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Peng D, Zhai H. Application of antithrombotic drugs and risk factor analysis in ICU patients with lower gastrointestinal bleeding from MIMIC-IV. BMC Gastroenterol 2024; 24:319. [PMID: 39294584 PMCID: PMC11409781 DOI: 10.1186/s12876-024-03380-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 08/21/2024] [Indexed: 09/20/2024] Open
Abstract
OBJECTIVE This study aims to assess the effects of antithrombotic therapy on the outcomes of lower gastrointestinal bleeding (LGIB) in ICU patients, focusing on in-hospital mortality, rebleeding, and length of hospital and ICU stays. METHOD This retrospective observational study utilized the MIMIC-IV 2.2 database, which includes 513 ICU patients with LGIB. RESULT The in-hospital mortality rate was 7.6%, and the rebleeding rate was 11.1%. The average Oakland risk score among the study population was 22.54. Multivariate Cox regression analysis identified the use of antiplatelet drugs as an independent protective factor for in-hospital mortality (HR = 0.37, 95% CI 0.15-0.90, p = 0.029). Patients on anticoagulants experienced significantly longer hospital stays (13.1 ± 12.2 days vs. 17.4 ± 12.6 days, p = 0.031) compared to those not using these drugs. Propensity score matching also supported these findings, indicating that antithrombotic therapy was associated with lower in-hospital mortality and longer hospital stays even after adjusting for factors like age, gender, and primary diagnosis. CONCLUSIONS Our analysis using various statistical methods, including propensity score matching and multivariate regression, confirms that use of antithrombotic drugs in 2.3 days, particularly antiplatelets, are associated with a lower risk of in-hospital mortality. However, they may increase the risk of rebleeding and extend hospital stays in certain subgroups.
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Affiliation(s)
- Ding Peng
- Department of Gastroenterology, Xuanwu Hospital Capital Medical University, Beijing, 100053, China
| | - Huihong Zhai
- Department of Gastroenterology, Xuanwu Hospital Capital Medical University, Beijing, 100053, China.
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Damjanovska S, Karb D, Chen A, Margevicius S, Fu P, Isenberg G. Patients on Antithrombotic Agents with Small Bowel Bleeding -Yield of Small Bowel Capsule Endoscopy and Subsequent Management. Dig Dis Sci 2024; 69:2140-2146. [PMID: 38637455 PMCID: PMC11162371 DOI: 10.1007/s10620-024-08433-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND AND AIMS Small bowel gastrointestinal bleeding (GIB) is associated with multiple blood transfusions, prolonged and/or multiple hospital admissions, utilization of significant healthcare resources, and negative effects on patient quality of life. There is a well-recognized association between antithrombotic medications and small bowel GIB. We aimed to identify the diagnostic yield of small bowel capsule endoscopy (SBCE) in patients on antithrombotic medications and the impact of SBCE on treatment course. METHODS The electronic medical records of nineteen hundred eighty-six patients undergoing SBCE were retrospectively reviewed. RESULTS The diagnostic yield for detecting stigmata of recent bleeding and/or actively bleeding lesions in SBCE was higher in patients that were on antiplatelet agents (21.6%), patients on anticoagulation (22.5%), and in patients that had their SBCE performed while they were inpatient (21.8%), when compared to the patients not on antiplatelet agents (12.1%), patients not on anticoagulation (13.5%), and with patients that had their SBCE performed in the outpatient setting (12%). Of 318 patients who had stigmata of recent bleeding and/or actively bleeding lesion(s) identified on SBCE, SBCE findings prompted endoscopic evaluation (small bowel enteroscopy, esophagogastroduodenoscopy (EGD), and/or colonoscopy) in 25.2%, with endoscopic hemostasis attempted in 52.5%. CONCLUSIONS Our study, the largest conducted to date, emphasizes the importance of performing SBCE as part of the evaluation for suspected small bowel bleeding, particularly in patients taking antithrombotic therapy, and especially during their inpatient hospital stay.
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Affiliation(s)
- Sofi Damjanovska
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
| | - Daniel Karb
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Allen Chen
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Seunghee Margevicius
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Pingfu Fu
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Gerard Isenberg
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
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Acehan F, Karsavuranoğlu B, Aslan M, Kalkan C, Sahiner ES, Inan O, Comoglu M, Yilmaz Y, Ates I. Improved outcomes in patients with non-variceal upper gastrointestinal bleeding while undergoing antithrombotic therapy: A propensity score matching analysis. Dig Liver Dis 2024:S1590-8658(24)00741-2. [PMID: 38755023 DOI: 10.1016/j.dld.2024.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/22/2024] [Accepted: 04/30/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND This study sought to examine the effect of antithrombotic use on clinical outcomes in non-variceal upper gastrointestinal bleeding (UGIB). METHODS Patients consecutively diagnosed with non-variceal UGIB between February 2019 and September 2020 were divided into two groups based on their antithrombotic use: users and non-users. Using propensity score matching (PSM) and multivariable regression analyses, the impact of antithrombotic use prior to UGIB presentation on clinical outcomes was examined. RESULTS In the entire cohort, there were 210 and 260 patients in the antithrombotic user and non-user groups, respectively. Using PSM analysis with seven covariates, two matched groups of 157 patients were created at a 1:1 ratio. In the matched cohort, despite their longer hospital stays and a higher rate of intensive care unit admissions, the patients in the user group had lower 30- and 90-day mortality rates (4.5% vs. 14.0 %; p = 0.003 and 8.9% vs. 18.5 %; p = 0.014, respectively). In the entire cohort, multivariable analyses adjusted for confounding factors revealed that antithrombotic use was associated with lower risks of in-hospital (adjusted OR: 0.437; 95 % CI: 0.191-0.999), 30-day (adjusted OR: 0.261; 95 % CI: 0.099-0.689), and 90-day (adjusted OR: 0.386; 95 % CI: 0.182-0.821) mortality. CONCLUSION Antithrombotic use prior to UGIB presentation was found to be an independent protective factor for all-cause mortality.
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Affiliation(s)
- Fatih Acehan
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey.
| | | | - Meryem Aslan
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Cagdas Kalkan
- Department of Gastroenterology, Ankara City Hospital, Ankara, 06800, Turkey
| | - Enes Seyda Sahiner
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Osman Inan
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Mustafa Comoglu
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Yusufcan Yilmaz
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Ihsan Ates
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
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Peng D, Zhai H. Application of Antithrombotic Drugs in Different Age-Group Patients with Upper Gastrointestinal Bleeding. Gastroenterol Res Pract 2024; 2024:1710708. [PMID: 38606387 PMCID: PMC11008970 DOI: 10.1155/2024/1710708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/02/2024] [Accepted: 03/21/2024] [Indexed: 04/13/2024] Open
Abstract
Objective This study aimed at exploring the safety and timing of antithrombotic drugs in different age-group patients with UGIB. Methods An observational study retrospectively based on the single-center database with 713 patients with UGIB. Result Among the 713 patients, 62.13% were elderly patients (aged > 60 years) and the mortality was 2.9%. In elderly patients with UGIB, we found that previous medication history, resumption of medication, and time of resumption did not affect the in-hospital mortality. The resumption of anticoagulants increased the risk of rebleeding. The independent risk factors of mortality were CHF, cirrhosis, creatine kinase, and albumin. The independent risk factors of rebleeding were the application of anticoagulants during hospitalization, variceal bleeding, black stool, red blood cells (lab), platelets (lab), and heart rate. Conclusions In UGIB patients, a history of antiplatelet or antithrombotic drugs and the use of antiplatelet drugs after UGIB did not affect the patient's prognosis. In elderly UGIB patients, although antithrombotic drugs did not increase the risk of death, the increased risk of rebleeding after resumption of use deserved careful treatment. It was safe to recover anticoagulant drugs as soon as possible in young UGIB patients.
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Affiliation(s)
- Ding Peng
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Huihong Zhai
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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Wang Y, Wu Y, Wang J, Zhang H, Du L, Wang K, Duan H. Predictors of gastrointestinal bleeding in patients with acute coronary syndrome and the optimal duration of dual antiplatelet therapy. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2024; 29:15. [PMID: 38808215 PMCID: PMC11132419 DOI: 10.4103/jrms.jrms_452_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 11/05/2023] [Accepted: 11/13/2023] [Indexed: 05/30/2024]
Abstract
Background This study aims to estimate the risk factors of gastrointestinal (GI) bleeding in patients with acute coronary syndrome (ACS) and to evaluate the optimal duration of dual antiplatelet therapy (DAPT). Materials and Methods We enrolled 1266 patients with ACS in a telephone follow-up program to determine whether any of the patients were hospitalized for GI bleeding. We collected baseline data, laboratory tests, electrocardiograms, and echocardiography covering all ACS patients. Multivariable regression was performed to adjust for confounders and predictors of GI bleeding. At the same time, the optimal duration of DAPT for ACS patients was evaluated. Results A total of 1061 ACS patients were included in the study. After 13-68 months, 48 patients (4.5%) were hospitalized for GI bleeding. The risk of GI bleeding was significantly increased in patients treated with DAPT for more than 18 months (hazard ratio 12.792, 5.607-29.185, P < 0.01). Receiver Operating Characteristic curve showed that the duration of DAPT using a cutoff of 14.5 months resulted in a sensitivity of 66.7% and a specificity of 77%. Conclusion In patients with ACS, DAPT time are the main risk factors of GI bleeding. The optimal duration of DAPT is 14.5 months.
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Affiliation(s)
- Yanyu Wang
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Yingle Wu
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Jingqiao Wang
- Henan Key Laboratory of Epigenetics, School of Basic Medical Sciences, Henan University of Science and Technology, Luoyang, China
| | - Hengliang Zhang
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Laijing Du
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Ke Wang
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Hongqiang Duan
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
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Wang B, Yu W, Zhang Z, Jin W, Chen H, Wang L, Xu M, Hou C, Qian Z, Qiu Z, Zhang S. Assessing peptic ulcer risk with the HAMPROW score in the general Chinese population. Sci Rep 2024; 14:4442. [PMID: 38396123 PMCID: PMC10891164 DOI: 10.1038/s41598-024-55224-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 02/21/2024] [Indexed: 02/25/2024] Open
Abstract
The timely identification of individuals at high risk for peptic ulcers (PUs) is vital in preventing gastrointestinal bleeding after antiplatelet therapy. This study was designed to determine PU risk factors and develop a risk assessment model for PU detection in the general Chinese population. In a prospective dataset, clinical data from individuals undergoing gastroscopic evaluation between April 2019 and May 2022 were recorded. PUs were defined as mucosal defects exceeding 5 mm confirmed via gastroscopy. Participants were categorized into development (April 2019 to April 2021) and validation (May 2021 to May 2022) sets based on chronological order. LASSO-derived logistic regression analysis was employed to create a score, which was further validated via temporal validation. A total of 902 patients were ultimately enrolled, 204 (22.6%) of whom had PUs based on endoscopic findings. In the development cohort (n = 631), seven independent risk factors emerged: male sex (OR = 2.35, P = 0.002), white blood cell (WBC) count (OR = 1.16, P = 0.010), red blood cell (RBC) count (OR = 0.49, P < 0.001), globulin level (OR = 0.92, P = 0.004), albumin level (OR = 0.94, P = 0.020), pepsinogen I (PGI) level (OR = 1.01, P < 0.001), and positive Helicobacter pylori (HP) antibody (OR = 2.50, P < 0.001). Using these factors, a nomogram (HAMPROW score [hazard ratio (HP) antibody, albumin, male, PGI, RBC, globulin, and WBC]) was developed for individual PU prediction. The ability of the HAMPROW score to predict survival was confirmed with AUCs of 0.854 (95% CI 0.816-0.891) and 0.833 (95% CI 0.771-0.895) in the development and validation sets, respectively. In conclusion, the HAMPROW score can be used to screen for PUs effectively in the general Chinese population, facilitating personalized early detection of high risk of gastrointestinal bleeding before antiplatelet therapy.
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Affiliation(s)
- Binli Wang
- Department of Neurology, Huzhou Nanxun People's Hospital, Zhejiang Provincial People's Hospital Nanxun District, Huzhou, China
| | - Weitao Yu
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 310014, Zhejiang, China
- The Second School of Clinical Medicine, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Zheyu Zhang
- Department of Neurology, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Weili Jin
- Department of Gastroenterology, Huzhou Nanxun People's Hospital, Zhejiang Provincial People's Hospital Nanxun District, Huzhou, China
| | - Haojun Chen
- Department of Nephrology, Huzhou Nanxun People's Hospital, Zhejiang Provincial People's Hospital Nanxun District, Huzhou, China
| | - Linfeng Wang
- Department of Science and Education, Huzhou Nanxun People's Hospital, Zhejiang Provincial People's Hospital Nanxun District, Huzhou, China
| | - Min Xu
- Department of Neurology, Huzhou Nanxun People's Hospital, Zhejiang Provincial People's Hospital Nanxun District, Huzhou, China
| | - Chaoqun Hou
- Department of Neurology, Huzhou Nanxun People's Hospital, Zhejiang Provincial People's Hospital Nanxun District, Huzhou, China
| | - Zhiquan Qian
- Department of Neurology, Huzhou Nanxun People's Hospital, Zhejiang Provincial People's Hospital Nanxun District, Huzhou, China
| | - Ziyue Qiu
- Department of Neurology, Huzhou Nanxun People's Hospital, Zhejiang Provincial People's Hospital Nanxun District, Huzhou, China
| | - Sheng Zhang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, 310014, Zhejiang, China.
