Discontinuation Of Aspirin Research Articles

One-year clinical outcome of aspirin-free prasugrel monotherapy following stent implantation in patients with chronic coronary syndrome: insight from ASET-JAPAN study

Abstract Background Single antiplatelet therapy with a potent P2Y12 inhibitor without aspirin after coronary stent implantation may provide an adequate balance between ischemic and bleeding risks in selected patients. The 3-month follow-up of the Acetyl-Salicylic Elimination Trial (ASET)-Japan pilot study demonstrated the feasibility and safety of Prasugrel monotherapy without aspirin after successful percutaneous coronary intervention (PCI) in selected patients with chronic coronary syndrome (CCS). Purpose The current study aimed to evaluate the 1-year clinical outcome in the ASET-Japan. Methods The ASET-Japan pilot study was designed to demonstrate the feasibility and safety of the approved dose of prasugrel monotherapy in Japan without aspirin after optimal PCI with a platinum-chromium everolimus-eluting stent in CCS population. After successful procedure, all patients were treated with a locally approved maintenance dose of 3.75 mg/day of Prasugrel monotherapy up to 3-month. After 3-month, the choice of antiplatelet therapy was left to the discretion of the investigators. Patients were followed up to 1 year. The target lesion-related endpoint was a composite of cardiac death, spontaneous target-vessel myocardial infarction (MI) >48 h after the index PCI or clinical-driven target lesion revascularisation. Patient-Oriented Composite Endpoint (POCE) was defined as a composite of all cause mortality, any stroke, any MI and any revascularisation. Spontaneous MI was defined according to Forth universal definition. The event rate was estimated by the Kaplan-Meier method. The event was adjudicated by an independent clinical event committee. Results A total of 208 patients were enrolled in the study. The average anatomical SYNTAX score was 7.96 (±4.6). After procedure, prasugrel monotherapy was immediately initiated. After 3-month, Prasugrel monotherapy was continued in 88.6% up to 1-year. Aspirin monotherapy was prescribed to 10 patients (5.0%), while 6 patients (3.0%) were on DAPT at 1-year. All-cause mortality rate was 1.49%, with no occurrence of cardiovascular death. Revascularisation occurred in 4.0% (n=8) with no occurrence of TLR, while one patient (0.5%) underwent a clinical driven target vessel revascularisation. In summary, 7 out of 8 revascularisations were non-target vessel revascularisation (6 clinically-driven non-TVR). Spontaneous non TV-MI occured in 0.5% (n=1) of patients. There was no definite/probable stent thrombosis up to 1 year. The target lesion related endpoint rate at 1-year was 0%, whereas 1-year POCE rate was 7.0% (n=14). Conclusion Discontinuation of Aspirin and Prasugrel monotherapy at a low maintenance dose of 3.75 mg/day following an angiographically successful stent deployment was feasible and safe in selected patients with CCS and low SYNTAX score. This safety profile is confirmed at 1 year while the investigators, in their large majority and at their own discretion, had maintained the prasugrel treatment.

Impact of ticagrelor with or without aspirin on total and recurrent bleeding and ischemic events after percutaneous coronary intervention: A sub-study of the TWILIGHT trial.

In standard time-to-first event analysis, early aspirin discontinuation followed by ticagrelor monotherapy has been shown to reduce bleeding without increasing ischemic complications compared with ticagrelor plus aspirin after percutaneous coronary intervention (PCI). We evaluated whether these treatment effects are preserved when recurrent events are considered. In this TWILIGHT trial post hoc analysis, we assessed the effects of ticagrelor monotherapy on the total number of events that occurred over the 12-month follow-up among 7 119 high-risk patients randomized to aspirin or placebo in addition to ticagrelor at 3 months post-PCI if event-free and adherent to treatment. There were 391 patients with at least one Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding (primary endpoint). Of those, 28 (7.2%) had a recurrent event. The total number of BARC 2, 3, or 5 bleeding events were 148 in the ticagrelor monotherapy arm compared with 278 with ticagrelor plus aspirin arm (p<0.001). Among 272 patients with at least one key secondary ischemic endpoint (all-cause death, myocardial infarction, or stroke), 37 (13.6%) sustained a recurrent event. Total ischemic events were similar (155vs 159) in the two groups. Among selected high-risk patients who underwent PCI and completed 3 months of dual antiplatelet therapy followed by ticagrelor with or without aspirin, recurrent bleeding was less common than recurrent ischemic events over 12 months. Analysis of total events indicates that ticagrelor monotherapy continues to be more effective than ticagrelor plus aspirin in reducing bleeding without a signal of ischemic harm.

Placental growth factor at 24-28 weeks for aspirin discontinuation in pregnancies at high risk for preterm preeclampsia: Post hoc analysis of StopPRE trial.

