Combination Of Antiplatelet Agents Research Articles

Personalized Approaches to Antiplatelet Treatment for Cardiovascular Diseases: An Umbrella Review.

Antiplatelet therapy is the cornerstone of antithrombotic prevention in patients with established atherosclerosis, since it has been proven to reduce coronary, cerebrovascular, and peripheral thrombotic events. However, the protective effect of antiplatelet agents is counterbalanced by an increase of bleeding events that impacts on patients' mortality and morbidity. Over the last years, great efforts have been made toward personalized antithrombotic strategies according to the individual bleeding and ischemic risk profile, aiming to maximizing the net clinical benefit. The development of risk scores, consensus definitions, and the new promising artificial intelligence tools, as well as the assessment of platelet responsiveness using platelet function and genetic testing, are now part of an integrated approach to tailored antithrombotic management. Moreover, novel strategies are available including dual antiplatelet therapy intensity and length modulation in patients undergoing myocardial revascularization, the use of P2Y12 inhibitor monotherapy for long-term secondary prevention, the implementation of parenteral antiplatelet agents in high-ischemic risk clinical settings, and combination of antiplatelet agents with low-dose factor Xa inhibitors (dual pathway inhibition) in patients suffering from polyvascular disease. This review summarizes the currently available evidence and provides an overview of the principal risk-stratification tools and antiplatelet strategies to inform treatment decisions in patients with cardiovascular disease.

Optimal use of antithrombotic agents in ischemic stroke with atrial fibrillation and large artery atherosclerosis.

Optimal antithrombotic regimens to prevent recurrent stroke in patients with ischemic stroke due to atrial fibrillation (AF) and atherosclerotic large-vessel stenosis remain unknown. This study aimed to evaluate the effect of multiple antithrombotic therapies on outcomes at 1 year after ischemic stroke due to two or more causes. We identified 862 patients with ischemic stroke due to AF and large artery atherosclerosis from the linked data. These patients were categorized into three groups according to antithrombotic therapies at discharge: (1) antiplatelets, (2) oral anticoagulants (OAC), and (3) antiplatelets plus OAC. The study outcomes were recurrent ischemic stroke, composite outcomes for cardiovascular events, and major bleeding after 1 year. Inverse probability of treatment weighting (IPTW) was used to balance the three groups using propensity scores. Among 862 patients, 169 (19.6%) were treated with antiplatelets, 405 (47.0%) were treated with OAC, and 288 (33.4%) were treated with antiplatelets and OAC. After applying IPTW, only OAC had a significant beneficial effect on the 1-year composite outcome (hazard ratio (HR): 0.37, 95% confidence interval (CI): 0.23-0.60, p < 0.001) and death (HR: 0.35, 95% CI: (0.19-0.63), p < 0.001). The combination of antiplatelet agents and OAC group had an increased risk of major bleeding complications (HR: 5.27, 95% CI: (1.31-21.16), p = 0.019). However, there was no significant difference in 1-year recurrent stroke events among the three groups. This study demonstrated that OAC monotherapy was associated with lower risks of composite outcome and death in patients at 1 year after ischemic stroke due to AF and atherosclerotic stenosis. In addition, the combination of an antiplatelet and OAC had a high risk of major bleeding.

Prediction and Implications of Edoxaban-Associated Bleeding in Patients after Critical Illness.

In this retrospective study, we aimed to identify the risk factors for bleeding in patients after critical illness during edoxaban treatment. Data from patients who received edoxaban after critical illness at the Emergency Department at a tertiary care hospital were obtained from the hospital medical records. Multivariate analysis revealed the risk factors for edoxaban-associated bleeding. Additionally, we developed an edoxaban-associated bleeding score (EAB score) based on these results. The derived EAB score was compared with the HAS-BLED score using receiver operating characteristic (ROC) curve analysis. Bleeding was observed in 42 of 114 patients (36.8%). We identified the following bleeding predictors (odds ratios, 95% confidence interval, score points) using multivariate analysis: concomitant use of antiplatelet agents (6.759, 2.047-22.32, 2 points), concomitant use of P-glycoprotein inhibitors (3.825, 1.484-9.856, 1 point), prothrombin time (PT)% following edoxaban administration of <75% and ≥60% (2.507, 0.788-7.970, 1 point), and PT% following edoxaban administration of <60% (11.23, 3.560-35.42, 3 points). The ROC curve analysis revealed an area under the curve of 0.826 for the EAB score and 0.625 for the HAS-BLED score. Under appropriate edoxaban dosing regimens in patients after critical illness, a combination of antiplatelet agents, P-gp inhibitors, and a low PT% following edoxaban administration were identified as strong risk factors for bleeding.