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Fischbach W, Bornschein J, Hoffmann JC, Koletzko S, Link A, Macke L, Malfertheiner P, Schütte K, Selgrad DM, Suerbaum S, Schulz C. Update S2k-Guideline Helicobacter pylori and gastroduodenal ulcer disease of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:261-321. [PMID: 38364851 DOI: 10.1055/a-2181-2225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Affiliation(s)
| | - Jan Bornschein
- Translational Gastroenterology Unit John, John Radcliffe Hospital Oxford University Hospitals, Oxford, United Kingdom
| | - Jörg C Hoffmann
- Medizinische Klinik I, St. Marien- und St. Annastiftskrankenhaus, Ludwigshafen, Deutschland
| | - Sibylle Koletzko
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU-Klinikum Munich, Munich, Deutschland
- Department of Paediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, 10-719 Olsztyn, Poland
| | - Alexander Link
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Lukas Macke
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
| | - Peter Malfertheiner
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
| | - Kerstin Schütte
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Niels-Stensen-Kliniken Marienhospital Osnabrück, Osnabrück, Deutschland
| | - Dieter-Michael Selgrad
- Medizinische Klinik Gastroenterologie und Onkologie, Klinikum Fürstenfeldbruck, Fürstenfeldbruck, Deutschland
- Klinik für Innere Medizin 1, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Sebastian Suerbaum
- Universität Munich, Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, Munich, Deutschland
- Nationales Referenzzentrum Helicobacter pylori, Pettenkoferstr. 9a, 80336 Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
| | - Christian Schulz
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
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Marx N, Federici M, Schütt K, Müller-Wieland D, Ajjan RA, Antunes MJ, Christodorescu RM, Crawford C, Di Angelantonio E, Eliasson B, Espinola-Klein C, Fauchier L, Halle M, Herrington WG, Kautzky-Willer A, Lambrinou E, Lesiak M, Lettino M, McGuire DK, Mullens W, Rocca B, Sattar N. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J 2023; 44:4043-4140. [PMID: 37622663 DOI: 10.1093/eurheartj/ehad192] [Citation(s) in RCA: 250] [Impact Index Per Article: 250.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Dutta AK, Jain A, Jearth V, Mahajan R, Panigrahi MK, Sharma V, Goenka MK, Kochhar R, Makharia G, Reddy DN, Kirubakaran R, Ahuja V, Berry N, Bhat N, Dutta U, Ghoshal UC, Jain A, Jalihal U, Jayanthi V, Kumar A, Nijhawan S, Poddar U, Ramesh GN, Singh SP, Zargar S, Bhatia S. Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship. Indian J Gastroenterol 2023; 42:601-628. [PMID: 37698821 DOI: 10.1007/s12664-023-01428-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/10/2023] [Indexed: 09/13/2023]
Abstract
Proton pump inhibitors (PPIs) have been available for over three decades and are among the most commonly prescribed medications. They are effective in treating a variety of gastric acid-related disorders. They are freely available and based on current evidence, use of PPIs for inappropriate indications and duration appears to be common. Over the years, concerns have been raised on the safety of PPIs as they have been associated with several adverse effects. Hence, there is a need for PPI stewardship to promote the use of PPIs for appropriate indication and duration. With this objective, the Indian Society of Gastroenterology has formulated guidelines on the rational use of PPIs. The guidelines were developed using a modified Delphi process. This paper presents these guidelines in detail, including the statements, review of literature, level of evidence and recommendations. This would help the clinicians in optimizing the use of PPIs in their practice and promote PPI stewardship.
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Affiliation(s)
- Amit Kumar Dutta
- Department of Gastroenterology, Christian Medical College and Hospital, Vellore, 632 004, India.
| | | | - Vaneet Jearth
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Ramit Mahajan
- Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | | | - Vishal Sharma
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | | | | | - Govind Makharia
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | | | - Richard Kirubakaran
- Center of Biostatistics and Evidence Based Medicine, Vellore, 632 004, India
| | - Vineet Ahuja
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Neha Berry
- BLK Institute of Digestive and Liver Disease, New Delhi, 201 012, India
| | - Naresh Bhat
- Aster CMI Hospital, Bengaluru, 560 092, India
| | - Usha Dutta
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Uday Chand Ghoshal
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Ajay Jain
- Choithram Hospital and Research Center, Indore, 452 014, India
| | | | - V Jayanthi
- Sri Ramachandra Medical College, Chennai, 600 116, India
| | - Ajay Kumar
- Institute of Digestive and Liver Diseases, BLK - Max Superspeciality Hospital, New Delhi, 201 012, India
| | | | - Ujjal Poddar
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226 014, India
| | | | - Shivram P Singh
- Kalinga Gastroenterology Foundation, Cuttack, 753 001, India
| | - Showkat Zargar
- Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Kashmir, 190 011, India
| | - Shobna Bhatia
- Sir H N Reliance Foundation Hospital, Mumbai, 400 004, India
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10
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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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Gigante B, Levy JH, van Gorp E, Bartoloni A, Bochaton-Piallat ML, Bäck M, Ten Cate H, Christersson C, Ferreiro JL, Geisler T, Lutgens E, Schulman S, Storey RF, Thachil J, Vilahur G, Liaw PC, Rocca B. Management of patients on antithrombotic therapy with severe infections: a joint clinical consensus statement of the ESC Working Group on Thrombosis, the ESC Working Group on Atherosclerosis and Vascular Biology, and the International Society on Thrombosis and Haemostasis. Eur Heart J 2023; 44:3040-3058. [PMID: 37439553 DOI: 10.1093/eurheartj/ehad388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 05/01/2023] [Accepted: 05/29/2023] [Indexed: 07/14/2023] Open
Abstract
Patients with severe infections and a pre-existing indication for antithrombotic therapy, i.e. antiplatelet agents, anticoagulant drugs, or their combinations, require integrated clinical counselling among coagulation, infectious disease, and cardiology specialists, due to sepsis-induced coagulopathy that frequently occurs. Bacterial and viral pathogens constitute an increasing threat to global public health, especially for patients with ongoing antithrombotic treatment who have a high risk of thrombotic recurrences and high susceptibility to severe infections with increased morbidity and mortality. Similarly, sepsis survivors are at increased risk for major vascular events. Coagulopathy, which often complicates severe infections, is associated with a high mortality and obligates clinicians to adjust antithrombotic drug type and dosing to avoid bleeding while preventing thrombotic complications. This clinical consensus statement reviews the best available evidence to provide expert opinion and statements on the management of patients hospitalized for severe bacterial or viral infections with a pre-existing indication for antithrombotic therapy (single or combined), in whom sepsis-induced coagulopathy is often observed. Balancing the risk of thrombosis and bleeding in these patients and preventing infections with vaccines, if available, are crucial to prevent events or improve outcomes and prognosis.
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Affiliation(s)
- Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Solnavägen 30. 17164 and Department of Cardiology, Danderyds Hospital, Entrévägen 2, 182 88, Stockholm, Sweden
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, United States; 2301 Erwin Road, Durham, NC 27710, USA
| | - Eric van Gorp
- Department of Viroscience, Erasmus MC, Rotterdam, PO box 2040 [Room Ee1726], 3000 CA Rotterdam, The Netherlands
| | - Alessandro Bartoloni
- Department of Experimental and Clinical Medicine, Infectious Diseases Unit, University of Florence, Largo Brambilla 3, 50100 Florence, Italy
| | - Marie-Luce Bochaton-Piallat
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, 1 rue Michel-Servet 1, CH-1211 Genève, Switzerland
| | - Magnus Bäck
- Department of Translational Cardiology, Karolinska Institutet and Karolinska University Hospital, CMM L8:01, 171 76 Stockholm, Sweden
- INSERM U1116, University of Lorraine, Nancy University Hospital, 2 rue Jean Lamour, 54505 Vandoeuvre les Nancy Cedex, France
| | - Hugo Ten Cate
- Department of Internal medicine, Thrombosis Expertise Center, Maastricht University Medical Center and CARIM school for cardiovascular diseases, Universiteitsingel 50, PO Box 616, 6200 MD Maastricht, The Netherlands
- Center for Thrombosis and Haemostasis, Gutenberg University Medical Center, Langenbeckstr. 1, Bldg. 403, 55131 Mainz, Germany
| | - Christina Christersson
- Department of Medical Sciences, Cardiology, Uppsala University, Akademiska Sjukhuset, 75185, Uppsala, Sweden
| | - José Luis Ferreiro
- Department of Cardiology and Bio-Heart Cardiovascular Diseases Research Group; Bellvitge University Hospital - Bellvitge Biomedical Research Institute (IDIBELL); CIBERCV; L'Hospitalet de Llobregat, Hospital Duran i Reynals - Edifici Terapèutic - 2a planta Gran Via de l'Hospitalet, 199, 08908 Hospitalet de Llobregat Barcelona -Spain
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Esther Lutgens
- Cardiovascular Medicine, Experimental CardioVascular Immunology Laboratory, Mayo Clinic, 200 First St SW, 55905, Rochester, MN, USA
- Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians Universität, München, Germany & German Center for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Pettenkoferstrasse 9, 80336, Munich, Germany
| | - Sam Schulman
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada HHS - General Hospital 237, Barton Street East, Hamilton, ON, L8L 2X2, Canada
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Bol'shaya Pirogovskaya Ulitsa, 2, стр. 4, Moscow 119435, Russia
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Pegasus House, 463a Glossop Road, Sheffield, S10 2QD, UK
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Oxford road, Manchester, M13 9WL, UK
| | - Gemma Vilahur
- Institut de Recerca Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, CIBERCV, Avda. Sant Antoni Maria Claret 167, 08025 Barcelona, Spain
| | - Patricia C Liaw
- Department of Medicine, Thrombosis & Atherosclerosis Research Institute (TaARI), McMaster University, 237 Barton Street East Hamilton, Ontario L8L 2X2, Canada
| | - Bianca Rocca
- Department of Safety and Bioethics, Section on Pharmacology, Catholic University School of Medicine, Largo F. Vito 1, 00168 Rome, Italy
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Wang W, Song L, Yang L, Li C, Ma Y, Xue M, Shi D. Panax quinquefolius saponins combined with dual antiplatelet therapy enhanced platelet inhibition with alleviated gastric injury via regulating eicosanoids metabolism. BMC Complement Med Ther 2023; 23:289. [PMID: 37596586 PMCID: PMC10436642 DOI: 10.1186/s12906-023-04112-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 08/01/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Panax quinquefolius saponin (PQS) was shown beneficial against platelet adhesion and for gastroprotection. This study aimed to investigate the integrated efficacy of PQS with dual antiplatelet therapy (DAPT) on platelet aggregation, myocardial infarction (MI) expansion and gastric injury in a rat model of acute MI (AMI) and to explore the mechanism regarding arachidonic acid (AA)-derived eicosanoids metabolism. METHODS Wistar rats were subjected to left coronary artery occlusion to induce AMI model followed by treatment with DAPT, PQS or the combined therapy. Platelet aggregation was measured by light transmission aggregometry. Infarct size, myocardial histopathology was evaluated by TTC and H&E staining, respectively. Gastric mucosal injury was examined by scanning electron microscope (SEM). A comprehensive eicosanoids profile in plasma and gastric mucosa was characterized by liquid chromatography-mass spectrometer-based lipidomic analysis. RESULTS PQS+DAPT further decreased platelet aggregation, lessened infarction and attenuated cardiac injury compared with DAPT. Plasma lipidomic analysis revealed significantly increased synthesis of epoxyeicosatrienoic acid (EET) and prostaglandin (PG) I2 (potent inhibitors for platelet adhesion and aggregation) while markedly decreased thromboxane (TX) A2 (an agonist for platelet activation and thrombosis) by PQS+DAPT, relative to DAPT. DAPT induced overt gastric mucosal damage, which was attenuated by PQS co-administration. Mucosal gastroprotective PGs (PGE2, PGD2 and PGI2) were consistently increased after supplementation of PQS+DAPT. CONCLUSIONS Collectively, PQS+DAPT showed synergistic effect in platelet inhibition with ameliorated MI expansion partially through upregulation of AA/EET and AA/PGI2 synthesis while suppression of AA/TXA2 metabolism. PQS attenuated DAPT-induced gastric injury, which was mechanistically linked to increased mucosal PG production.
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Affiliation(s)
- Wenting Wang
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
- Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Lei Song
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
- Center of Cardiovascular Disease, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Lin Yang
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
- Center of Cardiovascular Disease, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Changkun Li
- Shimadzu (China) Co., LTD Beijing Branch, Beijing, 100020, China
| | - Yan Ma
- Department of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology & Immunology, Vienna General Hospital, Medical University of Vienna, 1090, Vienna, Austria
| | - Mei Xue
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China.
- Center of Cardiovascular Disease, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China.
| | - Dazhuo Shi
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China.
- Center of Cardiovascular Disease, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China.
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Cao H, Xu H, Zhu M, Chu X, Zhang Z, Dong Y. A nomogram for predicting major gastrointestinal bleeding in patients treated with rivaroxaban. Scand J Gastroenterol 2023; 58:1228-1236. [PMID: 37317530 DOI: 10.1080/00365521.2023.2220460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/26/2023] [Accepted: 05/28/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Rivaroxaban is a direct oral anticoagulant with the highest risk of anticoagulant-induced major gastrointestinal bleeding (MGIB). Currently, there is a lack of tools to identify patients at high risk of rivaroxaban-induced MGIB. OBJECTIVE To establish a nomogram model to predict the risk of MGIB in patients receiving rivaroxaban. METHODS Demographic information, comorbidities, concomitant medications, and laboratory test results were collected from 356 patients (178 diagnosed with MGIB) who were taking rivaroxaban between January 2013 and June 2021. Univariate and multivariate logistic regression analyses were used to identify the independent predictors of MGIB, and a nomogram was constructed based on these predictors. A receiver operating characteristic curve, Brier score, calibration plot, decision curve, and internal validation was used to evaluate the calibration, discrimination, and clinical usefulness of the nomogram. RESULTS Age, haemoglobin level, platelet count, creatinine level, prior peptic ulcer disease, prior bleeding, prior stroke, proton pump inhibitor use, and antiplatelet agent use were independent predictors of rivaroxaban-induced MGIB. These risk factors were used to establish the nomogram. The area under the curve of the nomogram was 0.833 (95%CI, 0.782-0.866), the Brier score was 0.171, the internal validation accuracy was 0.73, and the kappa value was 0.46. CONCLUSION The nomogram demonstrated good discrimination, calibration, and clinical applicability. Therefore, it could accurately predict the risk of MGIB in patients treated with rivaroxaban.
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Affiliation(s)
- Haiyan Cao
- Department of Gastroenterology, Chengdu Second People's Hospital, Chengdu, People's Republic of China
| | - Hongyan Xu
- Department of Gastroenterology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Min Zhu
- Department of Gastroenterology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Xinglin Chu
- Department of General Practice, The Second Affiliated Hospital of Chongqing Medical University, People's Republic of China
| | - Zhihuan Zhang
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Yongqi Dong
- Department of Gastroenterology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
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14
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Yang HG, Kim DK. Concomitant Use of Antiplatelet Agents and Proton-Pump Inhibitors Increases the Risk of Adverse Cardiovascular Events: A Nationwide Population-Based Cohort Study Using Balanced Operational Definitions. J Cardiovasc Dev Dis 2023; 10:264. [PMID: 37367429 DOI: 10.3390/jcdd10060264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/02/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023] Open
Abstract
Antiplatelet agents are commonly used in combination with proton-pump inhibitors (PPIs) in patients with acute coronary syndrome who are at risk of gastrointestinal hemorrhage. However, studies have reported that PPIs can alter the pharmacokinetics of antiplatelet agents and result in adverse cardiovascular events. We enrolled 311 patients who received antiplatelet therapy with PPIs for >30 days and 1244 matched controls following a 1:4 propensity score matching during the index period. Patients were followed up until death, myocardial infarction, coronary revascularization, or the end of the follow-up period. Patients who used antiplatelet therapy with PPIs were found to be at higher risk of mortality than the controls (adjusted hazard ratio (HR): 1.77; 95% confidence interval (CI): 1.30-2.40). The adjusted HR for patients who used antiplatelet agents with PPIs developing myocardial infarction and coronary revascularization events was 3.52 (95% CI: 1.34-9.22) and 4.74 (95% CI: 2.03-11.05), respectively. Additionally, middle-aged patients or those within 3 years of concomitant use showed a higher risk of myocardial infarction and coronary revascularization. Our findings suggest that antiplatelet therapy combined with PPIs has a higher mortality risk in patients with gastrointestinal bleeding and is associated with an increased risk of myocardial infarction and coronary revascularization.
