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Anguita-Gámez M, Vivas D, Ferrandis R, González-Manzanares R, Anguita M, Esteve-Pastor MA, Echeverri M, Igualada J, Egocheaga I, Nozal-Mateo B, Abad-Motos A, Figuero E, Bouzó-Molina N, Lozano T, Álvarez-Ortega C, Torres J, Descalzo MJ, Catalá JC, Martín-Rioboo E, Molines A, Rodríguez-Contreras R, Carnero-Alcázar M, Marín F. Incidence and clinical impact of inappropriate periprocedural and perioperative management of antiplatelet therapy. Med Clin (Barc) 2024:S0025-7753(24)00355-5. [PMID: 38955604 DOI: 10.1016/j.medcli.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND AND AIMS There is little evidence on the impact of current recommendations on the use of antiplatelet therapy during the perioperative and periprocedural period in our setting. The aim of this study was to analyze the incidence and clinical impact of inappropriate use of antiplatelet therapy in a population of patients undergoing surgery or a diagnostic or therapeutic procedure in "real life" in Spain. METHODS A prospective multicenter observational study of patients treated with antiplatelet agents requiring intervention was conducted. The incidence of thrombotic and hemorrhagic events at 30 days was analyzed according to peri-intervention management of antiplatelet therapy. RESULTS We included 643 patients (31.9% women, 39.0% over 75 years of age), most of them (87.7%) receiving aspirin as antiplatelet therapy at a dose of 100mg/day. Indications for antiplatelet therapy were ischemic heart disease (44.9%), cerebrovascular disease (21.7%), and peripheral vascular disease (23.0%). Ischemic risk was low in 74.3%, while 51.6% had a low bleeding risk of the intervention. Periprocedural management was considered appropriate in 61.7% of cases. 30-day incidence of the combined primary endpoint of thrombotic events and major bleeding (12.1% versus 5.0%; p=0.002) and 30-day mortality (5.2% versus 1.5%; p=0.008) were significantly higher in patients with inappropriate periprocedural management of antiplatelet agents. CONCLUSIONS Despite current recommendations for the use of antiplatelet drugs in the perioperative/periprocedural period, their implementation in the "real world" remains low. Inappropriate use is associated with an increased incidence of adverse events, both thrombotic and hemorrhagic.
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Affiliation(s)
| | - David Vivas
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Raquel Ferrandis
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Rafael González-Manzanares
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Instituto Maimónides para la Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Manuel Anguita
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Instituto Maimónides para la Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - María Asunción Esteve-Pastor
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, El Palmar, Murcia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Marysol Echeverri
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Jesús Igualada
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - Beatriz Nozal-Mateo
- Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Ane Abad-Motos
- Servicio de Anestesiología y Reanimación, Hospital Universitario Donostia, San Sebastián, Gipuzkoa, Spain
| | - Elena Figuero
- Departamento de Especialidades Clínicas Odontológicas, Facultad de Odontología, Universidad Complutense, Madrid, Spain
| | - Nuria Bouzó-Molina
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Teresa Lozano
- Servicio de Cardiología, Hospital General Universitario Doctor Balmis, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Carlos Álvarez-Ortega
- Servicio de Cardiología, Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz (IdiPaz), Madrid, Spain
| | - Javier Torres
- Servicio de Cardiología, Hospital Universitario de Jaén, Jaén, Spain
| | | | - Juan Carlos Catalá
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, Spain
| | - Enrique Martín-Rioboo
- Medicina de Familia, Unidad de Gestión Clínica Poniente, Instituto Maimónides para la Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Alejandra Molines
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Marina Baixa, Villajoyosa, Alicante, Spain
| | - Rocío Rodríguez-Contreras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Torrecárdenas, Almería, Spain
| | | | - Francisco Marín
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Instituto Maimónides para la Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain; Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, El Palmar, Murcia, Spain
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Vivas D, Anguita-Gámez M, Ferrandis R, Esteve-Pastor MA, Echeverri M, Igualada J, Anguita M, Egocheaga I, Nozal-Mateo B, Abad-Motos A, Figuero E, Bouzó-Molina N, Lozano T, Álvarez-Ortega C, Torres J, Descalzo MJ, Catalá JC, Martín-Rioboo E, Molines A, Rodríguez-Contreras R, Carnero-Alcázar M, Marín F. Prospective observational registry of perioperative and periprocedural management of antithrombotic therapy in "real world": the REQXAA study. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:729-738. [PMID: 36914025 DOI: 10.1016/j.rec.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 01/23/2023] [Indexed: 03/15/2023]
Abstract
INTRODUCTION AND OBJECTIVES There is scarce real-world evidence on the management of perioperative antithrombotic treatment according to current recommendations. The aim of this study was to analyze the management of antithrombotic treatment in patients undergoing surgery or another invasive intervention and to assess the consequences of this management on the occurrence thrombotic or bleeding events. METHODS This prospective, observational, multicenter and multispecialty study analyzed patients receiving antithrombotic therapy who underwent surgery or another invasive intervention. The primary endpoint was defined as the incidence of adverse (thrombotic and/or hemorrhagic) events after 30 days of follow-up with respect to management of perioperative antithrombotic drugs. RESULTS We included 1266 patients (male: 63.5%; mean age 72.6 years). Nearly half of the patients (48.6%) were under chronic anticoagulation therapy (mainly for atrial fibrillation; CHA2DS2-VASC: 3.7), while 53.3% of the patients were under chronic antiplatelet therapy (mainly for coronary artery disease). Low ischemic and hemorrhagic risk was found in 66.7% and 51.9%, respectively. Antithrombotic therapy management was in line with current recommendations in only 57.3% of the patients. Inappropriate management of antithrombotic therapy was an independent risk factor for both thrombotic and hemorrhagic events. CONCLUSIONS The implementation of recommendations on the perioperative/periprocedural management of antithrombotic therapy in real-world patients is poor. Inappropriate management of antithrombotic treatment is associated with an increase in both thrombotic and hemorrhagic events.
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Affiliation(s)
- David Vivas
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense, Madrid, Spain.
| | - María Anguita-Gámez
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Raquel Ferrandis
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - María Asunción Esteve-Pastor
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, El Palmar, Murcia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Marysol Echeverri
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Jesús Igualada
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Manuel Anguita
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Instituto Maimónides para la Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | | | - Beatriz Nozal-Mateo
- Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Ane Abad-Motos
- Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Madrid, Spain; Servicio de Anestesiología y Reanimación, Hospital Universitario Donostia, San Sebastián, Gipuzkoa, Spain
| | - Elena Figuero
- Departamento de Especialidades Clínicas Odontológicas, Facultad de Odontología, Universidad Complutense, Madrid, Spain
| | - Nuria Bouzó-Molina
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Teresa Lozano
- Servicio de Cardiología, Hospital General Universitario Doctor Balmis, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Carlos Álvarez-Ortega
- Servicio de Cardiología, Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz (IdiPaz), Madrid, Spain
| | - Javier Torres
- Servicio de Cardiología, Hospital Universitario de Jaén, Jaén, Spain
| | | | - Juan Carlos Catalá
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, Spain
| | - Enrique Martín-Rioboo
- Medicina de Familia, Unidad de Gestión Clínica Poniente, Instituto Maimónides para la Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Alejandra Molines
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Marina Baixa, Villajoyosa, Alicante, Spain
| | - Rocío Rodríguez-Contreras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Torrecárdenas, Almería, Spain
| | | | - Francisco Marín
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, El Palmar, Murcia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
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Huang S, Rodriguez C, Shakfeh K, Smith J, Reddy K. Urgent Revascularization of the Left Proximal Circumflex Following Cessation of Cangrelor Within Six Hours of Procedure. Cureus 2023; 15:e40314. [PMID: 37448385 PMCID: PMC10337834 DOI: 10.7759/cureus.40314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/12/2023] [Indexed: 07/15/2023] Open
Abstract
Patients undergoing procedures are often transitioned off anticoagulants using anti-platelet agents with short half-lives as a "bridge." We present the case of a patient with a history of in-stent thromboses who experienced a thrombotic event following a literature-guided bridging protocol. This case is one of the first to show that stopping cangrelor within six hours led to a need for urgent revascularization and suggests that the timing for discontinuing bridging agents should be customized based on the patient's history of increased blood clotting.
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Affiliation(s)
- Sherri Huang
- Internal Medicine and Pediatrics, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Camilo Rodriguez
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Khalid Shakfeh
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Jorden Smith
- Internal Medicine, University of South Florida Morsani College, Tampa, USA
| | - Koushik Reddy
- Cardiology and Lifestyle Medicine, James A. Haley Veterans Affair Medical Center, Tampa, USA
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Ortega-Paz L, Giordano S, Franchi F, Rollini F, Pollack CV, Bhatt DL, Angiolillo DJ. Clinical and Pre-Clinical Pharmacokinetics and Pharmacodynamics of Bentracimab. Clin Pharmacokinet 2023; 62:673-692. [PMID: 37118383 DOI: 10.1007/s40262-023-01245-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/30/2023]
Abstract
Antiplatelet agents are among the most frequently used medications in cardiovascular medicine. Although in patients with atherosclerotic disease manifestations, in particular those treated by percutaneous coronary intervention, antiplatelet agents are beneficial for the prevention of ischemic events, they inevitably increase the risk of bleeding. Furthermore, 5-15% of patients treated by percutaneous coronary intervention may need a surgical procedure within 2 years, creating challenges to safe and effective antiplatelet drug management. Importantly, major spontaneous or procedural-related bleedings are associated with increased hospital admission, length, costs, and poor prognosis. Although the effects of other antithrombotic therapies, such as direct oral anticoagulants, can be reversed by approved specific agents, there are no approved reversal agents for any antiplatelet drugs. The fact that many antiplatelet agents, such as aspirin and thienopyridines (i.e., clopidogrel and prasugrel), bind irreversibly to their targets represents a challenge for the development of a drug-specific reversal agent. In contrast, ticagrelor is a non-thienopyridine with a plasma half-life of 7-9 h that reversely binds the P2Y12 receptor producing potent signaling blockage. In 2015, bentracimab (also known as PB2452 or MEDI2452), a neutralizing monoclonal antibody fragment that binds free plasma ticagrelor and its major active metabolite, was identified. This systematic overview provides a comprehensive summary of the drug development program of bentracimab, focusing on its pharmacodynamic, pharmacokinetic, and safety profiles.
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Affiliation(s)
- Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, ACC Building 5th Floor, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Salvatore Giordano
- Division of Cardiology, University of Florida College of Medicine, ACC Building 5th Floor, 655 West 8th Street, Jacksonville, FL, 32209, USA
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, ACC Building 5th Floor, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, ACC Building 5th Floor, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Charles V Pollack
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MI, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, ACC Building 5th Floor, 655 West 8th Street, Jacksonville, FL, 32209, USA.
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5
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Statman BJ. Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery: Part 2. Anesth Prog 2023; 70:37-48. [PMID: 36995961 PMCID: PMC10069535 DOI: 10.2344/anpr-70-01-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/27/2023] [Indexed: 03/31/2023] Open
Abstract
Part 1 of "Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery" covered the physiological process of hemostasis and the pharmacology of both traditional and novel oral antiplatelets and anticoagulants. Part 2 of this review discusses various factors that are considered when developing a perioperative management plan for patients on oral antithrombotic therapy in consultation with dental professionals and managing physicians. Additionally included are how thrombotic and thromboembolic risks are assessed as well as how patient- and procedure-specific bleeding risks are evaluated. Special attention is given to the bleeding risks associated with procedures encountered when providing sedation and general anesthesia within the office-based dental environment.
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Rajsic S, Breitkopf R, Rugg C, Bukumiric Z, Reitbauer J, Treml B. Thrombotic Events Develop in 1 Out of 5 Patients Receiving ECMO Support: An 11-Year Referral Centre Experience. J Clin Med 2023; 12:jcm12031082. [PMID: 36769730 PMCID: PMC9917555 DOI: 10.3390/jcm12031082] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/18/2023] [Accepted: 01/28/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) for critically ill patients is growing rapidly given recent developments in technology. However, adverse events are frequently reported that have potentially devastating impacts on patient outcomes. The information on predictors and risk factors for thrombotic events, especially that focusing on the comparison of veno-arterial and veno-venous ECMO configurations, are still inconsistent and sparse; therefore, we aimed to close this gap. METHODS We performed a retrospective analysis of all patients on extracorporeal life support admitted to the intensive care units of a tertiary university center in Europe. RESULTS From 645 patients, 417 who received extracorporeal life support due to cardiogenic shock (290, 70%), respiratory failure (116, 28%) or hypothermia (11, 3%) were included. In total, 22% (92) of the patients experienced thrombotic events with a similar incidence in both ECMO configurations. Anticoagulation consisted of unfractionated heparin (296, 71%) and argatroban (70, 17%). Univariate Cox analyses identified hemoconcentration and increased maximal clot firmness (thromboelastometry) as risk factors for thrombosis. Moreover, the patients experiencing thrombosis had longer ECMO duration and intensive care stays. CONCLUSIONS ECMO is a specialized life-support modality with a high risk of complications. A longer ECMO duration is associated with thrombosis occurrence in patients receiving ECMO support. Following hemorrhage, thromboembolic complications are common adverse events. However, in contrast to major bleeding, no impact on mortality was observed. The question arises if a protocol with less anticoagulation may have a role to play in the future.
