Continuation Of Aspirin Research Articles

Current Management in Transurethral Therapy of Benign Prostatic Obstruction in Patients on Oral Anticoagulation: A Worldwide Questionnaire.

To assess the current treatment of benign prostatic obstruction (BPO) in patients on ongoing oral anticoagulation (OA). An Internet survey was sent to all active members of the Endourological Society. The survey contained 32 questions regarding transurethral treatment of BPO in patients on ongoing OA, different techniques, and arising complications. Out of all members (n = 2000) of the Endourological Society, 133 participated in our survey. Eighty-eight percent of the participants indicated to perform transurethral therapy of BPO on ongoing OA, whereas 60% of this group temporarily pause the OA during the intervention. Sixteen percent perform >30 transurethral interventions of BPO on ongoing OA per year. Most operations are performed under continuation of aspirin (58.2%). The continuation of adenosine diphosphate (ADP)-receptor inhibitors (22.1%), vitamin K antagonists (18.9%), factor Xa inhibitors (15.6%), or the combination of two oral anticoagulants (16.4%) is continued less often. The decision for the operation on ongoing OA is usually approved by the cardiologist (58%) or it cannot be stopped in case of emergency (29%). GreenLight laser (39%) was the most frequently used technique on ongoing OA, followed by monopolar or bipolar transurethral resection of the prostate (35%) as well as other sources of laser [holmium (12%), thulium (12%), diode laser (2%)]. Although OA was continued during the interventions, cardiovascular complications were observed in 31.6%. Current practice shows that the majority of a representative group of the Endourological Society members perform transurethral therapy of BPO in patients on ongoing OA. The incidence of perioperative complications under transurethral therapy of BPO on ongoing OA is lower than previously assumed.

EVALUATION OF ASPIRIN USAGE SAFETY IN CORONARY BYPASS SURGERY

Recent guidelines it is permitted to continue aspirin before coronary bypass operation (CBG) (Class I, Level B). Nevertheless, absence of randomized multicenter studies makes it possible not to follow these in routine practice as the only. Practive of aspirin discontinuation before CBG is quite common due to anticipated risks of post-surgery complications. Aim . To evaluate the safety of CBG with continued aspirin. Material and methods. For the safety assessment of aspirin before CBG, we conducted prospective randomized study. Patients with stable coronary heart disease were included, who underwent CBG with continued aspirin (aspirin group), and another group included those who had aspirin discontinued (controls). Totally, 74 patients randomized. Treatment group included 37 patients, and 37 controls. Follow-up lasted for 5 minutes. As primary endpoint, the volume of operational blood loss was taken, during the next 24 hours post-surgery. As the second endpoint, the combination was taken as any cardiovascular adverse event: cardiac death, perioperational myocardial infarction, ischemic stroke. Results. There was noted, the comparability of intraoperational blood loss in comparison groups (p=0,166). Summary blood loss in 24 hours of postoperational blood loss showed statistical significance between groups (mean difference 100 mL, 95% CI 0-110 mL, p=0,027). This amount of blood loss is clinically non-significant. In aspirin group, there were 2 cases of perioperational myocardial infarction, by cardiac enzymes elevation, not statistically significant. Conclusion . Results of the study witness for the safety of CBG operations under continued aspirin as well as discontinued at least 5 days before surgery.

Combination of Modified Pinch-Burn-Cut (PBC) Technique and Harmonic FOCUS�for Pancreaticoduodenectomy under Preoperative Continuation of Antiplatelets in High Thromboembolic Risk Patients

AIM: The aim of the study was to assess the safety and feasibility of pancreaticoduodenectomy (PD) using modified Pinch-Burn-Cut (PBC) technique and Harmonic FOCUS® under continuation of antiplatelet therapy in patients with high thromboembolic risks. METHODS: Consecutive 78 patients who had undergone PD using combination of modified PBC technique and HF in a tertiary care setting from 2009 to 2016 were retrospectively reviewed. Among which 18 patients with high thromboembolic risks underwent preoperative aspirin continuation and were included in the study. Background and perioperative factors were described with detailed information, and the outcome variables of patients were compared between the pancreatic cancer patients (PC group) and those with the other diseases (non-PC group). RESULTS: The current cohort included 8 patients in PC group and 10 in non-PC group, respectively. The major indication of APT was history of percutaneous coronary intervention for angina pectoris (15/18, 83.3%). The median of operative time and estimated blood loss were 482 min and 511 mL, respectively. There were no differences between the groups in the operative time, blood loss, or the rates of postoperative complications. None suffered from excessive bleeding requiring platelet transfusion intraoperatively, and there is no case with massive intraoperative bleeding (≥ 1,000 mL). Three minor Grade B post-pancreatectomy hemorrhage (PPH, 16.7%) and 2 Grade B postoperative pancreatic fistula (POPF, 11.1%) occurred postoperatively, but no patient suffered from Grade C PPH/POPF or thromboembolic complications. Operative mortality was zero. CONCLUSION: PD using modified PBC technique and Harmonic FOCUS® can be performed safely and satisfactorily even in APT-burdened patients with high thromboembolic risks. Maintenance of single APT should be considered in patients with high thromboembolic risk, even when PD is performed.