Advances in Clinical Cardiology 2020: A Summary of Key Clinical Trials.

IntroductionDespite the challenge of a global pandemic, 2020 has been an invaluable year in cardiology research with numerous important clinical trials published or presented virtually at major international meetings. This article aims to summarise these trials and place them in clinical context.MethodsThe authors reviewed clinical trials presented at major cardiology conferences during 2020 including the American College of Cardiology, European Association for Percutaneous Cardiovascular Interventions, European Society of Cardiology, Transcatheter Cardiovascular Therapeutics and the American Heart Association. Trials with a broad relevance to the cardiology community and those with potential to change current practice were included.ResultsA total of 87 key cardiology clinical trials were identified for inclusion. New interventional and structural cardiology data included trials evaluating bifurcation percutaneous coronary intervention (PCI) techniques, intravascular ultrasound (IVUS)-guided PCI, instantaneous wave-free (iFR) physiological assessment, new generation stents (DynamX bioadaptor), transcatheter aortic valve implantation (TAVI) in low-risk patients, and percutaneous mitral or tricuspid valve interventions. Preventative cardiology data included new data with proprotein convertase subtilisin–kexin type 9 (PCSK9) inhibitors (evolocumab and alirocumab), omega-3 supplements, evinacumab and colchicine in the setting of chronic coronary artery disease. Antiplatelet data included trials evaluating both the optimal length of course following PCI and combination of antiplatelet agents and regimes including combination antithrombotic therapies for patients with atrial fibrillation (AF). Heart failure data included the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors (sotagliflozin, empagliflozin and dapagliflozin) and mavacamten in hypertrophic cardiomyopathy. Electrophysiology trials included early rhythm control in AF and screening for AF.ConclusionThis article presents a summary of key clinical cardiology trials during the past year and should be of relevance to both clinicians and cardiology researchers.

Optimal dual antiplatelet therapy strategy in elderly patients with acute coronary syndrome.

One out of three hospitalizations for acute coronary syndrome (ACS) involve nowadays elderly patients, carrying together a significant burden of comorbidities and a higher risk of complications. In particular, both ischemic and haemorrhagic risk are markedly enhanced in advanced age, and strictly interconnected, challenging the management of dual antiplatelet therapy (DAPT) in these patients. The recent development of several therapeutic options in terms of duration and combination of antiplatelet agents have offered a wider spectrum of opportunities for a more individualized approach in the management of DAPT after an ACS, although the criteria for the selection of the most appropriate strategy in each patient still lack validation. In particular, dose-adjustment, early aspirin discontinuation, laboratory-driven tailoring and shorter or extended DAPT have been addressed with promising safety and efficacy results. The present review provides an updated overview on the emerging evidencefrom randomized clinical trials and subanalyses dedicated to the management of DAPT in elderly patients presenting with ACS.