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Affiliation(s)
- Sasa Rajsic
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Christopher Rugg
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Jakob Reitbauer
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Benedikt Treml
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-50504-82231
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7
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Koshy AN, Cao D, Levin MA, Sartori S, Giustino G, Kyaw H, Claessen B, Zhang Z, Nicolas J, Camaj A, Roumeliotis A, Chandiramani R, Bedekar R, Waseem Z, Bagga S, Kini A, Sharma SK, Mehran R. Predictors of antiplatelet cessation in a real-world patient population undergoing non-cardiac surgery after PCI. Int J Cardiol 2022; 364:27-30. [PMID: 35716933 DOI: 10.1016/j.ijcard.2022.06.023] [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: 03/26/2022] [Revised: 05/17/2022] [Accepted: 06/10/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The optimal perioperative management of antiplatelet therapy (APT) therapy in patients undergoing noncardiac surgery (NCS) following percutaneous coronary intervention (PCI) is unclear. We sought to identify predictors of APT cessation in a real-world cohort of patients undergoing NCS within 1 year of PCI. METHODS Consecutive patients undergoing PCI at a tertiary center between 2011 and 2018 were prospectively enrolled. Perioperative interruption of APT was defined as cessation of either aspirin or P2Y12 inhibitor between 1 and 14 days prior to NCS. Predictors of APT discontinuation were identified by multivariable Cox regression with stepwise selection of candidate variables. RESULTS A total of 1092 surgeries corresponding to 747 patients were identified. Overall, there were 487 (44.6%) preoperative antiplatelet interruptions: discontinuation of either P2Y12 inhibitors only (47.4%), aspirin only (7.9%), or both agents (44.7%). Both patient-specific risk factors (prior stroke, lower BMI, anemia, MI) and procedure specific risk factors (chronic total occlusions, multivessel disease, drug-eluting stent use) affected decisions regarding APT cessation. Likelihood of APT cessation increased in higher-risk surgeries and in patients on more potent P2Y12 inhibitors (ticagrelor/prasugrel vs clopidogrel) whereas those undergoing NCS <90 days post PCI were less likely to have cessation of APT. CONCLUSION In this contemporary cohort of post-PCI patients undergoing NCS, patient-, angiographic- and surgery-specific factors all affected decision-making regarding APT cessation. Our findings reflective of real-world practice, highlight the importance of a multidisciplinary team approach to individualize decision making in these patients.
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Affiliation(s)
- Anoop N Koshy
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Cardiology and The University of Melbourne, Austin Health, Melbourne, Australia
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Cardiovascular Department, Humanitas Gavazzeni, Bergamo, Italy; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Htoo Kyaw
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bimmer Claessen
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anton Camaj
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anastasios Roumeliotis
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rishi Chandiramani
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rashi Bedekar
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zaha Waseem
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shiv Bagga
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Annapoorna Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029-6574, US.
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The Role of Excessive Anticoagulation and Missing Hyperinflammation in ECMO-Associated Bleeding. J Clin Med 2022; 11:jcm11092314. [PMID: 35566439 PMCID: PMC9102211 DOI: 10.3390/jcm11092314] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/26/2022] [Accepted: 04/19/2022] [Indexed: 12/30/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is increasingly used in carefully selected patients with cardiac or respiratory failure. However, complications are common and can be associated with worse outcomes, while data on risk factors and outcomes are inconsistent and sparse. Therefore, we sought to investigate potential risk factors and predictors of haemorrhage and adverse events during ECMO and its influence on mortality. We retrospectively reviewed all patients on ECMO support admitted to intensive care units of a tertiary university centre in Austria. In a period of ten years, ECMO support was used in 613 patients, with 321 patients meeting the inclusion criteria of this study. Haemorrhage, occurring in more than one third of the included patients (123, 38%), represented the most common and serious ECMO complication, being associated with an increased one year mortality (51% vs. 35%, p = 0.005). The main risk factors for haemorrhage were severity of the disease (hazard ratio (HR) = 1.01, p = 0.047), a prolonged activated partial thromboplastin time (HR = 1.01, p = 0.007), and lower values of C-reactive protein (HR = 0.96, p = 0.005) and procalcitonin (HR = 0.99, p = 0.029). In summary, haemorrhage remained the main ECMO complication with increased mortality. Moreover, we reported a possible association of lower inflammation and bleeding during ECMO support for the first time. This generated a new hypothesis that warrants further research. Finally, we recommend stricter monitoring of anticoagulation especially in patients without hyperinflammation.
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9
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Yun AN, Toyoda AY, Solomon EJ, Roberts RJ, Ji CS. Safety and Efficacy of Periprocedural Bridging With Cangrelor Versus Eptifibatide. J Cardiovasc Pharmacol 2022; 79:383-389. [PMID: 35255052 DOI: 10.1097/fjc.0000000000001192] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/28/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Patients with percutaneous coronary interventions undergoing procedures often require interruptions in their dual antiplatelet therapy. Periprocedural bridging is considered for patients at high thrombotic risk using intravenous cangrelor, a reversible P2Y12 inhibitor with a short half-life, or eptifibatide, a glycoprotein IIb/IIIa inhibitor, with a slightly longer half-life but less costly alternative. This study aims to assess the safety and efficacy of cangrelor compared with eptifibatide when used in a periprocedural setting. The primary outcome of this retrospective cohort study was the incidence of bleeding events defined by the global use of strategies to open occluded coronary arteries criteria, and the secondary outcomes include the transfusion requirements, inpatient major cardiac adverse events, and cost savings per patient. A total of 75 patients were included who were bridged to procedures (cangrelor, n = 50; eptifibatide, n = 25). There were no significant differences in overall bleeding events defined by global use of strategies to open occluded coronary arteries criteria: mild bleeding [8% (n= 4) vs. 8% (n= 2); P = 0.68], moderate bleeding [28% (n = 14) vs. 48% (n = 12); P = 0.07), and severe bleeding [8% (n = 4) vs. 8% (n = 2); P = 0.25] between cangrelor and eptifibatide. The composite inpatient major cardiac adverse events were also similar between cangrelor and eptifibatide [10% (n = 10) vs. 8% (n = 8); P = 0.78]. The average cost savings per each cangrelor patient on the equivalent duration of eptifibatide was calculated out to be $5824 per patient. Cangrelor and eptifibatide were similar in terms of safety and efficacy when used as a bridge in patients with recent coronary stents, but considerable cost savings could be made if cangrelor was substituted for by eptifibatide in select patients. Further studies are needed to determine its applicability specifically in patients at high thrombotic and hemorrhagic risk.
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Affiliation(s)
- Allison N Yun
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA
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10
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Fialho I, Augusto JB, Fevereiro S, Santos MB, Baptista SB, Roque D. Cangrelor as antiplatelet bridging therapy in non-cardiac surgery after percutaneous coronary intervention – First-time use in Portugal. Rev Port Cardiol 2022; 41:515-517. [DOI: 10.1016/j.repc.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/04/2021] [Indexed: 10/18/2022] Open
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11
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Regulation of Key Antiplatelet Pathways by Bioactive Compounds with Minimal Bleeding Risk. Int J Mol Sci 2021; 22:ijms222212380. [PMID: 34830261 PMCID: PMC8620148 DOI: 10.3390/ijms222212380] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 01/04/2023] Open
Abstract
Cardiovascular disease is strongly influenced by platelet activation. Platelet activation and thrombus formation at atherosclerotic plaque rupture sites is a dynamic process regulated by different signaling networks. Therefore, there are now focused efforts to search for novel bioactive compounds which target receptors and pathways in the platelet activation process while preserving normal hemostatic function. The antiplatelet activity of numerous fruits and vegetables and their multiple mechanisms of action have recently been highlighted. In this review, we review the antiplatelet actions of bioactive compounds via key pathways (protein disulfide isomerase, mitogen-activated protein kinases, mitochondrial function, cyclic adenosine monophosphate, Akt, and shear stress-induced platelet aggregation) with no effects on bleeding time. Therefore, targeting these pathways might lead to the development of effective antiplatelet strategies that do not increase the risk of bleeding.
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12
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Valenti R, Muraca I, Marcucci R, Ciatti F, Berteotti M, Gori AM, Carrabba N, Migliorini A, Marchionni N, Valgimigli M. "Tailored" antiplatelet bridging therapy with cangrelor: moving toward personalized medicine. Platelets 2021; 33:687-691. [PMID: 34672898 DOI: 10.1080/09537104.2021.1983162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the setting of patients with indication to receive dual antiplatelet therapy undergoing surgery or invasive procedures, the risk of perioperative cardiac ischemic events, particularly stent thrombosis, is high, because surgery has a prothrombotic effect and antiplatelet therapy is withdrawn in order to avoid bleeding complications. Cangrelor, an intravenous P2Y12 receptor antagonist, has been tested in a randomized trial as a "bridge" to cardiac surgery from discontinuation of oral P2Y12 receptor antagonists. Thus, a consensus document extended its off-label use in this setting and before non-cardiac surgery. Currently, despite the implementation of a standardized bridging protocol with cangrelor, a residual risk of adverse outcome mainly due to bleeding events, still persist during the perioperative phase.Accordingly, a personalized management driven by platelet reactivity serial measurements and careful assessment of ischemic and bleeding risks has potential to optimize outcomes and costs as compared to a standardized bridging protocol, based on average pharmacodynamic data of oral P2Y12 inhibitors.While specific indications for bridging have been extensively addressed in the aforementioned consensus statement, the aim of the present document is the proposal of a "tailored" clinical decision-making algorithm inspired to the principle of personalized medicine dealing with complex clinical scenarios.
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Affiliation(s)
- Renato Valenti
- From the Interventional Cardiology Unit, Cardiovascular Department, Careggi University Hospital, Florence, Italy
| | - Iacopo Muraca
- From the Interventional Cardiology Unit, Cardiovascular Department, Careggi University Hospital, Florence, Italy
| | - Rossella Marcucci
- From the Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Francesca Ciatti
- From the Interventional Cardiology Unit, Cardiovascular Department, Careggi University Hospital, Florence, Italy
| | - Martina Berteotti
- From the Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Anna Maria Gori
- From the Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Nazario Carrabba
- From the Interventional Cardiology Unit, Cardiovascular Department, Careggi University Hospital, Florence, Italy
| | - Angela Migliorini
- From the Interventional Cardiology Unit, Cardiovascular Department, Careggi University Hospital, Florence, Italy
| | - Niccolò Marchionni
- From the Interventional Cardiology Unit, Cardiovascular Department, Careggi University Hospital, Florence, Italy
| | - Marco Valgimigli
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (Eoc), Lugano, Switzerland; Department of Cardiology, University of Bern, Bern, Switzerland
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13
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Sullivan AE, Nanna MG, Wang TY, Bhatt DL, Angiolillo DJ, Mehran R, Banerjee S, Cantrell S, Jones WS, Rymer JA, Washam JB, Rao SV, Ohman EM. Bridging Antiplatelet Therapy After Percutaneous Coronary Intervention: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78:1550-1563. [PMID: 34620413 DOI: 10.1016/j.jacc.2021.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 11/26/2022]
Abstract
Patients undergoing early surgery after coronary stent implantation are at increased risk for mortality from ischemic and hemorrhagic complications. The optimal antiplatelet strategy in patients who cannot discontinue dual antiplatelet therapy (DAPT) before surgery is unclear. Current guidelines, based on surgical and clinical characteristics, provide risk stratification for bridging therapy with intravenous antiplatelet agents, but management is guided primarily by expert opinion. This review summarizes perioperative risk factors to consider before discontinuing DAPT and reviews the data for intravenous bridging therapies. Published reports have included bridging options such as small molecule glycoprotein IIb/IIIa inhibitors (eptifibatide or tirofiban) and cangrelor, an intravenous P2Y12 inhibitor. However, optimal management of these complex patients remains unclear in the absence of randomized controlled data, without which an argument can be made both for and against the use of perioperative intravenous bridging therapy after discontinuing oral P2Y12 inhibitors. Multidisciplinary risk assessment remains a critical component of perioperative care.