Continuation of antithrombotic therapy may be associated with a high incidence of colonic post-polypectomy bleeding.

Post-polypectomy bleeding (PPB) is the most common complication of endoscopic procedures. To reduce the risk of thromboembolic incidents, Japanese guidelines for gastroenterological endoscopy were revised to indicate that antithrombotic agents were not to be discontinued for endoscopic treatment. However, carrying out endoscopic procedures under antithrombotic medication potentially increases the incidence of hemorrhagic complications. The present study investigated the impact of the revised guidelines on the frequency of complications after colonoscopic procedures. The surveillance period comprised the year before the initiation of the new guidelines (2012), which served as a control period, and 2 years after initiation of the new guidelines (2013 and 2014). During the control period, 3955 cases were examined colonoscopically and 1601 lesions were treated endoscopically. During the 2-year period under the new guidelines, 8749 colonoscopies and 3768 endoscopic treatments were carried out. Changes in treatment methods and rates of complications were compared. PPB rate was not significantly different before and after the revision (0.87% vs 1.01%). With the new guidelines, PPB rates in antithrombotic non-users and users were 0.60% and 3.13%, respectively (OR 5.11, P = 0.000). Multivariable analysis showed that the risks for PPB were as follows: heparin bridging therapy (OR 6.34, P = 0.0002); low-dose aspirin (LDA) continuation (OR 5.30, P = 0.0079); and lesion size (OR 1.06, P < 0.0001). The present study showed that the overall PPB rate under the new guidelines was not significantly higher when compared with the previous data obtained before the new guidelines were introduced.

Comparison of preoperative continuation and discontinuation of aspirin in patients undergoing total hip or knee arthroplasty.

Preoperative discontinuation of aspirin (acetylsalicylic acid) can reduce bleeding risk but may increase the risk of perioperative cardiovascular events. We retrospectively assessed the impact of preoperative continuation versus discontinuation of aspirin compared with a control group in a cohort of 739 consecutive patients undergoing total hip (THA) (n=396) or knee arthroplasty (TKA) (n=343) at a tertiary hospital. Bleeding risk, local complications, orthopaedic outcome, and cardiac and cerebral complications were assessed. Four hundred and sixty-five patients did not receive antithrombotic or full-dose anticoagulant medication, 175 patients were taking low-dose aspirin, 99 vitamin K antagonists, clopidogrel, or a combination of these drugs. Of the patients taking aspirin, 139 discontinued and 36 continued aspirin. Blood loss and local bleeding complications were comparable in these two groups. TKA patients who continued aspirin more frequently showed marked knee swelling after 1week than those discontinuing aspirin (35.1 vs. 81.3%; p=0.001). However, orthopaedic outcome did not differ significantly between the two groups. There was a trend towards an increased risk of cardiac complications in patients who discontinued aspirin (6.5 vs. 0.0%; p=0.107). Continuation or discontinuation of aspirin did not show a statistically significant difference in the risk of relevant perioperative bleeding complications in our study. Continuation of aspirin was associated with a transitory increase in knee swelling, but had no effect on orthopaedic outcome. Continuation of aspirin may be associated with a favourable perioperative cardiac outcome. Our data support perioperative continuation of aspirin intake in patients undergoing THA or TKA.

Bleeding risk of endoscopic ultrasound-guided fine-needle aspiration in patients undergoing antithrombotic therapy.

