Risk Of Bleeding In Patients Research Articles

Effects of medication intake on the risk of haemorrhage in patients with sporadic cerebral cavernous malformations

Effects of medication intake on the risk of haemorrhage in patients with sporadic cerebral cavernous malformations

Effects of low molecular weight heparin and fondaparinux on mortality, hemorrhagic and thrombotic complications in COVID-19 patients.

Background:Coronavirus disease 2019 (COVID-19) is associated with increased thrombosis prevalence. However, there are insufficient data supporting the appropriate anticoagulation dose in COVID-19.Objective:We aim to systematically assess the currently available data regarding the effects of different dosing regimens of low molecular weight heparin and/or fondaparinux (LMWH/F) on mortality risk as well as the risk of arterial/venous thrombotic events and hemorrhagic complications in confirmed COVID-19 cases.Design:We conducted a living systematic review and meta-analysis on the effects of different LMWH/F doses on mortality, thrombotic and hemorrhagic events in COVID-19 patients.Data Sources and Methods:MEDLINE, Scopus, Embase, Cochrane Library, Cochrane COVID-19 study register, European Union Drug Regulating Authorities Clinical Trials Database, and ClinicalTrials.gov were searched to detect observational cohort studies and randomized-controlled clinical trials (RCTs) comparing difference doses of LMWH/F among confirmed COVID-19 cases.Results:Thirty-one eligible studies (6 RCTs and 25 cohort studies) with 11,430 hospitalized patients were included. No association was found between LMWH/F and mortality during the following comparisons: (1) no LMWH/F versus any LMWH/F; (2) prophylactic versus higher than prophylactic LMWH/F; (3) prophylactic versus therapeutic LMWH/F; (4) intermediate versus therapeutic LMWH/F; and (5) lower than therapeutic versus therapeutic LMWH/F. Mortality was higher in patients receiving prophylactic versus intermediate LMWH/F (OR = 2.01; 95% CI: 1.19–3.39). However, this effect was mostly driven by observational data. No associations were detected between the intensity of LMWH/F and the risk of thrombotic and hemorrhagic events, except the lower risk for hemorrhage in patients on prophylactic compared to higher LMWH/F doses.Conclusion:The risk for all-cause mortality was higher in patients receiving prophylactic LMWH/F compared to those on an intermediate dose of LMWH/F, based on observational data. These results should be interpreted in light of the moderate quality and heterogeneity of the included studies.Registration:The study protocol has been registered in the International Prospective Register of Ongoing Systematic Reviews PROSPERO (Registration number: CRD42021229771).

Medication intake and hemorrhage risk in patients with Familial Cerebral Cavernous Malformations

Medication intake and hemorrhage risk in patients with Familial Cerebral Cavernous Malformations

Dynamic Nomogram for Predicting Thrombocytopenia in Adults with Acute Pancreatitis.

ObjectiveThrombocytopenia increases the risk of hemorrhage in patients with acute pancreatitis (AP), leading to poor clinical outcomes. Currently, there is no reliable tool for the early assessment of thrombocytopenia in these patients. We aimed to develop a nomogram based on available clinical parameters and validate its efficacy in predicting thrombocytopenia.MethodsThis was a retrospective study. All the data were extracted from an electronic database from May 2018 to May 2019. Patients with a diagnosis of AP and staying in the intensive care unit for more than 3 days were retrospectively analyzed. A clinical signature was built based on reproducible features, using the least absolute shrinkage and selection operator method (LASSO), and logistic regression established the model (P < 0.05). Nomogram performance was determined by its discrimination, calibration, and clinical usefulness.ResultsA total of 594 eligible patients were enrolled, of whom 399 were allocated to the training sets and the 195 in the test sets. The clinical features, including blood urea nitrogen (BUN), fibrinogen (FIB), and antithrombase III, were significantly associated with the incidence of thrombocytopenia after acute pancreatitis (p < 0.05) in training sets. The individualized nomogram showed good discrimination in the training sample (area under the receiver operating characteristic curve [AUC], 0.881) and in the validation sample (AUC, 0.883) with good calibration.ConclusionThe proposed nomogram has good performance for predicting thrombocytopenia in patients with acute pancreatitis and may facilitate clinical decision-making.

