Risk Of Recurrent Ischemic Events Research Articles

Long-term combined antiplatelet therapy for secondary prevention of noncardioembolic stroke

Introduction. The high risk of recurrent ischemic events after non-cardioembolic ischemic stroke(IS), the prevalence of which is 25% of all strokes in the Russian Federation, determines the need to search for effective and safe secondary prevention strategies.Аim. The study was to evaluate the efficacy and safety of a combination of ADP receptor inhibitors (dipyridamole) with acetylsalicylic acid in patients with ischemic stroke (IS) in the secondary prevention of noncardioembolic stroke.Materials and methods. 229 patients in the early recovery period of noncardioembolic IS (139 women, 90 men), with an average age of 59.0 ± 5.7 years were included in the study. The duration of IS was 54.4 ± 6.1 days. All patients received a multimodal medical rehabilitation (MMR) program. Long-term double antiplatelet therapy with acetylsalicylic acid (ASA) 75 mg per day and dipyridamole at a daily dose of 225 mg divided into 3 doses were prescribed to all the patients. The neurological and neuropsychological status of the patient, quality of life and hemorheological parameters were assessed initially (T0), after MMR (T1, 6 weeks) and 12 months after IS(T2).Results. Motor and coordination indicators of patients as well as the cognitive and emotional parameters were significantly (p < 0,05) improved due to MMR technology. These were confirmed by the dynamics of the corresponding scales. The prescribed double antiplatelet therapy did not cause significant adverse events and worsening of the patients’ well-being both during the MMR process and during the observation period. The combination of ASA with dipyridamole was well tolerated. At the end of the study, recurrent IS, myocardial infarctions, and fatal bleeding were not recorded. In 5.2% patients with severe risks of cardiovascular complications there was occurred TIA. The effectiveness of the dual antiplatelet therapy was confirmed by a decrease in the level of platelet aggregation (p < 0,05).Conclusions. The high effectiveness of secondary prevention of IS with a combination of ASA and dipyridamole with good tolerability and safety in patients after IS has been shown.

Increased Risk of Recurrent Stroke in Symptomatic Large Vessel Disease With Impaired BOLD Cerebrovascular Reactivity.

Impaired cerebrovascular reactivity (CVR) has been correlated with recurrent ischemic stroke. However, for clinical purposes, most CVR techniques are rather complex, time-consuming, and lack validation for quantitative measurements. The recent adaptation of a standardized hypercapnic stimulus in combination with a blood-oxygenation-level-dependent (BOLD) magnetic resonance imaging signal as a surrogate for cerebral blood flow offers a potential universally comparable CVR assessment. We investigated the association between impaired BOLD-CVR and risk for recurrent ischemic events. We conducted a retrospective analysis of patients with symptomatic cerebrovascular large vessel disease who had undergone a prospective hypercapnic-challenged BOLD-CVR protocol at a single tertiary stroke referral center between June 2014 and April 2020. These patients were followed up for recurrent acute ischemic events for up to 3 years. BOLD-CVR (%BOLD signal change per mm Hg CO2) was calculated on a voxel-by-voxel basis. Impaired BOLD-CVR of the affected (ipsilateral to the vascular pathology) hemisphere was defined as an average BOLD-CVR, falling 2 SD below the mean BOLD-CVR of the right hemisphere in a healthy age-matched reference cohort (n=20). Using a multivariate Cox proportional hazards model, the association between impaired BOLD-CVR and ischemic stroke recurrence was assessed and Kaplan-Meier survival curves to visualize the acute ischemic stroke event rate. Of 130 eligible patients, 28 experienced recurrent strokes (median, 85 days, interquartile range, 5-166 days). Risk factors associated with an increased recurrent stroke rate included impaired BOLD-CVR, a history of atrial fibrillation, and heart insufficiency. After adjusting for sex, age group, and atrial fibrillation, impaired BOLD-CVR exhibited a hazard ratio of 10.73 (95% CI, 4.14-27.81; P<0.001) for recurrent ischemic stroke. Among patients with symptomatic cerebrovascular large vessel disease, those exhibiting impaired BOLD-CVR in the affected hemisphere had a 10.7-fold higher risk of recurrent ischemic stroke events compared with individuals with nonimpaired BOLD-CVR.

Characteristics and prognosis of patients with elevated triglycerides in acute myocardial infarction: observational data from a large database over a 17-year period: High triglycerides in acute myocardial infarction

From a large regional registry, we aimed to address the characteristics and prognosis of patients with elevated triglycerides (TG) among patients hospitalized for an acute myocardial infarction (MI). From the multicenter database of the RICO survey, all consecutive patients hospitalized for an acute MI (2001-2017) and alive at discharge were included. Among the 10,667 patients included, 17.7% had elevated TG. When compared with patients with TG ≤ 200 mg/dL, patients with high TG (>200 mg/dL) were 10 years younger, had a higher BMI, were more frequently men, diabetic, and smokers. At 1-year follow-up, recurrent ischemic events were more frequent in elevated TG patients. In multivariate logistic regression analysis, high TG (OR (95%CI): 1.356 (1.095-1.679)) remained an independent estimate for recurrent ischemic events, even after adjustment for confounding factors. In our large population-based cohort, elevated TG are common in acute MI, and associated with residual risk of recurrent ischemic events, beyond traditional prognostic markers.

