Antiplatelet In Patients Research Articles

Oral anticoagulants or antiplatelets for cryptogenic stroke: a systematic review and meta-analysis

Abstract Background Cryptogenic strokes comprise 20 to 30% of ischemic strokes and include a substantial proportion classified as embolic stroke of undetermined source (ESUS). However, the optimal antithrombotic strategy for cryptogenic stroke remains contentious. Purpose We conducted a systematic review and meta-analysis to compare the efficacy and safety of oral anticoagulants (OAC) versus antiplatelets in patients with cryptogenic stroke. Methods Six electronic databases of PubMed, Embase, Web of Science, the Cochrane Library, Google Scholar and ClinicalTrials.gov were searched from inception to Feb 15, 2024 to identify relevant randomized controlled trials (RCTs) comparing stroke recurrence and major bleeding rates between OAC and antiplatelets in cryptogenic stroke patients. We included trials adhering to a stringent diagnostic work-up for cryptogenic stroke, defined as cerebral infarction not attributed to definite sources of cardioembolism, large artery atherosclerosis, or small artery disease despite undergoing comprehensive investigations. The primary outcome was recurrent ischemic stroke, and the secondary outcome was major bleeding based on International Society of Thrombosis and Hemostasis criteria. Subgroup analysis was conducted for ESUS patients with an increased risk of cardiac emboli, such as patent foramen ovale (PFO) and atrial cardiopathy, defined as lead V1 terminal P-wave > 5000 μV × ms in electrocardiogram, serum N-terminal pro-B-type natriuretic peptide level > 250 pg/mL, and left atrial diameter (LAE) > 4 cm, or LAE index ≥ 3 cm/m2 on echocardiogram. Hazard ratio (HR) with 95% confidence (CI) was used as a measure of the effect estimates for aforementioned outcomes. Random-effects meta-analysis was performed using a restricted maximum likelihood model given between-study variance is inevitable. Results Our meta-analysis included 9 RCTs with a total of 15,139 patients (OAC = 7,343; antiplatelets = 7,796). ARCADIA, RE-SPECT ESUS, and NAVIGATE ESUS Trial investigated apixaban, dabigatran, and rivaroxaban, respectively, while warfarin was primarily used as OAC in the remaining six trials. Aspirin was predominantly utilized for antiplatelet therapy. There was no significant difference in recurrent ischemic stroke between OAC and antiplatelets (HR, 0.90; 95% CI, 0.78 to 1.04; I2 = 0%). However, OAC use was associated with a significantly higher risk of major bleeding (HR, 1.66; 95% CI, 1.07 to 2.56; I2 = 36%). Subgroup analysis in ESUS patients revealed comparable rates of recurrent ischemic stroke in those with atrial cardiopathy (HR, 0.91; 95% CI, 0.65 to 1.29; I2 = 0%) and PFO (HR, 0.72; 95% CI, 0.49 to 1.07; I2 = 0%). Conclusions Our meta-analysis suggests that OAC use does not decrease the risk of recurrent ischemic stroke compared with antiplatelet use but is associated with a significantly higher risk of major bleeding in patients with cryptogenic stroke.Primary (A) and secondary (B) outcomesSubgroup analysis for recurrent stroke

Efficacy and Safety of Sarpogrelate on Symptom Improvement in Patients with Peripheral Arterial Disease (PAD) and/or Being at Risk of PAD: A Single Arm, Multi-Centered, Open-Label Trial.

To assess the efficacy and safety of sarpogrelate (300 mg) for symptom improvement in patients having peripheral arterial disease (PAD) and/or being at risk of PAD in clinical practice using the Peripheral Artery Questionnaire (PAQ). Symptomatic changes with antiplatelets in patients with PAD are limited. To determine the effect and safety of sarpogrelate on the PAQ at 24 weeks from baseline. A total of 1003 patients having PAD and/or being at risk of PAD from 17 tertiary hospitals in South Korea who were treated with sarpogrelate, were enrolled in this study. PAQs were collected at baseline and at 12 and 24 weeks, together with physical examination and vital signs measurements. Lifestyle pattern was also investigated. The average PAQ Summary Score in the efficacy evaluation analysis group significantly improved from 62.9 ± 23.7 at baseline to 68.9 ± 21.7 at 24 weeks (P<0.0001). Physical limitation items significantly improved from 69.5 ± 30.0 at baseline to 72.9 ± 28.3 after 24 weeks (P=0.0011). Symptom stability also significantly improved from 52.1 ± 21.6 at baseline to 63.6 ± 22.9 after 24 weeks (P<0.0001). Symptoms, treatment satisfaction, quality of life, and social limitation domains all improved after treatment. A total of 201 patients reported adverse events (20.0%), not directly associated with treatment. Treatment with 300 mg (orally) of sarpogrelate demonstrated statistically significant improvements in all domains and for the summary score of the PAQ at 24 weeks, it gave good results in terms of safety. Sarpogrelate may be helpful in reducing symptoms related to PAD.

