Discontinuation Of Aspirin Research Articles

Fetal pulmonary valvuloplasty for pulmonary atresia with intact ventricular septum: a single-center clinical experience.

Fetal pulmonary valvuloplasty for pulmonary atresia with intact ventricular septum: a single-center clinical experience.

Important Considerations of Low-Dose Aspirin in the Prevention of Preeclampsia

Low-dose prophylactic aspirin is widely recommended for pregnant women for the prevention of preeclampsia (PE). Although the efficacy of aspirin in preventing PE has been evaluated in many studies, due to the differences in dosage, initiation time, and screening methods for the identification of women at high risk of PE and the lack of a uniform opinion on the medication regimen of aspirin, currently in China there is no consensus on the standardized treatment scheme of aspirin for the prevention of PE in clinical guidelines. Herein, we reviewed the current available evidence and the recommendations of clinical guidelines concerning the controversies about aspirin dosage as well as the timing of starting and stopping aspirin, so as to provide further guidance for clinical practice. Based on the existing research findings on and clinical practice of using aspirin for PE prevention, we suggested that PE risk screening should be conducted at 11-13+6 weeks of gestation. In addition, the recommended dose for prophylactic use of aspirin for pregnant women at high risk of PE is 150 mg/d, and the recommended minimum effective dose is 100 mg/d. Pregnant women at high risk of PE should start taking low-dose aspirin orally before 16 weeks of pregnancy. Week 36 of gestation is considered the window of opportunity for discontinuation of low-dose aspirin.

Aspirin Discontinuation at 24 to 28 Weeks’ Gestation in Pregnancies at High Risk of Preterm Preeclampsia

Aspirin reduces the incidence of preterm preeclampsia by 62% in pregnant individuals at high risk of preeclampsia. However, aspirin might be associated with an increased risk of peripartum bleeding, which could be mitigated by discontinuing aspirin before term (37 weeks of gestation) and by an accurate selection of individuals at higher risk of preeclampsia in the first trimester of pregnancy. To determine whether aspirin discontinuation in pregnant individuals with normal soluble fms-like tyrosine kinase-1 to placental growth factor (sFlt-1:PlGF) ratio between 24 and 28 weeks of gestation was noninferior to aspirin continuation to prevent preterm preeclampsia. Multicenter, open-label, randomized, phase 3, noninferiority trial conducted in 9 maternity hospitals across Spain. Pregnant individuals (n = 968) at high risk of preeclampsia during the first-trimester screening and an sFlt-1:PlGF ratio of 38 or less at 24 to 28 weeks of gestation were recruited between August 20, 2019, and September 15, 2021; of those, 936 were analyzed (intervention: n = 473; control: n = 463). Follow-up was until delivery for all participants. Enrolled patients were randomly assigned in a 1:1 ratio to aspirin discontinuation (intervention group) or aspirin continuation until 36 weeks of gestation (control group). Noninferiority was met if the higher 95% CI for the difference in preterm preeclampsia incidences between groups was less than 1.9%. Among the 936 participants, the mean (SD) age was 32.4 (5.8) years; 3.4% were Black and 93% were White. The incidence of preterm preeclampsia was 1.48% (7/473) in the intervention group and 1.73% (8/463) in the control group (absolute difference, -0.25% [95% CI, -1.86% to 1.36%]), indicating noninferiority. Aspirin discontinuation at 24 to 28 weeks of gestation was noninferior to aspirin continuation for preventing preterm preeclampsia in pregnant individuals at high risk of preeclampsia and a normal sFlt-1:PlGF ratio. ClinicalTrials.gov Identifier: NCT03741179 and ClinicalTrialsRegister.eu Identifier: 2018-000811-26.

Association Between CKD and Major Hemorrhage in Older Persons: Data From the Aspirin in Reducing Events in the Elderly Randomized Trial