Bleeding events related to endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) are rare. However, for patients treated with antithrombotic agents, the bleeding risk of EUS-FNA is uncertain. Hence, the aim of this study was to assess the bleeding event rate associated with EUS-FNA in patients receiving antithrombotic treatment. A retrospective study was conducted in 742 consecutive patients who underwent EUS-FNA for solid lesions between 2008 and 2015. We compared the bleeding event rates among patients who were not administered antithrombotic agents, those whose agent use was discontinued, those who continued treatment with aspirin or cilostazol, and those who were administered heparin as a replacement. There were 131 patients (17.7%) treated with antithrombotic agents. Seven experienced bleeding events, and the overall bleeding event rate was 0.9% (7/742). All bleeding events were intraoperative; there were no postoperative bleeding episodes. Subgroup analysis by antithrombotic agent revealed bleeding event rates of 1.0% (6/611), 0% (0/62), 1.6% (1/61), and 0% (0/8) for the non-administration, discontinuation of agents, continuation of aspirin or cilostazol, and heparin replacement groups, respectively. Only one severe bleeding event necessitated hemostatic treatment (1/742; 0.1%); this occurred in a patient in the non-administration group, and there were no severe bleeding events in patients receiving antithrombotic treatment. The present study found a low incidence of EUS-FNA-related bleeding in patients receiving antithrombotic treatment. The bleeding event rate was low even in patients who underwent EUS-FNA while continuing aspirin or cilostazol.

A survey of aspirin desensitization practices among allergists and fellows in training in the United States

A survey of aspirin desensitization practices among allergists and fellows in training in the United States

The Impact of Perioperative Aspirin on Bleeding Complications Following Robotic Partial Nephrectomy

Perioperative administration of aspirin for high-risk urologic procedures is controversial. We evaluated whether continuation of perioperative aspirin alters bleeding complications in patients who undergo robotic partial nephrectomy (RPN). Retrospective review identified 214 consecutive patients who underwent RPN at our institution from May 2012 to March 2015. Comparisons were performed between 49 patients continuing aspirin (81 mg), 34 patients holding aspirin for at least 7 days before surgery, and 131 patients who had never taken aspirin. Overall bleeding complications included postoperative hemoglobin drop of >3 g/dL during admission, postoperative blood transfusion, or necessity for urgent selective angiographic embolization. Multivariable logistic regression was performed to assess the independent association between aspirin administration and bleeding complications. Patients continuing aspirin were older and had higher Charlson Comorbidity Index (CCI) compared with patients who held or never took aspirin (both p < 0.01). Compared with those who held or never took aspirin, patients continuing aspirin had similar rates of overall bleeding complications (27% vs 15% vs 14%, p = 0.13), hemoglobin drop >3 g/dL (24% vs 15% vs 14%, p = 0.24), and postoperative blood transfusion (4% vs 3% vs 2%, p = 0.43). There was a trend for more frequent need for embolization in patients continuing aspirin (6% vs 3% vs 1%, p = 0.07). On multivariate analysis controlling for CCI and RENAL nephrometry score, aspirin administration was not significantly associated with bleeding complications. Continuation of aspirin was associated with higher overall 30-day complications compared with the other groups (24% vs 12% vs 8%, p = 0.03). Continuation of perioperative 81 mg aspirin for patients undergoing RPN was not associated with significantly higher overall bleeding complications. Patients continuing aspirin had increased comorbidities and overall 30-day complications. While our data suggest that continuing perioperative aspirin is safe in select patients, larger studies are needed to confirm these findings.

Clinical outcomes of various continued antiplatelet therapies in patients who were administered DAPT following the implantation of drug-eluting stents and developed gastrointestinal hemorrhage.

Although an increasing number of patients accept dual antiplatelet therapy (DAPT) following implantation of drug-eluting stents (DES) for coronary heart disease (CHD), the proportion of patients with DAPT who subsequently develop gastrointestinal hemorrhage continues to increase. To ensure the clinical outcomes from DES, it is important to formulate a novel continued antiplatelet therapy for patients who were administered DAPT and subsequently develop gastrointestinal hemorrhage following DES implantation. The present study aimed to evaluate the effects of continued aspirin, clopidogrel or DAPT use on the incidence of clinical adverse events and gastrointestinal rebleeding in patients who received DAPT and subsequently developed gastrointestinal hemorrhage following implantation of DES for CHD. Between 2004 and 2010, 108 consecutive patients receiving DAPT developed gastrointestinal hemorrhage following DES implantation for CHD at Liuzhou General Hospital (Liuzhou, Guangxi). These patients were divided into three groups according to the novel antiplatelet therapy. The occurrence of major adverse cardiac events (MACE), including cardiac death, non-fatal myocardial infarction, heart failure or target vessel revascularization, net adverse clinical events (NACE), including major bleeding, stroke or MACE, and gastrointestinal rebleeding during clinical follow-up following the initial procedure were compared among these three groups. The results of this analysis demonstrated that the occurrence rate of MACE, NECE and gastrointestinal rebleeding was not significantly different among these groups (P>0.05). Furthermore, survival analysis was performed and although the survival curves of MACE and NECE were not significantly different among these groups, gastrointestinal rebleeding was demonstrated to be significantly different among the three groups (P<0.05), and continued aspirin or clopidogrel use was superior to continued DAPT. In conclusion, the results of the present study indicated that there were no significant differences in the clinical effectiveness and safety of continuing antiplatelet monotherapy or DAPT in patients who are administered DAPT and experience gastrointestinal hemorrhage following DES implantation. As for the prevention of recurrent bleeding, antiplatelet monotherapy was demonstrated to be superior to DAPT. Moreover, the treatment of patients who are administered DAPT and experience gastrointestinal hemorrhage following DES implantation must involve an evaluation of the risk of complications, including stent thrombosis, continuous bleeding and recurrent hemorrhage.

