Antiplatelet Aggregation Therapy Research Articles

Haemostatic Gene Expression in Cancer-Related Immunothrombosis: Contribution for Venous Thromboembolism and Ovarian Tumour Behaviour.

Ovarian cancer (OC) is the deadliest gynaecological malignancy. Identifying new prognostic biomarkers is an important research field. Haemostatic components together with leukocytes can drive cancer progression while increasing the susceptibility to venous thromboembolism (VTE) through immunothrombosis. Unravelling the underlying complex interactions offers the prospect of uncovering relevant OC prognostic biomarkers, predictors of cancer-associated thrombosis (CAT), and even potential targets for cancer therapy. Thus, this study evaluated the expression of F3, F5, F8, F13A1, TFPI1, and THBD in peripheral blood cells (PBCs) of 52 OC patients. Those with VTE after tumour diagnosis had a worse overall survival (OS) compared to their counterparts (mean OS of 13.8 ± 4.1 months and 47.9 ± 5.7 months, respectively; log-rank test, p = 0.001). Low pre-chemotherapy F3 and F8 expression levels were associated with a higher susceptibility for OC-related VTE after tumour diagnosis (χ2, p < 0.05). Regardless of thrombogenesis, patients with low baseline F8 expression had a shorter progression-free survival (PFS) than their counterparts (adjusted hazard ratio (aHR) = 2.54; p = 0.021). Among those who were not under platelet anti-aggregation therapy, low F8 levels were also associated with a shorter OS (aHR = 6.16; p = 0.006). Moving forward, efforts should focus on external validation in larger cohorts.

Thromboelastographic and Gene Polymorphism Bimodality Detection for Dual Antiplatelet Aggregation Therapy in Individuals with Clopidogrel-resistant Symptomatic Intracranial Artery Stenosis.

Recent research indicates that clopidogrel resistance is connected with a patient's future ischemia risk, hence increasing the likelihood of recurrent ischemic cerebrovascular disease. Thromboelastographic and clopidogrel gene polymorphism testing can be used to see how a person responds to antiplatelet therapy and change the treatment plan accordingly. This may be a good way to make antiplatelet aggregation therapy more effective and safer. The objective of this study was to investigate the efficacy of dual antiplatelet aggregation therapy in patients with symptomatic intracranial large artery stenosis being resistant to clopidogrel tablets. The thromboelastographic and gene polymorphism bimodality detection techniques were used to analyze the clopidogrel resistance influencing factors. 89 patients with symptomatic intracranial large arterial stenosis who were admitted to our hospital from February 2021 to February 2022 were selected, classified as large artery atherosclerotic type by TOAST, and confirmed as having severe intracranial large arterial stenosis (70 % to 99 %) by magnetic resonance angiography (MRA), computed tomographic angiography (CTA), and digital subtraction angiography (DSA). All patients were treated with dual antiplatelet therapy with aspirin and clopidogrel, and thromboelastography and clopidogrel gene polymorphism were monitored 1 week later. 44 of 89 patients were clopidogrel-resistant. Among 44 patients, 20 were ticagrelorresistant and 24 were cilostazol-resistant. Clopidogrel had a resistance rate of 49.4%. The recurrence of ischemic cerebrovascular disease in the three groups was statistically significant (P<0.05) after 3 months of follow-up treatment, but bleeding (intracranial, gastrointestinal, respiratory, urinary, and mucocutaneous) and dyspnea were not. The clopidogrel-resistant group had a higher number of females, as well as higher levels of hypertension, diabetes, and platelet count than the sensitive group (P<0.05), but there was no significant difference in age, smoking, alcohol consumption, previous stroke, glycosylated haemoglobin, creatinine, or low-density cholesterol. Using thromboelastographic and gene polymorphism bimodality detection, we found switching to ticagrelor antiplatelet aggregation therapy as better than switching to cilostazol in patients with symptomatic intracranial large artery stenosis being resistant to clopidogrel tablets. The results may be biased due to the study being a single-centre study and having a limited sample size.

Inferior ST segment elevation myocardial infarction combined with hyperextension cervical spine injury: A rare case report.

