Antithrombotic Research Articles

Comparative Analysis of Anticoagulation Versus Combination Anticoagulation and Antiplatelet Therapy in Atrial Fibrillation Patients Presenting With Gastrointestinal Bleeding.

Patients with atrial fibrillation (AF) taking antithrombotic (AT) therapy are at increased risk of gastrointestinal bleeding (GIB). The comparative effect of a combination of anticoagulant (AC) and antiplatelet (AP) versus AC monotherapy on clinical outcomes in patients with AF presenting with GIB is not well characterized. This study compares outcomes in AF patients with GIB on AC alone to those on combination AP and AC therapy, as part of a larger prospective study from 2013 to 2023. 137 patients diagnosed with AF who presented with overt GIB were evaluated during their hospitalization, at one month and one year post-discharge, and then annually. The median follow-up of patients was 57 months. Patients in the combination AP +AC therapy group had a higher prevalence of CAD, myocardial infarction, and coronary/vascular stent placement compared to the AC monotherapy group. No statistically significant differences were noted between the two groups in terms of end-of-follow-up mortality, in-hospital mortality, major bleeding, rebleeding, and length of hospital stay. Cox regression analysis revealed chronic kidney disease (CKD) (hazard ratio (HR) 2.05, 95% confidence interval (CI) [1.04,4.05] (p= 0.038)] and warfarin use [(HR 4.94, 95% CI [1.11,22.09] (p= 0.037)] to be independent predictors of mortality at 12 months. Anti-thrombotic therapy in patients with AF who experience GIB should be mainly directed by their cardiovascular needs. Healthcare providers may explore non-vitamin K antagonist oral anticoagulants as alternatives to warfarin for AF patients at risk of GIB, and efforts must be maximized to prevent bleeding in patients with CKD.

Application of Antithrombotic Drugs in Patients with Acute Type B Aortic Dissection Underwent Thoracic Endovascular Aortic Repair.

This study aimed to evaluate the safety and necessity of antithrombotic drugs for acute type B aortic dissection (TBAD) treated with thoracic endovascular aortic repair (TEVAR).The patients of acute TBAD treated with TEVAR were retrospectively enrolled from January 2007 to October 2022 in General Hospital of Northern Theater Command. The primary outcomes such as mortality and aortic adverse events [stroke, paraplegia, limb ischemia, organ failure (renal and intestinal tract), endoleak, redissection, aortic rupture, reintervention, and mortality] were recorded and evaluated at 1 month (early term) and 18 months (late term).The 697 patients of TBAD treated with TEVAR were divided into the antithrombotic (AT) group (n = 208) and nonantithrombotic (NAT) group (n = 489). The incidence of early mortality, early aortic adverse events, and the 18 months of cumulative freedom from all-cause mortality and aortic adverse events were not significantly different between the AT and NAT groups (2.4% versus 1.4%, 2.9% versus 4.5%, 94.7% versus 96.5% and 88.4% versus 89.9%, respectively). Log-rank tests also indicated that there were no significant differences. In multivariate Cox regression models, only pleural effusion, partially thrombosed of false lumen, maximum diameter of false lumen, and branch involvement were independent predictors of mortality, whereas the systolic blood pressure (SBP), pleural effusion, partially thrombosed of false lumen, true lumen compression, maximum diameter of false lumen, branch involvement were independent predictors of adverse aortic events.The antithrombotic drug for acute TBAD treated with TEVAR does not influence the mortality and aortic events in the early and late terms.

