Combination Antiplatelet Research Articles

Micelle-Incorporated Liquid Chromatography in the Light of Green Chemistry: An Application for the Quality Control Analysis of Anti-Platelet Fixed-Dose Combinations.

Oral anti-platelet agents are the cornerstone of the treatment of multiple cardiovascular diseases and in the long-term prevention of their recurrence. In the present work, we report a method based on micellar liquid chromatography coupled with ultraviolet detection (MLC/UV), for the simultaneous quantification of combined anti-platelet therapy namely, clopidogrel bisulfate (CPS), aspirin (ASP), together with salicylic acid (SA), in their pharmaceutical dosage form. The incorporation of 0.1M polyoxyethylene 23 lauryl ether (Brij-35) as a surfactant into the mobile phase improved solute-mobile phase interaction allowing for minimal organic solvent utilization, enhanced resolution, and rapid analysis (7 min). Furthermore, we performed a comprehensive evaluation of the environmental impact caused by our procedures versus previously reported analytical procedures applied in the determination of CPS and ASP. The evaluation was made using the Eco-scale tool. The results of the developed method indicated the superiority of our procedures in terms of greenness without compromising the quality of performance characteristics. The method was linear in the range of 1-100 µg/mL with limits of detection of 0.28, 0.32, and 0.29 µg/mL for CPS, ASP, and SA, respectively. The developed method can also be utilized to test the purity and the stability of ASP in pharmaceutical formulations through monitoring SA as its main degradation product. The MLC/UV method was successfully applied to the quantitative analysis of CPS, ASP together with SA-as a main degradation product of ASP-in their pharmaceutical dosage form. The developed method was successfully applied for the determination of clopidogrel bisulfate (CPS), aspirin (ASP), together with salicylic acid (SA), in their pharmaceutical dosage form.

Antithrombotic therapy in patients with atrial fibrillation after percutaneous coronary interventions

Highlights. The article analyzes the current evidence base for anticoagulant and antiplatelet therapy in patients with atrial fibrillation undergoing percutaneous coronary interventions, and future perspectives of such therapy.Abstract. A number of patients undergoing percutaneous coronary intervention may require intensification of antithrombotic therapy. These include patients with atrial fibrillation. The difficulty of treatment of this group of patients consists in the achievement of a certain level of hypocoagulation, which will be sufficient for the prevention of acute ischemic events, mainly associated with the implanted coronary stent, but will not lead to the clinically relevant bleeding. Achieving this balance requires a careful and personalized approach to prescribing a variety of combination (antiplatelet and anticoagulant) therapy regimens. The article provides an overview of modern antithrombotic therapy regimens in this group of patients, their evidence base and promising directions for improving such therapy.

Direct Oral Anticoagulants and Coronary Artery Disease.

Coronary artery disease is a leading cause of morbidity and mortality worldwide. Acute coronary syndrome as a first presentation is common and patients with established disease have a high rate of recurrent ischemic events, despite antiplatelet therapy. Over the past several years, direct oral anticoagulants have become available and have been studied in patients with coronary artery disease. These medications directly inhibit either thrombin or factor Xa which contribute to atherothrombosis. This review will summarize the clinical data regarding the use of direct oral anticoagulants in different patient populations with coronary disease and the balance between protection against ischemia and bleeding. Additionally, the review will summarize the available data on the use of direct oral anticoagulants periprocedurally in patients undergoing percutaneous coronary intervention. The future direction of coronary artery disease and the role of direct oral anticoagulants will rely on further studies determining the optimal combination of antiplatelet and oral anticoagulant regimens that derive ischemic benefit without increased rates of bleeding. Additional upstream blockade of the coagulation cascade with factor XIIa and factor XIa inhibitors may also improve treatment in the future.

When and How to Combine Antiplatelet and Anticoagulant Drugs?