Data on the association between chronic kidney disease (CKD) and major hemorrhage in older adults are lacking. We used data from a double-blind randomized controlled trial of aspirin in persons aged≥ 70 years with prospective capture of bleeding events, including hemorrhagic stroke and clinically significant bleeding. CKD was defined as an estimated glomerular filtration rate (eGFR)< 60 ml/min per 1.73 m2 and/or urinary albumin-to-creatinine ratio (UACR)≥ 3 mg/mmol (26.6 mg/g). We compared bleeding rates in those with and without CKD, undertook multivariable analyses, and explored effect modification with aspirin. Of 19,114 participants, 17,976 (94.0%) had CKD status recorded, of whom 4952 (27.5%) had CKD. Participants with CKD had an increased rate of major bleeding events compared with those without CKD (10.4/1000 vs. 6.3/1000 person-years [py], respectively) and increased bleeding risk (risk ratio [RR] 1.60; 95% confidence interval [CI]: 1.40, 1.90 for eGFR< 60 ml/min per 1.73 m2) and RR (2.10; 95% CI: 1.70, 2.50) for albuminuria. In adjusted analyses, CKD was associated with a 35% increased risk of bleeding (hazard ratio [HR] 1.37; 95% CI: 1.15, 1.62; P< 0.001). Other risk factors were older age, hypertension, smoking, and aspirin use. There was no differential effect of aspirin on bleeding by CKD status (test of interaction P= 0.65). CKD is independently associated with an increased risk of major hemorrhage in older adults. Increased awareness of modifiable risk factors such as discontinuation of unnecessary aspirin, blood pressure control, and smoking cessation in this group is warranted.

Abstract 14192: Effect of Aspirin Dosing in Patients Treated With P2Y12 Inhibitors for Secondary Prevention of Cardiovascular Events

Background: The ADAPTABLE was a pragmatic randomized controlled trial that found no difference between high dose vs low dose aspirin for secondary prevention of ischemic or bleeding events. Whether concomitant P2Y12 inhibitor therapy modifies the effect of aspirin dose on clinical events remains unclear. Methods: Participants in ADAPTABLE were stratified according to baseline use of clopidogrel or prasugrel (P2Y12 group). Ticagrelor was not permitted due to a black box warning with high dose aspirin. The primary effectiveness endpoint was a composite of myocardial infarction, stroke, or death and the primary safety endpoint was hospitalization for major bleeding. We used multivariable Cox regression to compare the relative effectiveness and safety of aspirin dose within P2Y12 and non-P2Y12 groups. Results: Of the 13,815 (91.6%) participants with available data, 3,051 (22.1%) were on a P2Y12 inhibitor at baseline (clopidogrel: 93.4%; prasugrel: 6.6%). P2Y12 inhibitor use was associated with higher risk of the primary effectiveness endpoint (10.86% vs. 6.31%; adjusted HR 1.44 95% CI 1.22-1.62) but was not associated with bleeding (0.53% vs. 0.95%; adjusted HR:1.42; 95% CI 0.91, 2.22). We found no interaction in the relative effectiveness and safety of high vs. low dose aspirin by P2Y12 inhibitor use (Table, P interaction 0.09 and 0.73 for primary effectiveness and safety endpoint, respectively). Aspirin dose switching and discontinuation occurred in 28.6% of patients. Although this was more common in high dose vs. low dose aspirin, the above rates did not differ between the P2Y12 and non-P2Y12 groups. Conclusion: In this pre-specified subgroup analysis of a large, pragmatic trial, we found that the relative effectiveness and safety of high dose vs. low dose aspirin was not modified by baseline use of P2Y12 inhibitors. Decisions regarding aspirin dosing should be individualized based on clinical factors and patient preference, regardless of P2Y12 inhibitor use.

Early Discontinuation of Aspirin Among Patients With CKD Undergoing Percutaneous Coronary Intervention With a Drug Eluting Stent: A Meta-Analysis

Early Discontinuation of Aspirin Among Patients With CKD Undergoing Percutaneous Coronary Intervention With a Drug Eluting Stent: A Meta-Analysis

Early in-hospital discontinuation of aspirin following coronary stent implantation in patients with indication for direct oral anticoagulation

