Multiple Antithrombotic Agents Research Articles

Comparing prevalence and types of potentially inappropriate medications among patient groups in a post-acute and secondary care hospital

Reducing potentially inappropriate medications (PIMs) is a challenge in post-acute care hospitals. Some PIMs may be associated with patient characteristics and it may be useful to focus on frequent PIMs. This study aimed to identify characteristic features of PIMs by grouping patients as in everyday clinical practice. A retrospective review of medical records was conducted for 541 patients aged 75 years or older in a Japanese post-acute and secondary care hospital. PIMs on admission were identified using the Screening Tool for Older Person’s Appropriate Prescriptions for Japanese. The patients were divided into four groups based on their primary disease and reason for hospitalization: post-acute orthopedics, post-acute neurological disorders, post-acute others, and subacute. Approximately 60.8% of the patients were taking PIMs, with no significant difference among the four patient groups in terms of prevalence of PIMs (p = 0.08). However, characteristic features of PIM types were observed in each patient group. Hypnotics and nonsteroidal anti-inflammatory drugs were common in the post-acute orthopedics group, multiple antithrombotic agents in the post-acute neurological disorders group, diuretics in the post-acute others group, and hypnotics and diuretics in the subacute group. Grouping patients in clinical practice revealed characteristic features of PIM types in each group.

Retrospective analysis of immunosuppressive and anti-thrombotic protocols in nonassociative immune mediated hemolytic anemia in dogs.

Evidence supporting the effectiveness of therapeutic protocols for nonassociative immune-mediated hemolytic anemia (na-IMHA) is weak. Investigate the efficacy of various drugs in na-IMHA. Two hundred forty-two dogs. Multi-institutional retrospective study (2015-2020). Immunosuppressive effectiveness was determined by time to packed cell volume (PCV) stabilization and duration of hospitalization through analysis by mixed model linear regression. Occurrence of disease relapse, death, and antithrombotic effectiveness, were analyzed using mixed model logistic regression. Use of corticosteroids vs a multi-agent protocol had no effect on time to PCV stabilization (P=.55), duration of hospitalization (P=.13), or case fatality (P=.06). A higher rate of relapse (P=.04; odds ratio: 3.97; 95% confidence interval [CI]: 1.06-14.8) was detected in dogs receiving corticosteroids (11.3%) during follow-up (median: 28.5 days, range: 0-1631 days) compared to multiple agents (3.1%) during follow up (median: 47.0 days, range: 0-1992 days). When comparing drug protocols, there was no effect on time to PCV stabilization (P=.31), relapse (P=.44), or case fatality (P=.08). Duration of hospitalization was longer, by 1.8 days (95% CI: 0.39-3.28 days), for the corticosteroid with mycophenolate mofetil group (P=.01) compared to corticosteroids alone. Use of clopidogrel vs multiple agents had no effect on development of thromboses (P ≥ .36). Addition of a second immunosuppressive agent did not alter immediate outcome measures but might be associated with a reduction in relapse. Use of multiple antithrombotic agents did not reduce incidence of thrombosis.

Impact of Atrial Fibrillation on Patients Undergoing Transcatheter Aortic Valve Implantation (TAVI): The K-TAVI Registry.

The incidence and prognostic implications of atrial fibrillation (AF) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) are controversial, especially for Korean patients. Furthermore, the pattern of antithrombotic therapy for these patients is unknown. The present study sought to identify the impact of AF on Korean patients undergoing TAVI and demonstrate the status of antithrombotic therapy for these patients. A total of 660 patients who underwent TAVI for severe AS were recruited from the nationwide K-TAVI registry in Korea. The enrolled patients were stratified into sinus rhythm (SR) and AF groups. The primary endpoint was all-cause death at 1-year. AF was recorded in 135 patients [pre-existing AF 108 (16.4%) and new-onset AF 27 (4.1%)]. The rate of all-cause death at 1 year was significantly higher in patients with AF than in those with SR [16.2% vs. 6.4%, adjusted hazard ratio (HR): 2.207, 95% confidence interval (CI): 1.182-4.120, p=0.013], regardless of the onset timing of AF. The rate of new pacemaker insertion at 1 year was also significantly higher in patients with AF than in those with SR (14.0% vs. 5.5%, adjusted HR: 3.137, 95%CI: 1.621-6.071, p=0.001). Among AF patients, substantial number of patients received the combination of multiple antithrombotic agents (77.8%), and the most common combination was that of aspirin and clopidogrel (38.1%). AF was an independent predictor of 1-year mortality and new pacemaker insertion in Korean patients undergoing TAVI.

