Management Of Dual Antiplatelet Therapy Research Articles

Validation of prediction tools for GI bleeding in patients on dual anti-platelet therapy after percutaneous coronary intervention

Background & AimsThe management of dual anti-platelet therapy (DAPT) after percutaneous coronary intervention (PCI) and gastrointestinal bleeding (GIB) remains a clinical dilemma. We sought to identify predictors of a GIB and a rebleed and to determine whether a rebleed increases the risk of major adverse cardiovascular events (MACE). MethodsIn this single-center retrospective study, patients undergoing PCI were identified. The primary and secondary endpoints were a GIB at 180 days, and a rebleed or MACE at 365 days. Logistic regression was used to identify predictors of GIB and rebleed. Cox Proportional Hazard modeling was used to determine whether rebleed can predict MACE. ResultsA total of 536 patients were included. On multivariable analysis, PCI for acute coronary syndrome was associated with 95% increased odds of GIB, p < 0.001. The P2Y12 inhibitor was continued in > 90% of patients, which trended towards significance for a rebleed, p < 0.10. The HAS-BLED score, including a labile INR and prior major bleeding, were strongly associated with a rebleed, p ≤ 0.009. A rebleed was associated with a 115% increased risk of MACE, p = 0.02. We derived a novel risk score, named the SIGE score, to predict a rebleed at 365 days with a high predictive accuracy, AUC 0.773 (95% CI: 0.702 – 0.845). ConclusionThe SIGE score may help to predict rebleeding, which was shown to be associated with an increased risk of MACE. Further external validation is needed.

Perioperative cangrelor in patients with recent percutaneous coronary intervention undergoing liver transplantation: A case series.

Management of dual antiplatelet therapy (DAPT) in the perioperative setting is challenging, particularly in complex patient populations, such as those with underlying coagulopathy and/or recent percutaneous coronary interventions. In this case series, we describe the perioperative use of cangrelor bridge therapy in two patients undergoing liver transplantation after recent coronary drug-eluting stent placement. In both patient cases, cangrelor use as a P2Y12 bridge at a dose of 0.75μg/kg/min was safe and effective. Both patients were successfully switched back to their oral DAPT regimen post-operatively without additive bleeding or thrombotic complications. The use of cangrelor as bridge therapy in high-risk perioperative liver transplant patients appears to be a viable option when DAPT is warranted.

Clinical practice guidelines for management of dual antiplatelet therapy in patients with noncardiac surgery: A critical appraisal using the AGREE II instrument.

Despite the availability of clinical practice guidelines (CPGs), there are considerable differences in their recommendations in the perioperative management of stented patients who need elective noncardiac surgery. Our aim was to systematically review the quality of CPGs for perioperative management of dual antiplatelet therapy (DAPT) and summarize the recommendations. A systematic search for perioperative DAPT guidelines was conducted on PubMed, Embase and websites of guideline organizations and professional societies until 4 February 2021. Independently, two assessors appraised the quality of CPGs using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument and extracted the data. Recommendations were summarized, and a comparative study was conducted to analyse the consistency among guidelines. A total of 10guidelines fulfilled our inclusion criteria. The domain of scope and purpose and clarity of presentation obtained the highest median scores, while the domain of stakeholder involvement and rigour of development obtained the lowest median scores. Three guidelines (ACCP, ESC/ESA and ACC/AHA) with a score of at least 60% in most AGREE II domains were recommended. Recommendations across perioperative management of DAPT guidelines were inconsistent. The ACCP, ESC/ESA and ACC/AHA CPGs were recommended. There is a need for high-quality prospective studies assessing different management strategies on this issue. Given the lack of consensus, the results of this study will help to guide perioperative dual antiplatelet management strategies for patients with coronary stents who are undergoing noncardiac surgery.