Antiplatelet and anticoagulant drugs work at different places in the coagulation system. Antiplatelet drugs are usually indicated in patients with atherosclerosis. Anticoagulant drugs are mostly used in patients with atrial fibrillation, venous thromboembolism, or technical heart valves. In some clinical situations, combination of antiplatelet and anticoagulant therapy can be indicated. The most recent situations are a more intensive antithrombotic therapy for risk reduction in patients with atherosclerosis and temporary addition of antiplatelet drugs in patients with indication for long-term anticoagulation. Temporary combination of antiplatelet and anticoagulant drugs is usually necessary after coronary intervention in patients with atrial fibrillation. In patients with high-risk atherosclerosis, the combination of low-dose rivaroxaban and aspirin reduces major adverse cardiovascular events (myocardial infarction, stroke, cardiovascular death) and major adverse limb events. But every combination of antiplatelet and antithrombotic drugs can increase bleeding risk. Therefore, a careful assessment of thrombotic versus bleeding risk is necessary for each patient.

Relationship of pharmacotherapy and the incidence of embolic complications of carotid reconstructive surgery

Aim. To evaluate the relationship between lipid-lowering and antiplatelet therapy and the incidence of cerebral microembolism and related complications in open and endovascular revascularization of the carotid arteries (CA).Material and methods. This single-center study involved patients with internal CA stenosis. The patients were divided into 2 groups depending on the surgery type performed: carotid endarterectomy (CEA) — 163 patients; CA stenting (CAS) — 71 patients. All patients underwent intraoperative transcranial Doppler monitoring to register cerebral embolism during CAS and CE.Results. In CAS, microembolism episodes were observed in 66,2% vs 22,1% of patients in the CEA group (p=0,04), the largest number of which was recorded during catheterization of the internal CA and embolic filter installation (p=0,000). There were no significant differences between the groups in terms of the stroke incidence. In 8 patients in the CAS group and 1 patient in the CEA group, a transient ischemic attack was observed within 30 days after surgery (p=4x10-4 ). Intraoperative embolism was a predictor of a neurological event in the early postoperative period (odds ratio (OR), 33,08; 95% confidence interval (CI): 3,49-56,37 (p6 months before surgery reduces the likelihood of embolism by 4 times (OR 0,25; 95% CI: 0,11-0,58 (p=0,001), while lipid-lowering and antiplatelet therapy combination — by 12,5 times (OR, 0,08; 95% CI: 0,01-0,40 (p=0,001)).Conclusion. Preoperative antiplatelet and statin therapy reduces the likelihood of embolism during the CA revascularization procedure.

Brainstem stroke in a Nigerian male with prosthetic heart valves—A case report

Stroke following cardiac surgery particularly valvular implantation is an anticipated complication. This is due to the prosthetic valve as well as possible associated comorbid conditions. There is dearth of published data on stroke post valve replacement surgery in Nigeria. There is no general consensus on the role of antiplatelet agents in combination with anticoagulant therapy in at-risk patients. Our paper documents the case of a 46-year-old male hypertensive, who in 2016 had mitral and aortic valve replacement surgery in a Tertiary Teaching Hospital and presented in May 2020 with sudden onset abnormal tongue sensation and double vision. A left internuclear ophthalmoplegia with bilateral torsional nystagmus was evident. Brain magnetic resonance imaging confirmed pontine lacunar infarction. There were no intracardiac clots on echocardiography. He had full resolution of deficits following treatment with anticoagulants. This case report demonstrates that ischemic stroke can occur in people with prosthetic heart valve and that other comorbid risk factors may be contributory. Anticoagulation therapy is important, though there is no consensus on time of starting therapy and the role of adjunctive antiplatelet combination therapy in such patients. Individualized therapy should be based on the type of implant, numbers, and location of valve replaced, comorbid clinical conditions, and the risk of hemorrhagic transformation.

Early argatroban and antiplatelet combination therapy in acute non-lacunar single subcortical infarct associated with mild intracranial atherosclerosis