Inferior ST-segment elevation myocardial infarction (STEMI) is usually caused by acute occlusion of the right coronary artery or left circumflex coronary artery (LCX). Inferior STEMI can cause a high-grade atrioventricular block, sinus bradycardia, and hypotension, leading to hemodynamic collapse, syncope, and disturbance of consciousness. A case of a sudden disturbance of consciousness after chest tightness as the initial symptom, followed by incomplete paralysis and paresthesia of the extremities due to the collision of the face with the ground. Coronary angiography showed about 99% of stenosis in the LCX. Cervical spine magnetic resonance imaging showed C2/3, C3/4, C4/5, and C5/6 intervertebral disc herniation with secondary spinal stenosis, spinal cord compression, and edema. The patient was diagnosed with inferior STEMI combined with hyperextension cervical spine injury. Bivalirudin was used for anticoagulation, the LCX lesion was pre-expanded with a balloon and the thrombus was removed, and anti-platelet aggregation therapy was given postoperatively. After rehabilitation therapy, hyperextension cervical spine injury improved. There was no recurrence of syncope and precordial pain during the 6-month follow-up. Hyperextension cervical spine injury has unique hemodynamic features that mimic those associated with inferior STEMI, so a detailed medical history inquiry and physical examination should be carried out to avoid missed diagnoses.

Analysing the effectiveness of topical bleeding care following tooth extraction in patients receiving dual antiplatelet therapy-retrospective observational study

BackgroundPatients using antiplatelet drugs following infarctions, acute coronary syndrome or stroke pose a significant clinical problem if it is necessary to perform surgery, including dental surgery, since they are at risk of prolonged or secondary post-extraction bleeding. Discontinuation of this therapy is associated with a high risk of serious thromboembolic complications. The purpose of this study was to assess the effectiveness of TachoSil fibrin-collagen patches in stopping and preventing of secondary post-extraction bleeding in patients undergoing chronic antiplatelet therapy.MethodsThe study was conducted through retrospective examination of the medical records of 153 patients using chronic antiplatelet therapy and those qualified for tooth extraction. The largest group comprised 74 patients using aspirin and clopidogrel as dual platelet antiaggregation therapy; in this group 75 tooth extractions were carried out. In all of the patients TachoSil fibrin-collagen patches and stiches were applied to the wounds resulting from tooth removal.ResultsFollowing tooth extraction, primary bleeding was stopped in all the patients and their wounds closed via coagulation within 20–30 min. In eight cases, accounting for 4.9% of the patients, secondary bleeding occurred and was successfully stopped only by applying a pressure dressing soaked in tranexamic acid. Secondary bleeding occurred in three patients on the second day and in five patients on the third day following tooth removal.ConclusionTopical application of TachoSil patches following tooth removal in patients using single or dual antiplatelet therapy effectively stopped bleeding and prevented secondary bleeding after tooth extraction.

Heart Disease and the Kidneys.

Clinical Background: The heart can cause kidney disease, and the kidney can cause heart disease. As an example of the first situation, we can mention dilated cardiomyopathies, which can lead to renal failure of the pre-renal type due to the state of renal hypoflow. As an example of the second situation, we can remember that renal failure is a risk factor for cardiovascular diseases, such as coronary heart disease, due to the acceleration in the process of atherosclerosis that it promotes. Epidemiology: In this chapter, we will address what we consider to be the two main aspects of the interrelationships between heart and kidney disease that are "cardiorenal syndrome (CRS)" and "chronic kidney disease (CKD) and coronary heart disease (CHD)." Challenges: For CRS, we discuss its epidemiology, types, pathophysiological mechanisms common to CRS types 1, 2, 3 and 4 and pathogenesis of CSR type 5. Treatment: For "CKD and CHD" we discuss the association of CKD and CHD in community-based populations, traditional risk factor in CKD, non-traditional risk factor in CKD, reduced risk of CHD in patients with CKD, statin treatment, hypertension treatment, anti-platelet aggregation therapy, treatment of CHD in patients with CKD and prognosis of CHDF in CKD patients.