Abstract Background and purpose 5–10% of patients undergoing percutaneous coronary intervention (PCI) have an indication for oral anticoagulation (OAC). Triple therapy, i.e. anticoagulation plus dual antiplatelet therapy, is associated with a high bleeding rate. Discontinuation of aspirin while continuing direct OAC (DOAC) and a P2Y12 inhibitor (so-called dual therapy) after PCI, was investigated in four randomized trials demonstrating a reduction in bleeding without significant differences in ischemic events. Since randomization was performed several days after the index PCI, these trials allowed for a short period of triple therapy. Whether exclusive procedural application of aspirin and early discontinuation of aspirin at the first postprocedural day is safe, is unknown and was the scope of this work. Methods and results We retrospectively analysed 3613 patients (4564 PCIs) treated from 2017 to 2020 at our centre. 871 (24.1%) patients (1059 PCIs, 23.2%) had an indication for OAC. In 284 PCIs with stenting, patients received DOAC (71.8% Rivaroxaban, 25.7% Apixaban, 1.8% Dabigatran, 0.7% Edoxaban) + P2Y12 inhibitor (100% clopidogrel) + aspirin only at the day of procedure (group 1). In 52 PCIs with stenting, patients received DOAC (59.6% Rivaroxaban, 34.6% Apixaban, 1.9% Dabigatran, 3.9% Edoxaban) + P2Y12 inhibitor (100% clopidogrel) + 100 mg aspirin/d at ≥1 postprocedural day (group 2). Based on our local patient database, we analysed the rate of ischemic events (myocardial infarction, stent thrombosis, stroke/transient ischemic attack (TIA), pulmonary/systemic embolism (PE/SE), deep vein thrombosis) as well as major and minor bleeding according to the Thrombolysis in Myocardial Infarction (TIMI) criteria during hospitalisation. Data are presented as mean±standard deviation or median (range). Baseline characteristics were similar (group 1 vs. group 2: 74.3% vs. 73.1% male, age 75.9±8.5 vs. 74.3±9.3 years, atrial fibrillation 91.2% vs. 88.5%), except previous PE (3.5% vs. 11.5%; p=0.024), type of preprocedural DOAC (Rivaroxaban 52.5% vs. 34.6%; p=0.023) and creatinine clearance (62.4±19.7 vs. 68.9±20.3 ml/min; p=0.029). Median duration of postprocedural hospitalisation was 1 day for both groups (0–20 days vs. 1–21 days). In both groups, one TIA occurred (p=0.292), there were no other ischemic events. 36 (12.7%) bleeding events occurred in group 1 and 11 (21.2%) in group 2 (p=0.126). A subgroup analysis of cases being hospitalised for ≥2 postprocedural days (group 1: 87 cases, median 4 (2–20) days; group 2: 20 cases, median 2 (2–21) days) found no ischemic events and no difference regarding bleeding events (34.5% vs. 45.0%; p=0.443). Conclusions Exclusive procedural application of aspirin and start of dual therapy at the first postprocedural day appears safe regarding ischemic events in a real-world population. Nearly ¼ of patients undergoing PCI had an indication for OAC, which is much more frequent than previously reported. Funding Acknowledgement Type of funding sources: None.

Effect of aspirin discontinuation according to individualised patient bleeding and ischemic risks after PCI: a TWILIGHT trial sub-analysis

Abstract Background The TWILIGHT trial demonstrated a reduction in BARC 2, 3 or 5 (BARC-235) bleeding without an increase in ischemic events at 1-year in high-risk PCI patients randomized to placebo or aspirin (ASA) on a background of ticagrelor 3-months after PCI. However, the effect of ASA discontinuation according to baseline risk of bleeding and ischemic events remain unclear. Purpose To a) develop separate models to predict the risk of bleeding and ischemic events, and b) to assess treatment effect of ASA discontinuation across the risk strata. Methods Using the TWILIGHT patient database (N=7,119), two multivariable models, one for BARC-235 bleeding and one for CV death, nonfatal MI or nonfatal ischemic stroke (ischemic endpoint) were developed, and their predictive capacity was assessed. The effect of randomized treatment on bleeding and ischemic events across different patient risk-group categories as determined by the risk scores was investigated. Results At 1-year, 350 (5.4%) patients experienced a BARC-235 bleeding event and 258 (3.6%) experienced an ischemic event. Independent predictors of BARC-235 included haemoglobin levels at index PCI, proton-pump inhibitor non-use at discharge, age, liver disease and active smoking (c-statistic 0.64). Independent predictors of the ischemic outcome included a positive troponin ACS, prior CABG, diabetes, age, peripheral artery disease, prior PCI, a history of congestive heart failure, active smoking, the level of index PCI complexity, and prior MI (c-statistic 0.71). The risk of a BARC-235 almost doubled between patients in lower versus higher bleeding risk categories (4.3% versus 7.9%) and ischemic risk more than tripled between patients in lower versus higher ischemic risk categories (2.0% versus 7.0%) (see Figure 1). There was no evidence of a differential treatment effect for dual antiplatelet therapy versus ticagrelor monotherapy across the different risk categories of bleeding (interaction P=0.54) and ischemic risk (interaction P=0.95) (Table 1). Conclusion Individual patient bleeding and ischemic risks after PCI can both be readily characterised with good discrimination. The effect of ASA discontinuation in preventing bleeding in ticagrelor-treated patients was consistent regardless of baseline bleeding risk. There was no evidence for increased ischemic events with ASA discontinuation according to baseline ischemic risk. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZenecaIcahn School of Medicine at Mount Sinai

Restarting Antiplatelet Agents After Intracerebral Haemorrhage: A Reassurance To Physicians.

