Single Antiplatelet Research Articles

191 Intermittent: an audit of venous thromboembolism prophylaxis on our stroke unit

Abstract Background The National Clinical Guideline for Stroke for the United Kingdom and Ireland recommends immobile stroke patients receive Intermittent Compression Stockings (IPCs) to prevent Venous Thromboembolism (VTE) from days 3 to 30 of admission. We set out to audit IPC usage on the stroke unit in our hospital. Methods Data was collected for all 31 stroke unit patients on a single day by two NCHDs. We documented age, gender, length of stay, and mobility status. We recorded completion of the VTE risk section of the medication chart, and if the patient was prescribed single antiplatelet (SAPT), dual antiplatelet (DAPT), direct oral anticoagulant (DOAC) or IPCs. We also noted if the patient’s stroke was ischaemic or haemorrhagic. Results 16 patients were male (52%). Mean age was 72 years old. Median length of stay was 29 days. 23 patients had ischaemic strokes (74%), 8 had haemorrhagic strokes (26%). 21 patients had their VTE risk section completed (68%). 9 ischaemic stroke patients were on DOAC, 9 on SAPT, 4 on DAPT, and 1 was on no therapy. 19 patients (61%) were immobile (assistance of one or higher dependency). Of these, 9 had been admitted for between 3 and 30 days. None had IPCs prescribed and only 1 (11%) had them in situ. 3 were on DOAC therapy (33%). One other patient (admitted 41 days prior) had IPCs in situ but not prescribed. Conclusion 89% of appropriate stroke patients did not have IPCs in situ, and 56% had no VTE prophylaxis at all. The VTE risk section of the medication chart was blank in 32% of cases. Based on these results we are conducting a root cause analysis as to why guidelines are not adhered to. This will guide a planned quality improvement initiative.

175 Navigating the transient ischaemic attack pathway—unveiling the gaps and developing a standard solution

Abstract Background Hyperacute management of a Transient Ischemic Attack (TIA) is necessary to decrease subsequent stroke. We examined our current management of TIA patients to inform a quality improvement initiative to bring our practice in line with the 2023 UK and Ireland Clinical Guidelines for Stroke. Methods We completed a retrospective cohort study of patients who attended our hospital between December 1st 2022 and February 28th 2023. Patients with a primary diagnosis of TIA were identified though the Hospital In-Patient Enquiry (HIPE). Each diagnosis was verified with electronic records review, with exploration of key investigations and management parameters. Results 41 patients were coded as TIA from HIPE. 39 were a verified TIA diagnosis, with a mean age of 68.7 years. 10.2% were seen by direct GP referral to the Acute Medical Unit (AMU), with the rest attending ED initially. The median length of Stay (LoS) in hospital was 2.75 days. Most patients were admitted under the AMU (33%) or Stroke service (26%), with a shorter LoS if the patient was admitted under these services. 38 patients underwent neuroimaging; 94.8% CT Brain, 84.6% MRI Brain, and 82.1% both CT and MRI imaging. 1 patient went directly for MRI Brain without CT imaging. 82.1% were reviewed by a stroke specialist. Dual Anti-Platelet Therapy (DAPT) was used in 3 patients, single antiplatelet in 21, and oral anticoagulation in 9. 3 patients were discharged without any anti-thrombotic therapy. Conclusion This study highlights areas for improvement in the management of TIA in our facility. Our results have informed the development of a new TIA pathway, which will encourage an ambulatory approach to investigations and management of patients with a TIA. Improved patient-centred outcomes may include improved selection for DAPT, improved neuroimaging efficiency with increased direct to MRI imaging and higher numbers of patients being reviewed by a stroke specialist clinician.

105 Antiplatelet therapy and incident cognitive impairment or dementia—a systematic review and Meta-analysis of randomised clinical trials.