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Affiliation(s)
- Alexander E Sullivan
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA. https://twitter.com/aesullivan37
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Tracy Y Wang
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Deepak L Bhatt
- Division of Cardiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Roxana Mehran
- Division of Cardiology, Mount Sinai Hospital, New York, New York, USA
| | - Subhash Banerjee
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sarah Cantrell
- Duke University Medical Center Library & Archives, Duke University School of Medicine, Durham, North Carolina, USA
| | - W Schuyler Jones
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jennifer A Rymer
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Sunil V Rao
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - E Magnus Ohman
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA.
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14
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Patel KP, Michail M, Treibel TA, Rathod K, Jones DA, Ozkor M, Kennon S, Forrest JK, Mathur A, Mullen MJ, Lansky A, Baumbach A. Coronary Revascularization in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis. JACC Cardiovasc Interv 2021; 14:2083-2096. [PMID: 34620388 DOI: 10.1016/j.jcin.2021.07.058] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/25/2021] [Accepted: 07/27/2021] [Indexed: 01/09/2023]
Abstract
Aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist, with up to two thirds of patients with AS having significant CAD. Given the challenges when both disease states are present, these patients require a tailored approach diagnostically and therapeutically. In this review the authors address the impact of AS and aortic valve replacement (AVR) on coronary hemodynamic status and discuss the assessment of CAD and the role of revascularization in patients with concomitant AS and CAD. Remodeling in AS increases the susceptibility of myocardial ischemia, which can be compounded by concomitant CAD. AVR can improve coronary hemodynamic status and reduce ischemia. Assessment of the significance of coexisting CAD can be done using noninvasive and invasive metrics. Revascularization in patients undergoing AVR can benefit certain patients in whom CAD is either prognostically or symptomatically important. Identifying this cohort of patients is challenging and as yet incomplete. Patients with dual pathology present a diagnostic and therapeutic challenge; both AS and CAD affect coronary hemodynamic status, they provoke similar symptoms, and their respective treatments can have an impact on both diseases. Decisions regarding coronary revascularization should be based on understanding this complex relationship, using appropriate coronary assessment and consensus within a multidisciplinary team.
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Affiliation(s)
- Kush P Patel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Michael Michail
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Krishnaraj Rathod
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Daniel A Jones
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Mick Ozkor
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Simon Kennon
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - John K Forrest
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anthony Mathur
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Michael J Mullen
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Alexandra Lansky
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andreas Baumbach
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Yale University School of Medicine, New Haven, Connecticut, USA.
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15
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Khan AA, Murtaza G, Khalid M, Finniss M, Helton T. Efficacy of Cangrelor as Bridging Therapy Post PCI. Cardiovasc Hematol Disord Drug Targets 2021; 20:227-231. [PMID: 32108005 PMCID: PMC8226151 DOI: 10.2174/1871529x20666200228114925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 01/17/2020] [Accepted: 01/18/2020] [Indexed: 11/22/2022]
Abstract
Background Dual antiplatelet therapy (DAPT) remains the cornerstone management for the prevention of acute stent thrombosis after percutaneous intervention (PCI). Situations mandating early interruption of DAPT carry a high risk of ischemic complications. Perioperative bridge therapy using Cangrelor, an intravenous P2Y2 inhibitor, may offer a potential solution. Unfortunately, evidence for its use in non-cardiac procedures is limited. Methods Our protocol demonstrates successful off-label use of IV Cangrelor bridge therapy in a non-cardiac surgery patient. We describe a case of a 77-year old male; triple therapy with Aspirin, Apixaban, and Ticagrelor for recent drug-eluting stent placement required immediate surgical resection of stage I colonic adenocarcinoma. Results Cangrelor bridge therapy was utilized both preoperatively and postoperatively without ischemic or bleeding complications. The patient tolerated exploratory laparoscopic colectomy with minimal bleeding and good post-op recovery. Conclusion Minimizing the interruption of DAPT therapy in high-risk patients is achievable. However, careful planning with a team-based approach involving surgeons, cardiologists and pharmacists, along with close clinical follow-up and vigilant management of anti-platelet therapy is recommended.
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Affiliation(s)
- Abdul A Khan
- Division of Cardiovascular Medicine, East Tennessee State University, TN, United States
| | - Ghulam Murtaza
- Division of Cardiovascular Medicine, East Tennessee State University, TN, United States
| | - Muhammad Khalid
- Division of Cardiovascular Medicine, East Tennessee State University, TN, United States
| | - Mathew Finniss
- Department of Internal Medicine, East Tennessee State University, TN, United States
| | - Thomas Helton
- Division of Cardiovascular Medicine, Mountain Home VA Medical Center, TN, United States
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16
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Okur Mİ, Çetinbaş A, Altun S, Öztan M, Yıldız Altun A, Özercan İ. The effect of ticagrelor on microarterial thrombosis in an experimental model. J Plast Surg Hand Surg 2021; 55:297-301. [PMID: 33593206 DOI: 10.1080/2000656x.2021.1883629] [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: 10/22/2022]
Abstract
Thromboses that form in the pedicle after free flap and/or replantation may result in the loss of the flap and/or limb. Ticagrelor is an adenosine diphosphate (ADP) receptor antagonist antithrombotic that can inhibit ADP-dependent platelet activation and aggregation. It is clinically used in acute coronary syndrome and unstable angina. However, its effect on microarterial anastomoses has not been investigated in the literature. An experimental thrombosis model was developed in both femoral arteries of a total of 40 rats. Twenty rats were randomly selected as the drug-free control group, and 20 rats were randomly selected as the ticagrelor group. The rats in the ticagrelor group were administered a 20 mg/kg loading dose orally by gavage 24 h before the experiment, and a maintenance dose of 2x10 mg/kg ticagrelor for 14 days after surgery. After the experiment, the femoral artery was evaluated for macroscopic and microscopic thrombosis, inflammation, edema, and endothelialization. Macroscopically and microscopically, thrombosis was observed at rates of 73.3% and 33.3% in the control group and the ticagrelor group, respectively. Inflammation in the vessel wall was found as 56.7% in the control group and 16.7% in the ticagrelor group. Edema in the vessel wall was found in 63.3% of the control group and 20% of the ticagrelor group. A statistical difference was found between the two groups in terms of thrombosis, inflammation, and edema. Both groups had similar characteristics in terms of endothelialization. Ticagrelor has a reducing effect on thrombosis in the microarterial tuck model.
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Affiliation(s)
- Mehmet İhsan Okur
- Department of Plastic Surgery, Fırat Universitesi Tıp Fakultesi, Elazığ, Turkey
| | - Ahmet Çetinbaş
- Alanya Hastanesi, Department of Plastic Surgery, Başkent Üniversitesi, Antalya, Turkey
| | - Serdar Altun
- Department of Plastic Surgery, Fırat Universitesi Tıp Fakultesi, Elazığ, Turkey
| | - Mehmet Öztan
- Department of Plastic Surgery, Private Clinic, Konya, Turkey
| | - Aysun Yıldız Altun
- Department of Anestesiology, Fırat Universitesi Tıp Fakultesi, Elazığ, Turkey
| | - İbrahim Özercan
- Department of Pathology, Fırat Universitesi Tıp Fakultesi, Elazığ, Turkey
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17
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Rossini R, Masiero G, Fruttero C, Passamonti E, Calvaruso E, Cecconi M, Carlucci C, Mojoli M, Guido P, Talanas G, Pierini S, Canova P, De Cesare N, Luceri S, Barzaghi N, Melloni G, Baralis G, Locatelli A, Musumeci G, Angiolillo DJ. Antiplatelet Therapy with Cangrelor in Patients Undergoing Surgery after Coronary Stent Implantation: A Real-World Bridging Protocol Experience. TH OPEN 2020; 4:e437-e445. [PMID: 33376943 PMCID: PMC7758156 DOI: 10.1055/s-0040-1721504] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 11/02/2020] [Indexed: 01/04/2023] Open
Abstract
Objective
The aim of the study is to describe the real-world use of the P2Y
12
inhibitor cangrelor as a bridging strategy in patients at high thrombotic risk after percutaneous coronary intervention (PCI) and referred to surgery requiring perioperative withdrawal of dual antiplatelet therapy (DAPT).
Materials and Methods
We collected data from nine Italian centers on patients with previous PCI who were still on DAPT and undergoing nondeferrable surgery requiring DAPT discontinuation. A perioperative standardized bridging protocol with cangrelor was used.
Results
Between December 2017 and April 2019, 24 patients (mean age 72 years; male 79%) were enrolled. All patients were at high thrombotic risk after PCI and required nondeferrable intermediate to high bleeding risk surgery requiring DAPT discontinuation (4.6 ± 1.7 days). Cangrelor infusion was started at a bridging dose (0.75 µg/kg/min) 3 days before planned surgery and was discontinued 6.6 ± 1.5 hours prior to surgical incision. In 55% of patients, cangrelor was resumed at 9 ± 6 hours following surgery for a mean of 39 ± 38 hours. One cardiac death was reported after 3 hours of cangrelor discontinuation prior to surgery. No ischemic outcomes occurred after surgery and up to 30-days follow-up. The mean hemoglobin drop was <2 g/dL; nine patients received blood transfusions consistent with the type of surgery, but no life-threatening or fatal bleeding occurred.
Conclusion
Perioperative bridging therapy with cangrelor is a feasible approach for stented patients at high thrombotic risk and referred to surgery requiring DAPT discontinuation. Larger studies are warranted to support the safety of this strategy.
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Affiliation(s)
| | | | | | - Enrico Passamonti
- Ospedale di Cremona, Struttura Complessa di Cardiologia, Cremona, Italy
| | - Elba Calvaruso
- Ospedale di Cremona, Struttura Complessa di Cardiologia, Cremona, Italy
| | | | | | - Marco Mojoli
- Ospedale Santa Maria degli Angeli, Pordenone, Pordenone, Italy
| | - Parodi Guido
- Azienda Ospedaliera Universitaria di Sassari, Struttura Complessa di Cardiologia Clinica ed Interventistica, Sassari, Italy
| | - Giuseppe Talanas
- Azienda Ospedaliera Universitaria di Sassari, Struttura Complessa di Cardiologia Clinica ed Interventistica, Sassari, Italy
| | - Simona Pierini
- P.O. BASSINI-ASST Nord Milano, U.O.C. Cardiologia, Milano, Italy
| | - Paolo Canova
- ASST Papa Giovanni XXIII, Unità di Cardiologia 2, Bergamo, Italy
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18
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Urban P, Mehran R, Colleran R, Angiolillo DJ, Byrne RA, Capodanno D, Cuisset T, Cutlip D, Eerdmans P, Eikelboom J, Farb A, Gibson CM, Gregson J, Haude M, James SK, Kim HS, Kimura T, Konishi A, Laschinger J, Leon MB, Magee PFA, Mitsutake Y, Mylotte D, Pocock S, Price MJ, Rao SV, Spitzer E, Stockbridge N, Valgimigli M, Varenne O, Windhoevel U, Yeh RW, Krucoff MW, Morice MC. Defining high bleeding risk in patients undergoing percutaneous coronary intervention: a consensus document from the Academic Research Consortium for High Bleeding Risk. Eur Heart J 2020; 40:2632-2653. [PMID: 31116395 PMCID: PMC6736433 DOI: 10.1093/eurheartj/ehz372] [Citation(s) in RCA: 309] [Impact Index Per Article: 77.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Identification and management of patients at high bleeding risk undergoing percutaneous
coronary intervention are of major importance, but a lack of standardization in defining
this population limits trial design, data interpretation, and clinical decision-making.
The Academic Research Consortium for High Bleeding Risk (ARC-HBR) is a collaboration among
leading research organizations, regulatory authorities, and physician-scientists from the
United States, Asia, and Europe focusing on percutaneous coronary intervention–related
bleeding. Two meetings of the 31-member consortium were held in Washington, DC, in April
2018 and in Paris, France, in October 2018. These meetings were organized by the
Cardiovascular European Research Center on behalf of the ARC-HBR group and included
representatives of the US Food and Drug Administration and the Japanese Pharmaceuticals
and Medical Devices Agency, as well as observers from the pharmaceutical and medical
device industries. A consensus definition of patients at high bleeding risk was developed
that was based on review of the available evidence. The definition is intended to provide
consistency in defining this population for clinical trials and to complement clinical
decision-making and regulatory review. The proposed ARC-HBR consensus document represents
the first pragmatic approach to a consistent definition of high bleeding risk in clinical
trials evaluating the safety and effectiveness of devices and drug regimens for patients
undergoing percutaneous coronary intervention.