Abstract 1122‐000043: Vorapaxar as An Alternative for Ticagrelor Resistance in Neuroendovascular Intervention

Introduction : Perioperative dual‐antiplatelet therapy (DAPT) for flow diversion (FD) limits thromboembolic complications. Practice of DAPT varies across the neuroendovascular field but typically includes aspirin and an ADP receptor antagonist such as clopidogrel, prasugrel, or ticagrelor. Unfortunately, resistance to DAPT medications remains a concern for neuroendovascular intervention, and there is a current lack of standard alternatives for such resistance. The main goal of this abstract is to discuss ticagrelor resistance and to inform possible therapeutic options. Methods : We report a case of vorapaxar treated FD for an intracranial aneurysm in a patient with ticagrelor resistance. FD was deployed for a left internal carotid artery (ICA) blister aneurysm and bilateral ICA dissecting pseudoaneurysms (Figure 1). We also provide a narrative review on previous reports of ticagrelor resistance and associated treatment responses. We used the keywords: “ticagrelor,” “resistance,” “hypo‐response,” “stent thrombosis,” and “aneurysm.” These were implemented in various combinations with Boolean operators in three databases: PubMed, Ovid MEDLINE, and Ovid EMBASE. Results : During a complicated clinical course, the patient had three thromboembolic complications while on DAPT with ticagrelor or prasugrel leading to transition of antiplatelet therapy to vorapaxar. Thromboelastography with platelet mapping (TEG‐PM) routinely demonstrated inadequate platelet inhibition, which was confirmed with platelet function analyzer‐100. Initial TEG‐PM results were 0.0% ADP receptor inhibition and MA‐ADP of 62.2 mm. Repeat angiograms also indicated thromboembolic formation after each of the three events (Figure 1). After introduction of vorapaxar, the patient had adequate platelet inhibition with TEG‐PM results of 49.1% ADP receptor inhibition and MA‐ADP of 48.3 mm. At 84 days follow‐up, the patient was fully recovered with complete occlusion of the aneurysms. In a narrative review of the literature, there were ten previously reported cases of ticagrelor resistance or hypo‐response: three cases in the neuroendovascular literature and seven cases in the cardiovascular literature. Among all of the cases, there was a variability in protocol for treating patients with suggested ticagrelor resistance. All three neuroendovascular cases either employed another ADP receptor antagonist in hopes that the resistance would not generalize or eliminated DAPT altogether and settled for aspirin alone. In some of the cardiovascular cases, ticagrelor was even continued after patients exhibited laboratory evidence of resistance or hypo‐response. Conclusions : Given the paucity of cases describing ticagrelor resistance or hypo‐response in the neuroendovascular and cardiovascular literature, management of DAPT should remain a multifactorial decision depending on the clinical situation. Moreover, we need to consider therapeutic alternatives for cases of resistance such as thrombin receptor antagonists, specifically PAR1 receptor antagonists like vorapaxar. High quality randomized controlled trials are needed to elucidate the safety and efficacy of vorapaxar in neuroendovascular procedures.

Optimal dual antiplatelet therapy strategy in elderly patients with acute coronary syndrome.

One out of three hospitalizations for acute coronary syndrome (ACS) involve nowadays elderly patients, carrying together a significant burden of comorbidities and a higher risk of complications. In particular, both ischemic and haemorrhagic risk are markedly enhanced in advanced age, and strictly interconnected, challenging the management of dual antiplatelet therapy (DAPT) in these patients. The recent development of several therapeutic options in terms of duration and combination of antiplatelet agents have offered a wider spectrum of opportunities for a more individualized approach in the management of DAPT after an ACS, although the criteria for the selection of the most appropriate strategy in each patient still lack validation. In particular, dose-adjustment, early aspirin discontinuation, laboratory-driven tailoring and shorter or extended DAPT have been addressed with promising safety and efficacy results. The present review provides an updated overview on the emerging evidencefrom randomized clinical trials and subanalyses dedicated to the management of DAPT in elderly patients presenting with ACS.

Low hemoglobin predicts high-platelet reactivity and major cardiovascular ischemic events at long-term follow-up among ACS patients receiving dual antiplatelet therapy with ticagrelor.

