Administration Of Dual Antiplatelet Therapy Research Articles

Dual antiplatelet therapy after intravenous thrombolysis for patients with minor ischemic stroke：A meta-analysis

ObjectiveIntravenous thrombolysis (IVT) has been shown to effectively decrease both the disability rate and mortality associated with acute ischemic stroke, however, there is also a risk of vascular re-occlusion. Antiplatelet therapy can mitigate this risk. Nevertheless, there are no relevant guidelines recommending whether the administration of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel can be performed following thrombolysis. The aim of this study was to conduct a meta-analysis utilizing multiple studies in order to assess the effectiveness and safety of DAPT after IVT in cases of acute mild ischemic stroke (AMIS). MethodsA comprehensive search on English literature published was performed on databases including PubMed, Embase, Web of Science, and Cochrane up until September 1, 2023. All cases were ischemic stroke patients who underwent IVT within a 4.5-hour timeframe and had a National Institutes of Health Stroke Scale (NIHSS) score of ≤5 (or 3) upon admission. The primary efficacy endpoint is the 90-day Modified Rankin Scale (mRS) Score (MRS score 0–1), while the primary safety endpoint encompassed the occurrence of symptomatic intracranial hemorrhage (SICH) and 90-day mortality. The study's secondary objective is the recurrence of any type of stroke (hemorrhagic and ischemic) within a 90-day period. The included studies underwent an evaluation of bias risk using the Newcastle Ottawa scale. Risk ratios (RRs) and CIs were calculated using a random effects model, and the findings and heterogeneity among the included studies were visually presented on a forest plot. (There was a protocol registration (PROSPERO):). ResultsOut of the 1081 studies that were obtained, only 3 met the criteria and were included in the meta-analysis (657 patients in total). The findings indicate that, there was a significant difference in the mRS of 0–1 between single antiplatelet therapy (SAPT) with only aspirin or clopidogrel and DAPT with aspirin and clopidogrel ((RR,1.11[95%CI,0.99–1.24];P=0.07;I2=55%), and no significant difference in stroke recurrence after 90 days or 1 year ((RR,0.94[95%CI,0.41–2.16];P=0.89;I2=30%); Regarding safety evaluation, the results showed no significant difference in the SICH (RR,0.65[95%CI,0.11–3.97];P=0.64;I2=0%) and the incidence of mortality (RR,0.97[95%CI,0.19–4.96];P=0.97;I2=0%) between the two groups. ConclusionsFor patients with acute mild ischemic stroke (AMIS), in conjunction with DAPT after IVT can improve the 90-day prognosis, without increasing the risk of intracranial hemorrhage and 90-day mortality. However, it cannot reduce the risk of stroke recurrence.

Reduced Likelihood of Infarction in Crescendo Transient Ischemic Attack Caused by Vasculitic Middle Cerebral Artery Stenosis.

A 53-year-old woman was admitted to our hospital because of increasingly frequent transient speech disturbance and left upper limb weakness. Brain magnetic resonance imaging and angiography revealed multiple intracranial stenoses, including the proximal right middle cerebral artery (MCA), without evidence of infarction. The diagnosis of primary angiitis of the central nervous system was established based on circumferential vascular wall thickening with contrast enhancement observed in the right MCA. Following the administration of dual antiplatelet therapy and intravenous methylprednisolone pulse therapy, the patient experienced complete cessation of symptoms, and the stenosis gradually improved without infarction. The risk of infarct development in crescendo transient ischemic attacks may differ between inflammatory vascular stenosis and atherosclerosis.

A Novel Case of Transverse Sinus Stenting and Ticagrelor Use During Pregnancy for Idiopathic Intracranial Hypertension

BACKGROUND Idiopathic intracranial hypertension (IIH) is prevalent among the US population, with exacerbation of symptoms during pregnancy. Transverse sinus stenting is a new effective treatment for IIH. Stenting is avoided in pregnancy largely due to the requirement of dual antiplatelet therapy. METHODS We present a case of a pregnant patient in her first trimester with signs and symptoms of fulminant IIH, including progressive visual loss, who underwent placement of a transverse sinus stent and administration of dual antiplatelet therapy with ticagrelor. RESULTS Ticagrelor was administered pre–operatively. The patient underwent venous sinus stenting for fulminant IIH. There were no complications. She had resolution of symptoms and underwent cesarean delivery without issues. Her child displayed no signs and symptoms of abnormalities. CONCLUSION Venous sinus stenting for IIH can be considered in pregnant patients presenting with new or worsening IIH with associated papilledema. The use of ticagrelor did not lead to any adverse outcomes for the patient or the fetus in our case.