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Affiliation(s)
- Hee Gyu Yang
- Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
| | - Dong-Kyu Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
- Division of Big Data and Artificial Intelligence, Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
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15
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Arora A, Kumar A, Anand AC, Kumar A, Yadav A, Bhagwat A, Mullasari AS, Satwik A, Saraya A, Mehta A, Roy D, Reddy DN, Makharia G, Murthy JMK, Roy J, Sawhney JPS, Prasad K, Goenka M, Philip M, Umaiorubahan M, Sinha N, Mohanan PP, Sylaja PN, Ramakrishna P, Kerkar P, Rai P, Kochhar R, Yadav R, Nijhawan S, Sinha SK, Hastak SM, Viswanathan S, Ghoshal UC, Madathipat U, Thakore V, Dhir V, Saraswat VA, Nabi Z. Position statement from the Indian Society of Gastroenterology, Cardiological Society of India, Indian Academy of Neurology and Vascular Society of India on gastrointestinal bleeding and endoscopic procedures in patients on antiplatelet and/or anticoagulant therapy. Indian J Gastroenterol 2023; 42:332-346. [PMID: 37273146 PMCID: PMC10240467 DOI: 10.1007/s12664-022-01324-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 12/12/2022] [Indexed: 06/06/2023]
Abstract
Antiplatelet and/or anticoagulant agents (collectively known as antithrombotic agents) are used to reduce the risk of thromboembolic events in patients with conditions such as atrial fibrillation, acute coronary syndrome, recurrent stroke prevention, deep vein thrombosis, hypercoagulable states and endoprostheses. Antithrombotic-associated gastrointestinal (GI) bleeding is an increasing burden due to the growing population of advanced age with multiple comorbidities and the expanding indications for the use of antiplatelet agents and anticoagulants. GI bleeding in antithrombotic users is associated with an increase in short-term and long-term mortality. In addition, in recent decades, there has been an exponential increase in the use of diagnostic and therapeutic GI endoscopic procedures. Since endoscopic procedures hold an inherent risk of bleeding that depends on the type of endoscopy and patients' comorbidities, in patients already on antithrombotic therapies, the risk of procedure-related bleeding is further increased. Interrupting or modifying doses of these agents prior to any invasive procedures put these patients at increased risk of thromboembolic events. Although many international GI societies have published guidelines for the management of antithrombotic agents during an event of GI bleeding and during urgent and elective endoscopic procedures, no Indian guidelines exist that cater to Indian gastroenterologists and their patients. In this regard, the Indian Society of Gastroenterology (ISG), in association with the Cardiological Society of India (CSI), Indian Academy of Neurology (IAN) and Vascular Society of India (VSI), have developed a "Guidance Document" for the management of antithrombotic agents during an event of GI bleeding and during urgent and elective endoscopic procedures.
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Affiliation(s)
- Anil Arora
- Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India.
| | - Ashish Kumar
- Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Anil C Anand
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Kushabhadra Campus, 5, KIIT Road, Bhubaneswar, 751 024, India
| | - Ajay Kumar
- Department of Gastroenterology and Hepatology, BLK Max Multispeciality Hospital, Pusa Road, Radha Soami Satsang, Rajendra Place, New Delhi, 110 005, India
| | - Ajay Yadav
- Department of Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Ajit Bhagwat
- Department of Cardiology, Kamalnayan Bajaj Hospital, Gut No 43 Bajaj Marg, Beed Bypass Road, Satara Deolai Parisar, Aurangabad, 431 010, India
| | - Ajit S Mullasari
- Department of Adult Cardiology, Madras Medical Mission, 4-A, Dr. J. Jayalalitha Nagar, Chennai, 600 037, India
| | - Ambarish Satwik
- Department of Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, New Delhi, 110 029, India
| | - Ashwani Mehta
- Department of Cardiology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Debabrata Roy
- Department of Cardiology, Narayana Hrudayalaya Rabindranath Tagore International Institute of Cardiac Sciences, 124, Eastern Metropolitan Bypass, Mukundapur, Kolkata, 700 099, India
| | - Duvvur Nageshwar Reddy
- Department of Medical Gastroenterology, AIG Hospitals, Mindspace Road, Gachibowli, Hyderabad, 500 032, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, New Delhi, 110 029, India
| | - Jagarapudi M K Murthy
- Department of Neurology, CARE Hospitals, Road No.1, Banjara Hills, Hyderabad, 500 034, India
| | - Jayanta Roy
- Department of Neurology, Institute of Neurosciences, 185/1, Acharya Jagadish Chandra Bose Road, Kolkata, 700 017, India
| | - Jitendra P S Sawhney
- Department of Cardiology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Kameshwar Prasad
- Rajendra Institute of Medical Sciences, Bariatu, Ranchi, 834 009, India
| | - Mahesh Goenka
- Institute of Gastrosciences, Apollo Multispeciality Hospitals, 58, Canal Circular Road, Kadapara, Phool Bagan, Kankurgachi, Kolkata, 700 054, India
| | - Mathew Philip
- Department of Medical Gastroenterology, Lisie Hospital, Lisie Hospital Road, North Kaloor, Kaloor, Ernakulam, 682 018, India
| | - Meenakshisundaram Umaiorubahan
- Department of Neuro Science, SIMS Hospital, No.1, Jawaharlal Nehru Salai (100 Feet Road), Vadapalani, Chennai, 600 026, India
| | - Nakul Sinha
- Department of Cardiac Sciences, Medanta Super Speciality Hospital, Sector - A, Pocket - 1, Amar Shaheed Path, Golf City, Lucknow, 226 030, India
| | - Padinhare P Mohanan
- Department of Cardiology and Cardiothoracic Surgery, Westfort High-Tech Hospital, Guruayoor Road, Punkunnam, Thrissur, 680 002, India
| | - Padmavathy N Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Jai Nagar W Road, Chalakkuzhi, Thiruvananthapuram, 695 011, India
| | - Pinjala Ramakrishna
- Department of Vascular Surgery, Apollo Hospital Jubilee Hills, Road No 72, Opp. Bharatiya Vidya Bhavan School Film Nagar, Jubilee Hills, Hyderabad, 500 033, India
| | - Prafulla Kerkar
- Department of Cardiology, KEM Hospital and Seth G. S. Medical College, Acharya Donde Marg, Parel East, Parel, Mumbai, 400 012, India
| | - Praveer Rai
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Fortis Hospital, Sector 62, Phase - VIII, Mohali, 160 062, India
| | - Rakesh Yadav
- Department of Cardiology, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, New Delhi, 110 029, India
| | - Sandeep Nijhawan
- Department of Medical Gastroenterology, SMS Medical College and Hospitals, J.L.N. Marg, Jaipur, 302 004, India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Madhya Marg, Sector 12, Chandigarh, 160 012, India
| | - Shirish M Hastak
- Department of Neurology, Global Hospitals, 35, Dr. E Borges Road, Hospital Avenue, Opposite Shirodkar High School, Parel, Mumbai, 400 012, India
| | - Sidharth Viswanathan
- Department of Vascular and Endovascular Surgery, Amrita Institute of Medical Sciences, Ponekkara, AIMS (P.O.), Kochi, 682 041, India
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
| | - Unnikrishnan Madathipat
- Department of Vascular and Endovascular Surgery, SUT Pattom Multi Super Specialty Hospitals, Pattom, Thiruvananthapuram, 695 004, India
| | - Vijay Thakore
- Department of Vascular and Endovascular Surgery, Aadicura Superspeciality Hospital, Winward Business Park, Jetalpur Road, Vadodara, 390 020, India
| | - Vinay Dhir
- Institute of Digestive and Liver Care, SL Raheja Hospital, Raheja Rugnalaya Marg, Mahim West, Mahim, Mumbai, 400 016, India
| | - Vivek A Saraswat
- Department of Gastroenterology and Hepatology, Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Tonk Road, Jaipur, 302 022, India
| | - Zaheer Nabi
- Department of Medical Gastroenterology, AIG Hospitals, Mindspace Road, Gachibowli, Hyderabad, 500 032, India
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Hozman M, Hassouna S, Grochol L, Waldauf P, Hracek T, Pazdiorova BZ, Adamec S, Osmancik P. Previous antithrombotic therapy does not have an impact on the in-hospital mortality of patients with upper gastrointestinal bleeding. Eur Heart J Suppl 2023; 25:E25-E32. [PMID: 37234230 PMCID: PMC10206644 DOI: 10.1093/eurheartjsupp/suad103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The association between antithrombotics (ATs) and the risk of gastrointestinal bleeding is well known; however, data regarding the influence of ATs on outcomes are scarce. The goals of this study are: (i) to assess the impact of prior AT therapy on in-hospital and 6-month outcomes and (ii) to determine the re-initiation rate of the ATs after a bleeding event. All patients with upper gastrointestinal bleeding (UGB) who underwent urgent gastroscopy in three centres from 1 January 2019 to 31 December 2019 were retrospectively analysed. Propensity score matching (PSM) was used. Among 333 patients [60% males, mean age 69.2 (±17.3) years], 44% were receiving ATs. In multivariate logistic regression, no association between AT treatment and worse in-hospital outcomes was observed. Development of haemorrhagic shock led to worse survival [odds ratio (OR) 4.4, 95% confidence interval (CI) 1.9-10.2, P < 0.001; after PSM: OR 5.3, 95% CI 1.8-15.7, P = 0.003]. During 6-months follow-up, higher age (OR 1.0, 95% CI 1.0-1.1, P = 0.002), higher comorbidity (OR 1.4, 95% CI 1.2-1.7, P < 0.001), a history of cancer (OR 3.6, 95% CI 1.6-8.1, P < 0.001) and a history of liver cirrhosis (OR 2.2, 95% CI 1.0-4.4, P = 0.029) were associated with higher mortality. After a bleeding episode, ATs were adequately re-initiated in 73.8%. Previous AT therapy does not worsen in-hospital outcomes in after UGB. Development of haemorrhagic shock predicted poor prognosis. Higher 6-month mortality was observed in older patients, patients with more comorbidities, with liver cirrhosis and cancer.
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Affiliation(s)
- Marek Hozman
- Cardiocenter, Hospital Karlovy Vary, 360 01 Karlovy Vary, Czech Republic
| | - Sabri Hassouna
- Cardiocenter, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Ruska 87, 100 00 Prague, Czech Republic
| | - Lukas Grochol
- 2nd Department of Internal Medicine, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady,100 00 Prague, Czech Republic
| | - Petr Waldauf
- Department of Anaesthesia and Intensive Care, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, 100 00 Prague, Czech Republic
| | - Tomas Hracek
- Department of General Surgery, 3rd Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 00 Prague, Czech Republic
| | | | - Stanislav Adamec
- Department of Gastroenterology, Hospital Cheb, 350 02 Cheb, Czech Republic
| | - Pavel Osmancik
- Corresponding author. Tel: 00420-721544447, Fax: 00420-267162817,
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Aktualisierte S2k-Leitlinie Helicobacter
pylori und gastroduodenale Ulkuskrankheit der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – Juli 2022 – AWMF-Registernummer: 021–001. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:544-606. [PMID: 37146633 DOI: 10.1055/a-1975-0414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
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18
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Saydam ŞS, Molnar M, Vora P. The global epidemiology of upper and lower gastrointestinal bleeding in general population: A systematic review. World J Gastrointest Surg 2023; 15:723-739. [PMID: 37206079 PMCID: PMC10190726 DOI: 10.4240/wjgs.v15.i4.723] [Citation(s) in RCA: 6] [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: 10/19/2022] [Revised: 01/20/2023] [Accepted: 03/08/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is a common and potentially life-threatening clinical event. To date, the literature on the long-term global epidemiology of GIB has not been systematically reviewed.
AIM To systematically review the published literature on the worldwide epidemiology of upper and lower GIB.
METHODS EMBASE® and MEDLINE were queried from 01 January 1965 to September 17, 2019 to identify population-based studies reporting incidence, mortality, or case-fatality rates of upper GIB (UGIB) or lower GIB (LGIB) in the general adult population, worldwide. Relevant outcome data were extracted and summarized (including data on rebleeding following initial occurrence of GIB when available). All included studies were assessed for risk of bias based upon reporting guidelines.
RESULTS Of 4203 retrieved database hits, 41 studies were included, comprising a total of around 4.1 million patients with GIB worldwide from 1980–2012. Thirty-three studies reported rates for UGIB, four for LGIB, and four presented data on both. Incidence rates ranged from 15.0 to 172.0/100000 person-years for UGIB, and from 20.5 to 87.0/100000 person-years for LGIB. Thirteen studies reported on temporal trends, generally showing an overall decline in UGIB incidence over time, although a slight increase between 2003 and 2005 followed by a decline was shown in 5/13 studies. GIB-related mortality data were available from six studies for UGIB, with rates ranging from 0.9 to 9.8/100000 person-years, and from three studies for LGIB, with rates ranging from 0.8 to 3.5/100000 person-years. Case-fatality rate ranged from 0.7% to 4.8% for UGIB and 0.5% to 8.0% for LGIB. Rates of rebleeding ranged from 7.3% to 32.5% for UGIB and from 6.7% to 13.5% for LGIB. Two main areas of potential bias were the differences in the operational GIB definition used and inadequate information on how missing data were handled.
CONCLUSION Wide variation was seen in estimates of GIB epidemiology, likely due to high heterogeneity between studies however, UGIB showed a decreasing trend over the years. Epidemiological data were more widely available for UGIB than for LGIB.
