Chronic Antiplatelet Therapy Research Articles

Continuation of chronic antiplatelet therapy is not associated with increased need for transfusions: a cohort study in critically ill septic patients.

The decision to maintain or halt antiplatelet medication in septic patients admitted to intensive care units presents a clinical dilemma. This is due to the necessity to balance the benefits of preventing thromboembolic incidents and leveraging anti-inflammatory properties against the increased risk of bleeding. This study involves a secondary analysis of data from a prospective cohort study focusing on patients diagnosed with severe sepsis or septic shock. We evaluated the outcomes of 203 patients, examining mortality rates and the requirement for transfusion. The cohort was divided into two groups: those whose antiplatelet therapy was sustained (n = 114) and those in whom it was discontinued (n = 89). To account for potential biases such as indication for antiplatelet therapy, propensity score matching was employed. Therapy continuation did not significantly alter transfusion requirements (discontinued vs. continued in matched samples: red blood cell concentrates 51.7% vs. 68.3%, p = 0.09; platelet concentrates 21.7% vs. 18.3%, p = 0.82; fresh frozen plasma concentrates 38.3% vs. 33.3%, p = 0.7). 90-day survival was higher within the continued group (30.0% vs. 70.0%; p < 0.001) and the Log-rank test (7-day survivors; p = 0.001) as well as Cox regression (both matched samples) suggested an association between continuation of antiplatelet therapy < 7 days and survival (HR: 0.24, 95%-CI 0.10 to 0.63, p = 0.004). Sepsis severity expressed by the SOFA score did not differ significantly in matched and unmatched patients (both p > 0.05). The findings suggest that continuing antiplatelet therapy in septic patients admitted to intensive care units could be associated with a significant survival benefit without substantially increasing the need for transfusion. These results highlight the importance of a nuanced approach to managing antiplatelet medication in the context of severe sepsis and septic shock.

Effect of chronic antiplatelet therapy on clinical outcomes of endovascular thrombectomy for treatment of acute ischemic stroke.

The objective of this study was to investigate the prognostic significance of chronic antiplatelet therapy (APT) usage in acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT). Long-term APT may enhance recanalization but may also predispose patients to an increased risk of hemorrhagic transformation. Weighted hospitalizations for anterior-circulation AIS treated with EVT were identified in a large United States claims-based registry. Baseline clinical characteristics and outcomes were compared between patients with and without chronic APT usage prior to admission. Multivariable logistic regression analysis was performed to assess adjusted associations between APT and study endpoints. This analysis identified 36,560 patients, of whom 8170 (22.3%) were on a chronic APT regimen prior to admission. These patients were older and demonstrated a higher burden of comorbid disease, but had similar stroke severity on presentation in comparison with those not on APT. On unadjusted analysis, patients with prior APT demonstrated higher rates of favorable outcomes (24.3% vs 21.5%, p < 0.001), lower rates of mortality (7.0% vs 10.1%, p < 0.001), and lower rates of any intracranial hemorrhage (ICH; 20.3% vs 24.2%, p < 0.001), but no difference in rates of symptomatic ICH (sICH). Following multivariable adjustment for baseline clinical characteristics including age, acute stroke severity, and comorbidity burden, prior APT was associated with favorable outcome (adjusted odds ratio [aOR] 1.21, 95% CI 1.17-1.24, p < 0.001) and a lower likelihood of mortality (aOR 0.73, 95% CI 0.70-0.77, p < 0.001), without an increased likelihood of ICH (any ICH aOR 0.84, 95% CI 0.81-0.87, p < 0.001; sICH aOR 0.92, 95% CI 0.82-1.03, p = 0.131). Retrospective evaluation of patients with AIS treated with EVT using registry-based data demonstrated an association of prior APT usage with favorable outcomes, without an increased risk of hemorrhagic transformation.

Hemorrhagic risk in patients who undergo deep brain stimulation on chronic antiplatelet or anticoagulation therapy

Hemorrhagic risk in patients who undergo deep brain stimulation on chronic antiplatelet or anticoagulation therapy

Chronic antiplatelet therapy in prevetion of cardiovascular diseases (in population of elderly) from the perspective of oral health: Cardiologic safety versus complications risk. Influence of oral diseases on global health risk in elderly