Reduced levels of hemoglobin (Hb) represent an established marker of impaired outcomes and increased cardiovascular risk in patients with coronary artery disease, challenging the management of dual antiplatelet therapy (DAPT). However, while anemia has emerged as an independent predictor of suboptimal platelet inhibition in patients receiving clopidogrel, no study has so far evaluated the impact of Hb levels on high-on treatment platelet reactivity (HRPR) with ticagrelor and their prognostic consequences, that were the aim of the present study. Patients on DAPT with ASA + Ticagrelor (90 mg/twice a day) after percutaneous coronary revascularization for ACS were scheduled for platelet function assessment 30-90 days post-discharge. Aggregation tests were performed by multiple electrode aggregometry. Suboptimal platelet inhibition (HRPR-high residual platelet reactivity was defined if above the lower limit of normality (417 AU*min). The primary study endpoint was defined as the occurrence of major cardiovascular events (a composite of cardiovascular death, recurrent acute coronary syndrome [MI], target vessel revascularization) at longest available follow-up. We included 397 patients that were divided according to tertiles values of Hb (< 12.7, 12-7-14.09, ≥14.1g/dl). Patients with lower Hb were older and displayed a more severe cardiovascular risk profile. Mean levels of platelet reactivity were enhanced in patients with lower Hb after stimulation with TRAP peptide (TRAP test, p=.03) and ADP (p=.02). Elevated platelet reactivity (HRPR) on Ticagrelor was more frequent among patients with reduced Hb (16.4% vs. 12% vs. 5.4%, p=.005, adjusted OR [95%CI]=1.71[0.996;3.01], p=.056). At a mean follow-up of 820.9 ± 553.4 days, 21.4% of the patients experienced the primary composite endpoint, with a higher rate of events in patients with lower Hb (27.6% vs. 22.6% vs. 13.5%, p=.006, adjusted HR [95%CI]=1.51[1.12; 2.03], p=.006), mainly driven by a higher rate of recurrent ACS. After correction for baseline differences lower Hb tertiles but not HRPR emerged as independent predictor of MACE (adjusted HR [95%CI]=0.98[0.50; 1.92], p=.95). In the present study, we demonstrated that among patients on DAPT with ASA and ticagrelor after PCI for ACS, lower Hb levels are independently associated with a higher rate of HRPR and an increased rate of major ischemic events, and especially for recurrent ACS, although with no impact on survival. Neutral prognostic effect of HRPR was observed across Hb tertiles.

Dual Antiplatelet Therapy in Patients with High Cardiovascular Risk.

Coronary artery disease (CAD) is prevalent throughout the world, with a significant impact on global health. There is a vast collection of data in the medical literature relating to the topic of dual antiplatelet therapy (DAPT) in patients considered to be at high cardiovascular (CV) risk. In order to perform a narrative review of literature regarding the use of DAPT in patients with high CV risk, PubMed, Google Scholar and Embase were searched for English-language articles from 1985 to December 2020 by using the medical subject heading terms and keywords 'antiplatelet therapy' and 'high-risk cardiovascular disease', alone or in combination. Both authors critically reviewed the design, population characteristics and results of the selected studies. The topic of DAPT in patients with high CV risk is fluid and constantly evolving. The landmark trials of CURE, TRITON-TIMI 38 and PLATO provided evidence for the optimal use of DAPT in patients after acute coronary syndrome, while the CHARISMA and MATCH trials provided guidance for clinicians for their use in patients with stable coronary artery disease. The American College of Cardiology/American Heart Association focused update, published in 2016, and the European Society of Cardiology guidelines, published in 2017, were developed to provide guidance to clinicians based on the available data at the time to be able to choose the appropriate DAPT strategy that would provide patients with the maximum clinical benefit. The management of DAPT in patients with high CV risk is a challenging task, with new data on the subject constantly being reported. Balancing ischaemic benefit with potential bleeding complications adds to the complexity of managing DAPT in these patients. With all the available data and current clinical guidelines, patients deemed at high CV risk should be considered for DAPT, taking into account individual risk:benefit ratio. In most individuals with high CV risk, the net clinical benefit favours the use of DAPT.

Dual Antiplatelet Therapy Duration in Medically Managed Acute Coronary Syndrome Patients: Sub-Analysis of the OPT-CAD Study.