BackgroundPatients with acute non-lacunar single subcortical infarct (SSI) associated with mild intracranial atherosclerosis (ICAS) have a relatively high incidence of early neurological deterioration (END), resulting in unfavorable functional outcomes. Whether the early administration of argatroban and aspirin or clopidogrel within 6–12 h after symptom onset is effective and safe in these patients is unknown.MethodsA review of the stroke database of Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University and Qingdao Center Hospital, Qingdao University Medical College in China was undertaken from May 2017 to January 2020 to identify all patients with non-lacunar SSI caused by ICAS within 6–12 h of symptom onset based on MRI screening. Patients were divided into two groups, one comprising those who received argatroban and mono antiplatelet therapy with aspirin or clopidogrel on admission (argatroban group), and the other those who received dual antiplatelet therapy (DAPT) with aspirin and clopidogrel during hospitalization (DAPT group). The primary outcome was recovery by 90 days after stroke based on a modified Rankin scale (mRS) score (0 to 1). The secondary outcome was END incidence within 120 h of admission. Safety outcomes were intracranial hemorrhage (ICH) and major extracranial bleeding. The probability of clinical benefit (mRS score 0–1 at 90 days) was estimated using multivariable logistic regression analysis.ResultsA total of 304 acute non-lacunar SSI associated with mild ICAS patients were analyzed. At 90 days, 101 (74.2%) patients in the argatroban group and 80 (47.6%) in the DAPT group had an mRS score that improved from 0 to 1 (P < 0.001). The relative risk (95% credible interval) for an mRS score improving from 0 to 1 in the argatroban group was 1.50 (1.05–2.70). END occurred in 10 (7.3%) patients in the argatroban group compared with 37 (22.0%) in the DAPT group (P < 0.001). No patients experienced symptomatic hemorrhagic transformation.ConclusionsEarly combined administration of argatroban and an antiplatelet agent (aspirin or clopidogrel) may be beneficial for patients with non-lacunar SSI associated with mild ICAS identified by MRI screening and may attenuate progressive neurological deficits.Trial registrationOur study is a retrospectively registered trial.

Risk of Major Bleeding with Ibrutinib in Patients with Thrombocytopenia - a Retrospective Single-Center Canadian Study

Risk of Major Bleeding with Ibrutinib in Patients with Thrombocytopenia - a Retrospective Single-Center Canadian Study

Pharmacological treatment after acute coronary syndrome: Baseline clinical characteristics and gender differences in a population-based cohort study

ObjectiveTo describe baseline socio-demographic and clinical characteristics and drugs prescribed for secondary prevention after a first episode of ACS and to assess differences between men and women. SettingPHC in Catalonia. Data source: SIDIAP (Information System for Research in Primary Care). ParticipantsPatients who suffered an ACS during 2009–2016 and followed-up in PHC centres of the Catalan Health Institute in Catalonia. InterventionsNot applicable. Main measuresSocio-demographic and clinical characteristics at baseline: sex, age, socioeconomic index, toxic habits, comorbidities, study drugs (prescribed for cardiovascular secondary prevention: antiplatelets, betablockers, statins, drugs acting on the renin–angiotensin system) and comedications. Results8071 patients included, 71.3% of them were men and 80.2% had an acute myocardial infarction. Their mean age was 65.3 and women were older than men. The most frequent comorbidities were hypertension, dyslipidaemia and diabetes and they were more common in women. Antiplatelets (91.3%) and statins (85.7%) were the study drugs most prescribed. The uses of all comedications were significantly higher in women, except for nitrates. The combination of four study groups was initially prescribed in 47.7% of patients and combination of beta-blockers, statins and antiplatelets was prescribed in 18.4%. More men than women received all recommended pharmacological groups. ConclusionWomen were older, had more comorbidities and received more comedications. Most patients were treated with a combination of four or three study drugs for secondary prevention. Men initiated more drug treatments for secondary prevention and dual antiplatelet therapy than women. EUPAS RegisterEUPAS19017.

Dual Antiplatelet Therapy Using Cilostazol in Patients With Stroke and Intracranial Arterial Stenosis.