Effectiveness and safety of high dose clopidogrel plus aspirin in ischemic stroke patients with the single CYP2C19 loss-of-function allele: a randomized trial

BackgroundDual antiplatelet aggregation therapy leads to better outcomes in patients with carotid artery stenosis, intracranial artery stenosis, minor strokes, or transient ischaemic attacks. However, carriers of the CYP2C19 loss-of-function allele may not experience the desired effects. We attempted to increase the clopidogrel dose to determine whether it would improve the outcomes of stroke patients who carry a single loss-of-function allele.MethodsWe recruited 131 patients with minor ischaemic stroke, within less than 7 days of stroke onset and a CYP2C19 loss-of-function allele, who had moderate-to-severe cerebral artery stenosis. Patients were divided into the high dose group (clopidogrel 150 mg per day + aspirin 100 mg per day over 21 days.) and a normal dose group (clopidogrel 75 mg per day + aspirin 100 mg per day over 21 days). The reported outcomes included any vascular or major bleeding events as the primary and safety endpoints, respectively.ResultsOne and six vascular events occurred in the high dose and normal dose groups during the 3-months follow-up period, respectively. However, no significant difference was found between the two groups when adjusted for history of diabetes (hazard ratio, 5482; 95% confidence interval, 0.660 to 45.543; P = 0.115). No major bleeding events occurred.ConclusionsIn patients with ischaemic stroke who had a single CYP2C19 loss-of-function allele and moderate to severe cerebral stenosis, fewer vascular events occurred within 3 months with high dose of clopidogrel and aspirin than with normal dose of clopidogrel and aspirin. However, the difference between the two groups was not significant.Trial registrationClinical study of clopidogrel in the treatment of patients with symptomatic moderate to severe cerebral artery stenosis with intermediate metabolites of CYP2C19, URL: http://www.chictr.org.cn/. Unique identifier: ChiCTR1800017411, 07/28/2018;

Evaluasi Penggunaan Aspirin Jangka Panjang terhadap Fungsi Ginjal Pasien Penyakit Jantung Koroner

Low-dose aspirin (75-100 mg/day) is a long-term platelet antiaggregation therapy for certain coronary heart disease (CHD) patients. This study aims to evaluate the long-term use of aspirin on kidney function by examining the changes in the levels of serum creatinine, blood urea nitrogen (BUN), and creatinine clearance of CHD patients. The research method used was a prospective observational cohort analysis. The number of study subjects was 37 CHD patients who took 80 mg/day of aspirin and never experienced kidney disease. Serum creatinine and BUN levels were examined in the 1st and 3rd month of the study. Patient creatinine clearance values were calculated using the Cockcroft-Gault equation. The results of the study showed that the mean levels of serum creatinine, BUN, and creatinine clearance on the 1st and 3rd month were 1.03 ± 0.27 mg/dL and 1.03 ± 0.29 mg/dL; 13.05 ± 4.10 mg/dL and 14.65 ± 4.44 mg/dL; 73.16 ± 18.14 mL/min and 72.92 ± 19.76 mL/min, respectively. The paired t-test results showed that the differences in the mean of creatinine serum, BUN, and creatinine clearance on the 1st and 3rd month were not statistically significant (p &gt; 0.05). The One Way ANOVA test results on the effect of the duration of aspirin use on kidney function were also not statistically significant (p &gt; 0.05) however there is a tendency to decrease creatinine clearance and increase in serum creatinine and BUN. Long-term use of low-dose aspirin has the potential to cause a decrease in kidney function that is seen from a decrease in creatinine clearance as well as an increase in serum creatinine and BUN.

The Role of Xuefu Zhuyu Decoction in Prevention of Contrast‐Induced Nephropathy after Percutaneous Coronary Intervention

Objective This study aimed to investigate the effect of Xuefu Zhuyu decoction on preventing contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI). Methods A total of 256 patients undergoing selective PCI for coronary artery disease were consecutively enrolled and randomly divided into two groups: Group A (n = 126) and Group B (n = 130). Before and after PCI, all patients routinely received antiplatelet aggregation therapy, antilipidemic therapy, and hydration therapy. Besides routine therapy, patients in Group B received Xuefu Zhuyu decoction from 3 days before PCI to 3 days after PCI. Serum creatinine (Scr), estimated glomerular filtration rate (eGFR), superoxide dismutase (SOD), and malondialdehyde (MDA) were measured, respectively, at baseline (72 h before PCI) and at 24, 48, and 72 h after PCI. Results Compared with Group A, Group B presented a lower fluctuation of SCr and eGFR (P < 0.01). The incidence of CIN was less in Group B. According to the definition, CIN occurred in 5 patients (2.0%) in the intervention group and 5 (4.0%) in the control group (P=0.167). In terms of oxidative stress, Group B had a lower MDA (P < 0.05), but a higher SOD (P < 0.05). Conclusions Compared with the control group, Xuefu Zhuyu decoction intervention therapy increased the level of SOD and reduced MDA. The Xuefu Zhuyu decoction intervention group presented a higher level of eGFR at 24, 48, and 72 h after PCI in patients with coronary heart disease and a lower level of Scr. The results are propitious to prove that Xuefu Zhuyu decoction might play an antioxidative stress role in the prevention of CIN after PCI.