Optimal dual antiplatelet therapy (DAPT) duration for medically managed acute coronary syndrome (ACS) (MMACS) patients is still unknown. We explored the efficacy and safety of ≥ 12-month DAPT among MMACS patients. In this sub-analysis of the optimal antiplatelet therapy for Chinese Patients with Coronary Artery Disease study (NCT01735305), clinical outcomes among MMACS patients were compared between the < 12-month and ≥ 12-month DAPT groups. The primary efficacy endpoint was a composite of cardiac death, myocardial infarction, and stroke. Safety endpoints included the Bleeding Academic Research Consortium (BARC) 2-5, BARC 3-5, and all bleeding events. Propensity score matching (PSM) was used to compare baseline characteristics between the < 12-month and ≥ 12-month DAPT groups. In this cohort of ACS patients (n = 10,016), MMACS patients (n = 2967) were less likely to use DAPT at 12 (31.64% vs. 67.47%, P < 0.0001) and 24 (13.82% vs. 18.71%, P < 0.0001) months and experienced more ischemic events at 12 (4.55% vs. 3.40%, P = 0.006) and 24 (6.88% vs. 5.08%, P = 0.0004) months than those treated with percutaneous coronary intervention (n = 7049). Among MMACS patients, the rate of primary efficacy endpoint occurring within the second year was significantly higher in the < 12-month DAPT group than in the ≥ 12-month group both before (2.88% vs. 1.60%, P = 0.040) and after (3.19% vs. 1.71%, P = 0.045) PSM. After PSM, no significant differences in all bleeding, BARC 2-5, and BARC 3-5 bleeding were found between the groups. MMACS patients with insufficient DAPT management experienced relatively more ischemic events. DAPT for at least 1year may be beneficial to this special population without significantly increasing the bleeding risks. ClinicalTrials.gov identifier, NCT01735305.

P2815Antiplatelet therapy with cangrelor in patients undergoing surgery after coronary stent implantation: a real-world bridging protocol experience

Abstract Background Perioperative management of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in patients deemed at high thrombotic risk undergoing non-deferrable surgery remains poorly defined. Cangrelor represents a potential treatment option as a “bridge” from discontinuation of oral P2Y12 receptor antagonists to surgical procedures, but data in this setting are still scant. Purpose We sought to describe a real-world experience of a bridging protocol using cangrelor for patients referred to relevant bleeding risk surgery requiring withdrawal of DAPT. Methods We collected data from 7 Italian centers on patients with previous PCI, still on DAPT, undergoing non-deferrable surgery which required discontinuation of one or both antiplatelet agents. A standardized bridging protocol using cangrelor infusion before and eventually after surgery was applied (Figure 1). Results Between December 2017 and January 2019, a total of 18 patients (mean age 70±10 years; male 85%) were enrolled. In the majority (89%) of patients, the index PCI was performed due to acute coronary syndrome (ACS) and 2±1.7 stents per patient were implanted. All patients required non-deferrable, intermediate-high bleeding risk surgery as pulmonary lobectomy, colectomy, endoscopic bladder surgery, paranasal sinus surgery, coronary artery by-pass surgery and valvular repair, hip replacement, endoscopy sphincterotomy. High thrombotic risk categories included PCI time &lt;1 month, SCA time &lt;3 months, stent failure occurrence, previous Absorb BVS implantation. Due to the surgical bleeding risk, discontinuation of P2Y12 inhibitor was required 5 days before surgery (ticagrelor, n=13; prasugrel=1; clopidogrel, n=5). All patients but 1 maintained aspirin through the perioperative phase. Cangrelor infusion was started at a bridging dose (0.75 mcg/kg/min) 3 days before planned surgery and was discontinued 6.9±1.5 hours before. After surgery, drainages were left in all patients but 3. In 56% of patients, cangrelor was resumed within 24 hours from surgery (mean time 9±7 hours) for a mean of 36±38 hours. Drainages were removed after discontinuation of cangrelor, in order to reduce bleeding complications. Within 2 hours from post-operative cangrelor discontinuation, a 300 mg clopidogrel loading dose was administered. No major ischemic adverse outcomes occurred during hospital stay and up to 30 days follow-up. The mean Hb drop was 2±1.8 g/dl, 7 patients received blood transfusions consistent with the type of surgeries and no life-threatening or fatal bleeding occurred. Figure 1. Standardized bridging protocol. Conclusions Peri-operative bridge therapy with cangrelor is a feasible approach for stented patients at high thrombotic risk referred to non-deferrable surgery requiring DAPT discontinuation. Larger studies are warranted to support the safety of this strategy.

