Dual Antiplatelet Group Research Articles

Meta-analysis on safety and efficacy of dual antiplatelet therapy combining with proton pump inhibitors for patients after percutaneous coronary intervention

Objective: To analyze the impact of dual antiplatelet (DAPT) therapy combining with or without proton pump inhibitors (PPI) on the main outcomes after percutaneous coronary intervention (PCI). Methods: The PubMed, EMBASE and Cochrane Library were searched for relevant literature and the references obtained from these sources were retrieved manually from inception till September 2017. Inclusion and exclusion criteria were established follow the Cochrane review standard. A total of 977 literatures were included, 193 duplicates were excluded, 74 reviews, case reports, letters and systematic reviews were excluded, 667 literatures were excluded after reading the title and abstract, 34 literatures were excluded due to non-randomized control studies and unrelated outcome indicators, and 9 literatures were finally included with a total of 16 589 patients. RevMan 5.3 software was used to compare the incidence of major adverse cardiovascular events (MACE), cardiogenic death, recurrent myocardial infarction, target vessel revascularization, all-cause death, stent thrombosis, stroke, gastrointestinal bleeding and gastrointestinal events in patients with DAPT combining with or without PPI after PCI. Results: MACE was observed in 8 out of the 9 included literatures, and the results showed that MACE occurred in 561 out of 6 282 patients receiving DAPT combining with PPI therapy and in 951 out of 9 632 patients using DAPT alone (OR=1.15, 95%CI 0.88-1.51, P>0.05). Cardiogenic death was observed in 7 out of the 9 included literatures, and the results showed that cardiogenic death occurred in 172 out of 6 453 patients receiving DAPT combining with PPI treatment and in 321 out of the 9 839 patients using DAPT alone (OR=0.97, 95%CI 0.80-1.18, P>0.05). Recurrent myocardial infarction was observed in 7 out of the 9 included literatures, the results showed 416 out of 6 282 cases in DAPT combining with PPI therapy group experienced recurrent myocardial infarction and 691 out of 9 632 cases in DAPT group experienced recurrent myocardial infarction (OR=1.01, 95%CI 0.89-1.16, P>0.05). Four out of 9 literatures observed revascularization. The results showed that revascularization was performed in 64 out of 2 173 patients receiving DAPT combining with PPI therapy and in 105 out of the 2 770 patients using DAPT alone (OR=1.33, 95%CI 0.55-3.24, P>0.05). All-cause death was observed in 7 out of the 9 included literatures, and the results showed that all-cause death occurred in 172 out of the 6 453 patients in DAPT combining with PPI therapy group and in 321 out of the 9 839 patients using DAPT alone (OR=0.97, 95%CI 0.80-1.18, P>0.05). Three out of the 9 included articles observed stent thrombosis, and the results showed that stent thrombosis occurred in 99 out of 2 997 patients receiving DAPT combining with PPI therapy and in 245 out of the 6 198 patients treated with DAPT (OR=1.07, 95%CI 0.83-1.37, P>0.05). Stroke was observed in 2 out of the 9 included literatures. The results showed that stroke occurred in 5 out of 2 019 patients receiving DAPT combining with PPI therapy, and in 4 out of the 2 033 patients treated with DAPT (OR=1.00, 95%CI 0.29-3.49, P>0.05). Gastrointestinal bleeding was observed in 6 out of the 9 included literatures. The results showed that gastrointestinal bleeding occurred in 26 out of 3 517 patients receiving DAPT combined with PPI therapy, and in 93 out of the 3 506 patients treated with DAPT, gastrointestinal bleeding was significantly lower in the DAPT combining with PPI group than DAPT alone group (OR=0.27, 95%CI 0.17-0.41, P<0.01). Gastrointestinal events were reported in 6 out of the 9 included articles. Similarly, gastrointestinal events were observed in 51 out of 3 517 patients receiving DAPT combined with PPI therapy, and in 190 out of the 3 506 patients treated with DAPT alone, the incidence of gastrointestinal events in the DAPT combined with PPI group was significantly lower than DAPT alone group (OR=0.24, 95%CI 0.14-0.42, P<0.01). Conclusions: The incidence of MACE, cardiogenic death, recurrent myocardial infarction, target vessel revascularization, all-cause death, stent thrombosis and stroke are not affected by DAPT combined with PPI therapy after PCI, while the incidence of gastrointestinal bleeding and gastrointestinal events could be reduced by adding PPI to DAPT in patients undergoing PCI.

