Bleeding risk stratification in acute coronary syndromes. Is it still valid in the era of the radial approach?

Ischaemic and haemorrhagic risk distribution in real-life patients with acute coronary syndromes

BACKGROUND

Effective treatment of non-ST-segment elevation acute coronary syndromes (NSTEACS) requires careful assessment of both ischaemic and bleeding risks. We aimed to analyse risk distribution and evaluate antiplatelet prescription behaviours in real-life settings.

METHODS

Data from 1100 NSTEACS patients in Buenos Aires, Argentina, from the Buenos Aires I Registry, with a 15-month follow-up, were analysed. In-hospital and 6-month GRACE scores, CRUSADE, and Precise DAPT scores were calculated.

RESULTS

The mean age was 65.4 ± 11.5 years with a majority being male (77.2%). In-hospital mortality was 2.7%, primarily due to cardiovascular causes (1.8%). Bleeding events occurred in 20.9% of patients, with 4.9% classified as ≥ BARC 3. Predominance of low bleeding (71.3%) and ischaemic (55.8%) risks on admission was observed. At 6 months, the low-risk Precise category (70.9%) and GRACE (44.1%) categories prevailed. Linear correlation analysis showed a moderately positive correlation (r = 0.61, p < .05) between ischaemic-haemorrhagic risks. Regarding the prescription of antiplatelet agents, in the low ischaemic-haemorrhagic risk group, there was a predominance of aspirin + clopidogrel (41.2%) over other high-potency antiplatelet regimens (aspirin + ticagrelor or prasugrel). In the low ischaemic and high haemorrhagic risk group, aspirin and clopidogrel were also predominant (58%).

CONCLUSIONS

Our analysis underscores the significant relationship between ischaemic and haemorrhagic risks during NSTEACS hospitalisation. Despite the majority of patients falling into the low-intermediate risk category, the prescription of P2Y12 inhibitors in real-life settings does not consistently align with these risks.

Antithrombotic Therapy for Percutaneous Cardiovascular Interventions: From Coronary Artery Disease to Structural Heart Interventions

Percutaneous cardiovascular interventions have changed dramatically in recent years, and the impetus given by the rapid implementation of novel techniques and devices have been mirrored by a refinement of antithrombotic strategies for secondary prevention, which have been supported by a significant burden of evidence from clinical studies. In the current manuscript, we aim to provide a comprehensive, yet pragmatic, revision of the current available evidence regarding antithrombotic strategies in the domain of percutaneous cardiovascular interventions. We revise the evidence regarding antithrombotic therapy for secondary prevention in coronary artery disease and stent implantation, the complex interrelation between antiplatelet and anticoagulant therapy in patients undergoing percutaneous coronary intervention with concomitant atrial fibrillation, and finally focus on the novel developments in the secondary prevention after structural heart disease intervention. A special focus on treatment individualization is included to emphasize risk and benefits of each therapeutic strategy.

The optimal duration of dual antiplatelet therapy after coronary stent implantation: to go too far is as bad as to fall short

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is key for secondary prevention of recurrent coronary ischemic events and stent thrombosis. For this purpose, DAPT showed superior efficacy compared to aspirin alone, but it is also associated with an increased risk of major, and potentially fatal, bleeding. Hence, while secondary prevention with aspirin monotherapy is generally maintained for an indefinite period, the duration of DAPT after the index event is still debated. Multiple trials have challenged the guideline recommended standard of care of 12 months of DAPT duration. These studies tested on one side a treatment reduction to 6 or 3 months, and on the other side an extension of treatment beyond 12 months in order to define the optimal DAPT duration maximizing the anti-ischemic protection and minimizing bleeding. In this document we sought to summarize the existing evidence from more than 18 randomized controlled trials in the field, and discuss the benefit and risks of prolonging/shortening DAPT duration. In addition, a specific focus on treatment individualization will outline the current, evidence-based, decision-making process for optimal DAPT duration selection after coronary stenting.

Factors affecting treatment, management and mortality in cases of retroperitoneal hematoma after cardiac catheterization: a single-center experience

INTRODUCTION

There is little information available on the clinical aspects, results, treatment and management of cardiac catheterization-related retroperitoneal hematoma. Data on the subject are rather limited, and current publications are based on a limited number of retrospective cohort studies and case reports.

AIM

To perform a retrospective analysis of the demographic, clinical, and in-hospital results of patients who developed retroperitoneal hematoma (RPH) after cardiac catheterization (CC).

MATERIAL AND METHODS

The cases of 124,064 patients who had CCs between January 2010 and October 2016 were retrospectively analyzed. Patients diagnosed with RPH were classified into three groups depending on the method of treatment: conservative (group 1), endovascular stenting (group 2), and surgery (group 3). The independent risk factors, based on RPH-related mortality, were determined by logistic regression analysis.

RESULTS

Of the 68 (0.054%) patients with RPH, 75% received conservative treatment, 13.2% underwent angiographic stent placement, and 11.7% had surgical treatment. Red blood cell packets (RBCPs) (p = 0.043), duration of hospitalization (p = 0.007), and mortality rates (p = 0.006) were statistically significantly higher in group 3 in comparison to the other groups. Multivariate subgroup analysis was conducted to determine mortality rates, with post-procedural highest creatinine ≥ 2 mg/dl and RBCPs ≥ 10 established as independent risk factors.

CONCLUSIONS

Hemodynamically stable patients with no active hemorrhaging are shown to have good results with conservative treatment. We believe that endovascular methods should be used initially for hemodynamically unstable patients, while surgical treatment should be employed in cases where endovascular methods fail or abdominal compartment syndrome develops.

Antithrombotic management in patients with percutaneous coronary intervention requiring oral anticoagulation

The dynamic evolution of therapeutic options including the use of vitamin K antagonists (VKA), non-vitamin K oral anticoagulants (NOAC), more potent antiplatelet drugs as well as new generation drug-eluting stents could lead to the view that the current recommendations on the management of patients with percutaneous coronary intervention (PCI) requiring oral anticoagulation do not keep up with the results of several clinical studies published within the last 5 years. In the present overview, we summarize the recent advances in antithrombotic management used in atrial fibrillation patients undergoing PCI for stable coronary artery disease or acute coronary syndrome (ACS). The safety and efficacy of prasugrel and ticagrelor taken with oral anticoagulants also remain to be established in randomized trials; therefore the P2Y₁₂ inhibitor clopidogrel on top of aspirin or without is now recommended to be used together with a VKA or NOAC. It is still unclear which dose of a NOAC in combination with antiplatelet agents and different stents should be used in this clinical setting and whether indeed NOAC are safer compared with VKA in such cardiovascular patients. Moreover, we discuss the use of anticoagulation in addition to antiplatelet therapy for secondary prevention in patients with ACS. To minimize bleeding risk in anticoagulated patients following PCI or ACS, the right agent should be prescribed to the right patient at the right dose and supported by regular clinical evaluation and laboratory testing, especially assessment of renal function when a NOAC is used.