Comparison of sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists in myocardial infarction patients with type 2 diabetes

Abstract Background Both sodium–glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA) have been shown to reduce the risk of adverse cardiovascular outcomes in type 2 diabetes mellitus (T2DM) patients with established atherosclerotic cardiovascular disease. Purpose The aim of this study was to assess the comparative effectiveness of SGLT2i and GLP1-RA in myocardial infarction (MI) patients with T2DM. Methods This observational cohort study included MI patients with T2DM who were treated with SGLT2i or GLP1-RA within 180 days of hospital discharge between 2013 and 2021. Data was acquired from the SWEDEHEART registry, a nationwide quality register. The co-primary endpoints of this study were a composite of MI, ischemic stroke and all-cause mortality (MACE) and a composite of heart failure hospitalisation (HHF) and all-cause mortality. Inverse probability of treatment weighting was used to adjust for differences in baseline covariates between the treatment groups. Results This study consisted of 617 patients who were treated with SGLT2i and 543 patients who were treated with GLP1-RA. We observed no statistically significant differences between SGLT2i and GLP1-RA concerning the risk of MACE (adjusted incidence rate 76 vs. 68 events per 1000 person-years; HR 1.09 [95% CI 0.85 - 1.40]) and the risk of HHF or all-cause mortality (adjusted incidence rate 52 vs. 50 events per 1000 person-years; HR 1.04 [95% CI 0.80 - 1.36]). Similarly, we did not observe any statistically significant differences between the treatment groups concerning the secondary outcomes of MI (adjusted incidence rate 63 vs. 53 events per 1000 person-years; HR 1.08 [95% CI 0.83 - 1.40]), stroke (adjusted incidence rate 7 vs. 6 events per 1000 person-years; HR 1.22 [95% CI 0.57 - 2.87]), HHF (adjusted incidence rate 45 vs. 38 events per 1000 person-years; HR 1.06 [95% CI 0.80 - 1.41]) and all-cause mortality (adjusted incidence rate 11 vs. 15 events per 1000 person-years; HR 1.06 [95% CI 0.63 - 1.82]). Conclusions There were no statistically significant differences between SGLT2i and GLP1-RA concerning the risk of recurrent ischemic events, HHF and all-cause mortality in this cohort of MI patients with T2DM.Cumulative incidence of events

Hemostasis Biomarkers and Long-Term Risk of Recurrent Cardiovascular Events and Bleeding Complications in Young Patients with an Ischemic Stroke