Introduction and purpose: Oral cavity diseases are a common problem in everyday clinical practice, particularly important in the context of elderly people affected by numerous chronic diseases, on the verge of frailty. These patients are often characterized by an increased risk of cardiovascular events, but also an increased risk of bleeding, which is the reason for dentists' doubts regarding the maintenance or suspension of chronic antiplatelet therapy in the periprocedural period. The aim of our work is to present the risks of untreated oral diseases and to summarize the current knowledge and recommendations on the use of antiplatelet drugs during surgical dental treatment.&#x0D; Description of the state of knowledge: It has been proven that the ongoing disease processes in the oral cavity exacerbate the course of chronic diseases by several different mechanisms, the best known of which are: opening the gates to the bloodstream, blood circulation of inflammatory mediators and direct colonization of the respiratory tract by microorganisms from the focal point in the oral cavity. According to current research, standard dental surgeries can be safely performed in patients taking antiplatelet drug(s) chronically without the need to discontinue therapy in the periprocedural period. The risk of prolonged or excessive bleeding in such patients is not significantly increased, and bleeding complications that occur can be managed with local haemostasis measures. &#x0D; Conclusions: Prevention and early treatment of oral diseases can protect against their negative global impact on health. There is no indication to interrupt chronic antiplatelet therapy with one or two drugs prior to standard dental procedures.

#4878 STUDYING THE EFFECTIVENESS OF PRASUGREL AND CLOPIDOGEL IN PATIENTS WITH CHRONIC LOWER LIMB ISCHEMIA WITH STAGE 2 CKD

Abstract Background and Aims To compare the clinical and rheological efficacy of prasugrel and clopidogrel in patients with chronic lower limb ischemia with stage 2 chronic kidney disease. According to statistics, in Europe, peripheral arterial disease is common in more than 40 million Europeans. According to the developed tactics, not only stroke should be recognized as a serious, life-threatening condition, but other peripheral vascular diseases can lead to disability and death. Methods The study included 101 patients with critical lower limb ischemia of atherosclerotic origin. The mean age of the patients was 51.51±8.33 years. As a control group, 20 healthy volunteers (mean age 53.90 ± 9.05 years) were examined without signs of pathology of the cardiovascular system, including those of a vegetative nature. All patients included in the study were hospitalized in the Department of Interventional Cardiology of the Republican Specialized Scientific and Practical Center for Therapy and Medical Rehabilitation, Tashkent city. Results In 94 patients (93.07%), CLCI was accompanied by hemodynamically significant multifocal atherosclerotic lesions. The first place in frequency of combined lesions was occupied by the coronary vessels, the second place - by the arteries of the brachiocephalic basin. 82 patients (81.19%) had previously suffered arterial occlusion, also most often in the form of acute myocardial infarction, somewhat less often - acute cerebrovascular accident. 47 patients (46.53%) underwent revascularization earlier, mainly coronary artery stenting, coronary artery bypass grafting, carotid endarterectomy. 8 patients (7.92%) underwent revascularization of the contralateral leg. The study studied spontaneous (SAT) and ADP-induced platelet aggregation. In the CG, SAT was noted only in 50% of cases and in all patients of the CLCI group. After comparing the results in the groups of patients with CLCI and representatives of the CG, in whom SAT was noted, it was found that both the rate and degree of SAT in the group of patients were significantly higher than in healthy individuals (2.95±0.59% versus 0.55± 0.21% and 6.05±1.54% versus 1.24±0.21%, respectively, p&amp;lt;0.001 significance of the intergroup difference of both parameters). All patients due to CINC underwent endovascular revascularization of the affected leg. After the procedure, patients were prescribed an antiplatelet agent at a maintenance dose (prasugrel 10 mg/day, clopidogrel 75 mg/day). After 3 months, a control examination was carried out, during which the dynamics of platelet aggregation activity was studied. It was found that the indicators of CAT and ADP induced aggregation decreased by 22-37%. During the test, patients with resistance to antiplatelet agents were identified - in whom the decrease in the degree of ADP5 induced aggregation was less than 20%. Such resistance was found in 19 patients: 1 patient in the prasugrel group (1.69%) and 18 patients in the clopidogrel group (42.86%, chi square = 27.00, p&amp;lt;0.001). Isolation of patients with normal and reduced response to the loading dose of clopidogrel revealed some differences (Table 3.3). So, already initially in this group of patients, the degree of ADP5-induced aggregation was lower than in the group of patients with an antiplatelet response of more than 20%. After the application of a loading dose of clopidogrel, differences in relative dynamics were noted only in terms of the degree of ADP%-induced aggregation (p&amp;lt;0.001). Conclusions Thus, the present study revealed that in patients with CLCI, there is a significant activation of CAT and an increase in the aggregation response to the introduction of high doses of the inducer of ADP5 aggregation. The loading dose of antiplatelet agents contributed to a significant decrease in platelet aggregation activity after 2 hours with a large effect of prasugrel. Chronic antiplatelet therapy led to a decrease in the rate and degree of aggregation, both spontaneous and ADP-induced, a decrease in the endogenous ADP release response, also with a great effect in patients taking prasugrel.