Optimal use of antithrombotic agents in recent small subcortical strokes accompanied by atrial fibrillation.

This study aimed to evaluate the efficacy and safety of anticoagulants (AC) and antiplatelets (APT) in patients with recent small subcortical infarctions (RSSI) and atrial fibrillation (AF). We utilized a prospective multicenter stroke registry database to identify patients with RSSI with a concurrent diagnosis of AF. Propensity score matching analysis was used to balance baseline differences among the AC-only, APT-only, and their combination groups. The main outcomes of interest were time to occurrence of minor and major bleeding, stroke recurrence, and all-cause mortality. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for each outcome were calculated using the multivariable Cox proportional hazard regression analysis. Of the 404 eligible patients, 28.2% received APT only, 53.0% received AC only, and 18.9% received a combination of both. Notable differences were observed between these groups in terms of the 1-year stroke recurrence (APT, 32.5%; AC, 5.6%; APT + AC, 9.2%) and all-cause mortality (APT, 21.9%; AC, 6.1%; APT + AC, 14.5%), whereas the rates of bleeding events were comparable. The multivariable analysis indicated a significant association of AC alone with reduced risks of severe bleeding, stroke recurrence, and all-cause mortality compared with APT alone (aHR 0.64, 95% CI 0.41-0.98; aHR 0.11, 95% CI 0.06-0.22; aHR 0.22, 95% CI 0.11-0.44, respectively). The combination group showed a reduced risk of stroke recurrence compared to APT alone (aHR 0.19, 95% CI 0.08-0.46). These findings remained consistent with the propensity score-matched analysis. AC showed better clinical outcomes than APT in patients with RSSI and AF. Additionally, combination therapy with AC and APT was associated with a lower risk of stroke recurrence than APT alone.

Does the use of anticoagulation or antiplatelet therapy increase cerebrovascular events in patients with infective endocarditis - a systematic review and meta-analysis

Abstract Background Management of anticoagulant and antiplatelet therapy in patients with infective endocarditis (IE) remains challenging. We aimed to evaluate the impact of antiplatelet and anticoagulant therapy on cerebrovascular events (CVE) and mortality in IE-patients. Methods Assessing three databases (MEDLINE, EMBASE, and Cochrane Library), we performed a systematic review and meta-analysis of studies comparing patients with prior and/or ongoing use of antithrombotic therapy (anticoagulation or antiplatelet) versus those without any antithrombotic therapy during IE course. Primary outcome was CVE. Secondary outcomes were perioperative and mid-term (&amp;gt;6 months) mortality, intracranial hemorrhage (ICH), and systemic thromboembolism. Inverse variance method was performed. Results Twelve studies with a total of 11,960 patients were included. The primary endpoint (CVE) was not different between the anticoagulation or the antiplatelet group and the control group. Perioperative mortality was lower in the anticoagulation group compared to the control group (OR= 0.74, 0.57-0.96, p=0.03). There was no significant difference in the incidence of ICH between the anticoagulation or antiplatelet group and the control group. Conclusion The results suggest that the prior and/or ongoing use of anticoagulants or antiplatelets in patients with IE was associated with similar rates of CVE in general and of ICH in particular. Lack of information about the indications for stopping or continuing antithrombotic therapy in the majority of the included studies is a limitation of this meta-analysis, showing the necessity of a randomized setup.

Management of acute cholecystitis in patients on anti-thrombotic therapy: A single center experience

BackgroundAcute cholecystitis in patients on anti-thrombotic therapy (ATT) presents a clinical dilemma at the intersection between conflicting guidelines, specifically between timing of early operative management (OM) versus time-to-reversal of certain ATT agents. With growing recognition that nonoperative management (NOM) is associated with considerable morbidity, and evidence in the literature that early OM in patients on ATT is safe, we reviewed our own practice to examine how we addressed these conflicting guidelines. Materials and methodsWe performed a retrospective review of patients with acute cholecystitis between December 2017 and March 2022. Patients were classified as ATT or non-ATT; ATT patients were subdivided into anticoagulation (AC) and antiplatelet (AP) groups. Rates of OM were compared. Results502 patients with acute cholecystitis were identified, 464 non-ATT and 38 ATT. 30 ATT patients were on AC, 7 on AP, and 1 on both. Non-ATT patients were significantly more likely to receive OM at index presentation compared to those on ATT: 89.9 % vs 63.2 % (p < 0.05). Subgroup analysis of the ATT group showed AP patients were significantly less likely to receive OM compared to those on AC, 12.5 % vs 77 % (p < 0.05). ConclusionsAt our institution, patients on ATT were significantly less likely to undergo OM for acute cholecystitis compared with non-ATT patients. Those on AC received OM significantly more than patients on AP. Further study is needed to better define the management of this growing population so that acute cholecystitis guidelines might address this issue in the future.

