Analysis of post-extraction bleeding in patients taking antithrombotic therapy using data from the longevity improvement and fair evidence study

BACKGROUND

Several studies have investigated post-extraction bleeding in patients on antithrombotic therapy, but most included a small sample size.

OBJECTIVE

This study aimed to analyse post-extraction bleeding in patients on antithrombotic therapy using data from a large database.

MATERIALS AND METHODS

Claims data of National Health Insurance and Late-Stage Elderly Healthcare System enrollees who underwent tooth extraction between October 2014 and March 2019 (n = 107 767) in a large multiregional cohort study (Longevity Improvement and Fair Evidence study) were included. Antithrombotic therapy was determined based on the drug codes used at the time of tooth extraction (classified into six groups: no antithrombotic, single antiplatelet, dual antiplatelet, Direct Oral Anticoagulant, warfarin and combined antiplatelet and anticoagulant therapies). The outcome was defined as the presence of "post-extraction bleeding" as a receipt disease name in the same month as tooth extraction. To examine the association between antithrombotic therapy and post-extraction bleeding in detail, multiple logistic regression analysis was performed with post-extraction bleeding as the objective variable; each antithrombotic therapy as the explanatory variable; and age, sex and comorbidities as adjustment variables.

RESULTS

Antithrombotic therapy was administered in 14 343 patients (13.3%), and post-extraction bleeding was observed in 419 patients (0.4%). The rate of post-extraction bleeding was significantly lower in the no antithrombotic therapy and single antiplatelet groups than that in the other groups (odds ratio: 2.00-9.02).

CONCLUSION

The frequency of post-extraction bleeding is high in patients on anticoagulation or dual antithrombotic therapy. Therefore, careful preparation before extraction is necessary in these patients.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Management and Pharmacological Treatment of Peripheral Arterial Disease

Background: Peripheral arterial disease (PAD) is a complex, heterogeneous condition that has become a leading health concern globally. Peripheral arterial disease often co-exists with other vascular disease states, including cerebrovascular and cardiovascular disease. Optimal therapy for managing symptoms and progression of disease employs non-pharmacological, pharmacological, and contemporary revascularisation techniques to improve clinical outcomes and quality of life. However, large well-designed randomised control trials (RCT) and corresponding evidence-based guidelines for management of PAD are lacking, with current practice standards often extrapolated from evidence in coronary artery disease.Purpose: This review article aims to discuss currently accepted best pharmacological practice for PAD.Method: Relevant articles were searched between May 2023 and January 2024 through PubMed, Cochrane Library, Google Scholar and international guidelines, focusing on pharmacological management for PAD.Results: This narrative review discusses holistic pharmacological treatments for PAD.

Combined transcatheter aortic valve and tricuspid valve-in-valve implantation in a patient with a mitral mechanical prosthesis

Despite progressively uncommon in Western countries, rheumatic heart disease still portrays a significant global burden. In elderly or high-surgical risk patients, plurivalvular disease may require a complex percutaneous approach. Transcatheter aortic valve implantation (TAVI) in patients with previous monoleaflet mitral prosthesis is challenging due to interference between the aortic valve and the rigid mitral mechanical prosthesis "ring." Prior cases report the use of CoreValve or Edwards Sapien aortic valves in patients with adequate mitro-aortic distance. Performing a second major procedure, such as tricuspid valve-in-valve (TVIV), sequentially during a single percutaneous intervention, increases treatment complexity. An 83-year-old woman with rheumatic heart disease, with previous implantation of a Bjork-Shiley monoleaflet mitral prosthesis, and Carpentier-Edwards 29 tricuspid bioprosthesis presented with decompensated heart failure due to severe aortic stenosis and tricuspid bioprosthesis stenosis. After HeartTeam discussion, the patient was deemed as inoperable due to a prohibitive surgical risk. As an alternative, a TAVI (Navitor FlexNav) and a transcatheter TVIV replacement (Edwards Sapiens 3 Ultra) were discussed and proposed, with both techniques being performed sequentially in a single procedure. TAVI in a patient with a previous monoleaflet mitral mechanical prosthesis and TVIV may be a feasible approach in inoperable patients with plurivalvular disease.

Antiplatelet Therapy and Anticoagulation before, during, and after Acute Coronary Syndrome

Acute coronary syndrome (ACS) remains a major challenge in clinical practice, requiring rapid and effective antithrombotic treatment to mitigate adverse ischemic events while minimizing the risk of bleeding. In recent years, results from several clinical trials addressing this issue through various approaches have substantially improved the treatment landscape for patients presenting with ACS. The emergence of new, potent P2Y12 inhibitors has significantly enhanced thrombotic risk reduction and different strategies for de-escalating and shortening dual antiplatelet therapy (DAPT) have demonstrated promising outcomes in reducing bleeding rates. Furthermore, data from ongoing trials focusing on novel therapeutic agents and investigating alternative treatment strategies to optimize outcomes for ACS patients are expected in the next few years. In this review, we summarize the current knowledge and emphasize the critical role of individualized treatment approaches tailored to patient-specific risk factors and individual clinical scenarios.

Rationale and design for the randomized placebo-controlled double-blind trial studying the effect of single antiplatelet therapy (clopidogrel) versus dual antiplatelet therapy (clopidogrel/acetylsalicylic acid) on the occurrence of atherothrombotic events following lower extremity peripheral transluminal angioplasty (CLEAR-PATH)

RATIONALE

Antiplatelet therapy (APT) is the standard of care after endovascular revascularization (EVR) in patients with peripheral artery disease (PAD). APT aims to prevent both major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Nonetheless, the rates of MACE and MALE after EVR remain high. In coronary artery and cerebrovascular disease, dual APT (DAPT)compared to acetylsalicylic acid alone has proven to reduce MACE without increasing the risk of major bleeding when applied for a restricted number of weeks. However, within the PAD population, insufficient data are available to understand the potential attributable effect of DAPT over single APT (SAPT). Therefore, prospective randomized studies in targeted study populations are warranted.

TRIAL DESIGN

CLEAR-PATH is a Dutch multicenter, double-blind, placebo-controlled, randomized trial comparing SAPT (clopidogrel 75mg plus placebo) with DAPT (clopidogrel 75mg plus acetylsalicylic acid 80mg) in patients with PAD undergoing EVR. CLEAR-PATH includes a time-to-event analysis with a follow-up of one year. The primary composite efficacy endpoint consists of all-cause mortality, nonfatal stroke, nonfatal myocardial infarction, severe limb ischemia, (indication for) re-intervention due to any symptomatic restenosis, re-occlusion, or due to acute limb ischemia, and major amputation. The primary safety endpoint contains major bleeding following the Thrombolysis In Myocardial Infarction classification. The enrolment started in August 2022. In total 450 primary efficacy outcome events are required which expectedly amounts to 1696 subjects. Recruitment will take approximately 36 months.

CONCLUSION

CLEAR-PATH will assess the efficacy and safety of DAPT compared to SAPT following EVR in PAD patients.

Arterial Thromboembolism in Japanese Patients With Cancer: Incidence, Predictors, and Survival Impact

Background

Thromboembolism is a significant complication for patients with cancer, leading to treatment interruptions and poor outcomes.

Objectives

The aim of this study was to investigate the incidence of arterial thromboembolism (ATE) within cancer populations, identify the predictors of ATE, and determine its survival impact.

Methods

A retrospective multicenter study was performed using data from the Osaka Cancer Registry linked with administrative data from 2010 to 2015. Patients were monitored for 5 years after cancer diagnosis, and ATE incidence was calculated with death as a competing risk. Fine and Gray competing risk regression models and Cox proportional hazards models were used to evaluate the predictors of ATE and the survival impact. Restricted mean survival time (RMST) was used to assess whether antithrombotic therapy after ATE contributed to improved survival.