A novel method detecting the key clinic factors of portal vein system thrombosis of splenectomy & cardia devascularization patients for cirrhosis & portal hypertension

BackgroundPortal vein system thrombosis (PVST) is potentially fatal for patients if the diagnosis is not timely or the treatment is not proper. There hasn’t been any available technique to detect clinic risk factors to predict PVST after splenectomy in cirrhotic patients. The aim of this study is to detect the clinic risk factors of PVST for splenectomy and cardia devascularization patients for liver cirrhosis and portal hypertension, and build an efficient predictive model to PVST via the detected risk factors, by introducing the machine learning method. We collected 92 clinic indexes of splenectomy plus cardia devascularization patients for cirrhosis and portal hypertension, and proposed a novel algorithm named as RFA-PVST (Risk Factor Analysis for PVST) to detect clinic risk indexes of PVST, then built a SVM (support vector machine) predictive model via the detected risk factors. The accuracy, sensitivity, specificity, precision, F-measure, FPR (false positive rate), FNR (false negative rate), FDR (false discovery rate), AUC (area under ROC curve) and MCC (Matthews correlation coefficient) were adopted to value the predictive power of the detected risk factors. The proposed RFA-PVST algorithm was compared to mRMR, SVM-RFE, Relief, S-weight and LLEScore. The statistic test was done to verify the significance of our RFA-PVST.ResultsAnticoagulant therapy and antiplatelet aggregation therapy are the top-2 risk clinic factors to PVST, followed by D-D (D dimer), CHOL (Cholesterol) and Ca (calcium). The SVM (support vector machine) model built on the clinic indexes including anticoagulant therapy, antiplatelet aggregation therapy, RBC (Red blood cell), D-D, CHOL, Ca, TT (thrombin time) and Weight factors has got pretty good predictive capability to PVST. It has got the highest PVST predictive accuracy of 0.89, and the best sensitivity, specificity, precision, F-measure, FNR, FPR, FDR and MCC of 1, 0.75, 0.85, 0.92, 0, 0.25, 0.15 and 0.8 respectively, and the comparable good AUC value of 0.84. The statistic test results demonstrate that there is a strong significant difference between our RFA-PVST and the compared algorithms, including mRMR, SVM-RFE, Relief, S-weight and LLEScore, that is to say, the risk indicators detected by our RFA-PVST are statistically significant.ConclusionsThe proposed novel RFA-PVST algorithm can detect the clinic risk factors of PVST effectively and easily. Its most contribution is that it can display all the clinic factors in a 2-dimensional space with independence and discernibility as y-axis and x-axis, respectively. Those clinic indexes in top-right corner of the 2-dimensional space are detected automatically as risk indicators. The predictive SVM model is powerful with the detected clinic risk factors of PVST. Our study can help medical doctors to make proper treatments or early diagnoses to PVST patients. This study brings the new idea to the study of clinic treatment for other diseases as well.

Anti-Thrombotic Therapy of Peripheral Arterial Disease - A Review of Current Evidence, Practice and Outlook

Peripheral arterial occlusive disease is a frequent and chronic vascular disorder mostly affecting the lower limbs and caused by fibrous plaques in arteries that can result in stenoses and thrombi. Patients suffering from this condition show a high risk for cardiovascular complications of the complete arterial vascular system, especially post-procedural. Thus, there is a need to optimize anti-thrombotic therapy. Data on multiple antiplatelet aggregation therapy including new drug classes are expected in the coming years. In addition, recent studies showed that direct oral anticoagulation provided clinical advantages combined with a reasonable safety profile. Management of risk factors such as overweight and nicotine and correction of metabolic disorders are not to be ignored and the background to further therapy. All treating physicians should be aware of these aspects to guarantee an optimal care and motivation of their patients.