Risks of Bleeding Recurrence and Cardiovascular Events With Continued Aspirin Use After Lower Gastrointestinal Hemorrhage

It is not clear whether use of low-dose aspirin should be resumed after an episode of lower gastrointestinal (GI) bleeding. We assessed the long-term risks of recurrent lower GI bleeding and serious cardiovascular outcomes after aspirin-associated lower GI bleeding. We performed a retrospective study of patients diagnosed with lower GI bleeding (documented melena or hematochezia and absence of upper GI bleeding) from January 1, 2000 through December 31, 2007 at the Prince of Wales Hospital in Hong Kong. Using the hospital registry, we analyzed data from 295 patients on aspirin and determined their outcomes during a 5-year period. Outcomes included recurrent lower GI bleeding, serious cardiovascular events, and death from other causes, as determined by an independent, blinded adjudication committee. Outcomes were compared between patients assigned to the following groups based on cumulative duration of aspirin use: <20% of the follow-up period (121 nonusers) vs ≥50% of the observation period (174 aspirin users). Within 5 years, lower GI bleeding recurred in 18.9% of aspirin users (95% confidence interval [CI], 13.3%-25.3%) vs 6.9% of nonusers (95% CI, 3.2%-12.5%; P= .007). However, serious cardiovascular events occurred in 22.8% of aspirin users (95% CI, 16.6%-29.6%) vs 36.5% of nonusers (95% CI, 27.4%-45.6%; P= .017), and 8.2% of aspirin users died from other causes (95% CI, 4.6%-13.2%) vs 26.7% of nonusers (95% CI,18.7%-35.4%; P= .001). Multivariable analysis showed that aspirin use was an independent predictor of rebleeding, but protected against cardiovascular events and death. Among aspirin users with a history of lower GI bleeding, continuation of aspirin is associated with an increased risk of recurrent lower GI bleeding, but reduced risk of serious cardiovascular events and death.

Development and Validation of a Prediction Rule for Benefit and Harm of Dual Antiplatelet Therapy Beyond 1 Year After Percutaneous Coronary Intervention.

Dual antiplatelet therapy after percutaneous coronary intervention (PCI) reduces ischemia but increases bleeding. To develop a clinical decision tool to identify patients expected to derive benefit vs harm from continuing thienopyridine beyond 1 year after PCI. Among 11,648 randomized DAPT Study patients from 11 countries (August 2009-May 2014), a prediction rule was derived stratifying patients into groups to distinguish ischemic and bleeding risk 12 to 30 months after PCI. Validation was internal via bootstrap resampling and external among 8136 patients from 36 countries randomized in the PROTECT trial (June 2007-July 2014). Twelve months of open-label thienopyridine plus aspirin, then randomized to 18 months of continued thienopyridine plus aspirin vs placebo plus aspirin. Ischemia (myocardial infarction or stent thrombosis) and bleeding (moderate or severe) 12 to 30 months after PCI. Among DAPT Study patients (derivation cohort; mean age, 61.3 years; women, 25.1%), ischemia occurred in 348 patients (3.0%) and bleeding in 215 (1.8%). Derivation cohort models predicting ischemia and bleeding had c statistics of 0.70 and 0.68, respectively. The prediction rule assigned 1 point each for myocardial infarction at presentation, prior myocardial infarction or PCI, diabetes, stent diameter less than 3 mm, smoking, and paclitaxel-eluting stent; 2 points each for history of congestive heart failure/low ejection fraction and vein graft intervention; -1 point for age 65 to younger than 75 years; and -2 points for age 75 years or older. Among the high score group (score ≥2, n = 5917), continued thienopyridine vs placebo was associated with reduced ischemic events (2.7% vs 5.7%; risk difference [RD], -3.0% [95% CI, -4.1% to -2.0%], P < .001) compared with the low score group (score <2, n = 5731; 1.7% vs 2.3%; RD, -0.7% [95% CI, -1.4% to 0.09%], P = .07; interaction P < .001). Conversely, continued thienopyridine was associated with smaller increases in bleeding among the high score group (1.8% vs 1.4%; RD, 0.4% [95% CI, -0.3% to 1.0%], P = .26) compared with the low score group (3.0% vs 1.4%; RD, 1.5% [95% CI, 0.8% to 2.3%], P < .001; interaction P = .02). Among PROTECT patients (validation cohort; mean age, 62 years; women, 23.7%), ischemia occurred in 79 patients (1.0%) and bleeding in 37 (0.5%), with a c statistic of 0.64 for ischemia and 0.64 for bleeding. In this cohort, the high-score patients (n = 2848) had increased ischemic events compared with the low-score patients and no significant difference in bleeding. Among patients not sustaining major bleeding or ischemic events 1 year after PCI, a prediction rule assessing late ischemic and bleeding risks to inform dual antiplatelet therapy duration showed modest accuracy in derivation and validation cohorts. This rule requires further prospective evaluation to assess potential effects on patient care, as well as validation in other cohorts. clinicaltrials.gov Identifier: NCT00977938.