BackgroundLong‐term benefit of dual antiplatelet therapy (DAPT) over single antiplatelet therapy (SAPT) for the prevention of recurrent stroke has not been established in patients with intracranial arterial stenosis. We compared the efficacy and safety of DAPT with cilostazol and clopidogrel or aspirin to those of SAPT with clopidogrel or aspirin in patients with intracranial arterial stenosis, who were recruited to the Cilostazol Stroke Prevention Study for Antiplatelet Combination trial, a randomized controlled trial in high‐risk Japanese patients with ischemic stroke.Methods and ResultsWe compared the vascular and hemorrhagic events between DAPT and SAPT in patients with ischemic stroke and symptomatic or asymptomatic intracranial arterial stenosis of at least 50% in a major intracranial artery. Patients were placed in two groups: 275 were assigned to receive DAPT and 272 patients SAPT. The risks of ischemic stroke (hazard ratio [HR], 0.47; 95% CI, 0.23–0.95); and composite of stroke, myocardial infarction, and vascular death (HR, 0.48; 95% CI, 0.26–0.91) were lower in DAPT than SAPT, whereas the risk of severe or life‐threatening bleeding (HR, 0.72; 95% CI, 0.12–4.30) did not differ between the 2 treatment groups.ConclusionsDAPT using cilostazol was superior to SAPT with clopidogrel or aspirin for the prevention of recurrent stroke and vascular events without increasing bleeding risk among patients with intracranial arterial stenosis after stroke.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT01995370.

Cilostazol for Secondary Stroke Prevention: History, Evidence, Limitations, and Possibilities.

Cilostazol is a PDE3 (phosphodiesterase III) inhibitor with a long track record of safety that is Food and Drug Administration and European Medicines Agency approved for the treatment of claudication in patients with peripheral arterial disease. In addition, cilostazol has been approved for secondary stroke prevention in several Asian countries based on trials that have demonstrated a reduction in stroke recurrence among patients with noncardioembolic stroke. The onset of benefit appears after 60 to 90 days of treatment, which is consistent with cilostazol's pleiotropic effects on platelet aggregation, vascular remodeling, blood flow, and plasma lipids. Cilostazol appears safe and does not increase the risk of major bleeding when given alone or in combination with aspirin or clopidogrel. Adverse effects such as headache, gastrointestinal symptoms, and palpitations, however, contributed to a 6% increase in drug discontinuation among patients randomized to cilostazol in a large secondary stroke prevention trial (CSPS.com [Cilostazol Stroke Prevention Study for Antiplatelet Combination]). Due to limitations of prior trials, such as open-label design, premature trial termination, large loss to follow-up, lack of functional or cognitive outcome data, and exclusive enrollment in Asia, the existing trials have not led to a change in clinical practice or guidelines in Western countries. These limitations could be addressed by a double-blind placebo-controlled randomized trial conducted in a broader population. If positive, it would increase the evidence in support of long-term treatment with cilostazol for secondary prevention in the millions of patients worldwide who have experienced a noncardioembolic ischemic stroke.

A Clinical Update on Antiplatelet Therapy in Secondary Prevention of Ischemic Stroke.

Antiplatelet therapy remains the standard of care in secondary stroke prevention for non-cardioembolic ischemic stroke and transient ischemic attack. We aim to examine the use of antiplatelet agents in secondary prevention through highlighting relevant clinical trials and meta-analyses as well as providing commentary regarding our practice. In the POINT and CHANCE trials, dual antiplatelet therapy reduced recurrent stroke compared to aspirin monotherapy. Sub-analyses of these trials suggest that genetic polymorphisms could play a role in diminishing the effectiveness of clopidogrel. Similarly, THALES demonstrated better outcomes with ticagrelor-aspirin combination therapy over aspirin monotherapy. Combination antiplatelet therapy with aspirin and the P2Y12 inhibitors, clopidogrel and ticagrelor, reduced stroke recurrence in those presenting with mild ischemic stroke or high risk TIA. Genetic polymorphisms may play a role in determining the appropriate regimen. Questions remain regarding the optimal duration of combination antiplatelet therapy for various stroke etiologies.