Impact of oral antithrombotic agents on urinary continence recovery following robot-assisted radical prostatectomy: a retrospective cohort study

BackgroundRobot-assisted radical prostatectomy (RARP) is a preferred minimally invasive surgical treatment for prostate cancer. The number of elderly patients and those with cardiovascular and/or cerebrovascular issues undergoing surgery is increasing, and many of them are taking antithrombotic (AT) agents. However, the effect of AT agents on postoperative urinary recovery has not been adequately studied. In this study, we analyzed the differences in the postoperative recovery of urinary continence and oncological outcomes in patients undergoing RARP for localized prostate cancer between AT agent adherents and non-adherents.MethodsA total of 394 patients who underwent conventional anterior RARP between February 2015 and February 2021 were categorized into two groups: those taking oral AT agents (AT group) and the control group. Urinary continence recovery, complications, and oncological outcomes were compared between the groups. A Cox proportional hazards analysis was performed to identify clinical factors that affect urinary continence recovery.ResultsThe background data and bleeding complications did not differ significantly between the groups. The recovery of continence was significantly poorer in the AT group in terms of complete pad free (HR: 0.53 [95% CI: 0.39–0.71]) and use of ≤ 1 safety pad (HR: 0.74 [95% CI: 0.59–0.94]). The rate of anastomotic leakage on cystography was significantly higher in the AT group (20.9% vs. 6.7%). A univariate analysis revealed that taking antithrombotic agents, higher prostate-specific antigen levels, and a more advanced clinical stage were associated with a poor urinary continence recovery; a multivariate analysis showed that taking AT agents was an independent factor negatively associated with urinary continence recovery. There was no significant difference between the groups in the positive surgical margin rate (19.0% vs. 23.8%) or the biochemical-recurrence-free rate.ConclusionTaking oral AT agents may be associated with poor urinary continence recovery after RARP.

Safety of Postembolization Antithrombotic Therapy After Middle Meningeal Artery Embolization.

Middle meningeal artery embolization (MMAE) for the management of chronic subdural hematoma (cSDH) has been suggested as a preferred treatment in patients where reinitiating antithrombotic (AT) therapy is necessary. In this study, we evaluate whether reinitiating AT therapy before cSDH resolution after MMAE affects radiographic and clinical resolution. This is a retrospective study of patients who underwent MMAE at our institution between 2018 and 2024. Clinical and radiographic findings were analyzed with standard statistical approaches. Kaplan-Meier curves for nonresolution compared AT and no-AT groups and compared AT resumption before and after 30 days after surgery. In 111 MMAE procedures, the median age was 73 years, 27.9% were female, and 80.6% were White. The median follow-up was 5.1 months. Forty-six patients (41.4%) demonstrated complete resolution of their cSDH. Eleven patients (9.9%) had reoperation after MMAE. The median cSDH depth was 14.0 mm, and the median midline shift was 3.0 mm. Thirty-two patients (28.8%) resumed AT before resolution. The median time to resumption was 35.5 days. Patients in the AT group were less likely to have radiographic resolution (21.9% vs 49.4%, odds ratios = 0.2872, 95% CI = 0.1113-0.7404, P = .0103) but comparable rates of reoperation and residual symptomatic presentations. Resumption of AT therapy before or after 30 days from surgery had no effects on outcome measures on univariate analysis. Major outcomes were similar between patients receiving antiplatelet-only or anticoagulant-only medications. Reinitiating AT therapy before cSDH resolution was associated with decreased rates of resolution, but comparable rates of reoperation and residual symptoms. Our results support the cautious reinitiation of AT therapy in patients requiring it after MMAE.

258 Impact of Risk Stratified Antithrombotic Medication Resumption After Traumatic Brain Injury on Patient Outcomes

INTRODUCTION: The incidence of traumatic brain injury (TBI) in patients on antithrombotic (AT) medications to prevent thromboembolic events is increasing. AT medications include antiplatelets and/or anticoagulants. While these medications are generally stopped in the setting of intracranial bleed, the optimal medication resumption time is uncertain. Both brief and prolonged suspension carry risk. In March 2021 we adjusted our institutional guidelines from restarting AT therapy at two weeks or more after TBI to resuming medications based on patient risk factors. METHODS: We performed a retrospective case-control study of data from the University of Cincinnati Level 1 Trauma Center neurotrauma registry between February 2017-November 2022. Patients on AT therapy presenting with intracranial hemorrhage and a Glasgow Coma Scale (GCS) score of 13-15 were included. The LR cohort included patients from February 2017-December 2019. The RSR cohort included patients from March 2021-November 2022. Demographics, injury variables, medication history, medication resumption, and thrombotic or hemorrhagic events up to 6 months after injury were collected. Groups were compared using t-tests for linear variables and Chi-Square for categorical variables with p < 0.05 denoted as significant. RESULTS: We identified 406 patients with 337 patients in the LR cohort and 69 patients in the RSR cohort. Early resumption (during hospitalization) occurred in 21.7% of the RSR cohort compared to 9.5% in the LR group. The difference in occurrence of thrombotic and hemorrhagic events between groups was not significant. CONCLUSIONS: Resuming antithrombotic medications after a TBI based on risk stratification criteria allows earlier resumption of medication with no associated increase in thrombotic or hemorrhagic events.