Effects of morphine and P2Y inhibitor amongst patients with acute coronary syndrome: A meta-analysis of comparative studies

BackgroundP2Y inhibitor and morphine are widely used in caring for patients with the acute coronary syndrome (ACS), but there are some concerns about the combination use due to interaction in metabolism. Therefore, this study aimed to examine whether using morphine with antiplatelets in patients with ACS affects the clinical outcomes based on currently available evidence. MethodsThree databases were searched for comparative studies on this topic by using relevant keywords of ACS and morphine. Two authors independently extracted study information, mortality, major adverse cardiac event (MACE), major bleeding, and length of hospital stay. Then, they evaluated the quality of evidence independently. Meta-analysis was planned to be conducted in random-effects model. Risk ratio (RR) was used for most outcomes except hospital stay, and Peto odds ratio (POR) was used if there were any zero cells. Pooled estimate was presented with 95% confidence interval (CI). ResultsFourteen studies (n = 73,033) met eligibility criteria, and there was non-significant difference in mortality between antiplatelet with and without morphine (RR = 1.13, 95%CI: 0.78 to 1.64). Antiplatelet therapy without morphine significantly reduced the risk of MACE (RR = 0.78, 95%CI: 0.67 to 0.89; I-square = 0%), but increased the odds of major bleeding (POR = 1.87, 95%CI: 1.04 to 3.35; I-square = 0%) as compared with the combined use of antiplatelet therapy and morphine. ConclusionIn conclusion, there is no statistically significant difference in mortality in patients with ACS using morphine or not, but clinicians ought to make a trade-off between a lower risk of MACE and a higher risk of major bleeding before adding morphine to antiplatelet therapy.

A Cardiologists' Survey on the Use of Anticoagulants and Antiplatelets in Patients With Atrial Fibrillation and Acute Coronary Syndrome or Those Undergoing Percutaneous Coronary Intervention in India.

The management of patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) requires appropriate antithrombotic regimens for stroke prevention and in-stent thrombosis. Current practice recommendations are largely based on consensus options as there is limited evidence from randomized clinical trials. Hence, by surveying a group of cardiologists across India, we sought to better understand the current practice patterns of using oral anticoagulants (vitamin K antagonist, VKA or non-vitamin K antagonist oral anticoagulant, NOAC) and antiplatelet therapy in those patients in India. A cross-sectional questionnaire-based survey was conducted across India to better understand the clinical practices in AF management. A total of 151 cardiologists participated in this survey. The most commonly prescribed combination therapy in patients with AF and ACS/undergoing PCI was triple therapy (NOAC + dual antiplatelet [aspirin and P2Y12 inhibitor]) (54.30%) followed by NOAC + single antiplatelet (33.11%).Only 11.26% of cardiologists prescribed VKA + dual antiplatelet therapy. Among anticoagulants, cardiologists prescribed NOACs to 66.11%of patients andVKAs to 25.54%of patients. Among P2Y12 inhibitors, ticagrelor (50.99%) and clopidogrel (47.02%) were the most preferred medication. The physician reported patient adherence rates to NOACs were higher compared to VKAs. Around 41.06% of cardiologists reportedly changed antiplatelet therapy for patients from dual antiplatelet to single antiplatelet therapy in three months; 36.42%, in one month; and 19.21% in six months after PCI. Around 61.59% of cardiologists stopped prescribing antiplatelet therapy for patients by one year. Our survey demonstrated that the majority of cardiologists used triple therapy (NOAC + dual antiplatelet), followed by NOAC + single antiplatelet for managing patients with AF and ACS or undergoing PCI in line with the available guidelines.

Comparison of Efficacy and Safety of Anticoagulant Monotherapy and Combined Therapy of Anticoagulant and Antiplatelets in Patients With Stable Coronary Artery Disease and Atrial Fibrillation: A Meta-Analysis

It is still uncertain whether patients with atrial fibrillation (AF) andstable coronary artery disease (CAD) who require long-term oral anticoagulation (OAC) should also receive antiplatelet treatment (APT). This meta-analysis aims to compare the efficacy and safety of OAC alone with OAC plus APT in individuals with AF and stable CAD. The current meta-analysis was conducted as per the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Meta-analysis of Observational Studies in Epidemiology (MOOSE).We performed electronic searches using PubMed, EMBASE, and Cochrane Library. The efficacy outcomes assessed in this meta-analysis included cardiovascular death, myocardial infarction, stroke (ischemic and hemorrhagic), and all-cause mortality. The safety outcome included major bleeding events. A total of five studies were included in the current meta-analysis enrolling 9199 patients with stable CAD and AF. Out of these five studies, three were observational and two were randomized controlled trials (RCTs). Our study showed no significant difference between two groups in the incidence of cardiovascular mortality (Hazard ratio {HR}: 0.86, 95% confidence interval {CI}: 0.59-1.25, I-square: 44%), myocardial infarction (HR: 1.21, 95% CI: 0.73-2.01, I-square: 0%), all-cause mortality (HR: 0.95, 95% CI: 0.76-1.19, I-square: 68%) and stroke (HR: 0.83, 95% CI: 0.61-1.12, I-square: 45%). However, lower incidence of major bleeding events in patients who received OAC alone as compared to patients who received a combination of OAC and anti-platelet (HR: 1.37, 95% CI: 1.18-1.580, I-square: 78%) were found. The current meta-analysis showed that OAC monotherapy is associated with a lower incidence of major bleeding events in patients with stable CAD and AF. It is also not associated with an increased risk of all-cause mortality, cardiovascular death, stroke, and myocardial infarction.

