Routine Aspirin Research Articles

Routine Postoperative Aspirin for VTE Chemoprophylaxis in Primary Total Ankle Arthroplasty

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: The use of low-dose aspirin for postoperative venous thromboembolism (VTE) chemoprophylaxis has been widely studied and validated in adult reconstruction surgery with little to no reported adverse reactions. In total ankle arthroplasty (TAA) literature, low-molecular-weight heparin (LMWH) has been the predominant chemoprophylactic agent used, despite little evidence supporting it. To date, no studies have assessed the role of aspirin for VTE chemoprophylaxis after total ankle arthroplasty and no formalized clinical practice guideline exists. The purpose of this study was to evaluate outcomes of a large consecutive series of patients undergoing primary TAA at a single institution, in relation to routine postoperative aspirin administration. Methods: A prospective telephone survey and retrospective chart review was performed of patients undergoing primary TAA at a single institution by two fellowship trained foot and ankle surgeons. All patients were prescribed oral aspirin 81 mg BID for at least 2 weeks postoperatively, (or while weight-bearing was restricted). The primary outcome variable was postoperative development of deep vein thrombosis (DVT), pulmonary embolism (PE), or VTE related mortality within 3 months postoperatively. Venous ultrasounds were also queried. The secondary outcome variable was assessment of aspirin related adverse reaction including delayed wound healing and gastrointestinal (GI) bleeding. Patients with a history of bleeding disorder or history of prior VTE requiring non-Aspirin VTE chemoprophylaxis were excluded. Results: There were 217 patients included for retrospective review, and 81 patients completed the telephone survey (34% response rate). Concomitant procedures included gastrocnemius recession (104), teno-Achilles lengthening (20), ligament repair (17), tendon repair (3), tendon transfer (12), and plantar fasciectomy (1). The cohort included 119 males (54.8%), with a mean age 62.6 +/- 10.3 years (range 24 to 88), and mean BMI 30.6 +/- 5.6 (range 21.3 to 52.6). There were no GI bleeding or VTE events, yet 46/217 (21.2%) cases of delayed wound healing. Eleven patients underwent venous ultrasounds that all were negative. Sex (p=0.458), age (p=0.443), and BMI (p=0.335) were not associated with delayed wound healing, but current/former smoking status trended toward significant association (p=0.077). Time to weight-bearing was mostly bi-modal, between 1.5-3.5 weeks (37.8%) or 5.5-7.5 weeks (45.1%). Time to weight-bearing approached significance with delayed wound healing (p=0.05), which may represent surgeon intervention to promote healing. Conclusion: This study demonstrates effective use of aspirin in preventing VTE events after primary TAA in patients without risk factors for VTE and PE, which is cheaper and more widely available all around the world. Further randomized controlled studies may better elucidate any role of aspirin with regards to delayed wound healing, which had an an approximate incidence of 20% in our cohort. Limitations of the study include those inherent to a retrospective review, such as lack of a control group.

Association of aspirin therapy with prognosis in patients with non obstructive coronary artery disease: A systematic review and meta-analysis

Background: The effect of aspirin therapy in patients with nonobstructive Coronary Artery Disease (CAD) remains controversial. This study aimed to investigate the association between aspirin therapy and prognosis in nonobstructive CAD. Methods: We searched for observational cohort studies on Pubmed, Embase, the Cochrane Library and Web of Science. Studies were included that compared the endpoint differences in patients with nonobstructive CAD who were treated with aspirin or not. The primary endpoint was a composite of Major Adverse Cardiovascular Events (MACEs). Secondary endpoints included all-cause death, cardiovascular death and Myocardial Infarction (MI). The pooled effect size was estimated as Hazard Ratio (HR) with 95% Confidence Interval (CI), which was measured by a random effect model using the generic inverse variance method. Results: Thirteen published studies with 34,463 patients were included Pooled data showed that aspirin therapy was not associated with the risk of MACEs (HR 1.10; 95% CI 0.85–1.41; P=0.47, I2=57%). Similar results were observed in cardiovascular death (HR 1.12; 95% CI 0.73–1.73; P=0.60, I2=0%) and MI (HR 0.53; 95% CI 0.09–3.20; P=0.49, I2=68%), except all-cause death (HR 0.77; 95% CI 0.63–0.95; P=0.02, I2=25%). Subgroup analyses showed that there were no associations between aspirin therapy and MACEs in all subsets. Conclusions: Routine aspirin therapy might not be associated with a decreased risk of cardiovascular events in patients with nonobstructive CAD. Aspirin therapy in non-obstructive CAD should be better investigated and future research is needed. A personalized antiplatelet regimen may contribute to reduction in ischemic cardiovascular events for these patients.