Antiplatelet, anticoagulation, and elective aneurysm treatments in neurological patients

Developing more specialized care for neurological disorders, such as aneurysms, arteriovenous malformations, and strokes, can revolutionize patient healthcare and outcomes. With the advent of surgical techniques such as flow diversion, non-stent- and stent-assisted coiling, and catheter embolization for elective aneurysm treatment in neurological patients, the adverse effects and morbidities associated with aneurysms can be reduced. This paper aims to highlight three specific strengths and weaknesses of the newly emerged techniques. Flow diversion devices involve placing a stent in the parent artery, whereas Woven EndoBridge embolization involves manipulation of the wall of the artery without the administration of dual-antiplatelet therapy. In addition to aneurysm treatment, the administration of antiplatelets and anticoagulants is helpful in disrupting the coagulation cascade. As stated in the new and enhanced guidelines released by the American Heart Association, the administration of dual anticoagulants is beneficial to the patients if they have low ischemic severity. Understanding the various benefits and complications associated with each treatment can allow clinicians to gain insight into the potential trajectory of treatment for different patients.

Dual Antiplatelet Therapy and Cancer; Balancing between Ischemic and Bleeding Risk: A Narrative Review.

Cardiovascular (CV) events in patients with cancer can be caused by concomitant CV risk factors, cancer itself, and anticancer therapy. Since malignancy can dysregulate the hemostatic system, predisposing cancer patients to both thrombosis and hemorrhage, the administration of dual antiplatelet therapy (DAPT) to patients with cancer who suffer from acute coronary syndrome (ACS) or undergo percutaneous coronary intervention (PCI) is a clinical challenge to cardiologists. Apart from PCI and ACS, other structural interventions, such as TAVR, PFO-ASD closure, and LAA occlusion, and non-cardiac diseases, such as PAD and CVAs, may require DAPT. The aim of the present review is to review the current literature on the optimal antiplatelet therapy and duration of DAPT for oncologic patients, in order to reduce both the ischemic and bleeding risk in this high-risk population.

Impact of Cyp2c19 Allele 17 Mutase on Clopidogrel Hyper-Responsiveness in Indonesian Patients with Ischemic Stroke

BACKGROUND: Ischemic stroke dominated up to 76% of the 101.5 million stroke cases globally. One of the treatments for stroke is secondary prevention by administering antiplatelet. Clopidogrel is an add-on antiplatelet to the dual antiplatelet therapy (DAPT) regimen. In its metabolism, clopidogrel can show the nature of resistance and bleeding risk. Studies on resistance have been widely put forward but not with the bleeding. The study of the bleeding risk to Asian races focused only on East Asian races. AIM: The objective of the study is to determine the bleeding risk in the Indonesian population and the correlation with the polymorphism of CYP2C19 allele 17. METHODS: There were 112 participants in this study. About 45.5% showed a normal response to clopidogrel, but 40.2% had a bleeding risk. All participants (100.0%) had mutations in CYP2C19 allele 17, with 47.3% being intermediate metabolizers. RESULTS: The bleeding risk was significantly correlated with clopidogrel (p: 0.02). The Indonesian population has a high bleeding risk from the clopidogrel administration. CONCLUSION: Compared to DAPT administration, clopidogrel can be a monotherapy for secondary stroke prevention.

Inicijalni tretman, demografski podaci i praćenje pacijenata sa STEMI u službi za hitnu medicinsku pomoć Pančevo