Long-Term Antithrombotic Therapy after Venous Stent Placement

IntroductionChronic deep venous insufficiency (CVI) is a common disorder of the venous valves which can cause many debilitating symptoms including edema, pain, and skin changes. CVI may result from a primary non-thrombotic cause, such as May-Thurner syndrome (MTS) or extrinsic compression from a pelvic mass, or as the sequelae of an acute deep vein thrombosis (DVT). Endovascular interventions, including percutaneous transluminal angioplasty and venous stent placement, have been increasingly utilized as a minimally-invasive treatment option for CVI. In patients treated via endovascular therapy, stent restenosis is a significant area of clinical concern. However, there is a paucity of data on the optimal preventative long-term antithrombotic strategy. Current practice is highly variable and employs a combination of anticoagulation and antiplatelet agents, which borrows heavily from experience with venous thromboembolism and arterial stent management, respectively. This study examines the prescribing patterns and outcomes of various antithrombotic regimens after venous stent placement at a large academic medical center.MethodsPatients who received venous stents at our institution between January 1st, 2010 and December 31st, 2015 were eligible for the study. A retrospective review was performed to determine the antithrombotic regimens and the rates of stent restenosis and major bleeding within two years of stent placement. The relationship between these outcomes and antithrombotic regimens was analyzed via logistic regression. Additional logistic regression and linear regression models were used to evaluate the impact of indications and hypercoagulable risk factors on the selection of antithrombotic agents.ResultsA total of 151 patients were included in the study (Table 1). Antithrombotic regimens were variable: 58 patients (38%) received triple therapy (i.e., anticoagulation plus dual antiplatelet therapy), 25 (17%) received anticoagulation only, 21 (14%) received anticoagulation plus a single antiplatelet agent, 15 (10%) received dual antiplatelet therapy only, 10 (7%) received a single antiplatelet, and 22 (15%) received no antithrombotic therapy (Figure 1). Patients with acute DVTs with or without MTS were more frequently given multiple antithrombotic agents compared to those with extrinsic compression. The duration of antithrombotic therapy was also variable. When anticoagulation was prescribed (n = 104), 31% received indefinite therapy, followed by 22% for 6 months and 12% for 3 months. Patients with a history of prior DVTs or thrombophilia were more likely to be prescribed indefinite anticoagulation. Aspirin was most commonly prescribed for an indefinite duration (62 of 88 patients) while clopidogrel was most commonly prescribed for just 3 months (60 of 89 patients).Twenty-three patients (15%) developed stent restenosis. Triple antithrombotic therapy had significantly lower rates of stent restenosis compared to no antithrombotic therapy (OR = 0.05, p < 0.01), and was associated with lower rates of restenosis compared to anticoagulation alone (OR = 0.19, p = 0.07) and dual antiplatelet therapy (OR = 0.25, p = 0.09). Anticoagulation with a single antiplatelet agent also led to lower rates of stent restenosis when compared to no antithrombotic therapy (OR = 0.08, p = 0.04). Medication non-compliance and antiphospholipid antibody syndrome were identified as independent predictors of stent restenosis (OR = 8.84, p = 0.01 and OR = 7.11, p = 0.03, respectively). Major bleeding was observed in 11 patients (7%). Of note, there were no major bleeding events observed in the dual antiplatelet or single antiplatelet groups, which were thus excluded from the regression model. Among the remaining treatment groups, there was no significant difference in major bleeding rates.ConclusionsThis study emphasizes the considerable variability in the prescribing patterns of long-term antithrombotic therapy after venous stent placement. There appears to be benefit to antithrombotic therapy in preventing stent restenosis, particularly when anticoagulation is combined with antiplatelet agents. However, this may be counterbalanced by an increased risk of bleeding. Larger prospective trials are needed to evaluate the relative risks and benefits of each antithrombotic regimen, and ultimately determine the optimal management strategy, following venous stent placement. [Display omitted] DisclosuresDesai:Philips/Spectranetics: Other: consulting; Cook Medical: Other: consulting, Speakers Bureau; Boston Scientific: Other: consulting, Speakers Bureau; AngioDynamics: Other: consulting, Speakers Bureau; OptiMed: Other: consulting.