Free Flap Surgery Outcome Related to Antithrombotic Treatment Regime: An Analysis of 1000 Cases

Background:Autologous free tissue transfer is today an integral part of reconstructive plastic surgery, but still lacks generally accepted guidelines regarding antithrombotic agents. We hypothesized that the overuse of antithrombotic agents could be a risk factor for free flap complications and therefore studied a treatment protocol adjustment.Methods:Consecutive free flaps between 2005 and 2020 at a single center were analyzed for complications in relation to the use of pre- and intraoperative treatment with three different antithrombotic agents. The use of preoperative low molecular weight heparin (LMWH), intraoperative heparin, and dextran were analyzed in relation to outcome variables, thromboembolic events, or reexploration for hematoma.Results:Nine hundred thirty-one patients underwent 1000 microvascular free flaps for breast (n = 487), head and neck (n = 365), and extremity (n = 148) reconstruction. Within the first postoperative week, 44 cases had a thromboembolic event and 58 cases underwent hematoma-related reexploration. In the multivariate analysis, thromboembolic events were associated with extremity reconstruction (P = 0.02) and smoking (P = 0.02). Hematoma-related reexploration was more common with triple antithrombotic therapy compared with all other treatment regimes (P < 0.05). The number of antithrombotic agents used perioperatively was linearly decreased, from three to none, over the elapsed time period (P < 0.001).Conclusions:Hematoma was the most common reason for reexploration and was further associated with the use of multiple antithrombotic agents. Cessation of triple treatment was associated with less hematomas and further reduction of antithrombotic agents did not result in any increase of thromboembolic events. Evidence-based guidelines are warranted for antithrombotic regimes in standard free flap surgery.

Endoloop closure following gastric endoscopic submucosal dissection to prevent delayed bleeding in patients receiving antithrombotic therapy

Objectives Given the high risk of bleeding in post-endoscopic submucosal dissection (ESD) patients receiving antithrombotic therapy, a new effective method is needed to prevent delayed bleeding among such patients. The aim of this study was to assess the efficacy of endoloop closure, using an endoloop and clips, after gastric ESD to prevent bleeding among patients receiving antithrombotic therapy. Methods This retrospective study enrolled patients taking antithrombotic agents who underwent ESD for early gastric cancer between March 2016 and January 2019. Patients were classified into two groups: the endoloop closure group and the control group (no prophylactic treatment). We compared the rates of post-endoscopic submucosal dissection bleeding between the two groups. Results Overall, 178 patients were included, with 37 patients in the endoloop closure group and 141 patients in the control group. The rate of post-endoscopic submucosal dissection bleeding was in general lower in the endoloop closure group than in the control group; however, the difference was not statistically significant (8% vs. 23%, p = 0.06). Among patients with a resected specimen size <40 mm and those using multiple antithrombotic agents, the endoloop closure group showed a lower rate of post-endoscopic submucosal dissection bleeding (0% vs. 16%, p = 0.03 and 10% vs. 70%, p = 0.02, respectively). Conclusions Closure using an endoloop and endoclips after gastric ESD might prevent post-procedure bleeding in patients receiving antithrombotic therapy, particularly in those patients with a resected specimen <40 mm and those receiving multiple antithrombotic agents.

Enoxaparin-Induced Massive Abdominal Wall Hematoma in a Case Pretreated with Multiple Anti-Thrombotic Agents.

Enoxaparin-Induced Massive Abdominal Wall Hematoma in a Case Pretreated with Multiple Anti-Thrombotic Agents.

Combining antiplatelet and anticoagulant therapy in cardiovascular disease.