Prospective observational registry of perioperative and periprocedural management of antithrombotic therapy in “real world”: the REQXAA study

Introduction and objectivesThere is scarce real-world evidence on the management of perioperative antithrombotic treatment according to current recommendations. The aim of this study was to analyze the management of antithrombotic treatment in patients undergoing surgery or another invasive intervention and to assess the consequences of this management on the occurrence thrombotic or bleeding events. MethodsThis prospective, observational, multicenter and multispecialty study analyzed patients receiving antithrombotic therapy who underwent surgery or another invasive intervention. The primary endpoint was defined as the incidence of adverse (thrombotic and/or hemorrhagic) events after 30 days of follow-up with respect to management of perioperative antithrombotic drugs. ResultsWe included 1266 patients (male: 63.5%; mean age 72.6 years). Nearly half of the patients (48.6%) were under chronic anticoagulation therapy (mainly for atrial fibrillation; CHA2DS2-VASC: 3.7), while 53.3% of the patients were under chronic antiplatelet therapy (mainly for coronary artery disease). Low ischemic and hemorrhagic risk was found in 66.7% and 51.9%, respectively. Antithrombotic therapy management was in line with current recommendations in only 57.3% of the patients. Inappropriate management of antithrombotic therapy was an independent risk factor for both thrombotic and hemorrhagic events. ConclusionsThe implementation of recommendations on the perioperative/periprocedural management of antithrombotic therapy in real-world patients is poor. Inappropriate management of antithrombotic treatment is associated with an increase in both thrombotic and hemorrhagic events.

Quality of Life and Post-Surgical Complications in Patients on Chronic Antiplatelet Therapy with Proximal Femur Fracture: 12-Month Follow-Up after Implementing a Strategy to Shorten the Time to Surgery.

We evaluated a strategy to shorten the time from admission to surgery in patients with proximal femur fractures on chronic antiplatelet therapy. We reported a 12-month follow-up on complications and quality of life (QoL). Multicentre, open-label, randomized, parallel clinical trial. Patients were randomized to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Medical and surgical complications and QoL (EQ-5D-5L questionnaire) were assessed during the hospital stay, and after hospital discharge at 30 days, and 6 and 12 months. From 156 randomized patients, 143 patients underwent surgery. The mean age was 85.5 (7.8) years and 68.0% were female. After hospital discharge, 5.7% of patients had surgical wound complications and 55.9% had medical complications, with 42.7% having serious adverse events. QoL improved significantly after surgery, with the best scores at the six-month follow-up. The overall mortality was 32.2%. There were no differences between early and delayed surgery groups in any assessed outcomes. It seems safe to reduce the time of surgery under neuraxial anaesthesia in patients with hip fractures on chronic antiplatelet therapy by platelet function testing. QoL in particular improves in the first six months after surgery.

Registro observacional prospectivo sobre la utilización del tratamiento antitrombótico durante el periodo perioperatorio y periprocedimiento en el «mundo real»: estudio REQXAA

Introduction and objectivesThere is scarce real-world evidence on the management of perioperative antithrombotic treatment according to current recommendations. The aim of this study was to analyze the management of antithrombotic treatment in patients undergoing surgery or another invasive intervention and to assess the consequences of this management on the occurrence thrombotic or bleeding events. MethodsThis prospective, observational, multicenter and multispecialty study analyzed patients receiving antithrombotic therapy who underwent surgery or another invasive intervention. The primary endpoint was defined as the incidence of adverse (thrombotic and/or hemorrhagic) events after 30 days of follow-up with respect to management of perioperative antithrombotic drugs. ResultsWe included 1266 patients (male: 63.5%; mean age 72.6 years). Nearly half of the patients (48.6%) were under chronic anticoagulation therapy (mainly for atrial fibrillation; CHA2DS2-VASC: 3.7), while 53.3% of the patients were under chronic antiplatelet therapy (mainly for coronary artery disease). Low ischemic and hemorrhagic risk was found in 66.7% and 51.9%, respectively. Antithrombotic therapy management was in line with current recommendations in only 57.3% of the patients. Inappropriate management of antithrombotic therapy was an independent risk factor for both thrombotic and hemorrhagic events. ConclusionsThe implementation of recommendations on the perioperative/periprocedural management of antithrombotic therapy in real-world patients is poor. Inappropriate management of antithrombotic treatment is associated with an increase in both thrombotic and hemorrhagic events.