This study aims to evaluate the safety of discontinuing aspirin treatment at 24-28 weeks in women at high risk after first-trimester combined screening for preeclampsia (PE) and normal placental growth factor (PlGF) levels at 24-28 weeks of gestation. This is a post hoc analysis of the StopPRE trial, conducted at nine Spanish maternity hospitals from September 2019 to September 2021. In the StopPRE trial, all high-risk single pregnancies identified during first-trimester screening for PE were treated with 150 mg of daily aspirin. Out of 1604 eligible women with a soluble fms-like tyrosine kinase-1 to PlGF ratio (sFlt-1/PlGF) ≤38 at 24-28 weeks, 968 were randomly assigned in a 1:1 ratio to either continue aspirin until 36 weeks (control group) or discontinue it (intervention group). In this secondary analysis, only women with PlGF ≥100 pg/mL at 24-28 weeks were included. As in the StopPRE trial, the non-inferiority margin was set at a 1.9% difference in preterm PE incidence between the groups. Among the 13 983 screened pregnant women, 1984 (14.2%) were deemed high-risk for preterm PE, of which 397 (20.0%) were ineligible, 636 declined participation, and 32 were excluded. Ultimately, 919 women with PlGF >100 pg/mL were randomized and included in this analysis. Preterm PE occurred in 0.9% of the intervention group (4 out of 465) and 1.5% of the control group (7 out of 454), indicating non-inferiority of aspirin discontinuation. There were no significant differences between the groups in adverse pregnancy outcomes before 37 weeks, at <34 weeks, or ≥37 weeks. Minor antepartum hemorrhage incidence was significantly lower in the intervention group (absolute difference, -5.96; 95% CI, -10.10 to -1.82). Discontinuation of aspirin treatment at 24-28 weeks in women with PlGF levels ≥100 pg/mL was non-inferior to continuing until 36 weeks for preventing preterm PE. However, these findings should be interpreted with caution, as they originate from a subanalysis of the StopPRE trial.

Placental Senescence and the Two-Stage Model of Preeclampsia.

In this review, we summarize how an increasingly stressed and aging placenta contributes to the maternal clinical signs of preeclampsia, a potentially lethal pregnancy complication. The pathophysiology of preeclampsia has been conceptualized in the two-stage model. Originally, highlighting the importance of poor placentation for early-onset preeclampsia, the revised two-stage model explains late-onset preeclampsia as well, which is often preceded by normal placentation. We discuss how cellular senescence in the placenta may fit with the framework of the revised two-stage model of preeclampsia pathophysiology and summarize potential cellular and molecular mechanisms, including effects on placental and maternal endothelial function. Cellular senescence may occur in response to inflammatory processes and oxidative, mitochondrial, or endoplasmic reticulum stress and chronic stress induce accelerated, premature placental senescence. In preeclampsia, both circulating and tissue-based senescence markers are present. We suggest that aspirin prophylaxis, commonly recommended from the first trimester onward for women at risk of preeclampsia, may affect placentation and possibly mechanisms of placental senescence, thus attenuating the risk of preeclampsia developing clinically. We propose that biomarkers of placental dysfunction and senescence may contribute to altered preventive strategies, including discontinuation of aspirin at week 24-28 depending on placenta-associated biomarker risk stratification.

Knowledge of Practicing Students and Dental Surgeons Regarding Anti- coagulation Therapy of Patients Undergoing Dental Extractions

Introduction: Dentists are still confused about whether to stop anticoagulants during extractions or to practice local hemostatic measures and closely monitor patients' international normalized ratios (INR) levels. Aims &amp; Objectives: To determine and analyze the level of knowledge of practicing students and dental surgeons regarding anticoagulation therapy of patients undergoing dental extractions. Place and Duration of Study: A descriptive cross-sectional study was conducted among dentists and dental students in a teaching dental hospital (Islamabad Dental Hospital) for 5 months between August to December 2021. Material &amp; Method: There were a total of 127 participants including BDS students, house officers, postgraduate trainees, and faculty members of all dental clinical departments who responded to the printed questionnaire. A convenience sampling technique was used to gather the data. After encoding, the data was input into SPSS version 22. For qualitative variables, mean and standard deviation were computed, whereas for quantitative variables, frequencies and percentages were determined., p.value? 0.05 was considered significant. The findings were displayed as tables, charts, and figures. Results: Out of 127 participants, 63.7% (n=81/127) were in favor of consultation with the patient's physician before dental extractions whereas 59% (n=75/127) considered discontinuation of aspirin seven days before extractions. Different international normalized ratio (INR) levels were considered for different medical conditions by 78.7% (n=100/127) while 49.6% (n=63/127) of the participants believed that warfarin should be replaced with low molecular weight heparin before dental extractions. 79% of participants knew the antidote of heparin. Postoperative clot formation was not checked by 25.2% (n=32/127), and 87.4% (n=111/127) gave both verbal and written instructions after dental extractions. Conclusion: It is concluded that there is a good level of awareness and implementation of guidance among dental practitioners. Further research and training programs are advised to enhance the knowledge among dental practitioners and to upgrade the standard protocols for treating patients with anticoagulation therapy.

Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 after percutaneous coronary intervention in patients with acute coronary syndromes (ULTIMATE-DAPT): a randomised, placebo-controlled, double-blind clinical trial

Following percutaneous coronary intervention with stent placement to treat acute coronary syndromes, international clinical guidelines generally recommend dual antiplatelet therapy with aspirin plus a P2Y12 receptor inhibitor for 12 months to prevent myocardial infarction and stent thrombosis. However, data on single antiplatelet therapy with a potent P2Y12 inhibitor earlier than 12 months after percutaneous coronary intervention for patients with an acute coronary syndrome are scarce. The aim of this trial was to assess whether the use of ticagrelor alone, compared with ticagrelor plus aspirin, could reduce the incidence of clinically relevant bleeding events without an accompanying increase in major adverse cardiovascular or cerebrovascular events (MACCE). In this randomised, placebo-controlled, double-blind clinical trial, patients aged 18 years or older with an acute coronary syndrome who completed the IVUS-ACS study and who had no major ischaemic or bleeding events after 1-month treatment with dual antiplatelet therapy were randomly assigned to receive oral ticagrelor (90 mg twice daily) plus oral aspirin (100 mg once daily) or oral ticagrelor (90 mg twice daily) plus a matching oral placebo, beginning 1 month and ending at 12 months after percutaneous coronary intervention (11 months in total). Recruitment took place at 58 centres in China, Italy, Pakistan, and the UK. Patients were required to remain event-free for 1 month on dual antiplatelet therapy following percutaneous coronary intervention with contemporary drug-eluting stents. Randomisation was done using a web-based system, stratified by acute coronary syndrome type, diabetes, IVUS-ACS randomisation, and site, using dynamic minimisation. The primary superiority endpoint was clinically relevant bleeding (Bleeding Academic Research Consortium [known as BARC] types 2, 3, or 5). The primary non-inferiority endpoint was MACCE (defined as the composite of cardiac death, myocardial infarction, ischaemic stroke, definite stent thrombosis, or clinically driven target vessel revascularisation), with an expected event rate of 6·2% in the ticagrelor plus aspirin group and an absolute non-inferiority margin of 2·5 percentage points between 1 month and 12 months after percutaneous coronary intervention. The two co-primary endpoints were tested sequentially; the primary superiority endpoint had to be met for hypothesis testing of the MACCE outcome to proceed. All principal analyses were assessed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT03971500, and is completed. Between Sept 21, 2019, and Oct 27, 2022, 3400 (97·0%) of the 3505 participants in the IVUS-ACS study were randomly assigned (1700 patients to ticagrelor plus aspirin and 1700 patients to ticagrelor plus placebo). 12-month follow-up was completed by 3399 (>99·9%) patients. Between month 1 and month 12 after percutaneous coronary intervention, clinically relevant bleeding occurred in 35 patients (2·1%) in the ticagrelor plus placebo group and in 78 patients (4·6%) in the ticagrelor plus aspirin group (hazard ratio [HR] 0·45 [95% CI 0·30 to 0·66]; p<0·0001). MACCE occurred in 61 patients (3·6%) in the ticagrelor plus placebo group and in 63 patients (3·7%) in the ticagrelor plus aspirin group (absolute difference -0·1% [95% CI -1·4% to 1·2%]; HR 0·98 [95% CI 0·69 to 1·39]; pnon-inferiority<0·0001, psuperiority=0·89). In patients with an acute coronary syndrome who had percutaneous coronary intervention with contemporary drug-eluting stents and remained event-free for 1 month on dual antiplatelet therapy, treatment with ticagrelor alone between month 1 and month 12 after the intervention resulted in a lower rate of clinically relevant bleeding and a similar rate of MACCE compared with ticagrelor plus aspirin. Along with the results from previous studies, these findings show that most patients in this population can benefit from superior clinical outcomes with aspirin discontinuation and maintenance on ticagrelor monotherapy after 1 month of dual antiplatelet therapy. The Chinese Society of Cardiology, the National Natural Scientific Foundation of China, and the Jiangsu Provincial & Nanjing Municipal Clinical Trial Project. For the Mandarin translation of the abstract see Supplementary Materials section.