Study on the Relationship between Rivaroxaban and Factor Xa Activity in Blood Based on HPLC-MS/MS

The aim of the study was to investigate a high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) method for the determination of rivaroxaban and evaluate the correlation between plasma concentration and anti-Xa activity in patients using oral rivaroxaban. In this study, the plasma concentration of rivaroxaban and anti-Xa factor activities was determined in 125 patients, and the relationship between the two variables was analysed by SPSS 21.0 software. The results showed that the plasma concentrations of oral rivaroxaban patients were significantly correlated with the activity of the anti-Xa factor (Spearman's r = 0.990, P < 0.05). The plasma concentrations of rivaroxaban are a potentially useful monitoring indicator to assess the patient's bleeding risk if testing for plasma anti-Xa activity is not available.

American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma.

Trauma patients are at increased risk of venous thromboembolism (VTE), which includes both deep vein thrombosis and pulmonary embolism. Pharmacologic VTE prophylaxis is a critical component of optimal trauma care that significantly decreases VTE risk. Optimal VTE prophylaxis protocols must manage the risk of VTE with the competing risk of hemorrhage in patients following significant trauma. Currently, there is variability in VTE prophylaxis protocols across trauma centers. In an attempt to optimize VTE prophylaxis for the injured patient, stakeholders from the American Association for the Surgery of Trauma and the American College of Surgeons-Committee on Trauma collaborated to develop a group of consensus recommendations as a resource for trauma centers. The primary goal of these recommendations is to help standardize VTE prophylaxis strategies for adult trauma patients (age ≥15 years) across all trauma centers. This clinical protocol has been developed to (1) provide standardized medication dosing for VTE prophylaxis in the injured patient; and (2) promote evidence-based, prompt VTE prophylaxis in common, high-risk traumatic injuries. Therapeutic/Care Management; Level V.

Impact of prior history of cancer in the outcomes of patients with atrial fibrillation

Abstract Introduction Atrial fibrillation (AF) is common among cancer survivors, but anticoagulant therapy in is particularly challenging in this population. Aim We analyzed how a previous diagnosis of cancer influences the embolic and hemorrhagic risk in AF patients in order to guide anticoagulant therapies. Methods We used a large retrospective and observational cohort of AF patients from Vigo, Spain (2014–2018). Primary endpoint were embolic and haemorrhagic events during follow-up. Secondary endpoints were all cause mortality, CV mortality, acute myocardial infarction (AMI) and heart failure (HF) admission. Results From the 16,056 included patients, 7.1% had a current/past diagnosis of cancer. Median follow-up was 4.9 years. The rate of anticoagulation therapy was similar in cancer and non-cancer patients (74.8% vs 75.8) although there was a higher prescription of heparin and a lower prescription of VKA in cancer group. Cancer patients had a higher embolic (CHA2DS2-VASC 3.5±1.5 vs 3.2±1.5; p&amp;lt;.001) and hemorrhagic risk (HASBLED 3.0±1.2 vs 2.6±1.2; p&amp;lt;.001). Embolic and hemorrhagic risk stratification with CHA2DS2-VASC and HASBLED scores was only accurate in patients with past (non-active) cancer (sHR CHA2DS2-VASC for embolic events: 1.26, 95% CI 1.02–1.54, P=.028 and sHR HASBLED for bleeding events 1.11, 95% CI 1.01–1.23, P=.029) but not in active-cancer patients (CHADS2-VASC sHR 1.14, 95% CI 0.98–1.32; p=.076 and HASBLED sHR 1.08, 95% CI 0.99–1.17; p=.070). After adjusting by age, sex, CHA2DS2-VASC, HASBLED, and anticoagulation therapy, cancer was not associated with higher risk of embolic events (sHR 0.73, 95% CI 0.41–1.26; p=.256), neither in anticoagulated nor in non-anticoagulated patients. However, cancer patients presented a higher bleeding risk (sHR 1.18, 95% CI 1.07–1.30; p=0.001), both in anticoagulated and non-anticoagulated patients. Anticoagulation therapy was associated with lower rate of embolic events and with higher rate of bleeding events in both groups of patients with and without cancer, although the embolic-hemorrhagic balance associated with anticoagulation was more favorable in cancer patients (for each avoided embolism with anticoagulation, 5.7 bleeding and 11.7 bleeding episodes occurred in cancer and non-cancer group respectively). We found no association between cancer and AMI or CV mortality rates. All-cause mortality was higher in cancer patients. For HF, only chemotherapy-treated patients presented higher risk (sHR1.54, 95% CI 1.10–2.16; p=0.012). Conclusion Patients with prior history of cancer have higher bleeding risk but similar embolic risk compared to patients without cancer history. Anticoagulation significantly reduced embolic events, with an increase in bleeding outcomes. However, the embolic-hemorrhagic profile of anticoagulation was more favorable in patients with cancer than without it. Funding Acknowledgement Type of funding sources: None. Scores performances by cancer activityEmbolic/bleeding net clinical balance