Dual platelet antiaggregation therapy after myocardial revascularization surgery.

Coronary artery bypass graft (CABG) is a consolidated treatment in patients with coronary artery disease (CAD) for both symptom control and improvement of prognosis. The patency of venous grafts is still the most vulnerable point of the surgical treatment since it presents a high prevalence of occlusion both in the immediate postoperative period and in the long-term follow-up. Aspirin plays a well-established role in this setting, and for a long time, clopidogrel use has been restricted to patients allergic to aspirin. Recently, subgroup analyses of studies with different anti-platelet therapies have shown reduced mortality and cardiovascular events in patients on dual anti-platelet antiplatelet therapy (DAPT) undergoing CABG, although such studies have not been designed to evaluate this patient profile. However, there is still an insufficient number of randomized studies using DAPT in this context, resulting in a disagreement between the European and American cardiology societies guidelines regarding their indication and generating doubts in clinical practice.

Correlation between antiplatelet therapy in secondary prevention of acute cerebral infarction and cerebral microbleeds: A susceptibility-weighted imaging (SWI) study.

To investigate the clinical significance of antiplatelet aggregation therapy for patients diagnosed with acute cerebral infarction (ACI) complicated with the cerebral microbleeds (CMBs). Thirty patients with ACI and 36 patients with intracerebral hemorrhage (ICH) were included in this research. Two groups, studied by susceptibility-weighted imaging (SWI), were compared in terms of the number, location, and severity of CMBs. Then, 30 cases of ACI patients were divided into CMBs sub-group and non-CMBs sub-group. Univariate analysis between these two sub-groups was performed to determine the risk factors regarding the incidence of CMBs. For ACI patients, the number of CMBs before and after applying anti-platelet treatment were compared to examine the impacts of anti-platelet treatment on hemorrhagic transformation. CMBs were found to be more prevalent and severe in ICH patients than in ACI patients. CMBs in patients with ICH were more severe than in patients with ischemic stroke (IS), which indicates that CMBs closely relate to ICH. Hypertension and leukoaraiosis were found to have significant effects on the incidence of CMBs. After anti-platelet treatment, patients with CMBs (≥5) increased the number of CMB, whereas there was no obvious effect on patients with the CMBs less than 5 or no CMBs. The number of CMBs increased significantly among ACI patients with 5 or more CMBs before the anti-platelet treatment. CMBs are more frequently found in patients with hemorrhagic stroke than in patients with ischemic stroke, and more severe than the latter, which suggests that the clinical impact of higher association between the increase of the number of the CMBs and the hemorrhagic stroke.

Manejo clínico de hemorragia subaracnoidea por aneurisma intracraneal en una mujer embarazada en Quito, Ecuador: reporte de caso

Objetivo: describir el diagnóstico y manejo de la hemorragia subaracnoidea secundaria a un aneurisma arterial cerebral accidentado en la primera mitad del embarazo.Materiales y métodos: se presenta el caso de una mujer de 26 años en su segundo embarazo, sin abortos previos y con una cesárea anterior, que fue atendida en un centro de referencia de atención materno perinatal ubicado en Quito, Ecuador, por diagnóstico de hemorragia subaracnoidea durante la decimoséptima semana de gestación. En la panangiografía cerebral se observó un aneurisma cerebral de cuello ancho en la arteria temporal anterior con sangrado.Resultados: se realizó un tratamiento con prótesis endovascular y microespirales, con control de la hemorragia. Posteriormente, la paciente requirió doble antiagregación plaquetaria con clopidogrel y ácido acetilsalicílico que se mantuvo hasta una semana antes del parto. A la paciente se le realizó una cesárea electiva en la que nació un niño sano de 37,2 semanas.Conclusión: el tratamiento endovascular con la colocación de microespirales, asociado al uso de antiagregantes plaquetarios, es una alternativa por considerar en gestantes en la primera mitad del embarazo. Se requieren más estudios clínicos para establecer conductas terapéuticas bien fundamentadas en el manejo de estos casos.