Introduction: Acute coronary syndrome (ACS) is the most urgent medical condition. ST-elevation myocardial infarction (STEMI) is the most severe form, with complete interruption of blood flow to part of the myocardium. The main goal of treatment is reperfusion. Prehospital treatment, according to recommendations, includes dual antiplatelet therapy (DAPT) -aspirin and a P2Y12 inhibitor -clopidogrel or ticagrelor, with recent studies favoring ticagrelor. The aims of the study were to determine the frequency, demographic characteristics and initial treatment of ACS occurrence with a separate STEMI patients, as well as the frequency of DAPT administration in STEMI. We also monitored whether pre-hospital STEMI patients were referred for coronary angiography. Material and methodology: The retrospective research covered the period from 01.01.2022. until 30.06.2022. Patients with ACS, especially STEMI, were gathered from the protocols in order to determine the frequency of DAPT administration. Through the transport protocol (TR), we monitored which of the prehospital STEMI patients were referred for coronary angiography. The results are presented through descriptive statistics. The Independent Samples Test (p<0.05) was used to analyze the significance of the difference, and the data was processed in the SPSS 15.0 program. Results: Out of 10953 patients, 315 (2.87%) had ACS, and 34 (10.8%) of them had STEMI. There were more men with STEMI 26 (76.47%) than women (23.53%). The average age of men with STEMI was 63±10.58; and the woman 61.37±10.01 years. There is no statistically significant difference between the sexes (p=0.09). All 34 (100%) prehospital STEMI patients were given DAPT-aspirin and ticagrelor. All these patients were also referred for coronary angiography. Discussion: In our research, there were more men than women. In all STEMI patients, 34 (100%) were administered DAPT, while in the EUROMAX study, the use of P2Y12 inhibitors was 95.7%. All of ours prehospital STEMI pacients were then transported for coronary angiography. Conclusion: In the observed period, DAPT was used in all STEMI patients in prehospital conditions. Emergency medical service is an important link in the initial care of STEMI patients and their transport.

Adherence to Antiplatelet Medications among Persistent and Non-Persistent Older Patients with Peripheral Arterial Disease.

Secondary prevention of peripheral arterial disease (PAD) includes administration of antiplatelet agents, and adherence to medication is a requirement for an effective treatment. The aim of this study was to analyse adherence measured using the proportion of days covered (PDC) index separately in persistent and non-persistent patients, and to identify patient- and medication-related characteristics associated with non-adherence in these patient groups. The study cohort of 9178 patients aged ≥ 65 years in whom PAD was diagnosed in 1/–12/2012 included 6146 persistent and 3032 non-persistent patients. Non-adherence was identified as PDC < 80%. Characteristics associated with non-adherence were determined using the binary logistic regression model. In the group of persistent patients, 15.3% of subjects were identified as non-adherent, while among non-persistent patients, 26.9% of subjects were non-adherent to antiplatelet medication. Administration of dual antiplatelet therapy (aspirin and clopidogrel) and a general practitioner as index prescriber were associated with adherence in both patient groups. Our study revealed a relatively high proportion of adherent patients not only in the group of persistent patients but also in the group of non-persistent patients before discontinuation. These results indicate that most non-persistent PAD patients discontinue antiplatelet treatment rapidly after a certain period of adherence.

Bleeding from the upper gastrointestinal tract in patients with acute coronary pathology receiving dual antiplatelet therapy

Abstract Funding Acknowledgements Type of funding sources: None. Main funding source(s): own funds Routine administration of dual antiplatelet therapy reduces the incidence of thrombotic complications and deaths in patients with acute coronary syndrome. However, the widespread use of antithrombotic therapy in these patients is associated with a significant risk of bleeding from the upper gastrointestinal tract. Their frequency in patients with AMI according to various data ranges from 1.1% to 2.3%. Purpose of the study. To determine the risk factors for upper gastrointestinal bleeding and its outcome in patients with acute coronary pathology receiving dual antiplatelet therapy. Methods. Analyzed 2632 patients with acute myocardial infarction and 2114 patients with unstable angina who were admitted for a 10-year period (2011-2020) and underwent emergency coronary angiography. The average age of patients is 57 ± 9 years, women – 1649 (35%), men – 3097 (65%). All patients received dual antiplatelet therapy (acetylsalicylic acid and P2Y12 inhibitor). Studies of the state of the gastric mucosa and duodenum were carried out by endoscopic method, which revealed 31 cases of bleeding. Various baseline characteristics and risk factors for upper gastrointestinal bleeding were evaluated. Results. The source of bleeding was: gastric ulcer - 8 cases (26%), duodenal ulcer - 6 (20%), simultaneously 2 or more ulcers - 4 (14%), multiple acute erosions - 8 (26%), single acute erosions of the antral part of the stomach - 2 (7%), Mallory-Weiss syndrome - 2 (7%) and bleeding from varicose veins of the esophagus - 1 (3%). Clinically, patients noted pronounced weakness, dizziness, coffee ground vomitus was observed in 8 (26%) patients, melena in 14 (45 %) patients. Bleeding from the upper gastrointestinal tract was detected in 20 patients with AMI (1% of all AMI) and is characterized by a high frequency of deaths (9; 45%). Fatal cases are mainly associated with the appearance of several ulcers of different localization (multiple acute erosions of the stomach and duodenum). In patients with unstable angina, the frequency of bleeding from the upper GIT is about 0.5%, while the duration of hospitalization is extended by an average of 8 days. Predictors of bleeding from the GIT in patients with acute coronary pathology include the presence of peptic ulcer disease in the anamnesis, elderly (senile) age, previous long-term use of antiplatelet agents (anticoagulants). Conclusion Bleedings from the upper GIT are a serious clinical problem in patients with acute coronary pathology. They are characterized by a long stay in the hospital and a high mortality rate.