Thromboelastography predicts dual antiplatelet therapy-related hemorrhage in patients with acute ischemic stroke

BackgroundStratification of the risk of hemorrhage in patients with acute ischemic stroke following dual antiplatelet therapy (DAPT) is challenging. It remains unclear whether thromboelastography (TEG) can be used to predict...

Hemorrhage in patients with polycythemia vera receiving aspirin with an anticoagulant: a prospective, observational study.

Polycythemia vera (PV) is associated with increased risk of thrombosis and hemorrhage. Aspirin, recommended for primary thromboprophylaxis, is often combined with anticoagulants during management of acute thrombotic events. The safety of dual antiplatelet and anticoagulant therapy is not established in PV. In a prospective, observational study, 2,510 patients with PV were enrolled at 227 sites in the United States. Patients were monitored for the development of hemorrhage and thrombosis after enrollment. A total of 1,602 patients with PV received aspirin with median follow-up of 2.4 years (range, 0-3.6 years). The exposure-adjusted rate of all hemorrhages in patients receiving aspirin alone was 1.40 per 100 patient-years (95% confidence interval [CI]: 0.99-1.82). The combination of aspirin plus anticoagulant was associated with an incidence of hemorrhage of 6.75 per 100 patient-years (95% CI: 3.04-10.46). The risk of hemorrhage was significantly greater in patients receiving the combination of aspirin and anticoagulant compared with aspirin alone (total hemorrhages, hazard ratio [HR]: 5.83; 95% CI: 3.36-10.11; P<0.001; severe hemorrhage, HR: 7.49; 95% CI: 3.02-18.62; P<0.001). Periods of thrombocytosis (>600×109/L) were associated with an increased risk of hemorrhage (HR: 2.25; 95% CI: 1.16-4.38; P=0.02). Rates of hemorrhage were similar for aspirin in combination with warfarin or direct-acting oral anticoagulants. We conclude that the combination of aspirin and anticoagulants is associated with significantly increased risk of hemorrhage in patients with PV (clinicaltrials gov. Identifier: NCT02252159).

Additive Effect of Coexisting Aneurysms Increases Subarachnoid Hemorrhage Risk in Patients With Multiple Aneurysms