Aorto-Hepatic By-Pass Grafting as Treatment Option After Acute Thrombosis of a Celiac Trunk Stenting. Report of a Case

Celiac trunk thrombosis is a rare event after percutaneous stenting. Treatment options include surgery or endovascular approach. We report the case of a diabetic female patient of 56 years old with a recurrent chronic mesenteric ischemia related to celiac trunk stenosis. We choose endovascular approach and we performed a stenting of this lesion with a ballon expendable stent of 6 × 29 mm. Acute abdomen occurred at the first postoperative day. Acute mesenteric ischemia was suspected. CT scan objectified a stent thrombosis and beginning of intestinal distress. Because of doubt of intestinal viability, we performed urgently a laparotomy and an anterograde aorto-hepatic bypass. Post-operative course was satisfactory. We put the patient on platelet antiaggregant therapy. One year after, CT scan confirms graft patency. Acute thrombosis of a celiac trunk stenting is an emergency and diagnosis must be performed before the development of end-organ damage. Aorto hepatic bypass can be a good alternative.

Enterprise stent in recanalizing non-acute atherosclerotic intracranial internal carotid artery occlusion

ObjectiveTo investigate the safety and effectiveness of recanalization in non-acute occlusion of intracranial internal carotid arteries using the flexible Enterprise self-expanding stent. Patients and methodsFrom June 2014 to June 2016, 12 consecutive patients with non-acute occlusion of intracranial internal carotid arteries received endovascular recanalization with Enterprise stenting. All patients received medication for anti-platelet aggregation therapy before and after the operation. The perioperative complications and recanalization efficacy were evaluated with the modified Rankin scoring system and digital subtraction angiography (DSA) follow-up, respectively. ResultsEndovascular recanalization was successfully performed in 10 out of 12 patients with Enterprise stenting. Stent implantation following balloon dilatation failed in one patient because the lumen diameter was too small. Another recanalization failed because the guide wire could not pass through the occlusion. No perioperative mortality was observed. One case of acute thrombosis and one case of intraoperative carotid spasm occurred, but these were resolved with thrombolytic therapy by microcatheter exposure treatment and antispasmodic medications, respectively. DSA follow-up in seven patients revealed no re-occlusion. One stroke event occurred in the 10 patients who completed the follow-up. A meaningful improvement in the modified Rankin score during follow-up was suggested by Wilcoxon signed-rank test results. ConclusionThe Enterprise stent was shown to be safe and efficient in recanalizing non-acute atherosclerotic intracranial internal carotid artery occlusion. However, the long-term outcomes need to be further investigated.

Cardiac rhythm abnormalities after transcatheter device closure of perimembraneous ventricular septal defects in pediatric patients at intermediate term follow up

Background: Transcatheter closure of perimembranous ventricular septal defects in pediatric patients poses special challenges owing to anatomical relationship between conduction system and perimembraneous ventricular septal defect. Aims: The study aims to assess and evaluate the conduction disturbances after transcatheter device closure of perimembranous ventricular septal defect using different occluders at mid-term follow-up. Methods: We studied 297 patients having PMVSD with clinical and/or echocardiographic evidence of a significant left-to-right shunt. All subjects underwent clinical examination, electrocardiogram (ECG), chest X-rays and transthoracic echocardiography before discharge and at 1, 6 and 12-months after the procedure and yearly thereafter. Platelet anti-aggregation therapy with aspirin 5 mg/kg/day orally and endocarditis prophylaxis was prescribed for six months. Results: The mean age of the patients was 8.64±3.14 years (range 3-17.2 years). Majority (86.2%) had no residual shunt at follow-up. Total rhythm disturbances were seen in about 6% (18/297) of patients with transient complete atrioventricular block (CAVB) occurring in 3 patients. There was no mortality in our study which compares well with the surgical results in which it is between 0-3 percent. Conclusions: This study showed that transcatheter closure of PMVSD using symmetric PMVSD occluders and duct occluders is a safe and effective alternative to surgery. Oversizing of devices should be minimized and low profile devices appropriate to specific morphology of VSD should be used. It has excellent results in experienced hands with minimum morbidity and almost no mortality.

Anti-neutrophil cytoplasmic antibodies in cholesterol embolism: A case report and literature review.