Impact of aging on platelet reactivity in diabetic patients receiving dual antiplatelet therapy.

Advanced age and diabetes represent summative conditions in the determination of cardiovascular risk, and especially for the management of dual antiplatelet therapy (DAPT), often requiring balancing between bleeding and thrombotic complications. However, few studies have so far evaluated the impact of age on platelet reactivity and suboptimal platelet inhibition (high-on treatment platelet reactivity-HRPR) on DAPT among diabetic patients, that was, therefore the aim of the present study. In diabetic patients treated with DAPT (ASA + clopidogrel or ticagrelor) platelet reactivity was assessed at 30-90days post-discharge for an acute coronary syndrome or elective PCI. Aggregation was assessed by multiple-electrode aggregometry. HRPR was defined for values above the lower limit of normality (in non-treated patients). Elderly patients were considered ≥ 75years of age. We included 462 patients, among them 149 (32.2%) were ≥ 75years. Elderly patients were more often females (p = 0.006), with lower body size (p = 0.04), acute coronary syndrome at presentation and renal failure (p < 0.001), non-smokers (p = 0.002), in therapy with insulin (p = 0.02) and diuretics (p < 0.001) and lower rate of betablockers (p = 0.02). Age directly related with C reactive protein (p = 0.01), creatinine levels and inversely with hemoglobin (p < 0.001) and triglycerides (p = 0.003). No association was found at linear regression analysis for platelet reactivity and age with different activating stimuli, but for ASPI test (r = 0.12; p = 0.03). No significant difference in HAPR was found in elderly patients (2.4 vs. 3.2%, p = 0.76, OR[95% CI] = 0.45[0.1-2.11], p = 0.31). HRPR for ADP antagonists was similarly not affected by age (30.1% vs. 35.7%, p = 0.28, adjusted OR[95% CI] = 0.78[0.47-1.29], p = 0.33). Comparable results were obtained when considering separately the DAPT strategies with clopidogrel or ticagrelor, or when adjusting our results according to propensity score values. Among diabetic patients receiving dual antiplatelet therapy for an acute coronary syndrome or elective percutaneous coronary intervention, age does not affect platelet reactivity or the rate of high-on treatment platelet reactivity. Similar results were obtained for ASA and clopidogrel or ticagrelor.

Novel directions for the management of dual antiplatelet therapy in patients with coronary artery disease

Dual antiplatelet therapy has been extensively studied in the last two decades, giving opportunities for thorough evidence-based recommendations. The ESC/EACTS guidelines on DAPT in CAD provide guidance for DAPT type and duration, maintaining a patient-centred focus. Patient-specific and dynamic evaluation of the ischaemic and bleeding risks is key for optimal treatment decisions.

GW29-e1128 Comparison of Dual Antiplatelet Therapy with Clopidogrel and Ticagrelor in Patients with Acute Coronary Syndrome at High Risk of Bleeding

Optimal management of dual antiplatelet therapy (DAPT) of aspirin and P2Y12 receptor antagonists is not well studied in patients with acute coronary syndrome (ACS) at high risk of bleeding. This review and meta-analysis aimed to survey patients with ACS reported in primary literature to compare

TCT-643 Antiplatelet therapy with cangrelor in patients undergoing surgery after coronary stent implantation: a real-world bridging protocol experience

Perioperative management of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in patients at high thrombotic risk undergoing non-deferrable surgery remains poorly defined. Cangrelor represents a potential bridging treatment option. However, there is limited data in this

