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Ahmed T, Grigorian AY, Messerli AW. Management of Acute Coronary Syndrome in Patients with Liver Cirrhosis. Am J Cardiovasc Drugs 2022; 22:55-67. [PMID: 34050893 DOI: 10.1007/s40256-021-00478-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 12/12/2022]
Abstract
Liver cirrhosis (LC) is becoming increasingly common among patients presenting with acute coronary syndromes (ACS) and is associated with significant cardiovascular morbidity and mortality. Management of such patients is complicated by LC related complications. Literature is scarce on the safety of antithrombotic regimens and invasive strategies for ACS in patients with LC, especially those undergoing liver transplant evaluation. Recently there has been evidence that cirrhosis is an independent risk factor for adverse outcomes in ACS. As patients with LC are generally excluded from large randomized trials, definitive guidelines for the management of ACS in this particular cohort are lacking. Many antithrombotic drugs require either hepatic activation or clearance; hence, an accurate assessment of hepatic function is required prior to initiation and dose adjustment. Despite a demonstrated survival benefit of optimal medical therapy and invasive revascularization techniques in LC patients with ACS, both strategies are currently underutilized in this population. This review aims to present currently available data and provide a practical, clinically oriented approach for the management of ACS in LC. Randomized clinical trials in LC patients with ACS are the need of the hour to further refine their management for favorable outcomes.
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Shin WS, Ahn DK, Lee JS, Yoo IS, Lee HY. The Influence of Antiplatelet Drug Medication on Spine Surgery. Clin Orthop Surg 2018; 10:380-384. [PMID: 30174816 PMCID: PMC6107813 DOI: 10.4055/cios.2018.10.3.380] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/07/2018] [Indexed: 11/17/2022] Open
Abstract
Background The incidence of cardiovascular and neurovascular diseases has been increasing with the aging of the population, and antiplatelet drugs (APDs) are more frequently used than in the past. With the average age of spinal surgery patients also increasing, there has been a great concern on the adverse effects of APD on spine surgery. To our knowledge, though there have been many studies on this issue, their results are conflicting. In this study, we aimed to determine the influence of APDs on spine surgery in terms of intraoperative bleeding and postoperative spinal epidural hematoma complication. Methods Patients who underwent posterior thoracolumbar decompression and instrumentation at our institution were reviewed. There were 34 APD takers (APDT group). Seventy-nine non-APD takers (NAPDT group) were selected as a control group in consideration of demographic and surgical factors. There were two primary endpoints of this study: the amount of bleeding per 10 minutes and cauda equina compression by epidural hematoma measured at the cross-sectional area of the thecal sac in the maximal compression site on the axial T2 magnetic resonance imaging scans taken on day 7. Results Both groups were homogeneous regarding age and sex (demographic factors), the number of fused segments, operation time, and primary/revision operation (surgical factors), and the number of platelets, prothrombin time, and activated partial thromboplastin time (coagulation-related factors). However, the platelet function analysis-epinephrine was delayed in the APDT group than in the NAPDT group (203.6 seconds vs. 170.0 seconds, p = 0.050). Intraoperative bleeding per 10 minutes was 40.6 ± 12.8 mL in the APDT group and 43.9 ± 9.9 mL in the NAPDT group, showing no significant difference between the two groups (p = 0.154). The cross-sectional area of the thecal sac at the maximal compression site by epidural hematoma was 120.2 ± 48.2 mm2 in the APDT group and 123.2 ± 50.4 mm2 in the NAPDT group, showing no significant difference between the two groups (p = 0.766). Conclusions APD medication did not increase intraoperative bleeding and postoperative spinal epidural hematoma. Therefore, it would be safer to perform spinal surgery without discontinuation of APD therapy in patients who are vulnerable to cardiovascular and neurovascular complications.
