Use Of Thienopyridines Research Articles

Long-term Risks of Recurrence After Hospital Discharge for Acute Lower Gastrointestinal Bleeding: A Large Nationwide Cohort Study

Currently, large, nationwide, long-term follow-up data on acute lower gastrointestinal bleeding (ALGIB) are scarce. We investigated long-term risks of recurrence after hospital discharge for ALGIB using a large multicenter dataset. We retrospectively analyzed 5048 patients who were urgently hospitalized for ALGIB at 49 hospitals across Japan (CODE BLUE-J study). Risk factors for the long-term recurrence of ALGIB were analyzed by using competing risk analysis, treating death without rebleeding as a competing risk. Rebleeding occurred in 1304 patients (25.8%) during a mean follow-up period of 31 months. The cumulative incidences of rebleeding at 1 and 5 years were 15.1% and 25.1%, respectively. The mortality risk was significantly higher in patients with out-of-hospital rebleeding episodes than in those without (hazard ratio, 1.42). Of the 30 factors, multivariate analysis showed that shock index ≥1 (subdistribution hazard ratio [SHR], 1.25), blood transfusion (SHR, 1.26), in-hospital rebleeding (SHR, 1.26), colonic diverticular bleeding (SHR, 2.38), and thienopyridine use (SHR, 1.24) were significantly associated with increased rebleeding risk. Multivariate analysis of colonic diverticular bleeding patients showed that blood transfusion (SHR, 1.20), in-hospital rebleeding (SHR, 1.30), and thienopyridine use (SHR, 1.32) were significantly associated with increased rebleeding risk, whereas endoscopic hemostasis (SHR, 0.83) significantly decreased the risk. These large, nationwide follow-up data highlighted the importance of endoscopic diagnosis and treatment during hospitalization and the assessment of the need for ongoing thienopyridine use to reduce the risk of out-of-hospital rebleeding. This information also aids in the identification of patients at high risk of rebleeding.

Risk of Bleeding with Endoscopic Ultrasound-Guided Tissue Acquisition in Patients on Antithrombotic Therapy: A Systematic Review and Meta-Analysis.

The present guidelines stratify endoscopic ultrasound-guided tissue acquisition (EUS-TA) as a high-bleeding risk procedure in patients on antithrombotics. However, the data regarding the same are conflicting. Therefore, this meta-analysis aimed to analyze the bleeding event rates associated with EUS-TA in patients receiving antithrombotic therapy. A literature search from January 2000 to August 2022 was done for studies on EUS-guided TA in patients receiving antithrombotics. The primary outcome was incidence of overall and major bleeding. Pooled event rates across studies were expressed with summative statistics. A total of 12 studies were included in the meta-analysis. The pooled risk of overall bleeding and major bleeding in patients on antithrombotics was 2.0% (0.6-3.4) and 0.8% (0.0-1.6), respectively. In patients taking thienopyridine or anticoagulants, the pooled risk of overall bleeding and major bleeding was 2.4% (0.9-3.9) and 1.7% (0.4-3.1), respectively. Patients on antithrombotics had a higher odd of overall bleeding (OR 2.12, 1.20-3.83) and major bleeding (OR 3.58, 1.11-11.52) compared to controls. The odds of overall bleeding (OR 0.95, 95%CI 0.38-2.42) and major bleeding (OR 1.57, 95%CI 0.45-5.54) were comparable between patients on antithrombotics who continued and those who discontinued it preprocedural. Despite an increase risk of bleeding with EUS-TA in patients on antithrombotics, the pooled incidence remains low. Compared to the previous guidelines stating thienopyridine use as high risk for bleeding, the present analysis showed a bleeding rate of less than 1%. Discontinuing antithrombotics prior to EUS-TA does not reduce the bleeding risk significantly, requiring strict monitoring.

Factors associated with recurrent spontaneous coronary artery dissection: a systematic review and meta-analysis.