Effect of anticoagulant therapy for elderly patients with atrial fibrillation and stable coronary artery disease

Objective To evaluate the effect of different anticoagulant therapy regimens in patients with atrial fibrillation and stable coronary artery disease. Methods This was a retrospective cohort study.Patients with coronary artery disease and atrial fibrillation undergoing percutaneous coronary intervention(PCI)in our hospital from January 2014 to January 2017 were involved.Based on the anticoagulant regimen, all patients were divided into two groups: dual antiplatelet anticoagulant group(treated with aspirin and clopidogrel, as DT group), warfarin and one antiplatelet drug group(treated with warfarin and aspirin, or warfarin and clopidogrel, as WS group). We compared the safety(risk of bleeding)and efficacy(major adverse cardiac and cerebrovascular event)between groups after 12-month follow-up. Results 329 patients were included, with 173 males and mean age of(70.1±9.3)years.There were 82 patients in the DT group, and 247 patients in the WS group.Patients in the WS group were older, and with significantly higher rates of diabetes, higher levels of creatine kinase-MB(CK-MB)and thrombosis risk compared with WS group(all P 0.05). The rates of major adverse cardiacand cerebrovascular events(MACCE)were similar between groups(P>0.05), though there was a trend of increased risk of ischemic stroke in the DT group. Conclusions For patients with coronary artery disease and atrial fibrillation undergoing PCI, dual antiplatelet therapy is a safe and effective anticoagulant regimen.However, there is a trend of increased rate of ischemic stroke, which is needed to explore. Key words: Atrial fibrillation; Coronary artery disease; Anticoagulants

Clinical Evaluation of Role of Dual Antiplatelet Therapy on Bleeding after Dental Extraction.

Aims and Objectives:Altered platelet function and increased bleeding time (BT) can occur with antiplatelet therapy. This study was conducted to evaluate the need for stoppage of dual antiplatelet therapy in patients undergoing dental extractions.Materials and Methods:One hundred and fifty patients indicated for dental extraction were grouped as Group I: Consisted of 75 patients on dual antiplatelet therapy and Group II: Consisted of 75 patients who have discontinued antiplatelet therapy 1 week before dental extraction. BT of all the participants was recorded before extraction procedures. Under local anesthesia, single molar tooth indicated for simple extraction was done in both the groups. Suturing along with pressure pack was done after extraction. BT after extraction was statistically checked between the groups after 1 h and 24 h using Chi-square test with P < 0.05.Results:Postoperatively, none of the patients in both the groups showed active bleeding 1 h and 24 h. No bleeding was seen in 73 patients in Group I and 78 patients in Group II after 24 h.Conclusion:This study concluded that there is no significant difference in BT in both the groups. Antiplatelet monotherapy or even antiplatelet dual therapy needs no alteration or stopped before minor oral surgical procedures. Most of the postoperative bleeding can be easily controlled by local hemostatic measures.

Benefit of switching dual antiplatelet therapy after ACS on dual antiplatelet therapy adherence: A prespecified analysis of the TOPIC randomized study

The Timing Of Platelet Inhibition after acute Coronary Syndrome (TOPIC) trial showed that switching dual antiplatelet (DAPT) from aspirin plus a newer P2Y12 blocker (prasugrel or ticagrelor) to aspirin plus clopidogrel 1 month after an acute coronary syndrome (ACS) led to a reduction in bleeding complications with similar risk of ischemic recurrence. The objective of this prespecified analysis was to evaluate the impact of switching strategy on DAPT adherence. TOPIC study randomized patients admitted for an ACS without adverse event at 1 month on aspirin and a newer P2Y12 blocker, to aspirin and clopidogrel (switched DAPT) or continuation of their drug regimen (unchanged DAPT). Medical adherence to prescribed DAPT was assessed at 6 months and 1 year. Six hundred and forty-six patients were randomized and 645 analyzed, corresponding to 322 patients in the switched DAPT and 323 in the unchanged DAPT group. At 6 months and 1 year, the allocated DAPT regimen was significantly used more often in the switched group than in the unchanged DAPT group: 298 (92.5%) vs. 264 (81.7%) ( P < 0.01) at 6 months and 277 (87.7%) vs. and 242 (76.1%) ( P < 0.01) at 1 year. The reason for DAPT change was related to an adverse event in 66% of cases corresponding to an ischemic event in 17 patients (14.8%) and bleeding in 59 patients (51.3%) ( Fig. 1 ). In multivariable analysis, unchanged DAPT strategy and ischemic or bleeding events were significantly associated with non-adherence to prescribed DAPT ( Table 1 ). A switched DAPT was associated with significant improvement in the number of patients on prescribed DAPT at 6 months and 1 year following ACS. This improved adherence was related to reduction of side effects.