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Affiliation(s)
- Şiir Su Saydam
- Integrated Evidence Generation, Bayer AG, Berlin 13353, Germany
| | - Megan Molnar
- Integrated Evidence Generation, Bayer AG, Berlin 13353, Germany
| | - Pareen Vora
- Integrated Evidence Generation, Bayer AG, Berlin 13353, Germany
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19
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Zhou T, Gong Y, Li J, Wang Y, Wang X. Efficacy and safety of rivaroxaban plus clopidogrel versus aspirin plus clopidogrel in patients with coronary atherosclerotic heart disease and gastrointestinal disease undergoing percutaneous coronary intervention: study protocol for a non-inferiority randomized controlled trial. Trials 2023; 24:209. [PMID: 36945020 PMCID: PMC10031942 DOI: 10.1186/s13063-023-07236-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 03/10/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is recommended for patients with coronary heart disease (CHD) undergoing percutaneous coronary intervention (PCI) to antithrombosis, meanwhile, increasing the risks of gastrointestinal bleeding. Rivaroxaban, a novel oral anticoagulant, combined with a P2Y12 receptor inhibitor reduces adverse events in patients with CHD and atrial fibrillation who underwent PCI. The effect of rivaroxaban plus P2Y12 inhibitor on reducing bleeding events in patients with CHD and gastrointestinal disease (GID) undergoing PCI remains unclear. METHOD The study is a prospective, single-center, randomized controlled trial. A total of 1020 patients with CHD and GID undergoing PCI will be enrolled. Patients are randomized (1:1) to receive either rivaroxaban 10 mg plus clopidogrel 75 mg daily or aspirin 100 mg plus clopidogrel 75 mg daily; both treatments will last 6 months. The primary endpoint is Bleeding Academic Research Consortium (BARC) type 2-5 bleeding requiring medical intervention. The secondary endpoint is a composite of major adverse cardiovascular and cerebrovascular events (MACCE), including all-cause death, cardiac death, nonfatal myocardial infarction, stent thrombosis, ischemia-driven target vessel revascularization, and stroke. DISCUSSION The objective of this study is to evaluate the efficacy and safety of rivaroxaban plus clopidogrel versus aspirin plus clopidogrel in patients with CHD and GID undergoing PCI. We aim to explore an optimized antithrombotic strategy, which achieves the same anti-ischemic effect as standard DAPT without increasing the risk of GIB, for patients with CHD and GID undergoing PCI. TRIAL REGISTRATION This protocol is registered at the Chinese Clinical Trial Registry under the number ChiCTR2100044319. And this publication is based on version 1.4 of the trial protocol dated Sep 6, 2021.
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Affiliation(s)
- Tienan Zhou
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Rd, Shenyang, 110016, Liaoning, China
| | - Yinghui Gong
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Rd, Shenyang, 110016, Liaoning, China
| | - Jingyuan Li
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Rd, Shenyang, 110016, Liaoning, China
| | - Yasong Wang
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Rd, Shenyang, 110016, Liaoning, China
| | - Xiaozeng Wang
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Rd, Shenyang, 110016, Liaoning, China.
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20
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Lancaster I, Sethi V, Patel D, Tamboli C, Pacer E, Steinhoff J, Mizrahi M, Willinger A. Antithrombotics and Gastrointestinal Prophylaxis: A Systematic Review. Cardiol Rev 2023:00045415-990000000-00089. [PMID: 36946915 DOI: 10.1097/crd.0000000000000543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Antithrombotic medications include both antiplatelet and anticoagulants and are used for a wide variety of cardiovascular conditions. A common complication of antithrombotic use is gastrointestinal bleeding. As a result, gastrointestinal prophylaxis is a common consideration for patients on a single or combination antithrombotic regimen. Prophylaxis is typically achieved through use of either proton pump inhibitors or histamine 2 receptor antagonists. Current recommendations for use of gastrointestinal prophylaxis with concomitant use of antithrombotic medications are scarce. In this systematic review, we explore the current evidence and recommendations regarding gastrointestinal prophylaxis for patients on antiplatelet or anticoagulant therapy as well as combination regimens.
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Affiliation(s)
- Ian Lancaster
- From the HCA Healthcare/USF Morsani College of Medicine GME Programs, Largo Medical Center, Largo, FL
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21
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Kinoshita Y, Kato M, Sugizaki K, Ikeuchi S. Rabeprazole Coadministration Controls Ulcer Recurrence in Patients on Low-dose Aspirin Therapy: A Multicenter Prospective Study. Intern Med 2023; 62:495-502. [PMID: 35908971 PMCID: PMC10017235 DOI: 10.2169/internalmedicine.9646-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Objective To evaluate the efficacy and safety of rabeprazole coadministration with low-dose aspirin (LDA). Methods From 2015 to 2018, we conducted a large-scale, multicenter, prospective observational study to assess the safety and efficacy of treatment with rabeprazole (5 or 10 mg/day) in combination with LDA. Results The incidence of adverse reactions was 0.73% (11/1,513 patients), with no serious adverse reactions. We found no trend toward increases in the incidence of adverse reactions with increases in treatment duration. The cumulative recurrence rate of ulcers by Week 52 (Kaplan-Meier estimates) was 3.50% (range, 1.56-7.75%). No gastrointestinal bleeding was reported. Conclusion Rabeprazole in combination with LDA appears as safe and effective in real-world situations as in clinical trials.
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Affiliation(s)
| | - Mototsugu Kato
- National Hospital Organization, Hakodate National Hospital, Japan
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22
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A Randomized Controlled Trial of Fibrin Glue to Prevent Bleeding After Gastric Endoscopic Submucosal Dissection. Am J Gastroenterol 2023; 118:892-899. [PMID: 36594814 DOI: 10.14309/ajg.0000000000002172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/20/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION This study evaluated the efficacy of fibrin glue for preventing postendoscopic submucosal dissection (ESD) bleeding in high-risk patients for bleeding (expected iatrogenic ulcer size ≥40 mm or receiving antithrombotic therapy). METHODS A multicenter, open-label, randomized controlled trial was performed at 4 tertiary medical centers in South Korea between July 1, 2020, and June 22, 2022. Patients with gastric neoplasm and a high risk of post-ESD bleeding were enrolled and allocated at 1:1 to a control group (standard ESD) or a fibrin glue group (fibrin glue applied to iatrogenic ulcers after standard ESD). The primary outcome was overall bleeding events within 4 weeks. The secondary outcomes were acute bleeding (within 48 hours post-ESD) and delayed bleeding (48 hours to 4 weeks post-ESD). RESULTS In total, 254 patients were randomized, and 247 patients were included in the modified intention-to-treat population (125 patients in the fibrin glue group and 122 patients in the control group). Overall bleeding events occurred in 12.0% (15/125) of the fibrin glue group and 13.1% (16/122) of the control group ( P = 0.791). Acute bleeding events were significantly less common in the fibrin glue group than in the control group (1/125 vs 7/122, P = 0.034). Delayed bleeding events occurred in 11.2% (14/125) in the fibrin glue group and 7.3% (9/122) in the control group ( P = 0.301). DISCUSSION This trial failed to show a preventive effect of fibrin glue on overall post-ESD bleeding in high-risk patients. However, the secondary outcomes suggest a potential sealing effect of fibrin glue during the acute period.
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23
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Branzoli S, Guarracini F, Marini M, D’Onghia G, Catanzariti D, Merola E, Annicchiarico L, Casagranda G, Stegagno C, Fantinel M, La Meir M. Heart Team for Left Appendage Occlusion without the Use of Antithrombotic Therapy: The Epicardial Perspective. J Clin Med 2022; 11:6492. [PMID: 36362719 PMCID: PMC9656641 DOI: 10.3390/jcm11216492] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/25/2022] [Accepted: 10/28/2022] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Left atrial appendage occlusion is an increasingly proposed treatment for patients with atrial fibrillation and poor tolerance to anticoagulants. All endovascular devices require antithrombotic therapy. Anatomical and clinical variables predisposing to device-related thrombosis, as well as post-procedural peri-device leaks, could mandate the continuation or reintroduction of aggressive antithrombotic treatment. Because of the absence of foreign material inside the heart, epicardial appendage closure possibly does not necessitate antithrombotic therapy, but data of large series are missing. METHODS Multidisciplinary team evaluation for standalone totally thoracoscopic epicardial appendage closure was done in 180 consecutive patients with atrial fibrillation and poor tolerance to antithrombotic therapy. One hundred and fifty-two patients consented (male 66.1%, mean age 76.1 ± 7.4, CHA2DS2VASc mean 5.3 ± 1.6, HASBLED mean 3.8 ± 1.1). Indications were cerebral hemorrhage (48%), gastro-intestinal bleeding (33.3%), and other bleeding (20.7%). No antithrombotic therapy was prescribed from the day of surgery to the latest follow up. RESULTS Procedural success was 98.7%. At a mean follow up of 38.2 ± 18.8 months, cardioembolic and bleeding events were 1.3% and 0.6%, respectively. Among patients with a history of blood transfusions (41.1%), none needed further transfusions or treatment post procedure. CONCLUSION Epicardial appendage occlusion without any antithrombotic therapy appears to be safe and effective. This strategy could be advised when minimization of bleeding risk concomitant to stroke prevention is needed.
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Affiliation(s)
- Stefano Branzoli
- Department of Cardiac Surgery, UZ Brussel, 1050 Brussels, Belgium
- Cardiac Surgery Unit, Santa Chiara Hospital, 38122 Trento, Italy
| | | | - Massimiliano Marini
- Department of Cardiology, Santa Chiara Hospital, 38122 Trento, Italy
- Heart Rhythm Management Centre, UZ Brussel, 1050 Brussel, Belgium
| | - Giovanni D’Onghia
- Department of Cardiology, Santa Chiara Hospital, 38122 Trento, Italy
| | | | - Elettra Merola
- Gastroenterology Unit, Santa Chiara Hospital, 38122 Trento, Italy
| | | | | | - Chiara Stegagno
- Neurology Rehabilitation Unit, Eremo Hospital, 38122 Trento, Italy
| | - Mauro Fantinel
- Cardiology Unit, Santa Maria Hospital, 32032 Feltre, Italy
| | - Mark La Meir
- Department of Cardiac Surgery, UZ Brussel, 1050 Brussels, Belgium
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24
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Greco A, Mauro MS, Capodanno D, Angiolillo DJ. P2Y12 Inhibitor Monotherapy: Considerations for Acute and Long-Term Secondary Prevention Post-PCI. Rev Cardiovasc Med 2022; 23:348. [PMID: 39077128 PMCID: PMC11267341 DOI: 10.31083/j.rcm2310348] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 07/31/2024] Open
Abstract
Following percutaneous coronary intervention (PCI), an initial course of dual antiplatelet therapy (DAPT) with aspirin and a P2Y 12 inhibitor ( P2Y 12 -i) is recommended to minimize the risk of thrombotic complications. After the initial period of DAPT, antiplatelet monotherapy, usually consisting of aspirin, is administered for long-term secondary prevention. However, over the last few years there has been accruing evidence on P2Y 12 -i monotherapy, both in the acute (i.e., post-PCI; after a brief period of DAPT, transitioning to monotherapy before six or 12 months in patients with chronic or acute coronary syndrome, respectively) and chronic (i.e., long-term secondary prevention; after completion of six or 12 months of DAPT, in patients with chronic or acute coronary syndrome, respectively) settings. In aggregate, most studies of short DAPT with transition to P2Y 12 -i monotherapy showed a reduced risk of bleeding complications, without any significant increase in ischemic events as compared to standard DAPT. On the other hand, the evidence on long-term P2Y 12 -i monotherapy is scarce, but results from a randomized trial showed that clopidogrel monotherapy outperformed aspirin monotherapy in terms of net benefit, ischemic events and bleeding. Antiplatelet therapy is also recommended for patients undergoing PCI and with an established indication for long-term oral anticoagulation (OAC). In this scenario, a brief period of triple therapy (i.e., aspirin, P2Y 12 -i and OAC) is followed by a course of dual antithrombotic therapy (usually with P2Y 12 -i and OAC) and ultimately by lifelong OAC alone. European and American guidelines have been recently updated to provide new recommendations on antithrombotic therapy, including the endorsement of P2Y 12 -i monotherapy in different settings. However, some areas of uncertainty still remain and further randomized investigations are ongoing to fulfil current gaps in knowledge. In this review, we assess the current knowledge and evidence on P2Y 12 -i monotherapy for the early and long-term secondary prevention in patients undergoing PCI, and explore upcoming research and future directions in the field.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, 95125 Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, 95125 Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, 95125 Catania, Italy
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
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25
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Matsuura Y, Moribayashi K, Kaikita K. Optimal Antithrombotic Therapy in Patients Undergoing Percutaneous Coronary Intervention: A Focused Review on High Bleeding Risk. J Atheroscler Thromb 2022; 29:1409-1420. [PMID: 35934784 PMCID: PMC9529379 DOI: 10.5551/jat.rv17066] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/08/2022] [Indexed: 11/11/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) is a therapeutic cornerstone to prevent stent thrombosis following percutaneous coronary intervention (PCI) for coronary artery disease (CAD). However, the longer the DAPT duration, the higher the incidence of bleeding and mortality. Since the advent of second-generation drug-eluting stents (DES), the continuous evolution of DES has reduced the thrombotic risk and allowed for a shorter DAPT duration. On the other hand, concerns on the elevated risk of bleeding during antithrombotic therapy have been further raised due to the growing number of elderly CAD patients with multiple comorbidities. The consequent debate topic over post-PCI antithrombotic therapy has shifted from simply reducing thrombotic risk to safely minimizing bleeding risk. Due to the significant impact of bleeding on clinical outcomes, including prognosis, current guidelines on antithrombotic therapy for CAD prioritize stratification of patients at a high bleeding risk (HBR) as the top consideration in determining post-PCI antithrombotic therapy. Achieving optimal antithrombotic therapy for each patient undergoing PCI requires a better understanding of the clinical variables constituting the balance of bleeding and thrombotic risk. This review highlights relevant evidence required to optimize antithrombotic therapy for HBR patients undergoing PCI.
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Affiliation(s)
- Yunosuke Matsuura
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Kohei Moribayashi
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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26
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Comparison of the Degree of Gastric Mucosal Injury between Patients Who Are Receiving Dual Antiplatelet Therapy or Single Antiplatelet Therapy. Diagnostics (Basel) 2022; 12:diagnostics12102364. [PMID: 36292053 PMCID: PMC9600151 DOI: 10.3390/diagnostics12102364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/23/2022] [Accepted: 09/27/2022] [Indexed: 11/25/2022] Open
Abstract
Background: Patients taking low-dose aspirin have a higher incidence of gastroduodenal ulcers and higher risk of upper gastrointestinal bleeding than patients who do not. Thienopyridine antiplatelet agents may similarly cause bleeding gastroduodenal erosions and ulcers. The incidence of gastrointestinal bleeding is reported to be higher when these antithrombotic drugs are used in combination. Until now, most studies have focused on bleeding, and no study has compared the degree of gastric mucosal injury between patients receiving dual antiplatelet therapy (DAPT) and those receiving single antiplatelet therapy (SAPT) in real-world clinical practice. Aim: Our objective was to compare the degree of gastric mucosal injury in patients taking low-dose aspirin in combination with clopidogrel (one of the thienopyridine antiplatelet agents) with that of patients who were taking aspirin or clopidogrel as a single agent. Methods: Patients who were taking aspirin and/or clopidogrel and who underwent scheduled esophagogastroduodenoscopy between April 2015 and March 2020 were enrolled in this study. Endoscopic images were reviewed retrospectively, and the degree of gastric mucosal injury was assessed with the modified Lanza score (m-Lanza score). The m-Lanza score was compared between DAPT patients taking aspirin and clopidogrel and SAPT patients taking either aspirin alone or clopidogrel alone. Results: The m-Lanza scores of the DAPT group, the aspirin group, and the clopidogrel group were 1.67 ± 1.81 (mean ± standard deviation), 0.95 ± 1.61, and 0.72 ± 1.29, respectively. The m-Lanza score of the DAPT group tended to be higher than that of the aspirin group (p = 0.06) and was significantly higher than that of the clopidogrel group (p = 0.03). Conclusion: The degree of gastric mucosal injury in DAPT patients was significantly higher than that in patients using clopidogrel alone and tended to be higher than that in patients using aspirin alone in real-world clinical practice.