The risk of recurrent spontaneous coronary artery dissection (SCAD) is a major concern to SCAD patients and clinicians. Identifying the high-risk subsets of recurrent SCAD remains an ongoing challenge. The meta-analysis aimed to assess the potential predictors for SCAD recurrence. A literature search was performed in PubMed to collect studies that assessed potential factors associated with recurrence of SCAD among angiographically confirmed SCAD patients, including pregnancy, ventricular arrhythmia at presentation, history of hypertension, migraine, fibromuscular dysplasia (FMD), extracoronary vascular abnormalities (EVA), recent emotional or physical stress, and use of thienopyridine, beta-blocker, or statin. A meta-analytic approach was employed to estimate the relative risk (RR) with a 95% confidence interval (CI) by fitting random-effects models using the generic inverse variance weighted method. A total of 14 studies representing 4206 SCAD patients were included. Hypertension (RR, 1.49; 95% CI, 1.05-2.12; P = 0.0247) and FMD (RR, 2.02; 95% CI, 1.03-3.94; P = 0.0404) were associated with a greater risk of SCAD recurrence. The use of beta-blocker (RR, 0.51; 95% CI, 0.33-0.77; P = 0.0013) was associated with a lower risk of SCAD recurrence. Pregnancy, ventricular arrhythmia at presentation, migraine, EVA, recent emotional or physical stress, and use of thienopyridine or statin were not significantly associated with recurrent SCAD ( P > 0.05). SCAD patients with hypertension or FMD were at a higher risk of recurrence, whereas beta-blocker usage was related to a reduced risk. These findings may provide insights into risk prediction and management after the SCAD episode.

Safety of Cold Snare Polypectomy for Small Colorectal Polyps in Patients Receiving Antithrombotic Therapy

Background and AimsRecent guidelines do not specify the bleeding risk of cold polypectomy. We investigated delayed postpolypectomy bleeding (DPPB) after cold snare polypectomy (CSP) for colorectal polyps in patients receiving antithrombotic (AT) therapy. MethodsA total of 4770 patients who underwent endoscopic resection of colorectal polyps between April 2017 and December 2019 were included. Of them, we analyzed 3600 patients and 10,152 polyps with a size of < 10 mm, including 640 patients who took AT drugs. The patients were subdivided into 3 groups according to AT drug use: 1) continued use, 2) withdrawal, and 3) no use. We compared DPPB rates between hot snare polypectomy (HSP) and CSP in each group. ResultsThe DPPB rates in the CSP group were approximately one-tenth lower than those in the HSP group (per-patient analysis: 0 (0/2598) vs 0.9% (9/1002), per-polyp analysis: 0.04 (3/7928) vs 0.58% (13/2224)). The DPPB rates of HSP were significantly different among the continued use, withdrawal, and no use groups (per-polyp analysis: 2.08 (6/289), 0 (0/159), and 0.40% (7/1771), P = 0.0015). However, the DPPB rates of CSP did not differ among groups (per-polyp analysis: 0 (0/983), 0.17 (1/591), and 0.03% (2/6348), P = 0.2087). No DPPB was observed after CSP in patients with continued use of thienopyridine, aspirin, cilostazol, direct oral anticoagulants, or warfarin; except for 1 patient with direct oral anticoagulant withdrawal. ConclusionThe DPPB of CSP in patients taking an AT drug was low and similar to that in patients not taking drugs. CSP could be a safe procedure for colorectal polyps, even with continued use of AT drugs.