Intracerebral haemorrhage (ICH) is the second most common cause of stroke (after ischemic stroke) across the world and has significantly higher morbidity and mortality as compared to ischemic stroke and subarachnoid haemorrhage.1 Spontaneous (atraumatic) ICH occurs in up to 31 people per 100,000 globally and the incidence is even higher in Asian countries like Pakistan.2 Most patients experiencing spontaneous ICH have a history of occlusive vascular diseases like myocardial infarction (MI) and are consequently taking antithrombotic therapy (antiplatelets, anticoagulants) at the time of ICH occurrence. Antithrombotic therapy is usually halted for a certain period following ICH but data on the safety of therapy resumption is sparse and physicians largely use clinical judgment to weigh the benefit of therapy resumption against the risk of ICH recurrence. A randomized controlled trial called RESTART was published in The Lancet in 2019 to assess if restarting the ‘antiplatelet therapy only’ increased the risk of recurrent ICH. The trial suggested a slightly increased, but nonsignificant, risk of recurrent ICH but the results were limited by a short duration of follow-up. In the latter half of 2021, the extended follow-up of the RESTART trial was published in one of the most reputed Neurology journals i.e., JAMA Neurology.3 The trial recruited 537 participants with radiologically confirmed ICH and randomly allocated half patients to restart antiplatelets (aspirin, clopidogrel) and half patients to avoid antiplatelets. The primary outcome was the recurrent ICH events during the follow-up time of up to 7 years (mean time = 3 years). Recurrent ICH occurred in 22/268 (8.2%) participants assigned to antiplatelet therapy compared with 25/268 (9.3%) participants assigned to avoid antiplatelet therapy (adjusted HR=0.87; 95% CI, 0.49-1.55; p-value = .64). This suggests that re-starting antiplatelet therapy indicated for other occlusive vascular diseases (e.g., MI, ischemic stroke) is safe in patients who suffer from ICH while they are on antiplatelet therapy. This conclusion is in line with some observational studies4,5 published on the same topic but RESTART remains the only clinical trial to provide credible evidence. The exact incidence of ICH is not known in Pakistan but trends from Asian countries suggest a higher occurrence as compared to the Western world.1 The primary reason for such high occurrence is the predisposition of the elderly population to cardiovascular risk factors like hypertension and obesity. Pakistan suffers from a very high burden of coronary artery disease and a significant number of elderly people are on preventive antiplatelet therapy (especially aspirin). Discontinuation of aspirin after an ICH episode in such patients may lead to an increased risk of MI and studies also suggest that survivors of ICH are more likely to suffer from MI and ischemic stroke.6 This trial provides reasonable reassurance to the medical community about the use of antiplatelet therapy after ICH if indicated for secondary prevention of major vascular events. Therefore, the dissemination of this information to physicians practising in Pakistan is of paramount importance.

The Cost of Breaking Even: a Perspective on the Net Clinical Impact of Adding Aspirin to Antithrombotic Therapies in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention.

Outcomes from randomized controlled trials (RCTs) inform the latest recommendations on percutaneous coronary intervention (PCI) management of a short period of oral anticoagulation (OAC), a P2Y12 receptor inhibitor, and aspirin for 1week or until hospital discharge in patients with atrial fibrillation (AF) undergoing PCI, and up to 4weeks in individuals considered to be at high-risk for ischemic events, followed by discontinuation of aspirin and continuation of OAC and a P2Y12 inhibitor for up to 12months. We examined and summarized the outcomes of bleeding and major adverse cardiac events (MACEs) from RCTs and meta-analyses, published between 2013 and 2022, comparing therapy with OAC and a P2Y12 inhibitor with and without aspirin in AF patients undergoing PCI with stenting. Data comparing dual therapy with OAC and a P2Y12 inhibitor alone to triple therapy with OAC, a P2Y12 inhibitor, and aspirin with respect to the risks of MACEs, including stent thrombosis within the first 30days, are underpowered and inconclusive. The addition of aspirin does not appear to be associated with a decreased risk of ischemic events, even in patients with high-risk CHA2DS2-VASc scores, but does significantly increase bleeding hazards. The increased safety of newer generation drug-eluting stents may have further minimized any theoretical anti-ischemic benefits of aspirin. The possible attenuation of the pleiotropic effects of concomitant cardiovascular medications by aspirin may also have been a contributing factor. The addition of aspirin to OAC and a P2Y12 inhibitor is likely associated with a net clinical harm in patients with AF who undergo PCI with stenting, even within the first 1-4weeks after PCI. Revisiting the guideline recommendations to administer aspirin in this timeframe may be warranted.