Effectiveness and Safety of Antithrombotic Medication in Patients With Atrial Fibrillation and Intracranial Hemorrhage: Systematic Review and Meta-Analysis

For patients with atrial fibrillation who survive an intracranial hemorrhage (ICrH), the decision to offer oral anticoagulation (OAC) is challenging and necessitates balancing risk of thromboembolic events with risk of recurrent ICrH. This systematic review assesses the effectiveness and safety of OAC and/or antiplatelets in patients with atrial fibrillation with nontraumatic ICrH. Bibliographic databases CENTRAL, MEDLINE, EMBASE, and CINAHL were searched. Articles on adults with atrial fibrillation with spontaneous ICrH (intracerebral, subdural, and subarachnoid), receiving antithrombotic therapy for stroke prevention were eligible for inclusion. Twenty articles (50 470 participants) included 2 randomized controlled trials (n=304)' 8 observational studies, 8 cohort studies, and 2 studies that meta-analyzed individual-level data from observational studies. OAC therapy was associated with a significant reduction in thromboembolic events (summary relative risk [sRR], 0.51 [95% CI, 0.30-0.86], heterogeneity I2=2%; P=0.39, n=5 studies) and all-cause mortality (sRR, 0.52 [95% CI, 0.38-0.71], heterogeneity I2=0; P=0.44, n=3 studies). OAC therapy was not associated with an increased risk of recurrent ICrH (sRR, 1.44 [95% CI, 0.38-5.46], heterogeneity I2=70%, P=0.02, n=5 studies). Nonvitamin K antagonist OACs were more effective at reducing the risk of thromboembolic events (sRR, 0.65 [95% CI, 0.44-0.97], heterogeneity I2=72%, P=0.03, n=3 studies) and were associated with a lower risk of recurrent ICrH (sRR, 0.52 [95% CI, 0.40-0.67], heterogeneity I2=0%, P=0.43, n=3 studies) than warfarin. In nontraumatic ICrH survivors with atrial fibrillation, OAC therapy is associated with a reduced risk of thromboembolic events and all-cause mortality without significantly increasing risk of recurrent ICrH. This finding is primarily based on observational data, and further larger randomized controlled trials are needed to corroborate or refute these findings.

Non-Vitamin K Oral Anticoagulant After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis.

Objective: We aimed to compare non-vitamin K oral anticoagulants (NOACs) with a traditional antithrombotic such as vitamin K antagonist (VKA) and antiplatelet agents in patients after transcatheter aortic valve replacement (TAVR). Methods: We conducted a search in PubMed, EMBASE, and the Cochrane Library until November 2021 for studies involving comparisons of any type of NOACs, including dabigatran, apixaban, rivaroxaban, and edoxaban, with VKA or antiplatelet agents after TAVR. A comparison of NOACs versus VKA was performed in patients with an indication for oral anticoagulation. In addition, we compared NOACs versus antiplatelet in patients without such indication. We calculated the hazard ratios with 95% confidence intervals (CIs) to determine long-term outcomes. The primary outcome was a combined endpoint consisting of all-cause mortality, stroke, major bleeding, or any related clinical adverse events. Secondary outcomes were all-cause mortality, major bleeding, and stroke, respectively. Results: A total of 10 studies including 10,563 patients after TAVR were included in this meta-analysis. There were no significant differences in any of the long-term outcomes between the NOAC and VKA groups. Although there were no significant differences in the combined endpoint, major bleeding, or stroke, a significant difference was observed in the all-cause mortality (HR 1.74, 95% CI 1.25–2.43, p = 0.001) between the NOAC and antiplatelet groups. Conclusion: For patients with an indication for oral anticoagulation after TAVR, NOACs seem to be associated with noninferior outcomes compared with VKA therapy. However, for patients without an indication for oral anticoagulation, NOACs appear to be associated with a higher risk of all-cause death as compared with antiplatelet treatment. Systematic Review Registration: https://clinicaltrials.gov/, identifier CRD42020155122.

Ticagrelor versus prasugrel in acute coronary syndrome: sex-specific analysis from the RENAMI Registry.