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27
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Lai J, Feng S, Xu S, Liu X. Effects of oral anticoagulant therapy in patients with pulmonary diseases. Front Cardiovasc Med 2022; 9:987652. [PMID: 36035947 PMCID: PMC9399807 DOI: 10.3389/fcvm.2022.987652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 07/26/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundTo evaluate the effect of oral anticoagulants (OACs) therapy, including vitamin K antagonist (VKA) and direct oral anticoagulants (DOAC) in patients with pulmonary diseases.MethodsLiterature from PubMed, MEDLINE, and Cochrane Library were screened until June 2022. Studies assessing OACs for pulmonary hypertension (PH), pulmonary embolism (PE), pulmonary fibrosis (PF), or chronic obstructive pulmonary disease (COPD) were evaluated for inclusion.ResultsOur study indicated that in patients with PH, PE, and COPD, OACs could significantly reduce the mortality risk, and the effects of VKA and DOACs without statistical difference in reducing the risk of recurrent embolism events. In patients with sclerosis-associated pulmonary arterial hypertension (SSc-PAH) or idiopathic pulmonary fibrosis (IPF), vitamin K antagonist (warfarin) significantly increased the mortality risk, while DOACs were not. As for the safety outcome of OACs, existing studies indicate that compared with patients treated with warfarin, the users of DOAC have a lower risk of major bleeding, while there is no statistical significance between them in non-major bleeding events. In current guidelines, the anticoagulation regimen for patients with pulmonary disease has not been defined. The results of our study confirm that DOACs (apixaban, rivaroxaban, dabigatran, and edoxaban) are superior to VKAs in the efficacy and safety outcomes of patients with pulmonary disease.ConclusionsOral anticoagulant therapy brings benefits to patients with PH, PE, or COPD, while the anticoagulation regimen for patients with SSc-PAH or IPF requires serious consideration. Compared with VKA, DOAC is a non-inferior option for anticoagulation in pulmonary disease treatment. Further studies are still needed to provide more reliable evidence about the safety outcome of pulmonary disease anticoagulation.
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Affiliation(s)
- Jiying Lai
- Department of Critical Care Medicine, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Shenghui Feng
- Queen Mary School, Medical Department, Nanchang University, Nanchang, China
| | - Shuo Xu
- Department of Respiratory and Critical Care Medicine, The Ganzhou People's Hospital, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
- Shuo Xu
| | - Xin Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- *Correspondence: Xin Liu
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28
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Pottegård A. Core Concepts in Pharmacoepidemiology: Fundamentals of the cohort and case-control study designs. Pharmacoepidemiol Drug Saf 2022; 31:817-826. [PMID: 35621007 PMCID: PMC9545534 DOI: 10.1002/pds.5482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 11/09/2022]
Abstract
In this review paper, I outline the principles of the cohort as a sampling frame and provide a basic introduction to the cohort study design and the case–control study design, two of the most important designs in the pharmacoepidemiologist's toolbox. Further, I discuss when to prefer one design over the other. The paper is intended as a primer for people new to the field of pharmacoepidemiology and contains a range of suggestions for additional reading regarding the study designs and related epidemiological topics.
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Affiliation(s)
- Anton Pottegård
- Clinical Pharmacology, Pharmacy, and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
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29
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Akimoto T, Goto O, Sasaki M, Mizutani M, Tsutsumi K, Kiguchi Y, Takatori Y, Nakayama A, Kato M, Fujimoto A, Ochiai Y, Maehata T, Kaise M, Iwakiri K, Yahagi N. Endoscopic hand suturing for mucosal defect closure after gastric endoscopic submucosal dissection may reduce the risk of postoperative bleeding in patients receiving antithrombotic therapy. Dig Endosc 2022; 34:123-132. [PMID: 34021512 DOI: 10.1111/den.14045] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/11/2021] [Accepted: 05/16/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Endoscopic hand suturing (EHS) is expected to decrease the risk of post-endoscopic submucosal dissection (ESD) bleeding by closing mucosal defects. We investigated the efficacy of EHS after gastric ESD in patients with antithrombotic agents. METHODS In this prospective single-arm trial, patients taking antithrombotic agents for cardiovascular disease, arrhythmia, cerebrovascular disease and/or peripheral arterial disease and having <3-cm gastric neoplasms were recruited. The mucosal defects after ESD were closed by EHS in which the needle was delivered through an overtube, and the mucosal rim of the defect was continuously sutured in a linear fashion by manipulating the needle grasped with the needle holder, followed by cutting the remnant suture and retrieval of the needle. The primary endpoint was the incidence of postoperative bleeding within 4 weeks after ESD. RESULTS Twenty-two lesions in 20 patients (continuing antiplatelet agents in 11, anticoagulant agents in eight, both in one) underwent ESD followed by EHS. All defects (median size, 30 mm; range, 12-51 mm) were completely closed by EHS and remained closed on postoperative day 3. The median number of stitches was six (range, 4-8) and median suturing time was 36 (range, 24-60) min. There were no adverse events during/after EHS or postoperative bleeding. CONCLUSIONS Postoperative bleeding was not observed in patients taking antithrombotic agents without perioperative cessation. EHS appears to be useful for prevention of post-gastric ESD bleeding in high-risk patients. (Clinical registration number: UMIN000024184).
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Affiliation(s)
- Teppei Akimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.,Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.,Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Motoki Sasaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Mari Mizutani
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Koshiro Tsutsumi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiyuki Kiguchi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yusaku Takatori
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Atsushi Nakayama
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Motohiko Kato
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Ai Fujimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yasutoshi Ochiai
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Tadateru Maehata
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
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Rees J, Evison F, Mytton J, Patel P, Trudgill N. The outcomes of emergency hospital admissions with non-malignant upper gastrointestinal bleeding in England between 2003 and 2015. Endoscopy 2021; 53:1210-1218. [PMID: 33601430 DOI: 10.1055/a-1330-7118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) is a common medical emergency with significant mortality. Despite developments in endoscopic and clinical management, only minor improvements in outcomes have been reported. METHODS This was a retrospective cohort study of patients with non-malignant UGIB emergency admissions in England between 2003 and 2015, using Hospital Episode Statistics. Multilevel logistic regression analysis examined the associations with mortality. RESULTS 242 796 patients with an UGIB admission were identified (58.8 % men; median age 70 [interquartile range (IQR) 53 - 81]). Between 2003 and 2015, falls occurred in both 30-day mortality (7.5 % to 7.0 %; P < 0.001) and age-standardized mortality (odds ratio (OR) 0.74, 95 % confidence interval [CI] 0.69 - 0.80; P < 0.001), including from variceal bleeding (OR 0.63, 95 %CI 0.45 - 0.87; P < 0.005). Increasing co-morbidity (Charlson score > 5, OR 2.94, 95 %CI 2.85 - 3.04; P < 0.001), older age (> 83 years, OR 6.50, 95 %CI 6.09 - 6.94; P < 0.001), variceal bleeding (OR 2.03, 95 %CI 1.89 - 2.18; P < 0.001), and a weekend admission (Sunday, OR 1.18, 95 %CI 1.12 - 1.23; P < 0.001) were associated with 30-day mortality. Of deaths at 30 days, 8.9 % were from ischemic heart disease (IHD) and the cardiovascular age-standardized mortality rate following UGIB was high (IHD deaths within 1 year, 1188.4 [95 %CI 1036.8 - 1353.8] per 100 000 men in 2003). CONCLUSIONS Between 2003 and 2015, 30-day mortality among emergency admissions with non-malignant UGIB fell by 0.5 % to 7.0 %. Mortality was higher among UGIB admissions at the weekend, with important implications for service provision. Patients with UGIB had a much greater risk of subsequently dying from cardiovascular disease and addressing this risk is a key management step in UGIB.
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Affiliation(s)
- James Rees
- Department of Gastroenterology, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Felicity Evison
- Department of Health Informatics, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jemma Mytton
- Department of Health Informatics, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Prashant Patel
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Nigel Trudgill
- Department of Gastroenterology, Sandwell & West Birmingham NHS Trust, West Bromwich, UK
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Yi KH, Tan XR. Advances in prevention and treatment of digestive tract damage induced by antithrombotic therapy with traditional Chinese and Western medicine. Shijie Huaren Xiaohua Zazhi 2021; 29:1089-1095. [DOI: 10.11569/wcjd.v29.i19.1089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The incidence of cardiovascular diseases has increased due to the aging of the population. Therefore, antithrombotic therapy is increasingly prescribed for cardiovascular prevention. However, long-term use of antithrombotic drugs can cause damage to the digestive tract. Gastrointestinal complications, including ulcer and bleeding, are relatively common during antithrombotic therapy. In order to minimize the digestive tract damage induced by antithrombotic drugs, there are several strategies available, including reducing modifiable risk factors, using the most optimal antithrombotic regimen to ensure gastrointestinal risk-cardiovascular benefit balance, and using gastroprotective agents. In recent years, researchers are attempting to find new solutions from traditional Chinese medicine. Studies have shown that traditional Chinese medicine has its own characteristics and clinical advantages in preventing and treating diseases. In this review, we provide a summary of recent updates regarding gastrointestinal damage induced by antithrombotic therapy as well as its prevention and treatment with both traditional Chinese and Western medicine.
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Affiliation(s)
- Kai-Hong Yi
- Clinical Medical Research Center, First Affiliated Hospital of Shantou University Medical College, Shantou 515041, Guangdong Province, China
| | - Xue-Rui Tan
- Clinical Medical Research Center, First Affiliated Hospital of Shantou University Medical College, Shantou 515041, Guangdong Province, China
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Gastroprotective Effect of Enteral Nutrition Formula in Mice Injected Subcutaneously with Indomethacin. Nutrients 2021; 13:nu13093297. [PMID: 34579173 PMCID: PMC8468157 DOI: 10.3390/nu13093297] [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: 07/24/2021] [Revised: 09/01/2021] [Accepted: 09/17/2021] [Indexed: 11/17/2022] Open
Abstract
We have previously shown that two enteral nutrition formulas suppressed gastric lesions induced by the oral administration of indomethacin (IND) in mice. However, the mechanism of their protective effect is unknown. In this study, the effect of the two enteral nutrition formulas on gastric lesions induced by subcutaneous IND injection was investigated, with the objective of exploring the possibility that they may interact directly with IND in the gastrointestinal tract. Ten-week-old, male, ICR mice were fasted, then orally given either purified water, Mermed® One, or 2-fold diluted Terumeal® 2.0α as enteral nutrition formula (25 mL/kg). IND was injected subcutaneously at 20 mg/kg after 30 min, and the stomach was removed 6 h later and fixed in formalin. The number and area of lesions in the stomachs of mice given enteral nutrition formula was reduced to 56–89% and 34–61%, respectively, compared with the mice given purified water. The time courses of plasma IND concentrations were comparable among the three groups. These results suggested that the effect of these enteral nutrition formulas on gastric lesions did not originate from their direct interaction with IND in the gastrointestinal tract or their effect on the disposition of IND.
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Hellström PM, Benno P, Malfertheiner P. Gastrointestinal bleeding in patients with Helicobacter pylori and dual platelet inhibition after myocardial infarction. Lancet Gastroenterol Hepatol 2021; 6:684-685. [PMID: 34391514 DOI: 10.1016/s2468-1253(21)00192-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/21/2021] [Accepted: 05/26/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Per M Hellström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
| | - Peter Benno
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, Magdeburg, Germany; Department of Medicine II, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
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Safety and Efficacy of the Noncessation Method of Antithrombotic Agents after Emergency Endoscopic Hemostasis in Patients with Nonvariceal Upper Gastrointestinal Bleeding: A Multicenter Pilot Study. Can J Gastroenterol Hepatol 2021; 2021:6672440. [PMID: 34095017 PMCID: PMC8164533 DOI: 10.1155/2021/6672440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 05/01/2021] [Accepted: 05/13/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND AIMS The present study aimed to clarify the safety and efficacy of the noncessation method of antithrombotic agents after emergency endoscopic hemostasis in patients with nonvariceal upper gastrointestinal bleeding (UGIB). METHODS In this multicenter, prospective, pilot study, we performed emergency endoscopic hemostasis for nonvariceal UGIB in patients taking antithrombotic agents and resumed the medications without a cessation period (group A). The clinical characteristics, types of antithrombotic agents, UGIB etiology, treatment outcome, and adverse events were evaluated. We used propensity score matching to compare treatment outcomes and adverse events with our previous cohort (group B) in whom antithrombotic agents were transiently discontinued after emergency endoscopic hemostasis. RESULTS Forty-three consecutive patients were prospectively enrolled. The main antithrombotic agents were low-dose aspirin and direct oral anticoagulants; 11 patients (25.6%) were taking multiple antithrombotics. Peptic ulcers were the main cause of bleeding (95.4%). Endoscopic hemostasis was successful in all patients and the incidence of rebleeding within a month was 7.0%. Propensity score matching created 40 matched pairs. Endoscopic hemostasis was performed by soft coagulation significantly more frequently in group A than in group B (97.5% versus 60.0%, P < 0.001). Neither the rebleeding rate within a month nor thromboembolic event rate was different between the two groups. However, the mean duration of hospitalization was significantly shorter in group A than in group B (8.6 ± 5.2 d versus 14.4 ± 7.1 d, P < 0.001). CONCLUSIONS Antithrombotic agents possibly can be continued after successful emergency endoscopic hemostasis for nonvariceal UGIB.
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Pioppo L, Bhurwal A, Reja D, Tawadros A, Mutneja H, Goel A, Patel A. Incidence of Non-variceal Upper Gastrointestinal Bleeding Worsens Outcomes with Acute Coronary Syndrome: Result of a National Cohort. Dig Dis Sci 2021; 66:999-1008. [PMID: 32328894 DOI: 10.1007/s10620-020-06266-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/10/2020] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Upper gastrointestinal bleeding (UGIB) is a feared complication of acute coronary syndrome (ACS) and has been shown to increase morbidity and mortality. Our aim was to assess the incidence of non-variceal UGIB in patients with ACS in a national cohort and its impact on in-hospital mortality, length of stay (LOS), and cost of hospitalization. METHODS This was a retrospective cohort study analyzing the 2016 Nationwide Inpatient Sample (NIS) utilizing ICD 10 CM codes. Principal discharge diagnoses of ACS (STEMI, NSTEMI, and UA) in patients over 18 years old were included. Non-variceal UGIB with interventions including endoscopy, angiography, and embolization were also evaluated. Primary outcome was the national incidence of concomitant non-variceal UGIB in the setting of ACS. Secondary outcomes included in-hospital mortality, length of stay, and cost of stay. RESULTS A total of 661,404 discharges with principal discharge diagnosis of ACS in 2016 were analyzed. Of the included cohort, 0.80% (n = 5324) were complicated with non-variceal UGIB with increased frequency in older patients (OR 1.03, 95% CI 1.03-1.04; p = 0.0001). Despite endoscopic evaluation, 17.35% (n = 744) underwent angiography. After adjustment of confounders, inpatient mortality was significantly higher in patients with UGIB (OR 2.07, 95% CI 1.63-2.63, p = 0.0001). Non-variceal UGIB also led to significantly longer LOS (10.38 days vs 4.37 days, p = 0.0001) and cost of stay ($177,324 vs $88,468, p = 0.0001). DISCUSSION Our study shows that the national incidence of non-variceal UGIB complicating ACS is low at less than 1%, but resulted in significantly higher inpatient mortality, LOS, and hospitalization charges.