Antithrombotics in the Fall Patient: Appropriateness and Risk-Benefit Analysis.

Falls are the leading cause of hospitalizations following trauma nationwide, resulting in over 3 million admissions in 2020. This population is typically aged, and many are prescribed antithrombotic (AT) therapy. In this prospective study, we aimed to analyze fall history while assessing appropriateness of AT regimen relative to fall risk. Patients presenting following ground level fall (GLF) and meeting inclusion criteria during the study period were enrolled. Primary outcome was the relationship between AT therapy necessity (CHA2DS2-VASc) and fall risk (Morse Fall Risk). The cohort of 30 patients had an average age of 77. CHA2DS2-VASc and Morse Fall Risk showed a moderate-positive correlation (r = 0.47; P = 0.012); however, 17% of patients categorized as high fall risk had a <5% 1-year risk of VTE. This study demonstrates that risks of hemorrhage may outweigh thromboembolism prophylaxis in a significant number of patients and sheds light on the astonishing fall volume in this population.

Impact of blood transfusion on mortality and rebleeding in gastrointestinal bleeding: an 8-year cohort from a tertiary care center.

The aim of this study was to investigate the impact of blood transfusion (BT) on mortality and rebleeding in patients with gastrointestinal bleeding (GIB) and whether BT at a threshold of ≤7 g/dL may improve these outcomes. A prospective study was conducted in patients admitted with GIB between 2013 and 2021. Antithrombotic (AT) use and clinical outcomes were compared between transfused and non-transfused patients, and between those transfused at a threshold of ≤7 vs. >7 g/dL. Multivariate analysis was performed to identify predictors of mortality and rebleeding. A total of 667 patients, including 383 transfused, were followed up for a median of 56 months. Predictors of end-of-follow-up mortality included: age-adjusted Charlson Comorbidity Index, stigmata of recent hemorrhage (SRH), and being on anticoagulants only upon presentation (P=0.026). SRH was a predictor of end-of-follow-up rebleeding, while having been on only antiplatelet therapy (AP) upon presentation was protective (P<0.001). BT was not associated with mortality or rebleeding at 1 month or end of follow up. Among transfused patients, being discharged only on AP protected against mortality (P=0.044). BT at >7 g/dL did not affect the risk of short or long-term rebleeding or mortality compared to BT at ≤7 g/dL. Short- and long-term mortality and rebleeding in GIB were not affected by BT, nor by a transfusion threshold of ≤7 vs. >7 g/dL, but were affected by the use of AT. Further studies that account for AT use are needed to determine the best transfusion strategy in GIB.

Risk of Bleeding After Percutaneous Endoscopic Gastrostomy in Patients Using Antithrombotic Drugs.