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Affiliation(s)
- Philip Urban
- La Tour Hospital, Geneva, Switzerland.,Cardiovascular European Research Center, Massy, France
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Roisin Colleran
- Deutsches Herzzentrum München, Technische Universität München, Germany
| | | | - Robert A Byrne
- Deutsches Herzzentrum München, Technische Universität München, Germany
| | - Davide Capodanno
- Cardio-Thoracic-Vascular Department, Centro Alte Specialità e Trapianti, Catania, Italy.,Azienda Ospedaliero Universitario "Vittorio Emanuele-Policlinico," University of Catania, Italy
| | - Thomas Cuisset
- Département de Cardiologie, Centre Hospitalier Universitaire Timone and Inserm, Inra, Centre de recherche en cardiovasculaire et nutrition, Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Donald Cutlip
- Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - John Eikelboom
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Andrew Farb
- US Food and Drug Administration, Silver Spring, MD
| | - C Michael Gibson
- Harvard Medical School, Boston, MA.,Baim Institute for Clinical Research, Brookline, MA
| | - John Gregson
- London School of Hygiene and Tropical Medicine, UK
| | - Michael Haude
- Städtische Kliniken Neuss, Lukaskrankenhaus GmbH, Germany
| | - Stefan K James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Sweden
| | - Hyo-Soo Kim
- Cardiovascular Center, Seoul National University Hospital, Korea
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Japan
| | - Akihide Konishi
- Office of Medical Devices 1, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | | | - Martin B Leon
- Columbia University Medical Center, New York, NY.,Cardiovascular Research Foundation, New York, NY
| | | | - Yoshiaki Mitsutake
- Office of Medical Devices 1, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Darren Mylotte
- University Hospital and National University of Ireland, Galway
| | | | | | - Sunil V Rao
- Duke Clinical Research Institute, Durham, NC
| | - Ernest Spitzer
- Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands.,Cardialysis, Clinical Trial Management and Core Laboratories, Rotterdam, the Netherlands
| | | | - Marco Valgimigli
- Department of Cardiology, Inselspital, University of Bern, Switzerland
| | - Olivier Varenne
- Service de Cardiologie, Hôpital Cochin, Assistance publique - hôpitaux de Paris, Paris, France.,Université Paris Descartes, Sorbonne Paris-Cité, France
| | | | - Robert W Yeh
- Beth Israel Deaconess Medical Center, Boston, MA
| | - Mitchell W Krucoff
- Duke Clinical Research Institute, Durham, NC.,Duke University Medical Center, Durham, NC
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19
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Cao D, Chandiramani R, Capodanno D, Berger JS, Levin MA, Hawn MT, Angiolillo DJ, Mehran R. Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management. Nat Rev Cardiol 2020; 18:37-57. [PMID: 32759962 DOI: 10.1038/s41569-020-0410-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2020] [Indexed: 12/18/2022]
Abstract
Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, particularly in patients with coronary artery disease (CAD). Although preoperative cardiac risk assessment can facilitate the identification of vulnerable patients and implementation of adequate preventive measures, excessive evaluation might lead to undue resource utilization and surgical delay. Owing to conflicting data, there remains some uncertainty regarding the most beneficial perioperative strategy for patients with CAD. Antithrombotic agents are the cornerstone of secondary prevention of ischaemic events but substantially increase the risk of bleeding. Given that 5-25% of patients undergoing coronary stent implantation require non-cardiac surgery within 2 years, surgery is the most common reason for premature cessation of dual antiplatelet therapy. Perioperative management of antiplatelet therapy, which necessitates concomitant evaluation of the individual thrombotic and bleeding risks related to both clinical and procedural factors, poses a recurring dilemma in clinical practice. Current guidelines do not provide detailed recommendations on this topic, and the optimal approach in these patients is yet to be determined. This Review summarizes the current data guiding preoperative risk stratification as well as periprocedural management of patients with CAD undergoing non-cardiac surgery, including those treated with stents.
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Affiliation(s)
- Davide Cao
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rishi Chandiramani
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. "G. Rodolico", Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Jeffrey S Berger
- Center for the Prevention of Cardiovascular Disease, New York University Langone Health, New York, NY, USA
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary T Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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20
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Safety of aortic aneurysm repair 8 weeks after percutaneous coronary intervention for coronary artery disease: a cohort study. Updates Surg 2020; 72:1213-1221. [DOI: 10.1007/s13304-020-00729-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/14/2020] [Indexed: 01/04/2023]
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21
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PERK Inhibition Mitigates Restenosis and Thrombosis: A Potential Low-Thrombogenic Antirestenotic Paradigm. JACC Basic Transl Sci 2020; 5:245-263. [PMID: 32215348 PMCID: PMC7091514 DOI: 10.1016/j.jacbts.2019.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 12/13/2019] [Accepted: 12/13/2019] [Indexed: 12/18/2022]
Abstract
Drug-eluting stents impede neointimal smooth muscle cell hyperplasia but exacerbate endothelial cell dysfunction and thrombogenicity. It has been a challenge to identify a common target to inhibit both. Findings in this study suggest PERK as such a target. A PERK inhibitor administered either via an endovascular (in biomimetic nanocarriers) or perivascular (in hydrogel) route effectively mitigated neointimal hyperplasia in rats. Oral gavage of the PERK inhibitor partially preserved the normal blood flow in a mouse model of induced thrombosis. Dampening PERK activity inhibited STAT3 while activating SRF in smooth muscle cells, and also reduced prothrombogenic tissue factor and growth impairment of endothelial cells.
Developing endothelial-protective, nonthrombogenic antirestenotic treatments has been a challenge. A major hurdle to this has been the identification of a common molecular target in both smooth muscle cells and endothelial cells, inhibition of which blocks dysfunction of both cell types. The authors’ findings suggest that the PERK kinase could be such a target. Importantly, PERK inhibition mitigated both restenosis and thrombosis in preclinical models, implicating a low-thrombogenic antirestenotic paradigm.
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Key Words
- ATF, activating transcription factor
- Ad, adenovirus
- CHOP, CCAAT-enhancer-binding protein homologous protein
- DES, drug-eluting stents
- DMSO, dimethyl sulfoxide
- EC, endothelial cell
- ER, endoplasmic reticulum
- FBS, fetal bovine serum
- GFP, green fluorescent protein
- HA, hemagglutinin
- I/M, intima to media
- IEL, internal elastic lamina
- IH, intimal hyperplasia
- IRE1, inositol-requiring kinase 1
- MRTF-A, myocardin related transcription factor A
- PDGF, platelet-derived growth factor
- PDGF-BB, platelet-derived growth factor with 2 B subunits
- PERK
- PERK, protein kinase RNA-like endoplasmic reticulum kinase
- SMA, smooth muscle actin
- SMC, smooth muscle cell
- SRF, serum response factor
- STAT3, signal transducer and activator of transcription 3
- TNF, tumor necrosis factor
- eIF2, eukaryotic translation initiation factor 2
- endothelial cells
- restenosis
- siRNA, small interfering ribonucleic acid
- smooth muscle cells
- thrombosis
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22
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Doménech López P, Robles García JE, Gutiérrez Castañé C, Chiva San Román S, García Cortés A, Ancizu Marckert FJ, Tamariz Amador LE, Andrés Boville G, Villacampa Aubá F, de Fata Chillón FR, Diez-Caballero Alonso F, Torres Roca M, Rosell Costa D, Miñana López B, Pascual Piedrola JI, Páramo Fernández JA. Surgical thromboprophylaxis in daily urologic surgery: Beyond bridge therapy. Actas Urol Esp 2019; 43:455-466. [PMID: 31351747 DOI: 10.1016/j.acuro.2019.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 05/05/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION With the advanced laparoscopic and robotic surgery, thromboembolic prophylaxis in urologic procedures has traditionally been based on the experience of other surgical specialties. This paper aims to analyze the current recommendations, through a detailed study of the European clinical guidelines and bibliography, applying the recommendations of thromboprophylaxis to the daily urological practice. OBJECTIVES To elaborate general recommendations to surgical patients in Urology, avoiding the risk of perioperative thromboembolic events. Optimize medication in chronic patients and accurately classify who are eligible for bridge therapy. MATERIAL AND METHODS A review of the available literature and the European clinical guidelines was carried out. We analyzed the most recent consensus articles by studying the available bibliography, trials and reviews on which the European guidelines for thromboprophylaxis in urology are based. RESULTS Thromboembolic prophylaxis should be targeted towards surgeries that require abdominal approaches, prolonged bed rest or oncological pathologies. Bridge therapies with low molecular weight heparins should be limited. Patients undergoing treatment for chronic conditions can benefit from bridge therapies in specific cases. CONCLUSIONS According to the current guidelines, there might be an overuse of heparins in the daily clinical practice. The development of -direct oral- anticoagulants have shown to reduce the time to reintroduction of medication for chronic conditions as well as a more effective bleeding management.
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Affiliation(s)
- P Doménech López
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España.
| | - J E Robles García
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - C Gutiérrez Castañé
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - S Chiva San Román
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - A García Cortés
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - F J Ancizu Marckert
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - L E Tamariz Amador
- Departamento de Hematología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - G Andrés Boville
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - F Villacampa Aubá
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - F R de Fata Chillón
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | | | - M Torres Roca
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - D Rosell Costa
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - B Miñana López
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - J I Pascual Piedrola
- Departamento de Urología Clínica, Universidad de Navarra, Pamplona, Navarra, España
| | - J A Páramo Fernández
- Departamento de Hematología Clínica, Universidad de Navarra, Pamplona, Navarra, España
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23
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Sharma G, Hanipah ZN, Aminian A, Punchai S, Bucak E, Schauer PR, Brethauer SA. Bariatric Surgery in Patients on Chronic Anticoagulation Therapy. Obes Surg 2019; 28:2225-2232. [PMID: 29455405 DOI: 10.1007/s11695-018-3120-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Perioperative management of chronically anti-coagulated patients undergoing bariatric surgery requires a balance of managing hemorrhagic and thromboembolic risks. The aim of this study is to evaluate the incidence of hemorrhagic complications and their management in chronically anticoagulated (CAT) patients undergoing bariatric surgery. METHODS A retrospective review of CAT patients undergoing bariatric surgery at an academic center from 2008 to 2015 was studied. RESULTS A total of 153 patients on CAT underwent surgery [Roux-en-Y gastric bypass (n = 79), sleeve gastrectomy (n = 63), and adjustable gastric banding (n = 11)] during the study period: 85 patients (55%) were females; median age was 56 years (interquartile range [IQR] 49-64), and median BMI was 49 kg/m2 (IQR 43-56). The most common indications for CAT were venous thromboembolism (n = 87) and atrial fibrillation (n = 83). Median duration of procedure and estimated intraoperative blood loss was 150 min (IQR 118-177) and 50 ml (IQR 25-75), respectively. Thirty-day postoperative complications were reported in 33 patients (21.6%) including postoperative bleeding (n = 19), anastomotic leak (n = 3), and pulmonary embolism (n = 1). Nineteen patients (12%) with early postoperative bleeding were further categorized to intra-abdominal (n = 10), intraluminal (n = 6), and at the port site or abdominal wall (n = 3). All-cause readmissions within 30 days of surgery occurred in 19 patients (12%). There was no 30-day mortality. CONCLUSION In our experience, patients who require chronic anticoagulation medication are higher than average risk for postoperative complications and all-cause readmission rates. Careful surgical technique and close attention to postoperative anticoagulation protocols are essential to decrease perioperative risk in this high-risk cohort.
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Affiliation(s)
- Gautam Sharma
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Desk M61, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Zubaidah Nor Hanipah
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Desk M61, 9500 Euclid Ave, Cleveland, OH, 44195, USA.,Department of Surgery, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor, Malaysia
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Desk M61, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Suriya Punchai
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Desk M61, 9500 Euclid Ave, Cleveland, OH, 44195, USA.,Department of Surgery, Faculty of Medicine, KhonKaen University, KhonKaen, Thailand
| | - Emre Bucak
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Desk M61, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Philip R Schauer
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Desk M61, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Stacy A Brethauer
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Desk M61, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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24
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Urban P, Mehran R, Colleran R, Angiolillo DJ, Byrne RA, Capodanno D, Cuisset T, Cutlip D, Eerdmans P, Eikelboom J, Farb A, Gibson CM, Gregson J, Haude M, James SK, Kim HS, Kimura T, Konishi A, Laschinger J, Leon MB, Magee PFA, Mitsutake Y, Mylotte D, Pocock S, Price MJ, Rao SV, Spitzer E, Stockbridge N, Valgimigli M, Varenne O, Windhoevel U, Yeh RW, Krucoff MW, Morice MC. Defining High Bleeding Risk in Patients Undergoing Percutaneous Coronary Intervention. Circulation 2019; 140:240-261. [PMID: 31116032 PMCID: PMC6636810 DOI: 10.1161/circulationaha.119.040167] [Citation(s) in RCA: 413] [Impact Index Per Article: 82.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Supplemental Digital Content is available in the text. Identification and management of patients at high bleeding risk undergoing percutaneous coronary intervention are of major importance, but a lack of standardization in defining this population limits trial design, data interpretation, and clinical decision-making. The Academic Research Consortium for High Bleeding Risk (ARC-HBR) is a collaboration among leading research organizations, regulatory authorities, and physician-scientists from the United States, Asia, and Europe focusing on percutaneous coronary intervention–related bleeding. Two meetings of the 31-member consortium were held in Washington, DC, in April 2018 and in Paris, France, in October 2018. These meetings were organized by the Cardiovascular European Research Center on behalf of the ARC-HBR group and included representatives of the US Food and Drug Administration and the Japanese Pharmaceuticals and Medical Devices Agency, as well as observers from the pharmaceutical and medical device industries. A consensus definition of patients at high bleeding risk was developed that was based on review of the available evidence. The definition is intended to provide consistency in defining this population for clinical trials and to complement clinical decision-making and regulatory review. The proposed ARC-HBR consensus document represents the first pragmatic approach to a consistent definition of high bleeding risk in clinical trials evaluating the safety and effectiveness of devices and drug regimens for patients undergoing percutaneous coronary intervention.