Meta-Analysis of Usefulness of Antiplatelet Therapy in Ischemic Stroke or Transient Ischemic Attack

The efficacy of early administration of dual antiplatelet therapy (DAPT) for secondary prevention after acute ischemic stroke or transient ischemic attack (TIA) is uncertain. This systematic review and meta-analysis compares the safety and efficacy of early administration (<24 hours) of DAPT (using either clopidogrel or ticagrelor with aspirin) versus single antiplatelet therapy (SAPT; aspirin alone) in acute non-cardioembolic ischemic stroke or TIA, incorporating data from large randomized controlled trials. Published trials fulfilling our criteria were identified from an electronic search of MEDLINE, with key words including: "clopidogrel or ticagrelor", "aspirin", "ischemic stroke", "transient ischemic attack", and "randomized controlled trial". Included were 3 randomized controlled trials of 21,067 patients assessing early administration (<24 hours from symptom onset) of DAPT versus SAPT in non-cardioembolic acute ischemic stroke or TIA. Our efficacy outcomes were ischemic stroke and all-cause mortality. Our safety outcome was severe bleeding. We performed a meta-analysis to pool results with a hierarchical Bayesian random-effects model. Dual antiplatelet therapy significantly reduced the risk of ischemic stroke (hazard ratio [HR], 0.73; 95% credible interval [CrI]: 0.54, 0.97), while increasing the risk of severe bleeding (HR, 2.48; 95% CrI: 1.07, 5.26). There was a non-significant numerical trend toward increased mortality with DAPT (HR, 1.29; 95% CrI: 0.73, 2.23). These observations were robust under the sensitivity analysis. In the present systematic review and meta-analysis of randomized controlled trials, DAPT reduced the risk of ischemic stroke at the cost of an increase in severe bleeding. Additional trials examining the ideal timing of DAPT administration are needed to thoroughly investigate the role, if any, of routine DAPT in patients with non-cardioembolic ischemic stroke or high-risk TIA.

The effect of early dual antiplatelet timing on the microvascular resistance and ventricular function in primary percutaneous coronary intervention.

Although dual antiplatelet therapy (DAPT) has been shown to improve index of microcirculatory resistance (IMR), the importance of the early DAPT administration on IMR and left ventricular function has not been clearly defined. In this study, we aimed to assess whether early DAPT administration affect IMR, epicardial flow, and left ventricular function in ST-segment elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI).This was a prospective non-randomized study on STEMI receiving primary PCI in a tertiary hospital. All subjects received loading dose DAPT (Aspirin + Clopidogrel) before primary PCI. Patients were then divided into 2 groups, the first group consists of patients receiving DAPT time ≤2 hours and the second group consists of those with DAPT time >2 hours. The primary endpoint of this study was IMR, a microvasculature function index measured quantitatively by pressure-/temperature-tipped guidewire after balloon dilatation. The secondary endpoint was the mean difference of global longitudinal strain (GLS) change at 6 months follow-up, TIMI flow before, and after PCI between the 2 groups.There were 40 subjects qualified for the study, 20 subjects in each group. There was no significant difference in IMR (50.90 [34.66] vs 58.06 [45.56], P = .579) between the 2 groups. Early administration of DAPT improved ventricular function at 6 months, reflected by statistically significant greater improvement in terms of ΔGLS (–3.48 [2.61] vs –1.23 [2.87], P = .013) and Δejection fraction (10.65% [8.74] vs –0.75% [12.83], P = .002) in the DAPT time ≤2 hours group compared with DAPT time >2 hours group. TIMI flow before PCI (P = .653) and TIMI flow after PCI (P = .205) were similar in the 2 groups.Early DAPT administration ≤2 hours may improve left ventricular function, but not IMR and TIMI flow.