Background: Patients with ischemic stroke at a young age (18-50 years) have a persistent increased risk of recurrent ischemic cardiovascular events, despite antithrombotic treatment. Additionally, antithrombotic agents result in a higher risk of bleeding complications. Balancing hemostasis to prevent thrombotic events and minimizing the risk of hemorrhagic events is challenging. Previous research observed a hypercoagulable state and a significant degree of inflammation years after an acute ischemic stroke in young adults. It is known that an increased clotting tendency is a risk factor for a first ischemic stroke, especially in young adults. However, the risk profile of a recurrent event in these individuals can be different. To this end, our study aims to investigate the role of plasma pro- and anticoagulation biomarkers, platelet activation markers and thrombin generation parameters in the risk of recurrent ischemic arterial events and bleeding complications after a first ischemic stroke or transient ischemic attack (TIA) at a young age. Method: Patients from a single-center cohort study (the FUTURE cohort) with a first-ever TIA or ischemic stroke event between 1980 and 2010 were included. Blood was collected in 2010 and patients were followed on recurrent ischemic events or bleeding complications between 2010 and 2023. The following coagulation parameters were measured: blood cell count, Von Willebrand factor, active Von Willebrand factor, factor VIII, prothrombin, fragment 1.2, d-dimer, fibrinogen, fibrin degradation products, antithrombin, alpha-2-macroglobulin, serum CXCL-4 and CXCL-7. In addition, thrombin generation (TG) was determined using 1pM and 5pM tissue factor, and thrombomodulin in platelet-poor plasma to assess the functional capacity of plasma to form thrombin. The primary outcome was a composite of recurrent ischemic stroke, TIA, acute coronary syndrome or peripheral artery disease. The secondary outcome was the occurrence of a bleeding complication using the Bleeding Academic Research Consortium (BARC) criteria. We applied Cox proportional hazard models to estimate hazard ratios (HR) with 95% confidence intervals (CI). Results : Among 378 patients (median age 42.1 years, 56% women), 74 experienced a recurrent ischemic event during a mean follow-up of 6.5 years. An increased platelet and leukocyte count, along with elevated levels of fragment 1.2, fibrinogen and D-dimer were associated with a higher risk of ischemic events (table 1). Patients with low plasma antithrombin activity had a higher risk of recurrent ischemic events, especially in women (HR 0.67 [0.47-0.96]). After adjustment for age, sex and traditional risk factors, the association between leukocytes numbers, fragment 1.2 and fibrinogen levels and antithrombin activity and the risk of recurrent ischemic events remained: HR 1.14 [1.05-1.25], 1.07 [1.01-1.14], 0.80 [0.65-0.98], and 1.09 [1.00-1.17], respectively. In patients without vitamin K antagonist treatment, the association between antithrombin activity (HR 0.78 [0.62-0.98]) and leukocytes numbers (HR 1.15 [1.05-1.25]) with recurrent ischemic events were stronger. Thrombin generation parameters were not related to recurrence. Bleeding complications were observed in 16% of patients, mainly among women and predominantly attributable to gynecological bleedings. Hemoglobin, platelets, CXCL-4 and -7, prothrombin, fragment 1.2 and alpha-2-macroglobulin were associated with a bleeding complication (table 2). The association for platelets (HR 0.93 [0.89-0.97]), CXCL-4 (HR 0.90 [0.82-0.99]) and alpha-2-macroglobulin (HR 1.15 [1.03-1.29]) remained after adjustment. Conclusion: Lower antithrombin activity and, higher fragment 1.2, fibrinogen levels, and leukocytes counts were linked to an increased risk of recurrent ischemic events. Bleeding was associated with platelets, CXCL4, and alpha-2-macroglobulin. Overall, especially platelets appear to be significantly involved in the risk of both recurrent arterial thrombosis and bleeding, whereas the observed association with risk of recurrent ischemic events implies a more dominant role of the coagulation system.

Approaches to classification of microembolic signals in patients recovering from ischemic stroke

Introduction. Microembolus detection by transcranial Doppler (TCD) is the only non-invasive modality for visualization of cerebral embolism. Currently, there is no unified classification of recorded microembolic signals (MES) that could be used in clinical practice.&#x0D; The aim of the study is to investigate biophysical MES parameters in patients with ischemic stroke, as well as to assess approaches to microemboli differentiation by structure and origin to improve the diagnostic accuracy of the method and to reduce the risk of recurrent ischemic events.&#x0D; Materials and methods. The inclusion criterion was TCD-detected signs of MES. We analyzed the data of 28 patients with ischemic stroke (9 women and 19 men; mean age was 58 years 13). We recorded power, duration, and frequency for each MES, and calculated an energy index.&#x0D; Results. A total of 938 MES were reported. In patients with cardioembolic stroke and all other pathogenetic stroke subtypes, biophysical parameter limits were as follows: 14.65 dB for the average power, 9.45 ms for the average duration, and 0.16 J for the average energy index. For patients with atrial fibrillation, characteristic MES power was found to be 13 dB. The MES frequency limit was determined to be 650 Hz for microemboli differentiation by acoustic density.&#x0D; Conclusion. The data obtained can be used to further search for optimal limit ranges for biophysical parameters of various MES in order to establish a single MES classification, which will increase the diagnostic value of microembolus detection by TCD in stroke treatment practice.

Who may benefit from low-dose Rivaroxaban plus Aspirin? Practical implications for outpatients with cardiovascular disease.

Despite the availability of effective preventive therapies based on guidelines, patients with vascular diseases continue to be at a high risk for recurrent ischemic events. Therefore, novel therapeutic strategies are required to further reduce the residual risk present in these patients at high risk. Platelet aggregation and fibrin organization are involved in arterial thrombosis, and rivaroxaban is capable of targeting both processes and has a synergistic effect when used in combination with acetylsalicylic acid (ASA), the so-called dual pathway inhibition (DPI). The COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial showed that the DPI (a combination of rivaroxaban 2.5 mg/bid (vascular dose) and ASA 100 mg once daily), reduced cardiovascular death, stroke, or myocardial infarction by 24% in patients with chronic coronary artery disease (CAD) and peripheral artery disease (PAD). Subsequently, the VOYAGER PAD (Vascular Outcomes Study of ASA Along with Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD) trial confirmed the effectiveness of the vascular dose of rivaroxaban in patients with PAD after lower-extremity revascularization, compared to ASA alone. Therefore, DPI is recommended in patients with CAD (+/- PAD) or symptomatic PAD at high ischaemic risk. The purpose of this review is to examine the clinical benefits and practical implications of DPI in CAD and PAD patients.