Up to 10% of the >3 million Americans with atrial fibrillation will experience an acute coronary syndrome or undergo percutaneous coronary intervention. Therefore, concurrent indications for multiple antithrombotic agents is a common clinical scenario. Although each helps reduce thrombotic risk, their combined use significantly increases the risk of major bleeding events, which can be life threatening. In the past 5 years, a number of randomized clinical trials have explored different combinations of anticoagulation plus antiplatelet agents aimed at minimizing bleeding risk while preserving low thrombotic event rates. In general, shorter courses with fewer antithrombotic agents have been found to be effective, particularly when direct oral anticoagulants are combined with clopidogrel. Combined use of very low-dose rivaroxaban plus aspirin has also demonstrated benefit in atherosclerotic diseases, including coronary and peripheral artery disease. Use of proton pump inhibitor therapy while patients are taking multiple antithrombotic agents has the potential to further reduce upper gastrointestinal bleeding risk in select populations. Applying this evidence to patients with multiple thrombotic conditions will help to avoid costly and life-threatening adverse medication events.

P473Safety and efficacy of direct oral anticoagulants compared to vitamin K antagonists in patients with atrial fibrillation undergoing percutaneous coronary interventions: A meta-analysis

Abstract Background Coronary artery disease (CAD) and atrial fibrillation (AF) are commonly associated. Co-treatment with multiple anti-thrombotic agents can increase the risk of bleeding. Purpose We sought to evaluate patient-centered outcomes in patients with AF on double therapy with direct oral anticoagulants (DOACs) compared to patients with standard triple therapy, [a vitamin K antagonist (VKA) plus dual antiplatelet therapy]. Methods We performed an extensive systematic review of the literature and meta-analysis of randomized controlled trials reporting outcomes of patients receiving double therapy with DOACs compared to triple therapy with VKAs in patients with AF undergoing percutaneous coronary intervention (PCI). Patient-centered outcomes were the International Society of Thrombosis and Hemostasis (ISTH) major or clinically relevant non-major bleeding (CRNB), all-cause mortality, major adverse cardiovascular events (MACE), myocardial infarction, stent thrombosis, and stroke. Results Four randomized controlled trials (9602 patients) met our inclusion criteria. Compared to VKAs, DOACs were associated with significantly lower ISTH major bleeding/ CRNB (RR - 0.75, 95% CI: 0.67-0.82, p &amp;lt; 0.00001, I2 = 11%). There were no statistically significant differences in the efficacy outcomes, including myocardial infarction (RR- 0.99, 95% CI :0.79-1.25, p = 0.96, I2 = 0%), stent thrombosis (RR - 0.97, 95% CI: 0.6-1.55, p = 0.89, I2 = 0%), ischemic stroke (RR - 0.76, 95% CI: 0.5-1.15, p = 0.19, I2 = 0%), all-cause mortality (RR - 1.06, 95% CI: 0.85-1.31, p = 0.61, I2 = 0%) and MACE (RR - 1.06, 95% CI: 0.91-1.22, p = 0.97, I2 = 0%). Conclusion Compared with triple therapy with VKAS, double therapy with DOACs is associated with a reduced risk of bleeding and is as effective in patients with AF undergoing PCI. Abstract Figure.

Tu1108 FEASIBILITY OF ENDOLOOP CLOSURE AFTER GASTRIC ENDOSCOPIC SUBMUCOSAL DISSECTION TO PREVENT DELAYED BLEEDING IN PATIENTS RECEIVING ANTITHROMBOTIC THERAPY