Results

The cohort comprised 97,448 patients with cancer (42.3% women, median age 70 years). ATE incidence displayed an annual increase, peaking 1 year after cancer diagnosis (1-, 2-, 3-, 4-, and 5-year cumulative incidences were 1.29%, 1.77%, 2.05%, 2.22%, and 2.32%, respectively). Male sex, advanced age, advanced cancer stage, and hematologic malignancies correlated with a high risk for ATE. Patients with ATE had a 2-fold increased risk for mortality compared with those without ATE. The 90-day and 1-year RMST differences for those on antithrombotic therapy were 13.3 days (95% CI: 10.4-16.2 days; P < 0.001) and 57.8 days (95% CI: 43.1-72.5 days; P < 0.001), favoring the antithrombotic therapy group. The RMST differences varied by cancer stage.

Conclusions

The risk for ATE varies according to sex, age, and cancer progression and type. Antithrombotic therapy after ATE is associated with improved survival among patients with cancer.

A Case of Traumatic Hemothorax From an Isolated Thoracic Vertebral Fracture in an Elderly Patient on Combined Anticoagulant and Antiplatelet Therapy

Traumatic hemothorax is typically easy to diagnose because of the distinct onset of trauma with significant complaints such as severe chest pains. However, in elderly patients, the clinical symptoms are less clear and the frequent use of antithrombotic therapy may prolong the bleeding from a minor fracture. We report a case of traumatic hemothorax from an isolated thoracic vertebral fracture in an elderly patient on anticoagulant and antiplatelet therapy. A 91-year-old male on anticoagulant and antiplatelet therapy was admitted to our hospital with a complaint of persistent hemoptysis after a fall. A computed tomography (CT) demonstrated a worsening right hemothorax and thoracic vertebral fracture without lung or diaphragm injury, rib fracture, or contrast medium extravasation. The patient was taken to the operating room for the exploratory thoracoscopy and evacuation of the hemothorax without a preoperative diagnosis of the bleeding source. The bleeding was from the transverse laceration of the 10th thoracic vertebra exposed to the pleural space. The minor bleeding from the cancellous bone was prolonged, possibly due to the use of anticoagulant and antiplatelet therapy, which was not identified as contrast medium extravasation on chest CT before surgery. In cases of hemothorax with an unclear bleeding source, a vertebral fracture could be considered a source of bleeding even without any signs of bone dislocation or contrast medium extravasation on a CT scan.

In situ formed depot of elastin-like polypeptide-hirudin fusion protein for long-acting antithrombotic therapy

Thrombosis, induced by abnormal coagulation or fibrinolytic systems, is the most common pathology associated with many life-threatening cardio-cerebrovascular diseases. However, first-line anticoagulant drugs suffer from rapid drug elimination and risk of hemorrhagic complications. Here, we developed an in situ formed depot of elastin-like polypeptide (ELP)-hirudin fusion protein with a prodrug-like feature for long-term antithrombotic therapy. Highly secretory expression of the fusion protein was achieved with the assistance of the Ffu312 tag. Integration of hirudin, ELP, and responsive moiety can customize fusion proteins with properties of adjustable in vivo retention and controllable recovery of drug bioactivity. After subcutaneous injection, the fusion protein can form a reservoir through temperature-induced coacervation of ELP and slowly diffuse into the blood circulation. The biological activity of hirudin is shielded due to the N-terminal modification, while the activated key proteases upon thrombus occurrence trigger the cleavage of fusion protein together with the release of hirudin, which has antithrombotic activity to counteract thrombosis. We substantiated that the optimized fusion protein produced long-term antithrombotic effects without the risk of bleeding in multiple animal thrombosis models.

Ticagrelor vs clopidogrel when coadministered with bivalirudin in patients with acute coronary syndrome undergoing percutaneous coronary intervention

Background

The optimal perioperative antithrombotic strategy for patients with acute coronary syndrome (ACS) during percutaneous coronary intervention (PCI) remains controversial.

Objectives

To determine the safety and effectiveness of bivalirudin plus ticagrelor vs bivalirudin plus clopidogrel in patients with ACS undergoing PCI in the real world.

Methods

Between March 2016 and March 2019, 7234 patients with ACS who had undergone PCI, received bivalirudin periprocedurally, and were prescribed ticagrelor or clopidogrel were enrolled in a single-center, all-comer, modern, retrospective cohort study. Incidence rates of 12-month ischemia (cardiac death, myocardial infarction, or stroke), all-cause death, Bleeding Academic Research Consortium (BARC) type 2,3,5 bleeding, and BARC type 3,5 bleeding were compared between different groups.

Results

In total, 4960 patients received bivalirudin plus clopidogrel and 2274 patients received bivalirudin plus ticagrelor. Compared with bivalirudin plus clopidogrel, bivalirudin plus ticagrelor was associated with lower ischemic events (1.74% vs 2.84%; relative risk, 0.61; 95% CI, 0.41-0.91; P = .02) and stroke (0.05% vs 1.01%, P < .001) within 12 months after PCI without excessive risk of bleeding (BARC type 2,3,5 bleeding: 4.49% vs 3.76%, P = .22; BARC type 3,5 bleeding: 2.84% vs 2.02%, P = .08). The beneficial effects of bivalirudin plus ticagrelor were consistent among subgroups.

Conclusion

As an initial treatment strategy, bivalirudin plus ticagrelor could reduce the 12-month risk of ischemic events compared with bivalirudin plus clopidogrel significantly without increasing the bleeding risk in ACS patients undergoing PCI.

Optimal antithrombotic strategy following valve-in-valve transcatheter aortic and mitral valve replacement

The treatment of aortic and mitral valve disease requiring replacement has shifted to an increasing use of bioprosthetic heart valves. Due to their limited durability, there is a growing need for reintervention in the setting of failing bioprosthesis. Even though the gold standard for the treatment of failed bioprosthesis remains surgical repair or replacement, valve-in-valve (ViV) transcatheter aortic and mitral valve replacement have emerged as safe and effective alternatives for patients who are at high or prohibitive risk for surgery. Both procedures are associated with a substantial risk of postprocedural thromboembolic events and valvular thrombosis that is often higher than transcatheter replacement of native valves. With guidelines lacking specific protocols and a limited number of available studies, the optimal postprocedural antithrombotic therapy remains to be clarified. Multiple factors including valvular hemodynamics, the characteristics of the failing surgical valve, and the choice of the new transcatheter heart valve (THV) must be considered. Additionally, patients are often at an advanced age with multiple comorbidities and may require oral anticoagulation (OAC) due to other indications such as atrial fibrillation. Although the recommended antithrombotic strategy for native transcatheter aortic valve replacement (TAVR) is antiplatelet monotherapy with aspirin or a P2Y12 inhibitor in the absence of another anticoagulation indication, the use of oral anticoagulants including vitamin K antagonists (VKAs) and direct thrombin inhibitors has been shown to be effective in reducing valvular thrombosis and are commonly used after ViV procedures. Prospective studies investigating these results specifically for ViV transcatheter aortic and mitral valve replacement are needed to identify the optimal antithrombotic therapy.

Bleeding and thrombotic risk of different antiplatelet regimens posttranscatheter edge-to-edge mitral valve repair in patients with an indication for oral anticoagulation: Results from an all-comers national registry

BACKGROUND

Evidence-based recommendations for antithrombotic treatment in patients who have an indication for oral anticoagulation (OAC) after transcatheter edge-to-edge mitral valve repair (TEER) are lacking.

AIMS

To compare bleeding and thrombotic risk for different antithrombotic regimens post-TEER with MitraClip in an unselected population with the need for OACs.