Aspin: neurosurgical aspirin intervention prognostic study — perioperative continuation versus discontinuation of aspirin in lumbar spinal surgery, a randomized controlled, noninferiority trial

RationaleAspirin is typically discontinued in cranial and spinal surgery because of the increased risk of hemorrhagic complications, but comes together with the risk of resulting in an increase of cardiac and neurologic thrombotic perioperative events.ObjectiveThe aim of this study is to investigate the non-inferiority of perioperative continuation of aspirin patients undergoing low complex lumbar spinal surgery, compared with the current policy of perioperative discontinuation of aspirin.Study designA randomized controlled trial with two parallel groups of 277 cases (554 in total).Study populationPatients undergoing low complex lumbar spinal surgery and using aspirin. All patients are aged >18 years.InterventionPeri-operative continuation of aspirin.Study outcomesPrimary study outcome: composite of the following bleeding complications:Neurological deterioration as a result of hemorrhage in the surgical area with cauda and/or nerve root compression.Post-surgical anemia with hemoglobin level lower than 5 mmol/l, requiring transfusion.Subcutaneous hematoma leading to wound leakage and pain higher than NRS=7.Major and/or minor hemorrhage in any other body system according to the definition of the International Society on Thrombosis and Haemostasis bleeding scale.Secondary study outcomes:Each of the individual components of the primary outcomeAbsolute mean difference in operative blood loss between the study armsThrombo-embolic-related complications:Myocardial infarctionVenous thromboembolismStrokeArterial thromboembolismFurther study outcomesAnticoagulant treatment satisfaction by the Anti-Clot Treatment Scale (ACTS) and general health by the Patient-Reported Outcomes Measurement Information System (PROMIS Global-10) in the pre- and postoperative phase.Nature and extent of the burden and risks associated with participation, benefit, and group relatednessParticipation in this study imposes no additional risk to patients. Currently, there is no consensus on whether or not aspirin should be discontinued before cranial or spinal surgery. Currently, aspirin is typically discontinued in cranial and spinal surgery, because of a potential increased risk of hemorrhagic complication. An argument not based on a clinical trial. However, this policy might delay surgical procedures or carry the risk of resulting in an increase in cardiac and neurologic thrombotic perioperative events. It is unclear if the possibility of an increase in hemorrhage-related complications outweighs the risk of an increase in cardiac and neurologic thrombotic perioperative events.Furthermore, the Data Safety Monitoring Board (DSMB) will be asked for safety analysis by monitoring the study.There are no further disadvantages to participating in this study. Outcome measurements are recorded during admission and regular outpatient visits, and thus, do not require additional visits to the hospital.

808 Timing of aspirin discontinuation prior to delivery and risk of peripartum bleeding complications

808 Timing of aspirin discontinuation prior to delivery and risk of peripartum bleeding complications

Early in-hospital discontinuation of aspirin on the first post-procedural day after percutaneous coronary stent implantation in patients on direct oral anticoagulation.

Previous trials investigating antithrombotic therapy with a direct oral anticoagulant (DOAC) and a P2Y12 inhibitor after percutaneous coronary intervention (PCI), termed dual therapy, allowed a short period of triple therapy including a DOAC, a P2Y12 inhibitor, and aspirin. This study aimed to determine whether discontinuation of aspirin on the first post-procedural day is safe or causes ischemic events. Ischemic and bleeding events during hospitalization were investigated retrospectively in all patients treated with dual therapy (DOAC + P2Y12 inhibitor, designated as group 1) or triple therapy (DOAC + P2Y12 inhibitor+aspirin, designated as group 2) from day 1 after PCI at our center. Of 4,564 consecutive PCI procedures, 1,059 (23.2%) had an indication for OAC. Of these, 322 met the inclusion criteria for group 1 and 62 for group 2. Baseline characteristics, CHA2DS2-VASc and HAS-BLED scores showed no relevant differences between the two groups, and the main indication for DOAC therapy was atrial fibrillation in both groups. Approximately ¼ of patients were treated for acute coronary syndrome. The mean length of post-procedural hospitalization was 2.1 ± 2.5 and 2.2 ± 3.0 days in group 1 and 2, respectively (p = 0.305). One patient per group suffered a TIA (p = 0.297). There were no other ischemic events and no statistically significant differences in bleeding events. A subgroup analysis of cases hospitalized for ≥2 post-procedural days (group 1: 100 cases, mean 4.4 ± 3.4 days vs. group 2: 25 cases, mean 4.0 ± 4.1 days) confirmed these results. The initiation of dual therapy and thus discontinuation of aspirin on the first postprocedural day appears to be safe with respect to short-term ischemic events in a real-world population. Almost ¼ of patients undergoing PCI have an indication for OAC, highlighting the relevance of this issue.