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Affiliation(s)
- Philip Urban
- La Tour Hospital, Geneva, Switzerland (P.U.).,Cardiovascular European Research Center, Massy, France (P.U., U.W., M.-C.M.)
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY (R.M.)
| | - Roisin Colleran
- Deutsches Herzzentrum München, Technische Universität München, Germany (R.C., R.A.B.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
| | - Robert A Byrne
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (R.A.B.)
| | - Davide Capodanno
- Cardio-Thoracic-Vascular Department, Centro Alte Specialità e Trapianti (D. Capodanno), Catania, Italy.,Azienda Ospedaliero Universitario "Vittorio Emanuele-Policlinico," University of Catania, Italy (D. Capodanno)
| | - Thomas Cuisset
- Département de Cardiologie, Centre Hospitalier Universitaire Timone and Inserm, Inra, Centre de recherche en cardiovasculaire et nutrition, Faculté de Médecine, Aix-Marseille Université, Marseille, France (T.C.)
| | - Donald Cutlip
- Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D. Cutlip)
| | - Pedro Eerdmans
- Head of the Notified Body, DEKRA Certification B.V. (P.E.)
| | - John Eikelboom
- Department of Medicine, McMaster University, Hamilton, Canada (J.E.)
| | - Andrew Farb
- US Food and Drug Administration, Silver Spring, MD (A.F., J.L., P.F.A.M., N.S.)
| | - C Michael Gibson
- Baim Institute for Clinical Research, Brookline, MA (C.M.G.).,Harvard Medical School, Boston, MA (C.M.G.)
| | - John Gregson
- London School of Hygiene and Tropical Medicine, UK (J.G., S.P.)
| | - Michael Haude
- Städtische Kliniken Neuss, Lukaskrankenhaus GmbH, Germany (M.H.)
| | - Stefan K James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Sweden (S.K.J.)
| | - Hyo-Soo Kim
- Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.)
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Japan (T.K.)
| | - Akihide Konishi
- Office of Medical Devices 1, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan (A.K., Y.M.)
| | - John Laschinger
- US Food and Drug Administration, Silver Spring, MD (A.F., J.L., P.F.A.M., N.S.)
| | - Martin B Leon
- Columbia University Medical Center, New York, NY (M.B.L.).,Cardiovascular Research Foundation, New York, NY (M.B.L.)
| | - P F Adrian Magee
- US Food and Drug Administration, Silver Spring, MD (A.F., J.L., P.F.A.M., N.S.)
| | - Yoshiaki Mitsutake
- Office of Medical Devices 1, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan (A.K., Y.M.)
| | - Darren Mylotte
- University Hospital and National University of Ireland, Galway (D.M.)
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, UK (J.G., S.P.)
| | | | - Sunil V Rao
- Duke Clinical Research Institute, Durham, NC (S.V.R., M.W.K.)
| | - Ernest Spitzer
- Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands (E.S.).,Cardialysis, Clinical Trial Management and Core Laboratories, Rotterdam, the Netherlands (E.S.)
| | - Norman Stockbridge
- US Food and Drug Administration, Silver Spring, MD (A.F., J.L., P.F.A.M., N.S.)
| | - Marco Valgimigli
- Department of Cardiology, Inselspital, University of Bern, Switzerland (M.V.)
| | - Olivier Varenne
- Service de Cardiologie, Hôpital Cochin, Assistance publique - hôpitaux de Paris, Paris, France (O.V.).,Université Paris Descartes, Sorbonne Paris-Cité, France (O.V.)
| | - Ute Windhoevel
- Cardiovascular European Research Center, Massy, France (P.U., U.W., M.-C.M.)
| | - Robert W Yeh
- Beth Israel Deaconess Medical Center, Boston, MA (R.W.Y.)
| | - Mitchell W Krucoff
- Duke Clinical Research Institute, Durham, NC (S.V.R., M.W.K.).,Duke University Medical Center, Durham, NC (M.W.K.)
| | - Marie-Claude Morice
- Cardiovascular European Research Center, Massy, France (P.U., U.W., M.-C.M.)
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25
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Rossini R, Tarantini G, Musumeci G, Masiero G, Barbato E, Calabrò P, Capodanno D, Leonardi S, Lettino M, Limbruno U, Menozzi A, Marchese UOA, Saia F, Valgimigli M, Ageno W, Falanga A, Corcione A, Locatelli A, Montorsi M, Piazza D, Stella A, Bozzani A, Parolari A, Carone R, Angiolillo DJ. A Multidisciplinary Approach on the Perioperative Antithrombotic Management of Patients With Coronary Stents Undergoing Surgery: Surgery After Stenting 2. JACC Cardiovasc Interv 2019. [PMID: 29519377 DOI: 10.1016/j.jcin.2017.10.051] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Perioperative management of antithrombotic therapy in patients treated with coronary stents undergoing surgery remains poorly defined. Importantly, surgery represents a common reason for premature treatment discontinuation, which is associated with an increased risk in mortality and major adverse cardiac events. However, maintaining antithrombotic therapy to minimize the incidence of perioperative ischemic complications may increase the risk of bleeding complications. Although guidelines provide some recommendations with respect to the perioperative management of antithrombotic therapy, these have been largely developed according to the thrombotic risk of the patient and a definition of the hemorrhagic risk specific to each surgical procedure, key to defining the trade-off between ischemia and bleeding, is not provided. These observations underscore the need for a multidisciplinary collaboration among cardiologists, anesthesiologists, hematologists and surgeons to reach this goal. The present document is an update on practical recommendations for standardizing management of antithrombotic therapy management in patients treated with coronary stents (Surgery After Stenting 2) in various types of surgery according to the predicted individual risk of thrombotic complications against the anticipated risk of surgical bleeding complications. Cardiologists defined the thrombotic risk using a "combined ischemic risk" approach, while surgeons classified surgeries according to their inherent hemorrhagic risk. Finally, a multidisciplinary agreement on the most appropriate antithrombotic treatment regimen in the perioperative phase was reached for each surgical procedure.
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Affiliation(s)
- Roberta Rossini
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy.
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Giuseppe Musumeci
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Giulia Masiero
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Emanuele Barbato
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Paolo Calabrò
- Division of Cardiology, Department of Cardio-Thoracic Sciences, Università degli Studi della Campania "Luigi Vanvitelli," Naples, Italy
| | - Davide Capodanno
- Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele, Catania, Italy; Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Sergio Leonardi
- Coronary Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maddalena Lettino
- Cardiovascular Department, Humanitas Research Hospital, Rozzano, Italy
| | - Ugo Limbruno
- U.O.C. Cardiologia, Azienda USL Toscana Sudest, Grosseto, Italy
| | - Alberto Menozzi
- Unità Operativa di Cardiologia, Azienda Ospedaliero-Universitaria di Parma, Italy
| | - U O Alfredo Marchese
- U.O.C. Cardiologia Interventistica, Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Francesco Saia
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Marco Valgimigli
- Swiss Cardiovascular Centre Bern, Bern University Hospital, Bern, Switzerland
| | - Walter Ageno
- Degenza Breve Internistica e Centro Trombosi ed Emostasi, Dipartimento di Medicina e Chirurgia, Università dell'Insubria, Varese, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, Thrombosis and Hemostasis Center, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Antonio Corcione
- Department of Anaesthesia and Critical Care, AORN Dei Colli, Naples, Italy
| | - Alessandro Locatelli
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Marco Montorsi
- Dipartimento di Chirurgia Generale, Humanitas Research Hospital and University, Milano, Italy
| | - Diego Piazza
- Policlinico Vittorio Emanuele di Catania, Catania, Italy
| | - Andrea Stella
- Chirurgia Vascolare, Università di Bologna, Ospedale Sant'Orsola-Malpighi, Bologna, Italy
| | - Antonio Bozzani
- UOC Chirurgia Vascolare, Dipartimento di Scienze Chirurgiche, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Alessandro Parolari
- Dipartimento di Scienze Biomediche per la Salute, Policlinico San Donato IRCCS, University of Milano, Milan, Italy
| | - Roberto Carone
- Azienda Ospedaliera Universitaria Città della salute e della scienza, Torino, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida, College of Medicine-Jacksonville, Jacksonville, Florida
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26
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Vlachou M, Didagelos M, Kouparanis A, Karvounis H, Ziakas A. Bridging with Tirofiban During Temporary Withdrawal of Oral Antiplatelets for Two Major Surgical Procedures in High Ischaemic Risk Patients. Open Cardiovasc Med J 2019. [DOI: 10.2174/1874192401913010001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
Recent coronary stent implantation requires Dual Antiplatelet Therapy (DAPT) for at least 6 months. Serious issues are raised when non-cardiac surgery is required during this period, because of the balance between ischemic and haemorrhagic complications.
Case Reports:
We report 2 high ischemic risk cases requiring intermediate bleeding risk non-cardiac surgery, during the first month of DAPT initiation. Perioperative management with discontinuation of the P2Y12 inhibitor and bridging with tirofiban, while aspirin was uninterrupted, was uneventful.
Conclusion:
Bridging with intravenous glycoprotein IIb/IIIa receptor inhibitors may be a safe and effective alternative to P2Y12 inhibitor discontinuation in non-deferrable non-cardiac surgery.
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27
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Howell S, Hoeks S, West R, Wheatcroft S, Hoeft A, Leva B, Plichon B, Damster S, Momeni M, Watremez C, Kahn D, Dincq AS, Danila A, Wittmann M, Struck R, Rüddel T, Kessler F, Rasche S, Matsota P, Hasani A, Gudaityte J, Karbonskiene A, Ferreira R, Carvalho S, Tomescu D, Martac C, Grintescu I, Mirea L, Serrano L, Serrano L, Sierra P, Sabaté S, Hernando D, Matute P, Trashorras M, Suñé M, Sarmiento L, Hervias A, González O, Hermina A, González O, Hermina A, Navarro Perez R, Orts M, Fernandez-Garcia R, Sanchez Pérez D, Sepulveda Gil I, Monedero P, Hidalgo F, Mbongo C, Pont A, Reyes H, Bartolo C, Galera S, Valentijn T, Stolker R, Tugrul M, Emre Demirel E, Hough M, Griffiths K, Birch S, Beardow Z, Elliot S, Thompson J, Bowrey S, Northey M, Melson H, Telford R, Nadolski M, Potter A, Fuller D, Rose A, Varma S, Simeson K, Pettit J, Smith N, Martinson V, Sleight L, Naylor C, Watt P, Raymode P, Dunk N, Twohey L, Hollos L, Davies S, Gibson A, Coleman Z, Tamm T, Joscak J, Zsisku L, Zuleika M, Carvalho P, Collyer T, Ryan J, Colling K, Dharmarajah S, Krishnan A, Paddle J, Fouracres A, Arnell K, Muhammad K. Prospective observational cohort study of the association between antiplatelet therapy, bleeding and thrombosis in patients with coronary stents undergoing noncardiac surgery. Br J Anaesth 2019; 122:170-179. [DOI: 10.1016/j.bja.2018.09.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/16/2018] [Accepted: 09/24/2018] [Indexed: 01/19/2023] Open
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28
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Mahla E, Tantry US, Prüller F, Gurbel PA. Is There a Role for Preoperative Platelet Function Testing in Patients Undergoing Cardiac Surgery During Antiplatelet Therapy? Circulation 2018; 138:2145-2159. [DOI: 10.1161/circulationaha.118.035160] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Elisabeth Mahla
- Department of Anesthesiology and Intensive Care Medicine (E.M.), Medical University of Graz, Austria
| | - Udaya S. Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA (U.S.T., P.A.G.)
| | - Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics (F.P.), Medical University of Graz, Austria
| | - Paul A. Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA (U.S.T., P.A.G.)