Endoscopic submucosal dissection (ESD) has been established as a standard treatment for early gastric cancer without the possibility of lymph node metastasis. However, adverse events, such as post-ESD bleeding occurs approximately 5%. In particular, antithrombotic therapy increases the rate of post-ESD bleeding to about 21-38%. Therefore, effective methods for prevention of post-ESD bleeding are desirable. The aim of this study was to assess the efficacy of endoloop closure (ELC) using endoloops and clips in preventing post-ESD bleeding among patients receiving antithrombotic therapy. This study was a nonrandomized, retrospective, single-center study of 1634 early gastric cancers among 1163 patients who were treated by ESD from March 2016 to January 2019. Patients who were taking antithrombotic agents were reviewed. Antithrombotic agents were defined as antiplatelet agents (low-dose aspirin, cilostazol, thienopyridine derivatives) or anticoagulants (warfarin, direct oral anticoagulants) . Exclusion criteria were follows; (1) other upper gastrointestinal endoscopic intervention within 28 days; (2) with an advanced gastric cancer; (3) who underwent ESD for multiple lesions; (4) another prevention after ESD (covering using polyglycolic acid sheets or clip closure). We divided the patients into two groups; ELC group and control group (no preventive treatment). We compared the post-ESD bleeding rates between the two groups. A total of the 178 patients were included, 37 patients underwent ELC and 141 patients were control. Post-ESD bleeding occurred in 8.1% (3/37) and 22.7% (32/141) in the ELC and control groups, respectively; there was no significant difference between the two groups (p=0.06). However, subgroup analysis showed significant difference. Post-ESD bleeding in the resected specimen less than 40 mm occurred in 0% (0/26) lesions in the ELC group and in 16% (12/75) lesions in the control group (p=0.03). Post-ESD bleeding in multiple antithrombotic agents occurred in 10% (1/10) lesions in the ELC group and 70% (7/10) lesions in the control group (p=0.02). Closure using endoloop and endoclips after gastric ESD would prevent post-ESD bleeding in patients receiving antithrombotic therapy, particularly in those with resected specimen <40 mm and among patients undergoing treatment with multiple antithrombotic agents.

Impact of perioperative aspirin continuation on bleeding complications in laparoscopic colorectal cancer surgery: a propensity score-matched analysis.

In laparoscopic surgery for colorectal cancer (CRC) for patients who receive antiplatelet therapy (APT), it remains unclear whether APT should be continued or temporarily withdrawn. We investigated the safety of perioperative aspirin continuation, specifically focused on bleeding complications. We performed retrospective analysis utilizing propensity score-matching (PSM). In total, 789 patients satisfied the inclusion criteria, and were divided into two groups. Patients in the continued aspirin monotherapy (cAPT) group continued treatment perioperatively with not more than 2days of withdrawal (n = 140). Patients with more than 3days withdrawal of aspirin or who did not receive APT at all were assigned to the non-cAPT group (n = 649). After 1:1 PSM, 105 patients were extracted from each group. Perioperative APT management was determined based on our institutional committee-approved guidelines for antithrombotic management. In PSM cohorts, all patient demographics were comparable between the groups. Regarding intraoperative outcomes, we found no significant difference in operation duration (p = 0.969), blood loss (p = 0.068), and blood transfusion (p = 0.517). Postoperative overall morbidity was 20.0% and 13.3% in the cAPT and non-cAPT groups, respectively (p = 0.195). The incidence of bleeding complications was also comparable between the groups (2.9% vs. 1.0%, p = 0.317). Assessing the 14 cases with bleeding complications overall in the full cohort, all 7 cases in the non-cAPT group had anastomotic bleeding, which was generally observed shortly after surgery [median postoperative day (POD) 1]. All 7 cases in the cAPT group received additional antithrombotics other than aspirin; bleeding occurred at various sites relatively later (median POD 7), mostly after reinstitution of additional antithrombotic agents. For patients receiving APT, perioperative continuation of aspirin monotherapy could be safe in laparoscopic CRC surgery; however, careful consideration is required at reinstitution of additional antithrombotics where multiple antithrombotic agents are used.

Upper gastrointestinal bleeding in Japanese patients with ischemic heart disease receiving vonoprazan or a proton pump inhibitor with multiple antithrombotic agents: A nationwide database study