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Affiliation(s)
- Lauren Pioppo
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, New Brunswick, NJ, 09801, USA.
| | - Abhishek Bhurwal
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, New Brunswick, NJ, 09801, USA
| | - Debashis Reja
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, New Brunswick, NJ, 09801, USA
| | - Augustine Tawadros
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, New Brunswick, NJ, 09801, USA
| | - Hemant Mutneja
- Department of Internal Medicine, John H Stroger, Hospital of Cook County, 1969 Ogden Ave, Chicago, IL, 60612, USA
| | - Akshay Goel
- Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR, 72205, USA
| | - Anish Patel
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, New Brunswick, NJ, 09801, USA
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Abrignani MG, Gatta L, Gabrielli D, Milazzo G, De Francesco V, De Luca L, Francese M, Imazio M, Riccio E, Rossini R, Scotto di Uccio F, Soncini M, Zullo A, Colivicchi F, Di Lenarda A, Gulizia MM, Monica F. Gastroprotection in patients on antiplatelet and/or anticoagulant therapy: a position paper of National Association of Hospital Cardiologists (ANMCO) and the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO). Eur J Intern Med 2021; 85:1-13. [PMID: 33279389 DOI: 10.1016/j.ejim.2020.11.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/03/2020] [Accepted: 11/16/2020] [Indexed: 02/05/2023]
Abstract
Aspirin and P2Y12 receptor antagonists are widely used across the spectrum of cardiovascular and cerebrovascular diseases. Gastrointestinal complications, including ulcer and bleeding, are relatively common during antiplatelet treatment and, therefore, concomitant proton pump inhibitor (PPI) treatment is often prescribed. However, potential increased risk of cardiovascular events has been suggested for PPIs, and, in recent years, it has been discussed whether these drugs may reduce the cardiovascular protection by aspirin and, even more so, clopidogrel. Indeed, pharmacodynamic and pharmacokinetic studies suggested an interaction through hepatic CYP2C19 between PPIs and clopidogrel, which could translate into clinical inefficacy, leading to higher rates of cardiovascular events. The FDA and the EMA sent a warning in 2010 discouraging the concomitant use of clopidogrel with omeprazole or esomeprazole. In addition, whether the use of PPIs may affect the clinical efficacy of the new P2Y12 receptor antagonists, ticagrelor and prasugrel, remains less known. According to current guidelines, PPIs in combination with antiplatelet treatment are recommended 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 infection. Like vitamin K antagonists (VKAs), DOACs can determine gastrointestinal bleeding. Results from both randomized clinical trials and observational studies suggest that high-dose dabigatran (150 mg bid), rivaroxaban and high-dose edoxaban (60 mg daily) are associated with a higher risk of GI bleeding as compared with apixaban and warfarin. In patients taking oral anticoagulant with GI risk factor, PPI could be recommended, even if usefulness of PPIs in these patients deserves further data. Helicobacter pylori should always be searched, and treated, in patients with history of peptic ulcer disease (with or without complication). Given the large number of patients treated with antithrombotic drugs and PPIs, even a minor reduction of platelet inhibition or anticoagulant effect potentially carries a considerable clinical impact. The present joint statement by ANMCO and AIGO summarizes the current knowledge regarding the widespread use of platelet inhibitors, anticoagulants, and PPIs in combination. Moreover, it outlines evidence supporting or opposing drug interactions between these drugs and discusses consequent clinical implications.
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Affiliation(s)
| | - Luigi Gatta
- Gastroenterogy Unit, Versilia Hospital, Lido di Camaiore, Italy
| | | | - Giuseppe Milazzo
- Department of Medicine, Ospedale Vittorio Emanuele III, Salemi, Italy
| | | | - Leonardo De Luca
- Dept. Of Cardiosciences, Azienda Ospedaliera San Camillo-Forlanini, Roma, Italy
| | - Maura Francese
- Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy
| | - Massimo Imazio
- Cardiology, AOU Città della Salute e della Scienza, Turin, Italy
| | - Elisabetta Riccio
- Department of Transplantation, UOSC of Gastroenterology and Endoscopy, AORN 'A. Cardarelli', Napoli, Italy
| | | | | | | | - Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Furio Colivicchi
- Cardiology Division, San Filippo Neri Hospital, ASL ROMA 1, Rome, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, University Hospital and Health Services of Trieste, Italy
| | - Michele Massimo Gulizia
- Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy; President, Heart Care Foundation, Italy
| | - Fabio Monica
- Gastroenterology and Digestive Endoscopy, Academic Hospital Cattinara, Trieste, Italy
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Wärme J, Sundqvist M, Mars K, Aladellie L, Pawelzik SC, Erlinge D, Jernberg T, James S, Hofmann R, Bäck M. Helicobacter pylori screening in clinical routine during hospitalization for acute myocardial infarction. Am Heart J 2021; 231:105-109. [PMID: 33144087 DOI: 10.1016/j.ahj.2020.10.072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Potent antithrombotic therapy has significantly improved prognosis for patients with acute myocardial infarction (AMI), however, at a price of increased bleeding risk. Chronic gastric infection with Helicobacter pylori (Hp) commonly causes upper gastrointestinal bleeding and is proposed as a risk factor for subsequent bleeding post AMI. The prevalence of active Hp in a current AMI population and the feasibility of Hp screening as part of routine clinical care are unclear. OBJECTIVE To determine the prevalence of active Hp infection in a contemporary AMI cohort and to establish the feasibility of Hp diagnosis as part of routine clinical MI care. DESIGN Multicenter, prospective cohort study. SETTING Two university hospitals in Stockholm, Sweden. PARTICIPANTS Patients admitted for AMI between November 6, 2019 and April 4, 2020. After written informed consent, Hp diagnostics was performed with a bedside urea breath test (Diabact, Mayoly Spindler) incorporated into routine care during the hospitalization period. EXPOSURE Positive test for Hp infection. MAIN OUTCOMES AND MEASURES The primary outcome was the prevalence of Hp infection. Secondary aims included predictive factors in patient characteristics and outcomes which were obtained from linkage with national registries. Predefined subgroup analyses included stratification for proton pump inhibitor use and infarct type. RESULTS Three hundred and ten consecutive AMI patients (median age 67; 23% female; 41% ST-elevation MI [STEMI]) were enrolled. Overall, the Hp prevalence was 20% (95%CI, 15.5-24.7). Hp positive status was significantly more common in smokers compared with nonsmokers (36% vs 21%, respectively; P < .05) and in patients presenting with STEMI compared with Non-STEMI (26% vs 15%, respectively; P = .02). The latter observation remained significant after multivariable adjustment. After exclusion of 97 subjects with current proton pump inhibitor use, the Hp prevalence was 24% (95%CI, 18.9-31.0). CONCLUSIONS Active Hp infection is common in a contemporary AMI population and may represent a modifiable risk factor for upper gastrointestinal bleeding, which has been hitherto disregarded. Hp screening as part of clinical routine during AMI hospitalization was feasible. A future randomized trial is needed to determine whether routine Hp screening and subsequent eradication therapy reduces bleeding complications and improves prognosis. KEY POINTS Question: Is Helicobacter pylori (Hp) infection sufficiently common in patients with acute myocardial infarction (AMI) to consider systematic screening, and can Hp diagnostics be performed during AMI hospitalization? FINDINGS In this multicenter prospective cohort study of 310 consecutive AMI patients, Hp infection was established in at least 20% of patients. Infected patients were significantly more likely to be active smokers and to present with ST-elevation MI. Meaning: Hp screening as part of clinical routine during AMI hospitalization was feasible. Given the high Hp prevalence detected, Hp diagnostics and eradication to reduce bleeding complications and to improve prognosis after AMI should be further investigated.
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Affiliation(s)
| | | | - Katarina Mars
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Layth Aladellie
- Department of Medicine, Solna, Karolinska Institutet and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Sven-Christian Pawelzik
- Department of Medicine, Solna, Karolinska Institutet and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - David Erlinge
- Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Cardiology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
| | - Magnus Bäck
- Department of Medicine, Solna, Karolinska Institutet and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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Bozkurt H, Sert ÖZ, Ölmez T, Keklikkıran ZZ, Uzun O, Gülmez S, Polat E, Duman M. The risk of post-polypectomy bleeding among patients receiving antithrombotic agents: A prospective observational study. SAO PAULO MED J 2021; 139:218-225. [PMID: 33759909 PMCID: PMC9625013 DOI: 10.1590/1516-3180.2020.0305.r1.10122020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/10/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In July 2012, the Japan Gastroenterological Endoscopy Society updated their guidelines for gastroenterological endoscopy in patients receiving antithrombotic therapy. Colonoscopic polypectomy procedures are associated with a high risk of bleeding. OBJECTIVES The present study evaluated the safety of colonoscopic polypectomy procedures in terms of bleeding, among patients receiving antithrombotic therapy. DESIGN AND SETTING Prospective observational study conducted in a tertiary-level public cardiovascular hospital in Istanbul, Turkey. METHODS Colonoscopic polypectomies carried out in a single endoscopy unit between July 2018 and July 2019 were evaluated prospectively. The patients' data, including age, gender, comorbidities, whether antithrombotic drug use was ceased or whether patients were switched to bridging therapy, polyp size, polyp type, polyp location, histopathology, resection methods (hot snare, cold snare or forceps) and complications relating to the procedures were recorded. RESULTS The study was completed with 94 patients who underwent a total of 167 polypectomy procedures. As per the advice of the physicians who prescribed antithrombotic medications, 108 polypectomy procedures were performed on 60 patients without discontinuing medication and 59 polypectomy procedures were performed on 34 patients after discontinuing medication. The age, gender distribution and rate of bleeding did not differ significantly between the patients whose medication was discontinued and those whose medication was continued (P > 0.05). CONCLUSION This study found that the colonoscopic polypectomy procedure without discontinuation of antithrombotic medication did not increase the risk of bleeding. This procedure can be safely performed by experienced endoscopists in patients with an international normalized ratio (INR) below 2.5.
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Affiliation(s)
- Hilmi Bozkurt
- MD, MSc. General Surgeon, Gastrointestinal Surgeon and Molecular Oncology Doctoral Student, University of Health Sciences, Haseki Research and Education Hospital, Istanbul, Turkey.
| | - Özlem Zeliha Sert
- MD, MSc. General Surgeon, Gastrointestinal Surgeon and Molecular Oncology Doctoral Student, University of Health Sciences, Haydarpaşa Research and Education Hospital, Istanbul, Turkey.
| | - Tolga Ölmez
- MD. General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
| | - Zeynep Zehra Keklikkıran
- MD. General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
| | - Orhan Uzun
- MD. General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
| | - Selçuk Gülmez
- MD. General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
| | - Erdal Polat
- MD. Associate Professor, General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
| | - Mustafa Duman
- MD. Professor, General Surgeon and Gastrointestinal Surgeon, University of Health Sciences, Koşuyolu Research and Education Hospital, Istanbul, Turkey.
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Ikeda R, Hirasawa K, Sato C, Ozeki Y, Sawada A, Nishio M, Fukuchi T, Kobayashi R, Makazu M, Taguri M, Maeda S. Third-look endoscopy prevents delayed bleeding after endoscopic submucosal dissection under antithrombotic therapy. World J Gastroenterol 2020; 26:6475-6487. [PMID: 33244206 PMCID: PMC7656207 DOI: 10.3748/wjg.v26.i41.6475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/22/2020] [Accepted: 10/20/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Postoperative delayed bleeding (PDB) after gastric endoscopic submucosal dissection (ESD) is the most common adverse event in patients receiving antithrombotics even with second-look endoscopy. Moreover, with the increasing prevalence of cardiovascular and cerebrovascular diseases in an aging population with associated lifestyle-related diseases, an increasing number of patients receive antithrombotics. Several attempts have been made to prevent PDB in aging population; however, a consensus has yet to be reached.
AIM To examine the efficacy of third-look endoscopy (TLE) for PDB prevention.
METHODS One hundred patients with early gastric neoplasms receiving antithrombotics were prospectively enrolled and subjected to ESD with TLE between February 2017 and July 2019. The primary endpoint was PDB rate, which was compared with our preset threshold. Furthermore, we divided the bleeding period into early-and late-onset PDB (E-PDB and L-PDB, respectively) and analyzed its rate. As a secondary analysis, we compared PDB rates with those of a historical control group, using propensity score matching, and calculated the PDB rates per antithrombotic agent use in each group.
RESULTS In total, 96 patients and 114 specimens were finally evaluated. The overall PDB rate was 7.9% (9/114) [90%CI: 4.7-13.1, P = 0.005], while the late-and early-onset PDB rates (L-PDB and E-PDB) were 5.3% [90%CI: 2.7-9.9, P < 0.0001] and 2.6% [90%CI: 1.1-6.4, P = 0.51], respectively. Propensity score matching generated 58 matched pairs for TLE and control groups. No differences were found in overall PDB incidence (10.3% vs 20.7%, P = 0.12), whereas L-PDB occurrence significantly differed (5.2% vs 17.2%, P = 0.04) between groups. Considering antithrombotics’ use, the overall PDB rate was higher for direct oral anticoagulants and multiple antithrombotics in the control group, while L-PDB incidence was lower in the TLE group for these agents (8.7% vs 23.1% and 5.0% vs 29.4%, respectively).
CONCLUSION TLE for gastric ESD reduces overall PDB, and especially L-PDB incidence, among patients receiving antithrombotics.