The use of potent P2Y12 inhibitors (ticagrelor & prasugrel) in acute coronary syndrome (ACS) patients undergoing percutaneous coronary interventions (PCI) is a class I recommendation. We performed a sex-specific analysis comparing the difference in efficacy and safety outcomes between ticagrelor and prasugrel in a real-world ACS population. Data from the multicenter REgistry of New Antiplatelets in patients with Myocardial Infarction (RENAMI) for 4424 ACS patients who underwent PCI and were treated with ticagrelor or prasugrel between 2012 to 2016 were analyzed. Mean follow-up was 17±9 months. After propensity score matching, there was no significant difference in the occurrence of primary endpoint of net adverse cardiac events between ticagrelor and prasugrel in men (HR: 0.94; 95% CI: 0.69-1.29; P=0.71), or women (HR: 1.17; 95% CI: 0.63-2.20; P=0.62; P interaction [sex] = 0.40). Similarly, no differences were found in the occurrence of any of the secondary endpoints (MACE, all cause death, re-infarction, stent thrombosis, BARC major bleeding and BARC any bleeding) between the two P2Y12 groups between men and women. In this real-world ACS population, no relative difference in efficacy or safety outcomes were found between ticagrelor and prasugrel between sexes.

Antiplatelets in patients with atrial fibrillation: a systematic review and meta-analysis of randomized clinical trials

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Dr. Benz reports a personal research grant from the German Heart Foundation (Deutsche Herzstiftung e.V.). Dr. Johansson reports personal unrestricted research grants from Swedish Heart-Lung Foundation (Hjärt-Lungfonden) and from Stockholm County Council (Region Stockholm). Dr. McIntyre holds a fellowship award from the Canadian Institutes for Health Research (CIHR). Dr. Shoamanesh reports funding support from the Marta and Owen Boris Foundation and the Heart and Stroke Foundation of Canada. Background/Introduction: There is an ongoing controversy surrounding the efficacy and safety of antiplatelet agents in patients with atrial fibrillation (AF). Purpose We aimed to systematically assess the effects of antiplatelets on stroke and other outcomes in patients with AF, both receiving oral anticoagulation or not. Methods We searched MEDLINE, Embase and CENTRAL up until September 2020 to identify randomized trials allocating patients with AF to aspirin or a P2Y12 inhibitor, versus control. Where applicable, we obtained unpublished data from study authors. Random-effects models were applied for meta-analysis. Results Based on 21,518 patients from 18 randomized trials, there was no reduction in stroke with antiplatelet therapy (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.76-1.04). There was a significant qualitative interaction according to whether patients were receiving concomitant oral anticoagulation or not (p &amp;lt; 0.001). Without concomitant anticoagulation, antiplatelets reduced stroke (RR 0.77, 95% CI 0.69-0.86), while they appeared to increase stroke with it (RR 1.33, 95% CI 0.98-1.79). A similar pattern emerged for ischaemic stroke. Antiplatelets increased major bleeding (RR 1.54, 95% CI 1.35-1.77) and intracranial haemorrhage (RR 1.64, 95% CI 1.20-2.24), and reduced myocardial infarction (RR 0.79, 95% CI 0.65-0.94), consistently and irrespective of concomitant anticoagulation. Antiplatelets had a neutral effect on mortality (RR 1.02, 95% CI 0.89-1.17). Conclusions Antiplatelet therapy did not reduce stroke and increased major bleeding in patients with AF. Antiplatelets did not affect mortality. Subgroup analysis suggests a reduction in stroke with antiplatelets in patients without concomitant oral anticoagulation, and a corresponding signal for harm in those with it. Abstract Figure.

SIDE EFFECTS PROFILE OF ANTIPLATELET MEDICATION IN PATIENTS WITH CORONARY HEART DISEASE AT BHAYANGKARA HOSPITAL BALI-INDONESIA

Introduction: Coronary heart disease (CHD) is a disorder of heart function due to a lack of blood in the heart muscle due to narrowing of the coronary arteries. Antiplatelet in patients with CHD is a therapy that must be obtained by patients throughout their lives to prevent recurrent attacks and deaths from CHD. In the Province of Bali, especially in Denpasar, there is a lack of information about the type of side effects that occur on antiplatelet medication, so it is necessary to do a related study. Objective: The aim of this study is to identify the type of side effects that occur on antiplatelet medication in patients with CHD. Methods: A cross-sectional study involving 97 patients was done by observed the CHD patients treated with antiplatelet medication. Side effects were evaluate using Naranjo Algorithm. Patients were divided into three groups, including a low dose aspirin user group, clopidogrel user group, and aspirin-clopidogrel combination user group. Results: Antiplatelet side effects that occur in patients include headache (2.06%), diarrhea (1.03%), cyanosis (1.03%), gastrointestinal bleeding (8.25%), heartburn (11.34%), and nausea (6.19%). These side effects only occurred in 31.96% of the total subjects. The incidence of aspirin side effects was significantly greater than clopidogrel as well as aspirin-clopidogrel in combination (p &lt;0.05). Conclusion: Patients with CHD who use antiplatelet agents in the long term to be more aware of the potential side effects that will occur, especially heartburn in chronic low-dose aspirin users.&#x0D; Keywords: Coronary Heart Disease, Side Effects, Antiplatelet, Aspirin, Clopidogrel

Anticoagulant and Antiplatelet Use Not Associated with Improvement in Severe Outcomes in COVID-19 Patients