Abstract Background The benefit of antiplatelet therapy in the prevention of cognitive impairment or dementia is uncertain. We investigated the association between antiplatelet therapy with incident cognitive impairment or dementia in randomised clinical trials. Methods We searched PubMed, EMBASE, and CENTRAL for randomised clinical trials published from database inception through Feb 1st, 2023. Trials that evaluated the association of antiplatelet therapy with incident cognitive impairment or dementia were included. For single agent antiplatelet, the control group was placebo and for dual agent antiplatelet therapy, the control group was single agent monotherapy. Two authors screened and independently extracted all data, and a random-effects meta-analysis model was used to report pooled treatment effects and 95% Confidence Intervals. The primary outcome was incident cognitive impairment or dementia. Secondary outcomes included change in cognitive test scores. Results Eleven randomised clinical trials were eligible for inclusion (109,860 participants), all of which reported the incidence of cognitive impairment or dementia on follow-up. The mean (SD) age of trial participants was 66.2 (7.9) years and 46,150 (42%) were women. The mean duration of follow-up was 70 months. Antiplatelet therapy, compared to control, was not significantly associated with a reduced risk of cognitive impairment or dementia (11 trials; 109,860 participants) (3.49% vs 4.18% of patients over a mean trial follow-up of 5.8 years; odds ratio [OR], 0.94 [95% CI, 0.88–1.00]; absolute risk reduction, 0.2% [95% CI, −0.4% to 0.009%]; I2 = 0.0%). Antiplatelet therapy was not significantly associated with mean change in cognitive test scores. Conclusion In this meta-analysis of randomised clinical trials, antiplatelet therapy was not significantly associated with a lower risk of incident cognitive impairment or dementia. The confidence intervals around this outcome do not exclude a modest preventative effect, and at a population level this could have a substantial benefit. Further large trials with longer term follow up are needed.

Analysis of post-extraction bleeding in patients taking antithrombotic therapy using data from the longevity improvement and fair evidence study.

Several studies have investigated post-extraction bleeding in patients on antithrombotic therapy, but most included a small sample size. This study aimed to analyse post-extraction bleeding in patients on antithrombotic therapy using data from a large database. Claims data of National Health Insurance and Late-Stage Elderly Healthcare System enrollees who underwent tooth extraction between October 2014 and March 2019 (n = 107 767) in a large multiregional cohort study (Longevity Improvement and Fair Evidence study) were included. Antithrombotic therapy was determined based on the drug codes used at the time of tooth extraction (classified into six groups: no antithrombotic, single antiplatelet, dual antiplatelet, Direct Oral Anticoagulant, warfarin and combined antiplatelet and anticoagulant therapies). The outcome was defined as the presence of "post-extraction bleeding" as a receipt disease name in the same month as tooth extraction. To examine the association between antithrombotic therapy and post-extraction bleeding in detail, multiple logistic regression analysis was performed with post-extraction bleeding as the objective variable; each antithrombotic therapy as the explanatory variable; and age, sex and comorbidities as adjustment variables. Antithrombotic therapy was administered in 14 343 patients (13.3%), and post-extraction bleeding was observed in 419 patients (0.4%). The rate of post-extraction bleeding was significantly lower in the no antithrombotic therapy and single antiplatelet groups than that in the other groups (odds ratio: 2.00-9.02). The frequency of post-extraction bleeding is high in patients on anticoagulation or dual antithrombotic therapy. Therefore, careful preparation before extraction is necessary in these patients.

A Prospective Observational Study on Single Vs Dual Antiplatelet Drug Therapy in Patients with Ischemic Stroke in a Tertiary Care Hospital

From the study, we conclude that patients aged 60–69 are prone to stroke, and the patients who are receiving DAPT have a higher rate of recovery with fewer major bleeding risks when compared with SAPT, but reoccurrence is seen more in SAPT.

Is It Really Safe to Discontinue Antiplatelet Therapy 12 Months After Percutaneous Coronary Intervention in Patients with Atrial Fibrillation?

The prevalence of AF in patients with coronary artery disease is high. The guidelines from many professional groups, including the European Society of Cardiology, American College of Cardiology/American Heart Association and Heart Rhythm Society, recommend a maximum duration of 12 months of combination single antiplatelet and anticoagulation therapy in patients who undergo percutaneous coronary intervention and who have concurrent AF, followed by anticoagulation alone beyond 1 year. However, the evidence that anticoagulation alone without antiplatelet therapy adequately reduces the well-documented attritional risk of stent thrombosis after coronary stent implantation is relatively sparse, particularly given that very late stent thrombosis (>1 year from stent implantation) is the commonest type. By contrast, the elevated risk of bleeding from combined anticoagulation and antiplatelet therapy is clinically important. The aim of this review is to assess the evidence for long-term anticoagulation alone without antiplatelet therapy 1 year post-percutaneous coronary intervention in patients with AF.