METHODS

Bleeding and thrombotic complications (stroke and myocardial infarction) up to 3 months after TEER with mitraclip were evaluated in 322 consecutive pts with an indication for OACs. These endpoints were defined by the Mitral Valve Academic Research Consortium criteria and were compared between two antithrombotic regimens: single antithrombotic therapy with OAC (single ATT) and double/triple ATT with a combination of OAC and aspirin and/or clopidogrel (combined ATT).

RESULTS

Collectively, 108 (34%) patients received single ATT, 203 (63%) received double ATT and 11 (3%) received triple ATT. Bleeding events occurred in 67 patients (20.9%), with access site related events being the most frequent cause (37%). Bleeding complications were observed more frequently in the combined ATT group than in the single ATT group: 24% versus 14% [p = 0.03, adjusted RR: 0.55 (0.3-0.98)]. Within the combined group, the bleeding risk was 23% in the double ATT and 45% in the triple ATT group. Thrombotic complications occurred in only three patients (0.9%), and all belonged to the combined ATT group.

CONCLUSIONS

In patients with an indication for OACs, withholding of antiplatelet therapy post-TEER with Mitraclip was associated with a 45% reduction in bleeding and without a signal of increased thrombotic risk.

Successful Multimodal Treatment of Pancreatic Cancer With Extensive Superior Mesenteric Vein Thrombosis Utilizing Chemotherapy Combined With Direct Oral Anticoagulant

It is well known that portal vein thrombosis (PVT) sometimes occurs in pancreatic cancer (PC). However, no effective treatment plan for PVT in PC patients has yet been proposed. We experienced a successfully treated case of borderline resectable pancreatic cancer (PC-BR) with extensive superior mesenteric vein thrombosis utilizing intensive chemotherapy combined with direct oral anticoagulant. The thrombus disappeared and the tumor shrank, enabling curative surgery, and long-term survival for more than five years has been achieved. We report this successful case that we experienced as an option for the treatment of PC-BR with PVT in the future era when multimodal treatment is important.

High-Risk Aortic Plaque in Atrial Fibrillation: A Therapeutic Dilemma

Atrial fibrillation (AF), a common cardiac arrhythmia, is often accompanied by aortic plaques that are associated with an increased risk of embolic events, including stroke. Evidence-based management in this population is lacking. We present a case of a 77-year-old female with new-onset AF who was found to have a high-risk aortic plaque at the level of the ascending aorta and ostium of the right coronary artery. Definitive treatment for AF, cardioversion, high-risk aortic plaque, and cardiothoracic surgery, could not be performed due to the elevated risk of ischemic stroke and embolic complications. Based on existing literature, the cardiologist and cardiothoracic surgeon collaboratively decided to treat both conditions with anticoagulation, statin, and periodic imaging surveillance of high-risk aortic plaque. The patient was successfully managed without any thromboembolic complications despite an elevated risk. This case report provides a comprehensive literature review of managing AF with high-risk aortic plaques. It delves into the integration of anticoagulation and antiplatelet agents in the dual challenge of stroke prevention in AF and mitigating embolic risks associated with aortic plaques. To date, there has been no consensus on managing AF and high-risk aortic plaques; thus, we aim to fill this gap.

Treatments for COVID-19

The treatment for COVID-19 has evolved rapidly since the start of the pandemic and now consists mainly of antiviral and immunomodulatory agents. Antivirals, such as remdesivir and nirmatrelvir-ritonavir, have proved to be most useful earlier in illness (e.g., as outpatient therapy) and for less severe disease. Immunomodulatory therapies, such as dexamethasone and interleukin-6 or Janus kinase inhibitors, are most useful in severe disease or critical illness. The role of anti-SARS-CoV-2 monoclonal antibodies has diminished because of the emergence of viral variants that are not anticipated to be susceptible to these treatments, and there still is not a consensus on the use of convalescent plasma. COVID-19 has been associated with increased rates of venous thromboembolism, but the role of antithrombotic therapy is limited. Multiple investigational agents continue to be studied, which will alter current treatment paradigms as new data are released.

Sutureless Repair for Open Treatment of Inguinal Hernia: Three Techniques in Comparison

Currently, groin hernia repair is mostly performed with application of mesh prostheses fixed with or without suture. However, views on safety and efficacy of different surgical approaches are still partly discordant. In this multicentre retrospective study, three sutureless procedures, i.e., mesh fixation with glue, application of self-gripping mesh, and Trabucco's technique, were compared in 1034 patients with primary unilateral non-complicated inguinal hernia subjected to open anterior surgery. Patient-related features, comorbidities, and drugs potentially affecting the intervention outcomes were also examined. The incidence of postoperative complications, acute and chronic pain, and time until discharge were assessed. A multivariate logistic regression was used to compare the odds ratio of the surgical techniques adjusting for other risk factors. The application of standard/heavy mesh, performed in the Trabucco's technique, was found to significantly increase the odds ratio of hematomas (p = 0.014) and, most notably, of acute postoperative pain (p < 0.001). Among the clinical parameters, antithrombotic therapy and large hernia size were independent risk factors for hematomas and longer hospital stay, whilst small hernias were an independent predictor of pain. Overall, our findings suggest that the Trabucco's technique should not be preferred in patients with a large hernia and on antithrombotic therapy.

Percutaneous Coronary Interventions Using a Ridaforolimus-Eluting Stent in Patients at High Bleeding Risk

BACKGROUND

Patients treated with percutaneous coronary intervention are often considered to be at a high bleeding risk (HBR). Drug-eluting stents have been shown to be superior to bare-metal stents in patients with HBR, even when patients were given abbreviated periods of dual antiplatelet therapy (DAPT). Short DAPT has not been evaluated with the EluNIR ridaforolimus-eluting stent. The aim of this study was to evaluate the safety and efficacy of a shortened period of DAPT following implantation of the ridaforolimus-eluting stent in patients with HBR.

METHODS AND RESULTS

This was a prospective, multicenter, binational, single-arm, open-label trial. Patients were defined as HBR according to the LEADERS-FREE (Prospective Randomized Comparison of the BioFreedom Biolimus A9 Drug-Coated Stent versus the Gazelle Bare-Metal Stent in Patients at High Bleeding Risk) trial criteria. After percutaneous coronary intervention, DAPT was given for 1 month to patients presenting with stable angina. In patients presenting with an acute coronary syndrome, DAPT was given for 1 to 3 months, at the investigator's discretion. The primary end point was a composite of cardiac death, myocardial infarction, or stent thrombosis up to 1 year (Academic Research Consortium definite and probable). Three hundred fifteen patients undergoing percutaneous coronary intervention were enrolled, and 56.4% presented with acute coronary syndrome; 33.7% were receiving oral anticoagulation. At 1 year, the primary end point occurred in 15 patients (4.9%), meeting the prespecified performance goal of 14.1% (P<0.0001). Stent thrombosis (Academic Research Consortium definite and probable) occurred in 2 patients (0.6%). Bleeding Academic Research Consortium type 3 and 5 bleeding occurred in 6 patients (1.9%).

CONCLUSIONS

We observed favorable results in patients with HBR who underwent percutaneous coronary intervention with a ridaforolimus-eluting stent and received shortened DAPT, including a low rate of ischemic events and low rate of stent thrombosis.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03877848.

Review of Bleeding and Thrombotic Risks Associated With Antithrombotic Therapy After Transcatheter Structural Heart Interventions

Transcatheter structural heart interventions have drastically evolved over the past 2 decades. However, most catheterization procedures require the deployment of devices in the body; therefore, the adhesion of thrombi to those devices is a major problem, resulting in the requirement of a period of postprocedural antithrombotic regimen. However, in recent years, bleeding associated with these antithrombotic therapies has also become a major concern, attracting the attention of investigators. This is complicated by the fact that patients at high thrombotic risk are also at high bleeding risk, making the issue of administrating antithrombotic therapy challenging. The objective of this review was to identify the important issues and summarize the current status of postoperative antithrombotic therapy and assessment of the bleeding risk following transcatheter structural heart interventions such as transcatheter aortic valve replacement, transcatheter edge-to-edge repair, and transcatheter left atrial appendage occlusion.