Optimising antithrombotic therapy after ACS and PCI

Dual antiplatelet therapy, combining aspirin with a platelet P2Y12 receptor inhibitor, is the standard treatment for acute coronary syndrome patients undergoing percutaneous coronary intervention. The optimal type and duration of dual antiplatelet therapy depend on the patient's risk for ischemic and hemorrhagic complications. De-escalation strategies, such as switching to a less potent P2Y12 inhibitor, reducing the dose, or discontinuing one of the antiplatelet agents, may be suitable for high-risk bleeding patients with low risk of recurrent ischemic events, and platelet function testing and genetic testing can guide de-escalation. For patients at high ischemic risk, strategies include drug switching, dose escalation, or adding a new drug. Patients at high ischemic and hemorrhagic risk require individualized treatment decisions and trade-off considerations.

Baseline Cardiovascular Risk Factor Control in Patients With Type 2 Diabetes and Coronary Disease Versus Stroke: Secondary Analysis of Cardiovascular Outcome Trials.

Patients with type 2 diabetes (T2D) and cardiovascular disease are at increased risk for recurrent ischemic events. Cardiovascular risk factor control is vital for secondary prevention, but how this compares among individuals with different T2D macrovascular complications is unknown. We aimed to determine if there might be differences in risk factor control in patients with T2D with previous stroke versus coronary artery disease (CAD). Cross-sectional analyses were performed on 12 856 patients with T2D with prior history of stroke with or without CAD from 3 diabetes cardiovascular outcome trials: CARMELINA (The Cardiovascular and Renal Microvascular Outcome Study With Linagliptin), EMPA-REG OUTCOME (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients), and CAROLINA (The Cardiovascular Outcome Study of Linagliptin vs Glimepiride in Type 2 Diabetes). Risk factors at baseline assessed included dyslipidemia, hypertension, smoking, and current antiplatelet/anticoagulant therapy. Control, respectively, was defined as LDL (low-density lipoprotein)-C <100 mg/dL or statin use, systolic blood pressure <140 and diastolic blood pressure <90 mm Hg, not currently smoking, and use of an antiplatelet/anticoagulant medication. The odds ratio of 3 to 4 (or good) versus 0 to 2 (or suboptimal) risk factors controlled was analyzed by logistic regression models. The odds for good versus suboptimal risk factor control in patients with CAD alone was higher than in those with stroke alone across all 3 trials odds ratios (95% CI): CARMELINA, 2.05 (1.67-2.51), EMPA-REG OUTCOME, 2.50 (2.10-2.99), and CAROLINA, 1.63 (1.21-2.20). The respective odds ratios were lower (and rendered nonsignificant in CAROLINA) when cardiovascular risk factor control in patients with both CAD and stroke were compared with those with stroke alone: CARMELINA, 1.45 (1.13-1.87); EMPA-REG OUTCOME, 1.62 (1.25-2.08); and CAROLINA, 1.16 (0.74-1.83). In contemporary populations of patients with T2D, there was significant discordance in control of cardiovascular risk factors between patients with stroke versus CAD, with the former having less optimal control. The intermediate results in patients with both CAD and stroke suggest that these differences could be related at least in part to clinician factors. URL: https://www. gov; Unique identifiers: NCT01243424, NCT01131676, NCT01897532.

Characteristics and prognosis of patients with elevated triglycerides in acute myocardial infarction: observational data from a large database over a 17 years period

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Amarin Corp. Background and aim From a large database of a regional registry, we aimed to address the prevalence, characteristics and prognosis of patients with elevated triglycerides (TG) in patients hospitalized for an acute myocardial infarction (MI). Methods From the multicenter database (RICO survey), all consecutive patients hospitalized for an acute MI (2001-2017) and alive at discharge were included. Patients with TG &amp;gt; 500 mg/dL, lost to follow-up (FU), or under chronic fibrate treatment were excluded. Patients with high TG (&amp;gt; 200 mg/dL) on admission were compared to those with TG ≤ 200 mg/dL. Endpoints were recurrent ischemic events (i.e. recurrent MI, angina, unstable angina, stroke or urgent revascularization (PCI or CABG)) at 1-year FU. Results Among the 10667 patients included, 1886 (17.7%) had elevated TG. When compared with patients with TG £ 200 mg/dL, patients with high TG were younger (59 vs 69 y, p&amp;lt;0.001), had a higher BMI (28 vs 26 kg/m², p&amp;lt;0.001), were more frequently men (77 vs 68%, p&amp;lt;0.001), diabetic (27 vs 21%, p&amp;lt;0.001), and smokers (42 vs 28%, p&amp;lt;0.001). The rate of statin therapy at discharge was similar for the 2 groups (79 vs 77%, p=0.285), as well as SYNTAX score and rate of multivessel disease (p=0.368 and p=0.791). In high TG group, LDL cholesterol was higher (130 vs 120 mg/dL, p&amp;lt;0.001) and HDL-cholesterol was lower (37 vs 46 mg/dL). At 1-Y FU, recurrent ischemic events were more frequent in elevated TG patients (11.2 vs 9.1%, p=0.004). In multivariate logistic regression analysis, high TG (OR (95%CI): 1.356(1.095-1.679)) remains an independent estimate for recurrent ischemic event, even after adjustment for confounding (GRACE score, diabetes, obesity). Conclusions In our large population-based cohort, elevated TG are common in acute MI, and associated with residual risk of recurrent ischemic events, beyond traditional prognostic markers. Our data may help to identify candidates for targeted therapies to reduce recurrent ischemic risk after MI.