Cardiovascular disease after COVID-19 infection in elderly patients. Results of annual follow-up of a cohort of survivors

Funding AcknowledgementsType of funding sources: None.IntroductionAlthough the effects of SARS-CoV-2 infection on the cardiovascular system are well known in the acute phase, the cardiovascular impact in the elderly population surviving respiratory COVID-19 infection after 1-year follow-up has not been sufficiently studied.MethodsObservational registry of 240 elderly patients (75 years or older) consecutively admitted for and surviving COVID-19 respiratory infection between March 1 and April 30, 2020. The incidence of major cardiovascular events [MACE] (cardiovascular death [CD], acute coronary syndrome [ACS], cerebrovascular disease [CVD], venous thromboembolic disease [VTE], and heart failure [HF]) was prospectively analyzed.ResultsThe mean age was 83.8 ± 5.6 years (range 75-103 years). A total of 54.2% were women. Most patients had a personal history of cardiovascular risk factors: hypertension (83.3%), diabetes mellitus (27.9%), dyslipidemia (43.8%). Among the main cardiological comorbidities, a history of atrial fibrillation was the most frequent (18.8%). Of note was the high percentage of institutionalized patients (37.1%) and those with moderate-severe dementia (16.7%). After a mean follow-up of 352.2±70.4 days, 13.8% of patients died and 9.6% had MACE, the most frequent being heart failure (7.5%), with no differences in the severity or overall evolution of the acute disease. Of the 33 patients who developed HF, only 3 died of cardiovascular causes. Only 2 patients suffered a stroke, in both cases without a history of AF or anticoagulants. Only 2 patients had a thromboembolic event (0.8%). The low incidence of thrombotic events may be due in part to the high rate of anticoagulation and chronic antiplatelet therapy and the high percentage of prophylactic heparin prescription at discharge, as well as the fact that only cases with clinical repercussions. COPD, CKD, institutionalization and moderate-severe dementia are associated with an increased risk of MACE, although only COPD and prescription of loop diuretics were identified as independent risk markers in the multivariate analysis.ConclusionsIn elderly COVID-19 survivors, the incidence of MACE after one year of follow-up is high, the main manifestation being heart failure. COPD and the prescription of loop diuretics were identified as independent risk markers for the development of MACE in the multivariate analysis.Baseline clinical characteristicsCox survival analysis.Predictors of MACE

Early Surgery with Neuraxial Anaesthesia in Patients on Chronic Antiplatelet Therapy with a Proximal Femur Fracture: Multicentric Randomised Clinical Trial

Background: Patients with proximal femur fracture on antiplatelet treatment benefit from early surgery. Our goal was to perform early surgery under neuraxial anaesthesia when indicated by the platelet function test. Methods: We conducted a multicentre randomised open-label parallel clinical trial. Patients were randomised to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Early surgery was programmed when the functional platelet count (as measured by Plateletworks) was >80 × 109/L. The primary outcome was the emergency admission-to-surgery interval. Secondary outcomes were platelet function, postoperative bleeding, medical and surgical complications, and mortality. Results: A total of 156 patients were randomised, with 78 in each group, with a mean (SD) age of 85.96 (7.9) years, and 67.8% being female. The median (IQR) time to surgery was 2.3 (1.5–3.7) days for the experimental group and 4.9 (4.4–5.6) days for the control group. One-third of patients did not achieve the threshold functional platelet count on the first day of admission, requiring more than one test. There was no difference in clinical outcomes between groups. Conclusions: A strategy individualised according to the platelet function test shortens the time to proximal femur fracture surgery under neuraxial anaesthesia in patients on chronic antiplatelet treatment. Better powered randomised clinical trials are needed to further evaluate the clinical impact and safety of this strategy.

Antithrombotic treatment in COVID-19 – from theory to practical approach

Although initially considered a strictly respiratory pathology, the novel coronavirus disease-19 (COVID-19) has emerged as a significant prothrombotic trigger, inducing hypercoagulable status and increased risk of thrombotic events. This is due to a plethora of mechanisms, either from inflammation-induced endothelial dysfunction, overexpression of procoagulant molecules doubled by down-regulation of physiological antithrombotic pathways, or from an exagerated response to otherwise normal procoagulant stimuli. This complex association of factors define the concept of immunothrombosis, which can be influenced by several antithrombotic medications. Despite the lack of an „universal” guideline, the general consensus is to recommend antithrombotic treatment in COVID-19 patients, but its administration should take into account the patient’s clinical status, comorbidities or the other previous indications for antithrombotic treatment. This precaution is due to the multiple drug interactions with antivirals or other molecules used in COVID-19. Concerning anticoagulant treatment, heparins are the optimal choice, compared to antivitamins K and direct oral anticoagulants (DOACs), because they exhibit the most protective effects doubled by the least interactions with other substances. Hospitalized patients should receive prophylactic doses of anticoagulation, but not for the prevention of arterial thrombosis, unless they have a previous indication such as atrial fibrillation or prosthetic valve. It is generally recommended that patients on chronic anticoagulant or antiplatelet therapy for other conditions will continue their prescribed medication, here including special categories such as pregnant women. However, non-hospitalized patients with mild forms of the disease should not be initiated anticoagulant and antiplatelet therapy unless they have other indication. Continuation of prophylaxis after discharge is a matter of debate, the existing data suggesting it may be considered in those patients at high risk for venous thromboembolism (VTE) and/or who had a moderate-severe form of the disease, always assessing the bleeding risk. Further data from extensive studies are required in order to standardize the antithrombotic approach in COVID-19 patients.