Introduction:SARS-CoV-2 coronavirus (COVID-19) associated coagulopathy leads to higher morbidity and mortality. It is unclear if anticoagulants or antiplatelets in patients with COVID-19 influences disease severity. We report outcomes of COVID-19 patients prescribed anticoagulants or antiplatelets for preexisting conditions within Kaiser Permanente Northern California (KPNC), a large integrated health system serving 4.4 million members.Methods:This retrospective cohort study included KPNC adult members (≥18 years) with positive COVID-19 testing between February 25,2020, and May 8,2020. Patients were stratified based on electronic medical records indicating a filled prescription or actively taking antiplatelets or anticoagulants within 90 days prior to COVID-19 diagnosis.Primary outcomes included emergency department (ED) visit, inpatient hospitalization, intensive care unit (ICU) stay, venous thromboembolism (VTE), mechanical ventilation, and mortality between date of COVID-19 diagnosis and the first of either 45 days after diagnosis or 6/9/2020. Any severe outcome was defined as any of inpatient hospitalization, mechanical ventilation, or mortality. Logistic regression was used to calculate odds ratios and 95% confidence intervals (CI) for the association of anticoagulants or antiplatelets with primary outcomes, adjusting for sociodemographic and clinical characteristics. Models were adjusted for week of diagnosis given changing testing and treatment guidelines over time.The Research Determination Committee for KPNC has determined the project does not meet the regulatory definition of research involving human subjects per 45 CFR 46.102(d).Results:Of 2,972 patients with confirmed positive COVID-19, 167(6%) were on antiplatelets, 69(2%) were on anticoagulants, and 7(<1%) on both. Most patients on anticoagulants or antiplatelets were older (77% aged >60 years), non-white (53%), overweight or obese (69%), and had >3 comorbidities (62%).After adjusting for sociodemographic and clinical characteristics, chronic anticoagulants or antiplatelets use was not associated with a lower risk of any primary outcome, including VTE, ED visit, ICU stay or severe outcome (OR 1.03, CI 0.74-1.45). Older patients had an increased risk of all outcomes except VTE, with the highest risk of severe outcomes in those > 80 years compared to 18-29 years (OR 13.62, CI 7.69-24.11). Male patients and Asian or Hispanic patients (compared to white patients) also had increased risk of severe outcomes. A higher mortality risk was noted in patients with underlying obesity (OR 2.28, CI 1.31-3.95) and hypertension (OR 2.03, CI 1.30-3.19), but not with diabetes (OR 1.43, CI 0.89-2.28). (Table 1)Conclusions:This analysis using a socio-demographically diverse cohort of COVID-19 positive patients demonstrated that patients on chronic anticoagulants or antiplatelets did not have lower risk for inpatient hospitalization, invasive ventilator, or death. There was a significantly higher risk of severe outcomes in those with older age, Asian or Hispanic ethnicity, male gender, obesity, hypertension and diabetes.Infection with COVID-19 can lead to a severe systemic inflammatory response, vascular endothelial dysfunction and hemostatic derangements, predisposing to microvascular and macrovascular thrombi and significant morbidity. Efforts to mitigate the disease severity have generated discussions regarding empiric use of anticoagulants and antiplatelets in COVID-19 patients. We did not find a difference in the risk of hospitalizations, mechanical ventilation or death for patients on chronic anticoagulants or antiplatelets. Our findings argue against the empiric use of these agents at COVID-19 diagnosis until prospective studies powered to evaluate thrombosis risk and clinical outcomes with value to patients and health care systems are completed.The major strength of this study included the availability of all outcomes data for inpatients and outpatients with COVID19. Limitations include possible missed data from undiagnosed COVID-19 patients due to evolving COVID-19 testing and variance in inpatient treatments which may influence outcomes. Despite this, our findings do not suggest a clinical benefit of chronic anticoagulants or antiplatelets in mitigating disease severity in COVID-19 patientsDisclosuresNo relevant conflicts of interest to declare.

Antithrombotic treatment in patients with stroke and supracardiac atherosclerosis.