Dual Antiplatelet Therapy Is Associated With Coagulopathy Detectable by Thrombelastography in Acute Stroke.

Thrombelastography (TEG) provides a global, dynamic measure of coagulation. We examined the effect of antiplatelet (AP) medications on coagulation in patients with acute stroke as measured by TEG. We reviewed prospectively collected data on patients presenting with acute ischemic stroke (AIS) and spontaneous intracerebral hemorrhage (ICH) between 2009 and 2014. Patient demographics and baseline TEG values were compared among 4 different drug use groups: aspirin only, clopidogrel only, both aspirin and clopidogrel, and no AP. Multivariable regression models were conducted to compare the differences in TEG components. A total of 202 patients were included, 139 with AIS and 63 with ICH. Forty-eight (24%) patients were taking aspirin alone, 12 (6%) were taking clopidogrel, 16 (8%) dual AP, and 126 (62%) no AP. Dual AP use was associated with prolonged mean R (time to initiate clotting) of 5.5 minutes as compared to no AP use (4.6 minutes, P = .04). Additionally, mean maximal amplitude (MA; final clot strength) and angle (rate of clot formation) were decreased in the dual AP group (MA = 59.3 mm, angle = 57.8°) as compared to the no AP group (MA = 64.5 mm, angle = 64.5°; P = .04 and P = .01, respectively). Patients on single AP therapy (either aspirin or clopidogrel) did not differ from those on no AP therapy in any TEG parameters measured. Dual AP therapy is associated with a detectable coagulopathy which may have implications in the management of patients with AIS and hemorrhagic stroke. The effects of single AP therapy may not be demonstrated by TEG.

PS 02-07 Effects and cost-effectiveness analysis of Naoxintong capsule combined with dual antiplatelet therapy in patients with CYP2C19 loss-of-function gene mutant after PCI

Objective: To analyze the effect and cost-effectiveness of Chinese Traditional Medicine-Naoxintong capsule combined with standard dual antiplatelet therapy on patients with CYP2C19 loss-of-function gene mutant after PCI. Design and Method: 529 patients carried at least one loss-of-function (LOF) gene mutant (CYP2C19 *2 or *3) underwent selective PCI were divided into two groups: (1) Dual antiplatelet group (n = 271): patients received standard dual antiplatelet therapy. (2) Additional Naoxintong group (n = 258): patients received standard dual antiplatelet therapy in concomitant with Naoxintong capsule (3.2 g before PCI and 1.6 g TID for at least 6 months). We collected clinical data of all patients and followed up he major adverse cardiovascular events (MACE) scheduled in advance (include cardiac death, myocardial infarction, readmission because of unstable angina or progressive angina) and major bleeding events after PCI for 1 year. In addition, we analyze the cost (the sum of antiplatelet drugs cost, hospitalization expense caused by MACE and bleeding events) and cost-effectiveness of the two groups according to the principles of pharmacoeconomic. Results: The incidence of MACE in Dual antiplatelet group and Additional Naoxintong group was 22.5% and 11.2% respectively. The incidence of MACE was significantly lower in Additional Naoxintong group (P = 0.001). The incidence of major bleeding events between two groups was similar (P > 0.05). Cost-effectiveness analysis: the cost of Dual antiplatelet group and Additional Naoxintong group was 9585.1 yuan and 10216.5 yuan RMB and Cost-effectiveness ratio was 12448.2 and 11609.7 yuan RMB per case respectively. Additional Naoxintong group has lower cost-effectiveness ratio than Dual antiplatelet group. Conclusions: Naoxintong combined with dual antiplatelet therapy could lower down the recurrence of MACE in one year follow-up after PCI in patients carried CYP2C19 LOF allele, it is also a good cost-effective strategy.