A dissection … of the Dacron?

A dissection … of the Dacron?

Clinical Characteristics and Pharmacological Management of COVID-19 Vaccine–Induced Immune Thrombotic Thrombocytopenia With Cerebral Venous Sinus Thrombosis

The COVID-19 pandemic saw one of the fastest developments of vaccines in an effort to combat an out-of-control pandemic. The 2 most common COVID-19 vaccine platforms currently in use, messenger RNA (mRNA) and adenovirus vector, were developed on the basis of previous research in use of this technology. Postauthorization surveillance of COVID-19 vaccines has identified safety signals, including unusual cases of thrombocytopenia with thrombosis reported in recipients of adenoviral vector vaccines. One of the devastating manifestations of this syndrome, termed vaccine-induced immune thrombotic thrombocytopenia (VITT), is cerebral venous sinus thrombosis (CVST). This review summarizes the current evidence and indications regarding biology, clinical characteristics, and pharmacological management of VITT with CVST. VITT appears to be similar to heparin-induced thrombocytopenia (HIT), with both disorders associated with thrombocytopenia, thrombosis, and presence of autoantibodies to platelet factor 4 (PF4). Unlike VITT, HIT is triggered by recent exposure to heparin. Owing to similarities between these 2 conditions and lack of high-quality evidence, interim recommendations suggest avoiding heparin and heparin analogues in patients with VITT. Based on initial reports, female sex and age younger than 60 years were identified as possible risk factors for VITT. Treatment consists of therapeutic anticoagulation with nonheparin anticoagulants and prevention of formation of autoantibody-PF4 complexes, the latter being achieved by administration of high-dose intravenous immunoglobin (IVIG). Steroids, which can theoretically inhibit the production of new antibodies, have been used in combination with IVIG. In severe cases, plasma exchange should be used for clearing autoantibodies. Monoclonal antibodies, such as rituximab and eculizumab, can be considered when other therapies fail. Routine platelet transfusions, aspirin, and warfarin should be avoided because of the possibility of worsening thrombosis and magnifying bleeding risk. Adverse events like VITT, while uncommon, have been described despite vaccination remaining the most essential component in the fight against the COVID-19 pandemic. While it seems logical to consider the use of types of vaccines (eg, mRNA-based administration) in individuals at high risk, treatment should consist of therapeutic anticoagulation mostly with nonheparin products and IVIG.

Pediatric stroke as the presenting symptom of new-onset type 1 diabetes mellitus without DKA: case report and literature review

Background Stroke and other neurologic complications are rare in pediatric type 1 diabetes mellitus (T1DM) without severe diabetic ketoacidosis (DKA) or poor glycemic control. Case presentation A previously healthy, 10-year-old female presented with acute thalamic stroke, non-acidotic new T1DM diagnosis and negative hypercoagulopathy workup. She received routine insulin therapy and aspirin, and returned to neurologic baseline within a year without stroke recurrence. Conclusions The contribution of non-acidotic hyperglycemia to stroke risk is better described in adults. Even though unable to prove causality, this case should at least raise awareness of the possible association of pediatric new-onset diabetes and stroke for optimal outcomes.

Hypertension Editors' Picks Preeclampsia.

Hypertension Editors' Picks Preeclampsia.

Preeclampsia Prevention Using Routine Versus Screening Test-Indicated Aspirin in Low-Risk Women.