The rate of using antithrombotic (AT) drugs is frequently high in patients who require percutaneous endoscopic gastrostomy (PEG). The aim of this study was to determine whether the risk of bleeding after PEG increases in patients whose AT drugs were discontinued according to the European Society Gastrointestinal Endoscopy guidelines (warfarin for 5d, low molecular weight heparin for 24h, DOAC for 3d, and clopidogrel for 7d). Data from 243 patients, who underwent PEG tube placement and received AT drugs and 206 patients who did not between 2018 and 2021 in our hospital, were evaluated retrospectively. Bleeding was defined as requiring blood transfusion, hematemesis and/or melena, decreased hemoglobin, or bleeding from PEG. A total of 243 (54.1%) patients (121 (49.7%), women, mean age (75.7y) who underwent PEG and received AT drugs, and 206 (45.9%) patients who did not (92 (44.6%), women, mean age (63.15y). The medications and bleeding rates of the patients are given in Table 1. The rate of bleeding in patients using AT medication was significantly higher than that in patients not using medication (Table 2) ( P = 0.007). When the AT drugs were compared among themselves, the bleeding risk did not differ. Bleeding was detected in 10 patients with bleeding from the PEG tube in 4 with melena. Bleeding detected in 14 patients was controlled with adrenaline injections. None of the patients required transfusion or repeat endoscopies. No bleeding-related deaths were reported. Even if patients receiving AT drugs are treated as recommended by international guidelines, it should be kept in mind that bleeding may occur after PEG, and the patients should be followed accordingly.

Development and Validation of a Novel 1-year Mortality Risk Score That Includes the Use of Antithrombotic in Patients With Overt Gastrointestinal Bleeding.

We aimed to develop a novel 1-year mortality risk-scoring system that includes use of antithrombotic (AT) drugs and to validate it against other scoring systems in patients with acute gastrointestinal bleeding (GIB). We developed a risk-scoring system from prospectively collected data on patients admitted with GIB between January 2013 and August 2020, who had at least 1- year of follow-up. Independent predictors of 1-year mortality were determined after adjusting for the following confounders: the age-adjusted Charlson Comorbidity Index (CCI) (divided into 4 groups: CCI-0=0, CCI-1=1 to 3, CCI-2=4 to 6, CCI-3 ≥7), need for blood transfusion, GIB severity, need for endoscopic therapy, and type of AT. The risk score was based on independent predictors. Five hundred seventy-six patients were included and 123 (21%) died at 1-year follow-up. Our risk -score was based on the following: CCI-2 (2 points), CCI-3 (4 points), need for blood transfusion (1 point), and no use of aspirin (1 point), as aspirin use was protective (maximum score=6). Patients with higher risk scores had higher mortality. The model had a better predictive accuracy [AUC=0.82, 95% confidence interval (0.78-0.86), P <0.0001] than the Rockall score for upper GIB (Area Under the Curve (AUC)=0.68, P <<0.0001), the Oakland score for lower GIB (AUC=0.69, p =0.004), or the Shock Index for all (AUC=0.54, P <0.0001). A simple and novel score that includes use of AT upon admission accurately predicts 1-year mortality in patients with GIB. This scoring system may help guide follow-up decisions and inform the prognosis of patients with GIB.

Do antiplatelets and anticoagulants have an impact on the clinical outcomes of robotic ventral hernia repair?

BackgroundWe sought to study the impact of antithrombotics(antiplatelets and anticoagulants) on robotic ventral hernia repair(RVHR). MethodsRVHR cases were divided into antithrombotic (AT) (−) and AT (+) groups. After comparing both groups, a logistic regression analysis was performed. Results611 patients had no AT-medication. The AT(+) group had 219 patients of which 153 were only on antiplatelets, 52 only on anticoagulants, and 14(6.4%) patients on both antithrombotics. Mean age, American Society of Anesthesiology scores, and comorbidities were significantly higher in the AT(+) group. Intraoperative blood loss was greater in the AT(+) group. Postoperatively, the AT(+) group had greater rates of Clavien-Dindo grade-II and IV-a complications(p=0.001, and p=0.013, respectively), and postoperative hematomas(p=0.013). Mean follow-up was greater than 40 months. Age[Odds Ratio(OR): 1.034] and anticoagulants(OR: 3.121) were associated with increased bleeding-related events. ConclusionThere were no associations between maintained antiplatelet therapy and postoperative bleeding-related events in RVHR whereas age and anticoagulants had the highest association.

Findings on Repeat Posttraumatic Brain Computed Tomography Scans in Older Patients With Minimal Head Trauma and the Impact of Existing Antithrombotic Use.