Complicated Mycotic Thoracic Aortic Aneurysm Secondary to Staphylococcus aureus Endocarditis

A mycotic aortic aneurysm is a rare and life-threatening condition, with the most common culprit being Staphylococcus aureus. The incidence varies widely from 0.6% to 13%. It usually affects immunocompromised patients, such as those undergoing haemodialysis who are subjected to repeated skin punctures. The insidiousness of the presentation of this high-risk condition makes diagnosis and management challenging. The authors document the case of a 75-year-old woman with multiple comorbidities on maintenance haemodialysis, who also recently underwent central line reinsertions, presenting with progressive leukocytosis and persistent anaemia. Diagnostic work-ups initially showed pneumonia and methicillin-resistant S aureus bacteraemia, later revealing infective endocarditis and a mycotic aortic aneurysm in the descending aorta with contained rupture. A hybrid two-step procedure with debranching and anastomoses of aortic branches was employed, followed by transthoracic endovascular aortic repair. However, the initial success was complicated by a type IIIa endoleak and was repaired using a tapered endograft stent deployed in an overlapping fashion to cover the leak. Long-term management involves a single antiplatelet and antibiotics taken according to the patient’s condition and close surveillance of imaging.

Long-term outcomes of successful left atrial appendage occlusion with focus on stroke prevention: 10-year follow-up of a single-center registry.

Percutaneous left atrial appendage occlusion (LAAO) is an alternative to anticoagulation in the prevention of stroke in patients with nonvalvular atrial fibrillation, especially in patients with a contraindication for oral anticoagulation therapy (OAT). The study sought to obtain long-term patient outcomes after successful LAAO in everyday clinical practice. In this single-center registry spanning over 10 years, data of all consecutive patients that underwent percutaneous LAAO were collected. Observed thromboembolic and major bleeding event rates after successful LAAO during follow-up were compared with expected event rates based on CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category) and HAS-BLED (hypertension, abnormal renal or liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol) scores. Furthermore, anticoagulation and antiplatelet use during follow-up was evaluated. Of 230 patients scheduled for LAAO (38% women, 69.5 ± 8.2 years of age, CHA2DS2-VASc score 3.9 ± 1.6, HAS-BLED score 2.9 ± 1.0), 218 patients had a successful implantation (95%) with a follow-up duration of 5.2 ± 3.1 years. The procedure was combined with catheter ablation in 52% of the patients. Fifty thromboembolic complications (24 ischemic stroke, 26 transient ischemic attack) were observed during follow-up in 40 (18%) of 218 patients. Ischemic strokes occurred with a rate of 2.1 per 100 patient-years, accounting for a 66% relative risk reduction compared with the CHA2DS2-VASc predicted event rate. Device-related thrombus was observed in 5 (2%) patients. Sixty-five nonprocedural major bleeding complications occurred in 24 (11%) of 218 patients with a rate of 5.7 per 100-patient years, which is comparable to estimated HAS-BLED-bleeding rates under OAT use. At end of follow-up 71% of all patients were on single antiplatelet or no antiplatelet or anticoagulation treatment, while 29% were on OAT. Thromboembolic event rates during long-term follow-up after successful LAAO remained consistently lower than expected supporting the efficacy of LAAO.

Antithrombotic regimen in emergent carotid stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis of aggregate data

BackgroundThe periprocedural antithrombotic regimen might affect the risk-benefit profile of emergent carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to tandem lesions, especially after intravenous thrombolysis....

Net clinical benefit of oral anticoagulants in Korean atrial fibrillation patients with low to intermediate stroke risk: A report from the Clinical Survey on Stroke Prevention in patients with Atrial Fibrillation (CS-SPAF).