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Affiliation(s)
- Won Shik Shin
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Dong Ki Ahn
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Jung Soo Lee
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - In Sun Yoo
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Ho Young Lee
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
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Iliescu CA, Cilingiroglu M, Giza DE, Rosales O, Lebeau J, Guerrero-Mantilla I, Lopez-Mattei J, Song J, Silva G, Loyalka P, Paixao ARM, Yusuf SW, Perin E, Anderson VH, Marmagkiolis K. "Bringing on the light" in a complex clinical scenario: Optical coherence tomography-guided discontinuation of antiplatelet therapy in cancer patients with coronary artery disease (PROTECT-OCT registry). Am Heart J 2017; 194:83-91. [PMID: 29223438 DOI: 10.1016/j.ahj.2017.08.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 08/17/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cancer patients with recently placed drug-eluting stents (DESs) often require premature dual antiplatelet therapy (DAPT) discontinuation for cancer-related procedures. Optical coherence tomography (OCT) can identify risk factors for stent thrombosis such as stent malapposition, incomplete strut coverage and in-stent restenosis and may help guide discontinuation of DAPT. METHODS We conducted a single-center prospective study in cancer patients with recently placed (1-12 months) DES who required premature DAPT discontinuation. Patients were evaluated with diagnostic coronary angiogram and OCT. Individuals with appropriate stent strut coverage, expansion, apposition, and absence of in-stent restenosis or intraluminal masses were considered low risk and transiently discontinued DAPT to allow optimal cancer therapy. Patients who did not meet all these criteria were considered high risk and underwent further endovascular treatment when appropriate and bridging with low-molecular weight heparin. The incidence of adverse cardiovascular events was assessed after the procedure and at 12 months. RESULTS A total of 40 patients were included. Twenty-seven patients (68%) were considered low risk by OCT criteria and DAPT was transiently discontinued. Thirteen patients (32%) were considered high risk with one or more OCT findings: uncovered stent struts (4 patients, 10%); stent underexpansion (3 patients, 8%); malapposition (8 patients, 20%); in-stent restenosis (2 patients, 5%). The high-risk patients with uncovered stent struts and malapposition underwent additional stent dilatation. There were no cardiovascular events in the low-risk group. One myocardial infarction occurred in the high-risk group. Fourteen non-cardiac deaths were registered before 12 months due to cancer progression or cancer therapy. CONCLUSION OCT imaging allows identification of low-risk cancer patients with DES placed who may safely discontinue DAPT and proceed with cancer-related surgery or procedures.
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Affiliation(s)
- Cezar A Iliescu
- The University of Texas MD Anderson Cancer Center, Houston, TX.
| | | | - Dana E Giza
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | - Juhee Song
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Pranav Loyalka
- University of Texas Health Science Center, Memorial Hermann Hospital, Houston, TX
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Krill T, Brown G, Weideman RA, Cipher DJ, Spechler SJ, Brilakis E, Feagins LA. Patients with cirrhosis who have coronary artery disease treated with cardiac stents have high rates of gastrointestinal bleeding, but no increased mortality. Aliment Pharmacol Ther 2017; 46:183-192. [PMID: 28488370 DOI: 10.1111/apt.14121] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 02/19/2017] [Accepted: 04/08/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with coronary artery disease (CAD) treated with stents require dual antiplatelet therapy (DAPT). For cirrhotics, who often have varices and coagulopathy, it is not clear if the risk of gastrointestinal bleeding (GIB) should preclude use of DAPT. AIM To compare GIB and mortality rates in cirrhotics with CAD treated medically or with stents. METHODS Using institutional databases, we identified patients with cirrhosis and CAD treated with stents or medical therapy between January 2000-September 2015. Primary outcomes were GIB and mortality. RESULTS We identified 148 cirrhotics with CAD; 68 received stents (cases), 80 were treated with medical therapy (controls). Cases and controls had similar demographics, comorbidities, MELD scores and clinical presentation; DAPT was used in 98.5% of cases vs 5% of controls. The incidence of GIB was significantly higher in cases than controls (22.1% vs 5% at 1 year, P=.003; 27.9% vs 5% at 2 years, P=.0002), whereas all-cause mortality was similar (20.6% vs 21.3%). No patient required surgery or angiography for GIB, and no known patients died due to GIB. Multivariate analysis revealed use of a proton pump inhibitor (PPI) was highly protective against GIB (OR=0.26, 95%CI=0.08-0.79). CONCLUSIONS CAD treatment with stents in our cirrhotics was associated with a significantly increased risk of GIB, but no adverse effects on survival. Although it remains unclear whether the cardiovascular benefits of stents outweigh the GIB risk, our findings suggest that DAPT should not be withheld from stented cirrhotics for fear of GIB. Moreover, the use of a PPI should be strongly considered.
