, Université de Montréal, Montreal, QC H3T 1J4, Canada
| | - Aurélien Philippe
- INSERM, Innovations Thérapeutiques en Hémostase, Université de Paris, F-75006 Paris, France; (A.P.); (C.B.-L.)
- Service d’Hématologie Biologique, AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France
| | - Christilla Bachelot-Loza
- INSERM, Innovations Thérapeutiques en Hémostase, Université de Paris, F-75006 Paris, France; (A.P.); (C.B.-L.)
| | - Pascale Gaussem
- INSERM, Innovations Thérapeutiques en Hémostase, Université de Paris, F-75006 Paris, France; (A.P.); (C.B.-L.)
- Service d’Hématologie Biologique, AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France
- Correspondence: (G.J.); (P.G.)
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Sullivan AE, Nanna MG, Wang TY, Bhatt DL, Angiolillo DJ, Mehran R, Banerjee S, Cantrell S, Jones WS, Rymer JA, Washam JB, Rao SV, Ohman EM. Bridging Antiplatelet Therapy After Percutaneous Coronary Intervention: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78:1550-1563. [PMID: 34620413 DOI: 10.1016/j.jacc.2021.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 11/26/2022]
Abstract
Patients undergoing early surgery after coronary stent implantation are at increased risk for mortality from ischemic and hemorrhagic complications. The optimal antiplatelet strategy in patients who cannot discontinue dual antiplatelet therapy (DAPT) before surgery is unclear. Current guidelines, based on surgical and clinical characteristics, provide risk stratification for bridging therapy with intravenous antiplatelet agents, but management is guided primarily by expert opinion. This review summarizes perioperative risk factors to consider before discontinuing DAPT and reviews the data for intravenous bridging therapies. Published reports have included bridging options such as small molecule glycoprotein IIb/IIIa inhibitors (eptifibatide or tirofiban) and cangrelor, an intravenous P2Y12 inhibitor. However, optimal management of these complex patients remains unclear in the absence of randomized controlled data, without which an argument can be made both for and against the use of perioperative intravenous bridging therapy after discontinuing oral P2Y12 inhibitors. Multidisciplinary risk assessment remains a critical component of perioperative care.
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Affiliation(s)
- Alexander E Sullivan
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA. https://twitter.com/aesullivan37
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Tracy Y Wang
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Deepak L Bhatt
- Division of Cardiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Roxana Mehran
- Division of Cardiology, Mount Sinai Hospital, New York, New York, USA
| | - Subhash Banerjee
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sarah Cantrell
- Duke University Medical Center Library & Archives, Duke University School of Medicine, Durham, North Carolina, USA
| | - W Schuyler Jones
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jennifer A Rymer
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Sunil V Rao
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - E Magnus Ohman
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA.
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Rossini R, Masiero G, Fruttero C, Passamonti E, Calvaruso E, Cecconi M, Carlucci C, Mojoli M, Guido P, Talanas G, Pierini S, Canova P, De Cesare N, Luceri S, Barzaghi N, Melloni G, Baralis G, Locatelli A, Musumeci G, Angiolillo DJ. Antiplatelet Therapy with Cangrelor in Patients Undergoing Surgery after Coronary Stent Implantation: A Real-World Bridging Protocol Experience. TH OPEN 2020; 4:e437-e445. [PMID: 33376943 PMCID: PMC7758156 DOI: 10.1055/s-0040-1721504] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 11/02/2020] [Indexed: 01/04/2023] Open
Abstract
Objective
The aim of the study is to describe the real-world use of the P2Y
12
inhibitor cangrelor as a bridging strategy in patients at high thrombotic risk after percutaneous coronary intervention (PCI) and referred to surgery requiring perioperative withdrawal of dual antiplatelet therapy (DAPT).
Materials and Methods
We collected data from nine Italian centers on patients with previous PCI who were still on DAPT and undergoing nondeferrable surgery requiring DAPT discontinuation. A perioperative standardized bridging protocol with cangrelor was used.
Results
Between December 2017 and April 2019, 24 patients (mean age 72 years; male 79%) were enrolled. All patients were at high thrombotic risk after PCI and required nondeferrable intermediate to high bleeding risk surgery requiring DAPT discontinuation (4.6 ± 1.7 days). Cangrelor infusion was started at a bridging dose (0.75 µg/kg/min) 3 days before planned surgery and was discontinued 6.6 ± 1.5 hours prior to surgical incision. In 55% of patients, cangrelor was resumed at 9 ± 6 hours following surgery for a mean of 39 ± 38 hours. One cardiac death was reported after 3 hours of cangrelor discontinuation prior to surgery. No ischemic outcomes occurred after surgery and up to 30-days follow-up. The mean hemoglobin drop was <2 g/dL; nine patients received blood transfusions consistent with the type of surgery, but no life-threatening or fatal bleeding occurred.
Conclusion
Perioperative bridging therapy with cangrelor is a feasible approach for stented patients at high thrombotic risk and referred to surgery requiring DAPT discontinuation. Larger studies are warranted to support the safety of this strategy.
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Affiliation(s)
| | | | | | - Enrico Passamonti
- Ospedale di Cremona, Struttura Complessa di Cardiologia, Cremona, Italy
| | - Elba Calvaruso
- Ospedale di Cremona, Struttura Complessa di Cardiologia, Cremona, Italy
| | | | | | - Marco Mojoli
- Ospedale Santa Maria degli Angeli, Pordenone, Pordenone, Italy
| | - Parodi Guido
- Azienda Ospedaliera Universitaria di Sassari, Struttura Complessa di Cardiologia Clinica ed Interventistica, Sassari, Italy
| | - Giuseppe Talanas
- Azienda Ospedaliera Universitaria di Sassari, Struttura Complessa di Cardiologia Clinica ed Interventistica, Sassari, Italy
| | - Simona Pierini
- P.O. BASSINI-ASST Nord Milano, U.O.C. Cardiologia, Milano, Italy
| | - Paolo Canova
- ASST Papa Giovanni XXIII, Unità di Cardiologia 2, Bergamo, Italy
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Smelser WW, Jones CP. Management of anticoagulation and antiplatelet agents in the radical cystectomy patient. Urol Oncol 2020; 39:691-697. [PMID: 31928866 DOI: 10.1016/j.urolonc.2019.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/02/2019] [Accepted: 12/10/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Bladder cancer is a disease of the older adult, and management of comorbid conditions requiring anticoagulation (AC) or antiplatelet agents (APA) around the time of radical cystectomy (RC) is a frequent clinical challenge. It is estimated that 10% of adult surgical patients are on chronic anticoagulation medications, and considerations surrounding the perioperative disruption, resumption, and modification or substitution of AC and APA in patients undergoing radical cystectomy are critical for the practicing urologist. METHODS In our report, we performed a comprehensive literature review using PubMed to evaluate all available studies from 1950 to present. Additionally, we reviewed current multidisciplinary guideline papers from the American College of Surgeons, American College of Cardiology, and CHEST Society regarding perioperative management of anticoagulation and antiplatelet agents. RESULTS Our keyword search yielded 35 articles from 1950 to 2019. We identified 16 studies pertaining specifically to evaluation and perioperative management of anticoagulation in patient undergoing RC. Many of the recommendations in this realm are informed by trial data outside the RC population in the general surgical population or general adult population. Current guidelines from the American College of Surgeons, American College of Cardiology/American Heart Association, and CHEST Society inform our recommendations heavily and are summarized in Table 1. CONCLUSIONS Radical cystectomy remains both a mainstay of therapy for patients with muscle-invasive bladder cancer and a morbid procedure. Competing risks of perioperative hemorrhage and thromboembolic events make management of anticoagulation and antiplatelet agents an important and modifiable risk factor. Our review of the current literature highlights the knowledge gap that exists in management of these agents in the radical cystectomy patient. A multi-disciplinary approach to management of this clinical challenge remains a mainstay of treatment.