Cholesterol embolism is a multisystemic disorder with clinical manifestations that resemble vasculitis. Anti-neutrophil cytoplasmic antibodies (ANCA) are a defining feature of ANCA-associated vasculitis, and the presence of ANCA in cholesterol embolism complicates its differential diagnosis and treatment. At present, the role of ANCA in cholesterol embolism remains unclear and no effective treatment is currently available. The present study reports the case of an Asian male who presented with spontaneous cholesterol embolism with proteinase 3 (PR3)-specific ANCA, subacute interstitial nephritis and late-developing skin lesions. The 69-year-old patient was admitted to The First Affiliated Hospital of Xiamen University (Xiamen, China) complaining of chest tightness, fatigue, progressive renal failure and refractory hypertension. In addition, transient eosinophilia was detected. Following immunosuppressive therapy with steroids and cyclophosphamide for 6 months, hemodialysis treatment was initiated. Skin lesions appeared at >1 month following hemodialysis initiation; however, they were gradually improved following treatment with atorvastatin and anti-platelet aggregation therapy for 5 months. The patient was maintained on hemodialysis for ~2 years and exhibited general good health at the most recent follow-up. In addition, 11 cases of cholesterol embolism associated with ANCA reported in the literature were discussed in the present study.

A survey on anti-thrombosis treatment plans for elderly patients with non-valvular atrial fibrillation in the different divisions of internal medicine

Objective To identify anti-thrombosis treatment plans for hospitalized elderly patients with non-valvular atrial fibrillation adopted by the different divisions of the internal medicine department. Methods Retrospective data on CHADS2 scores and the frequencies of anti-platelet aggregation and anticoagulation medication in 990 elderly hospitalized patients with non-valvular atrial fibrillation in the different divisions of internal medicine were analyzed. Results Most of the 990 subjects were located in Cardiology (357 cases, 36.1%), Geriatrics (131 cases, 13.2%), the Cadres' Ward (162 cases, 16.4%) and Neurology (138 cases, 13.9%), while a minority stayed in Emergency Medicine (70 cases, 7.0%), Respiratory Medicine (56 cases, 5.7%), Endocrinology (38 cases, 3.8%), Gastroenterology (20 cases, 2.0%) and Nephrology (18 cases, 1.8%). Of the 573 cases with a CHADS2 score of 2 or higher, 58.1% (333/573) received single antiplatelet aggregation therapy, 24.1% (138/573) received dual antiplatelet aggregation therapy and only 14% (80/573) received anticoagulation therapy (warfarin + new oral anticoagulants). The proportion of patients receiving anticoagulation (warfarin) was relatively high in Cardiology (20.1%, 43/214), Geriatrics (17.2%, 10/58) and the Cadres' Ward (13.1%, 11/84). Conclusions The use of anticoagulation therapy in elderly patients with non-valvular atrial fibrillation is generally infrequent and is relatively more commonly used in Cardiology, Geriatrics, and the Cadres' Ward than in other divisions of internal medicine. Key words: Atrial fibrillation; Platelet aggregation inhibitors

Antiplatelet and anticoagulation pretreatment in acute coronary syndrome: current guidelines and unresolved issues.

2016;11(3-4):106. VII. nacionalni sastanak o kardiovaskularnim intervencijama s međunarodnim sudjelovanjem VI. sastanak intervencijskih kardioloskih medicinskih sestara i tehnicara Background: Current evidence clearly show that patients with ST-segment elevation myocardial infarction (STEMI) should be pretreated with dual antiplatelet therapy (DAPT) and anticoagulation therapy immediately after confirmed diagnosis, and that pretreatment can be even performed safely prehospitally.1 In non ST-segment elevation myocardial infarction (NSTEMI), recommendations are not so clear, with data showing that pretreatment depends on what combination of DAPT is used and what is the risk profile of the patient. Also, less than 70% of all patients with NSTEMI undergo stenting after coronary angiography whereas the rest continue medical treatment or are scheduled for coronary artery bypass graft surgery. We present our data on anticoagulation and platelet antiaggregation therapy selection and timing in patients with STEMI and NSTEMI scheduled for early invasive approach, that were collected using our acute coronary syndrome flow chart, and compare them to current guidelines.

