Incidence and Risk Factors for Antiplatelet Therapy-Related Bleeding Complications Among Elderly Patients After Coronary Stenting: A Multicenter Retrospective Observation

Naoxintong capsule for treating cardiovascular and cerebrovascular diseases: from bench to bedside

Naoxintong Capsule (NXT), a renowned traditional Chinese medicine (TCM) formulation, has been broadly applied in China for more than 30 years. Over decades, accumulating evidences have proven satisfactory efficacy and safety of NXT in treating cardiovascular and cerebrovascular diseases (CCVD). Studies have been conducted unceasingly, while this growing latest knowledge of NXT has not yet been interpreted properly and summarized comprehensively. Hence, we systematically review the advancements in NXT research, from its chemical constituents, quality control, pharmacokinetics, to its profound pharmacological activities as well as its clinical applications in CCVD. Moreover, we further propose specific challenges for its future perspectives: 1) to precisely clarify bioactivities of single compound in complicated mixtures; 2) to evaluate the pharmacokinetic behaviors of NXT feature components in clinical studies, especially drug-drug interactions in CCVD patients; 3) to explore and validate its multi-target mechanisms by integrating multi-omics technologies; 4) to re-evaluate the safety and efficacy of NXT by carrying out large-scale, multicenter randomized controlled trials. In brief, this review aims to straighten out a paradigm for TCM modernization, which help to contribute NXT as a piece of Chinese Wisdom into the advanced intervention strategy for CCVD therapy.

Epidemiology, Pathophysiology, and Management of Coronary Artery Disease in the Elderly

Elderly patients over the age of ≥ 75 years are especially susceptible to coronary artery disease (CAD) as age is an important nonmodifiable risk factors for atherosclerosis and a predictor of poorer outcomes. In fact, CAD is a major cause of mortality and morbidity in this population. Due to concerns of functional frailty, comorbidities, and patient preference of conservative to no treatment have played a role in reducing the interest in pursuing prospective studies in this high-risk group. In this review, we provide an overview of the epidemiology, pathophysiology, and management of CAD in older adults.

Factors affecting physician decision-making regarding antiplatelet therapy in minor ischemic stroke

Purpose

To identify the most important factors affecting physician decision-making regarding antiplatelet therapy.

Methods

We retrospectively gathered data from minor ischemic stroke patients with NIHSS scores ≤ 5 within 72 h of onset from 2010 to 2018. The population was divided into four groups by initial antiplatelet therapy: aspirin monotherapy (AM), dual antiplatelet therapy with aspirin and a loading dose of clopidogrel (clopidogrel loading dose of 300 mg on the first day; DAPT-ALC), dual antiplatelet therapy with aspirin and no loading dose of clopidogrel (clopidogrel 75 mg daily, no loading dose; DAPT-AUC), and clopidogrel monotherapy (CM).

Results

In total, 1,377 patients were included in the analysis (excluding patients who accepted thrombolytic drugs, participated in other clinical trials, or had not used antiplatelet drugs). The mean ± S.D. age was 62.0 ± 12.7 years; 973 (70.7%) patients were male. The four groups were AM (n = 541, 39.3%), DAPT-ALC (n = 474, 34.4%), DAPT- AUC (n = 301, 21.9%), and CM (n = 61, 4.4%). Patients receiving antiplatelet monotherapy were older than those receiving dual antiplatelet therapy (63.7–65.7 vs. 59.6–61.4 years), and the median initial systolic blood pressure level was higher in the DAPT-ALC group than in the other groups (all P < 0.05). Patients under 75 years old with an admission SBP lower than 180 mmHg, a history of AM, coronary heart disease, no history of intracerebral hemorrhage, stroke onset occurring after guideline recommendations were updated (the year of 2015), onset-to-arrival time within 24 h, and initial NIHSS score ≤ 3 were more likely to take DAPT-ALC than AM. Compared with DAPT-ALC, DAPT-AUC was associated with an initial SBP level lower than 180 mmHg, a history of smoking, hypertension, no history of ICH, previous treatment with antihypertensives, and onset year after the recommendations were updated.

Conclusions

Many factors affect doctors' decisions regarding antiplatelet therapy, especially guidelines, age, admission SBP level, and hypertensive disease.

Performance of PRECISE-DAPT and Age–Bleeding–Organ Dysfunction Score for Predicting Bleeding Complication During Dual Antiplatelet Therapy in Chinese Elderly Patients

Background

Recently, the Age–Bleeding–Organ Dysfunction (ABO) algorithm was recommended by the Asian Pacific Society of Cardiology Consensus as a binary approach to evaluate bleeding risk. This analysis made comparison of the predictive performances between the PRECISE-DAPT and ABO bleeding score in identifying the risk of 12-months major bleeding in Chinese elderly patients over 65 years old patients who underwent percutaneous coronary intervention (PCI) during dual-antiplatelet therapy period.

Methods

A total of 2,037 elderly coronary artery disease (CAD) patients (≥65 years) receiving dual antiplatelet therapy (DAPT) after PCI were enrolled in the study. The predictive accuracy of the two bleeding risk scores (PRECISE-DAPT and ABO) was compared for identifying the risk of bleeding during the dual-antiplatelet therapy in patients who underwent PCI. Major clinically relevant bleeding events were defined according to the Bleeding Academic Research Consortium (BARC) criteria.

Results

The PRECISE-DAPT score in the no bleeding, BARC = 1 bleeding, BARC ≥ 2 bleeding patients was 23.55 ± 10.46, 23.23 ± 10.03, and 33.54 ± 14.33 (p < 0.001), respectively. Meanwhile, the ABO score in the three groups was 0.72 ± 0.80, 0.69 ± 0.81, and 1.49 ± 0.99 (p < 0.001), respectively. The C-statistic of the PRECISE-DAPT model for prediction of BARC ≥ 2 bleeding in overall patients was 0.717 (95% CI, 0.656–0.777) and 0.720 (95% CI, 0.656–0.784) in acute coronary syndrome (ACS) patients. Similar discriminatory capacity was demonstrated in the ABO risk score [overall, patients, AUC: 0.712 (95% CI, 0.650–0.774); ACS patients, AUC: 0.703 (95% CI, 0.634–0.772)]. No differences were observed when the ABO model was in comparison with the PRECISE-DAPT model, regardless in overall patients (z = −0.199, p = 0.842) or ACS patients (z = −0.605, p = 0.545). The calibration for BARC ≥ 2 bleeding of the PRECISE-DAPT and ABO score were acceptable, regardless in overall patients [goodness-of-fit (GOF) Chi-square = 0.432 and 0.001, respectively; p-value = 0.806 and 0.999, respectively] or ACS patients (GOF Chi-square = 0.008 and 0.580, respectively; p-value = 0.996 and 0.748, respectively).

Conclusion

No matter of clinical presentation in Asian 65-years older patients with DAPT, the PRECISE-DAPT, and ABO scores had the similar discriminative ability for 12-months BARC ≥ 2 bleeding. Considering the simplicity and reliability, the PRECISE-DAPT score might be more clinically applicable in the overall population and ACS patients in bleeding prediction.