Effects of cardiovascular medications on primary patency of hemodialysis arteriovenous fistula

While the patency of vascular access is essential for hemodialysis patients, optimal pharmaceutical treatment to maintain arteriovenous fistula (AVF) patency remains lacking. As cardiovascular diseases are highly prevalent in patients with end-stage renal disease, various cardiovascular medications have also been used to maintain AVF patency. However, previous studies revealed inconsistent therapeutic effects and a comprehensive evaluation of this issue is needed. The present retrospective, longitudinal cohort study included patients receiving successful AVF creation. The evaluated cardiovascular medications included antiplatelet agents, antihypertensive agents, nitrates and nitrites, statins, dipyridamole, and pentoxifylline. The outcome was AVF primary patency. All laboratory data and medication profiles were recorded at baseline and followed at 3-month interval, until the end of the 2-year study period. Cox proportional regression model with time-dependent covariates was used to evaluate the risk for AVF patency loss. A total of 349 patients were included in the present study, in which 57% were men and the mean age was 65 ± 14 years. Among the included patients, 40% used antiplatelet agents, 27% used dipyridamole and 36% used statins at baseline. Of all the evaluated cardiovascular medications, only dipyridamole showed significant association with a higher risk for loss of AVF patency. To evaluate the effect of combination of antiplatelet agents and dipyridamole, the patients were classified into four groups, I: combine use of antiplatelet agents and dipyridamole, II: antiplatelet only, III: dipyridamole only; IV: none of both were used. Of the four groups, group IV exhibited highest AVF patency (52.4%), which was followed by group III (42.7%), group II (40%), and group I (28.6%), respectively. Compared with group IV, only group I showed a significantly higher risk for AVF patency loss. None of the cardiovascular medications evaluated in the present study showed a beneficial effect on AVF patency. Furthermore, dipyridamole showed an association with a higher risk of AVF patency loss. We do not suggest a beneficial effect of dipyridamole on maintaining AVF patency, particularly in combination with antiplatelet agents.

Advances in Clinical Cardiology 2019: A Summary of Key Clinical Trials.

IntroductionA large number of important clinical trials in cardiology were published or presented at major international conferences during 2019. This paper aims to offer a concise overview of these significant advances and to put them into clinical context.MethodsTrials presented at the major international cardiology meetings during 2019 were reviewed including The American College of Cardiology (ACC), Euro PCR, The European Society of Cardiology (ESC), Transcatheter Cardiovascular Therapeutics (TCT), and the American Heart Association (AHA). In addition to this a literature search identified several other publications eligible for inclusion based on their relevance to clinical cardiology, their potential impact on clinical practice and on future guidelines.ResultsA total of 70 trials met the inclusion criteria. New interventional and structural data include trials examining use of drug-coated balloons in patients with acute myocardial infarction (MI), interventions following shockable cardiac arrest, mechanical circulatory support in cardiogenic shock complicating MI, intervention in stable coronary artery disease, surgical or percutaneous revascularisation strategies in left main coronary artery disease, revascularisation strategy in ST elevation MI, transcatheter aortic valve replacement in low-risk patients, and percutaneous mitral or tricuspid valve interventions. Preventative cardiology data included the use of sodium–glucose cotransporter 2 (SGLT2) inhibitors (dapagliflozin), proprotein convertase subtilisin–kexin type 9 (PCSK9) inhibitors (evolocumab), bempedoic acid, and novel approaches to the management of hypertension. Antiplatelet data included trials evaluating both the optimal length of course and combination of antiplatelet agents and regimes including combination antithrombotic therapies for patients with atrial fibrillation. Heart failure data included trials of sacubitril–valsartan in heart failure with preserved ejection fraction and the use of SGLT2 inhibitors in patients with heart failure but without diabetes. Electrophysiology data included trials examining alcohol in atrial fibrillation and the use of wearable fitness devices for identifying atrial fibrillation.ConclusionThis article presents key clinical trials completed during 2019 and should be valuable to clinicians and researchers working in cardiology.

Intracranial Hemorrhage in Hospitalized Patients: An Infrequently Studied Condition with High Mortality.