Evaluate the utility of routine rescanning of older, mild head trauma patients with an initial negative brain computed tomography (CT), who is on a preinjury antithrombotic (AT) agent by assessing the rate of delayed intracranial hemorrhage (dICH), need for surgery, and attributable mortality. Participating centers were trained and provided data collection instruments per institutional review board-approved protocols. Data were obtained from manual chart review and electronic medical record download. Adults ≥55 years seen at Level I/II Trauma Centers, between 2017 and 2019 with suspected head trauma, Glasgow Coma Scale 14 to 15, negative initial brain CT, and no other Abbreviated Injury Scale injuries >2 were identified, grouped by preinjury AT therapy (AT- or AT+) and compared on dICH rate, need for operative neurosurgical intervention, and attributable mortality using univariate analysis (α=.05). A total of 2,950 patients from 24 centers were enrolled; 280 (9.5%) had a repeat brain CT. In those rescanned, the dICH rate was 15/126 (11.9%) for AT- and 6/154 (3.9%) in AT+. Assuming nonrescanned patients did not suffer clinically meaningful dICH, the dICH rate would be 15/2001 (0.7%) for AT- and 6/949 (0.6%) for AT+. No surgical operations were done for dICH. All-cause mortality was 9/2950 (0.3%) and attributable mortality was 1/2950 (0.03%). The attributable death was an AT+, dICH patient whose family declined intervention. In older patients with an initial Glasgow Coma Scale of 14 to 15 and a negative initial brain CT scan, the dICH rate is low (<1%) and of minimal clinical consequence, regardless of AT use. In addition, no patient had operative neurosurgical intervention. Therefore, routine rescanning is not supported based on the results of this study.

Učestalost vaskularnih faktora rizika i uticaj njihovog lečenja na ishod akutnog ishemijskog moždanog udara kod pacijenata lečenih rekanalizacionom terapijom

Introduction: Stroke is one of the leading causes of death and long-term disability worldwide. Timely diagnosis and control of vascular risk factors is a priority for stroke prevention. Aim: The aim of this study was to analyze the prevalence of vascular risk factors and the impact of their treatment on the outcome of acute ischemic stroke in patients treated with recanalization therapy. Material and methods: A retrospective analysis of data on stroke patients treated with recanalization therapy in one year was performed. The analysis contained the characteristics of the study population, risk factors and comorbidities, and the therapy used in stroke primary prevention. Symptomatic intracerebral hemorrhage (sICH) was defined according to ECASS-2 criteria. Patients' functional outcomes after three months were assessed by using a modified Rankin scale score (mRS). Results: The study included a total of 117 stroke patients of whom 70 (60%) were male. The average age of the study population was 65 years (64.6 ± 14), with a baseline NIHSS score of 12 (12 ± 6.7). The most often present risk factors were arterial hypertension and hypercholesterolemia. The most commonly used drugs in primary prevention were antihypertensives and antithrombotic therapy. Afterward, patients were divided into two groups (those with previous antithrombotic (AT) therapy and those without). Patients who were not on previous AT therapy were: more often male, aged 45 - 75 years or younger than 45 years, less often had previous AF, hypercholesterolemia and previous stroke (p = &lt; 0.01, p = 0.014, p = 0.002). They also had a trend of initially lower NIHSS scores. There were no statistical differences in the occurrence of sICH between the two groups (p = 0.922). Conclusion: The identification of stroke risk factors within all age groups and their treatment is of great importance in the primary prevention of stroke. Previous use of antithrombotic therapy does not increase the likelihood of sICH occurrence in stroke patients treated with recanalization therapy.

Evaluation of antithrombotic use and COVID-19 outcomes in a nationwide atrial fibrillation cohort

ObjectiveTo evaluate antithrombotic (AT) use in individuals with atrial fibrillation (AF) and at high risk of stroke (CHA2DS2-VASc score ≥2) and investigate whether pre-existing AT use may improve COVID-19 outcomes.MethodsIndividuals...

Ground-level falls among nonagenarians: the impact of pre-injury antithrombotic therapy.