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Affiliation(s)
- Woodson W Smelser
- Department of Urology, The University of Kansas Health System, Kansas City, KS.
| | - Charles P Jones
- Department of Urology, The University of Kansas Health System, Kansas City, KS
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Swan D, Loughran N, Makris M, Thachil J. Management of bleeding and procedures in patients on antiplatelet therapy. Blood Rev 2020; 39:100619. [DOI: 10.1016/j.blre.2019.100619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/31/2019] [Accepted: 10/10/2019] [Indexed: 02/06/2023]
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11
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Perioperative kardiovaskuläre Morbidität und Letalität bei nichtherzchirurgischen Eingriffen. Anaesthesist 2019; 68:653-664. [DOI: 10.1007/s00101-019-0616-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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12
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Rossini R, Tarantini G, Musumeci G, Masiero G, Barbato E, Calabrò P, Capodanno D, Leonardi S, Lettino M, Limbruno U, Menozzi A, Marchese UOA, Saia F, Valgimigli M, Ageno W, Falanga A, Corcione A, Locatelli A, Montorsi M, Piazza D, Stella A, Bozzani A, Parolari A, Carone R, Angiolillo DJ. A Multidisciplinary Approach on the Perioperative Antithrombotic Management of Patients With Coronary Stents Undergoing Surgery: Surgery After Stenting 2. JACC Cardiovasc Interv 2019. [PMID: 29519377 DOI: 10.1016/j.jcin.2017.10.051] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Perioperative management of antithrombotic therapy in patients treated with coronary stents undergoing surgery remains poorly defined. Importantly, surgery represents a common reason for premature treatment discontinuation, which is associated with an increased risk in mortality and major adverse cardiac events. However, maintaining antithrombotic therapy to minimize the incidence of perioperative ischemic complications may increase the risk of bleeding complications. Although guidelines provide some recommendations with respect to the perioperative management of antithrombotic therapy, these have been largely developed according to the thrombotic risk of the patient and a definition of the hemorrhagic risk specific to each surgical procedure, key to defining the trade-off between ischemia and bleeding, is not provided. These observations underscore the need for a multidisciplinary collaboration among cardiologists, anesthesiologists, hematologists and surgeons to reach this goal. The present document is an update on practical recommendations for standardizing management of antithrombotic therapy management in patients treated with coronary stents (Surgery After Stenting 2) in various types of surgery according to the predicted individual risk of thrombotic complications against the anticipated risk of surgical bleeding complications. Cardiologists defined the thrombotic risk using a "combined ischemic risk" approach, while surgeons classified surgeries according to their inherent hemorrhagic risk. Finally, a multidisciplinary agreement on the most appropriate antithrombotic treatment regimen in the perioperative phase was reached for each surgical procedure.
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Affiliation(s)
- Roberta Rossini
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy.
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Giuseppe Musumeci
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Giulia Masiero
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Emanuele Barbato
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Paolo Calabrò
- Division of Cardiology, Department of Cardio-Thoracic Sciences, Università degli Studi della Campania "Luigi Vanvitelli," Naples, Italy
| | - Davide Capodanno
- Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele, Catania, Italy; Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Sergio Leonardi
- Coronary Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maddalena Lettino
- Cardiovascular Department, Humanitas Research Hospital, Rozzano, Italy
| | - Ugo Limbruno
- U.O.C. Cardiologia, Azienda USL Toscana Sudest, Grosseto, Italy
| | - Alberto Menozzi
- Unità Operativa di Cardiologia, Azienda Ospedaliero-Universitaria di Parma, Italy
| | - U O Alfredo Marchese
- U.O.C. Cardiologia Interventistica, Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Francesco Saia
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Marco Valgimigli
- Swiss Cardiovascular Centre Bern, Bern University Hospital, Bern, Switzerland
| | - Walter Ageno
- Degenza Breve Internistica e Centro Trombosi ed Emostasi, Dipartimento di Medicina e Chirurgia, Università dell'Insubria, Varese, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, Thrombosis and Hemostasis Center, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Antonio Corcione
- Department of Anaesthesia and Critical Care, AORN Dei Colli, Naples, Italy
| | - Alessandro Locatelli
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Marco Montorsi
- Dipartimento di Chirurgia Generale, Humanitas Research Hospital and University, Milano, Italy
| | - Diego Piazza
- Policlinico Vittorio Emanuele di Catania, Catania, Italy
| | - Andrea Stella
- Chirurgia Vascolare, Università di Bologna, Ospedale Sant'Orsola-Malpighi, Bologna, Italy
| | - Antonio Bozzani
- UOC Chirurgia Vascolare, Dipartimento di Scienze Chirurgiche, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Alessandro Parolari
- Dipartimento di Scienze Biomediche per la Salute, Policlinico San Donato IRCCS, University of Milano, Milan, Italy
| | - Roberto Carone
- Azienda Ospedaliera Universitaria Città della salute e della scienza, Torino, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida, College of Medicine-Jacksonville, Jacksonville, Florida
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13
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Dargham BB, Baskar A, Tejani I, Cui Z, Chauhan S, Sum-Ping J, Weideman RA, Banerjee S. Intravenous Antiplatelet Therapy Bridging in Patients Undergoing Cardiac or Non-Cardiac Surgery Following Percutaneous Coronary Intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:805-811. [PMID: 30579773 DOI: 10.1016/j.carrev.2018.11.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 10/23/2018] [Accepted: 11/16/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND The effect of perioperative bridging therapy on risks of ischemic cardiac events and major bleeding complications in patients on dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) remains undefined. METHODS We report on 60 consecutive patients between 2010 and 2017 who required cardiac (CS; n = 15) or non-cardiac (NCS; n = 45) surgeries following PCI at our institution. Short-acting intravenous (IV) antiplatelet (APT) bridging with eptifibatide, tirofiban and cangrelor were instituted after DAPT interruption. RESULTS All patients were men with multiple atherosclerosis risk factors. An acute coronary syndrome indication (56.7%) was the most common PCI indication in the CS and NCS groups. Drug-eluting stents were used in 93.33% and 95.56% of the above groups, respectively. The median duration from PCI to CS and NCS were 11.17 and 18.25 months, respectively and 38.33% of all surgeries were performed within 6 months of the index PCI. Most patients were on background aspirin (83.33%) and clopidogrel (81.67%) and median duration of DAPT interruption was 7 days. Median duration of perioperative IV APT bridging was 3 days for CS and 5 days for NCS groups. In the CS group, two patients (13.33%) had non-fata myocardial infarction (MI), and four (26.67%) had clinically significant bleeding. No patients had perioperative stent thrombosis. In the NCS group, one patient (2.22%) had stent thrombosis; four (6.67%) had myocardial infarction, and five (11.11%) clinically significant bleeding. CONCLUSIONS Despite using IV APT as bridging therapy during perioperative DAPT interruption in post-PCI patients, postoperative cardiac events and bleeding complications can still occur.
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Affiliation(s)
- Bassel Bou Dargham
- University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Amutharani Baskar
- Veterans Affairs North Texas System Dallas Texas, Dallas, TX, United States of America
| | - Ishita Tejani
- University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Zhonghao Cui
- University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Siddarth Chauhan
- University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - John Sum-Ping
- University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Veterans Affairs North Texas System Dallas Texas, Dallas, TX, United States of America
| | - Rick A Weideman
- Veterans Affairs North Texas System Dallas Texas, Dallas, TX, United States of America
| | - Subhash Banerjee
- University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Veterans Affairs North Texas System Dallas Texas, Dallas, TX, United States of America.
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14
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Mahla E, Tantry US, Prüller F, Gurbel PA. Is There a Role for Preoperative Platelet Function Testing in Patients Undergoing Cardiac Surgery During Antiplatelet Therapy? Circulation 2018; 138:2145-2159. [DOI: 10.1161/circulationaha.118.035160] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Elisabeth Mahla
- Department of Anesthesiology and Intensive Care Medicine (E.M.), Medical University of Graz, Austria
| | - Udaya S. Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA (U.S.T., P.A.G.)
| | - Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics (F.P.), Medical University of Graz, Austria
| | - Paul A. Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA (U.S.T., P.A.G.)
