Antiplatelet therapy discontinuation and the risk of serious cardiovascular events after coronary stenting: observations from the CREDO-Kyoto Registry Cohort-2

Regulation of mitochondrial function by hydroquinone derivatives as prevention of platelet activation

Platelet activation plays an essential role in the pathogenesis of thrombotic events in different diseases (e.g., cancer, type 2 diabetes, Alzheimer's, and cardiovascular diseases, and even in patients diagnosed with coronavirus disease 2019). Therefore, antiplatelet therapy is essential to reduce thrombus formation. However, the utility of current antiplatelet drugs is limited. Therefore, identifying novel antiplatelet compounds is very important in developing new drugs. In this context, the involvement of mitochondrial function as an efficient energy source required for platelet activation is currently accepted; however, its contribution as an antiplatelet target still has little been exploited. Regarding this, the intramolecular hydrogen bonding of hydroquinone derivatives has been described as a structural motif that allows the reach of small molecules at mitochondria, which can exert antiplatelet activity, among others. In this review, we describe the role of mitochondrial function in platelet activation and how hydroquinone derivatives exert antiplatelet activity through mitochondrial regulation.

External Validation of the SYNTAX Score II 2020

BACKGROUND

The SYNTAX score II 2020 (SSII-2020) was derived from cross correlation and externally validated in randomized trials to predict death and major adverse cardiac and cerebrovascular events (MACE) following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with 3-vessel disease (3VD) and/or left main coronary artery disease (LMCAD).

OBJECTIVES

The authors aimed to investigate the SSII-2020's value in identifying the safest modality of revascularization in a non-randomized setting.

METHODS

Five-year mortality and MACE were assessed in 7,362 patients with 3VD and/or LMCAD enrolled in a Japanese PCI/CABG registry. The discriminative abilities of the SSII-2020 were assessed using Harrell's C statistic. Agreement between observed and predicted event rates following PCI or CABG and treatment benefit (absolute risk difference [ARD]) for these outcomes were assessed by calibration plots.

RESULTS

The SSII-2020 for 5-year mortality well predicted the prognosis after PCI and CABG (C-index = 0.72, intercept = -0.11, slope = 0.92). When patients were grouped according to the predicted 5-year mortality ARD, <4.5% (equipoise of PCI and CABG) and ≥4.5% (CABG better), the observed mortality rates after PCI and CABG were not significantly different in patients with lower predicted ARD (observed ARD: 2.1% [95% CI: -0.4% to 4.4%]), and the significant difference in survival in favor of CABG was observed in patients with higher predicted ARD (observed ARD: 9.7% [95% CI: 6.1%-13.3%]). For MACE, the SSII-2020 could not recommend a specific treatment with sufficient accuracy.

CONCLUSIONS

The SSII-2020 for predicting 5-year death has the potential to support decision making on revascularization in patients with 3VD and/or LMCAD.

Effects of Antithrombotic Treatment on Bleeding Complications of EBUS-TBNA

Background and Objectives: The application of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been markedly increased over the past decade. EBUS-TBNA is known to be a very safe and accurate procedure; however, the incidence of bleeding complications in patients who are taking antithrombotic agents (ATAs) is not well established. Materials and Methods: We conducted a retrospective analysis of a prospectively registered EBUS-TBNA cohort in a single tertiary hospital from May 2009 to December 2016. The patients were divided into two groups: an insufficient discontinuation group, defined as having a prescription for ATAs on the procedure day or only interrupting them for a short period of time, and a sufficient discontinuation group, defined as having prescription for ATAs during 30 days prior to the procedure and interrupting them for a sufficient period of time. Results: During the study period, a total of 4271 patients, after excluding 3773 patients who did not take ATAs at all, 498 patients were classified into the insufficient discontinuation group (n = 102) and the sufficient discontinuation group (n = 396). The baseline characteristics of patients and examined lesions between two groups were not significantly different, except insufficient discontinuation group had longer prothrombin times than the sufficient discontinuation group. In the insufficient discontinuation group, the most common reasons for prescriptions of ATAs were ischemic heart disease (48.0%) and cerebral vascular disease (28.4%), and half of the patients were taking two or more ATAs. Eventually, only one bleeding complication in the insufficient discontinuation group (1/102, 1.0%) and one event in the sufficient discontinuation group (1/396, 0.3%) occurred (p = 0.368). Conclusions: EBUS-TBNA is considered a safe procedure in terms of bleeding complications, even in patients with insufficient stopping of ATAs.