Antithrombotic strategy in cancer patients comorbid with acute coronary syndrome and atrial fibrillation

It has been shown that patients with cancer have a longer expected life duration, benefiting from advanced medical therapy. Meanwhile, the risk of suffering from cardiovascular disease (CVD) has been increasing with ageing. A growing number of studies have elucidated the association between cancer and CVD. Cancer, atrial fibrillation (AF) and coronary artery disease share some common factors and interact with each other, such as obesity, aging, diabetes, and inflammation, but the potential specific mechanism is still unclear. In addition, cancer-specific and therapy-related factors may increase the risk of embolism and bleeding in patients with cancer than in general population. However, current available embolic and bleeding risk scores applied in patients with CVD may not be applicable for risk assessment in cancer patients, which would be difficult for clinicians to select an appropriate antithrombotic regimen and ensure the balance between bleeding and embolism. Moreover, different types of cancer have distinct risks, which may increase the complexity of antithrombotic therapy. In this review, we review the literature related to cancer, AF, and acute coronary syndrome, focusing on the epidemiological status, physiological mechanism, embolism and bleeding risks, and strategies of antithrombotic therapy.

Short- and Long-Term Mortality for Patients With and Without a Cancer Diagnosis Following Pulmonary Embolism in Denmark, 2000 to 2020: A Nationwide Study

BACKGROUND

New treatment regimens have been introduced in the past 20 years, which may influence the short- and long-term prognosis for patients with and without a cancer diagnosis following pulmonary embolism. However, newer studies investigating these trends are lacking. Therefore, we aimed to investigate the 30- and 31- to 365-day mortality following pulmonary embolism.

METHODS AND RESULTS

Using the Danish nationwide registries, patients with a diagnosis of pulmonary embolism between 2000 and 2020 were included. Age- and sex-standardized 30- and 31- to 365-day mortality was calculated and stratified by cancer status. In total, 60 614 patients (29.6% with recent cancer; mean age, 68.2 years) were included. The 30-day mortality for patients with no recent cancer decreased from 19.1% (95% CI, 17.9%-20.4%) in 2000 to 7.3% (95% CI, 6.7%-8.0%) in 2018 to 2020 (hazard ratio [HR], 0.36 [95% CI, 0.32-0.40]; P<0.001). The 30-day mortality for patients with recent cancer decreased from 32.2% (95% CI, 28.8%-36.6%) to 14.1% (95% CI, 12.7%-15.5%) (HR, 0.38 [95% CI, 0.33-0.44]; P<0.001). The 31- to 365-day mortality for patients with no recent cancer decreased from 12.5% (95% CI, 11.4%-13.6%) to 9.4% (95% CI, 8.6%-10.2%) (HR, 0.73 [95% CI, 0.64-0.83]; P<0.001).The 31- to 365-day mortality for patients with recent cancer remained stable: 39.4% (95% CI, 35.1%-43.7%) to 38.3% (95% CI, 35.9%-40.6%) (HR, 0.97 [95% CI, 0.84-1.12]; P=0.69).

CONCLUSIONS

From 2000 to 2020, improvements were observed in 30-day mortality following pulmonary embolism regardless of cancer status. For patients with recent cancer, 31- to 365-day mortality did not improve, whereas a minor improvement was observed for patients without recent cancer.

First-in-human study to assess the safety, pharmacokinetics, and pharmacodynamics of BMS-986141, a novel, reversible, small-molecule, PAR4 agonist in non-Japanese and Japanese healthy participants

BMS-986141 is a novel, oral, protease-activated, receptor 4 (PAR4)-antagonist that exhibited robust antithrombotic activity and low bleeding risk in preclinical studies. The pharmacokinetic, pharmacodynamic, and tolerability profiles of BMS-986141 in healthy participants were assessed in a randomized, double-blind, placebo-controlled, single-ascending-dose (SAD; N = 60) study; a multiple-ascending-dose (MAD; N = 32) study; and a Japanese MAD (JMAD; N = 32) study. Exposure was dose-proportional for BMS-986141 2.5 mg and 150 mg; maximum concentrations were 17.6 ng/mL and 958 ng/mL; and areas under the curve (AUC) to infinity were 183 h* × ng/mL and 9207 h* × ng/mL, respectively. Mean half-life ranged from 33.7 to 44.7 hours across dose panels. The accumulation index following once-daily administration for 7 days suggested a 1.3- to 2-fold AUC increase at steady state. In the SAD study, BMS-986141 75 and 150 mg produced ≥80% inhibition of 25-100 µM PAR4 agonist peptide (AP)-induced platelet aggregation, without affecting PAR1-AP-induced platelet aggregation, through ≥24 hours postdose. In the MAD and JMAD studies, BMS-986141 doses ≥10 mg completely inhibited 12.5 μM and 25 μM PAR4-AP-induced platelet aggregation through 24 hours. This study found BMS-986141 was safe and well tolerated, with dose-proportional pharmacokinetics and concentration-dependent pharmacodynamics in healthy participants over a wide dose range. ClinicalTrials.gov ID: NCT02341638.

Left atrial appendage closure for stroke prevention in atrial fibrillation patients: A promise that came true

Anticoagulation therapy plays a crucial role in the management of atrial fibrillation (AF), considering the high morbidity and mortality of AF-related ischemic strokes. With the plausible hypothesis that left atrial appendage is the main source of thrombus in AF patients, left atrial appendage closure (LAAC) has been regarded as a potential substitute to oral anticoagulation in order to meet the unmet needs for stroke prevention, particularly in patients with high bleeding risk. Notable advancements in safety, efficacy, and device innovation have been made in recent years, albeit concerns still remain regarding the insufficient efficacy data, device-related complications, and the need for procedural optimization. We aim to review current knowledge about LAAC and provide potential future directions for the remaining key issues.

Preventive Therapies in Peripheral Arterial Disease

Atherosclerosis, while initially deemed a bland proliferative process, is now recognized as a multifactorial-lipoprotein-mediated inflammation-driven pathway. With the rising incidence of atherosclerotic disease of the lower extremity arteries, the healthcare burden and clinical morbidity and mortality due to peripheral artery disease (PAD) are currently escalating. With a healthcare cost burden of over 21 billion USD and 200 million patients afflicted worldwide, accurate knowledge regarding the pathophysiology, presentation, and diagnosis of the disease is crucial. The role of lipoproteins and their remnants in atherosclerotic vessel occlusion and plaque formation and progression has been long established. This review paper discusses the epidemiology, pathophysiology, and presentation of PAD. PAD has been repeatedly noted to portend to poor cardiovascular and limb outcomes. We discuss major therapeutic avenues for the prevention of major cardiovascular adverse events and major limb adverse events in patients with PAD.

Antithrombotic treatment following percutaneous coronary intervention in patients with high bleeding risk

PURPOSE OF REVIEW

Review the clinical outcomes of different antithrombotic strategies in patients with high bleeding risk (HBR) after percutaneous coronary intervention (PCI).