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Okere AN, Ezendu K, Berthe A, Diaby V. An Evaluation of the Cost-effectiveness of Comprehensive MTM Integrated with Point-of-Care Phenotypic and Genetic Testing for U.S. Elderly Patients After Percutaneous Coronary Intervention. J Manag Care Spec Pharm 2018; 24:142-152. [PMID: 29384027 PMCID: PMC10397765 DOI: 10.18553/jmcp.2018.24.2.142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Poor health outcomes after percutaneous coronary intervention (PCI) in elderly patients is an area of concern among policymakers and administrators. In an effort to determine the best strategy to improve outcomes among elderly patients who underwent PCI, several studies have evaluated the cost-effectiveness of genotype-guided antiplatelet therapy compared with universal use of any one of the antiplatelet drugs indicated for patients with acute coronary syndrome (ACS) who underwent PCI. The results have either been in favor of genotype-guided antiplatelet therapy or universal use of ticagrelor. However, no study has yet evaluated the cost-effectiveness of pharmacist-provided face-to-face medication therapy management (MTM) combined with point-of-care genotype-guided antiplatelet therapy (POCP) when compared with universal use of ticagrelor or clopidogrel for the elderly after PCI. OBJECTIVE To evaluate the cost-effectiveness of a pharmacist integration of MTM with POCP (MTM-POCP) when compared with universal use of ticagrelor or clopidogrel combined with MTM (MTM-ticagrelor or MTM-clopidogrel). METHODS We conducted a cost-effectiveness analysis from the perspective of the U.S. health care system. A hybrid model, consisting of a 1-year decision tree and a 20-year Markov model, was used to simulate a cohort of elderly patients (aged at least 65 years) with ACS who underwent PCI. Treatment strategies available to patients were POCP, POCP-MTM, MTM-clopidogrel, or MTM-ticagrelor. Data used to populate the model were obtained from the PLATO trial and other published studies. Outcome measures were costs, quality-adjusted life-years (QALYs) and incremental cost per QALY gained. A deterministic and probabilistic sensitivity analysis was conducted to account for the joint uncertainty around the key parameters of the model. Finally, a benchmark willingness to pay of $50,000-200,000 was considered. RESULTS The use of PCOP (with dual antiplatelet therapy) resulted in 5.29 QALYs, at a cost of $50,207. MTM-clopidogrel resulted in 5.34 QALYs, at a cost of $50,011. The use of POCP-MTM resulted in 5.36 QALYs, at a cost of $50,270. Finally, MTM-ticagrelor resulted in 5.42 QALYs, at a cost of $53,346. MTM-ticagrelor was found to be cost-effective compared with MTM-clopidogrel or MTM-POCP, irrespective of the willingness to pay. The deterministic and probabilistic sensitivity analyses confirmed the robustness of the base-case analysis. CONCLUSIONS The combination of MTM-ticagrelor was cost-effective when compared with MTM-POCP or MTM-clopidogrel. The transitional probabilities, however, were mostly based on published studies. Analysis based on a prospective randomized clinical study, comparing all the treatment strategies included in this study, is warranted to confirm our findings. DISCLOSURES No outside funding supported this study. The authors have no conflicts of interest to declare. Study concept and design were contributed by Okere and Diaby. Ezendu took the lead in data collection, along with Okere. Data interpretation was performed by all the authors. The manuscript was written by Okere, Diaby, and Berthe and revised by Okere and Diaby.
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Affiliation(s)
| | - Kyrian Ezendu
- 1 College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee
| | - Abdrahmane Berthe
- 2 Consortium in Management, Evaluation and Decision Aid, Longueuil (Québec), Canada
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Calnan MW, Crawford AN. A Case Report of Cangrelor Bridge Therapy for a Diagnostic Bronchoscopy With Biopsy. J Pharm Pract 2018; 33:231-235. [PMID: 30139291 DOI: 10.1177/0897190018795343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Although premature discontinuation of dual antiplatelet therapy (DAPT) is associated with an increased risk of ischemic complications, patients may present with an urgent need for surgery that would require interruption of DAPT. Antiplatelet bridge therapy using cangrelor, an intravenous P2Y12 inhibitor, has been studied as a potential option to ensure continuation of DAPT perioperatively. However, limited evidence exists supporting the off-label use of cangrelor bridge therapy to noncardiac procedures. We describe the case of a 67-year-old class 3 obese female on DAPT (aspirin and ticagrelor) for recent drug-eluting stent placement who required a bronchoscopy with biopsy for suspected lung cancer. Cangrelor bridge therapy was utilized both preoperatively and postoperatively without ischemic or bleeding complications, and the patient was subsequently able to begin radiation therapy after a confirmed diagnosis of lung cancer.
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Affiliation(s)
- Matthew W Calnan
- Department of Pharmacy, Bon Secours Memorial Regional Medical Center, Mechanicsville, VA, USA
| | - Alexis N Crawford
- Department of Pharmacy, Bon Secours Memorial Regional Medical Center, Mechanicsville, VA, USA
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Manejo perioperatorio y periprocedimiento del tratamiento antitrombótico: documento de consenso de SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT y AEU. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2018.01.001] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Vivas D, Roldán I, Ferrandis R, Marín F, Roldán V, Tello-Montoliu A, Ruiz-Nodar JM, Gómez-Doblas JJ, Martín A, Llau JV, Ramos-Gallo MJ, Muñoz R, Arcelus JI, Leyva F, Alberca F, Oliva R, Gómez AM, Montero C, Arikan F, Ley L, Santos-Bueso E, Figuero E, Bujaldón A, Urbano J, Otero R, Hermida JF, Egocheaga I, Llisterri JL, Lobos JM, Serrano A, Madridano O, Ferreiro JL. Perioperative and Periprocedural Management of Antithrombotic Therapy: Consensus Document of SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT and AEU. ACTA ACUST UNITED AC 2018; 71:553-564. [PMID: 29887180 DOI: 10.1016/j.rec.2018.01.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 01/05/2018] [Indexed: 01/17/2023]
Abstract
During the last few years, the number of patients receiving anticoagulant and antiplatelet therapy has increased worldwide. Since this is a chronic treatment, patients receiving it can be expected to need some kind of surgery or intervention during their lifetime that may require treatment discontinuation. The decision to withdraw antithrombotic therapy depends on the patient's thrombotic risk versus hemorrhagic risk. Assessment of both factors will show the precise management of anticoagulant and antiplatelet therapy in these scenarios. The aim of this consensus document, coordinated by the Cardiovascular Thrombosis Working Group of the Spanish Society of Cardiology, and endorsed by most of the Spanish scientific societies of clinical specialities that may play a role in the patient-health care process during the perioperative or periprocedural period, is to recommend some simple and practical guidelines with a view to homogenizing daily clinical practice.
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Affiliation(s)
- David Vivas
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain; Unidad de Cardiología, Clínica MD Anderson, Madrid, Spain.
| | - Inmaculada Roldán
- Servicio de Cardiología, Hospital Universitario La Paz, CIBER-CV, Madrid, Spain
| | - Raquel Ferrandis
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Universitat de València, Valencia, Spain
| | - Francisco Marín
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, CIBER-CV, Murcia, Spain
| | - Vanessa Roldán
- Servicio de Hematología, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - Antonio Tello-Montoliu
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, CIBER-CV, Murcia, Spain
| | - Juan Miguel Ruiz-Nodar
- Servicio de Cardiología, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante ISABIAL, CIBER-CV, Alicante, Spain
| | - Juan José Gómez-Doblas
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Victoria, CIBER-CV, Málaga, Spain
| | - Alfonso Martín
- Servicio de Urgencias, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - Juan Vicente Llau
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínic Universitari, València, Universitat de València, Valencia, Spain
| | | | - Rafael Muñoz
- Servicio de Cirugía Cardiaca, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Juan Ignacio Arcelus
- Servicio de Cirugía General y Digestiva, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Francisco Leyva
- Servicio de Cirugía Plástica, Estética y Reparadora, Hospital Clínico San Carlos, Madrid, Spain
| | - Fernando Alberca
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Raquel Oliva
- Servicio de Ginecología y Obstetricia, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Ana María Gómez
- Servicio de Cirugía Torácica, Hospital Clínico San Carlos, Madrid, Spain
| | - Carmen Montero
- Servicio de Neumología, Hospital Universitario A Coruña, A Coruña, Spain
| | - Fuat Arikan
- Servicio de Neurocirugía, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Luis Ley
- Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Elena Figuero
- Departamento de Especialidades Clínicas Odontológicas (DECO), Facultad de Odontología, Universidad Complutense de Madrid UCM, Madrid, Spain
| | - Antonio Bujaldón
- Facultad de Odontología, Universidad Complutense de Madrid UCM, Madrid, Spain
| | - José Urbano
- Servicio de Radiología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Rafael Otero
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Clínico San Carlos, Madrid, Spain
| | | | | | - José Luis Llisterri
- Medicina de Familia, Centro de Salud Ingeniero Joaquín Benlloch, Valencia, Spain
| | | | - Ainhoa Serrano
- Servicio de Medicina Intensiva, Hospital Clínico Universitario, Valencia, Spain
| | - Olga Madridano
- Servicio de Medicina Interna, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - José Luis Ferreiro
- Área de Enfermedades del Corazón, Hospital Universitario de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
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Hajizadeh R, Ghaffari S, Ziaee M, Shokouhi B, Separham A, Sarbakhsh P. In vitro inhibition of platelets aggregation with generic form of clopidogrel versus branded in patients with stable angina pectoris. J Cardiovasc Thorac Res 2018; 9:191-195. [PMID: 29391931 PMCID: PMC5787330 DOI: 10.15171/jcvtr.2017.33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 09/18/2017] [Indexed: 12/22/2022] Open
Abstract
Introduction: Clopidogrel is a potent platelet activation and aggregation inhibitor that prevents thrombosis in coronary artery diseases (CADs). In comparison to locally produced generic one (Osvix®), original brand of clopidogrel (Plavix®) is expensive. This study was designed to evaluate the effectiveness and uniformity of Osvix® versus Plavix® in patients with percutaneous coronary intervention (PCI) by means of platelet aggregation indexes.
Methods: This randomized, double blind clinical study was conducted at Shahid Madani heart hospital, Tabriz, Iran, and 129 patients with previous PCI were enrolled in two independent treatment groups. All patients participated in this study were on dual antiplatelet therapy at least for 30 days. ASA 80 mg/d and clopidogrel 75 mg/d and a stat dose of 300 mg of clopidogrel before PCI were administered for all patients. To evaluate the anti-platelet activity, blood samples were taken from the patients and platelet aggregation test was performed.
Results: The total study population represents a group of 129 patients (99 men and 30 women) with mean age of 57.7 ± 9.7 years with stable angina pectoris. The baseline characteristics and laboratory findings of two groups (except mean platelet volume [MPV]) were not different statistically. The mean platelets aggregation at 30th day was 13.7±7.0 in Plavix® group and 14.8±5.8 in Osvix® group (P value = 0.35).
Conclusion: This study showed that Osvix® as a generic form of clopidogrel was not significantly different from the original brand (Plavix) in terms of in vitro platelet inhibition.
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Affiliation(s)
- Rza Hajizadeh
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samad Ghaffari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mojtaba Ziaee
- Medicinal Plant Research Center, Institute of Medicinal Plants, ACECR, Karaj, Iran
| | - Behrooz Shokouhi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ahmad Separham
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Parvin Sarbakhsh
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Nicht-Vitamin-K-abhängige orale Antikoagulanzien und Plättchenhemmer in der Herzchirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2017. [DOI: 10.1007/s00398-017-0186-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Musumeci G, Lettieri C, Limbruno U, Senni M, Guagliumi G, Valsecchi O, Angiolillo D, Rossini R, Capodanno D. Impact of bridging with perioperative low-molecular-weight heparin on cardiac and bleeding outcomes of stented patients undergoing non-cardiac surgery. Thromb Haemost 2017; 114:423-31. [DOI: 10.1160/th14-12-1057] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 03/04/2015] [Indexed: 11/05/2022]
Abstract
SummaryWhen patients with coronary stents undergo non-cardiac surgery, bridging therapy with low-molecular-weight heparin (LMWH) is not infrequent in clinical practice. However, the efficacy and safety of this approach is poorly understood. This was a retrospective analysis of patients with coronary stent(s) on any antiplatelet therapy undergoing non-cardiac surgery between March 2003 and February 2012. The primary efficacy endpoint was the 30-day incidence of major adverse cardiac or cerebrovascular events (MACCE), defined as the composite of cardiac death, myocardial infarction, acute coronary syndrome leading to hospitalisation, or stroke. The primary safety endpoint was the 30-day composite of Bleeding Academic Research Consortium (BARC) bleedings ≥ 2. Among 515 patients qualifying for the analysis, LMWH bridging was used in 251 (49 %). At 30 days, MACCE occurred more frequently in patients who received LMWH (7.2 % vs 1.1 %, p=0.001), driven by a higher rate of myocardial infarction (4.8 % vs 0 %, p< 0.001). This finding was consistent across several instances of statistical adjustment and after the propensity matching of 179 pairs. Patients bridged with LMWH also experienced a significantly higher risk of BARC bleedings ≥ 2 (21.9 % vs 11.7 %, p=0.002) compared to those who were not, which remained significant across different methods of statistical adjustment and propensity matching. In conclusion, LMWH bridging in patients with coronary stents undergoing surgery is a common and possibly harmful practice, resulting in worse ischaemic outcomes at 30 days, and a significant risk of bleeding.