MO122: Bleeding Complications after Allograft Kidney Biopsy and Role of Antiplatelet Therapy

Abstract BACKGROUND AND AIMS Percutaneous biopsy is an important tool for monitoring renal allograft and early diagnosis when dysfunction occurs. Bleeding is the most dangerous adverse event, even if it is rare (risk of 0.5%). Cardiovascular (CV) disease affects 2/3 of elderly with CKD and antiplatelet therapy is taken for primary and secondary prevention of CV events. A systematic review on aspirin discontinuation among 50 279 patients at risk for coronary disease shows a 3-fold risk of adverse CV event. The aim of this study is to compare bleeding complications of antiplatelet administration within 5 days from renal biopsy versus absence of therapy. METHOD We conducted a 10-year (2010–2020) single-centre retrospective study on 285 consecutive ultrasound assisted percutaneous allograft kidney biopsy. We collected information about demographic, laboratory (eGFR, platelets, haemoglobin pre/post biopsy, proteinuria) data, biopsy indication (elective/urgent), clinical presentation [acute kidney injury (AKI)/nephrotic syndrome], needle gauge, use of antiplatelet or anticoagulant, diagnosis and complications (categorized as minor and major, according to the need for intervention). We divided patients in two groups: antiplatelet therapy within 5 days versus therapy discontinuation or absence. Bivariate logistic regression was used to analyse possible risk factors associated with complications. RESULTS Among the 285 patients: 173 patients received antiplatelet agents (low-dose aspirin in &amp;gt;90% of cases) within 5 days from biopsy and 112 patients were not on antiplatelet therapy. Diastolic hypertension, AKI and proteinuria were statistically greater in the group without antiplatelet therapy. Histologic diagnoses were evenly present in the two groups, and no differences were observed in the rate of complications. Major complications were diagnosed in 0/112 patients without antiplatelet therapy and 1/173 patients with therapy within 5 days. Minor complications were documented in 14/112 and in 15/173 patients, respectively. There were no statistically significant differences in terms of complications between antiplatelet therapy within 5 days and absence of therapy (Table 1). Furthermore, there were no differences between taking antiplatelet within 48 h or stopping it within 48 h of the procedure (Table 2). No deaths were attributed to procedure and all events occurred within 24 h from biopsy, irrespective of their severity. The univariate logistic regression model (dependent variable: major complication) documented a lower BMI as a significant risk factor; indeed, this was not confirmed at multivariate regression. The analysis did not find a significant difference between 16-G and 18-G biopsy needle in terms of major/minor complications; however, the use of the latter was associated with a significant lower number of glomeruli in the sample. CONCLUSION Our study suggests that the use of antiplatelet agents within 5 days from procedure does not increase the bleeding risk, so it should be safe to continue the therapy in patients at risk for CV events. However, this is a weak evidence that needs prospective studies to be validated. Our data also suggest that 16-G biopsy needle may be safely used to obtain enough tissue for histologic diagnosis.

Impact of pharmacist intervention to deprescribe inappropriate aspirin therapy in an outpatient anticoagulation clinic at a community hospital

Study objectiveThis study describes a pharmacist-led process to identify and discontinue inappropriate aspirin in patients receiving concomitant anticoagulant therapy and to evaluate the effectiveness of the intervention. SettingThe study took place in an outpatient anticoagulation clinic within a small community hospital. ParticipantsPatients ≥40 years old on indefinite anticoagulation therapy for atrial fibrillation and/or venous thromboembolism were included. DesignThis is a quality improvement initiative. InterventionsUtilizing the electronic medical record and patient interview, use and indication for daily aspirin therapy was confirmed. Prospectively collected patient demographics and past medical history were used to determine appropriateness of aspirin therapy. For patients identified as receiving inappropriate aspirin therapy, a fax was sent to the referring provider recommending aspirin discontinuation. Main outcome measuresTo assess the effectiveness of the intervention, outcomes were retrospectively measured. The primary outcome was the percentage of “accepted” recommendations. Secondary outcomes included the prevalence, dosing, and indications for aspirin therapy. ResultsEighty (33 %) of 242 patients were on aspirin. Fifty-two patients with atrial fibrillation and/or venous thromboembolism were assessed and aspirin was deemed inappropriate in 22 patients. The provider agreed with deprescribing aspirin therapy in 45 %. The most common dose and indication of aspirin therapy was 81 mg (98 %) and primary prevention (40 %) respectively. ConclusionsIn our small practice, pharmacist-led interventions were an effective means to recommend aspirin discontinuation in our identified patients. Further studies are needed to optimize a pharmacist's role and address the long-term effects of deprescription.