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15
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American College of Surgeons' Guidelines for the Perioperative Management of Antithrombotic Medication. J Am Coll Surg 2018; 227:521-536.e1. [DOI: 10.1016/j.jamcollsurg.2018.08.183] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 12/23/2022]
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16
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Laehn SJ, Feih JT, Saltzberg MT, Garner Rinka JR. Pharmacodynamic-Guided Cangrelor Bridge Therapy for Orthotopic Heart Transplant. J Cardiothorac Vasc Anesth 2018; 33:1054-1058. [PMID: 30087023 DOI: 10.1053/j.jvca.2018.06.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Spencer J Laehn
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM.
| | - Joel T Feih
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, WI
| | - Mitchell T Saltzberg
- Department of Medicine, Division of Cardiology, Froedtert & the Medical College of Wisconsin, Milwaukee, WI
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Gulizia MM, Colivicchi F, Abrignani MG, Ambrosetti M, Aspromonte N, Barile G, Caporale R, Casolo G, Chiuini E, Di Lenarda A, Faggiano P, Gabrielli D, Geraci G, La Manna AG, Maggioni AP, Marchese A, Massari FM, Mureddu GF, Musumeci G, Nardi F, Panno AV, Pedretti RFE, Piredda M, Pusineri E, Riccio C, Rossini R, di Uccio FS, Urbinati S, Varbella F, Zito GB, De Luca L. Consensus Document ANMCO/ANCE/ARCA/GICR-IACPR/GISE/SICOA: Long-term Antiplatelet Therapy in Patients with Coronary Artery Disease. Eur Heart J Suppl 2018; 20:F1-F74. [PMID: 29867293 PMCID: PMC5978022 DOI: 10.1093/eurheartj/suy019] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of pharmacologic management of patients with acute coronary syndrome (ACS) and/or those receiving coronary stents. Long-term (>1 year) DAPT may further reduce the risk of stent thrombosis after a percutaneous coronary intervention (PCI) and may decrease the occurrence of non-stent-related ischaemic events in patients with ACS. Nevertheless, compared with aspirin alone, extended use of aspirin plus a P2Y12 receptor inhibitor may increase the risk of bleeding events that have been strongly linked to adverse outcomes including recurrent ischaemia, repeat hospitalisation and death. In the past years, multiple randomised trials have been published comparing the duration of DAPT after PCI and in ACS patients, investigating either a shorter or prolonged DAPT regimen. Although the current European Society of Cardiology guidelines provide a backup to individualised treatment, it appears to be difficult to identify the ideal patient profile which could safely reduce or prolong the DAPT duration in daily clinical practice. The aim of this consensus document is to review contemporary literature on optimal DAPT duration, and to guide clinicians in tailoring antiplatelet strategies in patients undergoing PCI or presenting with ACS.
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Affiliation(s)
- Michele Massimo Gulizia
- U.O.C. di Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Furio Colivicchi
- U.O.C. Cardiologia e UTIC, Ospedale San Filippo Neri, Roma, Italy
| | | | - Marco Ambrosetti
- Servizio di Cardiologia Riabilitativa, Clinica Le Terrazze Cunardo, Varese, Italy
| | - Nadia Aspromonte
- U.O. Scompenso e Riabilitazione Cardiologica, Polo Scienze Cardiovascolari, Toraciche, Policlinico Agostino Gemelli, Roma, Italy
| | | | - Roberto Caporale
- U.O.C. Cardiologia Interventistica, Ospedale Annunziata, Cosenza, Italy
| | - Giancarlo Casolo
- S.C. Cardiologia, Nuovo Ospedale Versilia, Lido di Camaiore (LU), Italy
| | - Emilia Chiuini
- Specialista Ambulatoriale Cardiologo, ASL Umbria 1, Perugia, Italy
| | - Andrea Di Lenarda
- S.C. Cardiovascolare e Medicina dello Sport, Azienda Sanitaria Universitaria Integrata di Trieste, Italy
| | | | - Domenico Gabrielli
- ASUR Marche - Area Vasta 4 Fermo, Ospedale Civile Augusto Murri, Fermo, Italy
| | - Giovanna Geraci
- U.O.C. Cardiologia Azienda Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | | | | | | | - Ferdinando Maria Massari
- U.O.C. Malattie Cardiovascolari "Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | | | | | - Federico Nardi
- S.C. Cardiologia, Ospedale Santo Spirito, Casale Monferrato (AL), Italy
| | | | | | - Massimo Piredda
- Centro Cardiotoracico, Divisione di Cardiologia, Istituto Clinico Sant'Ambrogio, Milano, Italy
| | - Enrico Pusineri
- U.O.C. di Cardiologia, Ospedale Civile di Vigevano, A.S.S.T., Pavia, Italy
| | - Carmine Riccio
- Prevenzione e Riabilitazione Cardiopatico, AZ. Ospedaliera S. Anna e S. Sebastiano, Caserta, Italy
| | | | | | - Stefano Urbinati
- U.O.C. Cardiologia, Ospedale Bellaria, AUSL di Bologna, Bologna, Italy
| | | | | | - Leonardo De Luca
- U.O.C. Cardiologia, Ospedale San Giovanni Evangelista, Tivoli, Roma, Italy
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18
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Polito MV, Asparago S, Galasso G, Farina R, Panza A, Iesu S, Piscione F. Early myocardial surgical revascularization after ST-segment elevation myocardial infarction in multivessel coronary disease: bridge therapy is the solution? J Cardiovasc Med (Hagerstown) 2018; 19:120-125. [PMID: 29389817 DOI: 10.2459/jcm.0000000000000621] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Many ST-segment elevation myocardial infarction (STEMI) patients have a multivessel disease that initially require percutaneous coronary intervention (PCI) of the culprit vessel but subsequently may require coronary artery bypass graft (CABG) of nonculprit vessels. Evidence supports staged revascularization, but the identification of optimal strategies (percutaneous or surgical), the timing and the management of antiplatelet therapy after recent PCI with stenting are matters of great controversies. METHODS In our retrospective registry, we have enrolled 21 patients presenting with STEMI and multivessel disease, who underwent PCI of the culprit vessel only and then CABG of nonculprit vessels. Demographic, clinical, echocardiographic, angiographic findings, preoperative score, surgical data and postoperative complications were collected. At 21.6 ± 15.6 months follow-up death, reinfarction and/or cardiovascular and noncardiovascular events were recorded. RESULTS Patients were 62 ± 9 years old and had in the most cases a good ejection fraction. At angiography, the culprit lesion was right coronary artery in 16 patients (76%). Angiographic characteristics excluded a staged PCI (SYNTAX score = 31.6 ± 7.4) and European System for Cardiac Operative Risk Evaluation II resulted low (1.46 ± 1.01). Following the indication to cardiac surgery after Heart Team discussion, the withdrawal of oral P2Y12 inhibitor was planned and tirofiban intravenous was started. Off-pump CABG was performed after 7.2 ± 3.2 days. No death, reinfarction and/or cardiovascular and noncardiovascular events occurred at follow-up. CONCLUSION We can conclude that a careful preoperative selection is mandatory for a good postoperative course and long-term survival and that early-staged CABG can, however, be performed using bridge therapy, also after STEMI.
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Affiliation(s)
- Maria V Polito
- Department of Medicine and Surgery, University of Salerno
| | | | | | | | - Antonio Panza
- Cardiac Surgery, Heart Department, A.O.U. 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Severino Iesu
- Cardiac Surgery, Heart Department, A.O.U. 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
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19
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Prader R, De Broca B, Chevallier D, Amiel J, Durand M. Outcome of Transurethral Resection of Bladder Tumor: Does Antiplatelet Therapy Really Matter? Analysis of a Retrospective Series. J Endourol 2017; 31:1284-1288. [PMID: 29037064 DOI: 10.1089/end.2017.0587] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Transurethral resection of bladder tumor (TURBT) is considered to be at a moderate or high risk of bleeding during surgical procedure. The number of patients on antiplatelet (AP) drugs has been increasing; we wanted to assess their impact on the outcome of patients undergoing scheduled TURBT. MATERIALS AND METHODS A retrospective assessment of noninferiority of 450 consecutive procedures performed between April 2013 and June 2015 was conducted. Patients were divided in two groups: naive or AP drug users. The primary endpoint was the average length of stay (ALOS). Noninferiority was set at 1 day. A subgroup analysis comparing the acetylsalicylic acid (ASA) group and clopidogrel group to the naive group was performed. Multivariate analysis was performed to find the determinants of a longer ALOS. Chi-square or Fisher tests were used to analyze categorical variables, and Student's or Mann-Whitney tests were used to analyze quantitative variables. RESULTS We included 325 patients who underwent TURBT: 117 received AP drugs (ASA, 85; clopidogrel, 32) and 208 were naive to AP drugs (of whom 117 were consecutively analyzed). The ALOSs were 2.5 days (naive group) and 2.9 days (AP group). The subgroup analysis showed ALOSs of 2.6 days (ASA group) and 3.7 days (clopidogrel group). Clopidogrel therapy (odds ratio = 4.1 [1.7-9.6]) and the duration and depth of resection emerged as determinants of a longer ALOS in multivariate analysis. Perioperative management of AP therapies was achieved according to recommended practices. CONCLUSIONS The ALOS of patients receiving AP drugs was not clinically different from naive patients. This result was identical for patients receiving ASA. However, clopidogrel increased the length of stay, making us question its use in perioperative management.