Physician Approaches to the Initial Management of an Intraluminal Thrombus in Recently Symptomatic Carotid Artery Stenosis: Results from the Hot Carotid Study (S20.005)

Physician Approaches to the Initial Management of an Intraluminal Thrombus in Recently Symptomatic Carotid Artery Stenosis: Results from the Hot Carotid Study (S20.005)

Debate on dual pathway inhibition: Antiplatelet and anticoagulant therapies in patients undergoing percutaneous coronary intervention at high risk for recurrent ischemic events. Focus on anticoagulation-based strategies

Debate on dual pathway inhibition: Antiplatelet and anticoagulant therapies in patients undergoing percutaneous coronary intervention at high risk for recurrent ischemic events. Focus on anticoagulation-based strategies

Efficacy, Safety, and Role of Antiplatelet Drugs in the Management of Acute Coronary Syndrome: A Comprehensive Review of Literature.

Acute coronary syndrome (ACS) is a complex condition characterized by myocardial ischemia or infarctionwhich can lead to significant morbidity and death. Antiplatelet drugs play a crucial role in the management of ACS and have been shown to minimize the incidence of significant adverse cardiovascular events and recurrent myocardial infarction (MI). This comprehensive literature review is intended to summarize current information on the effectiveness, safety, and function of frequently used antiplatelet medications in treating ACS. Aspirin, clopidogrel, prasugrel, ticagrelor, abciximab, tirofiban, dipyridamole, cilostazol, and novel antiplatelets are included in the review. Aspirin's effectiveness as a first-line antiplatelet medication in ACS is well established. It has significantly lowered the risk of serious adverse cardiovascular events. Clopidogrel, prasugrel, and ticagrelor are P2Y12 receptor inhibitors found to lower the incidence of recurrent ischemia episodes in ACS patients. Using glycoprotein IIb/IIIa inhibitors such as abciximab, tirofiban, and eptifibatide is effective in managing ACS, especially in high-risk patients. Dipyridamole effectively reduces the risk of recurrent ischemic events in patients with ACS, particularly when used with aspirin. Cilostazol, a phosphodiesterase III inhibitor, has also been shown to reduce the risk of major adverse cardiovascular events (MACE) in patients with ACS. Antiplatelet drugs' safety in managing ACS has also been well established. Aspirin is generally well-tolerated with a low risk of adverse effects, although the risk of bleeding events, particularly gastrointestinal bleeding, cannot be eliminated. The P2Y12 receptor inhibitors have been associated with a small increase in the risk of bleeding events, particularly in patients with a high risk of bleeding. The glycoprotein IIb/IIIa inhibitors are associated with a higher risk of bleeding than other antiplatelet drugs, especially in high-risk patients. To summarize, antiplatelet drugs play a crucial role in the management of ACS, and the efficacy and safety of these drugs have been well-established in the literature. The choice of antiplatelet drugs will depend on the patient's risk factors, including age, comorbidities, and bleeding risk. The novel antiplatelets may offer new therapeutic options for managing ACS, and further studies are needed to determine their role in managing this complex condition.

Secondary Cardiovascular Prevention after Acute Coronary Syndrome: Emerging Risk Factors and Novel Therapeutic Targets.

The control of cardiovascular risk factors, the promotion of a healthy lifestyle, and antithrombotic therapy are the cornerstones of secondary prevention after acute coronary syndrome (ACS). However, many patients have recurrent ischemic events despite the optimal control of traditional modifiable risk factors and the use of tailored pharmacological therapy, including new-generation antiplatelet and lipid-lowering agents. This evidence emphasizes the importance of identifying novel risk factors and targets to optimize secondary preventive strategies. Lipoprotein(a) (Lp(a)) has emerged as an independent predictor of adverse events after ACS. New molecules such as anti-PCSK9 monoclonal antibodies, small interfering RNAs, and antisense oligonucleotides can reduce plasma Lp(a) levels and are associated with a long-term outcome benefit after the index event. The inflammatory stimulus and the inflammasome, pivotal elements in the development and progression of atherosclerosis, have been widely investigated in patients with coronary artery disease. More recently, randomized clinical trials including post-ACS patients treated with colchicine and monoclonal antibodies targeting cytokines yielded promising results in the reduction in major cardiovascular events after an ACS. Gut dysbiosis has also raised great interest for its potential pathophysiological role in cardiovascular disease. This evidence, albeit preliminary and needing confirmation by larger population-based studies, suggests the possibility of targeting the gut microbiome in particularly high-risk populations. The risk of recurrent ischemic events after ACS is related to the complex interaction between intrinsic predisposing factors and environmental triggers. The identification of novel risk factors and targets is fundamental to customizing patient clinical management with a precision medicine perspective.