Comparison of the perioperative complications among three prophylactic antiplatelet strategies in unruptured intracranial aneurysms treated by stent assisted coiling

Objective To compare the perioperative complications of prophylactic use of three antiplatelet strategies in unruptured intracranial aneurysms treated by stent assisted coiling. Methods A total of 203 consecutive patients were brought into this retrospective study including the following three groups: the loading group (n=54), with a loading dose of 300 mg to 600 mg clopidogrel at 2 h to 24h before the stenting; tirofiban group (n=50), a loading dosage of tirofiban (8 μg/kg/min over 3 min) followed by a 0.1μg/kg/min maintenance dosage; dual antiplatelet group (n=99), dual oral antiplatelet drugs (clopidogrel 75 mg+ aspirin 100 mg) pretreated for 3-5 days before the operation. Events of hemorrhage and thromboembolism were recorded and the complications were compared to assess the safety and efficacy of various antiplatelet strategies. Chi-square or Fisher exact tests were used for categorical variables. Results The hemorrhagic rates were 11.1% in loading group, 2.0% in dual antiplatelet group, and 0% in tirofiban group, respectively, while the thromboembolic rates were 7.4% in loading group, 4.0% in dual antiplatelet group, and 0% in tirofiban group, respectively. For total complications, significant difference (P 0.05). The hemorrhagic rate in loading group was significantly higher than that of the dual group (P=0.023) and tirofiban group (P=0.027), while there was no significant difference between tirofiban group and dual antiplatelet group (P>0.05). In subgroup analysis of the loading group, the postoperative thromboembolic rate was significantly higher in those exposed to low molecular weight heparin than those not (P=0.039) with no increase of hemorrhagic events (P>0.05). Conclusions When compared with the dual antiplatelet strategy, tirofiban strategy may be used as a new prophylactic protocol in unruptured intracranial aneurysms treated by stent assisted coiling. Those treated by low molecular weight heparin postoperatively after receiving dual antiplatelet therapy may increase the hemorrhagic risk, although there was a significant decrease in thromboembolic events postoperatively. Key words: Intracranial aneurysm; Thromboembolism; Platelet aggregation inhibitors; Stents

Discussion on the application of ABCD3-I score in preventing and treating transient ischemic attack

Objective To evaluate the efficacy and safety of aspirin monotherapy and aspirin combining with clopidogrel therapy in treating transient ischemic attack (TIA) according to different risk stratification. Methods A total of 122 TIA patients was divided into 2 groups: single resistance group (treated only by aspirin) and dual anti-platelet aggregation group (treated with aspirin and clopidogrel). According to Age, Blood pressure, Clinical features, Duration, and Diabetes plus Dual TIA (ABCD3-Ⅰ) score, they were further divided into low-risk, middle-risk and high-risk groups. The incidences of ischemic stroke and adverse events in each group were evaluated. Results After 3-week treatment, the incidence of ischemic stroke in low-risk groups was both 0, while it was 9/20 in middle-risk single resistance group, 2/19 in middle-risk dual anti-platelet aggregation group, 10/19 in high-risk single resistance group, and 3/20 in high-risk dual anti-platelet aggregation group. The differences among those groups were statistically significant ( P = 0.031, 0.019). The most common drug adverse reactions were nausea and acid regurgitation ( χ 2 = 0.000, P = 1.000). No obvious bleeding tendency or liver and kidney dysfunction was found. Conclusions ABCD3-Ⅰ score may be used as the safety evaluation index of anti-platelet drugs. The application of aspirin combining with clopidogrel may have an advantage over aspirin monotherapy in the prevention of ischemic stroke. DOI: 10.3969/j.issn.1672-6731.2015.01.011

Interaction of Panax quinquefolius Saponin and Dual Antiplatelets on Vascular Endothelial Function in Rats with Acute Myocardial Infarction.

The objective of this study is to investigate the interaction of Panax quinquefolius saponin (PQS) and dual antiplatelets (aspirin and clopidogrel) on antiplatelet activity and vascular endothelial function in rats with acute myocardial infarction (AMI). Forty-eight male SD rats were randomly designed into sham group, model group, dual antiplatelet group, and PQS plus dual antiplatelet group. AMI rats were induced by ligation of left anterior descending coronary artery (LAD) and dual antiplatelet agents and additional PQS to dual antiplatelets were intragastrically administered for 28 days, respectively. The ventricular cavity area and cardiac transverse area ratio in PQS + dual antiplatelet group showed a decreased tendency. PAgT(%) decreased significantly in both dual antiplatelet group and PQS + dual antiplatelet group. TXB2 concentration significantly decreased in dual antiplatelet and PQS + dual antiplatelet groups, whereas 6-keto-PGF1α concentration significantly increased in PQS + dual antiplatelet group. Rats in PQS + dual antiplatelet group demonstrated a significant decrease in plasma ET-1 concentration and an increase in serum NO concentration compared with dual antiplatelet group. The combination therapy of PQS and dual antiplatelets showed some beneficial effects on vascular endothelial function and ventricular remodeling in rats with AMI.