The objective was to evaluate whether routine aspirin 75 mg is more cost-effective than the Fetal Medicine Foundation screen-and-treat approach for preeclampsia prevention in low-risk nulliparous women. A health economic decision analytical model was devised to estimate the discounted net health and cost outcomes of routine aspirin versus Fetal Medicine Foundation screening test-indicated aspirin for a cohort of 100 000 low-risk nulliparous women. Both strategies were compared with no intervention. A subanalysis also compared disaggregated components of the algorithm. The analysis used data from hospital administration, literature, and a randomized controlled trial. Sensitivity analyses assessed the impact of aspirin adherence, test cost, and accuracy on study results. Presumed rates of preeclampsia were 3.75% with no intervention versus 0.45% with aspirin use. Results found that routine aspirin was the preferred strategy, in terms of greater health gains and larger cost savings. It provided 163 quality-adjusted life-years relative to no intervention, whereas the screen-and-treat policy achieved 108 quality-adjusted life-years. Routine aspirin would result in an estimated cost saving of €14.9 million annually relative to no intervention, whereas screen-and-treat approach would result in a smaller cost saving of €3.1 million. When the analysis was extended to consider alternative screen-and-treat strategies, routine aspirin remained the optimally cost-effective approach. In conclusion, routine aspirin use in low-risk nulliparous women has a greater health gain and cost saving compared with both the Fetal Medicine Foundation and other screen-and-treat approaches.

The Impact of Aspirin on Ultrasound Markers of Uteroplacental Flow in Low-Risk Pregnancy: Secondary Analysis of a Multicenter RCT.

This article evaluates the effect of low-dose aspirin on uterine artery (UtA) Doppler, placental volume, and vascularization flow indices in low-risk pregnancy. In this secondary analysis of the TEST randomized controlled trial, low-risk nulliparous women were originally randomized at 11 weeks to: (1) routine aspirin 75 mg; (2) no aspirin; and (3) aspirin based upon the preeclampsia Fetal Medicine Foundation screening test. UtA Doppler, three-dimensional (3D) placental volume, and vascularization flow indices were assessed prior to and 6 weeks postaspirin commencement. A total of 546 women were included (aspirin n = 192, no aspirin n = 354). Between first and second trimesters, aspirin use was not associated with a change in UtA Doppler, placental volume, or vascular flow indices. There was no significant difference in the change in UtA Doppler pulsatility index (PI) Z-scores or notching (PI Z-score -0.2 vs. -0.2, p = 0.17), nor was there a significant change in placental volume Z-score and vascular flow indices (volume Z-score change: 0.74 vs. 0.62, p = 0.34). Low-dose aspirin commenced at 11 weeks in low-risk women does not appear to improve uterine and placental perfusion or placental volume. Any perceived effect on uteroplacental vasculature is not reflected in changes in placental volume nor uteroplacental flow as assessed by two-dimensional and 3D ultrasound.

Trial of feasibility and acceptability of routine low-dose aspirin versus Early Screening Test indicated aspirin for pre-eclampsia prevention (TEST study): a multicentre randomised controlled trial

ObjectiveEvaluate the feasibility and acceptability of routine aspirin in low-risk women, compared with screening-test indicated aspirin for the prevention of pre-eclampsia and fetal growth restriction.DesignMulticentre open-label feasibility randomised controlled trial.SettingTwo...

Retrospective Study on the Safety and Efficacy of Clopidogrel in the Treatment of Acute Cerebral Infarction