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Affiliation(s)
- Romain Prader
- 1 Department of Urology and Transplantation, University Hospital of Nice , Nice, France
| | - Bruno De Broca
- 2 Department of Anesthesia, University Hospital of Amiens, Salouel, France
| | - Daniel Chevallier
- 1 Department of Urology and Transplantation, University Hospital of Nice , Nice, France
| | - Jean Amiel
- 1 Department of Urology and Transplantation, University Hospital of Nice , Nice, France
| | - Matthieu Durand
- 1 Department of Urology and Transplantation, University Hospital of Nice , Nice, France
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20
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Musumeci G, Capodanno D, Lettieri C, Limbruno U, Tarantini G, Russo N, Calabria P, Romano M, Inashvili A, Sirbu V, Guagliumi G, Valsecchi O, Senni M, Gavazzi A, Angiolillo DJ, Rossini R. Perioperative management of oral antiplatelet therapy and clinical outcomes in coronary stent patients undergoing surgery. Thromb Haemost 2017; 113:272-82. [DOI: 10.1160/th14-05-0436] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 08/27/2014] [Indexed: 11/05/2022]
Abstract
SummaryThe aim was to investigate the perioperative risk of ischaemic and bleeding events in patients with coronary stents undergoing cardiac and non-cardiac surgery and how these outcomes are affected by the perioperative use of oral antiplatelet therapy. This was a multicentre, retrospective, observational study conducted in patients with coronary stent(s) undergoing cardiac or non-cardiac surgery. The primary efficacy endpoint was the 30-day incidence of major adverse cardiac events (MACE), defined as the composite of cardiac death, myocardial infarction (MI) or stroke. The primary safety endpoint was the 30-day incidence of Bleeding Academic Research Consortium (BARC) bleeding ≥ 2. A total of 666 patients were included. Of these, 371 (55.7 %) discontinued their antiplatelet medication(s) (all or partly) before undergoing surgery. At 30 days, patients with perioperative discontinuation of antiplatelet therapy experienced a significantly higher incidence of MACE (7.5 % vs 0.3 %, p < 0.001), cardiac death (2.7 % vs 0.3 %, p=0.027), and MI (4.0 % vs 0 %, p < 0.001). After adjustment, peri-operative antiplatelet discontinuation was the strongest independent predictor of 30-day MACE (odds ratio [OR]=25.8, confidence interval [CI]=3.37–198, p=0.002). Perioperative aspirin (adjusted OR 0.27, 95 % CI 0.11–0.71, p=0.008) was significantly associated with a lower risk of MACE. The overall incidence of BARC ≥ 2 bleeding events at 30-days was significantly higher in patients who discontinued oral antiplatelet therapy (25.6 % vs 13.9 %, p < 0.001). However, after adjustment, antiplatelet discontinuation was not independently associated with BARC ≥ 2 bleeding. In conclusion antiplatelet discontinuation increases the 30-day risk of MACE, in patients with coronary stents undergoing cardiac and non-cardiac surgery, while not offering significant protection from BARC≥ 2 bleeding.
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21
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Azboy I, Barrack R, Thomas AM, Haddad FS, Parvizi J. Aspirin and the prevention of venous thromboembolism following total joint arthroplasty: commonly asked questions. Bone Joint J 2017; 99-B:1420-1430. [PMID: 29092979 PMCID: PMC5742873 DOI: 10.1302/0301-620x.99b11.bjj-2017-0337.r2] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/19/2017] [Indexed: 12/17/2022]
Abstract
The number of arthroplasties being performed
increases each year. Patients undergoing an arthroplasty are at
risk of venous thromboembolism (VTE) and appropriate prophylaxis
has been recommended. However, the optimal protocol and the best
agent to minimise VTE under these circumstances are not known. Although
many agents may be used, there is a difference in their efficacy
and the risk of bleeding. Thus, the selection of a particular agent relies
on the balance between the desire to minimise VTE and the attempt
to reduce the risk of bleeding, with its undesirable, and occasionally
fatal, consequences. Acetylsalicylic acid (aspirin) is an agent for VTE prophylaxis
following arthroplasty. Many studies have shown its efficacy in
minimising VTE under these circumstances. It is inexpensive and
well-tolerated, and its use does not require routine blood tests.
It is also a ‘milder’ agent and unlikely to result in haematoma
formation, which may increase both the risk of infection and the
need for further surgery. Aspirin is also unlikely to result in persistent
wound drainage, which has been shown to be associated with the use
of agents such as low-molecular-weight heparin (LMWH) and other
more aggressive agents. The main objective of this review was to summarise the current
evidence relating to the efficacy of aspirin as a VTE prophylaxis
following arthroplasty, and to address some of the common questions
about its use. There is convincing evidence that, taking all factors into account,
aspirin is an effective, inexpensive, and safe form of VTE following
arthroplasty in patients without a major risk factor for VTE, such
as previous VTE. Cite this article: Bone Joint J 2017;99-B:1420–30.
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Affiliation(s)
- I Azboy
- Rothman Institute at Thomas Jefferson University Hospital, Sheridan Building, Suite 1000, 125 South 9th Street, Philadelphia, PA 19107, USA
| | - R Barrack
- Washington University Orthopedics, Barnes Jewish Hospital, 660 South Euclid Avenue, Campus Box 8233, St. Louis, Missouri 63110, USA
| | - A M Thomas
- The Royal Orthopaedic Hospital, Bristol Road South, Birmingham B31 2AP, UK
| | - F S Haddad
- University College London Hospitals, 235 Euston Road, London NW1 2BU, UK and NIHR University College London Hospitals Biomedical Research Centre, UK
| | - J Parvizi
- Rothman Institute at Thomas Jefferson University Hospital, Sheridan Building, Suite 1000, 125 South 9th Street, Philadelphia, PA 19107, USA
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Role of New Antiplatelet Drugs on Cardiovascular Disease: Update on Cangrelor. Curr Atheroscler Rep 2017; 18:66. [PMID: 27714642 DOI: 10.1007/s11883-016-0617-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Dual therapy with a P2Y12 receptor antagonist in addition to aspirin is the antiplatelet treatment of choice in patients with acute coronary syndromes or undergoing percutaneous coronary intervention (PCI). However, available oral P2Y12 antagonists have several limitations, mostly due to their pharmacological profile, which can affect outcomes in certain clinical settings. Cangrelor is an intravenous, direct-acting, potent P2Y12 inhibitor with rapid onset and offset of action, which has been recently approved for clinical use in patients undergoing PCI. In clinical trials, cangrelor has demonstrated greater efficacy than clopidogrel with a favorable safety profile among PCI patients not receiving pretreatment with oral P2Y12 antagonists. However, its definitive role in contemporary practice is yet to be determined. This review aims to provide a comprehensive overview of the current status of knowledge on cangrelor, focusing on its pharmacological properties, clinical development, and the potential applications of this newly available agent.
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23
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Patrono C, Morais J, Baigent C, Collet JP, Fitzgerald D, Halvorsen S, Rocca B, Siegbahn A, Storey RF, Vilahur G. Antiplatelet Agents for the Treatment and Prevention of Coronary Atherothrombosis. J Am Coll Cardiol 2017; 70:1760-1776. [PMID: 28958334 DOI: 10.1016/j.jacc.2017.08.037] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 08/08/2017] [Accepted: 08/09/2017] [Indexed: 01/06/2023]
Abstract
Antiplatelet drugs provide first-line antithrombotic therapy for the management of acute ischemic syndromes (both coronary and cerebrovascular) and for the prevention of their recurrence. Their role in the primary prevention of atherothrombosis remains controversial because of the uncertain balance of the potential benefits and risks when combined with other preventive strategies. The aim of this consensus document is to review the evidence for the efficacy and safety of antiplatelet drugs, and to provide practicing cardiologists with an updated instrument to guide their choice of the most appropriate antiplatelet strategy for the individual patient presenting with different clinical manifestations of coronary atherothrombosis, in light of comorbidities and/or interventional procedures.