Reparative effects of panax quinquefolius saponin on gastric mucosal lesions induced by dual antiplatelet drugs in AMI model rats

We sought to evaluate the reparative effects of panax quinquefolius saponin (PQS) on gastric mucosal lesions induced by dual antiplatelet drugs. Sprague-Dawley (SD) rats (<italic>n</italic>=36) were randomly divided into two groups (<italic>n</italic>=12), the acute myocardial infarction (AMI) model group and the dual antiplatelet plus PQS group. The other 12 rats served as sham-operated controls. Infusing the rats after modelling for 28 days, we evaluated several factors. Blood plasma was collected to measure the content of serum gastrin (GAS), nitric oxide (NO), interleukin-1 beta (IL-1β), tumor necrosis factor alpha (TNFα), plasma motilin (MTL), and endothelin-1 (ET-1). We observed changes in histology and gastric mucosa ultrastructure. Compared with the AMI group, the gastric mucosa Guth and Whittle scores of the dual antiplatelet group increased significantly (<italic>P</italic><0.01). Compared with the dual antiplatelet group, the Guth and White scores of the dual antiplatelet plus PQS group significantly decreased (<italic>P</italic><0.01). Interestingly, the plasma MTL, serum IL-1β, and TNFα levels in the dual antiplatelet group improved compared with the AMI group (<italic>P</italic><0.05). However, ET-1 and GAS levels were reduced (<italic>P</italic><0.05). Compared with the dual antiplatelet group, the serum NO and GAS levels in the dual antiplatelet plus PQS group significantly increased (<italic>P</italic><0.05), and the plasma ET-1, MTL, serum IL-1β, and TNFα levels were reduced (<italic>P</italic><0.05). These results suggest that PQS has a certain reparative effect on gastric mucosa damage induced by dual antiplatelet drugs. The mechanism by which this occurs may be related to the promotion of GAS and NO protective factor formation, reduction of IL-1β and TNFα inflammatory factors, or the secretion of ET-1 and formation of MTL damage factors.

ASA failure

To assess whether adding clopidogrel to acetylsalicylic acid (ASA) has a long-term protective vascular effect in patients with lacunar stroke while taking ASA. Post hoc analysis of 838 patients with ASA failure and recent lacunar stroke from the Secondary Prevention of Small Subcortical Strokes Trial (SPS3) cohort randomly allocated to aspirin (325 mg/day) and clopidogrel (75 mg/day) or placebo. Primary efficacy outcome was stroke recurrence (ischemic and intracranial hemorrhage) and main safety outcome was major extracranial hemorrhage. Patients were followed for a mean period of 3.5 years. The ASA failure group had a significantly higher risk of vascular events including ischemic stroke when compared with the non-ASA failure group (n = 2,151) in SPS3 (p = 0.03). Mean age was 65.6 years and 65% were men. The risk of recurrent stroke was not reduced in the dual antiplatelet group, 3.1% per year, compared to the aspirin-only group, 3.3% per year (hazard ratio [HR] 0.91; 95% confidence interval [CI] 0.61-1.37). There was also no difference between groups for ischemic stroke (HR 0.90; 95% CI 0.59-1.38). The risk of gastrointestinal bleeding was higher in the dual antiplatelet group (HR 2.7; 95% CI 1.1-6.9); however, the risk of intracranial hemorrhage was not different. In patients with a recent lacunar stroke while taking ASA, the addition of clopidogrel did not result in reduction of vascular events vs continuing ASA only. This study provides Class I evidence that for patients with recent lacunar stroke while taking ASA, adding clopidogrel as compared to continuing ASA alone does not reduce the risk of recurrent stroke.