RECENT FINDINGS

Patients with HBR after PCI include those with advanced age (e.g. >75 years of age), a prior history of major bleeding, anemia, chronic kidney disease, and those with indications for long-term anticoagulation. Strategies that successfully decrease bleeding risk in this population include shorter durations of dual antiplatelet therapy (DAPT; of 1-3 months) followed by single antiplatelet therapy with aspirin or a P2Y 12 inhibitor, or de-escalating from a more potent P2Y 12 inhibitor (prasugrel or ticagrelor) to less potent antiplatelet regimens (aspirin with clopidogrel or half-dose ticagrelor or half-dose prasugrel). Patients on DAPT, and a full dose anticoagulation for other indications, have a lower risk of major bleeding without an increase in 1-2-year adverse ischemic events, when rapidly switched from DAPT to a single antiplatelet therapy (within a week after PCI) with aspirin or clopidogrel. Longer term data on the benefits and risks of these strategies is lacking.

SUMMARY

In patients with HBR after PCI, shorter durations of DAPT (1-3 months) decrease the risk of major bleeding without increasing the risk of adverse ischemic events.

Network Meta-Analysis of Initial Antithrombotic Regimens After Left Atrial Appendage Occlusion

BACKGROUND

The optimal antithrombotic therapy following left atrial appendage occlusion (LAAO) in patients with nonvalvular atrial fibrillation (AF) remains uncertain.

OBJECTIVES

In this study, the authors sought to compare the efficacy and safety of various antithrombotic strategies after LAAO.

METHODS

We searched the Medline, Cochrane, EMBASE, LILACS, and ClinicalTrials.gov databases for studies reporting outcomes after LAAO, stratified by antithrombotic therapy prescribed at postprocedural discharge. Direct oral anticoagulants (DOACs), vitamin K antagonists (VKAs), single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), DOAC plus SAPT, VKA plus SAPT, and no antithrombotic therapy were analyzed. We performed a frequentist random effects model network meta-analysis to estimate the OR and 95% CI for each comparison. P-scores provided a ranking of treatments.

RESULTS

Forty-one studies comprising 12,451 patients with nonvalvular AF were included. DAPT, DOAC, DOAC plus SAPT, and VKA were significantly superior to no therapy to prevent device-related thrombosis. DOAC was associated with lower all-cause mortality than VKA (OR: 0.39; 95% CI: 0.17-0.89; P = 0.03). Compared with SAPT, DAPT was associated with fewer thromboembolic events (OR: 0.50; 95% CI: 0.29-0.88; P = 0.02), without a difference in major bleeding. In the analysis of P-scores, DOAC monotherapy was the strategy most likely to have lower thromboembolic events and major bleeding.

CONCLUSIONS

In this network meta-analysis comparing initial antithrombotic therapies after LAAO, monotherapy with DOAC had the highest likelihood of lower thromboembolic events and major bleeding. DAPT was associated with a lower incidence of thromboembolic events compared with SAPT and may be a preferred option in patients unable to tolerate anticoagulation.

Antithrombotic Therapy for Primary and Secondary Prevention of Ischemic Stroke: JACC State-of-the-Art Review

Stroke is a devastating condition with significant morbidity and mortality worldwide. Antithrombotic therapy plays a crucial role in both primary and secondary prevention of stroke events. Single or dual antiplatelet therapy is generally preferred in cases of large-artery atherosclerosis and small-vessel disease, whereas anticoagulation is recommended in conditions of blood stasis or hypercoagulable states that mostly result in red thrombi. However, the benefit of antithrombotic therapies must be weighed against the increased risk of bleeding, which can pose significant challenges in the pharmacological management of this condition. This review provides a comprehensive summary of the currently available evidence on antithrombotic therapy for ischemic stroke and outlines an updated therapeutic algorithm to support physicians in tailoring the strategy to the individual patient and the underlying mechanism of stroke.

Stroke risk related to intentional discontinuation of antithrombotic therapy for invasive procedures

OBJECTIVE

Antithrombotic medications pose a challenge for conducting surgical or invasive procedures, because their discontinuation is required to avoid postprocedural hemorrhagic complications but potentially increases the ischemic risk for the patient. This study aimed to estimate the increased risk of developing cerebral ischemic events during hospitalization requiring discontinuation of antithrombotic therapy.

METHODS

This investigation was a single-center retrospective observational study. Clinical data in patients scheduled for admission between January 1, 2021, and December 31, 2022, were collected. Patients requiring discontinuation of antithrombotic therapy were identified by referring to the admission database. Patients who developed cerebral ischemia were identified by referring to the institution's stroke center database.

RESULTS

Seven hundred ninety-six patients scheduled for nonneurosurgical procedures and 39 scheduled for neurosurgical procedures underwent discontinuation of antithrombotic therapy. Anticoagulation therapy was prescribed in 40.0%, and antiplatelet therapy was prescribed in 69.1% of the patients. A total of 9.2% of the entire cohort of patients were receiving both anticoagulation and antiplatelet therapy. Bridging therapy was administered in 20.9% of nonneurosurgical patients. No ischemic event was observed in the patients undergoing neurosurgical procedures. Among the entire cohort, 3 patients encountered some kind of thrombotic event-2 of which were cerebral ischemia-accounting for an incidence of 0.24%, which was significantly higher than incidental in-hospital stroke unrelated to discontinuation of antithrombotic therapy (p = 0.04). Patients undergoing both anticoagulation and antiplatelet therapy harbored a significantly higher risk for cerebral ischemia related to discontinuation of antithrombotic therapy (p < 0.0001).

CONCLUSIONS

Discontinuing antithrombotic therapy during hospitalization for elective invasive procedures-including neurosurgical procedures-entailed a relatively small risk of developing cerebral ischemic events, but the risk was significantly higher compared to hospitalized patients without discontinuation of antithrombotic therapy.

Young stroke patient with patent foramen ovale and intracranial stenosis-a case report

The prevalence of patent foramen ovale is approximately 20% in the global population. In patients under the age of 55 years, it has been proven as a cause of acute ischemic embolic stroke of otherwise undetermined source. We present a case of a 25-year-old patient who experienced an acute stroke of dominant hemisphere due to internal carotid artery occlusion.The patient underwent mechanical thrombectomy, followed by acute intracranial stenting due to persistent subocclusion of internal carotid artery. Further diagnostic investigations revealed a significant patent foramen ovale. During subsequent follow-up periods, the patient encountered multiple transient ischemic attacks despite receiving antithrombotic therapy. The indicated angiography examination revealed in-stent stenosis and thrombosis, which were resolved after optimal medical treatment. Following patent foramen ovale closure, the patient remained free from further neurological events during the subsequent two-year follow-up periods. This case emphasizes the necessity of comprehensive diagnostic evaluations in young individuals with stroke and underscores the importance of prudent slection of medical therapies.

Protein S Deficiency and COVID-19: A Brutal Combination Leading to Acute Submassive Bilateral Pulmonary Embolism

Protein S deficiency is a form of inherited thrombophilia that occurs due to low levels of or improper function of protein S. The role of protein S is to inactivate procoagulant factors, and a deficiency results in an increased risk of thrombotic events. The coronavirus disease 2019 (COVID-19) infection has also been studied to increase the risk of venous thromboembolism (VTE) due to an interplay of several mechanisms. However, the risk of VTE in patients affected by both of these disease processes simultaneously has not been thoroughly studied, and so recommendations regarding routine screening and prophylaxis of VTE have also not been established. We discuss the case of a 46-year-old woman with a past history of protein S deficiency and a recent COVID-19 infection who presented with complaints of shortness of breath. Upon examination, she was found to be hypoxic and tachycardic. A computed tomography angiography of the chest was done and revealed acute submassive bilateral pulmonary embolism with right heart strain and pulmonary infarcts. She was initially treated with intravenous heparin and later transitioned to oral anticoagulation for a minimum of six months.