It remains unclear whether the additive effect of coexisting intracranial aneurysms increases the risk of subarachnoid hemorrhage (SAH) in patients with multiple intracranial aneurysms. We have performed a tentative analysis for the additive effect of coexisting aneurysms. This multi-institutional cross-sectional study included 1781 aneurysms from 746 patients with multiple intracranial aneurysms. Using the generalized linear mixed model, we analyzed risk factors associated with individual aneurysm rupture and assessed the additive risk of SAH for each patient. The coexisting aneurysms number was not significantly associated with individual intracranial aneurysm rupture, both in unadjusted and adjusted analyses. Patient-level analysis found that an increased number of coexisting aneurysms was significantly associated with a greater estimated additive risk (P<0.001). Estimated additive risks of patients with 2, 3, and 4 or more coexisting intracranial aneurysms were 25.9%, 31.8%, and 38.1%, respectively, which are comparable to the actual incidence of SAH in those patients (26.6%, 29.5%, and 36.5%, respectively), with a Spearman correlation coefficient of 1.000 (P<0.001). Compared with aneurysm-related factors, the estimated additive effect had better discrimination power for SAH risk, with areas under the receiver operating characteristic curve of 0.821. We found that a greater number of coexisting aneurysms did not increase rupture risk of individual aneurysms, but the potential additive effect might increase SAH risk in patients with multiple intracranial aneurysms.

Using the ORACLE Risk Score to Assess Hemorrhagic Risk in Patients with Acute Coronary Syndrome and Atrial Fibrillation

Aim. To study the prognostic value of the ORACLE risk score for assessing the risk of bleeding in patients with acute coronary syndrome (ACS) undergoing anticoagulants for atrial fibrillation using the combined database of the ORACLE II and RECORD 3 registers.Material and methods. This analysis included patients with ACS from 2 observational studies: ORACLE II (ObseRvation after Acute Coronary syndrome for deveLopment of trEatment options; n=1803) and the RECORD-3 register (n=2370). In total, the database included 4173 patients, of which 246 (6.08%) received oral anticoagulants for atrial fibrillation. The mean age of patients was 64.7±11.9 years, 2493 (59.7%) were men. Hemorrhagic risk was assessed using the ORACLE, CRUSADE, ORBIT, and HAS-BLED risk score.Results. Patients receiving anticoagulant therapy were older (69.9±11.3 years and 64.0±12.2 years, p&lt;0.001). Among these patients there was a larger proportion of women, and a smaller proportion of patients with ACS with ST elevation, they were more likely to have chronic heart failure, chronic kidney disease, history of stroke. Among patients receiving anticoagulants and included in the ORACLE study, the frequency of percutaneous coronary intervention was higher than in patients included in the RECORD study. In the joint database, 71 significant bleeding was recorded during the hospitalization period – 64 (1.7%) in patients without anticoagulants and 7 (2.8%) among patients taking anticoagulants (p=0.06). Over 6 months, among patients who did not receive anticoagulants, there were 97 cases of bleeding (in 2.6% of patients), in the group of patients receiving anticoagulants – 12 cases of bleeding (4.9%) – the differences in frequency were significant (p=0.029). The ORACLE risk score had the greatest prognostic value (area under the ROC curve 0.874±0.0416, sensitivity 82.7%, specificity 79.1%). The predictive value of the HAS-BLED risk score was slightly lower (area under the ROC curve 0.710±0.0360, sensitivity 63.2%, specificity 56.8%). The value of the CRUSADE risk score (area under the ROC curve 0.612±0.0269, sensitivity 53.7%, specificity 59.5%) and ORBIT risk score (area under the ROC curve 0.606±0.0457, sensitivity 62.5%, specificity 58.3%) were lower (p&lt;0.001 for all scales).Conclusion. The use of the ORACLE bleeding risk score can be recommended for patients with ACS requiring anticoagulant therapy.

Abstract 4: Glucose Control and Risk of Tpa-Related Symptomatic Intracerebral Hemorrhage in Patients With Hyperglycemic Acute Ischemic Stroke: Preplanned Analysis From the SHINE Trial