Clinical impact of dual antiplatelet therapy on peptic ulcer disease

Increased incidence of coronary artery disease has led to the increased use of dual antiplatelet therapy composed of aspirin and clopidogrel. We investigated the incidence of gastrointestinal complications in patients who received single or dual antiplatelet therapy and analyzed their clinical characteristics in order to predict the prognostic factors. Between January 2009 and December 2011, we retrospectively reviewed the medical records of patients who underwent coronary angiography at Chung-Ang University Hospital (Seoul, Korea). One hundred and ninety-four patients were classified into two groups: aspirin alone group and dual antiplatelet group. Clinical characteristics, past medical history, and presence of peptic ulcer were analyzed. During the follow-up period, 11 patients had duodenal ulcer; the event rate was 2.02% in the aspirin alone group and 9.47% in the dual antiplatelet group (hazard ratio [HR] 5.24, 95% CI 1.03-26.55, p<0.05). There was no significant difference in the rate of significant upper gastrointestinal bleeding: 0% vs. 4.2% (p=0.78). In patients who received proton pump inhibitor (PPI), 24 patients had gastric ulcer; the event rate was significantly different between the two groups: 4.87% vs. 22.98% (HR 3.40, 95% CI 1.02-11.27, p<0.05). Dual antiplatelet groups had a higher incidence of duodenal ulcers without significant bleeding compared with the aspirin alone group. In patients who received PPI, the dual antiplatelet therapy group had a higher incidence of gastric ulcers without significant bleeding compared with the aspirin alone group. Therefore, physicians must pay attention to high risk groups who receive dual antiplatelet therapy and aggressive diagnostic endoscopy should also be considered.

GW24-e3551 Repair effect of panax quinquefolius saponin on gastric mucosal lesion induced by aspirin combined with clopidogrel

Objectivesgastric mucosal lesion induced by dual antiplatelet (aspirin combined with clopidogrel) is an universal concern of the first and second prevention of Coronary heart disease. This study is to observe...

Thrombocytopenia, Dual Antiplatelet Therapy, and Heparin Bridging Strategy Increase Pocket Hematoma Complications in Patients Undergoing Cardiac Rhythm Device Implantation

BackgroundPocket hematoma is a troublesome complication associated with the implantation of cardiac implantable electronic devices (CIEDs). This study aims to determinate the risk factors of pocket hematoma complications in relation to different antithrombotic strategies and severity of thrombocytopenia in Chinese patients. MethodsWe conducted a retrospective study of 1093 consecutive patients undergoing implantation of CIEDs and divided them into 3 groups: no antithrombotic group (n = 512), continuing antiplatelet group (n = 477), and temporarily discontinuing warfarin with or without heparin bridging strategy (n = 104). ResultsA pocket hematoma developed in 40 patients (3.7%). The temporarily discontinuing warfarin group (7.7%) had a higher incidence of pocket hematoma than no oral antithrombotic group (2.1%) and continuing antiplatelet group (4.4%) (P = 0.012). The dual antiplatelet group (16.2%) and the heparin bridging strategy group (14.0%) had significantly higher incidence of pocket hematoma compared with the no antithrombotic group (2.1%; P < 0.001, both). Patients having aspirin or clopidogrel alone had low incidence of pocket hematoma (3.9% and 1.2%, respectively), similar to the no antithrombotic group (P = not significant). Multivariate analysis revealed that dual antiplatelet agents (P = 0.004), heparin bridging strategy (P < 0.001), and moderate to severe thrombocytopenia (P = 0.007) were independent predictors for pocket hematoma complications. ConclusionsThe use of dual antiplatelet agents, heparin bridging strategy, and the presence of moderate to severe thrombocytopenia significantly increased the risk of pocket hematoma complications in the periprocedural period of CIED implant. Aspirin or clopidogrel alone did not increase the risk of pocket hematoma complications.

EFFECTS OF DIFFERENT DOSES OF NAOXINTONG COMBINED WITH DUAL ANTIPLATELET THERAPY IN PATIENTS WITH CYTOCHROME P450 2C19*2 GENE MUTATION AFTER PERCUTANEOUS CORONARY INTERVENTION

ObjectivesOur prevenient study found that Buchang Naoxintong Capsules (BNC) showed obvious increase effect on the catalytic activities of drug metabolism CYP2C19 enzyme. BNC to clopidogrel can enhance the antiplatelet effect...