Novel Tissue Factor Inhibition for Thromboprophylaxis in COVID-19: Primary Results of the ASPEN-COVID-19 Trial

BACKGROUND

Thrombo-inflammation is central to COVID-19-associated coagulopathy. TF (tissue factor), a driver disordered coagulation and inflammation in viral infections, may be a therapeutic target in COVID-19. The safety and efficacy of the novel TF inhibitor rNAPc2 (recombinant nematode anticoagulation protein c2) in COVID-19 are unknown.

METHODS

ASPEN-COVID-19 was an international, randomized, open-label, active comparator clinical trial with blinded end point adjudication. Hospitalized patients with COVID-19 and elevated D-dimer levels were randomized 1:1:2 to lower or higher dose rNAPc2 on days 1, 3, and 5 followed by heparin on day 8 or to heparin per local standard of care. In comparisons of the pooled rNAPc2 versus heparin groups, the primary safety end point was major or nonmajor clinically relevant International Society of Thrombosis and Haemostasis bleeding through day 8. The primary efficacy end point was proportional change in D-dimer concentration from baseline to day 8, or discharge if before day 8. Patients were followed for 30 days.

RESULTS

Among 160 randomized patients, median age was 54 years, 43.1% were female, and 38.8% had severe baseline COVID-19. There were no significant differences between rNAPc2 and heparin in bleeding or other safety events. Overall, median change in D-dimer was -16.8% (interquartile range, -45.7 to 36.8; P=0.41) with rNAPc2 treatment and -11.2% (-36.0 to 34.4; P=0.91) with heparin (P_intergroup=0.47). In prespecified analyses, in severely ill patients, D-dimer levels tended to increase more within the heparin (median, 29.0% [-14.9 to 145.2]; P=0.02) than the rNAPc2 group (median, 25.9% [-49.1 to 136.4]; P=0.14; P_intergroup=0.96); in mildly ill patients, D-dimer levels were reduced within each group with a numerically greater reduction with rNAPc2 versus heparin (rNAPc2 median, -32.7% [-44.7 to 4.3]; P=0.007 and heparin median, -16.8% [-36.0 to 0.5]; P=0.008, P_intergroup=0.34).

CONCLUSIONS

rNAPc2 treatment in hospitalized patients with COVID-19 was well tolerated without excess bleeding or serious adverse events but did not significantly reduce D-dimer more than heparin at day 8.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04655586.

Peri- and Post-procedural Anticoagulation with Left Atrial Appendage Occlusion Devices

In patients with atrial fibrillation and high stroke risk, anticoagulation with direct oral anticoagulants or vitamin K antagonists is the standard of care for stroke prevention. The benefit of anticoagulation is driven by attenuating the risk of thrombus formation in the left atrial appendage. Percutaneous left atrial appendage occlusion offers an alternative therapeutic strategy for stroke prevention in patients with high bleeding risk or contraindications for long-term anticoagulation. This review of the current literature delineates the standard protocols of peri- and post-procedural anticoagulation/antithrombotic therapy after left atrial appendage occlusion, the complications of the procedure, and the risk of device-related thrombosis and of incomplete occlusion of the appendage. Finally,the limitations and gaps in the literature are identified.

Impact of antithrombotic therapy on clinical outcomes in patients with type B acute aortic syndrome

Objective

Antithrombotic therapy has the potential to interfere with false lumen thrombosis. In type B acute aortic syndrome, the degree of false lumen thrombosis affects clinical outcomes. We aimed to explore the association of antithrombotic therapy with the prognosis of patients with type B acute aortic syndrome.

Methods

We reviewed 406 patients with type B acute aortic syndrome who were discharged alive with and without antithrombotic therapy. The primary outcome was aorta-related adverse events, defined as a composite of aorta-related death, aortic rupture, aortic repair, and progressive aortic dilation.

Results

Of the 406 patients, 64 (16%) were discharged with antithrombotic therapy and 342 (84%) were discharged without antithrombotic therapy. A total of 249 patients (61%) presented with intramural hematoma with complete thrombosis of the false lumen, and 157 patients (39%) presented with aortic dissection. During a median follow-up of 4.6 years, 32 patients (50%) in the antithrombotic group and 93 patients (27%) in the nonantithrombotic group had a primary outcome event. Cumulative incidence of aorta-related events at 1 and 3 years with death as the competing risk was higher in the antithrombotic group than in the nonantithrombotic group (19% ± 5% vs 9% ± 2% at 1 year and 40% ± 7% vs 17% ± 2% at 3 years, P < .001).

Conclusions

Antithrombotic therapy might be associated with an increased risk of aorta-related events in patients with type B acute aortic syndrome.

Left atrial appendage occlusion after thromboembolic events or left atrial appendage sludge during anticoagulation therapy: Is two better than one? Real-world experience from a tertiary care hospital

BACKGROUND

The role of left atrial appendage occlusion (LAAO) for atrial fibrillation patients that during oral anticoagulant therapy (OAC) suffer from ischemic events or present LAA sludge, and the best postinterventional anticoagulant regimen, need to be defined. We present our experience with a hybrid approach of LAAO+ lifelong OAC therapy in this cohort of patients.

METHODS

Out of 425 patients treated with LAAO, 102 underwent LAAO because, despite OAC, suffered from ischemic events or presented with LAA sludge. Patients without high bleeding risk were discharged with the aim of maintaining lifelong OAC. This cohort was then matched to a population who underwent LAAO in primary ischemic events prevention. The primary endpoint was the composite of all-cause death and major adverse cardiovascular events consisting of ischemic stroke, systemic embolism (SE), and major bleeding.

RESULTS

Procedural success was 98%, and 70% of patients were discharged with anticoagulant therapy. After a median follow-up of 47.2 months, the primary endpoint occurred in 27 patients (26%). At multivariate analyses, coronary artery disease (OR 5.1, CI 1.89-14.27, p = .003) and OAC at discharge (OR 0.29, CI 0.11-0.80, p = .017) were associated with the primary endpoint. After propensity score matching, no significant difference was found in the survival free from the primary endpoint according to the indication for LAAO (p = .19).

CONCLUSIONS

In this high-ischemic risk cohort, LAAO + OAC seem a long-term safe and effective therapeutical approach, with no difference in the survival free from the primary endpoint according to the indication for LAAO in a matched cohort.

Preventing Lower Limb Graft Thrombosis after Infrainguinal Arterial Bypass Surgery with Antithrombotic Agents (PATENT Study): An International Expert Based Delphi Consensus

(1) Background: High-level evidence on antithrombotic therapy after infrainguinal arterial bypass surgery in specific clinical scenarios is lacking. (2) Methods: A modified Delphi procedure was used to develop consensus statements. Experts voted on antithrombotic treatment regimens for three types of infrainguinal arterial bypass procedures: above-the-knee popliteal artery; below-the-knee popliteal artery; and distal, using vein, prosthetic, or biological grafts. The treatment regimens for these nine procedures were then voted on in three clinical scenarios: isolated PAOD, atrial fibrillation, and recent coronary intervention. (3) Results: The survey was conducted with 28 experts from 15 European countries, resulting in consensus statements on 25/27 scenarios. Experts recommended single antiplatelet therapy after above-the-knee popliteal artery bypasses regardless of the graft material used. For below-the-knee popliteal artery bypasses, experts suggested combining single antiplatelet therapy with low-dose rivaroxaban if the graft material used was autologous or biological. They did not recommend switching to triple therapy for patients on oral anticoagulants for atrial fibrillation or dual antiplatelet therapy in any scenario. (4) Conclusions: Great inconsistency in the antithrombotic therapy administered was found in this study. This consensus offers guidance for scenarios that are not covered in the current ESVS guidelines but must be interpreted within its limitations.