Platelet aggregometry for hip fracture surgery in patients treated with clopidogrel: a pilot study.

Surgery for hip fractures should be performed within 48h from patient's admission. However, several factors including chronic antiplatelet therapy could delay operation. Among the totality of patients taking clopidogrel, up to 30% are resistant to the drug and have a normal platelets reactivity. We propose thromboelastography (TEG) with an ADP Platelet Mapping assay kit to assess platelet aggregation, a safe tool that could help to avoid surgery delay in those patients treated with antiplatelet therapy. A patient's blood sample was collected for aggregometry. If MA-ADP and platelets aggregation (%) were within normal values, the patient was fit for immediate surgery with neuraxial anesthesia and ultrasound-guided nerve block. If one of the two parameters or both were deranged, a mortality risk assessment was estimated. In the low risk category, the patients waited till normalization of the parameters, whereas in the high-risk group a general anesthesia and peripheral antalgic block was carried out. Nine patients were enrolled. Four of them showed normal aggregometry and surgery was performed within 24h from admission. Two patients were classified as high mortality risk and surgery was carried out under general anesthesia. Three patients awaited operation till normalization of parameters. No peri or post-operative complications were reported. An aggregometry-guided protocol can safely expedite hip fracture surgery in patients taking clopidogrel. Nonetheless, in presence of a normal platelets function, clinician can opt for a neuraxial instead of general anesthesia reducing the incidence of postoperative delirium and cognitive dysfunction.Trial registration: prospectively registered at clinicaltrials.gov (NCT04642209; date of registration: 23rd November 2020).

Analysing the effectiveness of topical bleeding care following tooth extraction in patients receiving dual antiplatelet therapy-retrospective observational study

BackgroundPatients using antiplatelet drugs following infarctions, acute coronary syndrome or stroke pose a significant clinical problem if it is necessary to perform surgery, including dental surgery, since they are at risk of prolonged or secondary post-extraction bleeding. Discontinuation of this therapy is associated with a high risk of serious thromboembolic complications. The purpose of this study was to assess the effectiveness of TachoSil fibrin-collagen patches in stopping and preventing of secondary post-extraction bleeding in patients undergoing chronic antiplatelet therapy.MethodsThe study was conducted through retrospective examination of the medical records of 153 patients using chronic antiplatelet therapy and those qualified for tooth extraction. The largest group comprised 74 patients using aspirin and clopidogrel as dual platelet antiaggregation therapy; in this group 75 tooth extractions were carried out. In all of the patients TachoSil fibrin-collagen patches and stiches were applied to the wounds resulting from tooth removal.ResultsFollowing tooth extraction, primary bleeding was stopped in all the patients and their wounds closed via coagulation within 20–30 min. In eight cases, accounting for 4.9% of the patients, secondary bleeding occurred and was successfully stopped only by applying a pressure dressing soaked in tranexamic acid. Secondary bleeding occurred in three patients on the second day and in five patients on the third day following tooth removal.ConclusionTopical application of TachoSil patches following tooth removal in patients using single or dual antiplatelet therapy effectively stopped bleeding and prevented secondary bleeding after tooth extraction.

Correlation between PlateletWorks® and PFA-100® for Measuring Platelet Function before Urgent Surgery in Patients with Chronic Antiplatelet Therapy.

Hemostasis is crucial for reducing bleeding during surgical procedures. The points-of-care based on the platelet function test could be useful to minimize the complications related to chronic antiplatelet therapy during surgery. The present study is aimed at comparing two point-of-care platelet function devices—Platelet Function Analyzer PFA-100® (Siemens Canada, Mississauga, ON, Canada) and Plateletworks®(Helena Laboratories, Beaumont, TX, USA). Our objective is to evaluate if they provide comparable and useful information to manage anti-aggregate patients before surgery. We included patients with a femoral fracture receiving chronic antiplatelet therapy and a median age of 89 years (range from 70 to 98). A platelet function evaluation was performed on all patients before surgery using both devices—Plateletworks® and PFA-100®. The correlation between Plateletworks® and PFA-100® was performed using Cohen’s Kappa coefficient. Twenty consecutive patients participated in the trial; 16 patients were under treatment with 75 mg/day of clopidogrel, three with >300 mg/day of acetylsalicylic acid (ASA), and only one was in treatment with both antiplatelet agents. Cohen’s Kappa coefficient was 0.327 comparing PFA-100®-ADP (adenosine diphosphate) and Plateletworks® and, 0.200 comparing PFA-100®-EPI (epinephrine) and Plateletworks®. In conclusion, we found a weak concordance comparing PFA-100® and Plateletworks®. This could partially be due to the advanced age of the included patients. However, given the limited sample size, more studies are necessary to confirm these results.