Introduction: In acute ischemic stroke (AIS), hyperglycemia promotes enhanced blood brain barrier permeability, tissue acidosis, and oxygen free radicals, and may increase risk of post-tPA symptomatic intracerebral hemorrhage (sICH). We performed a pre-planned analysis from the SHINE trial (NCT01369069) to examine the effects of blood glucose (BG) control on post-thrombolysis ICH. Hypothesis: In AIS, (1) post-tPA BG measures are associated with sICH, and (2) intensive insulin therapy can reduce the risk of sICH. Methods: Hyperglycemic AIS patients &lt;12 hours onset were randomized to intensive insulin (target range 80-130 mg/dL) vs standard BG control (80-179 mg/dL) over a 72-hour period. Randomization was stratified by tPA treatment. Three independent vascular neurologists reviewed all sICH events occurring within 7 days, defined by neurologic deterioration of ≥4 points on the NIHSS. Associations between BG control and sICH were analyzed using a logistic regression model accounting for NIHSS, age, systolic blood pressure, onset to tPA time, and endovascular therapy. Associations were reported as odds ratios (95% CI). Categorical variables and outcomes were compared using the chi-square test (p &lt; 0.05). Results: Of the 1151 SHINE participants, 725 (63%) received IV tPA (median age 65, 46% women, 29% Black, 18% Hispanic). Median NIHSS was 7, baseline BG 187 (IQR 153-247) mg/dL, and onset to tPA was 2.2 hrs (1.6-2.9). Post-tPA sICH occurred in 3.6% (3% intensive vs. 4.3% standard, OR 1.10, 95% CI 0.60-2.01, p=0.697). There was a consistent association between post-tPA BG measures and sICH. In the first 12 hours, every 10 mg/dL increase in median BG increased odds of sICH by ~8% (OR 1.08, 95% CI 1.03-1.14, p=0.004), and a greater percentage of BG measures 80-130 mg/dL decreased odds of sICH by ~11% (0.89, 95% CI 0.80-0.99, p=0.030). Conclusion: In this pre-planned analysis, intensive insulin therapy was not associated with a reduced risk of post-tPA sICH. However, post-tPA hyperglycemia was associated with a higher risk of sICH overall, particularly in the early post-treatment period. These data provide class IIa, level B-R evidence that post-tPA glucose levels between 80-130 mg/dL are associated with decreased risk of sICH. Acknowledgments: NIH-NINDS U01 NS069498.

Case-control study of postprocedural arterial puncture site hemorrhage after neuroendovascular treatment.

ABSTRACTPuncture site hemorrhage following femoral artery catheterization is a significant cause of morbidity. The aim of this case-control study was to identify predictors of postprocedural arterial hemorrhage at the puncture site. We retrospectively reviewed 255 patients who underwent endovascular treatment at our institution over a 23-month period and classified them into a hemorrhage group and a non-hemorrhage group. Puncture site hemorrhage occurred in 15 patients (5.9%). Clinical factors associated with a significantly increased risk of puncture site bleeding included patients whose postoperative activated clotting time of ≥300 seconds before removal of the sheath (9 patients, 11.8%; P<0.05), those who received triple antiplatelet therapy (n=4, 17.4%; P<0.05) and the group administered heparin postoperatively (7 patients, 13.2%; P<0.05). The effects of low on-treatment platelet reactivity, i.e., P2Y12 reaction units <95%, sheath size, hemostasis method used, and operating time were not clinically significant. Our findings suggest an increased risk of puncture site hemorrhage in patients who either had an activated clotting time ≥300 seconds before the postoperative removal of the sheath, had received triple antiplatelet therapy, or were administered heparin postoperatively.

Association of a history of falls or syncope with intracranial bleeding in patients with atrial fibrillation