Impact of Antiplatelet Therapies on Patients Outcome in Osteosynthetic Surgery of Proximal Femoral Fractures

BACKGROUND

Proximal femoral fractures should be treated in a timely manner. Affected patients often require antiplatelet therapy (APT) due to cardiovascular diseases. Guidelines recommend 5-7 days APT interruption for elective surgery. Early osteosynthetic surgery of proximal femoral fractures despite of APT should be considered.

AIM OF THE STUDY

To evaluate whether early osteosynthetic surgery despite of APT is associated with increased blood loss, complications and mortality.

METHODS

Data of patients with proximal femoral fractures, who were treated by osteosynthesis at the Department of Trauma Surgery at the Medical University of Vienna were collected retrospectively. Study groups were formed by time to surgery and APT interruption. The primary endpoint of the study was the perioperative blood loss. Secondary endpoints were complications, 30-day and 1-year mortality, time to surgery, and the total length of hospital stay.

RESULTS

The osteosynthetic treatment of proximal femoral fractures despite of APT resulted in a shorter time to surgery (13.8 vs. 66.0 h; p < 0.01). In patients on APT, the TBL (total perioperative blood loss) was higher without need for revision or an increase in the need for packed red blood cells if surgery was performed within 24 h after admission. APT had no significant influence on mortality. Patients who underwent surgery within 24 h after admission had a lower mortality. The complication rate was higher in patients who underwent surgery later than 24 h after admission.

CONCLUSIONS

Surgery within 24 h after admission, regardless of APT, resulted in a shorter hospitalization length and was associated with less common complications and a lower mortality.

Omitting aspirin in PCI patients: Myth or reality?

In the current era of percutaneous coronary intervention (PCI), with the use of contemporary drug-eluting stents, refined techniques, and adjunctive pharmacotherapy, the role of aspirin peri-PCI remains undisputable. Beyond the initial period, dual antiplatelet therapy (DAPT) consisting of aspirin and a P2Y₁₂ receptor inhibitor for 6 months in stable coronary artery disease and 12 months in acute coronary syndromes is the standard of care. However, concerns regarding bleeding adverse events caused by aspirin have led to shortened DAPT duration or even omission of aspirin. Aspirin free-strategies have been increasingly encountered in several studies and showed a significant reduction in bleeding events, without any sign of increased ischemic risk. Individualization of DAPT duration particularly in high bleeding risk patients appears therefore mandatory, making aspirin not necessary in several cases. Moreover, recent randomized trials have shed light on how to treat PCI patients in the presence of concomitant anticoagulant treatment with P2Y₁₂ monotherapy and excluding aspirin. These aspirin-free strategies have been proved safer than the "older" standard triple antithrombotic treatment, without compromising safety. Ongoing studies may further dispel the myths and establish real facts regarding post-PCI-tailored treatment with or without aspirin.

Bleeding Complications in Patients Undergoing Intrathecal Drug Delivery System Implantation

Introduction

Intrathecal drug delivery systems (IDDSs) have dramatically improved analgesia and the functional status of cancer patients and those with chronic pain states. However, given the close proximity to the neuraxis and frequent concomitant use of antiplatelet or anticoagulant medications, this intervention is not without risk. The goal of this investigation was to determine the incidence of bleeding complications following IDDS placement.

Methods

This is a retrospective review from 2005 through 2014 of adult patients undergoing IDDS implantation or revision at a tertiary care center. The primary outcome was a bleeding-related neurological complication requiring emergency medicine, neurology, or neurosurgical evaluation within 31 days.

Results

A total of 247 procedures were performed on 216 unique patients. Patients received aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) within seven days of needle placement for 64 procedures (25.9%). A preprocedural platelet count or international normalized ratio (INR) was available within 30 days for 138 procedures (55.9%). Of these, two patients had a platelet count lower than 100 x 109/L and one patient had an INR of 1.5 or higher at the time of the procedure. One neurological complication was identified (0.4%) that was not related to procedural bleeding. Similarly, three patients (1.2%) received a periprocedural red blood cell transfusion, none of which were related to procedural bleeding.