BackgroundVonoprazan has been launched as an alternative to proton-pump inhibitors (PPIs). This was the first study to compare the occurrence of upper gastrointestinal bleeding (UGIB) with vonoprazan treatment to that with PPI treatment in patients with ischemic heart disease (IHD) taking ≥2 antithrombotic agents, including those receiving dual antiplatelet therapy (DAPT). MethodsUsing Japanese Diagnosis Procedure Combination data from 2016 to 2017, we identified 16,415 patients with IHD who were prescribed ≥2 antithrombotic agents, including new antiplatelet medication with concurrent vonoprazan (n = 2226 or PPIs n = 14,189). UGIB occurrence was analyzed using an inverse probability-weighted Cox proportional hazards model. Non-inferiority of vonoprazan to PPI treatment for UGIB occurrence was assessed. ResultsSix-month incidence of UGIB in patients treated with vonoprazan and PPIs was 3.14% 70/2226 and 4.17% (591/14,189), respectively. The adjusted hazard ratio (aHR) of 0.84 was significantly below the non-inferiority margin (HR 2.06) (p < 0.0001), and thus demonstrated that vonoprazan treatment was non-inferior to PPIs in terms of occurrence of UGIB events. The difference between the 2 treatments was also not statistically significant [aHR 0.84; 95% confidence interval (CI): 0.65–1.07; p = 0.154). In a subgroup analysis, UGIB occurrence with vonoprazan and other PPI treatment in patients receiving DAPT was 2.82% (22/779) and 3.96% (209/5276) respectively; a non-significant difference (aHR 0.74; 95% CI: 0.48–1.16; p = 0.189) that demonstrated non-inferiority (p < 0.0001). ConclusionsVonoprazan was non-inferior to PPIs in terms of UGIB occurrence over 6 months in patients with IHD receiving ≥2 antithrombotic agents, including new antiplatelet medication.

Impact of antithrombotic therapy on surgical treatment in patients with chronic subdural hematoma

ObjectiveThe effects of antithrombotic therapy on chronic subdural hematoma (CSDH) are controversial. Herein, we investigated the association of antithrombotic therapy with surgical complications and outcomes in patients with CSDH. MethodsWe retrospectively analyzed 323 consecutive patients with CSDH who underwent single burr-hole craniostomy. ResultsOne hundred and eight patients (33%) underwent preoperative antithrombotic therapy. Hemorrhagic and thromboembolic complications were detected in 6 and 8 patients, respectively, which peaked at 3 and 4.5 days after CSDH surgery, respectively. CSDH recurrence was detected in 62 cases, and reoperation was required in 16 cases. Discontinuance of antiplatelet therapy for >2 weeks was significantly associated with thromboembolic complications (43%; p = 0.005). Postoperative use of multiple antithrombotic agents was significantly associated with CSDH recurrence (40%; p = 0.03). Further, earlier recurrence within 2 weeks was significantly associated with the following reoperation (62%; p = 0.006). ConclusionsTo reduce morbidity and minimize the risk of CSDH reoperation, the optimal timing for resumption of antithrombotic agents is approximately 3 days after CSDH surgery. Postoperative use of multiple antithrombotic agents can increase CSDH recurrence, while earlier recurrence may be a predictor for the following reoperation.

Safety and efficacy of direct oral anticoagulants compared to Vitamin K antagonists postpercutaneous coronary interventions in patients with atrial fibrillation: A systematic review and meta-analysis.

BackgroundAtrial fibrillation (AF) and coronary artery disease (CAD) are commonly associated. Cotreatment with multiple antithrombotic agents can increase the risk of bleeding. We sought to evaluate patient‐centered outcomes in patients with AF on double therapy with direct oral anticoagulants (DOACs) compared to patients with standard triple therapy, [a vitamin K antagonist (VKA) plus dual antiplatelet therapy].MethodsWe performed a literature search of randomized controlled trials (RCTs) reporting outcomes of patients receiving double therapy with DOACs compared to triple therapy with VKAs in patients with AF undergoing percutaneous coronary intervention (PCI). Patient‐centered outcomes were the International Society of Thrombosis and Hemostasis (ISTH) major or clinically relevant nonmajor bleeding (CRNB), all‐cause mortality, major adverse cardiovascular events (MACE), stent thrombosis, myocardial infarction, and stroke.ResultsFour RCTs (9602 patients) met our inclusion criteria. Compared to VKAs, DOACs were associated with significantly lower ISTH major bleeding/ CRNB (RR: 0.75, 95% CI: 0.67‐0.82, P < .00001, I 2 = 11%). There were no statistically significant differences in the efficacy outcomes, including myocardial infarction (RR: 0.99, 95% CI :0.79‐1.25, P = .96), stent thrombosis (RR: 0.97, 95% CI: 0.6‐1.55, P = .89), ischemic stroke (RR: 0.76, 95% CI: 0.5‐1.15, P = .19), all‐cause mortality (RR: 1.06, 95% CI: 0.85‐1.31, P = .61), and MACE (RR: 1.06, 95% CI: 0.91‐1.22, P = .97).ConclusionCompared with triple therapy with VKAS, double therapy with DOACs is associated with a reduced risk of bleeding and is as effective in patients with AF undergoing PCI.