Till now there’s no large sample, randomized and double-blinded research of clopidogrel in acute cerebral infarction. There have been some studies of combined and loading dosage of clopidogrel for antiplatelet treatment but the NIHSS is no more than 5 potints. Our study is to evaluate the efficacy and safety of clopidogrel in acute ischemic stroke. It’s a single center retrospective study. Collect information of patients with acute ischemic stroke from January 1st 2012 to May 31st 2015, using of different antiplatelet drugs, occuring of progressive ischemic stroke, risk factors of cardiovascular and cerebrovascular diseases, etiological classification of cerebral infarction, NIHSS scores on admission and 7 days after admission were collected and was calssified into different groups (NIHSS≤3, 4-7, 8-15 and ＞15 potints). correlation statistical analysis was performed with chi-square test. A total of 1008 patients were collected, 94 of them had progressive ischemic stroke. There was no significant difference between aspirin group and clopidogrel group (routine clopidogrel group and loading clopidogrel group) within 7 days of onset. Clopidogrel group was superior to aspirin in reducing early recurrence and deterioration within 24 hours while NIHSS on admission was greater than 3 points. PIS has close relation to admission time after onset and severity of clinc. There was no significant difference in the incidence of safety events between aspirin and clopidogrel (routine clopidogrel and loading clopidogrel). Loading dosage of clopidogrel is as safe as the routine group and aspirin group.

Continuation of Aspirin Therapy before Cataract Surgery with Different Incisions: Safe or Not?

Purpose To assess whether to continue aspirin therapy while having uncomplicated phacoemulsification cataract surgery with different incisions. Methods Consecutive patients having cataract surgery under topical anesthesia with different incisions between May 2016 and August 2017 were followed. 236 eyes of 166 patients on routine aspirin therapy were randomized into 2 groups: continuation group, 112 eyes; discontinuation group, 124 eyes. 121 eyes of 94 patients on no routine anticoagulant therapy were used as the control group. Patients were examined 1 day preoperatively and 1 day and 7 days postoperatively. Intraoperative and postoperative complications were recorded. Results Statistically, there was no significant difference about postoperative BCVA among three groups. A higher incidence of subconjunctival hemorrhage was shown in the continuation group than in the discontinuation group and the control group (17.0% versus 8.1%, p=0.038; 17.0% versus 7.4%, p=0.025, resp.). Although corneal edema was greater in clear corneal incision cases than that of scleral tunnel incision cases (22.5% versus 12.0%, p=0.009), subconjunctival hemorrhage was greater in scleral tunnel incision cases (14.9% versus 6.6%, p=0.011). Subgroup analyses revealed that patients of scleral tunnel incision who continued taking aspirin had a higher incidence of subconjunctival hemorrhage compared with those who discontinued (25.5% versus 10.9%, p=0.038), but no same conclusion in clear corneal incision cases (8.8% versus 5.0%, p=0.483). Conclusions The outcomes indicated that phacoemulsification cataract surgery under topical anesthesia could be safely performed without ceasing systemic aspirin therapy. Clear corneal incision could be a better choice in patients treated with aspirin.

Antecedent Aspirin Use Is Associated with Less Severe Symptoms on Admission for Ischemic Stroke

Aspirin is known to reduce stroke risk; however, its role in reducing severity of ischemic syndrome is not clear. We sought to investigate the relationship between antecedent aspirin use and stroke severity in patients presenting with acute ischemic stroke (AIS). We retrospectively analyzed a prospectively collected database of consecutive AIS patients presenting to our center. Clinical characteristics (including antecedent aspirin use), imaging findings, and laboratory data were assessed in association with presenting stroke severity, as measured by the National Institutes of Health Stroke Scale (NIHSS). Logistic regression models were used to determine univariate and multivariate predictors of baseline NIHSS. Of the 610 AIS patients with admission brain magnetic resonance imaging available for volumetric analysis of acute infarct size, 241 (39.5%) used aspirin prior to stroke onset. Antecedent aspirin use (P = .0005), history of atrial fibrillation (P < .0001), acute infarct volume (P < .0001), initial systolic blood pressure (P = .041), admission glucose level (P = .0027), and stroke subtype (P < .0001) were associated with presenting stroke severity in univariate analysis. Antecedent aspirin use (P < .0001), history of atrial fibrillation (P < .0002), acute infarct volume (P < .0001), systolic blood pressure (P = .038), and glucose level (P = .0095) remained independent predictors of NIHSS in multivariable analysis. Antecedent aspirin use was independently associated with milder presenting stroke severity, even after accounting for acute infarct volume. While the underlying biology of this apparent protective relationship requires further study, patients at high risk of stroke may benefit from routine aspirin use.