DAPT Score Utility for Risk Prediction in Patients With or Without Previous Myocardial Infarction

BackgroundThe DAPT (Dual Antiplatelet Therapy) study enrolled patients after coronary stenting. Patients randomized to continued thienopyridine and aspirin after 12 months had lower ischemic risk but higher bleeding risk than those treated with placebo and aspirin. ObjectivesThis study sought to determine whether a decision tool (DAPT score) aids prescription of dual antiplatelet therapy duration in patients with or without prior myocardial infarction (MI) treated with coronary stents. MethodsPatients were categorized according to any history of MI before the index procedure or no history of MI. Risk differences during the randomized treatment period (12 to 30 months) for ischemic (MI and/or stent thrombosis) and bleeding (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries moderate/severe) events were compared according to DAPT score. ResultsRates of MI were 3.8% versus 2.4% (p = 0.01) for patients with any MI versus no MI. Continued thienopyridine reduced late MI compared with placebo regardless of MI history (hazard ratio [HR] for any MI: 0.46; p < 0.001; HR for no MI: 0.60; p = 0.003) and increased bleeding (HR: 1.86, p = 0.01 any MI; HR: 1.58, p = 0.01 no MI). DAPT scores ≥2 were associated with reductions in MI/stent thrombosis with continued thienopyridine compared with placebo (2.7% vs. 6.0%, p < 0.001 any MI; 2.6% vs. 5.2%, p = 0.002 no MI), with comparable bleeding rates. Among patients with DAPT scores <2 in both groups, continued thienopyridine was associated with significantly increased bleeding but similar rates of ischemia. ConclusionsPatients with previous MI have greater risk of late ischemic events than those with no MI history. The DAPT score improves prediction of patient benefit and harm from continued dual antiplatelet therapy beyond assessment of MI history alone. (The Dual Antiplatelet Therapy Study; NCT00977938).