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Affiliation(s)
- T Krill
- Division of Digestive and Liver Disease, VA North Texas Healthcare System, Dallas, TX, USA.,Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - G Brown
- Division of Digestive and Liver Disease, VA North Texas Healthcare System, Dallas, TX, USA.,Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - R A Weideman
- Department of Pharmacy, VA North Texas Healthcare System, Dallas, TX, USA
| | - D J Cipher
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, USA
| | - S J Spechler
- Division of Digestive and Liver Disease, VA North Texas Healthcare System, Dallas, TX, USA.,Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - E Brilakis
- Division of Cardiology, VA North Texas Healthcare System, Dallas, TX, USA.,Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - L A Feagins
- Division of Digestive and Liver Disease, VA North Texas Healthcare System, Dallas, TX, USA.,Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Vázquez-Alonso E, Iturri Clavero F, Valencia Sola L, Fábregas N, Ingelmo Ingelmo I, Valero R, Cassinello C, Rama-Maceiras P, Jorques A. Clinical practice guideline on thromboprophylaxis and management of anticoagulant and antiplatelet drugs in neurosurgical and neurocritical patients. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:406-418. [PMID: 26965554 DOI: 10.1016/j.redar.2016.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 01/18/2016] [Indexed: 06/05/2023]
Affiliation(s)
- E Vázquez-Alonso
- Servicio de Anestesiología, Complejo Hospitalario Universitario Granada, Granada, España.
| | - F Iturri Clavero
- Servicio de Anestesiología, Hospital Universitario Cruces, , Bilbao, Vizcaya, España
| | - L Valencia Sola
- Servicio de Anestesiología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, España
| | - N Fábregas
- Servicio de Anestesiología, Hospital Clinic, Universitat de Barcelona, Barcelona, España
| | - I Ingelmo Ingelmo
- Servicio de Anestesiología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - R Valero
- Servicio de Anestesiología, Hospital Clinic, Universitat de Barcelona, Barcelona, España
| | - C Cassinello
- Servicio de Anestesiología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - P Rama-Maceiras
- Servicio de Anestesiología, Complejo Hospitalario Universitario Juan Canalejo, A Coruña, España
| | - A Jorques
- Servicio de Neurocirugía, Complejo Hospitalario Universitario Granada, Granada, España
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Williams LA, Hunter JM, Marques MB, Vetter TR. Periprocedural management of patients on anticoagulants. Clin Lab Med 2014; 34:595-611. [PMID: 25168945 DOI: 10.1016/j.cll.2014.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Every year, new studies are undertaken to address the complex issue of periprocedural management of patients on anticoagulants and antiplatelet medications. In addition, newer drugs add to the confusion among clinicians about how to best manage patients taking these agents. Using the most recent data, guidelines, and personal experience, this article discusses recommendations and presents simplified algorithms to assist clinicians in the periprocedural management of patients on anticoagulants.
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Affiliation(s)
- Lance A Williams
- Department of Pathology, University of Alabama at Birmingham, 619 19th Street South, WPP230F, Birmingham, AL 35249-7331, USA.