Which is the best antiaggregant or anticoagulant therapy after TAVI? A propensity-matched analysis from the ITER registry. The management of DAPT after TAVI

The safety and efficacy of single vs. dual antiplatelet therapy (DAPT) in patients undergoing TAVI remain to be addressed. The aim of our study was to evaluate the usefulness of a DAPT compared to a single platelet therapy in patients undergoing TAVI with a balloon-expandable prosthesis. All consecutive patients enrolled in the ITER registry were included. Patients undergoing TAVI discharged with aspirin alone were compared to those taking DAPT before and after selection using propensity score with matching. Subgroup analysis was performed for those on OAT. Prosthetic heart valve dysfunction at follow-up was the primary endpoint, whereas all-cause death, cardiovascular death, bleedings, vascular complications and cerebrovascular accidents were the secondary ones. From 1,364 patients, after propensity score with matching, 605 were selected for each group (aspirin alone vs. DAPT). At 30 days, rates of VARC mortality were lower in patients with aspirin alone (1.5% vs. 4.1%, p=0.003), mainly driven by a reduction of major vascular complications (5.3% vs. 10.7%, p<0.001) and of major bleedings (6.6% vs. 11.5%, p<0.001), without a difference in prosthetic heart valve dysfunction after 45±14 months (2.8% vs. 3.0%, p=0.50). These results were confirmed on multivariable analysis. After TAVI with a balloon-expandable prosthesis, aspirin alone does not increase the risk of prosthetic valve dysfunction, and reduces the risk of periprocedural complications and of 30-day all-cause death.

Optimal duration of dual anti-platelet therapy after percutaneous coronary intervention: 2016 consensus position of the Italian Society of Cardiology.

Definition of the optimal duration of dual anti-platelet therapy (DAPT) is an important clinical issue, given the large number of patients having percutaneous coronary intervention (PCI), the costs and risks of pharmacologic therapy, the consequences of stent thrombosis, and the potential benefits of DAPT in preventing ischaemic outcomes beyond stent thrombosis. Nowadays, the rationale for a prolonged duration of DAPT should be not only the prevention of stent thrombosis, but also the prevention of ischaemic events unrelated to the coronary stenosis treated with index PCI. A higher predisposition to athero-thrombosis may persist for years after an acute myocardial infarction, and even stable patients with a history of prior myocardial infarction are at high risk for major adverse cardiovascular events. Recently, results of pre-specified post-hoc analyses of randomized clinical trials, including the PEGASUS-TIMI 54 trial, have shed light on strategies of DAPT in various clinical situations, and should impact the next rounds of international guidelines, and also routine practice. Accordingly, the 2015 to 2016 the Board of the Italian Society of Cardiology addressed newer recommendations on duration of DAPT based on most recent scientific information. The document states that physicians should decide duration of DAPT on an individual basis, taking into account ischaemic and bleeding risks of any given patient. Indeed, current controversy surrounding optimal duration of DAPT clearly reflects the fact that, nowadays, a one size fits all strategy cannot be reliably applied to patients treated with PCI. Indeed, patients usually have factors for both increased ischaemic and bleeding risks that must be carefully evaluated to assess the benefit/risk ratio of prolonged DAPT. Personalized management of DAPT must be seen as a dynamic prescription with regular re-evaluations of the risk/benefit to the patient according to changes in his/her clinical profile. Also, in order to derive more benefit than harm from new treatments, a multi-parametric approach using several risk scores of the ischaemic and bleeding risks might improve the process of risk factor characterization. In patients with high ischaemic risk, particularly those with a history of myocardial infarction, the benefits of extended DAPT (particularly with ticagrelor up to 3 years) are likely to outweigh the risks.

Perioperative management of patient with intracoronary stent presenting for noncardiac surgery.