Intracranial hemorrhage (ICH) may occur in patients admitted to the hospital for unrelated medical conditions, resulting in prolonged hospitalization and worse prognosis. We aim to assess the clinical presentation and outcomes of in-hospital ICH compared to patients with ICH presenting from the community. We conducted a retrospective analysis of all acute stroke alerts diagnosed with ICH in an urban academic hospital over a 4-year period. Demographics, clinical presentation, use of antithrombotic therapy, and presence of coagulopathy were recorded. ICH score and a sequential organ failure assessment score were calculated during the initial assessment. Initial head computed tomography was reviewed to determine ICH subtype, location, and volume of the hematoma. In-hospital mortality and discharge disposition were used as surrogate of clinical outcome. From the 1965 stroke alert cases analyzed over the studied years, 145 (7.4%) were diagnosed with ICH. Overall, the mean age was 62.9 ± 13.9 and 53.7% were women. Thirty-two patients (22%) developed ICH in the inpatient setting and 113 (78%) presented from the community. Systolic blood pressure at presentation was lower in the in-hospital group (p < 0.01). Inpatients who developed ICH were more likely than community ICH patients to be on combination of antiplatelet agents (21.9% vs. 5.3%, p < 0.05) or therapeutic heparinoids (21.9% vs. 0.9%, p < 0.01). Also, In-hospital ICH patients had a higher rate of spontaneous or iatrogenic coagulopathy (65.6% vs. 10.6%, p < 0.01) and thrombocytopenia (31.3% vs. 1.8%, p < 0.01). Lobar hemorrhages were more prevalent in the in-hospital group (82.6% vs. 39.1%, p < 0.01) and the mean hematoma volume was higher (40.9 ± 43.1mL vs. 24.1 ± 30.4mL; p < 0.02). Median ICH score in the in-hospital group was not statistically different from the emergency department group: 2 (IQR: 0-3) versus 1 (IQR: 0-3). When comparing patients with in-hospital ICH and those from the community, the short-term mortality was higher in the former group (81% vs. 31%, p < 0.01). The incidence of withdrawal of life-sustaining therapies as a proximate mechanism of death was higher, but not statistically significant, in the in-hospital group (86% vs. 61%). ICH is a critical complication in the inpatient setting, predominantly occurring in already ill patients with underlying spontaneous or iatrogenic coagulopathy. Large volume lobar intraparenchymal hemorrhage is a common radiographic finding. ICH is frequently a catastrophic event and powerfully weighs in with end-of-life discussion, resulting in high short-term mortality rate.

Antithrombotic therapy in patients with atrial fibrillation and coronary artery disease.

ABSTRACTAtrial fibrillation and coronary artery disease are commonly coexisting conditions that necessitate the use of an oral anticoagulant as well as dual antiplatelet therapy. Commonly referred to as triple oral antithrombotic therapy (TT), this helps prevent ischemic stroke and myocardial infarction but comes at the expense of an increased risk of bleeding. There is a growing body of evidence that the omission of aspirin from TT has the same preventive efficacy in terms of major adverse cardiacvascular and cerebrovascular events (MACCE) with significantly lower bleeding events. The combination of antiplatelet agents and direct oral anticoagulants (DOAC) is a matter of ongoing research. However, initial studies showed favorable safety profile of DOAC over vitamin K antagonist in combination with antiplatelet agents.

Advances in Clinical Cardiology 2018: A Summary of Key Clinical Trials.

IntroductionMany important clinical trials in cardiology were published or presented at major international meetings throughout 2018. This paper aims to offer a concise overview of these significant advances and to put them into clinical context.MethodsTrials presented at the major international cardiology meetings during 2018 were reviewed including The American College of Cardiology, EuroPCR, The European Society of Cardiology, PCR London Valves, Transcatheter Cardiovascular Therapeutics, and the American Heart Association. In addition to this a literature search identified several other publications eligible for inclusion based on their relevance to clinical cardiology, their potential impact on clinical practice and on future guidelines.ResultsA total of 78 trials met the inclusion criteria. New interventional and structural data include trials examining novel stent designs (Biofreedom™, COMBO), use of drug-coated balloons in patients with high bleeding risk, intervention in stable coronary artery disease, revascularisation strategy in ST elevation myocardial infarction, transcatheter aortic valve replacement in low-risk patients, and percutaneous mitral or tricuspid valve interventions. Preventative cardiology data included the use of sodium glucose cotransporter-2 inhibitors (empagliflozin, dapagliflozin, canagliflozin), proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors (alirocumab) and approaches of hypertension management. Antiplatelet data included trials evaluating both the optimal length of course and combination of antiplatelet agents. Heart failure data included trials of sacubitril–valsartan during acute hospital admission and the management of chemotherapy-induced cardiotoxicity. Electrophysiology data included trials examining atrial fibrillation ablation, wearable cardiac defibrillators (LifeVest) and His-bundle pacing.ConclusionThis article presents key clinical trials completed during 2018 and should be valuable to both cardiology clinicians and researchers.