Safety of direct oral anticoagulant - and antiplatelet therapy in patients with atrial fibrillation treated by carotid artery stenting

BackgroundThe periprocedural administration of dual antiplatelet therapy has been recommended in patients treated by carotid artery stenting. However, some patients with concurrent disease have been prescribed anticoagulants. We compared the post-operative incidence of hemorrhagic and thromboembolic events in two patient groups treated by different regimens of multi-antithrombotic agents. MethodsAs our 31 patients had a history of nonvalvular atrial fibrillation, they had received anticoagulants; they were also treated with aspirin and clopidogrel before carotid artery stenting. The prior anticoagulant therapy was continued in 17 patients and they received vitamin K antagonist plus dual antiplatelet therapy after the procedure (group 1). Other 14 patients underwent direct oral anticoagulant plus aspirin or clopidogrel (group 2). Post-procedural hemorrhagic and thromboembolic events were compared between two groups. ResultsCarotid artery stenting was angiographically successful in all patients. Complications were encountered in two group 1 patients. Post-operative image revealed a silent subarachnoid hemorrhage in one. The other presented with superior mesenteric artery occlusion 6 months after the procedure. No hemorrhagic or thromboembolic events occurred in group 2. ConclusionWe concluded that the administration of a direct oral anticoagulant plus an antiplatelet agent reduced the risk for periprocedural hemorrhagic and embolic events in patients with concurrent nonvalvular atrial fibrillation who underwent carotid artery stenting.

Acute Thrombus Burden on Coated Flow Diverters Assessed by High Frequency Optical Coherence Tomography.

The implantation of flow diverters requires administration of dual anti-platelet therapy, posing the potential for complications. The p48MW HPC (phenox, Bochüm,Germany) hydrophilic-coated flow diverting stent is designed to be anti-thrombotic, thus opening the potential for single anti-platelet therapy. We deploy a novel intravascular high-resolution imaging technique, high-frequency optical coherence tomography (HF-OCT), to study in an animal model the acute thrombus formation on coated p48MW devices versus uncoated control devices. Three pigs were implanted with 4 flow diverters each, two test hydrophilic-coated devices, and two control uncoated devices (p48MW). Each pig was treated with a different anti-platelet regime: no anti-platelet therapy, aspirin only, aspirin and clopidogrel. Twenty minutes after the flow diverter was implanted, an HF-OCT data set was acquired. Acute clot formed on the flow diverter at each covered side branch was measured from the HF-OCT slices. Factors considered to be important were the device type (pHPC versus bare metal), aspirin, clopidogrel, and vessel location. A linear model was constructed from the significant factors. Both coating (p < 0.001) and aspirin (p = 0.003) were significantly related to reduction in clot burden, leading to an approximate 100-fold and 50-fold reduction in clot, respectively. This study shows the power of HF-OCT not onlyin the detection of clot but also the quantification of clot burden. In an animal model, the pHPC-coated p48MW significantly reduced acute thrombus formation over jailed side branches as compared to the bare metal p48MW that was nearly eliminated when combinedwith aspirin administration.

Use of the PulseRider Device in the Treatment of Ruptured Intracranial Aneurysms: A Case Series

Wide-necked intracranial aneurysms present unique treatment challenges in the setting of subarachnoid hemorrhage. New generations of endoluminal devices (stents) have expanded our ability to treat complex aneurysms. The PulseRider Aneurysm Neck Reconstruction Device (PulseRider [Cerenovus, Irvine, California, USA]) is new to the U.S. market after receiving Food and Drug Administration approval in June 2017. Official recommendation for use of the PulseRider is with dual antiplatelet therapy (DAPT). Its design has been hypothesized to carry a lower risk of thromboembolic complications in the circumstance that DAPT needs to be discontinued. Between March and June 2018, we treated 4 cases of ruptured wide-necked basilar tip aneurysms at the University of Colorado Hospital, Aurora, Colorado, with PulseRider-assisted coil embolization. Imaging and chart reviews were performed retrospectively on each of these patients. All 4 aneurysms were successfully treated with PulseRider-assisted coil embolization. There were no periprocedural hemorrhages and no postprocedural reruptures. Two patients developed nonocclusive thrombi in the posterior cerebral arteries at the time of coiling, which was resolved with intra-arterial glycoprotein IIb/IIIa receptor antagonists. Two patients developed external ventricular drain-associated hemorrhages, only one of which developed after the administration of DAPT. All patients were eventually discharged to home. The PulseRider device represents a novel design for stent-assisted coil embolization. We report a small but promising series of its successful use in the acute treatment of wide-necked, ruptured basilar artery aneurysms. Additional experience is needed to determine if this device has a place in our armamentarium for treatment of ruptured aneurysms.