PD23-01 THE EFFECT OF CONTINUED ASPIRIN THERAPY IN PATIENTS UNDERGOING PCNL

You have accessJournal of UrologyStone Disease: Surgical Therapy IV1 Apr 2016PD23-01 THE EFFECT OF CONTINUED ASPIRIN THERAPY IN PATIENTS UNDERGOING PCNL Brandon Otto, Forat Lutfi, Russell Terry, Mohit Gupta, and VincentG Bird Brandon OttoBrandon Otto More articles by this author , Forat LutfiForat Lutfi More articles by this author , Russell TerryRussell Terry More articles by this author , Mohit GuptaMohit Gupta More articles by this author , and VincentG BirdVincentG Bird More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1740AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Aspirin (ASA) is usually stopped prior to percutaneous nephrolithotomy (PCNL) over the concern for increased surgical bleeding. There is evidence that discontinuing ASA perioperatively increases thromboembolic events. Since 2012 we have continued ASA in all patients undergoing PCNL. We sought to review our experience to date. METHODS We retrospectively reviewed 285 consecutive PCNLs between 2012-2015 at our institution. We compared outcomes and complications of PCNL in patients continuing ASA to patients not taking ASA. Statistical analysis was performed with students t-test and chi-squared test. RESULTS 77 (27%) patients were maintained on ASA and 208 (73%) were not on ASA. Table 1 summarizes ASA dose and indications. The ASA group was older (66 vs 51 years, p<0.001), had more tobacco users (55.8% vs 31.7%, p<0.001) and a higher American Society of Anesthesiologist score (2.9 vs 2.5, p<0.001). There were no differences in mean stone size or blood loss between the ASA and non-ASA groups (37 vs 40 mm, p=0.127 and 42 vs 54 mL, p=0.05 respectively). There were no differences in residual stone fragment size following PCNL between the ASA and non-ASA groups (0-2 mm: 66.7% vs 61.9%, 3-4 mm: 19% vs 16%, >4 mm: 14.3% vs 22.4%, p=0.265 respectively). Length of stay and change in hemoglobin, hematocrit and creatinine were similar between the groups. (Table 2) There were no differences in the number of readmissions or total complications between the ASA and non-ASA groups (12.4% vs 12.4%, p=0.949, 31.6% vs. 26.7%, p=0.401 respectively). Additionally, there were no differences in the number of major complications, bleeding complications and transfusion rates between the ASA and non-ASA groups (8.9% vs 5.7%, p=0.366; 3.8% vs 3.3%, p=0.853; and 1.3% vs 1%, p=1.00 respectively). CONCLUSIONS PCNL appears both effective and safe in patients continuing ASA perioperatively. Postoperative hemorrhage was uncommon and this concern should not dissuade urologists from offering PCNL with perioperative ASA use to this patient population. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e505-e506 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Brandon Otto More articles by this author Forat Lutfi More articles by this author Russell Terry More articles by this author Mohit Gupta More articles by this author VincentG Bird More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD23-03 A PROSPECTIVE AND RANDOMIZED COMPARISON OF FLUOROSCOPIC, SONOGRAPHIC OR COMBINED APPROACH FOR RENAL ACCESS IN MINIMALLY INVASIVE PERCUTANEOUS NEPHROLITHOTOMY

INTRODUCTION AND OBJECTIVES: There is increasing use of systemic antiplatelet and anticoagulant agents, potentially complicating the surgical management of patients with large stone burdens. Although published case series have reported successful PCNL in those on uninterrupted aspirin, the risks of clinically significant bleeding after PCNL in those with iatrogenic bleeding diatheses are not fully elucidated. We sought to assess the effect of uninterrupted antiplatelet or anticoagulation therapy within the first 24 hours following PCNL on risk of requiring interventional radiologic embolization. METHODS: We reviewed a retrospective cohort of 540 patients undergoing PCNL at 2 academic medical centers between 2006-2015. From within this cohort, we performed a nested case-control study, matching non-bleeding controls 3:1 by age, gender and stone complexity (as assessed by the Guy’s Stone Score) to the subset of patients suffering a clinically significant bleeding complication (transfusion or embolization). Logistic regression was then used to assess the odds ratio for embolization. RESULTS: The overall risk of bleeding complication requiring transfusion or embolization was 3.3% within the entire cohort. There were a total of 18 patients who experienced clinically significant bleeding following PCNL. Of these, 10 underwent embolization. After matching these 18 patients as described, the odds of requiring postoperative IR embolization were significantly increased in those with continued peri-operative anticoagulation/antiplatelet therapy (OR 15, 95% CI 1.23-187.85). CONCLUSIONS: Although the safety of continued aspirin during PCNL has been reported, our findings suggest increased risk of clinically significant bleeding associated with systemic antiplatelet and anticoagulant therapy within the first 24 hours post-operatively. Prospective studies are needed to further define risks of continuing antiplatelet/anticoagulant therapy in patients undergoing PCNL.

Continuous aspirin administration in patients of myocardial infraction during their hospital stay - a clinic audit

This audit was performed to check whether all patients suffering from myocardial infarction have received aspirin in dose of 160 - 325 mg during their stay in the medical ward in Mayo hospital Lahore. Objectives: The audit was performed to assess the application of ACC/AHA guidelines for management of patients with acute MI regarding administration of aspirin in a dose of 160-325 mg daily during their stay in the hospital. Criteria of audit: A dose of 160-325 mg of aspirin should be continued indefinitely daily after an attack of MI7. Standard of audit: All patients who have been diagnosed to have acute myocardial infarction should receive 160- 325 mg of aspirin daily during hospital stay and continuously thereafter. Material and methods: A retrospective audit was conducted in medical ward in Mayo hospital, Lahore in which notes of patients who were admitted with a diagnosis of acute myocardial infarction from 1st Jan 2005 to 31st August 2005 were studied. Results: We found that patients included in this audit had a mean age of 56 years +/- 13.55 out of which 45 patients 84% were discharged, 2% were discharged on request, 4 % were shifted to CCU, 6% left against medical advice and 2% expired. We found out that out of 45 cases only 24.4 % of cases were given aspirin in the recommended dose of 160- 325 mg daily, 40 % of patients received only 75 mg aspirin daily, while 33.3 % of them got 150mg daily and 2.2 % of patients did not receive aspirin during their stay in the hospital.