Dual antiplatelet therapy in patients with aspirin resistance following coronary artery bypass grafting: study protocol for a randomized controlled trial [NCT01159639

BackgroundCoronary artery disease remains the dominant cause of mortality in developed countries. While platelets have been recognized to play a pivotal role in atherothrombosis, the ideal antiplatelet regime after coronary artery surgery remains elusive.The evolution of CABG has presently moved beyond technical improvements to involve modulation of pharmacologic management designed to improve patient outcomes. The aim of this trial will be to test the hypothesis that the addition of clopidogrel to patients with documented postoperative aspirin resistance will reduce the incidence of major cardiovascular events.MethodsPatients scheduled for isolated coronary artery surgery will be eligible for the study. Patients in whom postoperative multiple electrode aggregometry documents aspirin resistance will be randomized into two groups. The control group will receive 300 mg of aspirin. The dual antiplatelet group will receive 75 mg of clopidogrel in addition to 300 mg of aspirin. Patients will be followed for 6 months. Major adverse cardiac and cerebrovascular events (death from any cause, myocardial infarction, stroke, hospitalization due to cardiovascular pathology) as well as bleeding events will be recorded.DiscussionThis will be the first trial that will specifically address the issue of dual antiplatelet therapy in patients undergoing coronary artery surgery who have been found to be aspirin resistant. In the event that the addition of clopidogrel proves to be beneficial in this subset of surgical patients, this study could significantly impact their future antiplatelet management.This randomized controlled trial has been registered at the ClinicalTrials.gov website (Identifier NCT01159639).

Dual Antithrombotic Therapy Increases Severe Bleeding Events in Patients With Stroke and Cardiovascular Disease

We sought to determine the incidence and severity of bleeding events in patients with stroke and cardiovascular diseases who were taking oral antithrombotic agents in Japan, where the incidence of hemorrhagic stroke is higher than in Western countries. A prospective, multicenter, observational study was conducted; 4009 patients who were taking oral antithrombotic agents for stroke and cardiovascular diseases were enrolled. The patients were classified into 4 groups according to their antithrombotic treatment: the single antiplatelet agent group (47.2%); the dual antiplatelet agent group (8.7%); the warfarin group (32.4%); and the warfarin plus antiplatelet agent group (11.7%). The primary end point was life-threatening or major bleeding according to the MATCH trial definition. During a median follow-up of 19 months, there were 57 life-threatening and 51 major bleeding events, including 31 intracranial hemorrhages. The annual incidence of the primary end point was 1.21% in the single antiplatelet agent group, 2.00% in the dual antiplatelet agent group, 2.06% in the warfarin group, and 3.56% in the warfarin plus antiplatelet agent group (P<0.001). After adjustment for baseline characteristics, adding an antiplatelet agent to warfarin increased the risk of the primary end point (relative risk=1.76; 95% CI, 1.05 to 2.95), and adding another antiplatelet agent to single antiplatelet agent therapy increased the secondary end point of any bleeding, including minor events (relative risk=1.37; 95% CI, 1.07 to 1.76). The incidence of bleeding events during antithrombotic therapy in Japan was similar to that reported for Western countries, although the trials used different study designs. Dual antithrombotic therapy was independently related to an increased risk of bleeding events.

A comparison of dual vs. triple antiplatelet therapy in patients with non-ST-segment elevation acute coronary syndrome: results of the ELISA-2 trial

To compare dual vs. triple antiplatelet pre-treatment in patients with non-ST-elevation acute coronary syndrome (NSTE ACS) who were planned for early catheterization. A total of 328 consecutive patients with NSTE ACS were included and were randomized to pre-treatment with dual (n = 166, aspirin, clopidogrel 600 mg) or triple antiplatelet therapy (n = 162, aspirin, clopidogrel 300 mg, and Tirofiban). The primary endpoint was enzymatic infarct size, defined as cumulative LDH release (LDHQ(48)). Initial TIMI flow of the culprit vessel was a pre-specified secondary endpoint. Angiography was performed in 98% of patients at a median of 23 h after admission. Enzymatic infarct size (median, 25-75%) was 166 (60-349) IU/L in the triple group compared with 193 (75-466) IU/L in the dual group (P = 0.2). Initial TIMI 3 flow of the culprit vessel was significantly more often observed after triple antiplatelet therapy (67 vs. 47%, P = 0.002). At 30 days follow-up, myocardial infarction (MI) occurred in 46% of patients in the triple antiplatelet group, compared with 57% in the dual antiplatelet group, P = 0.052. No significant difference in bleeding was present. This study showed that in patients with NSTE ACS, triple antiplatelet pre-treatment was associated with a non-significant reduction in enzymatic infarct size, a significantly better initial perfusion of the culprit vessel, and a trend towards a better survival without death or MI. Further, large-scale studies should be performed to find whether the beneficial trend in favour of triple antiplatelet pre-treatment can be reproduced.