Safety of Cold Snare Polypectomy in Patients Receiving Treatment with Antithrombotic Agents.

With the aging of the population and rising incidence of thromboembolic events, the clinical use of antithrombotic agents is also increasing. There are few reports yet on the management of antithrombotic agent use in patients undergoing cold snare polypectomy (CSP). The aim of this study was to evaluate whether continued administration of antithrombotic agents in patients undergoing CSP would be associated with an increased rate of delayed post-polypectomy bleeding (DPPB). A total of 1177 colorectal polyps in 501 patients were resected at Omori Red Cross Hospital between October 2017 and March 2018. The polyps were divided into two groups depending on whether the patients received antithrombotic agent treatment or not: the antithrombotic group (911 polyps) and the no-antithrombotic group (266 polyps). Among the 1177 polyp resections, there was no case of DPPB, including in the antithrombotic group. Immediate bleeding occurred in a total of 63 (5.4%) cases. Polyp location in the rectum (OR (95% CI) 2.64 (1.223-5.679); p = 0.013), polyp size ≥ 6mm (OR (95% CI) 4.64 (2.719-7.933); p < 0.001), polypoid growth pattern (OR (95% CI) 2.78 (1.607-4.793); p < 0.001), and antithrombotic agent use (OR (95% CI) 2.98 (1.715-5.183); p < 0.001) were identified as significant risk factors of immediate bleeding. Continued use of antithrombotic agents does not increase the risk of DPPB, even in those receiving multiple antithrombotic agents. Thus, it is safe to perform CSP even in multiple agent users. Prospective, randomized studies are necessary to confirm our results.

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.

Profile of acute upper gastro intestinal bleed: a referral hospital-based study in sub Himalayan region

Background: Acute upper gastrointestinal bleeding (UGIB) is one of the most common medical emergencies and remains a major cause of morbidity and mortality. We are likely to see more of it in coming years with ageing population, patients with liver disease, increasing use of NSAIDs, single or multiple antithrombotic agents and novel anticoagulants, the present study was designed with the aim to assess the clinical profile of UGIB presenting to the Department of Medicine in sub Himalayan region.Methods: Study done over 12 months included all patients presenting with acute hematemesis and/or melena. Detailed history, clinical examination, blood tests and Upper GI Endoscopy was done in all patients.Results: One hundred seventy-five patients were included in the study, 129 (73.7%) were males. The commonest age group was 41-60 years contributing to 44%, male to female ratio 2.8:1. The commonest presentation was melena, patients with hematemesis presented earlier, with mean duration 1.46 days. 42.3% of patients were hemodynamically unstable at admission. The mean hemoglobin (Hb) was 8.224±2.78 g%. The cause of bleed was shared by ulcer, varices, non-ulcer non-variceal approximately 1/3rd each, major cause being ulcer in 39.4%. Varices was common in age 30-40 yrs, ulcer in age 51 to 70 years.Conclusions: UGI bleed was more frequent in males age between 41-60 yrs, peptic ulcer being the leading cause in our study, presence of signs of liver failure were associated with varices.

Antithrombotic therapy in patients receiving saphenous vein coronary artery bypass grafts: a protocol for a systematic review and network meta-analysis

IntroductionThe current evidence for the prevention of saphenous vein graft failure (SVGF) after coronary artery bypass graft (CABG) surgery consists of direct head-to-head comparison of treatments (including placebo) in randomised-controlled...