Outpatient Prescription Practices in Patients with Atrial Fibrillation (From the NCDR PINNACLE Registry)

This study sought to evaluate inappropriate prescribing practices in an atrial fibrillation (AF) population, as outlined by the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults with Atrial Fibrillation or Atrial Flutter document. The 2016 AF quality measures document specified medications to avoid in certain AF populations, including aspirin and anticoagulant combination therapy in patients without cardiovascular disease, and non-dihydropyridine calcium channel blockers in patients with reduced ejection fraction. Using data from the NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed rates of inappropriate prescription of two types of medications among AF outpatients from 5/1/2008-5/1/2016. Overall rates of inappropriate prescription and variation by practice were calculated. Patient and practice factors associated with inappropriate prescription were assessed in adjusted analyses. A total of 107,759 of 658,250 (16.4%) patients without cardiovascular disease were inappropriately prescribed an antiplatelet and anticoagulant together, and 5,731 of 150,079 (3.8%) patients with reduced ejection fraction were inappropriately prescribed a non-dihydropyridine calcium channel blocker. Overall, 14.8% of AF patients were prescribed medications that were not recommended. Both patient and practice factors were associated with inappropriate prescribing, and the adjusted practice-level median odds ratio for inappropriate prescription was 1.70 (95% CI: 1.61-1.82), indicating a 70% likelihood that 2 random practices would treat identical AF patients differently. In a large registry of AF patients treated in cardiology practices, overall rates of inappropriate prescription practices, as defined by the 2016 AF quality measures, were relatively low, but significant practice variation was present.

Antithrombotic Therapy in Patients with Peripheral Artery Disease: A Focused Review on Oral Anticoagulation.

Peripheral artery disease (PAD) is a major cause of morbidity and mortality but it is usually underdiagnosed and undertreated. Patients with PAD present dysregulated procoagulant, anticoagulant, and fibrinolytic pathways leading to arterial and venous thrombosis. The risk of several ischemic-related complications could be mitigated with appropriate antithrombotic therapy, which plays a central role in all types of PAD. For years, antiplatelets have been indicated in patients with symptomatic PAD or those who have undergone revascularization. Unfortunately, a non-negligible proportion of patients with PAD will suffer from adverse events during the follow-up, even despite proper medical therapies for the prevention of PAD complications. Thus, there is room for improving clinical outcomes in these patients. Given the implication of both, primary and secondary hemostasis in arterial thrombosis and the pathophysiology of PAD, the combination of antiplatelets and anticoagulants has emerged as a potential antithrombotic alternative to antiplatelets alone. In this narrative review article, we have highlighted the most recent evidence about antithrombotic therapy in PAD patients, with a special focus on oral anticoagulation. Certainly, COMPASS and VOYAGER PAD trials have shown promising results. Thus, rivaroxaban in combination with aspirin seem to reduce cardiovascular outcomes with a similar bleeding risk compared to aspirin alone. Nevertheless, results from real-world studies are needed to confirm these observations, and other trials will provide novel evidence about the safety and efficacy of emerging anticoagulant agents.

A retrospective study of antithrombotic therapy use in an outpatient haemodialysis unit.

Patients on haemodialysis (HD) are at increased risk of both bleeding and thrombotic events, due to comorbidities and nature of dialysis treatment. However, there is a lack of research on evidence-based treatment strategies and prescribing patterns for antithrombotic therapies (ATT) in this population. To characterize ATT use and its main indications in an outpatient HD unit. A single-centre retrospective chart review was conducted in a Toronto outpatient HD unit (n=329). Medical histories, number of ATTs and corresponding indications were collected from adult patients prescribed at least one ATT from 1 October 2019 to 31 December 2019, inclusive. Of 329 patients in the unit, a total of 135 (41%) patients were on at least one ATT. Of these 135 patients, 80% were on monotherapy (55% antiplatelet, 25.1% anticoagulant), 12.6% were on dual antiplatelet therapy (DAPT), and 7.4% were on a antiplatelet and anticoagulant combination. Primary indications for ATT in our cohort were coronary artery disease (CAD; 55%), atrial fibrillation (18.5%) and venous thromboembolism (VTE; 17%). Described ATT use was in-line with current clinical guidelines. Monotherapy was primarily used in our HD cohort, whereas few patients were on dual therapy. Low-dose aspirin was the most common antiplatelet prescribed for secondary prevention of cardiovascular events. Warfarin monotherapy was primarily indicated for VTE, and DAPT aspirin/clopidogrel was the most commonly prescribed for CAD. Our characterization of ATT use in this HD cohort demonstrates that ATT is often prescribed for a number of different CVD reasons. Overlapping and confounding indications for prescribing ATTs, lack of randomized controlled trials and unclear clinical guidelines mean that individualized risk-benefit assessments for ATT use are still needed to provide care for these high-risk patients. More research to address the safety and efficacy of ATTs is warranted to develop more robust evidence-based treatment guidelines for the HD population.