Effects of ticagrelor monotherapy vs. clopidogrel monotherapy on platelet reactivity: a randomized, crossover clinical study (SINGLE study)

Increasing clinical trials demonstrated that the discontinuation of aspirin while maintaining a P2Y12 inhibitor monotherapy could decrease the risk of bleeding without losing the antithrombotic effect. However, no data are available on the platelet reactivity of patients undergoing ticagrelor monotherapy vs. clopidogrel. Therefore, we performed this study to observe the efficacy of ticagrelor monotherapy vs. clopidogrel in Chinese patients with chronic coronary syndrome. This randomized, single-blinded, crossover trial enrolled 50 patients who were administered with ticagrelor (90 mg twice daily for 2 weeks) or clopidogrel (75 mg once daily for 2 weeks). Followed by a 2-week washout period, the two groups of patients underwent a crossover trial. Light transmission aggregometry (LTA) and thromboelastography (TEG) assays were used to test platelet reactivity. The platelet aggregation rate (PAgR) of ADP and AA was significantly lower with ticagrelor than clopidogrel (PAgR of ADP, 27.30% (7.30%-42.635%) vs. 35.55% (12.03%-69.25%), P = .0254; PAgR of AA, 77.80% (21.60%-86.43%) vs. 83.10% (67.13%-87.20%), P = .0400). There was no significant difference in PAgR of collagen and epinephrine between the two groups. The TEG assay showed that ADP and AA, which induced the inhibition of platelet aggregation, were significantly higher in the ticagrelor group than those in the clopidogrel group [ADP%, 69.00% (59.68%–88.95%) vs. 60.55% (35.98%–78.35%), P = .0020; AA%, 53.65% (22.75%–79.28%) vs. 15.15% (5.75%–70.25%), P = .0127]. High on-treatment platelet reactivity (HTPR) on ADP was 2.17% with ticagrelor and 19.57% with clopidogrel. HTPR on AA was 50.00% with ticagrelor and 69.57% with clopidogrel. Ticagrelor and clopidogrel caused the inhibition of ADP and AA-induced platelet aggregation. Moreover, ticagrelor monotherapy had a stronger inhibitory effect than clopidogrel monotherapy (except on collagen and epinephrine).

Antiplatelet Therapy in Patients Undergoing Elective Percutaneous Coronary Intervention.

The evidence for use of dual antiplatelet therapy (DAPT) for patients undergoing percutaneous coronary intervention (PCI) in the elective setting is relatively sparse and is based on data from more than two decades ago. We will review the evidence supporting the use of DAPT with focus on stable patients undergoing elective PCI, including the role of potent P2Y12 inhibitors, modified DAPT durations, and more recently, aspirin discontinuation. Clopidogrel is the recommended P2Y12 inhibitor in the elective PCI setting. The benefit of more potent P2Y12 inhibitorssuch as ticagrelor or prasugrel in stable patients is unproven, but their use might be reasonable in those with high clinical or angiographic features of increased ischemic risk without increased risk of bleeding. Moreover, extending DAPT beyond 12months is associated with a reduction in ischemic events but also increased bleeding. In contrast, shortening DAPT (3-6months) reduces bleeding compared with 1year of treatment, but it is also probably associated with increased ischemic events, mainly in higher-risk patients undergoing complex PCI. Recently, early aspirin discontinuation at 3months (and perhaps as early as 1month) following PCI reduces bleeding, with no evidence to suggest an increase in ischemic events. Clopidogrel is the P2Y12 inhibitor of choice, whilemore data are required to support the use of more potent P2Y12 inhibitors in stable patients. The duration of DAPT should be tailored to individual patient ischemic and bleeding risks. New strategies, such as early aspirin discontinuation, are promising to reduce bleeding risk without increase in ischemic risk.