Implementation of a Patient Questionnaire in Community Pharmacies to Improve Care for Patients Using Combined Antithrombotic Therapy: A Qualitative Study

For several indications or combinations of indications the use of more than one antithrombotic agent is required. The duration of combined antithrombotic therapy depends on indication and patient characteristics. This study investigated the use of an antithrombotic questionnaire tool that had been developed for pharmacists to detect patients with possible incorrect combined antithrombotic therapy. The objective of this study was to identify potential barriers and facilitators that could influence the implementation of the developed antithrombotic questionnaire tool in daily community pharmacy practice. A qualitative study was conducted at 10 Dutch community pharmacies in which the antithrombotic questionnaire tool had been used with 82 patients. Semi-structured interviews were conducted with pharmacy staff who used the antithrombotic questionnaire tool. The interview questions to identify barriers and facilitators were based on the Consolidated Framework for Implementation Research. The interview data were analysed using a deductive thematic analysis. Ten staff members from nine different pharmacies were interviewed. Facilitators for implementation were that the questionnaire was easily adaptable and easy to use, as well as the relative short duration to administer the questionnaire. A possible barrier for using the questionnaire was a lower priority for using the questionnaire at moments when the workload was high. The pharmacists estimated that the questionnaire could be used for 70-80% of the patient population and they thought that it was a useful addition to regular medication surveillance. The antithrombotic questionnaire tool can be easily implemented in pharmacy practice. To implement the tool, the focus should be on integrating its use into daily activities. Pharmacists can use this tool in addition to regular medication surveillance to improve medication safety in patients who use combined antithrombotic therapy.

Antithrombotic Therapy in Peripheral Artery Disease: Current Evidence and Future Directions

Patients with peripheral artery disease (PAD) are at an increased risk of major adverse cardiovascular events, and those with disease in the lower extremities are at risk of major adverse limb events primarily driven by atherothrombosis. Traditionally, PAD refers to diseases of the arteries outside of the coronary circulation, including carotid, visceral and lower extremity peripheral artery disease, and the heterogeneity of PAD patients is represented by different atherothrombotic pathophysiology, clinical features and related antithrombotic strategies. The risk in this diverse population includes systemic risk of cardiovascular events as well as risk related to the diseased territory (e.g., artery to artery embolic stroke for patients with carotid disease, lower extremity artery to artery embolism and atherothrombosis in patients with lower extremity disease). Moreover, until the last decade, clinical data on antithrombotic management of PAD patients have been drawn from subanalyses of randomized clinical trials addressing patients affected by coronary artery disease. The high prevalence and related poor prognosis in PAD patients highlight the pivotal role of tailored antithrombotic therapy in patients affected by cerebrovascular, aortic and lower extremity peripheral artery disease. Thus, the proper assessment of thrombotic and hemorrhagic risk in patients with PAD represents a key clinical challenge that must be met to permit the optimal antithrombotic prescription for the various clinical settings in daily practice. The aim of this updated review is to analyze different features of atherothrombotic disease as well as current evidence of antithrombotic management in asymptomatic and secondary prevention in PAD patients according to each arterial bed.

Medical Management of Peripheral Artery Disease

Peripheral artery disease (PAD) is a common type of atherosclerotic disease of the lower extremities associated with reduced quality of life and ambulatory capacity. Major adverse cardiovascular events and limb amputations are the leading cause of morbidity and mortality in this population. Optimal medical therapy is therefore critical in these patients to prevent adverse events. Risk factor modifications, including blood pressure control and smoking cessation, in addition to antithrombotic agents, peripheral vasodilators, and supervised exercise therapy are key pillars of medical therapy. Revascularization procedures represent key touch points between patients and health care providers and serve as opportunities to optimize medical therapy and improve long-term patency rates and outcomes. This review summarizes the aspects of medical therapy that all providers should be familiar with when caring for patients with PAD in the peri-revascularization period.

Perioperative Management of Antithrombotic Therapy in Patients Who Undergo Dental Procedures: A Systematic Review of the Literature and Network Meta-Analysis

BACKGROUND

The surgical dental treatment of subjects admitted for anticoagulants therapy represents a consistent risk for peri-operative bleeding. The aim of the present study was to investigate the clinical findings of dental surgery operative management of the patients under anticoagulants drugs protocol.

METHODS

The literature screening was performed using Pubmed/Medline, EMBASE and Cochrane library, considering only randomized clinical trials (RCTs) papers. No limitations about the publication's period, follow-up time or clinical parameters were considered.

RESULTS

A total of eight RCTs were included for the qualitative synthesis. No thromboembolic complications were reported in any studies. Several bleeding episodes associated with anticoagulant drugs in dental surgery were mild and generally happened on the first day after the treatment.

CONCLUSIONS

The use of local haemostatic measures is generally effective for bleeding control with no further pharmacological drug management or suspension.

Clinical outcomes of left atrial appendage occlusion in patients with previous intracranial or gastrointestinal bleeding: Insights from the LOGIC (Left atrial appendage Occlusion in patients with Gastrointestinal or IntraCranial bleeding) International Multicenter Registry

AIMS

To compare outcomes of patients who underwent left atrial appendage occlusion (LAAO) for nonvalvular atrial fibrillation (NVAF) and contraindication to anticoagulants due to history of either gastrointestinal (GI) or intracranial (IC) bleeding.

METHODS

Patients with NVAF that underwent LAAO for GI or IC bleeding from seven centers were included in this observational study. Baseline characteristics, procedural features, and follow-up data were collected, and compared between the two groups. The primary outcomes were incidence of ischemic and hemorrhagic events at 12-month.

RESULTS

Six hundred twenty-eight patients were included, 57% with previous GI-bleeding, and 43% with previous IC-bleeding. Median CHA 2 DS 2-VASc score was 4 (interquartile range [IQRs]: 3-5) for both GI-bleeding and IC-bleeding patients, while GI-bleeding patients had a higher HAS-BLED score (4 [IQRs: 3-4] vs. 3 [IQRs]: 2-3]; p = 0.001). At 12-month follow-up, relative risk reduction for stroke was similar between the two groups. The GI-bleeding group had more hemorrhagic events compared to IC-bleeding group (any bleeding 8.4% vs. 3.2%; p = 0.012; major bleeding BARC 3-5: 4.3% vs. 1.8; p = 0.010). At multivariate analysis history of GI bleeding was an independent predictor of hemorrhagic events (adjusted HR: 2.39, 95% confidence interval: 1.02-5.63; p = 0.047).

CONCLUSIONS

Outcomes after LAAO may be affected by the different indications for the procedure. In our study, GI-bleeding and IC-bleeding as indication to LAAO differ in their baseline characteristics. LAAO confirms its efficacy in ischemic risk reduction in both groups, while GI bleeding seems to be an independent predictor of bleeding recurrence at 12 months behind the antithrombotic regimen.

Antiplatelet Strategies for Older Patients with Acute Coronary Syndromes: Finding Directions in a Low-Evidence Field

Patients ≥ 75 years of age account for about one third of hospitalizations for acute coronary syndromes (ACS). Since the latest European Society of Cardiology guidelines recommend that older ACS patients use the same diagnostic and interventional strategies used by the younger ones, most elderly patients are currently treated invasively. Therefore, an appropriate dual antiplatelet therapy (DAPT) is indicated as part of the secondary prevention strategy to be implemented in such patients. The choice of the composition and duration of DAPT should be tailored on an individual basis, after careful assessment of the thrombotic and bleeding risk of each patient. Advanced age is a main risk factor for bleeding. Recent data show that in patients of high bleeding risk short DAPT (1 to 3 months) is associated with decreased bleeding complications and similar thrombotic events, as compared to standard 12-month DAPT. Clopidogrel seems the preferable P2Y12 inhibitor, due to a better safety profile than ticagrelor. When the bleeding risk is associated with a high thrombotic risk (a circumstance present in about two thirds of older ACS patients) it is important to tailor the treatment by taking into account the fact that the thrombotic risk is high during the first months after the index event and then wanes gradually over time, whereas the bleeding risk remains constant. Under these circumstances, a de-escalation strategy seems reasonable, starting with DAPT that includes aspirin and low-dose prasugrel (a more potent and reliable P2Y12 inhibitor than clopidogrel) then switching after 2-3 months to DAPT with aspirin and clopidogrel for up to 12 months.