Aspirin Discontinuation at 24 to 28 Weeks’ Gestation in Pregnancies at High Risk of Preterm Preeclampsia: A Randomized Clinical Trial

(JAMA. 2023;329:542–550) Globally, 70,000 maternal deaths and 500,000 fetal deaths each year can be attributed to preeclampsia, which affects roughly 2-4% of pregnancies. Diagnosis of preeclampsia falls into several categories depending on gestational age at diagnosis, with early-onset preeclampsia (delivery &lt;34 wk), preterm preeclampsia (delivery &lt;37 wk), and term preeclampsia (delivery at or past 37 wk). Many serious complications can be associated with a diagnosis of preeclampsia, including preterm birth, fetal growth restriction, placental abruption, seizures, and others, with earlier onset correlating with more severe complications. Previous research has identified aspirin as an effective way to reduce the incidence of preeclampsia in high-risk individuals, especially when treatment is initiated in the late first trimester or early second trimester.

Safety and Efficacy of Ticagrelor Monotherapy in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention: An Individual Patient Data Meta-Analysis of TWILIGHT and TICO Randomized Trials.

Dual antiplatelet therapy with a potent P2Y12 inhibitor coupled with aspirin for 1 year is the recommended treatment for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). As an alternative, monotherapy with a P2Y12 inhibitor after a short period of dual antiplatelet therapy has emerged as a bleeding reduction strategy. We pooled individual patient data from randomized trials that included patients with ACS undergoing PCI treated with an initial 3-month course of dual antiplatelet therapy followed by ticagrelor monotherapy versus continued ticagrelor plus aspirin. Patients sustaining a major ischemic or bleeding event in the first 3 months after PCI were excluded from analysis. The primary outcome was Bleeding Academic Research Consortium type 3 or 5 bleeding occurring between 3 and 12 months after index PCI. The key secondary end point was the composite of death, myocardial infarction, or stroke. Hazard ratios and 95% CIs were generated using Cox regression with a one-stage approach in the intention-to-treat population. The pooled cohort (n=7529) had a mean age of 62.8 years, 23.2% were female, and 55% presented with biomarker-positive ACS. Between 3 and 12 months, ticagrelor monotherapy significantly reduced Bleeding Academic Research Consortium 3 or 5 bleeding compared with ticagrelor plus aspirin (0.8% versus 2.1%; hazard ratio, 0.37 [95% CI, 0.24-0.56]; P<0.001). Rates of all-cause death, myocardial infarction, or stroke were not significantly different between groups (2.4% versus 2.7%; hazard ratio, 0.91 [95% CI, 0.68-1.21]; P=0.515). Findings were unchanged among patients presenting with biomarker-positive ACS. Among patients with ACS undergoing PCI who have completed a 3-month course of dual antiplatelet therapy, discontinuation of aspirin followed by ticagrelor monotherapy significantly reduced major bleeding without incremental ischemic risk compared with ticagrelor plus aspirin. URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42023449646.

Effect of aspirin, warfarin, and proton-pump inhibitors on performance of fecal immunochemical test in colorectal cancer screening: a systematic review and meta-analysis.

This study aims to investigate the impact of antithrombotic agents and proton-pump inhibitors (PPIs) on fecal immunochemical test (FIT). PubMed, EMBASE, Web of Science, Cochrane Central, and Google Scholar were searched from inception until September 3, 2023. Studies comparing the diagnostic performance of FIT between medicine users and non-users in average-risk colorectal cancer screening populations were included. Pooled sensitivity, specificity, and positive predictive values (PPVs) for advanced neoplasia (AN) of FIT were compared by reporting pooled odds ratios (ORs) with 95% confidence intervals (CIs) using a random-effects model. Twenty-two studies enrolling 5,572,367 individuals were included. For aspirin, pooled sensitivity and specificity for AN were 57.2% and 88.4% in users versus 60.2% and 93.2% in non-users; while pooled ORs were 1.49 (95% CI 0.89-2.48, P = 0.13) and 0.72 (95% CI 0.62-0.83, P < 0.001), respectively. In subgroup analysis, there was no difference in sensitivity and specificity between the two groups at the cutoff of 20μg Hb/g (P = 0.57 and 0.29, respectively) but a significantly lower specificity in users compared with non-users at lower cutoffs (P < 0.001). Moreover, a significantly lower PPVAN in users compared with non-users was observed after matching age and sex confounders (P = 0.001). Warfarin had no significant influence on PPVAN of FIT (P = 0.43). PPIs were associated with a significantly lower PPVAN in users (P < 0.001). Aspirin use was associated with lower specificity and PPV of FIT. Aspirin discontinuation before FIT to reduce false-positive results should be interpreted with caution given concerns about cardiovascular events. Increasing cutoff values of FIT in aspirin users may be another possible approach. Additionally, warfarin withdrawal before FIT is unnecessary but PPIs withdrawal before FIT is recommended to reduce false-positive results.