The balance of stroke risk reduction and potential bleeding risk associated with antithrombotic treatment (ATT) remains unclear in atrial fibrillation (AF) at non-gender CHA2DS2-VASc scores 0-1. A net clinical benefit (NCB) analysis of ATT may guide stroke prevention strategies in AF with non-gender CHA2DS2-VASc scores 0-1. This multi-center cohort study evaluated the clinical outcomes of treatment with a single antiplatelet (SAPT), vitamin K antagonist (VKA), and non-VKA oral anticoagulant (NOAC) in non-gender CHA2DS2-VASc score 0-1 and further stratified by biomarker-based ABCD score (Age [≥60 years], B-type natriuretic peptide [BNP] or N-terminal pro-BNP [≥300 pg/mL], creatinine clearance [<50 mL/min], and dimension of the left atrium [≥45 mm]). The primary outcome was the NCB of ATT, including composite thrombotic events (ischemic stroke, systemic embolism, and myocardial infarction) and major bleeding events. We included 2465 patients (age 56.2 ± 9.5 years; female 27.0%) followed-up for 4.0 ± 2.8 years, of whom 661 (26.8%) were treated with SAPT; 423 (17.2%) with VKA; and 1040 (42.2%) with NOAC. With detailed risk stratification using the ABCD score, NOAC showed a significant positive NCB compared with the other ATTs (SAPT vs. NOAC, NCB 2.01, 95% confidence interval [CI] 0.37-4.66; VKA vs. NOAC, NCB 2.38, 95% CI 0.56-5.40) in ABCD score ≥1. ATT failed to show a positive NCB in patients with truly low stroke risk (ABCD score=0). In the Korean AF cohort at non-gender CHA2DS2-VASc scores 0-1, NOAC showed significant NCB advantages over VKA or SAPT with ABCD score ≥1.

Abstract Number ‐ 157: Effect of Antiplatelet Therapy in Acute Ischemic Stroke with Tandem Lesions

Introduction Recent studies have shown beneficial effects of Carotid artery stenting (CAS) in acute ischemic stroke patients with tandem lesions (TL). However, stent placement requires the use of antiplatelet medications to prevent in‐stent thrombosis and re‐occlusion of the artery. This must be balanced with the risk of intracerebral hemorrhage. In this multicenter study, we aimed to investigate the safety and feasibility of using antiplatelet regimens in patients with anterior circulation stroke with TLs. Methods Patient level data were pooled from 17 centers and included patients with intracranial occlusion of ICA or M1/M2 segment of MCA with a concomitant extracranial ICA occlusion or stenosis ≥ 50%. Inclusion criteria were; age ≥ 18 years, EVT for intracranial occlusion, and underwent treatment for extracranial ICA lesions demonstrated on CTA and/or DSA. Patients were divided into groups according to the number of antiplatelets administered at the time of endovascular therapy (EVT) procedure into four groups including; 1) no antiplatelets, 2) single oral antiplatelet, 3) dual antiplatelets, and 4) intravenous antiplatelets (in combination of single or dual antiplatelets). Multivariable logistic regression models with multiple imputations were built to assess the association of primary outcome; symptomatic intracranial hemorrhage (sICH), and secondary outcomes including; modified Rankin Score (mRS) 0–2 at 90 days, and successful reperfusion (mTICI score ≥ 2b). Results A total of 682 patients were included. Of these, 138 (20.2%) did not receive any antiplatelet therapy, while 143 (20.97%) were treated with single oral, 207 (30.35%) with dual oral, and 194 (28.5%) with intravenous combined with single or dual antiplatelets. The rate of favorable outcome was non‐significantly higher in the dual (53%) and IV‐combination (54.4%) antiplatelets, as compared with single (38.9%) and without antiplatelet (38.6%) medications. In the multivariable model, after adjusting, there was no significant differences in the sICH (single: aOR: 1.07, CI: 0.62‐1.84, p = 0.8, dual: aOR: 1.18, CI: 0.70‐1.99, p = 0.55, IV‐combination: aOR: 1.01, CI: 0.57‐1.78, p = 0.98) and functional outcome at 90 days (single: aOR: 1.15, CI: 0.63‐2.12, p = 0.64, dual: aOR: 1.03, CI: 0.55‐1.9, p = 0.9, IV‐combination: aOR: 0.83, CI: 0.42‐1.64, p = 0.59) among the study groups. Interestingly, successful reperfusion (mTICI score ≥ 2b) was significantly higher in dual oral and IV‐combination antiplatelets (single: aOR: 1.14, CI: 0.61‐2.14, p = 0.69, dual: aOR: 4.82, CI: 2.23‐10.42, p = &lt; 0.001, IV‐combination: aOR: 3.65, CI: 1.71‐7.79, p = 0.001). Conclusions Administration of antiplatelet medications during EVT was associated with successful reperfusion without increasing the rate of symptomatic hemorrhage in patients with anterior circulation LVO with TLs. Further large‐scale randomized studies are warranted to validate the optimal antiplatelet regimens during acute carotid artery stenting in patients with TLs.