Long-term follow-up of pediatric moyamoya disease treated by combined direct-indirect revascularization surgery: single institute experience with surgical and perioperative management.

Moyamoya disease (MMD) is a rare occlusive cerebrovascular disease that mainly presents in children as cerebral ischemia. Prompt treatment with either a direct or indirect revascularization procedure is necessary for children with MMD in order to prevent repeated ischemic events. We herein present our experience with combined direct and indirect bypass surgery for the treatment of pediatric MMD as well as our uniquely designed perioperative protocol. Twenty-three patients with MMD, aged between 2 and 16years old (mean 9.36), underwent 38 combined bypass procedures between 2008 and 2015. All patients underwent single superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis combined with encephalo-duro-myo-synangiosis (EDMS). The perioperative management protocol was stratified into two unique eras: the first era with normotensive care and the second era with strict blood pressure control (systolic 100-130mmHg) and routine aspirin administration. Patients were followed after surgery for a period ranging between 3 and 131months (mean 77months) in yearly clinical and radiological follow-ups. Three postoperative complications were observed: two cases of cerebral hyperperfusion (2/38, 5.3%) and one case of perioperative minor stroke (1/38, 2.6%), two of which were in the first era. No strokes, either ischemic or hemorrhagic, were observed in the follow-up period, and the activity of daily living as shown by the modified Rankin Scale improved in 20 patients, with no deterioration being observed in any of our patients. STA-MCA bypass with EDMS is safe and effective for the management of pediatric MMD and provides long-term favorable outcomes. Perioperative care with blood pressure control combined with the administration of aspirin may reduce the potential risk of surgical complications.

Aspirin for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer: A Decision Analysis for the U.S. Preventive Services Task Force.

Evidence indicates that aspirin is effective for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) but also increases the risk for gastrointestinal (GI) and cerebral hemorrhages. To assess the net balance of benefits and harms from routine aspirin use across clinically relevant age, sex, and CVD risk groups. Decision analysis using a microsimulation model. 3 systematic evidence reviews. Men and women aged 40 to 79 years with a 10-year CVD risk of 20% or less, and no history of CVD and without elevated risk for GI or cerebral hemorrhages that would contraindicate aspirin use. Lifetime, 20 years, and 10 years. Clinical. Low-dose aspirin (≤100 mg/d). Primary outcomes are length and quality of life measured in net life-years and quality-adjusted life-years. Benefits include reduced nonfatal myocardial infarction, nonfatal ischemic stroke, fatal CVD, CRC incidence, and CRC mortality. Harms include increased fatal and nonfatal GI bleeding and hemorrhagic stroke. Lifetime net quality-adjusted life-years are positive for most adults initiating aspirin at ages 40 to 69 years, and life expectancy gains are expected for most men and women initiating aspirin at ages 40 to 59 years and 60 to 69 years with higher CVD risk. Harms may exceed benefits for persons starting aspirin in their 70s and for many during the first 10 to 20 years of use. Results are most sensitive to the relative risk for hemorrhagic stroke and CVD mortality but are affected by all relative risk estimates, baseline GI bleeding incidence and case-fatality rates, and disutilities associated with aspirin use. Aspirin effects by age are uncertain. Stroke benefits are conservatively estimated. Gastrointestinal bleeding incidence and case-fatality rates account only for age and sex. Lifetime aspirin use for primary prevention initiated at younger ages (40 to 69 years) and in persons with higher CVD risk shows the greatest potential for positive net benefit. Agency for Healthcare Research and Quality.

47-Year-Old Man With Pruritus

47-year-old man with a medical history of headaches and seasonal allergies presented to the primary care clinic in late fall for evaluation of diffuse pruritus of 6 weeks’ duration that had occurred after initiating a new diet. The diet mostly restricted foods like dairy, soy, nuts, grains, and processed foods, but he stated that he had substantially increased his consumption of coconut and various spices including turmeric. The itching was present over most of his body but most prominent on the inner thighs and most notable after a hot shower. He provided picturesfromrecent episodes thatillustrated linear excoriations on the thighs. When he showered in cooler water, the diffuse pruritus was still present but minimally improved compared with a hot shower. He had been using the same body soap for years but tried a new soap without relief from the itching. In addition, he changed laundry detergent from one he had used for years with no relief. He had no occupational or habitual exposures that are suspected to contribute to pruritus. Overthe-counter hydrocortisone cream applied to his thighs provided minimal relief. His weight had been stable, and he reported no constitutional symptoms. On physical examination, the patient was a

Update on perioperative care of the cardiac patient for noncardiac surgery.