OC14.02: Mid‐trimester uterine artery Doppler for aspirin discontinuation in pregnancies at high risk for pre‐eclampsia: posthoc analysis of StopPRE trial

OC14.02: Mid‐trimester uterine artery Doppler for aspirin discontinuation in pregnancies at high risk for pre‐eclampsia: posthoc analysis of StopPRE trial

Is it Safe to Continue Aspirin in Patients Undergoing Percutaneous Nephrolithotomy?

To evaluate peri-operative outcomes in patients on chronic aspirin therapy undergoing percutaneous nephrolithotomy (PCNL), with and without discontinuation of aspirin. Anti-coagulation and anti-platelet therapy are contraindications for PCNL per American Urological Association guidelines due to bleeding risk. However, there is potentially increased cardiovascular risk with peri-procedural aspirin withdrawal. Patients on chronic aspirin undergoing PCNL between January 2014 and May 2019 were retrospectively reviewed and stratified by continued or discontinued aspirin >5days preoperatively. Hematologic complications, transfusions, and thrombotic complications were assessed with logistic regression model. Three hundred twenty-five patients on chronic aspirin therapy underwent PCNL-85 continued and 240 discontinued aspirin. There were no significant differences in hemoglobin change, estimated blood loss, transfusions, creatinine change, thrombotic complications, 30-days re-admissions, complications, or 30-day emergency department visits. Patients who continued aspirin had longer length of stay (1.6 vs 1.9days, P=.03). American Society of Anesthesiologists (ASA) score of 3 (OR 3.2, P=.02, 95% confidence intervals (CI) [1.2-8.4]), ASA score of 4 (OR 4.0, P=.02, 95% CI [1.2-13.1]), Black race, and previous smoking (OR 2.1, P=.02, 95% CI [1.1-3.9]) was associated with continued aspirin. Body mass index ≥30 was associated with aspirin discontinuation (OR 0.9, P=.004, 95% CI [0.9-1.0]). Increased postoperative hematologic complications were associated with additional anticoagulation medication (OR 2.9, P=.04, 95% CI [1.0-4.4]). Continued aspirin use did not increase in postoperative complications in patients undergoing PCNL. Patients who are on additional anticoagulation medication are at risk of hematologic complications.

Management and risk of postoperative bleeding in patients with low-dose antiplatelet aspirin medication during endoscopic endonasal surgery for pituitary adenomas.

To analyze the risk of postoperative bleeding following endoscopic endonasal transsphenoidal surgery (EETS) for treatment of pituitary adenomas (PA) in patients with short-term discontinuation of low-dose aspirin, if required for prevention of artherothrombotic disease (ATD). Patients with preoperative aspirin medication were identified in this single-center retrospective analysis of consecutive patients with PA, who underwent EETS between December 2008 and June 2022. Aspirin was discontinued perioperatively less than 2days, > 2 and < 4days, and > 4 and < 7days according to the assumed risk of perioperative ATD. For those patients, the rate of postoperative bleeding, which required surgery, was compared to patients without aspirin. Forty-five (14.8%) out of 304 patients underwent EETS with short-term perioperative aspirin discontinuation. Thirty-six (80%) patients discontinued aspirin < 2days, 6 (13.3%) patients > 2 and < 4days, and 3 patients (6.7%) > 4 but < 7days. Postoperative bleeding rate was not increased in patients with short-term perioperative aspirin discontinuation. One patient (0.3%) without perioperative aspirin medication underwent revision surgery for treatment of postoperative hemorrhage with suprasellar extension. Eight patients (2.6%) had postoperative epistaxis (1 patient (0.3%) with short-term discontinuation and 7 patients (2.3%) without aspirin). Patients with perioperative aspirin were significantly older (68.3 ± 8.6 vs. 57.9 ± 14.1; p < 0.01) and had a significantly lower rate of hormonally active tumors (11.1% vs. 25.1%; p < 0.05) compared to patients without aspirin. No differences were found for tumor characteristics (tumor extension, tumor volume, largest diameter) between both groups. Short-term discontinuation of low-dose aspirin was not associated with increased rate of postoperative bleeding in patients, who underwent EETS for treatment of PA.

Mid-trimester uterine artery Doppler for aspirin discontinuation in pregnancies at high risk for preterm pre-eclampsia: Post-hoc analysis of StopPRE trial.