Antiplatelet therapy with or without anticoagulant therapy for lower extremity peripheral artery disease: A systematic review.

To identify randomized controlled trials that compared antiplatelet monotherapy to combination antiplatelet plus anticoagulant therapy and evaluated major adverse cardiovascular events (MACE) or major adverse limb events (MALE), death, or bleeding in patients with lower extremity peripheral artery disease (PAD). A systematic search of MEDLINE, Embase, and CENTRAL databases revealed 5 trials. Two trials consisted of patients with stable PAD, while 3 trials examined patients with PAD post revascularization. Antiplatelet therapy was mostly aspirin (81-325 mg daily), and anticoagulation included rivaroxaban 2.5 mg twice daily or warfarin. Duration of follow-up ranged from 12 to 38 months. Two trials had low risk of bias, whereas 3 trials had high/unclear risk of bias. For patients with stable PAD, one trial showed that use of warfarin (or acenocoumarol) with antiplatelet therapy did not reduce MACE, MALE, or cardiovascular or all-cause death but increased the risk of life-threatening bleeding. A second trial demonstrated that low-dose rivaroxaban plus antiplatelet therapy lowered the risk of MACE and MALE, with no effect in preventing cardiovascular or all-cause death, but increased the risk of major bleeding. For patients with PAD post revascularization receiving warfarin and antiplatelet therapy, 2 trials showed no benefit in MACE or MALE but increased or similar rates of all-cause death and major bleeding. In a third trial, low-dose rivaroxaban plus aspirin reduced occurrence of the composite of MACE and MALE but increased major bleeding, with no effect on cardiovascular or all-cause death. Dual-pathway inhibition with low-dose rivaroxaban and aspirin reduced MACE and MALE in patients with stable or revascularized PAD, but net clinical benefit is questionable.

Role of Different Antithrombotic Regimens after Percutaneous Left Atrial Appendage Occlusion: A Large Single Center Experience.

Background: Optimal antithrombotic therapy after left atrial appendage (LAA) occlusion is still not clear. The aim of this study was to investigate the role of different antithrombotic regimens after the procedure. Methods and Results: We retrospectively analyzed data of 260 patients who underwent LAA occlusion and divided them into four groups according to therapy at discharge: dual antiplatelet therapy (group A, 71.5%); oral anticoagulants (group B, 19%); “minimal” antithrombotic therapy (single antiplatelet agent or without any antithrombotic therapy; group C, 4.5%) and other therapeutic regimens (such as a combination of antiplatelets and anticoagulants; group D, 4.5%). We analyzed baseline characteristics, procedural data, and clinical and transesophageal follow-up for each group. The incidence of adverse events was low in the whole population and had a similar distribution among groups. The majority of bleeding events was registered during the first 3 months after the procedure (34 out of 46, 70%). Ischemic events (2%), as well as silent left atrial thrombosis, were rare and not significantly higher in the population discharged with “minimal” antithrombotic therapy. Conclusion: Our experience seems to suggest that LAA occlusion was associated with a low incidence of adverse events, regardless of antithrombotic therapy. A “minimal” drug regimen may be feasible without losing efficacy on embolic prevention for patients with high bleeding risk.