DOCTOR’S ADHERENCE TO RECOMMENDATIONS GOVERNING THE ANTIPLATELET AGENTS USE IN THE CARDIOVASCULAR DISEASES PREVENTION AND TREATMENT

Aim. To study the doctors' opinions on the main aspects of antiplatelet agents use, and to test their knowledge of the basic provisions of the current recommendations on antiplatelet therapy. Material and methods. As a material for the study the results of an anonymous questionnaire in randomly selected doctors were used. The questionnaire contained 11 questions concerning the use of antiplatelet agents for primary and secondary prevention of cardiovascular diseases. 276 questionnaires filled out by 185 therapists, 84 cardiologists and 7 physicians of other therapeutic specialties were analyzed. Results. The results of the study reflect the doctor’s tendency to use acetylsalicylic acid for the primary prevention of cardiovascular diseases, including the patients who do not have indications for its prescribing. 11.6% of respondents never recommend acetylsalicylic acid for primary prevention of cardiovascular diseases. 22.8% of doctors don’t consider it necessary to stop acetylsalicylic acid in patients who do not have indications for such treatment. Therapists demonstrate very low adherence to recommendations which underline the need for a weighted approach to the acetylsalicylic acid prescription. Cardiologists less often than therapists recommend acetylsalicylic acid for the primary prevention of cardiovascular disease in patients with low cardiovascular risk. Less than 30% of therapists and cardiologists tend to prescribe gastroprotectors to patients with aspirin-induced gastropathy. Only 19.6% of the respondents correctly indicated the P2Y12 receptor inhibitor dose to be used in combination with acetylsalicylic acid on the 1st day of acute coronary syndrome depending on planed treatment strategy. 88.4% of doctors consider the use of antiplatelet agents, if the patient with atrial fibrillation and a high risk of thromboembolism refused to take oral anticoagulants. 51.8% of respondents recommend a combination of acetylsalicylic acid and clopidogrel for such patients. Cardiologists are better informed about the recommendations regarding the use of dual antiplatelet therapy and a combination of antiplatelet agents with oral anticoagulants. However, in general, doctors' knowledge of combined antithrombotic therapy is inadequate. Conclusion. The results of the study show that it is necessary to discuss current recommendations on the use of antiplatelet agents for the primary and secondary prevention of cardiovascular diseases in the context of continuous medical education more actively.

Antiplatelet Therapy in Acute Coronary Syndromes. Evidence Based Medicine.

Acute coronary syndromes (ACS) represent the final step in the chronic process of atherothrombotic coronary disease which begins early in life as thickening of intima layer and progresses to fibroatheroma and fibrocalcific lesions with vulnerable characteristics. As abrupt occlusion in the settings of ACS happens due to platelet aggregation and mobilization antiplatelet treatment has gained significant interest especially in the settings of primary percutaneous intervention and the aim of this review article is to understand the current evidence justifying the use and combination of different antiplatelet agents. Beyond aspirin, several antiplatelet agents (ADP receptor inhibitors, Glycoprotein IIb/IIIa inhibitors and varopaxar) are used in combination to effectively inhibit platelet activity. However the best choice, initiation, combination and duration of antithrombotic treatment, in order to maximize the effectiveness of therapy and reduce the hazard of bleeding, depends on the clinical setting and patient specific characteristics and is an issue of intense scientific interest. Early and potent platelet inhibition with safety reassurance can be achieved by a combination of antiplatelet agents and is essential for the management of ACS. Therefore in this review article we focus on the current evidence regarding rational, safety and effectiveness of current antiplatelet approaches in acute coronary syndromes.