Oral anticoagulation therapy and laser surgery for benign prostatic hyperplasia: stop, replace, or continue?

To update on the available literature that assessed laser surgery for benign prostatic obstruction (BPO) in patients under antithrombotic. All types of laser might be suitable to decrease the bleeding risk in patients under antithrombotic. However, there is no consensus on the appropriate perioperative management of antithrombotic. Most of the studies mixed patients with coumarin derivatives or platelet aggregation inhibitors and did not discriminate the results according to the type of antithrombotic. The continuation of low-dose aspirin is feasible and might not increase bleeding risk during the perioperative period. Conversely, the literature is still too sparse and the protocols reported are too heterogeneous to provide any firm recommendation regarding the continuation, withdrawn, or bridging of clopidogrel and coumarin derivatives during laser procedures for BPO. The approach with new oral anticoagulants is even more uncertain as no data are available in this setting. The decision to stop, continue, or replace antithrombotic should rely on both thrombotic and hemorrhagic risks. Therefore, urologist, cardiologist, and anesthesiologist should discuss altogether each case. Further studies are needed to provide a high level of evidence regarding the perioperative management of antithrombotic in the era of laser BPO procedures.

Benefits and Risks of Extended Dual Antiplatelet Therapy After Everolimus-Eluting Stents

The purpose of this study was to characterize outcomes for everolimus-eluting stent (EES)-treated subjects according to treatment with continued thienopyridine plus aspirin versus aspirin alone 12 to 30 months after stenting. In the DAPT (Dual Antiplatelet Therapy) study, continued thienopyridine plus aspirin beyond 1 year after coronary stenting reduced ischemic events. Given low rates of stent thrombosis and myocardial infarction (MI) for current drug-eluting stents, we examined outcomes among EES-treated subjects in the DAPT study. The DAPT study enrolled 25,682 subjects (11,308 EES-treated) after coronary stenting. Following 12 months of treatment with thienopyridine and aspirin, eligible subjects continued treatment with aspirin and 9,961 (4,703 with EES) were randomized to 18 months of continued thienopyridine or placebo. Stent type was not randomized, and the EES subset analysis was post hoc. Among EES-treated patients, continued thienopyridine reduced stent thrombosis (0.3% vs. 0.7%, hazard ratio [HR]: 0.38, 95% confidence interval [CI]: 0.15 to 0.97; p = 0.04) and MI (2.1% vs. 3.2%, HR: 0.63, 95% CI: 0.44 to 0.91; p = 0.01) versus placebo but did not reduce a composite of death, MI, and stroke (4.3% vs. 4.5%, HR: 0.89, 95% CI: 0.67 to 1.18; p = 0.42), and increased moderate/severe bleeding (2.5% vs. 1.3%, HR: 1.79, 95% CI: 1.15 to 2.80; p = 0.01), and death (2.2% vs. 1.1%, HR: 1.80, 95% CI: 1.11 to 2.92; p = 0.02). Death due to cancer and not related to bleeding was increased (0.64% vs. 0.17%; p = 0.01). In EES-treated subjects, significant reductions in stent thrombosis and MI and an increase in bleeding were observed with continued thienopyridine beyond 1 year compared with aspirin alone. (The Dual Antiplatelet Therapy Study [DAPT Study]); NCT00977938).

Impact of Foot Infection on Infrainguinal Bypass Outcomes in Patients With Limb-Threatening Ischemia