Increased 5-year risk of stroke, atrial fibrillation, acute coronary syndrome and heart failure in out-of-hospital cardiac arrest survivors relative to population controls: a nationwide register-based

Abstract Background Out-of-hospital cardiac arrest (OHCA) survivors are a selected group of patients with younger age and less comorbid conditions relative to non-survivors. Long-term risk of stroke, atrial fibrillation or flutter (AF), acute coronary syndrome (ACS) and heart failure (HF) in OHCA survivors not diagnosed with any of these conditions as part of the cardiac arrest is unknown. Purpose To examine 5-year risk of stroke, AF, ACS and HF in 30-day OHCA survivors relative to age- and sex-matched population controls. Methods OHCA 30-day survivors and age- and sex-matched population controls not previously diagnosed with stroke, AF, ACS or HF or during the first 30 days after cardiac arrest were included using Danish Cardiac Arrest Registry data from 2001–2015 as well as the Danish Civil Registration System. Characteristics are compared using totals and percentages for categorical data and median and 25–75% percentiles for continuous data. Five-year outcomes are compared using cumulative incidence plots as well as Shared Frailty Cox regression modeling, unadjusted and adjusted for potential confounders including age, sex, hypertension, diabetes, chronic obstructive pulmonary disease (COPD), peripheral arterial disease (PAD), chronic ischemic heart disease (IHD), transient ischemic attack (TIA), thyroid disease, cholesterol-lowering, antiplatelet and anticoagulant agents. Results Of 4362 30-day survivors, 1063 were stroke-, AF-, ACS- and HF-naïve and 1051 were matched to population controls using age, sex and time of OHCA event as matching variables. The figure depicts the risk of stroke beyond day 30 to 5 years of follow-up was 4.7% versus 1.7% for OHCA survivors vs. controls. Risks of AF, ACS and HF were 7.0% vs. 2.1%, 4.7% versus 1.2% and 12.2% vs. 1.0%, respectively. OHCA 30-day survivors were significantly more likely to have PAD relative to controls, 4.9% vs. 1.1%. Differences in IHD (22.0% vs. 1.7%), hypertension (28.1% vs. 14.6%), diabetes (9.5% vs. 4.1%), lipid-lowering agents (27.6% vs. 9.5%), COPD (11.3% vs. 2.2%) were also significant. When adjusting for these comorbidities as well as for thyroid diseases, chronic kidney disease, cancer, antiplatelet and anticoagulant therapy, differences remained highly significant: HR stroke 3.33 [95% CI 2.21–5.02], HR AF 3.26 [2.28–4.66], HR ACS 3.36 [2.14–5.27] and HR HF 11.50 [8.02–16.48]. Conclusion We demonstrate an increased five-year risk of stroke, atrial fibrillation or flutter, acute coronary syndrome and heart failure in out-of-hospital cardiac arrest survivors without prior existence of any of these conditions. These results indicate that OHCA survivors continue to remain high-risk patients for cardiovascular events and prevention intervention is warranted. Funding Acknowledgement Type of funding source: None

Early vascular responses to ultrathin biodegradable polymer sirolimus-eluting stent for the treatment of st-elevation myocardial infarction