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Tzimas P, Tsoumani M, Giannakis D, Kalantzi K, Petrou A, Chantzichristos V, Sofikitis N, Papadopoulos G, Milionis H, Tselepis A. Clopidogrel Therapy in Patients with Cardiovascular Disease Undergoing Transurethral Resection of the Prostate: A Step Towards Individualization. Drugs Aging 2017; 34:917-923. [PMID: 29177885 DOI: 10.1007/s40266-017-0504-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study was to test platelet function pre- and peri-operatively in clopidogrel-treated patients undergoing transurethral resection of the prostate. METHODS This was a pilot study involving 20 male patients treated with clopidogrel (75 mg/day) for the secondary prevention of cardiovascular disease and scheduled for elective transurethral resection of the prostate. Platelet function testing with light transmittance aggregometry in platelet-rich plasma of four samples (T0, T1, T2, and T3 drawn on the same day, 3 and 7 days of clopidogrel cessation and 24-h post-operatively, respectively) was performed and evaluated in each patient. P-selectin membrane expression was evaluated using monoclonal antibodies. RESULTS The platelet response to adenosine diphosphate 5 µΜ and 20 µΜ at T0 were 42 ± 15 and 60 ± 14%, respectively. After discontinuation of clopidogrel, corresponding maximum aggregation values at T1 were 60 ± 16 and 74 ± 14%, and increased to 69 ± 16 and 79 ± 18% at T2. No significant difference in platelet aggregation values were noted between T1 and T2, while similar aggregation values were recorded at T3. CONCLUSIONS Our findings indicate that in patients undergoing transurethral resection of the prostate, platelet activation is similar 3 and 7 days from clopidogrel cessation. These results may be of relevance in subjects at increased thrombotic risk prior to a surgical procedure carrying a high-bleeding risk.
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Affiliation(s)
- Petros Tzimas
- Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, University Campus, 45110, Ioannina, Greece.
| | - Maria Tsoumani
- Department of Chemistry, Laboratory of Biochemistry, Atherothrombosis Research Centre, University of Ioannina, Ioannina, Greece
| | - Dimitrios Giannakis
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Kallirroi Kalantzi
- Department of Chemistry, Laboratory of Biochemistry, Atherothrombosis Research Centre, University of Ioannina, Ioannina, Greece
| | - Anastasios Petrou
- Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, University Campus, 45110, Ioannina, Greece
| | - Vasileios Chantzichristos
- Department of Chemistry, Laboratory of Biochemistry, Atherothrombosis Research Centre, University of Ioannina, Ioannina, Greece
| | - Nikolaos Sofikitis
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Georgios Papadopoulos
- Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, University Campus, 45110, Ioannina, Greece
| | - Haralampos Milionis
- Department of Chemistry, Laboratory of Biochemistry, Atherothrombosis Research Centre, University of Ioannina, Ioannina, Greece
| | - Alexandros Tselepis
- Department of Chemistry, Laboratory of Biochemistry, Atherothrombosis Research Centre, University of Ioannina, Ioannina, Greece
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Angiolillo DJ, Rollini F, Storey RF, Bhatt DL, James S, Schneider DJ, Sibbing D, So DY, Trenk D, Alexopoulos D, Gurbel PA, Hochholzer W, De Luca L, Bonello L, Aradi D, Cuisset T, Tantry US, Wang TY, Valgimigli M, Waksman R, Mehran R, Montalescot G, Franchi F, Price MJ. International Expert Consensus on Switching Platelet P2Y
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Receptor–Inhibiting Therapies. Circulation 2017; 136:1955-1975. [DOI: 10.1161/circulationaha.117.031164] [Citation(s) in RCA: 231] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A., F.R., F.F.)
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A., F.R., F.F.)
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, United Kingdom (R.F.S.)
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
| | - Stefan James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Sweden (S.J.)
| | - David J. Schneider
- Department of Medicine, Cardiology Unit, Cardiovascular Research Institute, University of Vermont, Burlington (D.J.S.)
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, Germany (D.S.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany (D.S.)
| | - Derek Y.F. So
- Division of Cardiology, University of Ottawa Heart Institute, Ontario, Canada (D.Y.S.F.)
| | - Dietmar Trenk
- Department of Cardiology & Angiology II, University Heart Center Freiburg-Bad Krozingen, Germany (D.T., W.H.)
| | - Dimitrios Alexopoulos
- Second Department of Cardiology, National and Capodistrian University of Athens, Attikon University Hospital, Greece (D. Alexopoulos)
| | - Paul A. Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA (P.A.G., U.S.T.)
| | - Willibald Hochholzer
- Department of Cardiology & Angiology II, University Heart Center Freiburg-Bad Krozingen, Germany (D.T., W.H.)
| | - Leonardo De Luca
- Division of Cardiology, Laboratory of Interventional Cardiology, San Giovanni Evangelista Hospital, Tivoli-Rome, Italy (L.D.L.)
- Mediterranean Academic Association for Research and Studies in Cardiology, Marseille, France (L.D.L.)
- Aix-Marseille University, INSERM UMRS 1076, Marseille, France (L.D.L.)
| | - Laurent Bonello
- Assistance Publique-Hôpitaux de Marseille, Department of Cardiology, Hôpital Nord, Marseille, France (L.B.)
| | - Daniel Aradi
- Heart Center Balatonfüred and Semmelweis University Budapest, Hungary (D. Aradi)
| | - Thomas Cuisset
- Department of Cardiology, CHU Timone, and Aix-Marseille Université, Faculté de Médecine, Marseille, France (T.C.)
| | - Udaya S. Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA (P.A.G., U.S.T.)
| | - Tracy Y. Wang
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (T.Y.W.)
| | - Marco Valgimigli
- Swiss Cardiovascular Center Bern, Bern University Hospital, Switzerland (M.V.)
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (R.W.)
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York City, NY (R.M.)
| | - Gilles Montalescot
- Sorbonne Université Paris 6, ACTION Study Group, Hôpital Pitié-Salpêtrière, France (G.M.)
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A., F.R., F.F.)
| | - Matthew J. Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA (M.J.P.)
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Clinical outcomes after craniotomy for unruptured intracranial aneurysm in patients with coronary artery disease. J Clin Neurosci 2017; 46:113-117. [PMID: 28887082 DOI: 10.1016/j.jocn.2017.08.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/14/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) patients receiving antiplatelet agents occasionally undergo craniotomy. We aimed to clarify clinical outcomes after craniotomy for unruptured intracranial aneurysm (UIA) in patients with CAD. We also aimed to identify the possible predictive factors for morbidity and surgical complications in patients on antiplatelet treatment. METHODS We retrospectively analyzed 401 consecutive patients who had undergone craniotomy for UIA at our institution between January 2006 and December 2016. Forty-three patients (10.7%) received antiplatelet agents during the perioperative period. The underlying reasons for antiplatelet treatment were CAD in 12 patients and other diseases in 31 patients. RESULTS Severe morbidity and intracranial hemorrhage occurred more commonly and symptomatic brain infarction occurred less frequently in patients with CAD compared to patients with other underlying diseases (16.7% versus 3.2%, 16.7% versus 9.7%, and 8.3% versus 16.1%, respectively), though differences between the two groups were not significant. Univariate analysis revealed that a low preoperative baseline platelet count was significantly correlated with the occurrence of intracranial hemorrhage (cutoff value, 16.5×104/µL; odds ratio (OR), 46.67; 95% confidence interval (CI), 3.88-561.95; p=0.0005), and a high baseline platelet count tended to correlate with severe morbidity (cutoff value, 29.8×104/µL; OR, 11.33; 95% CI, 0.88-145.52; p=0.0550). CONCLUSIONS Our results suggest that surgical complications and clinical outcomes after craniotomy may depend on the underlying reason for antiplatelet treatment. Moreover, a preoperative platelet count can be useful in predicting the occurrence of intracranial hemorrhage and severe morbidity after craniotomy in patients receiving antiplatelet agents.
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Youness HA, Keddissi J, Berim I, Awab A. Management of oral antiplatelet agents and anticoagulation therapy before bronchoscopy. J Thorac Dis 2017; 9:S1022-S1033. [PMID: 29214062 DOI: 10.21037/jtd.2017.05.45] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although, bronchoscopy is a relatively safe procedure, small amount of bleeding in the airway can have serious consequences. Careful consideration of the risks of diagnostic and therapeutic bronchoscopic intervention can help minimize potential complications. With increasing number of patients using antiplatelet and anticoagulation therapies, strategies for minimizing thromboembolic and operative bleeding events need to be included in the risk and benefit analyses. Growing evidence suggests that aspirin is safe and does not increase bleeding during bronchoscopy. In addition, despite small studies reporting that it may be safe to perform bronchoscopic procedures that have low risk for bleeding such as endobronchial ultrasound with transbronchial needle aspiration on clopidogrel, it is still recommended to hold it for 7 days prior to performing elective bronchoscopy. It is recommended to hold vitamin K antagonist, as well as new oral anticoagulation agents prior to bronchoscopy. The timing for pre-procedural discontinuation of anticoagulation therapy and the decision to bridge depend on the agent used, the renal function and the thromboembolic risk. In this review article, we will discuss available data regarding management of anticoagulation and antiplatelet therapy as it applies to bronchoscopic procedures.
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Affiliation(s)
- Houssein A Youness
- Department of Medicine, Section of Pulmonary Diseases, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center, OK, USA
| | - Jean Keddissi
- Department of Medicine, Section of Pulmonary Diseases, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center, OK, USA
| | - Ilya Berim
- Department of Medicine, Section of Pulmonary Diseases, Critical Care and Sleep Medicine, Creighton University, NE, USA
| | - Ahmed Awab
- Department of Medicine, Section of Pulmonary Diseases, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center, OK, USA
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Rich K, Treat-Jacobson D, DeVeaux T, Fitzgerald K, Kirk L, Thomson L, Foley A, Hill D. Society for Vascular Nursing-Carotid endarterectomy (CEA) updated nursing clinical practice guideline. JOURNAL OF VASCULAR NURSING 2017; 35:90-111. [PMID: 28527733 DOI: 10.1016/j.jvn.2017.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 03/24/2017] [Indexed: 01/22/2023]
Affiliation(s)
| | | | | | | | - Laura Kirk
- University of Minnesota School of Nursing, Minneapolis, Minnesota
| | - Lily Thomson
- Section of Vascular Surgery, Health Sciences Centre, Vascular Research Lab, Winnipeg, Manitoba, Canada
| | - Anne Foley
- Department of Vascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Debbie Hill
- Vascular Health Partners, Community Care Physicians, Albany, New York
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Banerjee S, Angiolillo DJ, Boden WE, Murphy JG, Khalili H, Hasan AA, Harrington RA, Rao SV. Use of Antiplatelet Therapy/DAPT for Post-PCI Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol 2017; 69:1861-1870. [DOI: 10.1016/j.jacc.2017.02.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 01/21/2017] [Accepted: 02/03/2017] [Indexed: 01/19/2023]
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Emoto N, Fujikawa T, Yoshimoto Y, Kawamoto H, Tanaka A. Is breast cancer surgery safely performed in patients receiving antithrombotic therapy? Innov Surg Sci 2017; 2:15-21. [PMID: 31579729 PMCID: PMC6754011 DOI: 10.1515/iss-2017-0001] [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: 12/30/2016] [Accepted: 01/23/2017] [Indexed: 11/15/2022] Open
Abstract
Aim The aim of the study was to assess the safety of surgery for breast cancer in patients with antithrombotic therapy (ATT), including antiplatelet therapy (APT) and anticoagulation therapy (ACT) for thromboembolic risks. Methods One hundred ninety-three consecutive patients receiving breast surgery for breast cancer at our institution between 2010 and 2015 were retrospectively reviewed. Among them, ATT was regularly used in 50 patients (25.9%). Our perioperative management included maintenance of preoperative aspirin monotherapy for APT and bridging heparin for ACT in patients at high thromboembolic risks and early postoperative reinstitution in all ATT cases. The outcome variables of patients with ATT (ATT group) were compared to those of patients without ATT (non-ATT group), and the significant risk factors for postoperative complications were determined by multivariate analysis. Results This series included 127 mastectomy and 66 breast-conserving surgery. ATT group showed significantly high frequency of history of cerebral infarction and percutaneous coronary intervention (PCI). In the ATT group, 32 patients (16.6%) were categorized as high risk for thromboembolism, but there was neither thromboembolic event nor perioperative death in the whole cohort. Surgical blood loss and rates of intraoperative transfusion were identical between the groups. Whereas overall postoperative bleeding complication was more frequently observed in the ATT group compared to the non-ATT group (12.0% vs. 3.5%, p=0.360) in univariate analyses, multivariate analysis showed that neither ATT nor preoperative aspirin continuation affected postoperative bleeding complications. Conclusion Even in patients undergoing ATT, surgery for breast cancer is safely performed without any increase in blood loss or postoperative bleeding, and no thromboembolism was experienced in the series. Our perioperative management of ATT patients is valid during breast surgery, although this patient population is still challenging and should be rigorously managed.