To compare the efficacy and safety of oral anticoagulants vs antiplatelets in patients with stroke and atherosclerotic plaques in the aortic arch or cervical or intracranial arteries, collectively described as supracardiac atherosclerosis. We searched PubMed and Scopus until August 28, 2019, for randomized trials comparing oral anticoagulants vs antiplatelets in patients with stroke and supracardiac atherosclerosis using the terms "anticoagulant or anticoagulation" and "antiplatelet or aspirin" and "randomized controlled trial or RCT" and "stroke or cerebral ischemia" and "aortic or carotid or vertebrobasilar or intracranial or atherosclerosis or stenosis or arterial." Four outcomes were assessed: recurrent ischemic stroke, major ischemic event or death, major bleeding, and intracranial bleeding. Treatment effects (relative risk [RR] and 95% confidence interval [CI]) were estimated by meta-analysis using random-effects models. Among 1,117 articles identified in the literature search, results from 10 randomized controlled trials involving 6,068 patients with stroke/TIA with supracardiac atherosclerosis were included in the meta-analysis. Recurrent ischemic stroke rates were 2.94 per 100 patient-years in the anticoagulant-assigned patients vs 3.30 per 100 patient-years in the antiplatelet-assigned patients (RR, 0.91; 95% CI, 0.70-1.18 for the SJ estimator, I2 = 26%). Major ischemic event or death rates were 4.39 per 100 patient-years in anticoagulant-assigned patients vs 4.32 in antiplatelet-assigned patients (RR, 1.03; 95% CI, 0.79-1.35; I2 = 54.5%). Major bleeding rates were 2.88 per 100 patient-years in anticoagulant-assigned patients vs 0.82 in antiplatelet-assigned patients (RR, 3.21; 95% CI, 1.96-5.24; I2 = 46%). This systematic review and meta-analysis showed that anticoagulant-assigned patients with stroke and supracardiac atherosclerosis were not at different risk of ischemic stroke recurrence and increased risk of major bleeding compared to antiplatelet-assigned patients.

Aspirin or anticoagulation after cryptogenic stroke with patent foramen ovale: systematic review and meta-analysis of randomized controlled trials.

Since closure has restrictive eligibility criteria, the vast majority of patients with cryptogenic stroke and patent foramen ovale (PFO) receive medical treatment. However, the optimal antithrombotic strategy is still unclear. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to define risk/benefit profile of anticoagulation compared with antiplatelet treatment in PFO-related stroke. Systematic review protocol was registered in PROSPERO (CRD42019117559). Following PRISMA guidelines, we searched MEDLINE, EMBASE, and Cochrane CENTRAL database (2000-2019) for RCTs randomly allocating patients with cryptogenic stroke and PFO to medical treatment. Risk of bias was assessed with Cochrane RoB tool. Main outcomes were stroke recurrence and major bleeding. RoPE score-dependent analysis was implemented to define a possible role for patient selection. Five RCTs met inclusion criteria (3 high-, 1 fair-, 1 poor-quality RCTs). Overall, meta-analysis included 1565 patients (mean age 55.5years), 753 (48.1%) receiving anticoagulation. Compared with antiplatelet treatment, anticoagulation conveyed no net benefit in prevention of recurrent stroke (OR = 0.66, 95% CI 0.41-1.07, pheterogeneity= 0.46), and associated with a non-significant higher risk of major bleeding (OR = 1.64, 95% CI 0.79-3.43, pheterogeneity= 0.57). In patients with high RoPE score, anticoagulation significantly reduced the risk of recurrent stroke (OR = 0.22, 95% CI 0.06-0.8, pheterogeneity= 0.88). Our meta-analysis shows that anticoagulation confers no net benefit in recurrent stroke prevention over antiplatelets in patients with PFO-related stroke. RoPE score might help in selecting patients benefiting from anticoagulation, but further trials are needed to delineate risk/benefit profile of anticoagulation.

Study of Utilization of Antiplatelet Agents in Coronary Heart Disease Patients in Private Hospital in Surabaya

ABSTRACT Antiplatelet is the most commonly drug used as secondary prevention for Coronary Heart Disease (CHD). The aim of this study was to determine the profile of the use of antiplatelet related with its efficacy and side effects. Observational methods with cross sectional approach for 3 months follow up was used, a descriptive analysis carried out at the private hospital in Surabaya. Results from this study: aspirin 80 mg was the most prescribed antiplatelet in patients with the incidence of ischemic events 9%. Higher ischemic events also seen in patients with hypertension, dyslipidemia, and Diabetes Mellitus. Bleeding and gastrointestinal disturbance as side effects occurred in 4 patients who used aspirin as antiplatelet, and based for Naranjo scale can be concluded as possible adverse drug reaction. Keywords: Coronary Heart Disease, Antiplatelet , Ischemic events, Bleeding

Outcomes Associated With Oral Anticoagulants Plus Antiplatelets in Patients With Newly Diagnosed Atrial Fibrillation