As the number of percutaneous coronary interventions increase annually, patients with intracoronary stents (ICS) who present for noncardiac surgery (NCS) are also on the rise. ICS is associated with stent thrombosis (STH) and requires mandatory antiplatelet therapy to prevent major adverse cardiac events. The risks of bleeding and ischemia remain significant and the management of these patients, especially in the initial year of ICS is challenging. The American College of Cardiologists guidelines on the management of patients with ICS recommend dual antiplatelet therapy (DAT) for minimal 14 days after balloon angioplasty, 30 days for bare metal stents, and 365 days for drug-eluting stents. Postponement of elective surgery is advocated during this period, but guidelines concerning emergency NCS are ambiguous. The risk of STH and surgical bleeding needs to be assessed carefully and many factors which are implicated in STH, apart from the type of stent and the duration of DAT, need to be considered when decision to discontinue DAT is made. DAT management should be a multidisciplinary exercise and bridging therapy with shorter acting intravenous antiplatelet drugs should be contemplated whenever possible. Well conducted clinical trials are needed to establish guidelines as regards to the appropriate tests for platelet function monitoring in patients undergoing NCS while on DAT.

Abstract 19763: Role of HAS-BLED Score on Major Bleeding in Atrial Fibrillation Undergoing Percutaneous Coronary Intervention With Drug-eluting Stents

Background: While anticoagulant therapy is standard management for atrial fibrillation (Af), dual antiplatelet therapy (DAPT) is needed after stent implantation for coronary artery disease. HAS-BLED score estimates risk of major bleeding for patients on anticoagulation to assess risk-benefit in Af care. However, it is little known about usefulness of HAS-BLED score in Af patient treated with coronary stents requiring DAPT or DAPT plus warfarin (triple therapy: TT). The aim of this study was to evaluate the role of HAS-BLED score on major bleeding in Af patients undergoing DAPT or TT. Methods: A total of 837 consecutive patients were received PCI in our hospital from Jan. 2007 to Dec. 2010, and 66 patients had Af or paroxysmal Af at the time of PCI. Clinical events including major bleeding (cerebral or gastrointestinal bleeding) were investigated up to 3 years. Patients were divided into 2 groups based on HAS-BLED score (High-risk group: HAS-BLED score≥4, n=19 and Low-risk group: HAS-BLED score&lt;4, n=47). DAPT therapy was required for a minimum 12 months after stent implantation and warfarin was prescribed based on physicians’ discretion. Management/change of antiplatelet and anticoagulant therapy during follow-up periods were also up to physicians’ discretion. Results: Baseline characteristics were not different between High-risk and Low-risk group except for age. Overall incidence of major bleeding was observed in 8 cases (12.1%) at 3 years follow-up. Major bleeding event was significantly higher in High-risk group compared with Low-risk group (31.6% vs. 4.3%, p=0.002). However, management of DAPT and TT was not different between the 2 groups. Among component of HAS-BLED score, renal dysfunction and bleeding contributed with increased number of the score. Conclusion: High-risk group was more frequently observed major bleeding events compared with Low-risk group in patients with Af following DES implantation regardless of antiplatelet/anticoagulant therapy.

Dual anti-platelet therapy and dento-alveolar surgery. How do we manage patients on anti-platelet medication?

The optimum management of dual anti-platelet therapy (DAPT) in patients undergoing dentoalveolar surgery is controversial. The lack of guidelines has meant clinicians have been left to manage these cases from specialist advice or past experience. In view of this the British Association of Oral Surgeons (BAOS) membership was surveyed to assess current practice. An electronic survey consisting of nine closed multiple-choice questions was circulated to all 435 registered BAOS members. A section for open comments was also included. The data was transcribed, organised and reduced to themes by hand and finally analysed. One hundred and eighty members completed the questionnaire giving a response rate of 41%. Ninety-two percent of clinicians had direct involvement in managing patients on DAPT and of these 80% had not encountered a bleeding complication. DAPT was continued for simple dental extraction under local anaesthetic by 83% of respondents and 73% for surgical extractions. Two thirds of the respondents did not follow any guidelines but for those that did the most common was the UK Medicines Information protocols. Only 10% of respondents reported a significant post-operative bleeding complication following surgery in patients on DAPT. This survey confirmed the continued variable management of patients on DAPT undergoing dentoalveolar surgery. Reported bleeding rates were low with over 75% of patients not having their DAPT treatment interrupted.