To assess whether aspirin treatment can be discontinued in pregnancies with normal uterine artery pulsatility index (≤90th percentile) at 24-28 weeks. Post-hoc analysis of a clinical trial. Nine maternity hospitals in Spain. Pregnant individuals at high risk of pre-eclampsia at 11-13 weeks and normal uterine artery Doppler at 24-28 weeks. All participants received treatment with daily aspirin at a dose of 150 mg. Participants were randomly assigned, in a 1:1 ratio, either to continue aspirin treatment until 36 weeks (control group) or to discontinue aspirin treatment (intervention group), between September 2019 and September 2021. In this secondary analysis, women with a UtAPI >90th percentile at 24-28 weeks were excluded. The non-inferiority margin was set at a difference of 1.9% for the incidence of preterm pre-eclampsia. Incidence of preterm pre-eclampsia. Of the 1611 eligible women, 139 were excluded for UtAPI >90th percentile or if UtAPI was not available. Finally, 804 were included in this post-hoc analysis. Preterm pre-eclampsia occurred in three of 409 (0.7%) women in the aspirin discontinuation group and five of 395 (1.3%) women in the continuation group (-0.53; 95% CI -1.91 to 0.85), indicating non-inferiority of aspirin discontinuation. Discontinuing aspirin treatment at 24-28 weeks in women with a UtAPI ≤90th percentile was non-inferior to continuing aspirin treatment until 36 weeks for preventing preterm pre-eclampsia.

Aspirin Discontinuation at 24 to 28 Weeks’ Gestation in Pregnancies at High Risk of Preterm Preeclampsia: A Randomized Clinical Trial

ABSTRACT Preeclampsia affects up to 4% of pregnancies and is marked by the development of hypertension and proteinuria after 20 weeks of gestation. Complications associated with the disorder include preterm birth, fetal growth restriction, placental abruption, HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome, seizures, and other end organ damage. Aspirin has been shown to reduce the incidence of preterm preeclampsia by 62%. However, it can also lead to peripartum bleeding. Screening for preeclampsia in the first trimester (11 to 13 weeks' gestation) can help identify up to 60% of pregnant individuals who will develop preterm preeclampsia. If preeclampsia screening is conducted during this first trimester, aspirin can be initiated earlier and discontinued earlier to mitigate the risk of peripartum bleeding. In addition, increased soluble fms-like tyrosine kinase-1 to placental growth factor (sFlt-1:PlGF) ratio is associated with preeclampsia weeks before its clinical onset. An sFlt-1:PlGF of ≤38 has been shown to accurately exclude preeclampsia in pregnant individuals with suspected disease. The aim of this study was to compare the effect of discontinuing aspirin in pregnant individuals at 24 and 28 weeks' gestation with a normal sFlt-1:PlGF ratio of ≤38 against those who continued aspirin treatment until 36 weeks of gestation. This was an open-label, randomized, noninferiority trial conducted at 9 maternity hospitals in Spain. Included were adult individuals with singleton pregnancies who had live births, were found to be at high risk of preeclampsia at the first-trimester screening, and a normal sFlt-1:PlGF between 24 and 28 weeks of gestation. Participants were randomly assigned 1:1 to discontinue aspirin (intervention group) or continue aspirin treatment (control group). The primary outcome was delivery due to preterm preeclampsia (before 37 weeks' gestation). Noninferiority was met if the higher 95% confidence interval (CI) for the difference in the incidences of preterm preeclampsia between the 2 groups was &lt;1.9%. A total of 964 pregnant individuals, who were identified as high-risk for preterm preeclampsia and prescribed 150 mg of aspirin daily at bedtime, were eligible for the analysis. The rates of preterm preeclampsia in the intervention and control groups were 1.48% and 1.73%, respectively (absolute difference, −0.25% [95% CI, −1.86% to 1.36%]). In conclusion, the threshold for noninferiority was not met. In pregnant individuals at high risk of preeclampsia and a normal sFlt-1:PlGF ratio of ≤38, discontinuing aspirin at 24 to 28 weeks' gestation was noninferior to continuing aspirin until 36 weeks to prevent preterm preeclampsia.

Early Discontinuation of Aspirin Among Patients with Chronic Kidney Disease Undergoing Percutaneous Coronary Intervention with a Drug-Eluting Stent: A Meta-Analysis.

Conflicting evidence exists to support whether short duration of dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitor monotherapy reduces bleeding complications after coronary artery drug-eluting stent (DES) insertion, compared with standard 12-month DAPT, particularly among patients with CKD who are at increased risk of bleeding. A Medline search identified randomized trials comparing up to 3 months of DAPT followed by P2Y12 inhibitor monotherapy versus twelve months of DAPT after insertion of a DES for any indication. Trials were included if they reported ischemic or bleeding outcomes among patients with CKD. The primary outcome was a composite of all-cause mortality, cardiac or cerebrovascular events, stent thrombosis (MACE), and major or minor bleeding events. Secondary outcomes were the individual components of the primary outcome, and clinically significant bleeding. The relative risk (RR) was estimated using a random-effects model. Seven randomized trials were included for a total of 4,996 patients with CKD (14% of the trial population). Early discontinuation of aspirin was associated with a similar incidence of the primary outcome among patients with CKD compared with twelve-month DAPT (RR 0.97; 95% confidence interval (95% CI) 0.73-1.30). The relative risk of MACE was also similar between the two arms (RR 1.02; 95% CI 0.85-1.23). The risk of clinically significant bleeding was significantly lower with early discontinuation of aspirin (RR 0.60; 95% CI 0.46-0.78). P2Y12 inhibitor monotherapy after a shortened course of DAPT appears to be associated with a similar risk of ischemic events and a lower risk of bleeding events after DES insertion among patients with CKD compared to 12-month DAPT.