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Affiliation(s)
- Carlo Patrono
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy.
| | - Joao Morais
- Division of Cardiology, Santo Andre's Hospital, Leiria, Portugal
| | - Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jean-Philippe Collet
- Sorbonne Université Paris 6, ACTION Study Group, Institut de Cardiologie Hôpital Pitié-Salpêtrière (APHP), INSERM UMRS 1166, Paris, France
| | | | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevål, and University of Oslo, Oslo, Norway
| | - Bianca Rocca
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Agneta Siegbahn
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Gemma Vilahur
- Cardiovascular Science Institute-ICCC IIB-Sant Pau, CiberCV, Hospital de Sant Pau, Barcelona, Spain
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Clinical outcomes after craniotomy for unruptured intracranial aneurysm in patients with coronary artery disease. J Clin Neurosci 2017; 46:113-117. [PMID: 28887082 DOI: 10.1016/j.jocn.2017.08.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/14/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) patients receiving antiplatelet agents occasionally undergo craniotomy. We aimed to clarify clinical outcomes after craniotomy for unruptured intracranial aneurysm (UIA) in patients with CAD. We also aimed to identify the possible predictive factors for morbidity and surgical complications in patients on antiplatelet treatment. METHODS We retrospectively analyzed 401 consecutive patients who had undergone craniotomy for UIA at our institution between January 2006 and December 2016. Forty-three patients (10.7%) received antiplatelet agents during the perioperative period. The underlying reasons for antiplatelet treatment were CAD in 12 patients and other diseases in 31 patients. RESULTS Severe morbidity and intracranial hemorrhage occurred more commonly and symptomatic brain infarction occurred less frequently in patients with CAD compared to patients with other underlying diseases (16.7% versus 3.2%, 16.7% versus 9.7%, and 8.3% versus 16.1%, respectively), though differences between the two groups were not significant. Univariate analysis revealed that a low preoperative baseline platelet count was significantly correlated with the occurrence of intracranial hemorrhage (cutoff value, 16.5×104/µL; odds ratio (OR), 46.67; 95% confidence interval (CI), 3.88-561.95; p=0.0005), and a high baseline platelet count tended to correlate with severe morbidity (cutoff value, 29.8×104/µL; OR, 11.33; 95% CI, 0.88-145.52; p=0.0550). CONCLUSIONS Our results suggest that surgical complications and clinical outcomes after craniotomy may depend on the underlying reason for antiplatelet treatment. Moreover, a preoperative platelet count can be useful in predicting the occurrence of intracranial hemorrhage and severe morbidity after craniotomy in patients receiving antiplatelet agents.
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Walker EA, Dager WE. Bridging with Tirofiban during Oral Antiplatelet Interruption: A Single-Center Case Series Analysis Including Patients on Hemodialysis. Pharmacotherapy 2017; 37:888-892. [DOI: 10.1002/phar.1956] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Elizabeth A. Walker
- Department of Pharmacy; University of California Davis Medical Center; Sacramento California
| | - William E. Dager
- Department of Pharmacy; University of California Davis Medical Center; Sacramento California
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Themistoklis T, Theodosia V, Konstantinos K, Georgios DI. Perioperative blood management strategies for patients undergoing total knee replacement: Where do we stand now? World J Orthop 2017; 8:441-454. [PMID: 28660135 PMCID: PMC5478486 DOI: 10.5312/wjo.v8.i6.441] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/20/2017] [Accepted: 04/10/2017] [Indexed: 02/06/2023] Open
Abstract
Total knee replacement (TKR) is one of the most common surgeries over the last decade. Patients undergoing TKR are at high risk for postoperative anemia and furthermore for allogeneic blood transfusions (ABT). Complications associated with ABT including chills, rigor, fever, dyspnea, light-headedness should be early recognized in order to lead to a better prognosis. Therefore, perioperative blood management program should be adopted with main aim to reduce the risk of blood transfusion while maximizing hemoglobin simultaneously. Many blood conservation strategies have been attempted including preoperative autologous blood donation, acute normovolemic haemodilution, autologous blood transfusion, intraoperative cell saver, drain clamping, pneumatic tourniquet application, and the use of tranexamic acid. For practical and clinical reasons we will try to classify these strategies in three main stages/pillars: Pre-operative optimization, intra-operative and post-operative protocols. The aim of this work is review the strategies currently in use and reports our experience regarding the perioperative blood management strategies in TKR.
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Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R, Mukherjee D, Newby LK, O'Gara PT, Sabatine MS, Smith PK, Smith SC, Halperin JL, Levine GN, Al-Khatib SM, Birtcher KK, Bozkurt B, Brindis RG, Cigarroa JE, Curtis LH, Fleisher LA, Gentile F, Gidding S, Hlatky MA, Ikonomidis JS, Joglar JA, Pressler SJ, Wijeysundera DN. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease. J Thorac Cardiovasc Surg 2016; 152:1243-1275. [DOI: 10.1016/j.jtcvs.2016.07.044] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Gurajala I, Gopinath R. Perioperative management of patient with intracoronary stent presenting for noncardiac surgery. Ann Card Anaesth 2016; 19:122-31. [PMID: 26750683 PMCID: PMC4900389 DOI: 10.4103/0971-9784.173028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
As the number of percutaneous coronary interventions increase annually, patients with intracoronary stents (ICS) who present for noncardiac surgery (NCS) are also on the rise. ICS is associated with stent thrombosis (STH) and requires mandatory antiplatelet therapy to prevent major adverse cardiac events. The risks of bleeding and ischemia remain significant and the management of these patients, especially in the initial year of ICS is challenging. The American College of Cardiologists guidelines on the management of patients with ICS recommend dual antiplatelet therapy (DAT) for minimal 14 days after balloon angioplasty, 30 days for bare metal stents, and 365 days for drug-eluting stents. Postponement of elective surgery is advocated during this period, but guidelines concerning emergency NCS are ambiguous. The risk of STH and surgical bleeding needs to be assessed carefully and many factors which are implicated in STH, apart from the type of stent and the duration of DAT, need to be considered when decision to discontinue DAT is made. DAT management should be a multidisciplinary exercise and bridging therapy with shorter acting intravenous antiplatelet drugs should be contemplated whenever possible. Well conducted clinical trials are needed to establish guidelines as regards to the appropriate tests for platelet function monitoring in patients undergoing NCS while on DAT.