Conclusion

No cases of bleeding-related neurological complications were identified following IDDS placement or revision, including in those receiving aspirin or NSAIDs. Future investigations with larger numbers are needed to further explore the safety of antithrombotic therapy continuation or discontinuation periprocedurally.

Patterns of antiplatelet drug use after a first myocardial infarction during a 10-year period

AIMS

The aims of the present study were to assess antiplatelet drug use patterns after a first myocardial infarction (MI) and to evaluate the determinants of antiplatelet nonpersistence.

METHODS

The present study was conducted in 4690 patients from the Utrecht Cardiovascular Pharmacogenetics cohort with a first MI between 1986 and 2010, who were followed for a maximum of 10 years. Medication use and event diagnosis were obtained from the Dutch PHARMO Record Linkage System. Antiplatelet drug users were classified as persistent users (gap between prescriptions ≤90 days), nonpersistent users (>90-day gap and no refills), and restarters (a new prescription after a >90-day gap). The association between potential determinants and antiplatelet nonpersistence was analysed using Cox regression.

RESULTS

The proportions of persistent users decreased from 84.0% at the 1-year follow-up to 32.8% at 10 years for any antiplatelet drug, and 77.3% to 27.5% for aspirin; and 39.0% to 6.4% for clopidogrel at 6 years. Most nonpersistent users restarted antiplatelet drugs later, leading to 89.3% overall antiplatelet drug users at 10 years after MI. Diabetes (hazard ratio [HR] 0.44; 0.32-0.60), hypertension (HR 0.77; 0.60-0.99), hypercholesterolaemia (HR 0.49; 0.39-0.62) and more recent MI diagnosis period (2003-2007: HR 0.69, 0.61-0.79; 2008-2010: HR 0.38, 0.19-0.77, compared to ≤ 2002 period) lowered the risk of antiplatelet nonpersistence, while vitamin K antagonist (VKA) comedication (HR 18.97; 16.91-21.28) increased this risk.

CONCLUSIONS

A large proportion of patients with a first MI still used antiplatelet drugs after 10 years. The frequent discontinuations during this time frame are expected to reduce the effectiveness of antiplatelet drugs as secondary prevention of cardiovascular diseases. Diabetes, hypertension, hypercholesterolaemia, VKA comedication and MI diagnosis period were determinants of antiplatelet nonpersistence.

Modifying the Interagency Emergency Health Kit to include treatment for non-communicable diseases in natural disasters and complex emergencies

The Interagency Emergency Health Kit (IEHK) provides a standard package of medicines and simple medical devices for aid agencies to use in emergencies such as disasters and armed conflicts. Despite the increasing burden of non-communicable diseases (NCDs) in such settings, the IEHK includes few drugs and devices for management of NCDs. Using published data to model the population burden of acute and chronic presentations of NCDs in emergency-prone regions, we estimated the quantity of medications and devices that should be included in the IEHK. NCDs considered were cardiovascular diseases, diabetes, hypertension and chronic respiratory disease. In scenario 1 (the primary scenario), we assumed that resources in the IEHK would only include those needed to manage acute life-threatening conditions. In scenario 2, we included resources required to manage both acute and chronic presentations of NCDs. Drugs and devices that might be required included amlodipine, aspirin, atenolol, beclomethasone, dextrose 50%, enalapril, furosemide, glibenclamide, glyceryl trinitrate, heparin, hydralazine, hydrochlorothiazide, insulin, metformin, prednisone, salbutamol and simvastatin. For scenario 1, the number of units required ranged from 12 (phials of hydralazine) to ∼15 000 (tablets of enalapril). Space and weight requirements were modest and total cost for all drugs and devices was approximately US$2078. As expected, resources required for scenario 2 were much greater. Space and cost requirements increased proportionately: estimated total cost of scenario 2 was $22 208. The resources required to treat acute NCD presentations appear modest, and their inclusion in the IEHK seems feasible.