Patients with nonvalvular atrial fibrillation at risk of stroke should receive oral anticoagulants (OAC). However, approximately 1 in 8 patients in the Global Anticoagulant Registry in the Field (GARFIELD-AF) registry are treated with antiplatelet (AP) drugs in addition to OAC, with or without documented vascular disease or other indications for AP therapy. To investigate baseline characteristics and outcomes of patients who were prescribed OAC plus AP therapy vs OAC alone. Prospective cohort study of the GARFIELD-AF registry, an international, multicenter, observational study of adults aged 18 years and older with recently diagnosed nonvalvular atrial fibrillation and at least 1 risk factor for stroke enrolled between March 2010 and August 2016. Data were extracted for analysis in October 2017 and analyzed from April 2018 to June 2019. Participants received either OAC plus AP or OAC alone. Clinical outcomes were measured over 3 and 12 months. Outcomes were adjusted for 40 covariates, including baseline conditions and medications. A total of 24 436 patients (13 438 [55.0%] male; median [interquartile range] age, 71 [64-78] years) were analyzed. Among eligible patients, those receiving OAC plus AP therapy had a greater prevalence of cardiovascular indications for AP, including acute coronary syndromes (22.0% vs 4.3%), coronary artery disease (39.1% vs 9.8%), and carotid occlusive disease (4.8% vs 2.0%). Over 1 year, patients treated with OAC plus AP had significantly higher incidence rates of stroke (adjusted hazard ratio [aHR], 1.49; 95% CI, 1.01-2.20) and any bleeding event (aHR, 1.41; 95% CI, 1.17-1.70) than those treated with OAC alone. These patients did not show evidence of reduced all-cause mortality (aHR, 1.22; 95% CI, 0.98-1.51). Risk of acute coronary syndrome was not reduced in patients taking OAC plus AP compared with OAC alone (aHR, 1.16; 95% CI, 0.70-1.94). Patients treated with OAC plus AP also had higher rates of all clinical outcomes than those treated with OAC alone over the short term (3 months). This study challenges the practice of coprescribing OAC plus AP unless there is a clear indication for adding AP to OAC therapy in newly diagnosed atrial fibrillation.

Economic Evaluations of CYP2C19 Genotype-Guided Antiplatelet Therapy Compared to the Universal Use of Antiplatelets in Patients With Acute Coronary Syndrome: A Systematic Review.

Clopidogrel is widely used after the percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) and requires activation by cytochrome P450 (CYP), primarily CYP2C19. Patients with CYP2C19 loss-of-function alleles are at increased risk of major adverse cardiovascular events, while more expensive novel antiplatelet agents (ticagrelor and prasugrel) are unaffected by the CYP2C19 mutations. This systematic review aims to answer the question about whether overall evidence supports the genotype-guided selection of antiplatelet therapy as a cost-effective strategy in post-PCI ACS. A systematic literature search of PubMed, EMBASE, EconLit, and PharmGKB was done to identify all the economic evaluations related to genotype-guided therapy compared to the universal use of antiplatelets in ACS patients. Quality of Health Economic Studies tool was used for quality assessment. The search identified 13 articles, where genotype-guided treatment was compared to universal clopidogrel, ticagrelor, and/or prasugrel. Six studies showed that genotype-guided therapy was cost-effective compared to universal clopidogrel, while 5 studies showed that it was dominant. One study specified that genotype-guided with ticagrelor is cost-effective only in both CYP2C19 intermediate and poor metabolizers. Genotype-guided therapy was dominant when compared to universal prasugrel, ticagrelor, or both in 5, 1, and 3 studies, respectively. Only 2 studies reported that universal ticagrelor was cost-effective compared to genotype-guided treatment. All the included articles had good quality. Based on current economic evaluations in the literature, implementing CYP2C19 genotype-guided therapy is a cost-effective approach in guiding the selection of medication in patients with ACS undergoing PCI.

Abstract WMP115: Hemorrhagic and Ischemic Stroke in Patients on Oral Anticoagulants for Nonvalvular Atrial Fibrillation With and Without Antiplatelet Therapy

Introduction: Antiplatelet (APT) therapy is challenging in patients on oral anticoagulants (OACs) for nonvalvular atrial fibrillation (NVAF) who have coronary artery diseases (CAD). Analyzing large scale registry of consecutive patients with NVAF should provide further guide for the safety and efficacy of combination therapy. Methods: We conducted historical multicenter registry at 71 centers in Japan between March 2017 and March 2018. The eligibility criteria were patients on OACs for NVAF on February 2013. There were no exclusion criteria and consecutive patients who met the eligibility criteria were registered. All patients were followed until March 2017. Co-primary endpoints were ischemic strokes including transient ischemic attack and hemorrhagic stroke including subarachnoid hemorrhage. The secondary endpoints were all-cause mortality, ischemic events (acute coronary syndrome, ischemic strokes, or systemic embolism), and major bleedings defined by ISTH and TIMI criteria. We estimated HRs of OACs and APT combination relative to OACs alone by Cox proportional hazard model adjusting for clinically relevant confounders. Results: Median age was 74 (range 20-101) years of 7826 registered patients. Sustained NVAF accounted for 49% and 73% of patients had history of CAD. Cumulative incidences of ischemic stroke and hemorrhagic stroke at 4 years were 3.8% and 0.91% in No-APT group while 5.3% and 1.2% in APT group, respectively (Figure). Adjusted HRs (95%CI) of APT group for ischemic stroke and hemorrhagic stroke were 1.03 (0.76-1.40) and 1.27 (0.67-2.4), respectively. Adjusted HRs (95%CI) for all-cause mortality, ischemic events, and major bleedings were 0.98 (0.79-1.23), 0.98 (0.74-1.32), and 1.25 (1.00-1.57), respectively. Conclusions: Adding APT in patients on AOC for NVAF did not decrease ischemic strokes and not increase hemorrhagic strokes. Because combination therapy might increase the risk of major bleedings, OAC alone should be prioritized.