Impact of the Dual Antiplatelet Therapy Score on Clinical Outcomes in Acute Coronary Syndrome Patients Receiving P2Y12 Inhibitor Monotherapy.

BackgroundDual antiplatelet therapy (DAPT) score is used to stratify ischemic and bleeding risk for antiplatelet therapy after percutaneous coronary intervention (PCI). This study assessed the association between the DAPT score and clinical outcomes in acute coronary syndrome (ACS) patients who were treated with P2Y12 inhibitor monotherapy.MethodsA total of 498 ACS patients, with early aspirin discontinuation for various reasons and who received P2Y12 inhibitor monotherapy after PCI, were enrolled during the period from January 1, 2014 to December 31, 2018. The efficacy and safety between those with low (<2) and high (≥2) DAPT scores were compared during a 12-month follow-up after PCI. Inverse probability of treatment weighting was used to balance the covariates between the two groups. The primary endpoint was a composite outcome of all-cause mortality, recurrent ACS or unplanned revascularization, and stroke within 12 months. The safety endpoint was major bleeding, defined as Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding.ResultsThe primary composite endpoint occurred in 11.56 and 14.38% of the low and high DAPT score groups, respectively. Although there was no significant difference in the primary composite endpoint between the two groups in the multivariate Cox proportional hazards models, the risk of recurrent ACS or unplanned revascularization was significantly higher in the high DAPT score group (adjusted hazard ratio [HR]: 1.900, 95% confidence interval [CI]: 1.095–3.295). The safety outcome for BARC 3 or 5 bleeding was similar between the two groups.ConclusionsOur results indicate that ACS patients receiving P2Y12 monotherapy with high DAPT score had an increased risk of recurrent ACS or unplanned revascularization.

Impact of aspirin discontinuation on thrombotic complications in laparoscopic colorectal cancer surgery.

The number of patients taking antiplatelet therapy is increasing. However, there is no definitive guideline for the perioperative management of antiplatelet therapy. Conventionally, the discontinuation of antiplatelet drugs has been the basic treatment as perioperative management. Therefore, we investigated the risk of discontinuing aspirin concerning thrombotic complications in laparoscopic colorectal cancer surgery. Between January 2015 and December 2019, a total of 729 patients underwent laparoscopic colorectal cancer surgery in Toyonaka Municipal Hospital. Sixty-four patients taking antithrombotic drugs aside from aspirin were excluded from this study; the remaining 665 patients were considered eligible and divided into three groups. The patients not taking aspirin were classified as the "Control group" (n = 588). Among the patients taking aspirin, those who continued preoperative aspirin were classified as the "Aspirin group" (n = 30), and those who discontinued preoperative aspirin were classified as the "No-aspirin group" (n = 47). The Aspirin, No-aspirin, and Control groups were compared retrospectively. Among the 3 groups, there were no significant difference in operative time (p = 0.14), bleeding volume (p = 0.63), or postoperative hospital stay (p = 0.06). Assessing the postoperative complication, bleeding complications were significantly more frequent in the Aspirin group (p < 0.01), although those complications were all Clavien-Dindo grade II. In contrast, thrombotic complications were significantly more frequent in the No-aspirin group (p < 0.01). Note that those complications were all Clavien-Dindo Grade III/IV. This result suggested that discontinuing aspirin increased the risk of severe thrombotic complication. Discontinuation of aspirin as perioperative management in laparoscopic colorectal cancer surgery increased the risk of severe thrombotic complications.

Potential Impact of the 2019 ACC/AHA Guidelines on the Primary Prevention of Cardiovascular Disease Recommendations on the Inappropriate Routine Use of Aspirin and Aspirin Use Without a Recommended Indication for Primary Prevention of Cardiovascular Disease in Cardiology Practices: Insights From the NCDR PINNACLE Registry.