Duration of Dual Antiplatelet Therapy After Coronary Stenting.

Dual antiplatelet therapy (DAPT) is one of the cornerstones of coronary artery disease (CAD) treatment. Standard DAPT requires one of, P2Y12 receptor inhibitors, clopidogrel, prasugrel or ticagrelor as an adjunct therapy to aspirin administration. The decision over DAPT duration depends on the evaluation of thrombotic risk and the assessment of the probability for major bleeding events. The goal of this work was to identify which would be the appropriate combination of antiplatelet agents and the optimal duration of DAPT, based on the patient's medical history and clinical characteristics. A thorough search of PubMed and the Cochrane Database was conducted in order to identify randomized controlled trials, observational studies, current ESC and ACC/AHA guidelines and novel articles on the subject. The decision over DAPT duration is based on a careful approach which requires the evaluation of thrombotic risk and the assessment of the probability for major bleeding events. A series of aspects and special conditions may influence the duration of DAPT after stenting e.g. the type of the implanted stent (DES or BMS) or if the commencement of DAPT is administered in the context of an acute coronary syndrome or in the setting of stable CAD. Current guidelines can assist clinicians in making decisions but treating patients in special groups e.g. with diabetes mellitus or the elderly people can be very demanding. Studies which examined optimal DAPT duration, displayed controversial results, mainly observed because of the discrepancy and heterogeneity between different study designs or the decision of a great proportion of investigators to statistically test for non-inferiority. A careful, patient-centered approach, which considers thrombotic risk versus the risk for bleeding complications and other individual characteristics and comorbidities, is required when deciding DAPT duration.

Antithrombotic therapy for secondary prevention of atherothrombotic events in cerebrovascular disease.

Atherothrombosis is the common underlying process for numerous progressive manifestations of cardiovascular disease, including coronary artery disease (CAD) and cerebrovascular disease (CVD). Antiplatelet therapy is the cornerstone of pharmacological management in patients with atherothrombosis. Over the past 20 years, major advances in antiplatelet pharmacotherapy have been made, particularly for the treatment of patients with CAD. The treatment of patients with concomitant CAD and CVD is complex, owing to their increased risk of both ischaemia and bleeding. When CVD arises from large artery atherosclerosis, antithrombotic therapies are essential to prevent stroke or transient ischaemic attack (TIA). However, the use of antithrombotic medications in patients with CVD can put them at high risk of intracranial haemorrhage. As such, the risk-benefit profile of various combinations of antiplatelet agents in patients with both CAD and CVD is uncertain. This Review provides a state-of-the-art account of the available evidence on antithrombotic therapies for the secondary prevention of atherothrombotic events in patients with concomitant CAD and CVD, particularly those with a history of noncardioembolic stroke or TIA.

Duration of dual antiplatelet therapy after coronary stenting

Background: Dual antiplatelet therapy (DAPT) is one of the cornerstones of coronary artery disease (CAD) treatment. Standard DAPT requires one of, P2Y12 receptor inhibitors, clopidogrel, prasugrel or ticagrelor as an adjunct therapy to aspirin administration. The decision over DAPT duration depends on the evaluation of thrombotic risk and the assessment of the probability for major bleeding events. Methods: The goal of this work was to identify which would be the appropriate combination of antiplatelet agents and the optimal duration of DAPT, based on the patient’s medical history and clinical characteristics. A thorough search of PubMed and the Cochrane Database was conducted in order to identify randomized controlled trials, observational studies, current ESC and ACC/AHA guidelines and novel articles on the subject. Results: The decision over DAPT duration is based on a careful approach which requires the evaluation of thrombotic risk and the assessment of the probability for major bleeding events. A series of aspects and special conditions may influence the duration of DAPT after stenting e.g. the type of the implanted stent (DES or BMS) or if the commencement of DAPT is administered in the context of an acute coronary syndrome or in the setting of stable CAD. Current guidelines can assist clinicians in making decisions but treating patients in special groups e.g. with diabetes mellitus or the elderly people can be very demanding. Conclusion: Studies which examined optimal DAPT duration, displayed controversial results, mainly observed because of the discrepancy and heterogeneity between different study designs or the decision of a great proportion of investigators to statistically test for non-inferiority. A careful, patient-centered approach, which considers thrombotic risk versus the risk for bleeding complications and other individual characteristics and comorbidities, is required when deciding DAPT duration.