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Affiliation(s)
- Indira Gurajala
- Department of Anaesthesiology and Critical Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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Keeling D, Tait RC, Watson H. Peri-operative management of anticoagulation and antiplatelet therapy. Br J Haematol 2016; 175:602-613. [DOI: 10.1111/bjh.14344] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 07/26/2016] [Accepted: 07/31/2016] [Indexed: 12/14/2022]
Affiliation(s)
- David Keeling
- Oxford University Hospitals NHS Foundation Trust; Oxford UK
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Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R, Mukherjee D, Newby LK, O’Gara PT, Sabatine MS, Smith PK, Smith SC. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation 2016; 134:e123-55. [PMID: 27026020 DOI: 10.1161/cir.0000000000000404] [Citation(s) in RCA: 921] [Impact Index Per Article: 115.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Glenn N. Levine
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Eric R. Bates
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - John A. Bittl
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Ralph G. Brindis
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Stephan D. Fihn
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Lee A. Fleisher
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Christopher B. Granger
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Richard A. Lange
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Michael J. Mack
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Laura Mauri
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Roxana Mehran
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Debabrata Mukherjee
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - L. Kristin Newby
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Patrick T. O’Gara
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Marc S. Sabatine
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Peter K. Smith
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Sidney C. Smith
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
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Rossini R, Angiolillo DJ, Musumeci G, Capodanno D, Lettino M, Trabattoni D, Pilleri A, Calabria P, Colombo P, Bernabò P, Ferlini M, Ferri M, Tarantini G, De Servi S, Savonitto S. Antiplatelet therapy and outcome in patients undergoing surgery following coronary stenting: Results of the surgery after stenting registry. Catheter Cardiovasc Interv 2016; 89:E13-E25. [DOI: 10.1002/ccd.26629] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/15/2016] [Accepted: 05/23/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Roberta Rossini
- Dipartimento Cardiovascolare, ASST Papa Giovanni XXIII; Bergamo Italy
| | - Dominick J. Angiolillo
- College of Medicine-Jacksonville, University of Florida; Jacksonville Florida; Division of Cardiology, University of Florida College of Medicine-Jacksonville; Jacksonville, FL-USA
| | - Giuseppe Musumeci
- Dipartimento Cardiovascolare, ASST Papa Giovanni XXIII; Bergamo Italy
| | - Davide Capodanno
- Dipartimento Di Cardiologia, Ospedale Ferrarotto, Università Di Catania; Italy
| | - Maddalena Lettino
- U.O.C. Cardiologia Clinica I, Istituto Clinico Humanitas; Rozzano (MI) Italy; Dipartimento Cardiovascolare, Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Daniela Trabattoni
- Dipartimento Di Scienze Cardiovascolari, Centro Cardiologico Monzino, IRCCS, Università Degli Studi Di Milano; Milano Italy
| | - Annarita Pilleri
- SSD Centro di valutazione e consulenza cardiologica, Azienda Ospedaliera Brotzu, Presidio San Michele; Cagliari Italy
| | - Paolo Calabria
- UO Emodinamica, Ospedale Misericordia, Grosseto; USL Toscana Sudest Italy
| | - Paola Colombo
- Dipartimento Cardiovascolare, ASST Niguarda Grande Ospedale Metropolitano; Milano Italy
| | - Paola Bernabò
- Divisione di Cardiologia, Ente Ospedaliero Ospedali Galliera; Genova Italy
| | - Marco Ferlini
- SC Cardiologia, Fondazione IRCCS Policlinico San Matteo; Pavia Italy
| | - Marco Ferri
- S.C. Di Cardiologia, Arcispedale S. Maria Nuova, IRCCS; Reggio Emilia Italy
| | - Giuseppe Tarantini
- Dipartimento Di Scienze Cardiache, Toraciche E Vascolari, Università Di Padova; Italia
| | - Stefano De Servi
- SC Cardiologia, Fondazione IRCCS Policlinico San Matteo; Pavia Italy
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Cahoon WD, Oswalt AK, Francis KE, Magee LC, Lowe DK. Cangrelor Bridge Therapy for Gastroduodenal Biopsy. J Pharm Pract 2016; 30:270-273. [PMID: 27000137 DOI: 10.1177/0897190016636750] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Dual antiplatelet therapy (DAPT) is the key for secondary prevention of acute coronary syndromes and percutaneous coronary intervention with stent placement. Premature discontinuation of DAPT can result in an increase in cardiac ischemic events and death. If early interruption of DAPT for urgent procedures or surgery is necessary, then ischemic and bleed risks must be balanced with bridging therapy. To date, no medications have a Food and Drug Administration indication for antiplatelet bridge therapy. We present a case of a woman with a history of gastrointestinal bleeding on DAPT for a drug-eluting stent who received cangrelor as bridge therapy prior to gastroduodenal biopsy.
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Affiliation(s)
- William D Cahoon
- 1 Department of Pharmacy, Virginia Commonwealth University Health System/Medical College of Virginia Hospitals, Richmond, VA, USA.,2 Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - Allison K Oswalt
- 1 Department of Pharmacy, Virginia Commonwealth University Health System/Medical College of Virginia Hospitals, Richmond, VA, USA.,2 Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - Kerry E Francis
- 1 Department of Pharmacy, Virginia Commonwealth University Health System/Medical College of Virginia Hospitals, Richmond, VA, USA.,2 Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - Lauren C Magee
- 1 Department of Pharmacy, Virginia Commonwealth University Health System/Medical College of Virginia Hospitals, Richmond, VA, USA.,2 Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - Denise K Lowe
- 1 Department of Pharmacy, Virginia Commonwealth University Health System/Medical College of Virginia Hospitals, Richmond, VA, USA.,2 Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
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De Servi S, Morici N, Boschetti E, Rossini R, Martina P, Musumeci G, D'Urbano M, Lazzari L, La Vecchia C, Senni M, Klugmann S, Savonitto S. Bridge therapy or standard treatment for urgent surgery after coronary stent implantation: Analysis of 314 patients. Vascul Pharmacol 2016; 80:85-90. [DOI: 10.1016/j.vph.2015.11.085] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 11/02/2015] [Accepted: 11/27/2015] [Indexed: 11/30/2022]
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Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R, Mukherjee D, Newby LK, O'Gara PT, Sabatine MS, Smith PK, Smith SC. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016; 68:1082-115. [PMID: 27036918 DOI: 10.1016/j.jacc.2016.03.513] [Citation(s) in RCA: 1004] [Impact Index Per Article: 125.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Saia F, Belotti LMB, Guastaroba P, Berardini A, Rossini R, Musumeci G, Tarantini G, Campo G, Guiducci V, Tarantino F, Menozzi A, Varani E, Santarelli A, Tondi S, De Palma R, Rapezzi C, Marzocchi A. Risk of Adverse Cardiac and Bleeding Events Following Cardiac and Noncardiac Surgery in Patients With Coronary Stent: How Important Is the Interplay Between Stent Type and Time From Stenting to Surgery? Circ Cardiovasc Qual Outcomes 2015; 9:39-47. [PMID: 26646819 DOI: 10.1161/circoutcomes.115.002155] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 11/13/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Epidemiology and consequences of surgery in patients with coronary stents are not clearly defined, as well as the impact of different stent types in relationship with timing of surgery. METHODS AND RESULTS Among 39 362 patients with previous coronary stenting enrolled in a multicenter prospective registry and followed for 5 years, 13 128 patients underwent 17 226 surgical procedures. The cumulative incidence of surgery at 30 days, 6 months, 1 year, and 5 years was 3.6%, 9.4%, 14.3%, and 40.0%, respectively, and of cardiac and noncardiac surgery was 0.8%, 2.1%, 2.6%, and 4.0% and 1.3%, 5.1%, 9.1%, and 31.7%, respectively. We assessed the incidence and the predictors of cardiac death, myocardial infarction, and serious bleeding event within 30 days from surgery. Cardiac death occurred in 438 patients (2.5%), myocardial infarction in 256 (1.5%), and serious bleeding event in 1099 (6.4%). Surgery increased 1.58× the risk of cardiac death during follow-up. Along with other risk factors, the interplay between stent type and time from percutaneous coronary intervention to surgery was independently associated with cardiac death/myocardial infarction. In comparison with bare-metal stent implanted >12 months before surgery, old-generation drug-eluting stent was associated with higher risk of events at any time point. Conversely, new-generation drug-eluting stent showed similar safety as bare-metal stent >12 months and between 6 and 12 months and appeared trendly safer between 0 and 6 months. CONCLUSIONS Surgery is frequent in patients with coronary stents and carries a considerable risk of ischemic and bleeding events. Ischemic risk is inversely related with time from percutaneous coronary intervention to surgery and is influenced by stent type.
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Affiliation(s)
- Francesco Saia
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.).
| | - Laura Maria Beatrice Belotti
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
| | - Paolo Guastaroba
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
| | - Alessandra Berardini
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
| | - Roberta Rossini
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
| | - Giuseppe Musumeci
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
| | - Giuseppe Tarantini
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
| | - Gianluca Campo
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
| | - Vincenzo Guiducci
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
| | - Fabio Tarantino
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
| | - Alberto Menozzi
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
| | - Elisabetta Varani
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
| | - Andrea Santarelli
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
| | - Stefano Tondi
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
| | - Rossana De Palma
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
| | - Claudio Rapezzi
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
| | - Antonio Marzocchi
- From the Institute of Cardiology, Cardio-thoraco-vascular Department, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy (F.S., A.B., C.R., A. Marzocchi); Regional Health Care and Social Agency, Bologna, Italy (L.M.B.B., P.G., R.D.P.); Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy (R.R., G.M.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy (G.T.); Cardiology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria S.Anna, Cona (Ferrara), Italy (G.C.); Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia, Italy (V.G.); Interventional Cardiology Unit, Morgagni Hospital, Forlì, Italy (F.T.); Cardiovascular Department, Maggiore Hospital, Parma, Italy (A. Menozzi); Cardiovascular Department, S. Maria delle Croci Hospital, Ravenna, Italy (E.V.); Cardiology department, Ospedale degli Infermi, Rimini, Italy (A.S.); and Department of Cardiology, Baggiovara Hospital, Modena, Italy (S.T.)