Among nonagenarians admitted to our emergency department (ED) for ground-level falls, we assessed the impact of pre-injury antithrombotic (AT) treatment on the post-traumatic consequences, and identified risk factors for 1-month mortality. All eligible patients were consecutively included over an 18-month period. Head trauma was attested by reliable medical history, witnesses or recent external signs. Patient characteristics, post-traumatic consequences and outcomes were compared across patients with and without AT. Risk factors for 1-month mortality were assessed using multivariate logistic regression analyses. 1014 consecutive nonagenarians were analysed, 675 (66.6%) with AT and 339 (33.4%) without. Head trauma (n = 429, 42.3%) was significantly more frequent among patients with AT (49.2 vs 28.6%, p < 0.001). Intracranial hemorrhage (ICH, n = 43, 4.2%), mostly subdural hematomas (58%), were more frequently found among patients with AT (p < 0.015). At least one fracture was diagnosed for 23.9% of the population, mostly hip fractures, without any significant association with AT. At 1month, 103 patients (10.2%) had died. The independent risk factors for 1-month mortality were: ICH associated with head trauma (OR = 5.9, 95% CI 2.5-14), Glasgow coma score ≤ 12 at admission (OR = 10; 95% CI 2.2-46), atrial fibrillation (OR = 2.2, 95% CI 1.4-3.4) and age ≥ 95years (OR = 1.6, 95% CI 1.0-2.5). Our results support accurate and regular assessment of the benefit/risk ratio for antithrombotic treatment among elderly people at high risk for falls.

Safety of Antithrombotic Resumption in Chronic Subdural Hematoma Patients with Middle Meningeal Artery Embolization: A Case Control Study

ObjectiveChronic subdural hematoma (CSDH) is a serious problem with an incidence of 20.6/100,000/year in North America and is posited to grow as the population ages. Middle Meningeal Artery (MMA) embolization is an upcoming therapy for treatment of CSDH. Among patients with CSDH who undergo MMA embolization outcomes are no different in patients who resume the antithrombotic (AT) after MMA embolization as compared to patients who don't resume AT. MethodsWe did retrospective review of all cases of MMA embolization in the setting of CSDH done over 2.5 years in 2 centers. Comparison of cases in which AT was resumed vs controls with no AT was performed. A successful outcome was defined as reduction of at least 50% volume in CSDH. Univariate analysis regarding all outcome measures for baseline variables was performed using Fisher exact test or t-test. Multivariate logistic regression with controlling for age, surgical evacuation of the hematoma. ResultsThere were a total of 56 MMA embolization cases, 33 of them had no AT started and 23 of them had AT resumption at a mean of 2.4 days. About 40% of patients had surgical evacuation done prior to MMA embolization. There was no significant difference in hematoma reduction or volume even after adjusting for surgical evacuation (OR 1.00 95%CI 0.60- 1.67). Patients who had AT resumption had more CAD (71%vs 21% p= 0.001) and Afib (58% vs 18% p=0.002) necessitating AT. ConclusionAT therapy can be safely resumed in CSDH after MMA embolization as there is no significant difference in CSDH volume reduction and recurrence.

Cardiovascular disease preventive medication dispensing for almost every New Zealander 65years and over: a preventive treatment paradox?

To describe the dispensing of cardiovascular disease (CVD) preventive medications among older New Zealanders with and without prior CVD or diabetes. New Zealanders aged ≥65years in 2013 were identified using anonymised linkage of national administrative health databases. Dispensing of blood pressure lowering (BPL), lipid lowering (LL) or antithrombotic (AT) medications, was documented, stratified by age and by history of CVD, diabetes, or neither. Of the 593,549 people identified, 32% had prior CVD, 14% had diabetes (of whom half also had prior CVD) and 61% had neither diagnosis. For those with prior CVD, between 79-87% were dispensed BPL and 73-79% were dispensed AT medications, across all age groups. In contrast, LL dispensing was lower than either BPL or AT in every age group, falling from 75% at age 65-69years to 43% at 85+ years. For people with diabetes, BPL and LL dispensing was similar to those with prior CVD, but AT dispensing was approximately 20% lower. Among people without prior CVD or diabetes, both BPL and AT dispensing increased with age (from 39% and 17% at age 65-69 years to 56% and 35% at 85+ years respectively), whereas LL dispensing was 26-31% across the 65-84year age groups, falling to 17% at 85+ years. The much higher dispensing of BPL and AT compared to LL medications with increasing age suggests a preventive treatment paradox for older people, with the medications most likely to cause adverse effects being dispensed most often.