Aspirin is recommended in patients with atherosclerotic cardiovascular disease for secondary prevention. In patients without atherosclerotic cardiovascular disease and not at high 10-year risk, there is no evidence aspirin reduces adverse cardiovascular events and it could increase bleeding. The 2019 American College of Cardiology/American Heart Association Guidelines on Primary Prevention of Cardiovascular Disease state that aspirin may be considered for primary prevention (class IIb) in patients 40 to 70 years that are at higher risk of atherosclerotic cardiovascular disease and that routine use of aspirin should be avoided (class III:Harm) for patients >70 years. We examined the frequency of patients on aspirin for primary prevention that would have been considered unindicated or potentially harmful per the recent guideline where aspirin discontinuation may be beneficial. To assess the potential impact, within the National Cardiovascular Disease Registry Practice Innovation and Clinical Excellence Registry, we assessed 855 366 patients from 400 practices with encounters between January 1, 2018 and March 31, 2019, that were receiving aspirin for primary prevention. We defined inappropriate use as the use of aspirin in patients <40 or >70 years and use without a recommended indication as use of aspirin in patients 40 to 70 years with low, borderline, or intermediate 10-year atherosclerotic cardiovascular disease risk. Frequency of inappropriate use and use without a recommended indication were calculated and practice-level variation was evaluated using the median rate ratio. Inappropriate use occurred in 27.6% (193 674/701 975) and use without a recommended indication in 26.0% (31 810/122 507) with significant practice-level variation in inappropriate use (predicted median practice-level rate 33.5%, interquartile range, 24.1% to 40.8%; median rate ratio, 1.71 [95% CI, 1.67-1.76]). Immediately before the 2019 American College of Cardiology/American Heart Association Guidelines on Primary Prevention of Cardiovascular Disease, over one-fourth of patients in this national registry were receiving aspirin for primary prevention inappropriately or without a recommended indication with significant practice-level variation. These findings help to determine the potential impact of guideline recommendations on contemporary use of aspirin for primary prevention.

Knowledge and Practice of Dentists Managing Patients on Antithrombotic Medications: A Cross-Sectional Survey.

In this article, we explored the level of knowledge and practice of licensed dentists in the United Arab Emirates regarding managing patients on antithrombotic medications. Moreover, to assess the need for educational intervention in this area is one of the objectives. A total of 502 dentists answered 22 close-ended questionnaires. The sample size was determined based on the registry of the Ministry of Health. Only 5.6 and 5.9% showed satisfactory overall awareness about aspirin and plavix, respectively, as drugs may hamper hemostasis. A substantial proportion of dentists consider aspirin (63.1%) and clopidogrel (52.2%) discontinuation before treatment. More than one-third of the participants shall not consider extracting teeth before physician approval, and one-quarter to one-third of them refer patients on such medications to oral surgeons to perform tooth extraction. Most respondents did not adequately answer the questions about the additional hemostatic measures and postoperative analgesia. A significantly high number of participants (n = 440, 87.6%) want to attend updated courses on the dental management of such patients. The dentists demonstrate a contrasting diversity of knowledge and practice approaches to patient management on antiplatelet agents. There is an apparent demand to raise understanding of the evidence-based management of a patient on such medications. It is vital to keep formalized training sessions and provide the necessary expertise to students and dentists to prevent unwanted complications.

Risks and benefits of continuation and discontinuation of aspirin in elective craniotomies and transsphenoidal surgeries: a systematic review and meta-analysis

Risks and benefits of continuation and discontinuation of aspirin in elective craniotomies and transsphenoidal surgeries: a systematic review and meta-analysis

Perioperative effect of acetylsalicylic acid stoppage duration before coronary artery bypass grafting

ObjectiveTo assess the effect of timing of preoperative cessation of aspirin therapy on perioperative morbidity and mortality in patients undergoing coronary artery bypass graft (CABG) surgery.BackgroundAspirin is used for primary or secondary prevention of thrombotic complications. It inhibits platelet function and so there is an increased risk of hemorrhage among patients undergoing CABG. Aspirin discontinuation time before CABG surgery has been a controversy for years. We aimed at assessing the effect of timing of preoperative cessation of aspirin therapy on perioperative morbidity and mortality in patients undergoing CABG surgery.Patients and methodsSixty patients having coronary artery disease and indicated for CABG surgery were included. Patients were randomly allocated into two groups: group A (32 patients) patients received 100 mg (enteric coated aspirin)/day till the day of surgery and group B (28 patients) patients received aspirin 100 mg daily until 5 days before surgery. We followed postoperative hemodynamics, morbidity, and mortality for 30 days after surgery.ResultsGroup A had significantly lesser ICU stay, duration of inotropic support, and duration of mechanical ventilation than the other group. However, the need of intraoperative and postoperative blood transfusion, reopening for bleeding, postoperative myocardial infarction, and 30 days mortality were similar between the two groups.ConclusionsLate use of aspirin till the day of surgery in small doses was associated with less ICU stay and earlier weaning from mechanical ventilation and was not associated with increased risk of bleeding, increased need for blood transfusion nor increased rates of reoperation for bleeding. Hence, we can conclude that late aspirin use is recommended especially in high-risk patients