Shortened dual antiplatelet therapy in contemporary percutaneous coronary intervention era

Comparison of revascularization with conservative medical treatment in maintenance dialysis patient with coronary artery disease: a systemic review and meta-analysis

Background

The primary cause of death among maintenance dialysis patients is coronary artery disease (CAD). However, the best treatment plan has not yet been identified.

Methods

The relevant articles were retrieved from various online databases and references from their inception to October 12, 2022. The studies that compared revascularization [percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)] with medical treatment (MT) among maintenance dialysis patients with CAD were selected. The outcomes evaluated were long-term (with a follow-up of at least 1 year) all-cause mortality, long-term cardiac mortality, and the incidence rate of bleeding events. Bleeding events are defined according to TIMI hemorrhage criteria: (1) major hemorrhage, intracranial hemorrhage or clinically visible hemorrhage (including imaging diagnosis) with decrease of hemoglobin concentration ≥5 g/dl; (2) minor hemorrhage, clinically visible bleeding (including imaging diagnosis) with a drop in hemoglobin of 3-5 g/dl; (3) minimal hemorrhage, clinically visible bleeding with hemoglobin drop <3 g/dl. In addition, revascularization strategy, CAD type, and the number of diseased vessels were considered in subgroup analyses.

Results

A total of eight studies with 1,685 patients were selected for this meta-analysis. The current findings suggested that revascularization was associated with low long-term all-cause mortality and long-term cardiac mortality but a similar incidence rate of bleeding events compared to MT. However, subgroup analyses indicated that PCI is linked to decreased long-term all-cause mortality compared to MT but CABG did not significantly differ from MT in terms of long-term all-cause mortality. Revascularization also showed lower long-term all-cause mortality compared to MT among patients with stable CAD, single-vessel disease, and multivessel disease but did not reduce long-term all-cause mortality among patients with ACS.

Conclusion

Long-term all-cause mortality and long-term cardiac mortality were reduced by revascularization in comparison to MT alone in patients undergoing dialysis. Larger randomized studies are needed to confirm the conclusion of this meta-analysis.

A Case of Bilateral Hemorrhagic Pleural Effusion Due to Dual Antiplatelet Therapy in a Dialysis Patient

Etiologies of hemorrhagic pleural effusions (hemithoraces) are multifactorial. They can be traumatic, non-traumatic, or idiopathic in nature. In this report, we present a rare case of a 64-year-old male with end-stage renal disease (ESRD) on chronic hemodialysis and dual antiplatelet therapy (DAPT), due to a recent history of coronary arterial stent placement, who presented with progressive shortness of breath for one month. The CT of the chest revealed bilateral large pleural effusions (left > right) with a complete collapse of the left lung and partial collapse of the right lung. Ultrasound-guided left-sided thoracentesis revealed hemorrhagic pleural effusions. After the discontinuation of DAPT, drainage from the right-sided pleural effusion via a pigtail catheter showed continued drainage of pleural fluid without hemorrhage. The effusion on the left side was also noted to have resolved on the repeat chest X-ray. Prompt recognition of this rare cause of any hemorrhagic pleural effusion is essential for patients on dialysis to avoid complications. This report focuses on the possible etiology and potential complications of a hemorrhagic pleural effusion, followed by a brief discussion on the rare but significant association involving the incidence of a hemorrhagic pleural effusion in a dialysis patient receiving DAPT.

Current Therapeutic Approach to Acute Myocardial Infarction in Patients with Congenital Hemophilia

Advances in the treatment of hemophilia have made the life expectancy of hemophiliacs similar to that of the general population. Physicians have begun to face age-related diseases not previously encountered in individuals with hemophilia. Treatment of acute myocardial infarction (AMI) is particularly challenging because the therapeutic strategies influence both the patient's thrombotic and hemorrhagic risk. As progress has been made in the treatment of AMI over the last decade, we performed an in-depth analysis of the available literature, highlighting the latest advances in the therapy of AMI in hemophiliacs. It is generally accepted that after the optimal substitution therapy has been provided, patients with hemophilia should be treated in the same way as those in the general population. New-generation stents that allow short dual antiplatelet therapy and potent P2Y12 receptor inhibitors have begun to be successfully used. At a time when specific recommendations and relevant data are scarce, our study provides up-to-date information to physicians involved in the treatment of AMI in hemophiliacs.