Propensity-score-matched analysis of dual antiplatelet treatment and alternative antiplatelet regimens after transcarotid revascularizations

ObjectiveDual antiplatelet therapy (DAPT) continues to be the preferred medication regimen after the placement of a carotid stent using the transcarotid revascularization (TCAR) technique despite a dearth of quality data. Therefore, this investigation was performed to define the risks associated with antiplatelet choice. MethodsWe queried all patients who underwent TCAR captured by the Vascular Quality Initiative from September 2016 to June 2022, to determine the association between antiplatelet choice and outcomes. Patients maintained on DAPT were compared with those receiving alternative regimens consisting of single antiplatelet, anticoagulation, or a combination of the two. A 1:1 propensity-score match was performed with respect to baseline comorbidities, functional status, anatomic/physiologic risk, medications, and intraoperative characteristics. In-hospital and 1-year outcomes were compared between the groups. ResultsDuring the study period, 29,802 procedures were included in our study population, with 24,651 (82.7%) receiving DAPT and 5151 (17.3%) receiving an alternative antiplatelet regimen. A propensity-score match with respect to 29 variables generated 4876 unique pairs. Compared with patients on DAPT, in-hospital ipsilateral stroke was significantly higher in patients receiving alternative antiplatelet regimens (1.7% vs 1.1%, odds ratio [95% confidence interval]: 1.54 [1.10-2.16], P = .01), whereas no statistically significant difference was noted with respect to mortality (0.6% vs 0.5%, 1.35 [0.72-2.54], P = .35). A composite of stroke/death was also more likely in patients receiving an alternative regimen (2.4% vs 1.7%, 1.47 [1.12-1.93], P = .01). Immediate stent thrombosis (2.75 [1.16-6.51]) and a nonsignificant trend toward increased return to the operating room were more common in the alternative patients. Conversely, the incidence of perioperative myocardial infarction was lower in the alternative regimen group (0.4% vs 0.7%, 0.53 [0.31-0.90], P = .02). At 1 year after the procedure, we observed an increased risk of mortality (hazard ratio [95% confidence interval]: 1.34 [1.11-1.63], P < .01) but not stroke (0.52 [0.27-0.99], P = .06) in patients treated with an alternative medication regimen. ConclusionsThis propensity-score-matched analysis demonstrates an increased risk of in-hospital stroke and 1-year mortality after TCAR in patients treated with an alternative medication regimen instead of DAPT. Further studies are needed to elucidate the drivers of DAPT failure in patients undergoing TCAR to improve outcomes for carotid stenting patients.

A Cardiologists' Survey on the Use of Anticoagulants and Antiplatelets in Patients With Atrial Fibrillation and Acute Coronary Syndrome or Those Undergoing Percutaneous Coronary Intervention in India.

The management of patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) requires appropriate antithrombotic regimens for stroke prevention and in-stent thrombosis. Current practice recommendations are largely based on consensus options as there is limited evidence from randomized clinical trials. Hence, by surveying a group of cardiologists across India, we sought to better understand the current practice patterns of using oral anticoagulants (vitamin K antagonist, VKA or non-vitamin K antagonist oral anticoagulant, NOAC) and antiplatelet therapy in those patients in India. A cross-sectional questionnaire-based survey was conducted across India to better understand the clinical practices in AF management. A total of 151 cardiologists participated in this survey. The most commonly prescribed combination therapy in patients with AF and ACS/undergoing PCI was triple therapy (NOAC + dual antiplatelet [aspirin and P2Y12 inhibitor]) (54.30%) followed by NOAC + single antiplatelet (33.11%).Only 11.26% of cardiologists prescribed VKA + dual antiplatelet therapy. Among anticoagulants, cardiologists prescribed NOACs to 66.11%of patients andVKAs to 25.54%of patients. Among P2Y12 inhibitors, ticagrelor (50.99%) and clopidogrel (47.02%) were the most preferred medication. The physician reported patient adherence rates to NOACs were higher compared to VKAs. Around 41.06% of cardiologists reportedly changed antiplatelet therapy for patients from dual antiplatelet to single antiplatelet therapy in three months; 36.42%, in one month; and 19.21% in six months after PCI. Around 61.59% of cardiologists stopped prescribing antiplatelet therapy for patients by one year. Our survey demonstrated that the majority of cardiologists used triple therapy (NOAC + dual antiplatelet), followed by NOAC + single antiplatelet for managing patients with AF and ACS or undergoing PCI in line with the available guidelines.