Issue Highlights

Issue Highlights

The Effects of Direct Oral Anticoagulants, Warfarin, Aspirin and Thienopyridine on the Performance of Immunochemical, Faecal, Occult Blood Tests

Aim: To clarify whether antithrombotic drugs affect diagnosis using the immunochemical faecal occult blood test ­(iFOBT) of colorectal neoplasia. Methods: Using the Japan Endoscopy Database from 8 centres between 2015 and 2017, we analyzed data about patients who were iFOBT positive and had received direct oral anticoagulants (DOAC), warfarin, aspirin or thienopyridine. One-to-one matching-analogue propensity score weighted analyses were performed to compare the positive predictive value (PPV) of all neoplasms, invasive and non-invasive colorectal cancers and adenomas between drug users and non-users. All neoplasms included invasive and non-invasive colorectal cancer, and adenomas. Results: We analyzed 197 DOAC users and 196 non-users, 153 warfarin users and 153 non-users, 408 aspirin users and 415 non-users, and 97 thienopyridine users and 97 non-users. No significant differences were observed in the PPV for all neoplasms (56.67 vs. 50.43%), invasive cancer (4.32 vs. 3.53%), non-invasive cancer (15.58 vs. 15.56%) or adenoma (53.13 vs. 48.09%) between the DOAC user and non-user groups. No significant differences were observed in the PPV for all neoplasia, invasive and non-invasive cancer, or adenoma between warfarin, aspirin and thienopyridine use and non-users. Conclusions: DOAC, warfarin, aspirin and thienopyridine use did not decrease the PPVs of the iFOBT used to evaluate all colorectal neoplasia.

Risk factors for upper gastrointestinal bleeding among aspirin users: An old issue with new findings from a population-based cohort study

We aimed to identify the risk factors of first-time occurrence of non-variceal upper gastrointestinal bleeding (UGIB) among aspirin users after adjusting for confounding factors like age, gender, underlying co-morbidities, and medications. Using the National Health Insurance Research Database of Taiwan and matching age, gender, underlying co-morbidities and enrollment time by propensity score, 11105 aspirin users and 11105 controls were identified for comparison from a cohort dataset of 1,000,000 randomly sampled subjects. Cox proportional hazard regression models were used to identify independent risk factors for first-time occurrence of non-variceal UGIB in the study cohort and in the aspirin users after adjusting for age, gender, underlying co-morbidities, and medications (e.g., non-steroidal anti-inflammatory drugs [NSAIDs], cyclooxygenase-2 [COX-2] inhibitors, steroids, thienopyridines, selective serotonin reuptake inhibitors, warfarin, and dipyridamole). By Cox proportional hazard regression analysis, aspirin use increased the risk of first-time occurrence of UGIB (hazard ratio [HR]: 1.48; 95% confidence interval [CI]: 1.28-1.72). Age, male gender, Helicobacter pylori (H. pylori)infection, diabetes, chronic kidney disease (CKD), cirrhosis, history of uncomplicated peptic ulcer disease (PUD), and use of NSAIDs, COX-2 inhibitors, steroids, and thienopyridines were independent risk factors for UGIB among aspirin users. In addition to age, male gender, H. pylori infection, and concomitant use of NSAIDs, COX-2 inhibitors, steroids, and thienopyridines, underlying co-morbidities including diabetes, CKD, cirrhosis, history of PUD are also important risk factors for first-time occurrence of non-variceal UGIB in aspirin users.

TCT-644 Use of New Thienopyridines in Patients with Coronary Artery Disease Treated with Percutaneous Coronary Interventions in Argentina. Results From A “Real World” Multicenter Registry

TCT-644 Use of New Thienopyridines in Patients with Coronary Artery Disease Treated with Percutaneous Coronary Interventions in Argentina. Results From A “Real World” Multicenter Registry

Rebleeding vs Thromboembolism After Hospitalization for Gastrointestinal Bleeding in Patients on Direct Oral Anticoagulants