Abstract Background In patients with atrial fibrillation (AF), anticoagulation effectively reduces the risk of ischemic stroke. However, up to 50% of patients are not receiving this treatment. A history of falls or syncope and an associated risk of intracranial hemorrhage are commonly reported reasons for undertreatment, though these have not been well studied. Purpose To investigate the association of a history of falls or syncope with the risk of intracranial hemorrhage in patients with AF. Methods Patients with a history of AF from the RE-LY, AVERROES and ACTIVE A and W trials were combined into a large cohort. “Critical injury” was defined as any injury that resulted in death, was deemed to be life-threatening or resulted in permanent disability. A “serious injury” was defined as an injury that required hospitalization. “Other injuries” were defined as those that did not meet criteria for critical or serious injury. We used logistic regression and propensity-matched Cox models to assess the association between falls or syncope and adverse outcomes. Results Among 37,973 patients, 11.9% (n=4503) had a history of falls, 17.5% (n=6655) had a history of syncope and 25.1% (n=9518) had a history of either falls or syncope. The mean age of the cohort was 71±9.3 years and 58% were male. The median CHADS2 score was 2. A history of falls or syncope was not associated with the risk of incident intracranial hemorrhage (HR 1.11, 95% CI 0.88–1.4). In propensity-matched multivariable models, a history of falls or syncope was associated with an increased risk of death (HR 1.14, 95% CI 1.07–1.22), stroke (HR 1.17, 95% CI 1.05–1.3), myocardial infarction (HR 1.28, 95% CI 1.09–1.52) and major bleeding (HR 1.27, 95% CI 1.16–1.4). Moreover, a history of falls or syncope was associated with increased risk of critical injury (OR 1.97, 95% CI 1.52–2.54), serious injury (OR 2.06, 95% CI 1.75–2.43) and “other injury” (OR 1.58, 95% CI 1.46–1.72). Conclusions A history of falls or syncope is common in patients with atrial fibrillation; however, neither history was associated with increased risk of intracranial hemorrhage. These patients were at an increased risk of death, stroke, myocardial infarction and major bleeding, suggesting that they should receive anticoagulation for stroke prevention. Funding Acknowledgement Type of funding source: None

Haemorrhage rates of ruptured and unruptured brain arteriovenous malformation after radiosurgery: a nationwide population-based cohort study

ObjectivesThe present nationwide population-based cohort study aims to assess the effectiveness of gamma knife radiosurgery (GKS) on ruptured and unruptured brain arteriovenous malformations (AVMs) by evaluating the haemorrhage rates.DesignA nationwide,...

TCT CONNECT-64 Impact of DAPT Cessation in High Bleeding-Risk Patients Undergoing PCI: Insights From the PARIS Registry

TCT CONNECT-64 Impact of DAPT Cessation in High Bleeding-Risk Patients Undergoing PCI: Insights From the PARIS Registry

Periprocedural bridging anticoagulation in patients with venous thromboembolism: A registry‐based cohort study

BackgroundUse of bridging anticoagulation increases a patient's bleeding risk without clear evidence of thrombotic prevention among warfarin‐treated patients with atrial fibrillation. Contemporary use of bridging anticoagulation among warfarin‐treated patients with venous thromboembolism (VTE) has not been studied. MethodsWe identified warfarin‐treated patients with VTE who temporarily stopped warfarin for a surgical procedure between 2010 and 2018 at six health systems. Using the 2012 American College of Chest Physicians guideline, we assessed use of periprocedural bridging anticoagulation based on recurrent VTE risk. Recurrent VTE risk and 30‐day outcomes (bleeding, thromboembolism, emergency department visit) were each assessed using logistic regression adjusted for multiple procedures per patient. ResultsDuring the study period, 789 warfarin‐treated patients with VTE underwent 1529 procedures (median, 2; interquartile range, 1‐4). Unadjusted use of bridging anticoagulation was more common in patients at high risk for VTE recurrence (99/171, 57.9%) than for patients at moderate (515/1078, 47.8%) or low risk of recurrence (134/280, 47.86%). Bridging anticoagulation use was higher in high‐risk patients compared with low‐ or moderate‐risk patients in both unadjusted (P = .013) and patient‐level cluster‐adjusted analyses (P = .031). Adherence to American College of Chest Physicians guidelines in high‐ and low‐risk patients did not change during the study period (odds ratio, 0.98 per year; 95% confidence interval, 0.91‐1.05). Adverse events were rare and not statistically different between the two treatment groups. ConclusionsBridging anticoagulation was commonly overused among low‐risk patients and underused among high‐risk patients treated with warfarin for VTE. Adverse events were rare and not different between the two treatment groups.

Effect of three or more treatments with lusutrombopag in patients with cirrhotic thrombocytopenia: A retrospective single-center study.