Duration of dual antiplatelet therapy and outcome in patients with acute coronary syndrome undergoing percutaneous revascularization: A meta-analysis of 11 randomized trials

BackgroundAcute coronary syndromes (ACS) represent a context of higher thrombotic risk, where larger advantages have been achieved by the administration of dual antiplatelet therapy (DAPT). However, the indication of 1 year DAPT after coronary angioplasty for ACS has been supported by an outdated randomized trial (PCI-CURE). In addition, the initial fear of late thrombotic events emerged with first generation drug-eluting stents (DES), that suggested the need of a prolonged DAPT prescription, has been completely overcome by the recent technological evolution of DES, that have shown faster re-endothelization and lower rates of late thrombotic complications. By keeping in mind the balance between thrombotic and bleeding complications, and due to the paucity of dedicated randomized trials, the identification of the optimal duration of DAPT after ACS is still matter of debate, and is therefore the aim of the present meta-analysis. MethodsLiterature and main scientific session abstracts were searched. The primary efficacy endpoint was mortality, primary safety endpoint was the occurrence of major bleedings. A pre-specified analysis was conducted according to the DAPT strategy allocation (<12 vs standard 12 months duration and 6–12 months vs extended DAPT). ResultsWe included 3 RCTs and subanalyses from 8 RCTs, with a total of 17,941 patients. No difference in mortality was observed between shorter vs longer DAPT (OR[95%CI] = 1.11[0.90,1.36], p = 0.33; phet = 0.76). A shorter DAPT duration significantly reduced the rate of major bleeding events (1.5%, vs 1.9%, OR [95%CI] = 0.75 [0.60, 0.94], p = 0.01; phet = 0.43). The reduction in bleeding events was more significant in trials evaluating extended DAPT duration (OR[95%CI] = 0.62[0.45, 0.85], p = 0.003; phet = 0.49). No difference in cardiovascular mortality, myocardial infarction and stent thrombosis was observed with shorter vs standard 12-moth DAPT, whereas a more extended treatment (beyond 1 year), was associated with a significant reduction in recurrent ischemic events. Similar results were observed at a sensitivity analysis conducted according to the type of stent, time to randomization or DAPT duration. ConclusionsBased on the current meta-analysis including 17,941 ACS patients undergoing PCI, a short duration of DAPT may be safely considered, with similar rates of recurrent thrombotic complications as compared to the standard 12 months, and similar mortality. A more extended DAPT administration (beyond 1 year) provides benefits in ischemic events, but with an excess in haemorragic complications, with overall neutral effects on mortality.

Dvojna antitrombocitna terapija u koronarnoj arterijskoj bolest

Coronary artery disease encompasses a spectrum of clinical presentations caused by underlying coronary atherosclerosis. Acute manifestations of atherosclerotic disease occur when rupture/erosion of atherosclerotic plaque becomes substrate for platelet activation and aggregation, which have a central role in the formation and propagation of intracoronary thrombi. Therefore, antiplatelet therapy represents a standard of care in the primary and secondary prevention of CAD. Dual antiplatelet therapy (DAPT) typically refers to aspirin along with P2Y12 receptor inhibitor (clopi-dogrel, prasugrel or ticagrelor). Choice and duration of DAPT requires an individual approach and assessment of each patient, emphasizing the tailored antiplatelet treatment. This is largely driven by patient's clinical presentation (stable coronary artery disease or acute coronary syndrome), existing risk factors (ischemic vs. hemorrhagic risk), and following treatment plan (medical treatment, percu-taneous coronary intervention, or coronary artery bypass graft). In this review, we present the evidence supporting DAPT administration and therapy duration in different subpopulations of patients with CAD. Also, we will review these data in the context of current 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease, emphasizing the novelties from the present guidelines.