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Irwin MG, Wong GTC. Remifentanil and Opioid-Induced Cardioprotection. J Cardiothorac Vasc Anesth 2015; 29 Suppl 1:S23-6. [DOI: 10.1053/j.jvca.2015.01.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Indexed: 02/07/2023]
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Hassan C, Zullo A. Anti-platelet therapy and endoscopic procedures: eyes wide shut? Endosc Int Open 2015; 3:E179-80. [PMID: 26171426 PMCID: PMC4486034 DOI: 10.1055/s-0034-1392368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 05/06/2015] [Indexed: 12/02/2022] Open
Affiliation(s)
- Cesare Hassan
- Department of Gastroenterology, ONRM Hospital, Rome, Italy,Corresponding author Cesare Hassan, MD Department of GastroenterologyONRM HospitalVia Morosini 30Rome 00153Italy+39-06-58446533
| | - Angelo Zullo
- Department of Gastroenterology, ONRM Hospital, Rome, Italy
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Kristensen SD, Grove EL, Maeng M. Coronary stents and non-cardiac surgery: to bridge or not to bridge? Thromb Haemost 2015; 114:211-3. [PMID: 26018636 DOI: 10.1160/th15-04-0305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 04/13/2015] [Indexed: 11/05/2022]
Affiliation(s)
- S D Kristensen
- Prof. Steen Dalby Kristensen, Department of Cardiology, Aarhus University Hospital, DK-8200 Aarhus N, Denmark, E-mail:
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Squizzato A, Lussana F, Cattaneo M. Post-operative arterial thrombosis with non-vitamin K antagonist oral anticoagulants after total hip or knee arthroplasty. Thromb Haemost 2015; 114:237-44. [PMID: 25946985 DOI: 10.1160/th15-01-0073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 03/04/2015] [Indexed: 01/16/2023]
Abstract
The incidence of post-operative arterial thrombosis (AT) (acute myocardial infarction [AMI] and ischaemic stroke) is increased in patients undergoing total hip replacement (THR) or total knee replacement (TKR). We compared the incidence of post-operative AT in non-vitamin K antagonist oral anticoagulants (NOACs)-treated and enoxaparin-treated patients, performing a systematic review of phase III randomised controlled trials (RCTs) of venous thromboembolism (VTE) prophylaxis in THR and TKR. Studies were identified by electronic search of MEDLINE and EMBASE database until July 2014. Differences between NOACs and enoxaparin groups in the efficacy and safety outcomes were expressed as odds ratios (ORs) with pertinent 95 % confidence intervals (95 % CI). Statistical heterogeneity was assessed with the I² statistic. Eleven phase III RCTs for a total of 31,319 patients were included. Patients underwent TKR in six studies and THR in five studies. The NOACs under study were dabigatran (four studies), apixaban (three studies) and rivaroxaban (four studies). AT occurred in 0.23 % of patients on NOACs and in 0.27 % of patients on enoxaparin: the OR at fixed-effect model was 0.86 (95 % CI 0.53-1.40; I² 11 %). No differences in AT incidence among the three NOACs were observed. The incidence of major and clinically relevant bleeding was similar in NOACs and enoxaparin groups (OR 1.03, 95 % CI 0.92-1.15; I² 38 %). In conclusion, in RCTs of pharmacological VTE prophylaxis in patients undergoing THR or TKR, there was no difference in the incidence of post-operative AT among patients treated with NOACs, compared to those treated with enoxaparin.
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Affiliation(s)
- A Squizzato
- Alessandro Squizzato, MD, PhD, U. O. Medicina Interna 1, Ospedale di Circolo, Viale Borri 57, 21100 Varese, Italy, Tel.: +39 0332 278831, Fax: +39 0332 278229, E-mail:
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Siller-Matula JM, Petre A, Delle-Karth G, Huber K, Ay C, Lordkipanidzé M, De Caterina R, Kolh P, Mahla E, Gersh BJ. Impact of preoperative use of P2Y12 receptor inhibitors on clinical outcomes in cardiac and non-cardiac surgery: A systematic review and meta-analysis. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 6:753-770. [DOI: 10.1177/2048872615585516] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | - Alexandra Petre
- Department of Cardiology, Medical University of Vienna, Austria
| | | | - Kurt Huber
- 3rd Medical Department of Cardiology and Emergency Medicine, Wilhelminen Hospital, Vienna, Austria
| | - Cihan Ay
- Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Austria
| | - Marie Lordkipanidzé
- Faculty of Pharmacy, University of Montreal; Research Center, Montreal Heart Institute, Canada
| | - Raffaele De Caterina
- Institute of Cardiology, ‘G d’Annunzio’ University – Chieti-Pescara, Chieti, Italy
| | - Philippe Kolh
- Department of Cardiothoracic Surgery, University Hospital of Liege, Belgium
| | - Elisabeth Mahla
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Austria
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, College of Medicine Rochester, USA
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Perspectives on the management of antiplatelet therapy in patients with coronary artery disease requiring cardiac and noncardiac surgery. Curr Opin Cardiol 2014; 29:553-63. [DOI: 10.1097/hco.0000000000000104] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Perioperative cardiovascular complications versus perioperative bleeding in consecutive patients with known cardiac disease undergoing non-cardiac surgery. Focus on antithrombotic medication. The PRAGUE-14 registry. Neth Heart J 2014; 22:372-9. [PMID: 25120211 PMCID: PMC4160449 DOI: 10.1007/s12471-014-0575-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Interruption of antithrombotic treatment before surgery may prevent bleeding, but at the price of increasing cardiovascular complications. This prospective study analysed the impact of antithrombotic therapy interruption on outcomes in non-selected surgical patients with known cardiovascular disease (CVD). Methods All 1200 consecutive patients (age 74.2 ± 10.2 years) undergoing major non-cardiac surgery (37.4 % acute, 61.4 % elective) during a period of 2.5 years while having at least one CVD were enrolled. Details on medication, bleeding, cardiovascular complications and cause of death were registered. Results In-hospital mortality was 3.9 % (versus 0.9 % mortality among 17,740 patients without CVD). Cardiovascular complications occurred in 91 (7.6 %) patients (with 37.4 % case fatality). Perioperative bleeding occurred in 160 (13.3 %) patients and was fatal in 2 (1.2 % case fatality). Multivariate analysis revealed age, preoperative anaemia, history of chronic heart failure, acute surgery and general anaesthesia predictive of cardiovascular complications. For bleeding complications multivariate analysis found warfarin use in the last 3 days, history of hypertension and general anaesthesia as independent predictive factors. Aspirin interruption before surgery was not predictive for either cardiovascular or for bleeding complications. Conclusions Perioperative cardiovascular complications in these high-risk elderly all-comer surgical patients with known cardiovascular disease are relatively rare, but once they occur, the case fatality is high. Perioperative bleeding complications are more frequent, but their case fatality is extremely low. Patterns of interruption of chronic aspirin therapy before major non-cardiac surgery are not predictive for perioperative complications (neither cardiovascular, nor bleeding). Simple baseline clinical factors are better predictors of outcomes than antithrombotic drug interruption patterns.
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A systematic review on the effect of aspirin in the prevention of post-operative arterial thrombosis in patients undergoing total hip and total knee arthroplasty. Thromb Res 2014; 134:599-603. [DOI: 10.1016/j.thromres.2014.06.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 05/31/2014] [Accepted: 06/17/2014] [Indexed: 11/21/2022]
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[Thromboprophylaxis and platelet aggregation inhibitors in spinal surgery: perioperative management]. DER ORTHOPADE 2014; 43:833-40. [PMID: 25116247 DOI: 10.1007/s00132-014-2319-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The perioperative use of anticoagulants (AC) and platelet aggregation inhibitors (PAI) in the field of spinal surgery suggests an increased rate of epidural bleeding. However, evidence is lacking and these medications are most often indispensable in the prevention of thromboembolic complications. Comprehensive recommendations for the correct use of AC and PAI are lacking. OBJECTIVE The aim of this study was an analysis of the current situation with regards to the use of AC and PAI in spinal surgery and development of new recommendations. MATERIAL AND METHODS Two independent surveys on the perioperative use of AC and PAI were obtained from centers for spinal surgery in Germany. The study obtained information on the perioperative use of AC and PAI, risk assessment of thromboembolic and hemorrhagic events as well as on the type and extent of the substance groups used. RESULTS Almost the entire patient collective (98%) received perioperative low molecular weight heparin. In 64% the medical prophylaxis was started before surgery and in 36% after surgery. The period of prophylaxis was determined arbitrarily. Approximately 40% of interviewees employed paravertebral infiltration and 19% injected into the epidural space in patients on PAI medication. Open spinal canal surgery was performed in 30% of PAI medicated patients and closed spinal canal surgery was executed in 40%. The risk assessment of PAI differed significantly between aspirin and receptor blocker medication as well as dual administration of PAI. DISCUSSION The use of AC and PAI in spinal surgery in Germany is very heterogeneous and large deviations from the guidelines frequently occurred. Therefore, there is a strong need for further studies to accurately assess the perioperative use of AC and PAI and to formulate precise recommendations.