New Oral Anticoagulants in Addition to Dual Anti-platelet Therapy After an Acute Coronary Syndrome: A Systematic Review of Randomized Controlled Trials

BACKGROUND: Despite important advances in the treatment of acute coronary syndrome (ACS), the risk of recurrent ischemic events remains high. This generates interest for improved antithrombotic therapy in addition to the current standard management of dual anti-platelet therapy. OBJECTIVES: This study aimed to evaluate randomized controlled trials on the efficacy and safety of new oral anticoagulants (NOACs) compared with placebo in patients receiving dual anti-platelet therapy after an ACS. METHODS: An engine search using Pub Med database, Cochrane Central Registry of Controlled trials and Clinicaltrials.gov was conducted to search for randomized, placebo-controlled trials evaluating the efficacy and safety of NOACs in addition to dual anti-platelet therapy after ACS. Included studies were included in a meta-analysis, evaluating the effect of NOACs on the following endpoints: recurrence of myocardial infarction and severe ischemia; cardiovascular death; ischemic stroke; stent thrombosis; and bleeding based on Thrombolysis in Myocardial Infarction scheme. RESULTS: Six randomized-placebo controlled trials were included in the analysis, involving 31,264 patients. Compared with placebo, addition of NOACs to dual anti-platelet therapy after ACS was associated with a statistically significant decrease in the recurrence of myocardial infarction and severe ischemia (RR 0.90; 95% CI 0.82-1.00; p=0.041); stent thrombosis (RR 0.71; 95% CI 0.56-0.91; p=0.007); and ischemic stroke (RR 0.79; 95% CI 0.64-0.97; p=0.025). There was also a trend towards decreased cardiovascular death (RR 0.86; 95% CI 0.74-1.00; p=0.057). However, a significantly increased bleeding rate was noted (RR 2.26; CI 2.03-2.50, p&lt;0.001). CONCLUSION: The addition of NOACs on top of dual anti-platelet therapy in patients with ACS was associated with a significant decrease in ischemic event, stent thrombosis and ischemic stroke, with a trend towards lesser incidence of cardiovascular death. However, its efficacy was limited by higher bleeding episodes.

Abstract WMP25: Single-Center Experience with Dual Antiplatelet Therapy Management in Patients Treated with the Pipeline Embolization Device

Purpose: To determine the number of clopidogrel or prasugrel dose adjustments needed and final DAT regimen used to maintain patients undergoing Pipeline Embolization Device (PED) procedures within a target P2Y12 inhibition range. Methods: We recorded the number of clopidogrel or prasugrel dose adjustments, final DAT regimen and thromboembolic and hemorrhagic complications in patients undergoing PED procedures at our institution over an 8-month period. P2Y12 inhibition was measured with VerifyNow 10 and 30 days after dose adjustments (target range 80-200 P2Y12 reaction units). Patients received 325mg aspirin daily. Results: Forty-four patients underwent PED procedures at our institution during the study period, 36 female and 8 male, mean age 59 years (median 63 years, range 31-81 years). Thirteen patients did not require dose adjustments to remain within the target P2Y12 inhibition range (30%). Thirty-one patients required dose adjustments to remain within the target P2Y12 inhibition range (70%), with a mean of 2.1 dose adjustments per patient (median 2, range 1-5), and a mean time from initiation of DAT to last dose adjustment of 47.5 days (median 42 days, range 8-149 days). Four patients exceeded the target P2Y12 inhibition range after a dose adjustment (13%, 3 prasugrel, 1 clopidogrel), without complications. The table summarizes the final DAT regimen and associated major thromboembolic and hemorrhagic complications leading to death or a permanent neurological deficit in our cohort. Most major complications (80%) occurred in patients who were outside the target P2Y12 inhibition range shortly before or at the time of the complication. Conclusion: The majority of patients undergoing PED procedures in our cohort (70%) required an average of 2 clopidogrel or prasugrel dose adjustments to remain within a target P2Y12 inhibition range. Future research is needed to determine if active management of DAT may decrease the risk of major complications after PED procedures.