Abstract WP204: Real World Data On Spontaneous Cervical Artery Dissection From A Comprehensive Stroke Center

Introduction: Cervical artery dissection (CAD) is a common cause of stroke in the young and carries a high risk of early recurrence. We aim to compare the characteristics of patients from a real-world cohort to those from prior randomized controlled trials. Methods: We pooled data from consecutive patients with a diagnosis of spontaneous CAD treated at a comprehensive stroke center who were followed for at least 90 days. We excluded patients with traumatic dissection and those with primary intracranial hemorrhage in the setting of trauma or dissection. We compared the baseline characteristics and stroke recurrence rates in our cohort to the TREAT-CAD (2021) and CADISS (2019) trials. We report recurrence rates in patients treated with single antiplatelet (SAPT), dual antiplatelet (DAPT), and anticoagulation (AC). Results: 80 patients with CAD met our inclusion criteria. Our study sample characteristics differ from TREAT-CAD and CADISS, with our cohort more likely to have hypertension and diabetes but less likely to have a smoking history. The rate of recurrent stroke at 90 days was numerically higher in our patient cohort (6.3%) compared to TREAT-CAD (3.6%) and CADISS (1.6%). The rates of recurrent stroke were 8.6% (3/35) with SAPT, 4.2% (1/24) with DAPT, and 5% (1/20) with AC strategies. Conclusions: Characteristics of a real-world CAD population differ from those enrolled in clinical trials with an overall higher rate of recurrent stroke but comparable rates among patients treated with DAPT and AC. The ongoing STOP-CAD study will compare DAPT to AC with a substantially larger number of patients, with an estimated projection of at least 3000 patients in a multi-center international cohort.

Dual Antiplatelet Therapy Does Not Increase Bleeding Risk in Percutaneous Gastrostomy Tube Placement: Network Meta-Analysis.

Gastrostomy tube (G tube) is a commonly performed procedure for nutritional support. Current guidelines recommend discontinuation of dual antiplatelet therapy (DAPT) prior to G tube placement to reduce bleeding risk. We aim to compare bleeding risk in single, dual and no antiplatelet therapy during G tube placement. We searched PubMed, Embase, Cochrane, and Web of Sciences to include comparative studies evaluating single antiplatelet (aspirin, clopidogrel), dual antiplatelet (DAPT, aspirin and clopidogrel), and no antiplatelet therapy. Direct as well as network meta-analyses comparing these arms were performed. Risk Differences (RD) with confidence intervals were calculated. 12 studies with 8471 patients were included. On direct meta-analysis, there was no significant difference noted between DAPT compared to Aspirin (RD 0.001 95% CI - 0.012 to 0.014, p = 0.87), Clopidogrel (RD 0.001 95% CI - 0.009 to 0.010, p = 0.92) or no antiplatelet group (RD 0.007 95% CI - 0.011 to 0.026, p = 0.44). Results were consistent on network meta-analysis and no difference was noted in bleeding rates when comparing DAPT with Aspirin (RD 0.001, 95% CI - 0.007 to 0.01, p = 0.76), Clopidogrel (RD 0.001, 95% CI - 0.01 to 0.011, p = 0.90) and no antiplatelet group (RD 0.002, 95% CI - 0.007 to 0.012, p = 0.62). There is no significant difference in bleeding risk between DAPT, single antiplatelet or no antiplatelet therapy on a population level. On an individual level, risk of ischemic events should be weighed against the risk of bleeding based on patient circumstances and risk profile. Our findings offer to provide additional data to make an informed decision between patients and physicians to make clinical decisions by assessing individual risks and benefits for optimal care of complex patients.

Antithrombotics prescription pattern and clinical outcomes in atrial fibrillation patients with type 2 diabetes mellitus