Thrombocytopenia is a common complication among patients with chronic liver disease (CLD). Lusutrombopag, an oral thrombopoietin receptor agonist, is used to reduce the risk of hemorrhage in patients with thrombocytopenia who are undergoing invasive procedures. Platelet transfusion was the standard treatment for thrombocytopenia; however, multiple platelet transfusions lead to the production of antiplatelet antibody. The effect of giving lusutrombopag three times or more has not been previously reported. In this study, we investigated the effect of lusutrombopag readministration in patients with thrombocytopenia. This study included 14 patients (total, 24 readministrations) who received lusutrombopag two times or more. Changes in platelet counts were evaluated. Treatment response was defined as an increased platelet count of ≥20 000/μL after lusutrombopag treatment. Lusutrombopag was given twice in nine patients, three times in three patients, five times in one patient, and six times in one patient. An elevated platelet count of <20 000/μL was noted in only one of the 24 readministrations. There were no postoperative hemorrhagic complications, and no patient had an increased platelet count of >200 000/μL. One patient had a portal venous mural thrombus; however, he was asymptomatic, and the thrombus resolved after anticoagulant treatment, without recurrence. The comparison between the first, second, and third or more treatments showed there was no significant difference in platelet increase. Repeated treatment of lusutrombopag is effective for CLD patients with thrombocytopenia. Moreover, three or more treatments with lusutrombopag showed equal effect compared with one and two treatments with the medication.

Patterns of Antiplatelet Therapy During Noncardiac Surgery in Patients With Second-Generation Drug-Eluting Stents.

BackgroundContinuing antiplatelet therapy (APT) has been generally recommended during noncardiac surgery, but it is uncertain if preoperative discontinuation of APT has been avoided or harmful in patients with second‐generation drug‐eluting coronary stents.Methods and ResultsPatients undergoing noncardiac surgery after second‐generation drug‐eluting coronary stent implantation were assessed in a multicenter cohort in Korea. Net adverse clinical events within 30 days postoperatively, defined as all‐cause death, major adverse cardiac events, and major bleeding, were evaluated. Of 3582 eligible patients, 49% patients discontinued APT during noncardiac surgery. The incidence of net adverse clinical events was comparable between patients with continuation versus discontinuation (4.1% versus 3.4%; P=0.257) of APT during noncardiac surgery. Perioperative discontinuation of APT did not impact on net adverse clinical events (adjusted hazard ratio [HR], 1.00; 95% CI, 0.69–1.44; P=0.995). In subgroup analysis, patients undergoing intra‐abdominal surgery were exposed to less risk of major bleeding by discontinuing APT (adjusted HR, 0.26; 95% CI, 0.08–0.91; P=0.035). Prolonged discontinuation of APT for ≥9 days was associated with higher risk of a major adverse cardiac event compared with continuing APT (adjusted HR, 3.38; 95% CI, 1.36–8.38; P=0.009).Conclusions APT was discontinued preoperatively in almost half of patients with second‐generation drug‐eluting coronary stents. Our explorative analysis showed that there was no significant impact of discontinuing APT on the risk of perioperative adverse events except that discontinuing APT may be associated with decreased hemorrhagic risk in patients undergoing intra‐abdominal surgery.Registration URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT03908463.

Disseminated Intravascular Coagulation and Hemorrhage After Dilation and Evacuation Abortion for Fetal Death

(Obstet Gynecol. 2019;134:708–713) Second-trimester surgical abortion, or dilation and evacuation (D&amp;E) complications are rare. At a mere 0.7% to 3%, these complications can include cervical laceration, uterine perforation, infection, and hemorrhage [including hemorrhage related to disseminated intravascular coagulation (DIC)]. The possibility of excessive blood loss associated with DIC can even lead to the need for transfusion, or in extreme cases, maternal death. A dearth of well-controlled, large sample size studies evaluating the association of fetal death and abortion-related hemorrhage or DIC makes it difficult to create guidelines for appropriate preoperative preparation and anticipation of needed interventions. This study aimed to determine postabortion risk of hemorrhage for patients with a second trimester fetal death. It sources data from a large cohort at a public, urban abortion clinic.