Comparison of endoscopic closure versus non-closure for post-gastric endoscopic submucosal dissection artificial floor in antithrombotic therapy: a propensity score-matched analysis

Background

The management of delayed bleeding after gastric endoscopic submucosal dissection (ESD) is currently an important issue because of recent increases in the number of patients on antithrombotic therapy. Artificial ulcer closure has been shown to prevent delayed complications in the duodenum and colon. However, its effectiveness in cases involving the stomach remains unclear. In this study, we aimed to determine whether endoscopic closure reduces post-ESD bleeding in patients undergoing antithrombotic therapy.

Methods

We retrospectively analyzed 114 patients who had undergone gastric ESD while on antithrombotic therapy. The patients were allocated to one of 2 groups: a closure group (n=44) and a non-closure group (n=70). Endoscopic closure had been performed using multiple hemoclips or using the endoscopic ligation with O-ring closure method after coagulation of exposed vessels on the artificial floor. Propensity score matching resulted in 32 pairs of patients (closure vs. non-closure 32:32). The primary outcome was post-ESD bleeding.

Results

The post-ESD bleeding rate was significantly lower in the closure group (0%) than in the non-closure group (15.6%) (P=0.0264). There were no significant differences between the 2 groups regarding white blood cell count, C-reactive protein, maximum body temperature, or scores on a verbal rating scale that assesses the degree of abdominal pain.

Conclusion

Endoscopic closure may contribute to decreasing the incidence of post-ESD gastric bleeding in patients undergoing antithrombotic therapy.

What you need to know about migraine in Hughes syndrome patients

BACKGROUND

Headache, often migrainous, is common in patients with antiphospholipid antibodies, whether or not they meet Sydney criteria for a definite diagnosis of Hughes syndrome. Migraine may be a harbinger of stroke in this patient population and even refractory migraine may be highly responsive to antithrombotic therapy in this clinical context.

PURPOSE

To summarize what is known to date about managing this important manifestation of the immune-mediated hypercoagulable Hughes syndrome.

RESULTS

We provide a suggested management algorithm for refractory headache in this unique patient population.

CONCLUSION

Most neurologists don't see or recognize many aPL-positive patients in their practice, so hematologists and rheumatologists who see these patients should recognize that refractory headache may be a manifestation of their immune-mediated hypercoagulable disorder and understand that the potential risks of not addressing this issue may be high.

Advances in the available pharmacotherapy for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

INTRODUCTION

Non-ST-segment elevation acute coronary syndromes (NSTE-ACS), including non-ST-segment-elevation myocardial infarction (NSTEMI) and unstable angina, represent a leading cause of mortality worldwide, with important socio-economic consequences. NSTEMI accounts for the majority of acute coronary syndromes and usually develops on the background of a nonocclusive thrombus. We searched for relevant literature in the field in PubMed and clinicaltrials.gov as of July 2022.

AREAS COVERED

A number of pharmacotherapies are currently available for treatment and secondary prevention, mainly including antithrombotic, lipid-lowering and anti-inflammatory drugs. Pretreatment with aspirin, anticoagulant and statin therapy is of key importance in the preprocedural phase, while pretreating with an oral P2Y12 inhibitor is not routinely indicated in patients undergoing early invasive management. For patients undergoing percutaneous coronary revascularization, pharmacotherapy essentially consists of antithrombotic drugs, which should be carefully selected. Finally, antithrombotic, lipid-lowering and anti-inflammatory drugs are important components of long-term secondary prevention after a NSTE-ACS.

EXPERT OPINION

This article reviews the evidence supporting recommendation on pharmacotherapy in patients presenting with a NSTE-ACS. Several randomized clinical trials are still ongoing and are expected to further inform scientific knowledge and clinical practice, with the final aim to improve the treatment of NSTE-ACS patients.

Clinical Evaluation of Factor XIa Inhibitor Drugs: JACC Review Topic of the Week

Factor XI/XIa (FXI/FXIa) represents a potential target for improved precision in anticoagulation because it is involved primarily in thrombus formation and plays a much smaller role in clotting and hemostasis. This suggests that the inhibition of FXI/XIa could prevent pathologic thrombi from forming, but largely preserve a patient's ability to clot in response to bleeding or trauma. This theory is supported by observational data showing that patients with congenital FXI deficiency have lower rates of embolic events without an increase in spontaneous bleeding. Small phase 2 trials of FXI/XIa inhibitors have offered encouraging data with regard to bleeding and safety and evidence of efficacy for the prevention of venous thromboembolism. However, larger clinical trials across multiple patient groups are needed for this emerging class of anticoagulants to understand their possible role in clinical use. Here we review the potential clinical indications for FXI/XIa inhibitors, data available to date, and consider future trials.

Antithrombotic Management in AF Patients Following Percutaneous Coronary Intervention: A European Perspective

AF is a highly prevalent disease, often requiring long-term oral anticoagulation to prevent stroke or systemic embolism. Coronary artery disease, which is common among AF patients, is often referred for myocardial revascularisation by percutaneous coronary intervention (PCI), which requires dual antiplatelet therapy to minimise the risk of stent-related complications. The overlap of AF and PCI is a clinical conundrum, especially in the early post-procedural period, when both long-term oral anticoagulation and dual antiplatelet therapy are theoretically indicated as a triple antithrombotic therapy. However, stacking drugs is not a desirable option because of the increased bleeding risk. Several strategies have been investigated to mitigate this concern, including shortening triple antithrombotic therapy duration and switching to a dual antithrombotic regimen. This review analyses the mechanisms underlying thrombotic complications in AF-PCI, summarises evidence surrounding antithrombotic therapy regimens and reports and comments on the latest European guidelines.

Microembolic signal monitoring in patients with HeartMate 3 and HeartWare left ventricular assist devices: Association with antithrombotic treatment and cerebrovascular events

BACKGROUND

In patients with left ventricular assist devices (LVADs), ischemic and hemorrhagic stroke are dreaded complications. Predictive markers for these events are lacking. This study aimed to investigate the prevalence and predictive value of microembolic signals (MES) for stroke, detected by Transcranial Doppler sonography (TCD) in patients with HeartMate 3 (HM 3) or HeartWare (HW).

METHODS

A thirty-minute bilateral TCD monitoring of the middle cerebral artery (MCA) was performed in 62 outpatients with LVAD (HM 3 N = 31, HW N = 31) and 31 healthy controls. Prevalence and quantity of MES were investigated regarding clinical and laboratory parameters. Cerebrovascular events (CVE) were recorded on follow-up at 90 and 180 days.

RESULTS

MES were detected in six patients with HM 3, three patients with HW, and three controls. Within the LVAD groups, patients on monotherapy with vitamin-K-antagonist (VKA) without antiplatelet therapy were at risk for a higher count of MES (negative binomial regression: VKA: 1; VKA + ASA: Exp(B) = 0.005, 95%CI 0.001-0.044; VKA + clopidogrel: Exp(B) = 0.012, 95%CI 0.002-0.056). There was no association between the presence of MES and CVE or death on follow-up (p > 0.05).

CONCLUSION

For the first time, the prevalence of MES was prospectively investigated in a notable outpatient cohort of patients with HM 3 and HW. Despite optimized properties of the latest LVAD, MES remain detectable depending on antithrombotic therapy. No association between MES and CVE could be detected.