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) and Diabetes mellitus (DM) often coexist. As DM is considered while calculating the thromboembolic risk for AF patients, little is known about the prescription pattern of antithrombotic therapies in patients with AF and DM and their clinical outcomes. Purpose In this subsidiary study, we examined the prescription patterns of antithrombotic therapies and clinical outcomes of AF patients with type 2 DM. Methods We analyzed data from a single-center cohort of patients with a primary diagnosis of AF in a tertiary cardiac referral hospital in Malaysia from 1st January 2018 to 31st December 2020. Patients' clinical data and information related to antithrombotic therapy were traced through electronic Hospital Information system. A data collection form was used for data collection. The primary endpoint of the study was a composite cardiovascular (CV) event which consists of all-cause mortality, acute coronary syndrome (ACS), ischemic stroke and transient ischemic attack (TIA). The safety endpoint of the study was a bleeding event, defined as hemoglobin drop more than 2 g/dl, blood transfusion and bleeding at critical area. Results Of the 1006 AF patients (59.2% male; mean age 64.2 (12.1) years), 400 (39.8%) had a history of DM. Of these, 45.8% (n=183) were using warfarin; 46.5% (n=159) used direct oral anticoagulant (DOAC), 54.0% (n=216) used a single antiplatelet, 11.5% (n=46) used a double antiplatelet, 8.0% (n=32) used triple therapy which consists of two antiplatelet agents with one anticoagulant. The use of single antiplatelet agent (54.0% vs 46.4%, p=0.018) and double antiplatelet agents (11.5% vs 7.1%, p=0.016) was significantly associated with AF with DM patients, whereas there was no association between anticoagulant use and AF patients with or without DM (85.5% vs 82.5%, p=0.209). There was no association in composite CV events between AF patients with or without DM (12.0% vs 10.4%, p=0.427). The proportion of subjects who reported having bleeding events were also did not differ by the presence of AF patients with or without DM. (4.5% vs 2.8%, p=0.151). Conclusion Diabetes was associated with increased use of antiplatelet agents; however, DM was not associated with increased risk of composite CV events and bleeding events in patients with concurrent AF. The lack of an association between diabetes and CV risk contrasts with previous research, which could be due to improved diabetes treatment in this cohort of patients with relatively low fasting sugar readings. Further study on the degree of blood glucose as measured by glycosylated hemoglobin (HbA1c) is needed to confirm the finding.

Thrombosis in hereditary hemorrhagic telangiectasia

Thrombosis in hereditary hemorrhagic telangiectasia

Safety and efficacy of short-term dual antiplatelet therapy combined with intensive rosuvastatin in acute ischemic stroke

To investigate the safety and efficacy of short-term (7-day) Dual Antiplatelet Therapy (DAPT) with intensive rosuvastatin in Acute Ischemic Stroke (AIS). In this study, patients with AIS in the emergency department of the hospital from October2016 to December2019 were registered and divided into the control group (Single Antiplatelet Therapy [SAPT]+ rosuvastatin) and the study group (7-day DAPT+intensive rosuvastatin) according to the therapy regimens. The generalized linear model was used to compare the National Institute of Health Stroke Scale (NIHSS) scores between the two groups during the21-day treatment. A Cox regression model was used to compare recurrent ischemic stroke, bleeding events, Statin-Induced Liver Injury (SILI), and Statin-Associated Myopathy (SAM) between the two groups during the90-day follow-up. Comparison of NIHSS scores after21-day treatment: NIHSS scores in the study group decreased significantly, 0.273-times as much as that in the control group (Odds Ratio [OR]0.273; 95%Confidence Interval [95%CI]0.208-0.359; p < 0.001). Comparison of recurrent ischemic stroke during the90-day follow-up: The therapy of the study group reduced the risk of recurrent stroke by 65% (7.76%vs.22.82%, Hazard Ratio [HR]0.350; 95%CI0.167-0.730; p=0.005). Comparison of bleeding events: There was no statistical difference between the two groups (7.79%vs.6.71%, HR=1.076; 95%CI0.424-2.732; p=0.878). No cases of SILI and SAM were found. Short-term DAPT with intensive rosuvastatin effectively relieved the clinical symptoms and significantly reduced the recurrent stroke for patients with mild-to-moderate AIS within90 days, without increasing bleeding events, SILI and SAM.

Efficacy and safety of single versus dual antiplatelet therapy in carotid artery stenting