Abstract Background Recent clinical study suggests newer-generation drug-eluting stents (DES) that combine ultrathin strut and nano-coating with biodegradable polymers sirolimus-eluting stent (BP-SES) could improve long-term clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) over current generation DES. However, safety profiles in very early phase have not been systematically addressed. Objective and method We exploratory investigate early vascular response following BP-SES implantation in patients with STEMI to reveal mechanism of the favorable clinical outcomes in recent studies using frequency domain-optical coherence tomography (FD-OCT). Consecutive twenty patients with STEMI who underwent FD-OCT immediately after primary PCI and were eligible for follow-up FD-OCT at 2 weeks after implantation were enrolled between June 2018 and November 2019. Results Twenty patients (age 62.7±11.3 years, male 85.0%) were enrolled with frequencies of hypertension (45.0%), diabetes mellitus (35.0%), dyslipidemia (55.0%) and smoking (80.0%). Aspiration catheter were used in all patients, and 1.13±0.34 stents were used. Only one patient (5.0%) received chronic antiplatelet therapy with aspirin prior to the onset of STEMI. All patients started to receive prasugrel as thienopyridine from this event and continued dual antiplatelet therapy for 2 weeks. The percentage of uncovered struts significantly decreased from post-procedure to 2W follow-up (69±18% post-procedure versus 30±11% at 2W follow up, p&amp;lt;0.0001). Malapposed struts also decreased (5.6±5.7% post-procedure versus0.9±1.2% at 2W follow up, p&amp;lt;0.0001).The average protrusion area of athero-thrombotic burden numerically decreased (0.37±0.19 at post-procedure versus 0.34±0.14 mm2 at 2W follow up, p=0.19) and its volume showed similar tendency (10.60±6.40 at post-procedure versus 9.36±5.14 mm3 at 2W follow up, p=0.19). Conclusion(s) This study firstly elucidated very early vascular responses following ultrathin strut BP-SES implantation in STEMI patients, showing early progression of strut coverage and resolution of athero-thrombotic materials. This technology may have a potential to overcome the current generation DESs in this clinical setting. Thrombus, uncovered and malapposed struts Funding Acknowledgement Type of funding source: None

Antiplatelet Agent Reversal Is Unnecessary in Blunt Traumatic Brain Injury Patients Not Requiring Immediate Craniotomy.

The need to reverse the coagulation impairment caused by chronic antiplatelet agents in traumatic brain injury (TBI) patients with acute traumatic intracerebral hemorrhage (TICH) remains controversial. We sought to determine whether emergent platelet transfusion reduces the incidence of hemorrhage expansion, mortality, or need for neurosurgical intervention such as intracranial pressure (ICP) monitoring, burr holes, or craniotomy. All adult blunt TICH patients (age ≥16 years) over a 4-year period were retrospectively reviewed. Patients with penetrating TBI, blunt TBI without TICH on admission computed tomography (CT), receiving warfarin, not on antiplatelet agents, or requiring immediate operative intervention were excluded. Patients were divided into 2 groups depending on whether they received a platelet transfusion: reversal group (RV) versus no reversal group (NR). Patient outcomes were analyzed using Mann-Whitney U and Fisher's exact tests. 169 blunt TBI patients on chronic antiplatelet therapy were studied (102 RV group, 67 NR group). The groups were well matched with regard to age, Injury Severity Score, Abbreviated Injury Scale-head, Glasgow Coma Score, mechanism of injury, need for intubation, time to initial CT scan, and hospital length of stay. Immediate platelet transfusion did not alter the occurrence of TICH extension on follow-up CT (26% vs 21%, P = .71), TBI-specific mortality (9% vs 13%, P = .45), need for ICP monitor (2% vs 3%, P = 1.0), burr hole (1% vs 3%, P = .56), or craniotomy (1% vs 3%, P = .56). Immediate platelet transfusion is unnecessary in blunt TBI patients on chronic antiplatelet therapy who do not require immediate craniotomy.

Prostate Fiducial Marker Placement in Patients on Anticoagulation: Feasibility Prior to Prostate SBRT.

Background and Purpose: Fiducial marker placement is required in patients undergoing robotic-based Stereotactic Body Radiotherapy (SBRT) or image-guided radiation therapy (IGRT) for prostate cancer. Many patients take antiplatelet or anticoagulant medication due to other medical comorbidities. They are often required to temporarily discontinue these medications prior to invasive medical procedures as they are prone to bleed. Some patients are unable to discontinue therapy due to an elevated risk of thromboembolic events. The purpose of this study is to report this institution's experience placing fiducial markers in prostate cancer patients who are on chronic antiplatelet or anticoagulant medication.Materials and Methods: From August 2015–March 2019 57 patients on chronic antiplatelet or anticoagulation therapy who were not cleared to stop these medications underwent transrectal ultrasound guided (TRUS) fiducial marker placement for SBRT/IGRT. All patients were monitored by a registered nurse during the procedure for prolonged bleeding that required staff to hold pressure to the area with a 4 × 4 gauze until it resolved. All patients were also called the following day to assess for ongoing bleeding events. Treatment planning CT scan confirmed the ideal geometry of the marker placement.Results: All 57 patients on antiplatelet or anticoagulant medication who underwent fiducial marker placement were discharged home the same day of the procedure. Four patients experienced persistent bleeding that required a nurse to hold prolonged pressure to the area. No patient experienced significant bleeding the following day or any untoward cardiovascular event.Conclusions: This series suggests the use of antiplatelet or anticoagulant medication is not an absolute contraindication to fiducial marker placement in patients undergoing SBRT or IGRT for prostate cancer. These patients should be closely monitored after the procedure for bleeding complications. Practitioners may consider the patient's medical comorbidities, risk factors for thromboembolism, and overall functional status as there is no standardized protocol for discontinuing anticoagulant or antiplatelet therapy for fiducial marker placement.

