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Li M, Liu R, Wu Y. Randomised controlled trial of early magnetically controlled capsule endoscopy for the prevention of gastrointestinal bleeding in patients at high bleeding risk scheduled for percutaneous coronary intervention: MACE-GPS study protocol. BMJ Open 2024; 14:e077852. [PMID: 38262638 PMCID: PMC10806601 DOI: 10.1136/bmjopen-2023-077852] [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: 07/17/2023] [Accepted: 01/10/2024] [Indexed: 01/25/2024] Open
Abstract
INTRODUCTION Limited data are available regarding the decision-making process for preventing gastrointestinal bleeding in patients at high risk of bleeding scheduled for percutaneous coronary intervention (HBPCI), especially due to the lack of a simple, accurate and sensitive methods for gastrointestinal injury detection. This randomised trial aims to assess the effects of early magnetically controlled capsule endoscopy (MCE) in patients with HBPCI for the prevention of gastrointestinal bleeding compared with conventional management. METHODS AND ANALYSIS The Magnetic-Assisted Capsule Endoscopy Gastrointestinal bleeding Protection Strategy (MACE-GPS) is a multicentre, open-label, randomised controlled trial. Patients admitted for HBPCI will be randomised and placed into two study groups. In the early MCE group, 1228 patients will undergo MCE following admission to the hospital. If necessary, these patients may further undergo a multidisciplinary approach to determine treatment based on the MCE findings. A total of 1228 patients in the control group will undergo conventional treatment based on the attending cardiologist's interpretation of their clinical presentations. The primary end point is the incidence of gastrointestinal bleeding within 12 months of enrolment. ETHICS AND DISSEMINATION The MACE-GPS trial has been approved by the ethics committees of all participating sites. Participant recruitment began in April 2023 and will be completed in April 2025, and the 1-year follow-up will be completed in April 2026. The study results will be disseminated through conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER ChiCTR2300070025.
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Affiliation(s)
- Minghui Li
- Department of Cardiology, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Rong Liu
- Department of Cardiology, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yongjian Wu
- Department of Cardiology, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Abrignani MG, Lombardo A, Braschi A, Renda N, Abrignani V. Proton pump inhibitors and gastroprotection in patients treated with antithrombotic drugs: A cardiologic point of view. World J Cardiol 2023; 15:375-394. [PMID: 37771340 PMCID: PMC10523195 DOI: 10.4330/wjc.v15.i8.375] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/23/2023] [Accepted: 08/08/2023] [Indexed: 08/21/2023] Open
Abstract
Aspirin, other antiplatelet agents, and anticoagulant drugs are used across a wide spectrum of cardiovascular and cerebrovascular diseases. A concomitant proton pump inhibitor (PPI) treatment is often prescribed in these patients, as gastrointestinal complications are relatively frequent. On the other hand, a potential increased risk of cardiovascular events has been suggested in patients treated with PPIs; in particular, it has been discussed whether these drugs may reduce the cardiovascular protection of clopidogrel, due to pharmacodynamic and pharmacokinetic interactions through hepatic metabolism. Previously, the concomitant use of clopidogrel and omeprazole or esomeprazole has been discouraged. In contrast, it remains less known whether PPI use may affect the clinical efficacy of ticagrelor and prasugrel, new P2Y12 receptor antagonists. Current guidelines recommend PPI use in combination with antiplatelet treatment in patients with risk factors for gastrointestinal bleeding, including advanced age, concurrent use of anticoagulants, steroids, or non-steroidal anti-inflammatory drugs, and Helicobacter pylori (H. pylori) infection. In patients taking oral anticoagulant with risk factors for gastrointestinal bleeding, PPIs could be recommended, even if their usefulness deserves further data. H. pylori infection should always be investigated and treated in patients with a history of peptic ulcer disease (with or without complication) treated with antithrombotic drugs. The present review summarizes the current knowledge regarding the widespread combined use of platelet inhibitors, anticoagulants, and PPIs, discussing consequent clinical implications.