Application of the health belief model to improve the understanding of antihypertensive medication adherence among Chinese patients

ObjectivesWe aimed to gain insight into antihypertensive medication adherence on the basis of a well-developed behavior theory. MethodsA cross-sectional study of Chinese hypertensive patients was conducted using the health belief model as a theoretical framework. ResultsThe HBM explained 48.8% of the variance in antihypertensive medication adherence with an overall prediction accuracy was 82.8%. After adjusting for controlling factors, the HBM explained 50.5% of the variance in antihypertensive medication adherence with an overall prediction accuracy of 86.2%. Higher levels of perceived susceptibility (p=0.017), cues to action (p=0.034), and self-efficacy (p=0.002) and a lower level of perceived barriers (p<0.001) were significantly associated with better antihypertensive medication adherence. The risk factors of older age (p=0.037), longer duration of HTN (p=0.003), longer duration of drug use (p=0.001), and taking a combination of antiplatelet agents (p<0.001) were significantly associated with better antihypertensive medication adherence and influenced different HBM constructs. ConclusionThe HBM is reliable in predicting medication adherence among Chinese hypertensive patients. Intervention programs in clinical practice could be guided by the relationship between risk factors and HBM constructs and antihypertensive medication adherence. Practice implicationsThis study provides a structured understanding of the relationships between risk factors and HBM constructs and antihypertensive medication adherence.

Effect of medication adherence on blood pressure control and risk factors for antihypertensive medication adherence.

We aim to investigate a range of risk factors associated with medication adherence among Chinese hypertensive patients. We also aim to investigate the association between medication adherence and blood pressure control. A cross-sectional study was conducted among Chinese hypertensive patients in a comprehensive teaching hospital in Shanghai, China, using a validated scale, a self-designed questionnaire and patients' medical records. Of the 232 eligible participants, 61 (26.3%), 51 (22.0%) and 120 (51.7%) showed low, medium and high adherence, respectively. Adjusted for socio-demographic, clinical and patient-related factors, antihypertensive medication adherence was significantly associated with better systolic blood pressure control (P=0.001), whereas the association with diastolic blood pressure control was relatively weak (P=0.334). In the multivariate analysis, patients with longer duration of drug use [P=0.012, odds ratio (OR)=0.46, 95% confidence interval (CI) 0.25-0.84], combination of antiplatelet agents (0.002, 0.38, 0.20-0.71), less concerns of medical cost (0.001, 0.18, 0.02-0.51), more availability of professional guidance (0.002, 0.34, 0.17-0.66) and more availability of family support (0.036, 0.51, 0.27-0.96) were more likely to adhere to their drug regimens. The rate of suboptimal medication adherence among Chinese hypertensive patients is quite high. Interventions could focus upon the risk factors to improve antihypertensive medication adherence in clinical practice.

Evaluation of Antiplatelet Agents for Secondary Prevention of Stroke Using Mixed Treatment Comparison Meta-analysis