| | - James M Hunter
- Department of Anesthesiology, University of Alabama at Birmingham, 1720 2nd Avenue South, JT926C, Birmingham, AL 35249-6810, USA
| | - Marisa B Marques
- Department of Pathology, University of Alabama at Birmingham, 619 19th Street South, WPP230G, Birmingham, AL 35249-7331, USA
| | - Thomas R Vetter
- Department of Anesthesiology, University of Alabama at Birmingham, 619 19th Street South, JT865, Birmingham, AL 35249, USA
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Vetter TR, Cheng D. Perioperative Antiplatelet Drugs with Coronary Stents and Dancing with Surgeons. Anesth Analg 2013. [DOI: 10.1213/ane.0b013e3182982c90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Darvish-Kazem S, Gandhi M, Marcucci M, Douketis JD. Perioperative Management of Antiplatelet Therapy in Patients With a Coronary Stent Who Need Noncardiac Surgery. Chest 2013; 144:1848-1856. [DOI: 10.1378/chest.13-0459] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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Tandar A, Velagapudi KN, Wilson BD, Boden WE. Perioperative antiplatelet management in patients with coronary artery stenting. Hosp Pract (1995) 2012; 40:118-30. [PMID: 22615086 DOI: 10.3810/hp.2012.04.977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Coronary artery disease is the primary cause of mortality in men and women in the United States. Transcatheter coronary intervention is the mainstay of treatment for patients with acute coronary artery disease presentations and patients with stable disease. Although percutaneous intervention initially only included balloon angioplasty, it now typically involves the placement of intracoronary stents. To overcome the limitations of bare-metal stents, namely in-stent restenosis, stents have been developed that remove pharmaceuticals that reduce neointimal hyperplasia and in-stent restenosis. However, these pharmaceutical agents also delay stent endothelialization, posing a prolonged risk of in situ thrombosis. Placement of an intracoronary stent (eg, bare-metal or drug-eluting stent) requires dual antiplatelet therapy to prevent the potentially life-threatening complication of stent thrombosis. The optimal duration of dual antiplatelet therapy following stent placement is unknown. This article discusses the factors to be considered when deciding when dual antiplatelet therapy can be safely discontinued. Unfortunately, in the hospital setting, this decision to interrupt dual antiplatelet therapy frequently must be made shortly after stent placement because of unanticipated surgical procedures or other unforeseen complications. The decision of when dual antiplatelet therapy can be safely interrupted needs to be individualized for each patient and involves factoring in the type of stent; the location and complexity of the lesion stented; post-stent lesion characteristics; the amount of time since stent placement; and the antiplatelet regimen currently in use, along with its implication for bleeding during the proposed procedure. Having a protocol in place, such as the protocol described in this article, can help guide this decision-making process and avoid confusion and potential error.
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Affiliation(s)
- Anwar Tandar
- Division of Cardiology, University of Utah School of Medicine, Salt Lake City, UT.
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Abstract
GOALS To describe our experience with coronary artery stenting and antiplatelet therapy in cirrhotic patients and compare rates of bleeding with a control group. BACKGROUND Although there are data on cardiac evaluation and perioperative cardiac risk in cirrhotic patients, there is a paucity of information on outcomes in cirrhotic patients with coronary artery stents. Cirrhotic patients may be at increased risk for complications, including gastrointestinal bleeding as a result of antiplatelet therapy prescribed after stenting. STUDY We performed a retrospective study of complications in cirrhotics that received a coronary artery stent followed by clopidogrel and aspirin prescribed to prevent stent occlusion. Cirrhotics with stents were compared with an age and sex-matched control group with cirrhosis without stents and not on aspirin. RESULTS Among 423 cirrhotic patients who underwent liver transplant evaluation, 16 patients (3.8%) received a stent of which 9 underwent liver transplant. Two patients with varices (12.5%) in the stent group had fatal variceal bleeding and 2 controls (6.3%) had nonfatal variceal bleeding during follow-up while on antiplatelet therapy (P=0.86). There were no significant differences in transfusion requirements between the 9 liver transplant recipients with stents compared with the control group, P=0.69 for packed red blood cells. CONCLUSIONS In our experience, it is safe for cirrhotic patients without varices to receive a coronary artery stent and for cirrhotic patients with coronary artery stents to be considered for liver transplantation. Larger prospective studies are needed to confirm these results and evaluate the risk of bleeding in cirrhotics with varices who receive coronary artery stents and antiplatelet therapy.
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