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Affiliation(s)
| | - Alberto Lombardo
- Operative Unit of Cardiology, S. Antonio Abate Hospital, ASP Trapani, Erice 91100, Trapani, Italy
| | - Annabella Braschi
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo 90100, Italy
| | - Nicolò Renda
- Department of Direction, CTA Salus, Gibellina 91024, Trapani, Italy
| | - Vincenzo Abrignani
- Operative Unit of Internal Medicine with Stroke Care, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) "G. D'Alessandro", University of Palermo, Palermo 90100, Italy
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Wang X, Chen X, Liu W, Liang W, Liu M. Rationale and Design of LAPIS: A Multicenter Prospective Cohort Study to Investigate the Efficacy and Safety of Low-Dose Aspirin in Elderly Chinese Patients. Int J Gen Med 2022; 15:8333-8341. [DOI: 10.2147/ijgm.s391259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/17/2022] [Indexed: 11/25/2022] Open
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Wang X, Wang H, Zheng Q, Geng H, Zhang J, Fan Y, Feng X, Chen X, Liu M. Outcomes Associated with 50 mg/d and 100 mg/d Aspirin for the Prevention and Management of Cardiovascular Disease in Chinese Elderly: Single-Center Interim Analysis of a Multicenter, Prospective, Observational Study. Int J Gen Med 2022; 15:7089-7100. [PMID: 36097566 PMCID: PMC9464038 DOI: 10.2147/ijgm.s384375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 08/29/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Although aspirin can effectively reduce the occurrence of atherothrombosis, it is significantly associated with increased bleeding, with elderly individuals being at increased risk of cardiovascular diseases (CVD) and hemorrhage. This study aims to evaluate the efficacy and safety of aspirin 50 mg/d and 100 mg/d for the prevention and management of CVD in Chinese elderly. Patients and Methods The Low-dose Aspirin for Primary and Secondary Prevention of Cardiovascular Disease in the Elderly Study (LAPIS) is a multicenter, prospective, observational cohort study, this study was a single-center interim analysis of LAPIS. Patients aged ≥60 and required long-term aspirin for primary and secondary prevention of CVD were eligible. From Apr 1, 2019 to Feb 28, 2022, 165 patients who received 50 mg/d aspirin and 261 patients who received 100 mg/d aspirin were included in the study. The incidence of major cardiovascular events (MACEs), bleeding events, and gastrointestinal adverse events were compared between two groups. Results After adjusting for patient characteristics using propensity score matching, aspirin 100 mg/d was associated with increased incidence rates of total bleeding events (28.34 vs.17.25 events/100 patient-years, HR 1.671, 95% CI 1.024–2.712, P = 0.040) and minor bleeding events (27.63 vs.15.92 events/100 patient-years, HR 1.738, 95% CI 1.056–2.861, P = 0.031), whereas the incidence of MACE (6.35 vs 6.65 events/100 patient-years, HR 0.921, 95% CI 0.399–2.127, P = 0.848) and gastrointestinal adverse events (12.73 vs.10.42 events/100 patient-years, HR 1.206, 95% CI 0.623–2.337, P = 0.578) were similar between the two groups. Multivariate Cox analysis identified that aspirin dose (100 mg/d vs. 50 mg/d, HR 1.918, 95% CI 1.137–3.235, P = 0.015), concomitant use of other antiplatelets (HR 1.748, 95% CI 1.009–3.028, P = 0.046) and anticoagulants (HR 2.501, 95% CI 1.287–4.862, P = 0.007) were independently associated with bleeding events. Conclusion 50 mg/d aspirin may be preferred to balance the safety and effectiveness in Chinese individuals over 60 years of age who need long-term aspirin for the prevention and management of CVD. Trial Registration ChiCTR1900021980 (chictr.org.cn). Registered on 19 March 2019.