The current review will address key topics and recommendations of the recent 2014 update of the American College of Cardiology and American Heart Association clinical practice guideline for the perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. The completely rewritten guideline provides a stepwise approach for the identification and management of patients at highest risk for major adverse cardiac events and discusses new or updated recommendations. For example, β-blockers should be continued perioperatively but treatment should not be initiated within 24 h of noncardiac surgery. Angiotensin-converting enzyme inhibitors should be continued, but if held, may be restarted as soon as feasible. Routine aspirin therapy is not recommended without previous coronary stent implantation or risk assessment for myocardial ischemia. Elective noncardiac surgery should not be performed within 30 days of bare metal stent or 12 months of drug-eluting stent implantation because of in-stent thrombosis as well as bleeding risk from dual antiplatelet therapy during surgery. Noncardiac surgery may be considered, however, in patients on antiplatelet agents 180 days after drug-eluting stent placement if risk of surgical delay exceeds risk of stent thrombosis from cessation of antiplatelet therapy. In conclusion, this review will discuss the important topics from the 2014 American College of Cardiology/American Heart Association guideline in order to provide the perioperative physician with the most recent evidence necessary to minimize major adverse cardiac events in patients undergoing noncardiac surgery.

Aspirin use and knowledge in the community: a population- and health facility based survey for measuring local health system performance

BackgroundLittle is known about the relationship between cardiovascular risk, disease and actual use of aspirin in the community.MethodsThe Measuring Disparities in Chronic Conditions (MDCC) study is a community and health facility-based survey designed to track disparities in the delivery of health interventions for common chronic diseases. MDCC includes a survey instrument designed to collect detailed information about aspirin use. In King County, WA between 2011 and 2012, we surveyed 4633 white, African American, or Hispanic adults (45% home address-based sample, 55% health facility sample). We examined self-reported counseling on, frequency of use and risks of aspirin for all respondents. For a subgroup free of CAD or cerebral infarction that underwent physical examination, we measured 10-year coronary heart disease risk and blood salicylate concentration.ResultsTwo in five respondents reported using aspirin routinely while one in five with a history of CAD or cerebral infarction and without contraindication did not report routine use of aspirin. Women with these conditions used less aspirin than men (65.0% vs. 76.5%) and reported more health problems that would make aspirin unsafe (29.4% vs. 21.2%). In a subgroup undergoing phlebotomy a third of respondents with low cardiovascular risk used aspirin routinely and only 4.6% of all aspirin users had no detectable salicylate in their blood.ConclusionsIn this large urban county where health care delivery should be of high quality, there is insufficient aspirin use among those with high cardiovascular risk or disease and routine aspirin use by many at low risk. Further efforts are needed to promote shared-decision making between patients and clinicians as well as inform the public about appropriate use of routine aspirin to reduce the burden of atherosclerotic vascular disease.

Circulating interleukin-6, soluble CD14, and other inflammation biomarker levels differ between obese and nonobese HIV-infected adults on antiretroviral therapy.