Abstract Number ‐ 231: Role of Anticoagulation in Recurrent Basilar Artery Thrombosis Secondary to Dolichoectasia, a Case Report

Introduction Basilar artery thrombosis accounts for a small part of ischemic strokes but contributes to one‐fifth of the posterior circulation strokes. Recurrent basilar artery thrombosis secondary to dolichoectasia is caused by abnormal flow in the dilated artery and can result in cerebral ischemia. We present a similar case of recurrent thrombosis with a missed dose of anticoagulation and dehydration on two separate occasions. Methods An 81‐year‐old man with a past medical history of ulcerative colitis with colostomy, provoked deep venous thrombosis presented as a transfer from an outside hospital with acute onset of dysarthria, nausea/vomiting, unsteadiness, and left hemiparesis. CT angiogram of head and neck revealed right vertebral thrombosis extending into the basilar artery with dolichoectasia involving distal right vertebral artery and basilar artery. He was started on heparin infusion with improvement in symptoms and a return to baseline. He was later transitioned to apixaban and discharged home. On a follow‐up office visit two months later, his repeat CT angiogram revealed resolution of the thrombus. He was advised to continue the medication due to the risk of recurrent occlusion secondary to vessel anomaly. After four months, the patient returned to the emergency department with acute onset dizziness, imbalance, nausea, and vomiting. CT angiogram of the head and neck was performed which revealed non‐occlusive thrombosis in the basilar artery. On evaluation by neurology, he admits to three missed doses of apixaban. Clinical and laboratory data were concerning for volume depletion. On further questioning about his symptoms, he mentions decreased oral intake on the day of colostomy change. He was advised to continue apixaban and stay hydrated. Results After fifteen months of the first presentation, the patient is symptom‐free but was continued on anticoagulation with apixaban to prevent recurrent events. Conclusions The role of short‐term and long‐term anticoagulation in basilar artery occlusion is less studied. No prospective trials were done so far to suggest that antithrombotic therapy lowers the risk of recurrent ischemic events and/or anticoagulation is superior to antiplatelets. Dolichoectasia by itself can increase the risk of recurrent thrombosis and dehydration likely facilitated the thrombosis in our patient during the event of missed anticoagulation.

Abstract Number ‐ 49: Risk of HT with Early DOACs after Acute Ischemic Stroke: A Pooled Analysis

Introduction The risk of hemorrhagic transformation (HT) in the early phase of acute ischemic stroke (AIS) remains unknown, leading to potential unnecessary delays in initiation of anticoagulation for secondary stroke prevention. We sought to assess the rate of HT associated withdirect oral anticoagulant (DOAC) initiation within and beyond 48 hours after AIS, using a pooled analysis of available published data. Methods A pooled analysis of 6 studies (4 prospective observational blinded outcome studies and2 randomized trials) of DOAC initiation within 14 days of AIS or transient ischemic attack (TIA) was conducted. The primary endpoint was incident radiographic HT on follow‐up imaging. Secondary endpoints included symptomatic HT, new parenchymal hemorrhage, recurrent ischemic events, extracranial hemorrhage, mortality within the study period, and follow‐up modified Rankin Scale score.The results were reported as odds ratio (OR) andhazard ratio (HR)with 95% confidence interval (CI). Results We evaluated 509 patients; median infarct volume was1.5 (0.1‐7.8) ml, andmedian National Institutes of Health Stroke Scale was2 (0‐3).Incident radiographic HT was seen on follow‐up scan in 34 (6.8%) patients.DOAC initiation within 48 hours from index event was not associated with incident HT (adjusted OR 0.67, [0.30 – 1.50]P = 0.32).No patients developed symptomatic HT.Conversely, 31 (6.1%) patients developedrecurrent ischemic events, 64% of which occurred within 14 days.Initiating a DOAC within 48 hours of onset was associated with a trend towards lower rates of recurrent ischemic events, but this was not statistically significant (HR 0.42, [0.17 – 1.008]P = 0.052). In contrast to HT,recurrent ischemic events were associated with poor functional outcomes (OR = 6.8, [2.84 – 16.24], p&lt; 0.001). Conclusions Initiation of DOAC within 48 hours after stroke was not associated with decreased risk of recurrent ischemic events, or increasedincident risk of HT. Both recurrent ischemic events and incident HT occurred at similar rates.Unlike HT, however, recurrent ischemic events were associated with poor outcomes.