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Affiliation(s)
- Norio Emoto
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Takahisa Fujikawa
- Department of Surgery, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakita-ku, Kitakyushu, Fukuoka 802-8555, Japan
| | - Yasunori Yoshimoto
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Hiroshi Kawamoto
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Akira Tanaka
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
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Teng R, Carlson GF, Nylander S, Andersson TLG. Effects of autologous platelet transfusion on platelet inhibition in ticagrelor-treated and clopidogrel-treated subjects. J Thromb Haemost 2016; 14:2342-2352. [PMID: 27653814 DOI: 10.1111/jth.13511] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 08/30/2016] [Indexed: 01/19/2023]
Abstract
Essentials Limited data on hemostatic benefits of platelet transfusion (PT) exist. 44 healthy subjects had a single dose of ticagrelor or clopidogrel ± autologous PT post-dosing. PT did not reverse ticagrelor's antiplatelet effects and had minimal impact post clopidogrel. Post-ticagrelor, PT is unlikely to be beneficial, and the benefits post-clopidogrel are unknown. SUMMARY Background Antiplatelet agents increase bleeding risk. Few data on hemostatic benefits of platelet transfusion exist. Objective To assess the effect of autologous platelet transfusion on ticagrelor-mediated and clopidogrel-mediated platelet inhibition in a single-center, open-label, randomized, cross-over study (NCT01744288). Methods Forty-four healthy subjects received ticagrelor (180 mg) or clopidogrel (600 mg; two functional CYP2C19 alleles [*1 or *17] required) with or without platelet transfusion (14-day washout). Subjects received one autologous platelet apheresis unit (approximately six pooled donor platelet units) 24 h (n = 15) or 48 h (n = 13) after ticagrelor or 48 h after clopidogrel (n = 16). Platelet apheresis was conducted 72 h before transfusion. Aspirin (81 mg per day) was taken from after apheresis until 24 h before transfusion. P2Y12 reaction units (PRUs) and inhibition of platelet aggregation (IPA) induced by ADP were measured. Results Mean age and body mass index were 30 years (standard deviation [SD] 6 years) and 26.9 kg m-2 (SD 4.0 kg m-2 ), respectively; 98% of subjects were men, and 39 of 44 completed treatment. Platelet transfusion 24 h after ticagrelor had minimal effects on IPA or PRU values within 48 h after transfusion. Platelet transfusion 48 h after ticagrelor also had minimal effects on IPA or PRU values at most post-transfusion times. Platelet transfusion 48 h after clopidogrel, versus no transfusion, had a small reversing effect on IPA (24 h, 36 h, and 48 h) and PRU values (12 h, 24 h, and 36 h) after transfusion. Conclusions Autologous platelet transfusion is unlikely to be of clinical benefit in reversing the antiplatelet effects of ticagrelor. The clinical relevance of the small effects seen with clopidogrel is unknown.
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Affiliation(s)
- R Teng
- AstraZeneca LP, Gaithersburg, MD, USA
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Capodanno D, Angiolillo DJ. Pretreatment with Antiplatelet Agents in the Setting of Percutaneous Coronary Intervention: When and Which Drugs? Interv Cardiol Clin 2016; 6:13-24. [PMID: 27886816 DOI: 10.1016/j.iccl.2016.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Administering antiplatelet agents before coronary angiography to patients referred to elective or urgent percutaneous coronary intervention (PCI) requires a careful evaluation of advantages and disadvantages associated with platelet inhibition to avoid overtreatment on one side and undertreatment on the other. The delicate balance between ischemic protection and bleeding demands the ability to undertake risk stratification and individualized decisions, which is particularly challenging in the setting of ad hoc PCI and urgent procedures. This review analyzes the current evidence on pretreatment with oral and intravenous P2Y12 inhibitors in patients undergoing coronary angiography with intent to undergo PCI.
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Affiliation(s)
- Davide Capodanno
- Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Via Citelli, 6, Catania 95124, Italy.
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
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Gurajala I, Gopinath R. Perioperative management of patient with intracoronary stent presenting for noncardiac surgery. Ann Card Anaesth 2016; 19:122-31. [PMID: 26750683 PMCID: PMC4900389 DOI: 10.4103/0971-9784.173028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
As the number of percutaneous coronary interventions increase annually, patients with intracoronary stents (ICS) who present for noncardiac surgery (NCS) are also on the rise. ICS is associated with stent thrombosis (STH) and requires mandatory antiplatelet therapy to prevent major adverse cardiac events. The risks of bleeding and ischemia remain significant and the management of these patients, especially in the initial year of ICS is challenging. The American College of Cardiologists guidelines on the management of patients with ICS recommend dual antiplatelet therapy (DAT) for minimal 14 days after balloon angioplasty, 30 days for bare metal stents, and 365 days for drug-eluting stents. Postponement of elective surgery is advocated during this period, but guidelines concerning emergency NCS are ambiguous. The risk of STH and surgical bleeding needs to be assessed carefully and many factors which are implicated in STH, apart from the type of stent and the duration of DAT, need to be considered when decision to discontinue DAT is made. DAT management should be a multidisciplinary exercise and bridging therapy with shorter acting intravenous antiplatelet drugs should be contemplated whenever possible. Well conducted clinical trials are needed to establish guidelines as regards to the appropriate tests for platelet function monitoring in patients undergoing NCS while on DAT.
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Affiliation(s)
- Indira Gurajala
- Department of Anaesthesiology and Critical Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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Keeling D, Tait RC, Watson H. Peri-operative management of anticoagulation and antiplatelet therapy. Br J Haematol 2016; 175:602-613. [DOI: 10.1111/bjh.14344] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 07/26/2016] [Accepted: 07/31/2016] [Indexed: 12/14/2022]
Affiliation(s)
- David Keeling
- Oxford University Hospitals NHS Foundation Trust; Oxford UK
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Barra ME, Fanikos J, Gerhard-Herman MD, Bhatt DL. Bridging Experience With Eptifibatide After Stent Implantation. Crit Pathw Cardiol 2016; 15:82-88. [PMID: 27465001 DOI: 10.1097/hpc.0000000000000084] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Patients who have undergone intracoronary stent implantation often require surgery within the first year after the procedure. Planned or emergent surgical intervention requires interruption of antiplatelet therapy and is associated with an increased risk of stent thrombosis. Eptifibatide, an intravenous glycoprotein IIb/IIIa inhibitor (GPIIb/IIIa), can be considered for antiplatelet bridging of high-risk patients in the periprocedural period. OBJECTIVES The aim of this report is to describe the management of antiplatelet therapy and outcomes of patients who were bridged with eptifibatide perioperatively within 1 year of intracoronary stent implantation. METHODS We performed a retrospective analysis of patients identified through the hospital's computer system consecutively from January 1, 2011 to December 31, 2014. We included 18 patients who were bridged from an oral P2Y12-receptor antagonist with eptifibatide before surgery. Outcome measures were the incidence of thromboembolic events or stent thrombosis within 30 days of surgery and death within 90 days of hospital discharge. Safety measures were the incidence of thrombolysis in myocardial infarction major, minor, or minimal bleeding. RESULTS Of the 18 patients assessed, no patients experienced thromboembolic events or stent thrombosis. There was one major bleeding event and one minimal bleeding event postoperatively. Antiplatelet therapy management was highly variable in the perioperative period with 72.2% receiving the recommended GPIIb/IIIa loading dose, 50% of patients not continuing aspirin throughout the surgery, 27.8% of patients stopping antiplatelet therapy less than 5 days before surgery, and 50% not receiving a loading dose of an oral P2Y12-receptor antagonist postoperatively. CONCLUSIONS Within a limited sample size, bridging with an intravenous GPIIb/IIIa inhibitor appeared feasible. Further study is needed on the optimal strategy to manage patients with recent stenting who need surgical procedures.
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Affiliation(s)
- Megan E Barra
- From the Department of Pharmacy and Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA
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Lordkipanidzé M, So D, Tanguay JF. Platelet function testing as a biomarker for efficacy of antiplatelet drugs. Biomark Med 2016; 10:903-18. [DOI: 10.2217/bmm-2016-0070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Despite the overwhelming evidence in support of the efficacy of dual antiplatelet therapy with aspirin and clopidogrel, it is also obvious that not all patients benefit from these drugs to the same extent. This interindividual variability in platelet responses may underlie clinical differences in drug efficacy, with potential for optimization of antiplatelet therapy to prevent ischemic events without excessively increasing bleeding risk. This review presents the current evidence regarding platelet function testing for monitoring of antiplatelet therapy, with emphasis on the prognostic value of platelet function testing to predict ischemic and bleeding events. The potential of platelet function testing to provide personalized antiplatelet therapy is also discussed, with an outlook toward the future of platelet function testing in high-risk individuals.
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Affiliation(s)
- Marie Lordkipanidzé
- Faculté de Pharmacie, Université de Montréal, C.P. 6128, Succ. Centre-ville, Montréal, QC, H3C 3J7, Canada
- Research Center, Montreal Heart Institute, 5000 rue Bélanger, Montréal, QC, H1T 1C8, Canada
| | - Derek So
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, K1Y 4W7, Canada
| | - Jean-François Tanguay
- Faculté de Médecine, Université de Montréal, C.P. 6128, succ. Centre-ville, Montréal, QC, H3C 3J7, Canada
- Department of Medicine, Montreal Heart Institute, 5000 rue Bélanger, Montréal, QC, H1T 1C8, Canada
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Enhanced P-selectin expression on platelet-a marker of platelet activation, in young patients with angiographically proven coronary artery disease. Mol Cell Biochem 2016; 419:125-33. [DOI: 10.1007/s11010-016-2756-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 06/21/2016] [Indexed: 01/19/2023]
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50
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Rossini R, Angiolillo DJ, Musumeci G, Capodanno D, Lettino M, Trabattoni D, Pilleri A, Calabria P, Colombo P, Bernabò P, Ferlini M, Ferri M, Tarantini G, De Servi S, Savonitto S. Antiplatelet therapy and outcome in patients undergoing surgery following coronary stenting: Results of the surgery after stenting registry. Catheter Cardiovasc Interv 2016; 89:E13-E25. [DOI: 10.1002/ccd.26629] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/15/2016] [Accepted: 05/23/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Roberta Rossini
- Dipartimento Cardiovascolare, ASST Papa Giovanni XXIII; Bergamo Italy
| | - Dominick J. Angiolillo
- College of Medicine-Jacksonville, University of Florida; Jacksonville Florida; Division of Cardiology, University of Florida College of Medicine-Jacksonville; Jacksonville, FL-USA
| | - Giuseppe Musumeci
- Dipartimento Cardiovascolare, ASST Papa Giovanni XXIII; Bergamo Italy
| | - Davide Capodanno
- Dipartimento Di Cardiologia, Ospedale Ferrarotto, Università Di Catania; Italy
| | - Maddalena Lettino
- U.O.C. Cardiologia Clinica I, Istituto Clinico Humanitas; Rozzano (MI) Italy; Dipartimento Cardiovascolare, Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Daniela Trabattoni
- Dipartimento Di Scienze Cardiovascolari, Centro Cardiologico Monzino, IRCCS, Università Degli Studi Di Milano; Milano Italy
| | - Annarita Pilleri
- SSD Centro di valutazione e consulenza cardiologica, Azienda Ospedaliera Brotzu, Presidio San Michele; Cagliari Italy
| | - Paolo Calabria
- UO Emodinamica, Ospedale Misericordia, Grosseto; USL Toscana Sudest Italy
| | - Paola Colombo
- Dipartimento Cardiovascolare, ASST Niguarda Grande Ospedale Metropolitano; Milano Italy
| | - Paola Bernabò
- Divisione di Cardiologia, Ente Ospedaliero Ospedali Galliera; Genova Italy
| | - Marco Ferlini
- SC Cardiologia, Fondazione IRCCS Policlinico San Matteo; Pavia Italy
| | - Marco Ferri
- S.C. Di Cardiologia, Arcispedale S. Maria Nuova, IRCCS; Reggio Emilia Italy
| | - Giuseppe Tarantini
- Dipartimento Di Scienze Cardiache, Toraciche E Vascolari, Università Di Padova; Italia
| | - Stefano De Servi
- SC Cardiologia, Fondazione IRCCS Policlinico San Matteo; Pavia Italy
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