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Williams LA, Hunter JM, Marques MB, Vetter TR. Periprocedural management of patients on anticoagulants. Clin Lab Med 2014; 34:595-611. [PMID: 25168945 DOI: 10.1016/j.cll.2014.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Every year, new studies are undertaken to address the complex issue of periprocedural management of patients on anticoagulants and antiplatelet medications. In addition, newer drugs add to the confusion among clinicians about how to best manage patients taking these agents. Using the most recent data, guidelines, and personal experience, this article discusses recommendations and presents simplified algorithms to assist clinicians in the periprocedural management of patients on anticoagulants.
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Affiliation(s)
- Lance A Williams
- Department of Pathology, University of Alabama at Birmingham, 619 19th Street South, WPP230F, Birmingham, AL 35249-7331, USA.
| | - James M Hunter
- Department of Anesthesiology, University of Alabama at Birmingham, 1720 2nd Avenue South, JT926C, Birmingham, AL 35249-6810, USA
| | - Marisa B Marques
- Department of Pathology, University of Alabama at Birmingham, 619 19th Street South, WPP230G, Birmingham, AL 35249-7331, USA
| | - Thomas R Vetter
- Department of Anesthesiology, University of Alabama at Birmingham, 619 19th Street South, JT865, Birmingham, AL 35249, USA
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Franchi F, Rollini F, Muñiz-Lozano A, Cho JR, Angiolillo DJ. Cangrelor: a review on pharmacology and clinical trial development. Expert Rev Cardiovasc Ther 2014; 11:1279-91. [PMID: 24138516 DOI: 10.1586/14779072.2013.837701] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Dual antiplatelet therapy with aspirin and an oral ADP P2Y12 receptor antagonist is the standard-of-care for the prevention of ischemic events in patients with acute coronary syndrome or undergoing percutaneous coronary intervention (PCI). However, currently available ADP P2Y12 receptor antagonists have several limitations, such as interindividual response variability, drug-drug interactions, slow onset/offset and only oral availability. Cangrelor is a reversible, potent, intravenous, competitive inhibitor of the ADP P2Y12 receptor that rapidly achieves near complete and predictable platelet inhibition. Along with reversible binding to the receptor cangrelor also has a very short half-life (3-5 min), which in turn results in a rapid offset of action. These properties make cangrelor a promising drug for clinical use in patients undergoing PCI or patients waiting for major surgery but still require antiplatelet protection. This manuscript provides an update of the current status of knowledge on cangrelor, focusing on its pharmacologic properties and clinical trial development, including the BRIDGE and CHAMPION-PHOENIX trials.
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Affiliation(s)
- Francesco Franchi
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
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47
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Rossini R, Musumeci G, Visconti LO, Bramucci E, Castiglioni B, De Servi S, Lettieri C, Lettino M, Piccaluga E, Savonitto S, Trabattoni D, Capodanno D, Buffoli F, Parolari A, Dionigi G, Boni L, Biglioli F, Valdatta L, Droghetti A, Bozzani A, Setacci C, Ravelli P, Crescini C, Staurenghi G, Scarone P, Francetti L, D’Angelo F, Gadda F, Comel A, Salvi L, Lorini L, Antonelli M, Bovenzi F, Cremonesi A, Angiolillo DJ, Guagliumi G. Perioperative management of antiplatelet therapy in patients with coronary stents undergoing cardiac and non-cardiac surgery: a consensus document from Italian cardiological, surgical and anaesthesiological societies. EUROINTERVENTION 2014; 10:38-46. [DOI: 10.4244/eijv10i1a8] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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48
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Morici N, Moja L, Rosato V, Sacco A, Mafrici A, Klugmann S, D'Urbano M, La Vecchia C, De Servi S, Savonitto S. Bridge with intravenous antiplatelet therapy during temporary withdrawal of oral agents for surgical procedures: a systematic review. Intern Emerg Med 2014; 9:225-35. [PMID: 24419741 DOI: 10.1007/s11739-013-1041-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 12/21/2013] [Indexed: 01/21/2023]
Abstract
Patients needing surgery within 1 year after drug-eluting cardiac stent implantation are challenging to manage because of an increased thrombotic and bleeding risk. A "bridge therapy" with short-acting antiplatelet agents in the perioperative period is an option. We assessed the outcome and safety of such a bridge therapy in cardiovascular and non-cardiovascular surgery. We performed a comprehensive search of MEDLINE, EMBASE, the Cochrane Library, and ongoing trial registers, irrespective of type of design. Our primary outcome was the success rate of bridge therapy in terms of freedom from cardiac ischaemic adverse events, whereas secondary outcome was freedom from bleeding/transfusion. We also performed combined success rate for each bridge therapy drug (tirofiban, eptifibatide, and cangrelor). We included eight case series and one randomised controlled trial. Among the 420 patients included, the technique was effective 96.2 % of the times [95 % confidence interval (CI) 94.4-98.0 %]. The success rate was 100 % for tirofiban (4 studies), 93.8 % for eptifibatide (4 studies), and 96.2 % for cangrelor (1 study). Freedom from bleeding/transfusion events was observed in 72.6 % of the times (95 % CI 68.4-76.9 %), and was higher with cangrelor (88.7 %; 95 % CI 82.7-94.7 %) than with other drugs (81.0 % for tirofiban and 58.6 % for eptifibatide). Evidence from case series and one randomised controlled trial suggests that, in patients with recent coronary stenting undergoing major surgery, perioperative bridge therapy with intravenous antiplatelet agents is an effective and safe treatment option to ensure low rate of ischaemic events.
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Affiliation(s)
- Nuccia Morici
- Divisione di Cardiologia 1-Emodinamica, Dipartimento Cardio-toraco-vascolare "A. De Gasperis", Azienda Ospedaliera Ospedale Niguarda Cà Granda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy,
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Bonhomme F, Fontana P, Reny JL. How to manage prasugrel and ticagrelor in daily practice. Eur J Intern Med 2014; 25:213-20. [PMID: 24529662 DOI: 10.1016/j.ejim.2014.01.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 01/20/2014] [Accepted: 01/22/2014] [Indexed: 12/13/2022]
Abstract
Prasugrel and ticagrelor are next-generation antiplatelet agents that provide a rapider and more potent inhibition of platelet P2Y12 receptor than clopidogrel. In combination with aspirin, these new P2Y12 inhibitors are now the first line treatments for patients with acute coronary syndrome. However, these potent antiplatelet agents introduce a new paradigm in the daily management of antithrombotic drugs, particularly when an invasive procedure is planned. The pharmacology of these antiplatelet agents, and the results of the main clinical trials, are reviewed with a special focus on good prescription practices (indications, contra-indications, drug interactions), and on peri-operative management. Strategies are proposed for safely reducing the bleeding risk in elderly patients, in patients requiring concomitant oral anticoagulant therapy, or in patients with an increased haemorrhagic risk.
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Affiliation(s)
- Fanny Bonhomme
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Switzerland; Division of Anaesthesiology, Geneva University Hospitals, Geneva, Switzerland.
| | - Pierre Fontana
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Switzerland; Division of Angiology and Haemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Jean-Luc Reny
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Switzerland; Division of General Internal Medicine and Rehabilitation, Trois-Chêne, Geneva University Hospitals, Geneva, Switzerland
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50
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Vetter TR, Cheng D. Perioperative Antiplatelet Drugs with Coronary Stents and Dancing with Surgeons. Anesth Analg 2013. [DOI: 10.1213/ane.0b013e3182982c90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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