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Affiliation(s)
- Ryosuke Ikeda
- Endoscopy Division, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Kingo Hirasawa
- Endoscopy Division, Yokohama Medical University Center Hospital, Yokohama 232-0024, Japan
| | - Chiko Sato
- Endoscopy Division, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Yuichiro Ozeki
- Endoscopy Division, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Atsushi Sawada
- Endoscopy Division, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Masafumi Nishio
- Endoscopy Division, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Takehide Fukuchi
- Endoscopy Division, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Ryosuke Kobayashi
- Endoscopy Division, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Makomo Makazu
- Endoscopy Division, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Masataka Taguri
- Department of Data Science, Yokohama City University School of Data Science, Yokohama 236-0004, Japan
| | - Shin Maeda
- Division of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan
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Duan L, Li M, Wang F, Cai Y, Li H, Zhou W, Li Y, Chen Q, Bai J, Liu H. Increased Risk of Clopidogrel-Induced Gastric Mucosal Erosion in Elderly Chinese Men Harboring the ABCB1 3435T Allele. Risk Manag Healthc Policy 2020; 13:1237-1244. [PMID: 32904459 PMCID: PMC7455592 DOI: 10.2147/rmhp.s263625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/30/2020] [Indexed: 12/16/2022] Open
Abstract
Background It is uncertain whether long-term use of clopidogrel alone can cause gastric mucosal injury. This study aimed to evaluate the relationship between ABCB1 C3435T polymorphisms, which could affect the intestinal absorption of clopidogrel, and gastric mucosal erosion in elderly Chinese men who used clopidogrel alone. Methods We selected 298 male patients (aged between 68.2 and 89.5 years, average age 78); 201 of them constituted the control group, and 97 constituted the case group. Patients taking clopidogrel alone who had undergone endoscopic screening for gastric erosion were analyzed for ABCB1 C3435T polymorphisms by a TaqMan assay. Results The proportion of people carrying the ABCB1 3435T allele (n = 63, 64.9% vs n = 97, 48.3%, p = 0.007) was significantly higher in the case group than in the control group. After adjustments for significant factors were made, ABCB1 3435T allele carrier (OR 2.14, 95% CI 1.43–3.84, p <0.01) was found to be associated with gastric mucosal erosion in people who used clopidogrel alone. Conclusion Carrying the ABCB1 3435T allele may be a useful genetic predictor for clopidogrel-induced gastric mucosal erosion in elderly Chinese men.
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Affiliation(s)
- Lei Duan
- Department of Geriatric Cardiology, National Clinical Research Center for Geriatric Diseases, The Second Medical Center of PLA General Hospital, Beijing 100853, People's Republic of China
| | - Man Li
- Department of Geriatric Cardiology, National Clinical Research Center for Geriatric Diseases, The Second Medical Center of PLA General Hospital, Beijing 100853, People's Republic of China
| | - Fan Wang
- Department of Geriatric Cardiology, National Clinical Research Center for Geriatric Diseases, The Second Medical Center of PLA General Hospital, Beijing 100853, People's Republic of China
| | - Yulun Cai
- Department of Geriatric Cardiology, National Clinical Research Center for Geriatric Diseases, The Second Medical Center of PLA General Hospital, Beijing 100853, People's Republic of China
| | - Huiying Li
- Department of Geriatric Cardiology, National Clinical Research Center for Geriatric Diseases, The Second Medical Center of PLA General Hospital, Beijing 100853, People's Republic of China
| | - Wenli Zhou
- Department of Geriatric Cardiology, National Clinical Research Center for Geriatric Diseases, The Second Medical Center of PLA General Hospital, Beijing 100853, People's Republic of China
| | - Yuerui Li
- Department of Geriatric Cardiology, National Clinical Research Center for Geriatric Diseases, The Second Medical Center of PLA General Hospital, Beijing 100853, People's Republic of China
| | - Qiang Chen
- Department of Geriatric Cardiology, National Clinical Research Center for Geriatric Diseases, The Second Medical Center of PLA General Hospital, Beijing 100853, People's Republic of China
| | - Jing Bai
- Department of Geriatric Cardiology, National Clinical Research Center for Geriatric Diseases, The Second Medical Center of PLA General Hospital, Beijing 100853, People's Republic of China
| | - Hongbin Liu
- Department of Geriatric Cardiology, National Clinical Research Center for Geriatric Diseases, The Second Medical Center of PLA General Hospital, Beijing 100853, People's Republic of China
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Abbas H, Kumar Nayudu S, Ravi M, Saad M, Bathini K, Ravi P, Roy S, Arya D, Chilimuri S. Does Extended Use of Clopidogrel-Based Dual Anti-Platelet Therapy Increase the Risk of Gastrointestinal Bleeding? Gastroenterology Res 2020; 13:146-149. [PMID: 32864025 PMCID: PMC7433374 DOI: 10.14740/gr1285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/20/2020] [Indexed: 12/13/2022] Open
Abstract
Background Clopidogrel-based dual anti-platelet therapy (CDAPT) has shown significant benefits in the management of coronary artery disease (CAD), up to 1-year duration. Gastrointestinal bleeding (GIB) is one of the limiting factors for prolonged use of CDAPT. Methods We identified all patients taking CDAPT from our ambulatory clinics. Demographic, clinical, laboratory and pharmacological data were abstracted. American Heart Association (AHA) guidelines were used to determine the duration of CDAPT therapy. The study population was divided into two groups based on the duration of therapy. Individuals who received CDAPT more than 12 months were deemed as extended use. Results A total of 351 patients with CAD were taking CDAPT. Majority of patients (276/351, 79%) were taking CDAPT beyond 1 year. There were no differences in baseline characteristics between the two groups. There was no significant difference in the incidence of GIB between the two groups. However, in subgroup analysis, there was a significant difference in the incidence of GIB in men. Men who were taking CDAPT beyond 12 months had almost three times higher incidence of GIB compared to those who were taking less than 12 months (25% vs. 8%, P = 0.04). The excess GIB in men prevailed despite adjusting for non-steroidal anti-inflammatory drugs (NSAIDs) or direct oral anticoagulant (DOAC) use. Conclusions We found that a majority of patients were taking CDAPT beyond the recommended duration. We observed that men taking CDAPT for an extended duration had a three times higher incidence of GIB. It would be reasonable for physicians to be aware of the higher risk of GIB in men and carefully assess the risks and benefits of extended use of CDAPT.
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Affiliation(s)
- Hafsa Abbas
- Department of Medicine, Division of Gastroenterology, Bronxcare Health System, Bronx, NY 10457, USA
| | - Suresh Kumar Nayudu
- Department of Medicine, Division of Gastroenterology, Bronxcare Health System, Bronx, NY 10457, USA
| | - Madhavi Ravi
- Department of Medicine, Division of Gastroenterology, Bronxcare Health System, Bronx, NY 10457, USA
| | - Muhammad Saad
- Department of Medicine, Bronxcare Health System, Bronx, NY 10457, USA
| | - Kashyap Bathini
- Department of Medicine, Bronxcare Health System, Bronx, NY 10457, USA
| | - Pranav Ravi
- Department of Medicine, Bronxcare Health System, Bronx, NY 10457, USA
| | - Swathi Roy
- Department of Medicine, Bronxcare Health System, Bronx, NY 10457, USA
| | - Divya Arya
- Department of Medicine, Bronxcare Health System, Bronx, NY 10457, USA
| | - Sridhar Chilimuri
- Department of Medicine, Bronxcare Health System, Bronx, NY 10457, USA
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Bilal M, Samuel R, Khalil MK, Singh S, Parupudi S, Abougergi MS. Nonvariceal upper GI hemorrhage after percutaneous coronary intervention for acute myocardial infarction: a national analysis over 11 months. Gastrointest Endosc 2020; 92:65-74.e2. [PMID: 32017916 DOI: 10.1016/j.gie.2020.01.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 01/22/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Nonvariceal upper GI hemorrhage (NVUGIH) is a feared adverse event after percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). We aimed to determine the incidence of NVUGIH after PCI for AMI and its impact on mortality, morbidity, and health care resource utilization over 11 months. METHODS We used the Nationwide Readmission Database 2014. Inclusion criteria were (1) a principal diagnosis of ST or non-ST-elevation myocardial infarction, (2) in-hospital PCI, and (3) admission in January. Exclusion criteria were age less than 18 years and elective admission. The primary outcome was the 11-month incidence of NVUGIH. Secondary outcomes were 11-month mortality rate, prolonged mechanical ventilation, shock, upper endoscopy, length of stay, and total hospitalization costs and charges. Independent risk factors for NVUGIH were identified using multivariate logistic regression analysis. RESULTS A total of 22,669 patients were included in the study. The mean age was 63.8 years (range, 63.4-64.1 years), and 31.7% of patients were female. The 11-month incidence of NVUGIH was 1.6%. The onset of NVUGIH was associated with an increase in the 11-month mortality rate (adjusted odds ratio, 1.94; 95% confidence interval, 1.01-3.72; P =.04). The upper endoscopy, shock, and prolonged mechanical ventilation rates were 72%, 6.2%, and 1.9%, respectively. In total, 26,532 days were associated with NVUGIH, with a total health care in-hospital economic burden of U.S.$17.6 million. Independent predictors of NVUGIH were female gender, Charlson comorbidity score, and length of stay. CONCLUSIONS The 11-month incidence of NVUGIH among patients who undergo PCI for AMI is 1.6%. NVUGIH has a substantial impact on mortality, morbidity, and in-hospital health care resource utilization.
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Affiliation(s)
- Mohammad Bilal
- Division of Gastroenterology & Hepatology, The University of Texas Medical Branch, Galveston, Texas; Division of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ronald Samuel
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, Texas, USA
| | | | - Shailendra Singh
- Division of Gastroenterology, West Virginia University, Charleston Area Medical Center, Charleston, West Virginia, USA
| | - Sreeram Parupudi
- Division of Gastroenterology & Hepatology, The University of Texas Medical Branch, Galveston, Texas
| | - Marwan S Abougergi
- Catalyst Medical Consulting, Simpsonville, South Carolina, USA; Division of Gastroenterology, Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, South Carolina, USA
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Elzanaty AM, Nazir S, Awad MT, Elsheikh E, Ahuja KR, Donato A, Eltahawy EA. Meta-Analysis of the Efficacy and Safety of P2Y 12 Inhibitor Monotherapy After Short Course of Dual-Antiplatelet Therapy in Patients Undergoing Percutaneous Coronary Intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1500-1506. [PMID: 32457020 DOI: 10.1016/j.carrev.2020.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/29/2020] [Accepted: 05/12/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Guidelines recommend dual antiplatelet therapy (DAPT) following drug-eluting stent (DES) placement for ≥12 months in acute coronary syndrome or 6 months in stable coronary artery disease. However, with the advent of newer-generation stents, the optimal duration of DAPT to balance bleeding and thrombotic risks has been debated. OBJECTIVES We aimed to perform a meta-analysis of randomized controlled trials (RCT) comparing P2Y12 monotherapy in short-duration group (SDG) vs. standard treatment group (STG) course of DAPT in patients undergoing PCI. METHODS Electronic databases were searched for RCTs of patients undergoing percutaneous coronary intervention (PCI) with DES placement who received short (≤ 3 months) vs. standard DAPT course (≥12 months) and were followed for ≥12-months. Rates of major adverse cardiovascular events (a composite of cardiovascular mortality, non-fatal myocardial infarction, and non-fatal stroke) were the primary outcome. Study-specific odds ratios (OR) and corresponding 95% confidence intervals were calculated using random-effects model. RESULTS A total of 20,706 patients (10,344 in the SDG and 10,362 in the STG) were analysed from four studies. There was no significant difference observed for MACE (OR = 0.95, 95% CI: 0.81-1.08, P = .92, I2 = 0%) myocardial infarction or stent thrombosis. However, lower rates of major bleeding were noted in the SDG (1.20 vs. 1.80%; OR: 0.61; 95% CI: 0.37-0.99; P = .04; I2 = 71%) albeit with increased heterogeneity. CONCLUSION A short duration of DAPT followed by P2Y12 inhibitor monotherapy was comparable to 12 months of DAPT with respect to MACE and thrombotic events, with lower rates of major bleeding events in select group of patients undergoing PCI. More data is needed to assess efficacy in patients with complex lesions and high risk ACS population including those with STEMI presentation.
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Affiliation(s)
- Ahmed M Elzanaty
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Salik Nazir
- Departement of Cardiology, University of Toledo Medical Center, Toledo, OH, USA
| | - Mohammed T Awad
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Eman Elsheikh
- Departement of Cardiology, Tanta University Hospital, Tanta, Egypt
| | - Keerat Rai Ahuja
- Departement of Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Ehab A Eltahawy
- Departement of Cardiology, University of Toledo Medical Center, Toledo, OH, USA.
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No Differences in Gastrointestinal Bleeding Risk among Clopidogrel-, Ticagrelor-, or Prasugrel-Based Dual Antiplatelet Therapy. J Clin Med 2020; 9:jcm9051526. [PMID: 32443621 PMCID: PMC7290690 DOI: 10.3390/jcm9051526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/09/2020] [Accepted: 05/13/2020] [Indexed: 12/25/2022] Open
Abstract
The risk for gastrointestinal bleeding from dual antiplatelet therapy (DAPT) with new antiplatelets (prasugrel/ticagrelor) compared to clopidogrel is unclear. AIM To determine the risk and type of major (gastrointestinal bleeding requiring hospitalization) and minor (anemia and iron deficiency) gastrointestinal events with different types of DAPT. METHODS Retrospective observational cohort study of patients who started DAPT after percutaneous coronary intervention. Follow-up was censored after 12 months of DAPT, when a major gastrointestinal event occurred, or when DAPT was discontinued. RESULTS Among 1,327 patients (54.03% were treated with clopidogrel-based DAPT, 38.13% with ticagrelor-based DAPT, and 7.84% with prasugrel-based DAPT), 29.5% had at least one gastrointestinal event. Patients taking clopidogrel-DAPT were older, with more comorbidities, and higher gastrointestinal risk compared to those taking other DAPT regimens. Adjusted hazard ratios (HRs) showed no between-group differences in the risk for major (clopidogrel vs. new antiplatelets: HR 0.996; 95% confidence interval 0.497-1.996) and minor (HR 0.920; 0.712-1.189) gastrointestinal events. Most patients received proton pump inhibitors while on DAPT (93.3%) and after withdrawal (83.2%). CONCLUSION Prasugrel- or ticagrelor-based DAPT was not associated with increased gastrointestinal bleeding risk when compared to clopidogrel-DAPT. New antiplatelets do not necessarily need to be restricted to patients with low gastrointestinal risk.