Coronary embolism, an infrequent cause of acute coronary syndrome. A case serie

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Coronary embolism (CE) is a heterogeneous and infrequent aetiology of acute coronary syndrome (ACS), with current evidence from small case series and with an angiographic and etiological diagnostic challenge. Purpose Our work evaluated baseline characteristics and in-hospital management and prognostic of patients with CE. Methods Observational, retrospective descriptive study of patients admitted in our unit from July 2011 to February 2020 for ACS and diagnosed with CE (National Cerebral Cardiovascular Center Criteria). Results In this period, there were 2745 patients admitted because of ACS. Out of them, 36 patients had criteria of CE (1.3%, 95% confidence interval 0.9 to 1.8%). The mean age was 71 ± 13 years, 75% were women and 25% men. Most patients (66.7%) presented with STEMI. There was a history of hypertension in 80.6%, hyperlipidaemia in 47.2%, diabetes mellitus in 30.6%, active smoking in 19.4%, and 30.6% of atrial fibrillation (AF). Among patients with previous AF, 54.5% had no previous antithrombotic treatment. 77.1% do not have thromboembolic risk factors. The most frequent aetiology was AF (47.2%, 11.8% de novo), with unknown aetiology in second place (33.3%). Two cases were caused by thrombophilia (5.6%), three cases associated with left prosthetic valves (8.3%), one septic emboli (2.8%) and one caused by left ventricular thrombus (2.8%). The anterior descending artery was the most affected vessel (52.8%) and the treatment was stenting in 33.3%, isolated thrombus aspiration in 22.2%, and medical management in 33,3% of patients. At discharge, most of patients were under antiplatelet and anticoagulant combination therapy (61.1%), and 5.6% only with anticoagulant treatment. In our serie, in-hospital mortality was 8.4% (one cardiac arrest as clinical presentation). Conclusions CE is a relevant entity due to its clinical considerations, more frequent in women and with AF as main risk factor. One third of patients are of unknown aetiology. Currently therapeutic management is based on interventional cardiologist criteria. To date, there is still lacking a standardized diagnostic criteria and validated management guidelines.

Performance Metrics of the AGGRESTAR PL-12® Platelet Function Analyser in Patients with TIA or Ischaemic Stroke on Commonly-Prescribed Antiplatelet Regimens

Introduction: The optimal time interval after venepuncture to perform platelet function/reactivity testing at low shear stress on the novel AGGRESTAR PL-12® platelet function analyser in non-Chinese Cerebrovascular Disease (CVD) patients is unknown. Methods: Twelve TIA/ischaemic stroke patients were recruited to this cross-sectional, methodological study: 3 on aspirin monotherapy, aspirindipyridamole combination therapy, clopidogrel monotherapy and aspirinclopidogrel combination therapy, respectively. The PL-12 (‘mode 2’) was used to calculate the % maximum aggregation rate to fixed doses of arachidonic acid (%MARAA) and adenosine diphosphate (%MARADP). Samples were analysed every 15 minutes from 30-135 minutes, and every 30 minutes between 165-225 minutes after venepuncture to calculate the time interval providing optimal interassay Coefficients of Variation (CVs). Results: Mean CVs were ≤ 7.37% for the %MARAA assay in patients on aspirin monotherapy or combination therapy, and ≤ 10.24% for the %MARADP assay in patients on clopidogrel monotherapy or combination therapy if assays were performed between 90-120 minutes post-venepuncture. CVs ≤ 10% were also obtained from assays performed between 90-165 minutes postvenepuncture on aspirin monotherapy or combination therapy. Discussion: Reliable and reproducible platelet function/reactivity data can be obtained with the AGGRESTAR PL-12 analyser in non-Chinese CVD patients on commonly-prescribed antiplatelet monotherapy or combination therapy regimens between 90-120 minutes post-venepuncture.

The Role for Combined Antithrombotic Therapy With Platelet and Coagulation Inhibition After Lower Extremity Revascularization.

Evidence for antithrombotic treatment following lower extremity revascularization (LER) for peripheral artery disease (PAD) is limited, leading to weak and conflicting guideline recommendations and heterogeneous practice patterns. This variability in post-LER antithrombotic treatment raises quality-of-care issues that have long been under-studied. This Viewpoint reviews the most updated guidelines, currently-available evidence, and contemporary data about practice patterns and practitioner opinions in this area. Particular attention is paid to distinctions between antiplatelet therapy, anticoagulant therapy, and combination therapy in light of the recent VOYAGER-PAD (Vascular Outcomes Study of ASA [acetylsalicylic acid] Along with Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD) trial. The implications of VOYAGER-PAD pertaining to various subgroups of patients undergoing LER are explored. Overall, this Viewpoint argues for consideration of post-LER therapy targeted at both platelet function and the coagulation cascade, though further LER-specific analyses, including expected VOYAGER-PAD sub-analyses, are needed.