Obesity and chronic, treated HIV infection are both associated with persistent systemic inflammation and a similar constellation of metabolic and cardiovascular diseases, but the combined effects of excess adiposity and HIV on circulating proinflammatory cytokines and other biomarkers previously shown to predict disease risk is not well described. We measured inflammation biomarker levels in 158 predominantly virologically suppressed adults on long-term antiretroviral therapy (ART) with a range of body mass index (BMI) values from normal to morbidly obese. We assessed the relationship between BMI and each biomarker using multivariable linear regression adjusted for age, sex, race, CD4(+) count, tobacco use, data source, protease inhibitor use, and routine nonsteroidal antiinflammatory drug (NSAID) or aspirin use. Among normal-weight (n=48) and overweight participants (n=41; BMI <30 kg/m(2)), incremental BMI increases were associated with significantly higher serum highly sensitive C-reactive protein (hsCRP; β=2.47, p=0.02) and tumor necrosis factor (TNF)-α receptor 1 levels (β=1.53, p=0.03), and significantly lower CD14 levels (β=0.84, p=0.01), but similar associations were not observed in the obese participants. Among the obese (n=69; BMI ≥30 kg/m(2)), however, higher serum levels of interleukin-6 (IL-6; β=1.30, p=0.02) and macrophage inflammatory protein-1α (β=1.77, p<0.01) were associated with higher BMI, a finding not observed among the nonobese. Among all participants, IL-6 and TNF-α receptor 1 levels were most closely associated with hsCRP (p<0.01). Further studies are needed to determine whether higher serum inflammation biomarker levels found in obese HIV-infected individuals on ART reflect an increased likelihood of adverse health outcomes, or if novel markers to estimate mortality and disease risk are needed in this population.

Considerations in treating acute coronary syndromes with possible coexisting asthma

When a patient presents with symptoms of an acute coronary syndrome (ACS) routine administration of antiplatelet and betablocking therapy is recommended according to the NICE guidance ( Cooper 2010 ). However certain comorbid conditions that may point to underlying asthma should be considered and the risk:benefit ratio assessed before administration of routine aspirin prophylaxis and betablockers on diagnosis of ACS. Bronchial hyperreactivity in response to betablockers and/or aspirin may result in rapid bronchospasm, severe dyspnoea and possible death in susceptible individuals. The presence of allergic rhinitis, nasal polyposis and chronic rhinosinusitis must be considered in the overall assessment and where a decision to treat is made, cardio-selective betablockers should be initiated at very low doses with close monitoring.

Dual Antiplatelet Therapy Prior to Carotid Endarterectomy Reduces Post-operative Embolisation and Thromboembolic Events: Post-operative Transcranial Doppler Monitoring is now Unnecessary

Background Thrombotic stroke following carotid endarterectomy (CEA) is preceded by high-grade embolisation (detected using transcranial Doppler (TCD)) and can be prevented by incremental doses of Dextran. However, this strategy is labour intensive and Dextran manufacture has now ceased. A randomised trial has suggested that a single 75 mg dose of Clopidogrel (administered the night before surgery in addition to daily 75 mg Aspirin) significantly reduces post-CEA embolisation. We hypothesized that this model of dual antiplatelet therapy might significantly reduce the need for adjuvant Dextran therapy. Methods Retrospective audit of prospectively acquired data in 297 patients undergoing CEA between 01.08.2006 and 30.07.2009. All received routine Aspirin (75 mg daily) in addition to a single 75 mg dose of Clopidogrel the night before surgery. All underwent completion angioscopy and those with a temporal window ( n = 270) underwent intra- and post-operative TCD monitoring. Results High rate embolisation requiring Dextran (>25 emboli in any 10 min period) occurred in only 1/270 patients (0.4%), significantly less than the 3.2% rate in historical controls where Clopidogrel was not administered. There were no peri-operative deaths, but 3/297 patients suffered non-disabling strokes (intra-operative extension of a pre-existing deficit, haemorrhage into lentiform nucleus after hypertensive crisis, contralateral embolic stroke). The overall 30-day death/stroke rate (1.0%) was not-significantly lower than the 2.6% rate observed in the preceding 821 patients. Conclusions 75 mg Clopidogrel administered the night before surgery (in addition to daily 75 mg Aspirin) was associated with a significant reduction in post-operative embolisation and Dextran utilisation. No ipsilateral thromboembolic ischaemic events occurred in this series. As a consequence of this audit, one dose of 75 mg Clopidogrel will continue to be given pre-operatively (in addition to daily 75 mg Aspirin) and routine post-operative TCD monitoring has now ceased.