ObjectiveCurrent guidelines recommend dual antiplatelet (AP) therapy (DAPT) before carotid artery stenting (CAS); however, the true clinical effect of single AP therapy vs DAPT is unknown. We examined the efficacy and safety of preoperative single AP therapy vs DAPT in patients who had undergone transfemoral CAS (tfCAS) or transcarotid artery revascularization (TCAR). MethodsWe identified all patients who had undergone tfCAS or TCAR in the Vascular Quality Initiative database from 2016 to 2021. We stratified the patients by procedure and identified those who had received the following preoperative AP regimens: DAPT (acetylsalicylic acid [ASA] + P2Y12 inhibitor [P2Yi]), no AP therapy, ASA only, ASA + AP loading dose, P2Yi only, and P2Yi + AP loading dose. The AP loading dose was given within 4 hours of CAS. We generated propensity scores for each treatment regimen and assessed in-hospital outcomes using inverse probability weighted log binomial regression, with DAPT as the reference and adjusting for intraoperative protamine use. The primary efficacy outcome was a composite end point of stroke and death, and the primary safety outcome was access-related bleeding. ResultsOf the 18,570 tfCAS patients, 70% had received DAPT, 5.6% no AP therapy, 10% ASA only, 8.0% ASA + AP loading dose, 4.6% P2Yi only, and 2.9% P2Yi + AP loading dose. The corresponding unadjusted rates of stroke/death were 2.2%, 6.8%, 4.1%, 5.1%, 2.4%, and 2.3%. After adjustment, compared with DAPT, the incidence of stroke/death was higher with no AP therapy (relative risk [RR], 2.3; 95% confidence interval [CI], 1.7-3.2), ASA only (RR, 1.6; 95% CI, 1.2-2.1), and ASA + AP loading dose (RR, 2.0; 95% CI, 1.5-2.7) but was similar with P2Yi only (RR, 0.99; 95% CI, 0.58-1.7) and P2Yi + AP loading dose (RR, 1.1; 95% CI, 0.49-2.5). Of the 25,459 TCAR patients, 81% had received DAPT, 2.0% no AP therapy, 5.5% ASA only, 3.5% ASA + AP loading dose, 4.9% P2Yi only, and 2.4% P2Yi + AP loading dose. The corresponding unadjusted rates of stroke/death were 1.5%, 3.3%, 3.3%, 2.9%, 1.2%, and 1.1%. After adjustment, compared with DAPT, the incidence of stroke/death was higher with no AP therapy (RR, 2.0; 95% CI, 1.2-3.3) and ASA only (RR, 2.2; 95% CI, 1.5-3.1), with a trend toward a higher incidence with ASA + AP loading dose (RR, 1.6; 95% CI, 0.99-2.6), and was similar with P2Yi only (RR, 0.98; 95% CI, 0.54-1.8) and P2Yi + AP loading dose (RR, 0.66; 95% CI, 0.27-1.6). No differences were found in the incidence of access-related bleeding between the treatment groups after tfCAS or TCAR. ConclusionsCompared with DAPT, no AP therapy or ASA monotherapy was associated with higher rates of stroke/death after CAS and should be discouraged as unsafe practice. Meanwhile, P2Yi monotherapy was associated with similar rates of stroke/death. No differences were found in the incidence of bleeding complications, and adding an AP loading dose to ASA or P2Yi monotherapy within 4 hours of the procedure did not affect the outcomes. Overall, these findings support the current guidelines recommending DAPT before CAS but also suggest that P2Yi monotherapy might confer thromboembolic benefits similar to those with DAPT. However, an immediate preoperative AP loading dose might not provide additional thromboembolic benefits.

Role of Antiplatelet Therapy in Hemodialysis Arteriovenous Graft Secondary Patency Following Successful Percutaneous Thrombectomy.

The purpose of this study was to elicit the relationship of antiplatelet therapy (AP) in maintaining arteriovenous graft (AVG) patency after successful percutaneous pharmacomechanical thrombectomy ("declot"). This was an institutional review board-approved retrospective review of AVG declot procedures between July 2019 and August 2020. AVG characteristics, bleeding complications, anticoagulation and antiplatelet medication regimens, and thrombosis free survival were evaluated. Recurrent time-to-event analysis was performed using a Prentice-Williams-Peterson Gap time model was performed to evaluate AVG thrombosis free survival. A total of 109 declots were technically successful and performed in 63 individual patients. The majority of procedures were performed in upper arm grafts (71%, n = 45). Dual antiplatelet (DAPT) was prescribed after 52 declots (48%), single antiplatelet was prescribed after 36 declots (33%), and anticoagulation was prescribed after 31 declots (28%). Median thrombosis free survival was 37days (range 1-412days) in the no antiplatelet group, 84days (range 1-427days) in the single antiplatelet group, and 93days (range 3-407days) in the DAPT group. Anti-platelet medications trended towards protective of AVG thrombosis in multivariate analysis (hazard ratio 0.84, 95% confidence interval 0.60-1.19); however, this did not reach statistical significance (P = 0.33). A total of 4 major and 5 minor bleeding events occurred. The results of this study support further evaluation of AP therapy in preventing secondary rethrombosis of dialysis AVG.