Despite advances in endovascular therapy, infrainguinal bypass (IB) continues to play a major role in achieving limb salvage in the patients with extensive tissue loss and long-segment occlusive disease. In this study, we sought to compare the outcomes of IB in patients with limb-threatening ischemia who presented with or without foot infection. We conducted a retrospective cohort study of patients who underwent IB for limb-threatening ischemia at a single institution. Patient-related end points of interest included long-term mortality, 6-month readmission, and postoperative length of stay (LOS). Limb-related end points included major amputation (transfemoral, transtibial, or through the knee) and time to wound healing. Multivariable Cox, logistic, and robust regression were used to model time-to-event outcomes, readmission rates, and LOS respectively. Overall, 454 IB procedures that occurred over a 7-year period were analyzed. Demographics and baseline patient characteristics were similar between the infection and noninfection group, except congestive heart failure and diabetes were more common in the infection group. Presence of foot infection had no impact on mortality (HR, 0.72; P = .113). Statistically significant predictors of long-term mortality included increasing age, hypoalbuminemia, and congestive heart failure, whereas preoperative use of clopidogrel was protective (Table I). The presence of foot infection was an independent predictor of major ipsilateral amputation (HR, 1.86; P = .002). Other significant predictors of major amputation on multivariable analysis included history of statin administration, decreasing age, and low body mass index (Table I). In addition, foot infection was an independent predictor of prolonged LOS (mean LOS was 1.7 days longer in patients with vs those without infection; P < .001). Other independent predictors of prolonged LOS included intraoperative blood loss and reoperation in the index extremity; whereas, history of continuous preoperative aspirin use, normal renal function, and normal albumin levels were associated with decreased LOS (Table II). Readmission was influenced by the performance of a reoperation in the index extremity (OR, 2.57; P < .001) and history of diabetes (OR, 1.5; P = .023) but not the presence of foot infection (OR, 1.27; P = .192) There was a strong trend for prolonged wound healing time in patients with diabetes (HR, 1.57; P = .05), but not in those with foot infection (OR, 0.73; P = .36). Among patients requiring infrainguinal bypass for limb-threatening ischemia, infection was more common in patients with diabetes and was a significant predictor of major amputation and prolonged LOS. Infection was not predictive of mortality, wound healing time, or readmission. These findings lend additional support to the inclusion of infection in risk-stratification schemes for patients with limb-threatening ischemia, as recommended in the Society for Vascular Surgery WIfI Classification System, because of its adverse impacts on limb salvage.Table ISignificant predictors of mortality and major amputation among those undergoing infrainguinal bypassVariableHazard ratio95% Confidence intervalP valueMortality Age1.041.02-1.07<.001 Congestive heart failure2.061.26-3.36.004 Albumin0.610.45-0.82.001 Clopidogrel0.430.25-0.74.003Major amputation Infection1.861.25-2.78.002 Age0.960.93-0.99.025 Body mass index0.940.91-0.98.014 Statin1.921.14-3.24.014 Open table in a new tab Table IISignificant predictors of postoperative length of stay (LOS) among those undergoing infrainguinal bypass (IB)VariableCoefficient95% Confidence intervalP valueInfection1.660.76-2.55<.001Glomerular filtration rate−0.02−0.043 to −0.014<.001Aspirin−1.16−2.13 to −0.18.02Albumin−1.35−2.11 to −0.60<.001Redo-open1.360.49-2.24.02Operating room estimated blood loss0.0030.001-0.004<.001 Open table in a new tab

Aspirin for primary prevention of cardiovascular disease.

Although aspirin has a well-established role in preventing adverse events in patients with known cardiovascular disease (CVD), its benefit in patients without a history of CVD remains under scrutiny. Current data have provided insight into the risks of aspirin use, particularly bleeding, compared with its benefits in primary CVD prevention. Although aspirin is inexpensive and widely available, especially in developing countries, there is lack of evidence that the benefits outweigh the adverse events with continuous aspirin use in primary CVD prevention. Therefore, the decision to initiate aspirin therapy should be an individual clinical judgment that weighs the absolute benefit in reducing the risk of a first cardiovascular event against the absolute risk of major bleeding, and tailored to the patient’s CVD risk. This risk must be calculated, based on accurate and cost-benefit locally developed risk assessment tools, the most discriminating threshold be identified. Additionally, patients preferences should be taken into account when making the decision to initiate aspirin therapy in primary prevention of CVD or not. Physicians should continuously be trained to calculate their patients CVD risk, and concomitant strategies be emphasized.

Peri-operative cardiac protection for non-cardiac surgery.

Cardiovascular complications are an important cause of morbidity and mortality after non-cardiac surgery. Pre-operative identification of high-risk individuals and appropriate peri-operative management can reduce cardiovascular risk. It is important to continue chronic beta-blocker and statin therapy. Statins are relatively safe and peri-operative initiation may be beneficial in high-risk patients and those scheduled for vascular surgery. The pre-operative introduction of beta-blockers reduces myocardial injury but increases rates of stroke and mortality, possibly due to hypotension. They should only be considered in high-risk patients and the dose should be titrated to heart rate. Alpha-2 agonists may also contribute to hypotension. Aspirin continuation can increase the risk of major bleeding and offset the benefit of reduced myocardial risk. Contrary to the initial ENIGMA study, nitrous oxide does not seem to increase the risk of myocardial injury. Volatile anaesthetic agents and opioids have been shown to be cardioprotective in animal laboratory studies but these effects have, so far, not been conclusively reproduced clinically.