BackgroundThe current guidelines recommend various antiplatelet agents used alone or in combination for secondary prevention of noncardioembolic stroke. ObjectiveThe purpose of this study was to conduct a mixed treatment comparison meta-analysis to determine which antiplatelet or combination of antiplatelet agents is most efficacious and tolerable in patients with prior stroke. MethodsA comprehensive literature search was conducted in MEDLINE (1945 through March 2012), EMBASE (1974 through March 2012), and the Cochrane Controlled Trials Registry (1975 through April 2012) to identify randomized trials evaluating the role of various antiplatelet agents and combinations for the secondary prevention of stroke. Key articles were cross-referenced for additional studies. Data were screened and evaluated to generate direct and indirect comparisons for recurrent stroke and overall hemorrhagic events. Data were reported as rate ratios (RRs) and 95% CIs. ResultsA total of 24 articles were included in the analysis. Eleven antiplatelet regimens were compared in >88,000 patients. The combination of acetylsalicylic acid (ASA) plus dipyridamole (DP) was more protective against recurrent stroke than ASA alone (RR = 0.78; 95% CI, 0.64–0.93), and no differences were found in all other direct and indirect comparisons with active treatment. ASA plus DP was associated with more overall hemorrhagic events than DP (RR = 1.83; 95% CI, 1.17–2.81), cilostazol (RR = 2.12; 95% CI, 1.21–3.48), and triflusal (RR = 1.67; 95% CI, 1.05–2.78) but fewer events than the combination of ASA plus clopidogrel (RR = 0.38; 95% CI, 0.25–0.56). The combination of ASA plus clopidogrel was associated with an excess of overall hemorrhagic events compared with clopidogrel (RR = 2.81; 95% CI, 1.96–4.10), cilostazol (RR = 5.56; 95% CI, 3.03–9.66), DP (RR = 4.78; 95% CI, 2.80–8.21), sarpogrelate (RR = 3.59; 95% CI, 1.96–6.45), terutroban (RR = 2.13; 95% CI, 1.21–3.61), ticlopidine (RR = 2.80; 95% CI, 1.69–5.00), and triflusal (RR = 4.36; 95% CI, 2.62–7.81). ConclusionWe found that ASA plus DP was more protective than ASA alone for preventing recurrent stroke; however, no difference was found between most direct and indirect comparisons of antiplatelet agents and combinations. More overall hemorrhagic events seemed to occur with the combination of ASA and clopidogrel than with other treatments. Selection of antiplatelet therapy for the secondary prevention of stroke must be individualized according to patient comorbidities, including risk of stroke recurrence and bleeding.

Abstract 119: Risk of Intracerebral Hemorrhage with Combined Antiplatelet and Anticoagulant Use

Context: Intracranial bleeding is the most feared complication of antithrombotic use. Antiplatelet and anticoagulant drugs increase risk of intracerebral hemorrhage (ICH), yet in some instances, combinations of antiplatelet agents and anticoagulants are used without firm evidence of efficacy. Few studies have compared the risks of different agents and their combinations in a single population. We determined the risk of ICH associated with the most commonly used antiplatelet and anticoagulant drugs and their combinations in a population-based case-control study. Methods: This report includes data from subjects recruited from the Greater Cincinnati/Northern Kentucky area by the Genetic and Environmental Risk Factors for Hemorrhagic Stroke Study from 1997 to 2009. We compared individuals in different treatment groups to identify any differences in baseline covariates that could be associated with treatment assignment. As there were a number of statistically significant differences, we used multivariate matching to analyze risk for ICH conferred by different antithrombotic agents. Treatment effects on ICH were estimated using the matched samples while accounting for the dependence between matched individuals. Results: There were 733 subjects with ICH and 2555 controls included in this study period. Results are shown in the table. Use of aspirin, clopidogrel, or their combination was associated with a trend toward increased risk. Warfarin increased risk compared with no antithrombotic use (OR 3.98, p &lt; 0.0001). The combination of warfarin and either aspirin or clopidogrel produced the greatest risk, compared with no antithrombic therapy (OR 4.92 p&lt;0.001) or compared with warfarin alone (OR 3.00 p=0.009). Conclusions: The combination of warfarin and an antiplatelet drug significantly increases risk of ICH compared with no antithrombotic therapy or warfarin monotherapy. The use of combination therapy requires careful consideration in clinical practice.

Guidelines on oral anticoagulation with warfarin – fourth edition

Guidelines on oral anticoagulation with warfarin – fourth edition