Clinical effects with inhibition of multiple coagulative pathways in patients admitted for acute coronary syndrome.

Platelets and the coagulation cascade play key roles in initiation, amplification, and perpetuation of acute coronary syndromes (ACS). In the past few years, there has been great progress in ACS antithrombotic treatment with the introduction of novel anticoagulants (fondaparinux and bivalirudin), more potent P2Y12 inhibitors (prasugrel and ticagrelor) and protease-activated receptor antagonists (vorapaxar). Nonetheless, patients with ACS frequently have recurrent ischemic events despite the use of currently recommended dual antiplatelet therapy, revascularization procedures as appropriate, and other evidence-based secondary preventive measures. This is the rationale beyond intensification of antiplatelet therapy. However, the major downside of intensive antithrombotic therapy is bleeding. When treating ACS patients, clinicians should find the adequate balance between the reduction of thrombotic events by effective drug treatment and the induction of bleeding that is linked to the use of potent or multiple antithrombotic agents. Numerous antithrombotic cocktails including oral anticoagulants with or without aspirin have been tested in large clinical trials with the goal of further reduction of ischemia and bleeding risk. The aim of this review is to discuss clinical outcomes resulting from inhibition of multiple coagulative pathways in patients with ACS in light of evidence from large randomized controlled clinical trials.

Antithrombotic therapy for acute coronary syndrome: Past, present and future.

Plaque erosions and ruptures are the histopathological hallmarks of arterial thrombus formation in the coronary arteries. The clinical condition associated with this process is usually referred to as acute coronary syndrome (ACS). Importantly, both blood platelets and the coagulation cascade are key players for initiation, amplification and perpetuation of ACS. There has been great progress in ACS treatment in recent decades, both at the technical level of (percutaneous) revascularisation and at the level of antithrombotic treatment. Numerous trials have led to significant advancements in the development of effective anticoagulant and antiplatelet drugs. The large number of randomised controlled clinical trials (RCTs) and the huge number of patients enrolled in these RCTs, with mega trials including >10,000 patients, is unique in the history of medical research and also reflects the exceptional efforts associated with these huge research activities. The crucial issue, however, with respect to optimising treatment, relates to finding the delicate balance between the reduction of thrombotic events by effective drug treatment and the induction of bleeding that is linked to the use of potent or multiple antithrombotic agents. Interestingly, there is a gap in modern days between current guideline recommendations favouring potent platelet inhibition in ACS and the utilization of the respective drugs in clinical practice. In this review, we will summarise and discuss the past, present and future antithrombotic treatment for ACS patients with a focus on the development of optimised antiplatelet treatment strategies and their utilisation in the real world.

Bleeding Risk Related to Upper Gastrointestinal Endoscopic Biopsy in Patients Receiving Antithrombotic Therapy: A Multicenter Prospective Observational Study

BackgroundAlthough antithrombotic agents are widely used for cardiac and cerebrovascular disease prevention, they increase the risk of gastrointestinal (GI) bleeding. ObjectiveTo examine GI bleeding risk in association with an esophagogastroduodenoscopy (EGD) biopsy performed in patients without cessation of antithrombotic therapy. MethodsThis study was prospectively conducted at 14 centers. EGD biopsies were performed in patients receiving antithrombotic agents without cessation, as well as age- and sex-matched controls not receiving antithrombotic therapy. Patients treated with warfarin before the biopsy had a prothrombin time-international normalized ratio level <3.0. The proportion of GI bleeding events was compared between the groups. ResultsThe patient group (n = 277) underwent a total of 560 biopsies while continuing antithrombotic therapy, of whom 24 were receiving multiple antiplatelet drugs, and 9 were receiving both antiplatelet and anticoagulant agents. The control patients (n = 263) underwent 557 biopsies. The upper-GI bleeding rate within 30 days after the EGD biopsy did not increase in patients without cessation of antithrombotic treatment, regardless of receiving single or multiple antithrombotic agents. ConclusionsWe found no significant increase in upper-GI bleeding risk following an EGD biopsy in patients taking antithrombotic agents, suggesting its safety without the need for antithrombotic treatment interruption.