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Affiliation(s)
- Xiting Wang
- Department of Geriatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Hao Wang
- Department of Geriatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Qin Zheng
- Department of Geriatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Hui Geng
- Department of Geriatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Jing Zhang
- Department of Geriatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Yan Fan
- Department of Geriatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Xueru Feng
- Department of Geriatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Xiahuan Chen
- Department of Geriatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Meilin Liu
- Department of Geriatrics, Peking University First Hospital, Beijing, People’s Republic of China
- Correspondence: Meilin Liu, Department of Geriatrics, Peking University First Hospital, Beijing, People’s Republic of China, Email
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Zhu Y, Wang X, Yang Y, Liu L, Zhao Q, Yu L. Proton pump inhibitor in the prevention of upper gastrointestinal mucosal injury associated with dual antiplatelet therapy after coronary artery bypass grafting (DACAB-GI-2): study protocol for a randomized controlled trial. Trials 2022; 23:569. [PMID: 35840999 PMCID: PMC9287869 DOI: 10.1186/s13063-022-06464-w] [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: 06/21/2021] [Accepted: 06/09/2022] [Indexed: 11/25/2022] Open
Abstract
Background Dual antiplatelet therapy (DAPT) is recommended in secondary prevention after coronary artery bypass grafting (CABG), but it is inevitably associated with the risk of bleeding, of which gastrointestinal bleeding accounts for more than half. Proton pump inhibitors (PPIs) may increase the risk of major cardiovascular adverse events when reducing the risk of upper gastrointestinal bleeding. Therefore, the optimal duration of a PPI in combination with DAPT is unclear. Methods The “Proton Pump Inhibitor Preventing Upper Gastrointestinal Injury in Patients on Dual Antiplatelet Therapy after CABG” (DACAB-GI-2) study is a prospective, single-center, open-label, parallel, randomized controlled trial. A total of 232 eligible subjects who are scheduled or initiated on DAPT (clopidogrel plus aspirin or ticagrelor plus aspirin) for 12 months immediately after CABG will be enrolled and be randomized in a 1:1 ratio to either a 12-month pantoprazole treatment arm or a 1-month treatment arm. The primary outcome is to assess the rate of gastroduodenal erosions and ulcers evaluated by esophagogastroduodenoscopy (EGD) within 12 months after randomization, based on the modified Lanza score. Secondary outcomes include reflux esophagitis and upper gastrointestinal bleeding. Other pre-specified outcomes include major adverse cardiovascular events, graft failure, and all-cause death. Discussion This study aims to compare the efficacy and safety of 12 months and 1 month of pantoprazole treatment in preventing DAPT-related upper gastrointestinal mucosal injury after CABG. Trial registration ClinicalTrials.gov NCT03908593.
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Affiliation(s)
- Yunpeng Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Xiaojin Wang
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Yi Yang
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Lei Liu
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Lifen Yu
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
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Portela RC, Sharma I, Vahibe A, Hassan O, Spaniolas K, Dayyeh BA, Clapp B, Ghanem OM. Aspirin Use as a Risk Factor for Marginal Ulceration in Roux-en-Y Gastric Bypass Patients: A Meta-Analysis of 24,770 Patients. Am Surg 2022:31348221103647. [PMID: 35586872 DOI: 10.1177/00031348221103647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is a recognized, safe bariatric procedure with minimal complications. Marginal ulceration, however, remains a challenging problem with an incidence of 8-12%. While chronic NSAID use is an established risk factor for ulcer formation, aspirin use itself as a cause for marginal ulceration is still unclear. We aim to compare the rates of marginal ulceration in RYGB with and without aspirin use. METHODS PubMed, ScienceDirect, Cochrane, Web of Science, and Google Scholar were searched for articles between 2008 and 2021 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). The risk of bias was assessed using Newcastle-Ottawa Scale. Meta-analysis was conducted using a fixed-effect model. RESULTS From 5324 studies screened, we included 3 studies. Two studies had a low risk of bias, and the other one presented a high risk of bias on the Newcastle-Ottawa Scale. We included 24,770 patients, 1911 with aspirin use and 22,859 without aspirin use. After the meta-analysis, patients who used aspirin had a significantly higher marginal ulceration rate than those who did not (OR = 1.33 [95% CI 1.08 to 1.63], P < .002; I2 = 39%). CONCLUSIONS Aspirin use is associated with increased rates of marginal ulceration after RYGB.
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Affiliation(s)
- Ray C Portela
- Department of Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | - Ishna Sharma
- Department of Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | - Ahmet Vahibe
- Department of Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | - Omer Hassan
- Department of Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | | | | | - Benjamin Clapp
- Department of Surgery, 37316Texas Tech HSC Paul Foster School of Medicine, El Paso, TX, USA
| | - Omar M Ghanem
- Department of Surgery, 6915Mayo Clinic, Rochester, MN, USA
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Kanwal F, Ma M, Rehman MFU, Khan FU, Elizur SE, Batool AI, Wang CC, Tabassum T, Lu C, Wang Y. Aspirin Repurposing in Folate-Decorated Nanoparticles: Another Way to Target Breast Cancer. Front Mol Biosci 2022; 8:788279. [PMID: 35187067 PMCID: PMC8848101 DOI: 10.3389/fmolb.2021.788279] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/06/2021] [Indexed: 12/31/2022] Open
Abstract
Breast cancer affects more than 1 million women per year worldwide. Through this study, we developed a nanoparticle-based drug delivery system to target breast cancer cells. Aspirin has been found to inhibit thromboembolic diseases with its tumor-preventing activity. As a consequence, it relieves disease symptoms and severity. Here, mesoporous silica nanoparticles (MNPs) have been used to deliver aspirin to the tumor location. MNP-based aspirin in folic acid (F)-conjugated polydopamine (MNP-Asp-PD-PG-F) vehicles are prepared for targeted breast cancer therapy. The vehicle hinges on MNP altered with polymer polyethylene glycol (PG), polydopamine (PD), and F. The delivery vehicle was studied for in vitro drug release, cytotoxicity, and breast cancer cell proliferation. F-conjugated drug delivery vehicles let MNPs achieve an elevated targeting efficacy, ideal for cancer therapy. It was also observed that compared to free aspirin, our drug delivery system (MNP-Asp-PD-PG-F) has a higher cytotoxic and antiproliferative effect on breast cancer cells. The drug delivery system can be proposed as a targeted breast cancer therapy that could be further focused on other targeted cancer therapies. Delivering aspirin by the PD-PG-F system on the tumor sites promises a therapeutic potential for breast cancer treatment.