An Unusual Case of Hemiballism‐Hemichorea Associated with Nonketotic Hyperglycemia in Association with a Centrum Semiovale Stroke

To the Editor: An 86-year-old man with a medical history of diabetes mellitus, hypertension, dyslipidemia, severe tobacco use (10 pack-years), and brain trauma was admitted to the hospital for a left-sided hemichoreoathetosis that had started suddenly 48 hours before. Family history was unremarkable for movement disorders. On neurological examination, he was disoriented to time and space and presented with left-sided abnormal involuntary movements suggestive of hemichoreoathetosis associated with left facial spasms. Brain computed tomography (CT) revealed spontaneous hyperdensity within the right striatum. Blood sample examination showed high fasting glucose (306 mg/dL, normal <126 mg/dL), high glycosylated hemoglobin (HbA1c; 11.9%, normal <6.5%), and high osmolarity (303.3 mOsmol/kg, normal 285–295 mOsmol/kg); urinary ketones were absent; and cerebrospinal fluid analysis revealed high glucose and lactate levels. On brain magnetic resonance imaging (MRI), the right striatum was hyperintense on T1-weighted images without contrast administration, suggestive of diabetic striatopathy. Focal hyperintensity on diffusion-weighted imaging within the right centrum semiovale suggested the presence of an associated recent ischemic stroke (Figure 1). Diabetes mellitus decompensation, with fasting glucose levels reaching 540 mg/dL during the hospital stay, was treated with insulin, and platelet antiaggregation therapy for stroke treatment and recurrence prevention was started. As soon as blood glucose decreased toward normal values, hemichorea gradually subsided, making symptomatic treatment unnecessary; dramatic cognitive and motor improvement were obtained at discharge. Clinical and MRI follow-up were performed. Hypersignal of right lenticular and caudate nuclei and recurrence of left hemichorea were evident until 9 months later in a context of not-yet-satisfactory glycemic control (HbA1c 9.1%). Imaging and clinical findings had disappeared at 24-month follow-up, when better control of diabetes mellitus was evident (HbA1c 8.3%), reinforcing the diagnosis of hyperglycemic hemichorea. He had three recurrent strokes during 24 months of follow-up in the deep territory of the left middle cerebral artery, the right cerebellar hemisphere, and the left medulla oblongata and right corona radiata. This individual was characterized by the overlap of diabetic decompensation with hemichoreic symptomatology and ischemic stroke manifesting with confusion and postural instability. Hemichorea was recurrent during the 9-month period of persistence of basal ganglia abnormalities in the context of poor glycemic control. Diabetic striatopathy is a well-recognized but rare cause of hemiballism-hemichorea, associated with contralateral basal ganglia hyperdensity on CT and hyperintensity on T1-weighted MRI.1-4 The cause of clinical and imaging abnormalities is unclear. Several mechanisms attributed to hyperglycemia have been proposed: transient ischemic injury with microhemorrhage resulting in hyperviscosity caused by hyperosmotic state, calcium deposition, gemistocytosis, altered GABAergic and dopaminergic neurotransmission,5-8 paramagnetic mineral deposition including zinc-containing metallothionein expressed in swollen astrocytes,9 and autoimmunity-mediated inflammation.10 This was the first case, to the authors’ knowledge, of contemporary occurrence of hyperglycemia-related hemichorea and stroke. Two possible diagnostic hypothesis were taken into account: the first considered stroke to have played a central role in diabetes mellitus decompensation, which, in a context of cerebral frailty due to stroke, led to the development of hyperglycemia-related hemiballism-hemichorea; the second considered hyperglycemia as the trigger of stroke through an ischemic injury due to hyperviscosity.5 The available anamnestic data did not help identify which of the two disorders first appeared. The proximity of the stroke lesion to the altered basal ganglia, both in the right middle cerebral artery area, is interesting; although this strengthens the hypothesis of the ischemic mechanism for imaging abnormalities associated to hyperglycemia, it seems in accord with the second hypothesis. It could also be related to the first hypothesis, if the abnormal basal ganglia is considered to enter the ischemic penumbra of the documented stroke. Moreover, a participating direct role of the documented ischemic stroke to the abnormal movements cannot be excluded given the existence also of vascular hemichorea-hemiballism typically associated with lesions of the basal ganglia and, as in this case, of the adjacent white matter.1 Difficulties in optimal glycemic control probably contributed to the persistence for several months of basal ganglia abnormalities accompanied by recurrence of hemichorea, both finally disappearing 24 months later when diabetes mellitus compensation was also evident. Hyperglycemia-related hemiballism-hemichorea and the occurrence of four ischemic strokes during a 24-month period are rare in clinical practice. This man's case raises doubts also about the possible predictive role of hyperglycemia-related hemiballism-hemichorea for recurrence of stroke.