P3722Platelet reactivity changes following transcatheter aortic valve implantation

Abstract Introduction Although recent studies described changes in platelet reactivity (PR) in days following transcatheter aortic valve implantation (TAVI), precise time course and duration of these changes have not been fully investigated. Purpose To investigate PR changes during and after TAVI. Methods Study included 42 consecutive patients with severe and symptomatic aortic stenosis undergoing TAVI procedure in our institution. Patients' clinical characteristics were collected from medical records. All patients who did not have chronic dual antiplatelet therapy received loading dose of aspirin and clopidogrel (300 mg) one day before the procedure followed by their standard maintenance doses for next three months. PR was measured in six time points: just before induction of anaesthesia (T1), after heparin administration (T2), at the end of procedure (T3), and on 3rd, 6th and 30th postoperative day (T4–6). PR was measured using impedance aggregometer (Multiplate® analyzer, Roche, Munich, Germany) in response to three platelet aggregation agonists: arachidonic acid (ASPItest), ADP (ADPtest) and thrombin receptor activating peptide-6 (TRAPtest). Results Mean patient age was 82.1 years with majority of patients being male 57.1% (N=24). Mean valve area and mean transvalvular gradient prior to procedure were 0.71±0.21 cm2 and 49.1±18.7 mmHg, respectively. All patients underwent successful TAVI procedure using either self-expandable (N=25, 59.5%) or balloon-expandable valve. Two patients (4.7%) underwent transapical TAVI, while transfemoral approach was used in all other patients. Mean postimplantation gradient was 10.2±7.1 mmHg. Mean PR on T1 was 24.3±23.1 U for ASPItest, 41.6±26.5 U for ADPtest and 90.1±33.3 U for TRAPtest. There was no significant difference in PR on T2. However, on T3, ignificant reduction of PR in all 3 tests was observed (ASPI 9.4±10.1 U (p=0.001), ADP 23.1±15.0 U (p&lt;0.001) and TRAP 64.5±27.3 U (p&lt;0.001)). Lowest PR values for all tests were reached on T4, after which incline in PR has been observed. On T5, value of ASPItest reached levels not significantly different to those on T1 (15.1±17.2 U, p=0.13), while ADPtest and TRAPtest remained significantly lower (27.3±18.5 U, p=0.007 and 68.6±33.2 U, p=0.003, respectively). All PR values returned to initial levels on T6 (figure 1). Conclusions Our results show that successful TAVI procedure induces transient decrease in PR regardless of the platelet activation pathway. These findings add new knowledge in understanding complexed relations in intravascular milieu following TAVI. Further research on a larger number of patients is needed to confirm and asses clinical significance of these results. Acknowledgement/Funding Croatian Science Foundation

Safety of dental extractions in patients on dual antiplatelet therapy - a meta-analysis.

IntroductionSafety of dental extractions in patients on chronic antiplatelet therapy either with only acetylsalicylic acid (ASA) or clopidogrel or with both combined has been a matter of debate, with no clearly conclusive studies published.AimTo perform a meta-analysis of published observational studies in order to study the effect of single and double antiplatelet therapy in comparison to controls on the occurrence of immediate local bleeding complications during dental extractions.Material and methodsPubMed/Scopus/Embase database search revealed 22 papers (13 original and 9 review), 3 of which were finally included in the meta-analysis. Phrases searched: dual[All Fields] AND antiplatelet[All Fields] AND (“therapy”[Subheading] OR “therapy”[All Fields] OR “therapeutics”[MeSH Terms] OR “therapeutics”[All Fields]) AND (“tooth extraction”[MeSH Terms] OR (“tooth”[All Fields] AND “extraction”[All Fields]) OR “tooth extraction”[All Fields]).ResultsThe overall event incidence (bleeding complication after extraction) in the entire population was 1.59% (42 events in 2637 patients). As compared to the control group, the use of double antiplatelet therapy DAPT was associated with on odd ratio OR of 40.23 (95% CI: 4.37–370.36) increase in risk of bleeding events occurrence (p = 0.0011). Significant heterogeneity was observed (p < 0.001; I 2 of 76.7%).ConclusionsDental extractions following strict procedural protocols in patients on double antiplatelet therapy with clopidogrel and ASA are associated with an additional risk of immediate local bleeding complications.