P2Y12 Inhibitor Monotherapy versus Conventional Dual Antiplatelet Therapy in Patients with Acute Coronary Syndrome after Percutaneous Coronary Intervention: A Meta-Analysis.

P2Y12 inhibitor monotherapy is a feasible alternative treatment for patients after percutaneous coronary intervention (PCI) in the modern era. Clinical trials have shown that it could lower the risk of bleeding complications without increased ischemic events as compared to standard dual antiplatelet therapy (DAPT). However, the efficacy and safety of this novel approach among patients with acute coronary syndrome (ACS) are controversial because they have a much higher risk for recurrent ischemic events. The purpose of this study is to evaluate the efficacy and safety of this novel approach among patients with ACS. We conducted a meta-analysis of randomized controlled trials that compared P2Y12 inhibitor monotherapy with 12-month DAPT in ACS patients who underwent PCI with stent implantation. PubMed, Embase, the Cochrane library database, ClinicalTrials.gov, and other three websites were searched for data from the earliest report to July 2022. The primary efficacy outcome was major adverse cardiovascular and cerebrovascular events (MACCE), a composite of all-cause mortality, myocardial infarction, stent thrombosis, or stroke. The primary safety outcome was major or minor bleeding events. The secondary endpoint was net adverse clinical events (NACE), defined as a composite of major bleeding and adverse cardiac and cerebrovascular events. Five randomized controlled trials with a total of 21,034 patients were included in our meta-analysis. The quantitative analysis showed a significant reduction in major or minor bleeding events in patients treated with P2Y12 inhibitor monotherapy as compared with standard DAPT(OR: 0.59, 95% CI: 0.46-0.75, p < 0.0001) without increasing the risk of MACCE (OR: 0.98, 95% CI: 0.86-1.13, p = 0.82). The NACE was favorable in the patients treated with P2Y12 inhibitor monotherapy (OR: 0.82, 95% CI: 0.73-0.93, p = 0.002). Of note, the overall clinical benefit of P2Y12 inhibitor monotherapy was quite different between ticagrelor and clopidogrel. The incidence of NACE was significantly lower in ticagrelor monotherapy as compared with DAPT (OR: 0.79, 95% CI: 0.68-0.91), but not in clopidogrel monotherapy (OR: 1.14, 95% CI: 0.79-1.63). Both clopidogrel and ticagrelor monotherapy showed a similar reduction in bleeding complications (OR: 0.46, 95% CI: 0.22-0.94; OR: 0.60, 95% CI: 0.44-0.83, respectively). Although statistically insignificant, the incidence of MACCE was numerically higher in clopidogrel monotherapy as compared with standard DAPT (OR: 1.50, 95% CI: 0.99-2.28, p = 0.06). Based on these findings, P2Y12 inhibitor monotherapy with ticagrelor would be a better choice of medical treatment for ACS patients after PCI with stent implantation in the current era.

Prognostic impacts of Lipoxin A4 in patients with acute myocardial infarction: A prospective cohort study

Lipoxin A4 (LXA4) is one of the specialized pro-resolving lipid mediators proved to suppress the progression of atherosclerosis in vivo, but its clinical impacts in atherosclerotic patients is unclear. In this study, we assessed the prognostic impacts of LXA4 in patients with acute myocardial infarction (AMI). A total of 1569 consecutive AMI patients were prospectively recruited from March 2017 to January 2020. Plasma samples of AMI patients were collected, and LXA4 levels were determined using enzyme-linked immunosorbent assay. The primary outcome was major adverse cardiovascular event (MACE), a composite of all-cause death, recurrent MI, ischemic stroke, or ischemia-driven revascularization. Cox regression was used to assess associations between LXA4 and clinical outcomes. Overall, the median level of LXA4 was 5.637 (3.047-9.014) ng/mL for AMI patients. During a median follow-up of 786 (726-1108) days, high LXA4 (≥ 5.637ng/mL) was associated with lower risk of MACE (hazard ratio [HR]: 0.73, 95% confidence interval [CI]: 0.60-0.89, P=0.002), which was sustained in propensity score matching (HR: 0.73, 95% CI: 0.60-0.90, P=0.004) and inverse probability weighting analysis (HR: 0.74, 95% CI: 0.61-0.90, P=0.002). Combined with pro-inflammatory biomarker, patients with high levels of LXA4 (≥ 5.637ng/mL) but low levels of high-sensitivity C-reactive protein (< 5.7mg/L) acquired the lowest risk of MACE (HR: 0.68, 95% CI: 0.51-0.92, P=0.012). In sum, high levels of LXA4 were associated with lower risk of recurrent ischemic events for AMI patients, which could serve as new therapeutic target to tackle cardiovascular inflammation.