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Affiliation(s)
- Fariha Kanwal
- School of Biomedical Engineering, Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Mingming Ma
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Key Laboratory of Ocular Fundus Diseases, National Clinical Research Center for Eye Diseases, Shanghai Engineering Center for Visual Science and Photomedicine, Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, Shanghai, China
| | - Muhammad Fayyaz ur Rehman
- Institute of Chemistry, University of Sargodha, Sargodha, Pakistan
- *Correspondence: Muhammad Fayyaz ur Rehman, ; Yao Wang,
| | - Fahim-ullah Khan
- Department of Biotechnology, University of Science and Technology, Bannu, Pakistan
| | - Shai E. Elizur
- IVF Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Aima Iram Batool
- Department of Zoology, University of Sargodha, Sargodha, Pakistan
| | - Chi Chiu Wang
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Tahira Tabassum
- Department of Pathology, Sargodha Medical College, University of Sargodha, Sargodha, Pakistan
| | - Changrui Lu
- Department of Chemistry, Chemical Engineering and Biotechnology, Donghua University, Shanghai, China
| | - Yao Wang
- Department of Assisted Reproduction, School of Medicine, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Muhammad Fayyaz ur Rehman, ; Yao Wang,
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Magnetically-controlled Capsule Endoscopy for Assessment of Antiplatelet Therapy-induced Gastrointestinal Injury. J Am Coll Cardiol 2021; 79:116-128. [PMID: 34752902 DOI: 10.1016/j.jacc.2021.10.028] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/05/2021] [Accepted: 10/15/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Gastrointestinal bleeding is the most frequent major complication of antiplatelet therapy. In patients at low bleeding risk, however, clinically overt gastrointestinal bleeding is relatively uncommon. OBJECTIVE We sought to assess the effects of different antiplatelet regimens on gastrointestinal mucosal injury using a novel magnetically-controlled capsule endoscopy system in patients at low bleeding risk. METHODS Patients (n=505) undergoing percutaneous coronary intervention in whom capsule endoscopy demonstrated no ulcerations or bleeding (although erosions were permitted) after 6 months of dual antiplatelet therapy (DAPT) were randomly assigned to aspirin plus placebo (n=168), clopidogrel plus placebo (n=169), or aspirin plus clopidogrel (n=168) for an additional 6 months. The primary endpoint was the incidence of gastrointestinal mucosal injury (erosions, ulceration, or bleeding) at 6-month or 12-month capsule endoscopy. RESULTS Gastrointestinal mucosal injury through 12 months was less with single antiplatelet therapy (SAPT) compared with DAPT (94.3% vs. 99.2%, P=0.02). Aspirin and clopidogrel monotherapy had similar effects. Among 68 patients without any gastrointestinal injury at randomization (including no erosions), SAPT compared with DAPT caused less gastrointestinal injury (68.1% vs. 95.2%, P=0.006), including fewer new ulcers (8.5% vs. 38.1%, P=0.009). Clinical gastrointestinal bleeding between 6 and 12 months was less with SAPT compared with DAPT (0.6% vs. 5.4%, P=0.001). CONCLUSIONS Despite being at low risk of bleeding, nearly all patients receiving antiplatelet therapy developed gastrointestinal injury, although overt bleeding was infrequent. DAPT for 6 months followed by SAPT with aspirin or clopidogrel between 6 and 12 months resulted in less gastrointestinal mucosal injury and clinical bleeding compared with DAPT through 12 months.
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