Dual antiplatelet therapy after coronary artery bypass surgery: is there an increase in bleeding risk? A meta-analysis.

There is increasing evidence that dual antiplatelet therapy (DAPT) when compared with single antiplatelet therapy may improve venous graft patency after coronary artery bypass graft. However, it is not yet known whether postoperative administration of DAPT may increase the potential risk of bleeding, especially in the early postoperative period. We searched studies on PubMed, Embase, Web of Science and the Cochrane Central Register of Controlled Trials. Relative risk (RR) was pooled with 95% confidence intervals (CIs) for dichotomous data. Prior subgroup analyses were performed to look for potential heterogeneity. Thirteen studies involving 23591 participants were included. Our meta-analysis showed that DAPT does not increase the risk of major bleeding (randomized controlled trials group: RR = 1.28, 95% CI 0.95-1.71; cohort studies group: RR = 0.99, 95% CI 0.66-1.51) and minor bleeding (randomized controlled trials group: RR = 1.15, 95% CI 0.73-1.81; cohort studies group: RR = 0.84, 95% CI 0.37-1.93) when compared with single antiplatelet therapy. Meanwhile, DAPT does not increase the incidence of major bleeding events during hospitalization (randomized controlled trials group: RR = 1.27, 95% CI 0.91-1.78; cohort studies group: RR = 0.50, 95% CI 0.12-2.09). Sensitivity analyses showed that our results are stable, and there was no evidence of publication bias. DAPT does not increase the risk of major bleeding and minor bleeding when compared with single antiplatelet therapy. Postoperative administration of DAPT is considered to be safe in patients after coronary artery bypass graft, even in the early postoperative period.

Development of an intracranial dural arteriovenous fistula after venous sinus stenting for idiopathic intracranial hypertension

We report a case in which an intracranial dural arteriovenous fistula (DAVF) developed after endovascular treatment of a patient with idiopathic intracranial hypertension with venous sinus stenting (VSS). The pathogenesis...

Clopidogrel Resistance: Current Issues

Antiplatelet agents are mainly used in the prevention and management of atherothrombotic complications. Dual antiplatelet therapy, combining aspirin and clopidogrel, is the standard care for patients having acute coronary syndromes or undergoing percutaneous coronary intervention according to the current ACC/AHA and ESC guidelines. But in spite of administration of dual antiplatelet therapy, some patients develop recurrent cardiovascular ischemic events especially stent thrombosis which is a serious clinical problem. Antiplatelet response to clopidogrel varies widely among patients based on ex vivo platelet function measurements. Clopidogrel is an effective inhibitor of platelet activation and aggregation due to its selective and irreversible blockade of the P2Y12 receptor. Patients who display little attenuation of platelet reactivity with clopidogrel therapy are labeled as low or nonresponders or clopidogrel resistant. The mechanism of clopidogrel resistance remains incompletely defined but there are certain clinical, cellular and genetic factors including polymorphisms responsible for therapeutic failure. Currently there is no standardized or widely accepted definition of clopidogrel resistance. The future may soon be realised in the routine measurement of platelet activity in the same way that blood pressure, cholesterol and blood sugar are followed to help guide the therapy, thus improving the care for millions of people. This review focuses on the methods used to identify patients with clopidogrel resistance, the underlying mechanisms, metabolism, clinical significance and current therapeutic strategies to overcome clopidogrel resistance.J Enam Med Col 2016; 6(1): 38-46

Inadvertent administration of dual antiplatelet therapy to a patient with an indwelling epidural catheter

SummaryWe describe the case of a middle‐aged patient who suffered a non‐ST elevation myocardial infarction (NSTEMI) on day 1 postoperatively following an elective abdominal aortic aneurysm (AAA) repair. The NSTEMI was managed with dual antiplatelet therapy; unfortunately this was initiated without due consideration to the fact he had an epidural in situ. Once this clinical conflict was identified, careful decisions were taken regarding concurrent management of his NSTEMI and epidural, particularly regarding timing of catheter removal. The patient suffered no neurological sequelae.The case raises two clear learning points. Firstly, it highlights the logistical and ethical difficulties of managing serious medical conditions when treatments expose patients to significant harm. Secondly, it emphasises the contribution of human factors to medical errors in anaesthesia and intensive care. As a result of this case, we developed bedside epidural alert notices in our institution to reduce the risk of similar incidents occurring in the future.