1154 MYOCARDIAL INFARCTION IN A TRANSGENDER FEMALE UNDERGOING HORMONE THERAPY: THE IMPACT PROLONGED EXPOSURE TO HORMONE THERAPY

Abstract Background Gender Identity (GI) is defined by a complex interplay between biological, psychological, environmental, and cultural factors. Health care services provide counseling, hormone treatment, and gender-affirming surgery. Testosterone is used for cross-sex hormone therapy in female-to-male transgender persons. Previous evidence suggests that testosterone administration is associated with hypertension, decreased high-density lipoprotein (HDL), increased low-density lipoprotein (LDL), and obesity, thus increasing cardiovascular risk. Hereafter, we report the case of a patient female-to-male on testosterone therapy undergoing percutaneous coronary intervention (PCI) and stent implantation for acute myocardial infarction. Case Description A 44-year-old Italian transgender (female-to-male) without common cardiovascular risk factors and family risk was admitted to the local emergency room with a sudden onset of anterior chest pain. The electrocardiogram showed anterior ST-Segment Elevation, and accordingly, the patient was transferred to our Institution for emergency coronary angiography. Past medical history revealed breast reduction, osteosynthesis of the right femur, hemorrhoidal pathology, and iron deficiency anemia. Of interest, drug history revealed a hormonal therapy with intramuscular testosterone undecanoate over the from 2005 for gender conversion (250 mg every 3 weeks) and Tamoxifen 20 mg/die from 2006. The coronary angiography performed after 90 minutes to the symptom onset revealed a total occlusion of the proximal left anterior descending artery (LAD) and minimal atherosclerosis of the remaining vessels. Recanalization of the LAD was achieved by pre-dilatations with a 2.5×15mm balloon catheter, showing diffuse atherosclerosis of the middle and distal LAD involving the origin of a diagonal branch (Medina 1,1,1). Then the lesion was treated with the implantation of three drug-eluting stents in overlap, followed by POBA (Plain Old Balloon Angioplast) of the diagonal branch with a 2.5×12 mm balloon at the ostium (Final TIMI flow III). The patient was then moved to the intensive care unit. Laboratory tests showed an altered lipid panel (overall cholesterol 210 mg/dl and LDL-cholesterol 153 mg/dl), elevated levels of cardiac enzymes (CK-MB 92.5 ng/ml, myoglobin 1606 ng/ml, TnT hs 1014 ng/L and NTproBNP 1263 pg/ml) and anaemia (Hb 9,1 mg/dl). The echocardiogram revealed akinesia of the apex with thrombotic formation (2.0×1.0 mm) and mid-distal anterior wall, with a 40% ejection fraction. Accordingly, parenteral anticoagulant was started. No further complications were observed the day after the procedure, with a progressive reduction of the miocardionecrosis enzymes and thrombotic formation. Ten days after, at the resolution of the thrombotic formation, the patient was discharged. Discussion This case report highlights the importance of primary prevention in patients undergoing long-term testosterone therapy for gender conversion, regardless of age and risk factors. For instance, prior evidence about the risk of recurrent ischemic events in these high-risk patients is poor with a high heterogeneity across the studies. Accordingly, high quality prospective and multicentric studies are needed to assess if there is a correlation between hormonal therapy for gender conversion and cardiovascular disease.

342 TMAO PLASMA LEVELS PREDICT RECURRENT ISCHEMIC EVENTS IN SURVIVORS OF MYOCARDIAL INFARCTION

Abstract Background Recent studies have highlighted a direct link between dietary nutrients, microbiota and cardiovascular disease (CVD). In this context, trimethylamine-N-oxide (TMAO), a metabolite derived from the intestinal microbiota, stands out, paving its way as one of the important biomarkers associated with atherosclerosis, increased risk of CVD, recurrent events and adverse outcomes. Methods 81 patients who survived acute myocardial infarction (AMI), (both STEMI 50 / NSTEMI 31) were enrolled in this study together with 10 healthy individuals. Further, we evaluated the relationship between plasma TMAO levels and cardiovascular events during the follow-up. The measurement of plasma levels of TMAO was performed using liquid chromatography-tandem mass spectrometry (LC-MS). Results The median plasma concentration of TMAO were significantly higher in patients with AMI compared with healthy control (1.62 (1.37–2.25) µM. vs 0.55 (0.35–0.74) µM, p &amp;lt; 0.0001). During a median follow-up of 61.74 (59.34–64.24) months, 10 out of 81 patients (12.3%) had a re-infarction. Patients who had another ischemic event had higher TMAO values compared with individuals who did not (2.29 (1.60–6.49) µM vs 1.60 (1.34–2.09) µM, p = 0.026). Further, TMAO values positively correlate with CRP, a pro-inflammatory marker. However, at multivariate Cox regression analysis, plasma TMAO values were not predictive of re-infarction. Conclusions The data of our pilot study show that higher TMAO values are associated with the risk of recurrent ischemic event. A future prospective study, including larger cohort is necessary to analyze this issue.