Safety of Cold Snare Polypectomy for Small Colorectal Polyps in Patients Receiving Antithrombotic Therapy

Background and AimsRecent guidelines do not specify the bleeding risk of cold polypectomy. We investigated delayed postpolypectomy bleeding (DPPB) after cold snare polypectomy (CSP) for colorectal polyps in patients receiving antithrombotic (AT) therapy. MethodsA total of 4770 patients who underwent endoscopic resection of colorectal polyps between April 2017 and December 2019 were included. Of them, we analyzed 3600 patients and 10,152 polyps with a size of < 10 mm, including 640 patients who took AT drugs. The patients were subdivided into 3 groups according to AT drug use: 1) continued use, 2) withdrawal, and 3) no use. We compared DPPB rates between hot snare polypectomy (HSP) and CSP in each group. ResultsThe DPPB rates in the CSP group were approximately one-tenth lower than those in the HSP group (per-patient analysis: 0 (0/2598) vs 0.9% (9/1002), per-polyp analysis: 0.04 (3/7928) vs 0.58% (13/2224)). The DPPB rates of HSP were significantly different among the continued use, withdrawal, and no use groups (per-polyp analysis: 2.08 (6/289), 0 (0/159), and 0.40% (7/1771), P = 0.0015). However, the DPPB rates of CSP did not differ among groups (per-polyp analysis: 0 (0/983), 0.17 (1/591), and 0.03% (2/6348), P = 0.2087). No DPPB was observed after CSP in patients with continued use of thienopyridine, aspirin, cilostazol, direct oral anticoagulants, or warfarin; except for 1 patient with direct oral anticoagulant withdrawal. ConclusionThe DPPB of CSP in patients taking an AT drug was low and similar to that in patients not taking drugs. CSP could be a safe procedure for colorectal polyps, even with continued use of AT drugs.

Eastern Association for the Surgery of Trauma Multicenter Trial: Comparison of pre-injury antithrombotic use and reversal strategies among severe traumatic brain injury patients.

Trauma teams are often faced with patients on antithrombotic (AT) drugs, which is challenging when bleeding occurs. We sought to compare the effects of different AT medications on head injury severity and hypothesized that AT reversal would not improve mortality in severe traumatic brain injury (TBI) patients. An Eastern Association for the Surgery of Trauma-sponsored prospective, multicentered, observational study of 15 trauma centers was performed. Patient demographics, injury burden, comorbidities, AT agents, and reversal attempts were collected. Outcomes of interest were head injury severity and in-hospital mortality. Analysis was performed on 2,793 patients. The majority of patients were on aspirin (acetylsalicylic acid [ASA], 46.1%). Patients on a platelet chemoreceptor blocker (P2Y12) had the highest mean Injury Severity Score (9.1 ± 8.1). Patients taking P2Y12 inhibitors ± ASA, and ASA-warfarin had the highest head Abbreviated Injury Scale (AIS) mean (1.2 ± 1.6). On risk-adjusted analysis, warfarin-ASA was associated with a higher head AIS (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.34-4.42) after controlling for Injury Severity Score, Charlson Comorbidity Index, initial Glasgow Coma Scale score, and initial systolic blood pressure. Among patients with severe TBI (head AIS score, ≥3) on antiplatelet therapy, reversal with desmopressin (DDAVP) and/or platelet transfusion did not improve survival (82.9% reversal vs. 90.4% none, p = 0.30). In severe TBI patients taking Xa inhibitors who received prothrombin complex concentrate, survival was not improved (84.6% reversal vs. 84.6% none, p = 0.68). With risk adjustment as described previously, mortality was not improved with reversal attempts (antiplatelet agents: OR 0.83; 85% CI, 0.12-5.9 [p = 0.85]; Xa inhibitors: OR, 0.76; 95% CI, 0.12-4.64; p = 0.77). Reversal attempts appear to confer no mortality benefit in severe TBI patients on antiplatelet agents or Xa inhibitors. Combination therapy was associated with severity of head injury among patients taking preinjury AT therapy, with ASA-warfarin possessing the greatest risk. Prognostic, level II.