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Wu XT, He RR, Liang SZ, Ye GY, Ding SB. Effect of P2Y12 inhibitor monotherapy versus dual antiplatelet therapy on cardiovascular events in patients undergoing percutaneous coronary intervention: systematic review and meta-analysis. Minerva Med 2020; 111:173-180. [PMID: 32338843 DOI: 10.23736/s0026-4806.19.06281-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Clinical data on short mandatory dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitor monotherapy, compared with prolonged DAPT in patients undergoing percutaneous coronary intervention (PCI) are insufficient. We aim to evaluate the effectiveness and safety of P2Y12 inhibitor monotherapy and prolonged DAPT after short mandatory DAPT on cardiovascular events in patients undergoing PCI. EVIDENCE ACQUISITION A systematic literature search was performed in seven medical databases from building the database until July 2019. Three studies with randomized controlled trial (RCTs), totaling 21,970 patients, were included in this meta-analysis. The included studies were assessed by the Cochrane risk of bias and analyzed by Review Manager v. 5.3 software. EVIDENCE SYNTHESIS Our result of pooled analysis showed that there was noninferior rates of in major adverse cardiac and cerebrovascular events (MACCE), stroke, myocardial infarction and cardiac death between short mandatory DAPT followed by P2Y12 inhibitor monotherapy and prolonged DAPT in patients undergoing PCI. Pooled analysis showed that short mandatory DAPT followed by P2Y12 inhibitor monotherapy could significantly reduce the risk of bleeding BARC type 2-5 (OR=0.47, 95% CI: 0.31-0.70, P=0.002), compared with prolonged DAPT in patients undergoing PCI. However, Pooled analysis showed that short mandatory DAPT followed by P2Y12 inhibitor monotherapy was not associated with BARC type 3-5, compared with prolonged DAPT. CONCLUSIONS This meta-analysis demonstrated that short mandatory DAPT followed by P2Y12 inhibitor monotherapy compared with prolonged DAPT resulted in noninferior rates of MACCE, all-cause mortality, cardiac death, stroke, myocardial infarction and stent thrombosis. Furthermore, short mandatory DAPT followed by P2Y12 inhibitor monotherapy could significantly reduce the risk of bleeding BARC type 2-5.
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Affiliation(s)
- Xue-Ting Wu
- Department of Pharmacy, Dongguan People' s Hospital, Dongguan, China
| | - Rui-Rong He
- Department of Pharmacy, Dongguan People' s Hospital, Dongguan, China
| | - Shu-Zhen Liang
- Department of Pharmacy, Dongguan People' s Hospital, Dongguan, China
| | - Gen-Ying Ye
- Department of Pharmacy, Dongguan People' s Hospital, Dongguan, China
| | - Shao-Bo Ding
- Department of Pharmacy, Dongguan People' s Hospital, Dongguan, China -
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Akimoto T, Goto O, Sasaki M, Mizutani M, Tsutsumi K, Kiguchi Y, Nakayama A, Kato M, Fujimoto A, Ochiai Y, Maehata T, Kaise M, Iwakiri K, Yahagi N. Endoscopic suturing promotes healing of mucosal defects after gastric endoscopic submucosal dissection: endoscopic and histologic analyses in in vivo porcine models (with video). Gastrointest Endosc 2020; 91:1172-1182. [PMID: 31904381 DOI: 10.1016/j.gie.2019.12.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 12/06/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Endoscopic suturing of mucosal defects after endoscopic submucosal dissection (ESD) is expected to prevent postoperative adverse events. We aimed to endoscopically and histologically evaluate the healing process of post-ESD mucosal defects closed with endoscopic hand suturing (EHS) in in vivo porcine models. METHODS Twelve mucosal defects (2 cm in size) were created in 2 pigs (6 defects per pig). Initially, 2 defects were created: one was closed with EHS (sutured group) and the other was kept open (control group). On postoperative days (PODs) 7 and 14, 2 additional defects were created in each session, and they were treated in the same manner as in the initial procedure. On POD 21, the entire stomach, with the 6 lesion sites, was extracted for histologic evaluation after endoscopic observation. RESULTS Endoscopically, all sutured sites remained closed in all sessions (PODs 7, 14, and 21). Histologically, on POD 14, the epithelium and muscularis mucosae were appropriately connected. The mucosae were covered with the epithelium without inversion of the mucosal edge in the sutured group, whereas the ulcer bed was exposed in the control group. Furthermore, the degree of neovascularity and fibroblasts in the submucosa was smaller in the sutured group than that in the control group. CONCLUSIONS Our findings suggest that endoscopic suturing promotes healing of post-ESD mucosal defects histologically in in vivo porcine models. Thus, endoscopic mucosal closure after ESD might be clinically useful for the prevention of delayed perforation/bleeding if secure suturing is performed endoscopically.
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Affiliation(s)
- Teppei Akimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo; Department of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo; Department of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Motoki Sasaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Mari Mizutani
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Koshiro Tsutsumi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Yoshiyuki Kiguchi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Atsushi Nakayama
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Motohiko Kato
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Ai Fujimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Yasutoshi Ochiai
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Tadateru Maehata
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | | | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo
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Goto O, Oyama T, Ono H, Takahashi A, Fujishiro M, Saito Y, Abe S, Kaise M, Iwakiri K, Yahagi N. Endoscopic hand-suturing is feasible, safe, and may reduce bleeding risk after gastric endoscopic submucosal dissection: a multicenter pilot study (with video). Gastrointest Endosc 2020; 91:1195-1202. [PMID: 31923410 DOI: 10.1016/j.gie.2019.12.046] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 12/22/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic hand-suturing (EHS) provides secure intraluminal mucosal closure and should decrease the risk of adverse events after gastric endoscopic submucosal dissection (ESD). We prospectively investigated the feasibility and safety of EHS after gastric ESD, particularly for preventing post-ESD bleeding. METHODS Patients scheduled for gastric ESD at 3 institutions were prospectively recruited. Just after ESD, the mucosal defect was closed by EHS. The primary outcome was endoscopic assessment of adequately sustained closure of the defect on postoperative day 3. Endoscopy was performed to assess maintenance of the closure for the primary outcome. During postoperative weeks 3 to 4, patients were interviewed as outpatients about any occurrence of delayed bleeding. RESULTS Data from 30 patients (15 each who did or did not take antithrombotic agents) were analyzed. Mucosal closure by EHS was completed in 29 of 30 cases (97%) and was well maintained on postoperative day 3 in 25 cases (84%). Emergency endoscopy was required for major postoperative bleeding in 3 cases (10%), including 1 in which suturing had been incomplete. Excluding 1 patient with a remnant stomach, the other 24 with sustained closure had no bleeding, regardless of whether they did or did not take antithrombotic agents (0/11 and 0/13, respectively). No serious adverse events occurred during EHS. CONCLUSIONS Results show that EHS is feasible and safe with favorable outcomes. Provided that mucosal suturing is successfully completed and sustained, post-ESD bleeding can be decreased even in patients undergoing antithrombotic therapy. (Clinical trial registration number: UMIN 000033988.).
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Affiliation(s)
- Osamu Goto
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Tsuneo Oyama
- Division of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Akiko Takahashi
- Division of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukata Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Seiichiro Abe
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Department for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
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Bricout N, Chai F, Sobocinski J, Hertault A, Laure W, Ung A, Woisel P, Lyskawa J, Blanchemain N. Immobilisation of an anti-platelet adhesion and anti-thrombotic drug (EP224283) on polydopamine coated vascular stent promoting anti-thrombogenic properties. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2020; 113:110967. [PMID: 32487386 DOI: 10.1016/j.msec.2020.110967] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 04/11/2020] [Accepted: 04/12/2020] [Indexed: 11/24/2022]
Abstract
Current vascular drug-eluting stents based on immuno-proliferative drugs would reduce the rate of in-stent restenosis (ISR) but may be associated with a higher risk of acute stent thrombosis due to non-selective activity. In this paper, we aimed to develop a polydopamine (PDA) coated chromium‑cobalt (CoCr) stent functionalised with EP224283 (Endotis Pharma SA), which combines both a GPIIbIIIa antagonist (tirofiban moiety) and a factor Xa inhibitor (idraparinux moiety) to reduce acute stent thrombosis. PDA-coated chromium‑cobalt (CoCr) samples were first immersed in a polyethylenimine (PEI, pH 8.5) solution to increase amine function density (36.0 ± 0.1 nmol/cm2) on the CoCr surface. In a second step, avidin was grafted onto CoCr-PDA-PEI through the biotin linkage (strategy 1) or directly by coupling reactions (strategy 2). The HABA titration proved the fixation of biotin onto CoCr-PDA-PEI surface with a density of 0.74 nmol/cm2. The fixation of avidin was demonstrated by water contact angle (WCA) and surface plasmon resonance (SPR). SEM micrograph shows the flexibility of the thin layer coated onto the stent after balloon inflation. Independently of the strategy, a qualitative SEM analysis showed a reduction in platelet activation when the molecule EP224283 was immobilised on avidin. In parallel, the measurement of anticoagulant activity (anti-Xa) revealed a higher anti-factor Xa activity (2.24 IU/mL vs. 0.09 IU/mL in control) when EP224283 was immobilised on avidin. Interestingly, after seven days of degradation, the anticoagulant activity was persistent in both strategies and looked more important with the strategy 2 than in strategy 1. Throughout this work, we developed an innovative vascular stent through the immobilisation of EP224283 onto CoCr-PDA-PEI-(avidin) system, which provides a promising solution to reduce ISR and thrombosis after stent implantation.
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Affiliation(s)
- Nicolas Bricout
- Univ. Lille, Inserm, CHU Lille, U1008 - Controlled Drug Delivery Systems and Biomaterials, F-59000 Lille, France
| | - Feng Chai
- Univ. Lille, Inserm, CHU Lille, U1008 - Controlled Drug Delivery Systems and Biomaterials, F-59000 Lille, France
| | - Jonathan Sobocinski
- Univ. Lille, Inserm, CHU Lille, U1008 - Controlled Drug Delivery Systems and Biomaterials, F-59000 Lille, France
| | - Adrien Hertault
- Univ. Lille, Inserm, CHU Lille, U1008 - Controlled Drug Delivery Systems and Biomaterials, F-59000 Lille, France
| | - William Laure
- Univ. Lille, CNRS, INRAE, Centrale Lille, UMR 8207 - UMET - Unité Matériaux et Transformations, F-59000 Lille, France
| | - Alexandre Ung
- Service Hémostase, Regional Hospital Center University of Lille (CHRU-Lille), 2 Avenue Oscar Lambret, 59000 Lille, France
| | - Patrice Woisel
- Univ. Lille, CNRS, INRAE, Centrale Lille, UMR 8207 - UMET - Unité Matériaux et Transformations, F-59000 Lille, France
| | - Joel Lyskawa
- Univ. Lille, CNRS, INRAE, Centrale Lille, UMR 8207 - UMET - Unité Matériaux et Transformations, F-59000 Lille, France.
| | - Nicolas Blanchemain
- Univ. Lille, Inserm, CHU Lille, U1008 - Controlled Drug Delivery Systems and Biomaterials, F-59000 Lille, France.
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Petersen J, Møller Hansen J, Muckadell OBS, Dall M, Hallas J. A model to predict the risk of aspirin/non‐steroidal anti‐inflammatory drugs‐related upper gastrointestinal bleeding for the individual patient. Basic Clin Pharmacol Toxicol 2019; 126:437-443. [DOI: 10.1111/bcpt.13370] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/20/2019] [Indexed: 01/01/2023]
Affiliation(s)
- Jóhanna Petersen
- Department of Medical Gastroenterology Odense University Hospital Odense Denmark
| | - Jane Møller Hansen
- Department of Medical Gastroenterology Odense University Hospital Odense Denmark
| | | | - Michael Dall
- Department of Clinical Pharmacology and Pharmacy University of Southern Denmark Odense Denmark
| | - Jesper Hallas
- Department of Clinical Pharmacology and Pharmacy University of Southern Denmark Odense Denmark
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Kubosawa Y, Mori H, Kinoshita S, Nakazato Y, Fujimoto A, Kikuchi M, Nishizawa T, Suzuki M, Suzuki H. Changes of gastric ulcer bleeding in the metropolitan area of Japan. World J Gastroenterol 2019; 25:6342-6353. [PMID: 31754294 PMCID: PMC6861850 DOI: 10.3748/wjg.v25.i42.6342] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 09/11/2019] [Accepted: 11/01/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The two main causes of gastric ulcer bleeding are Helicobacter pylori (H. pylori) infection and ulcerogenic medicines, although the number of cases caused by each may vary with age. In Japan, the rate of H. pylori infection has fallen over the last decade and the number of prescriptions for non-steroidal anti-inflammatory drugs (NSAIDs) and antithrombotic drugs is increasing as the population ages. Methods of treatment for gastric ulcer bleeding have advanced with the advent of hemostatic forceps and potassium-competitive acid blocker (P-CAB). Thus, causes and treatments for gastric ulcer bleeding have changed over the last decade.
AIM To examine the trends of gastric ulcer bleeding over 10 years in the metropolitan area of Japan.
METHODS This is a single-center retrospective study. A total of 564 patients were enrolled from inpatients admitted to our hospital with gastric ulcer bleeding between 2006 and 2016. Age, medication history, H. pylori infection, method of treatment, rate of rebleeding, and the length of hospitalization were analyzed. Factors associated with gastric ulcer bleeding were evaluated using Fisher’s exact test, Pearson’s Chi-squared test or Student’s t-test as appropriate. The Jonckheere-Terpstra test was used to evaluate trends. A per-protocol analysis was used to examine the rate of H. pylori infection.
RESULTS There was a significant increase in the mean age over time (P < 0.01). The rate of H. pylori infection tended to decrease over the study period (P = 0.10), whereas the proportion of patients taking antithrombotic agents or NSAIDs tended to increase (P = 0.07). Over time, the use of NSAIDs and antithrombotic drugs increased with age. By contrast, the rate of H. pylori infection during the study period fell with age. H. pylori-induced ulcers accounted for the majority of cases in younger patients (< 70 years old); however, the rate decreased with age (P < 0.01). The method of treatment trend has changed significantly over time. The main method of endoscopic hemostasis has changed from clipping and injection to forceps coagulation (P < 0.01), and frequently prescribed medicines have changed from proton pump inhibitor to P-CAB (P < 0.01). The rate of rebleeding during the latter half of the study was significantly lower than that in the first half.
CONCLUSION These trends, gastric ulcers caused by ulcerogenic drugs were increasing with age and H. pylori-induced ulcers were more common in younger patients, were observed.
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Affiliation(s)
- Yoko Kubosawa
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Meguro, Tokyo 152-8902, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku, Tokyo 160-0016, Japan
| | - Hideki Mori
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Meguro, Tokyo 152-8902, Japan
- Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Diseases (TARGID), University of Leuven, Leuven 3000, Belgium
| | - Satoshi Kinoshita
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Meguro, Tokyo 152-8902, Japan
| | - Yoshihiro Nakazato
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Meguro, Tokyo 152-8902, Japan
| | - Ai Fujimoto
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Meguro, Tokyo 152-8902, Japan
| | - Masahiro Kikuchi
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Meguro, Tokyo 152-8902, Japan
| | - Toshihiro Nishizawa
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Meguro, Tokyo 152-8902, Japan
- Department of Gastroenterology, Digestive Disease Center, International University of Health and Welfare, Mita Hospital, Minato, Tokyo 108-8329, Japan
| | - Masayuki Suzuki
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Meguro, Tokyo 152-8902, Japan
| | - Hidekazu Suzuki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa 259-1193, Japan
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