Aspirin deprescribing in patients on oral anticoagulation for atrial fibrillation or venous thromboembolism: A national survey of clinician practices

AbstractIntroductionConcomitant use of oral anticoagulation (OAC) and aspirin increases bleeding risk without decreasing thromboembolic events compared with OAC monotherapy. Weak guideline recommendations and limited data exist for deprescribing aspirin for primary prevention or stable coronary artery disease in patients already on OAC for atrial fibrillation (AF) or venous thromboembolism (VTE).ObjectivesThe objective of this study was to identify aspirin deprescribing practices among clinicians for patients on OAC for AF or VTE and concomitant aspirin for non‐compelling reasons.MethodsA cross‐sectional, national survey was electronically distributed to pharmacists and non‐pharmacists (physicians, nurse practitioners, physician assistants). Co‐primary end points were composite aspirin discontinuation rates in patients on OAC for AF or VTE in primary prevention and stable coronary artery disease (CAD) cases. Key secondary end points were clinician comfort level with deprescribing aspirin and availability of institutional protocols.ResultsThree hundred four responses were included: 212 (69.7%) pharmacists and 92 (30.3%) non‐pharmacists. Mean age of respondents was 35.4 years, and 37.4% male. In the primary prevention cases, pharmacists were more likely to discontinue aspirin than non‐pharmacists (76.7% vs. 54.6%, p &lt; 0.001). In the stable CAD cases, composite rates of aspirin discontinuation by pharmacists and non‐pharmacists were similar (41.7% vs. 40.1%, p = 0.140). More pharmacists than non‐pharmacists stated that their aspirin deprescribing decisions were independent of the type of OAC that was used (60.4% vs. 35.9%, p &lt; 0.001). Pharmacists were more likely to discontinue aspirin after discussing with patients compared with non‐pharmacists (62.7% vs. 47.8%, p = 0.017). 27.3% of clinicians reported having a protocol to deprescribe aspirin at their institution/clinic.ConclusionThere are variations in aspirin deprescribing practices among clinicians in patients on OAC for AF or VTE and without compelling indications for aspirin. Further studies and stronger recommendations are warranted to guide clinicians regarding optimal antithrombotic therapy in these scenarios. Lack of institutional protocols for aspirin deprescribing creates opportunities for future quality improvement initiatives.

Iron Deficiency Anemia and Ischemic Stroke in Premenopausal Women (P14-5.022)

<h3>Objective:</h3> We describe three young women with iron deficiency anemia who developed ischemic strokes in the absence of typical risk factors. <h3>Background:</h3> Ischemic stroke is the third leading cause of death in women. Women have unique risk factors for ischemic stroke. Iron deficiency anemia disproportionately affects premenopausal women and has previously been identified to be associated with ischemic stroke. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 39-year old woman with hypertension and menorrhagia presented with left leg weakness and dizziness. Labs revealed a hemoglobin of 5.9g/dL, a unremarkable hypercoagulable work up, transesophageal echo, urine toxicology, rheumatological evaluation, and MRA brain vessel wall imaging. An ultrasound of her uterus revealed a pelvic fibroid measuring 6.5cm and MRI brain revealed a small right anterior cerebral artery territory infarction. A 46-year-old woman with chronic iron deficiency anemia with a hemoglobin of 6.8g/dL who presented with left mild sided weakness and was found to have a right MCA M3 occlusion by CT angiography of the head. She received intravenous tenecteplase and underwent decompressive craniectomy for a right temporal infarct associated with cerebral edema seen on MRI brain. Investigations revealed a normal hemoglobin electrophoresis, urine toxicology, hypercoagulable evaluation, rheumatological evaluation and transesophageal echo. A 43 year old woman presented with diplopia secondary to a vertical gaze palsy. MRI brain revealed an infarct in the left thalamus, cerebral peduncle, and midbrain. Cerebral angiography, transesophageal echocardiogram, urine toxicology, rheumatological evaluation, and hypercoagulable work up were unremarkable. Hemoglobin was 7.2g/dL on presentation and an EGD revealed an antral and duodenal ulcer. All three patients received packed RBC transfusions, iron replacement therapy and discontinuation of aspirin until hemoglobin stabilized. <h3>Conclusions:</h3> Iron deficiency anemia may be an important yet under-recognized risk factor for acute ischemic stroke and should be treated aggressively in premenopausal women. Further studies are warranted. <b>Disclosure:</b> Dr. Imam has nothing to disclose. Dr. Salahuddin has nothing to disclose.