Impact of preoperative antithrombotic therapy in patients undergoing elective isolated coronary artery bypass grafting.

The objective of this retrospective study was to assess differences in clinical outcomes between patients on acetylsalicylic acid (ASA) monotherapy and patients on other antithrombotic (AT) regimens undergoing elective coronary artery bypass grafting (CABG). Patients who underwent elective isolated CABG between 2017 and 2019 at the Catharina Hospital Eindhoven were eligible for this study. The primary end points were re-exploration for bleeding and postoperative blood product transfusion. Secondary end points included 30-day mortality, in-hospital stroke, in-hospital myocardial infarction and duration of hospitalization. Propensity matching was used to compare outcomes of the main study groups (ASA vs other AT therapy) and subgroups of AT therapy (guideline adherence vs non-adherence). A total of 1068 patients were included: 710 patients on ASA monotherapy and 358 patients on other AT regimens. In the 256 matched patients in the main study groups, using AT regimens other than ASA monotherapy was associated with increased risk of re-exploration for bleeding [6.6% vs 2.0%, P = 0.017; odds ratio (OR) 3.57 (1.29-9.83)] and increased use of blood products [37.5% vs 20.3%, P < 0.001; OR 2.35 (1.58-3.49)]. In 122 matched subgroup patients, non-adherence was associated with an increased risk of re-exploration [10.7% vs 3.3%, P = 0.044; OR 3.52 (1.11-11.12)] and increased blood product use [51.6% vs 25.4%, P < 0.001; OR 3.13 (1.83-5.38)]. Secondary end points were not significantly different among the main study groups and subgroups. Preoperative use of AT therapy other than ASA monotherapy in patients who elected CABG was associated with the increased postoperative use of blood products and risk of re-exploration for bleeding; this finding was even more pronounced in non-guideline-adherent patients.

Inappropriate Use of Oral Antithrombotic Combinations in an Outpatient Setting and Associated Risks: A French Nationwide Cohort Study.

With the increase in prevalence of cardiovascular diseases, multimorbidity, and medical progress, oral antithrombotic (AT) combinations are increasingly prescribed. The aims of this study were to estimate the incidence of oral AT combinations, their appropriateness (defined as indications compliant with guidelines), and the related risk of major bleeding (i.e., leading to hospitalization) or death, among new users. We conducted a 5-year historical cohort study, using the French national healthcare database, including all individuals ≥ 45 years old with a first delivery of oral ATs between 1 January 2013 and 31 December 2017. The cumulative incidence of oral AT combinations was estimated with the Fine and Gray method, taking into account the competitive risk of death. We compared the cumulative incidence of major bleeding according to the type of oral AT treatment initiated at study entry (monotherapy or oral AT combinations). During the study period, 22,220 individuals were included (mean (SD) age 68 (12) years). The cumulative incidence of oral AT combinations at 5 years was 27.8% (95% confidence interval (CI) 26.8–28.9). Overall, 64% of any oral AT combinations did not comply with guidelines. The cumulative incidence of major bleeding and death in the whole cohort at 5 years was 4.1% (95% CI 3.7–4.6) and 10.8% (95% CI 10.1–11.6), respectively. Risk of major bleeding increased among individuals with oral AT combinations versus oral AT monotherapy at study entry (subdistribution hazard ratio sHR: 2.16 (1.01–4.63)); with no difference in terms of death. The use of oral AT combinations among oral AT users is frequent, often inappropriately prescribed, and associated with an increased risk of major bleeding.