Little is known about outcomes of patients hospitalized for gastrointestinal bleeding (GIB) while they are taking direct oral anticoagulants (DOAC). We aimed to determine the frequency at which patients resume DOAC therapy following hospitalization for GIB in a real-world setting, and the risks and benefits. We conducted a retrospective analysis of medical claims data from the Truven Health Marketscan Commercial Claims and Encounters Database, from January 1, 2010, through December 31, 2014. We collected data on 1338 adults treated with DOACs and hospitalized for GIB (dabigatran, n= 679; rivaroxaban, n= 608, apixaban, n= 51). Patients who developed GIB within 1 year of DOAC initiation, and had a DOAC claim filled within 1 month of GIB, were included in the analysis. Postdischarge readmissions due to thromboembolism and recurrent GIB within 90 days were reviewed. We used proportional hazards to identify factors associated with thromboembolism and recurrent GIB. The median age of patients who did not resume DOAC therapy was older (79 vs 78 y for patients who did resume DOAC therapy; P= .0005). Higher proportions of patients who did not resume DOAC had heart failure (25% vs 20% who did resume DOAC therapy; P= .01), received blood (36% vs 24%; P < .0001), and required intensive care (18% vs 12%; P= .003). Restarting DOAC therapy within 30 days was not associated with thromboembolism within 90 days (hazard ratio [HR], 0.98; 95% CI, 0.37-2.21) or recurrent GIB (HR, 1.44; 95% CI 0.72-2.68). On multivariate regression, prior venous thromboembolism was associated with postdischarge thromboembolism (HR, 3.30; 95% CI, 1.29-7.38), and thienopyridine use was associated with recurrent GIB (HR, 3.12; 95% CI, 1.55-5.81). A higher proportion of patients who resumed treatment with rivaroxaban, compared with other DOACs, had recurrence of GIB (log rank, P= .04). In a retrospective analysis of medical claims data from adults treated with DOACs and hospitalized for GIB, we found that older patients who require blood and intensive care were less likely to restart treatment with DOACs after GIB. Resuming DOAC therapy was not associated with thromboembolism within 90 days or recurrence of GIB; a history of venous thromboembolism and thienopyridine use were associated with a risk of subsequent thromboembolism and GIB respectively.

Abstract 2: Co-administration of Proton-Pump Inhibitors with Thienopyridines Increases Risk of Adverse Cerebrovascular Outcomes

Background: Pharmacokinetic and prior interaction studies on thienopyridine-proton pump inhibitors (PPI) provide conflicting data for cardiovascular outcomes. There is no established evidence on the association of concomitant use of PPI-thienopyridine with adverse cerebrovascular outcomes. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCT) and cohort studies from inception to December 2016, reporting following outcomes among patients treated with thienopyridine + PPI vs. thienopyridine alone: 1. ischemic stroke (IS), 2. combined ischemic and hemorrhagic stroke, 3. composite outcome of stroke, myocardial infarction (MI) and cardiovascular (CV) death, 4. MI, 5. all-cause mortality, and 6. major or minor bleeding events. We performed subgroup analyses to assess IS recurrence rates for eligible studies, and assess outcomes amongst the two study designs. We calculated pooled relative risk (RR) ratios and 95% CI using random-effects models. Results: We identified 22 studies (12 RCTs and 10 cohort studies) with 131,714 participants. Concomitant use of PPI and thienopyridines was associated with increased risk of IS [RR=1.75 (95%CI: 1.41-2.16), I 2 =0%], composite stroke/MI/CV death [RR=1.14 (95%CI 1.01-1.29), I 2 =74%], and MI [RR=1.19 (95%CI: 1.0-1.4), I 2 =80%]. The co-administration of PPI and thienopyridines was not associated with the risk of combined ischemic and hemorrhagic stroke, cardiovascular death, major or minor bleeding, and all-cause mortality. Subgroup analyses demonstrated increased risk of IS [RR=1.6 (95%CI: 1.1-2.3), I 2 =33%] and combined ischemic and hemorrhagic stroke [RR=1.34 (95%CI: 1.1-1.63), I 2 =0%] in cohort studies, while RCTs demonstrated significant risk for composite stroke/MI/CV death [RR=1.17 (95%CI: 1.04-1.32), I 2 =72%]. PPI-thienopyridine co-prescription did not increase the risk of stroke recurrence in patients with prior IS. Conclusions: PPI-thienopyridine co-prescription increases the risk of IS and composite stroke/MI/CV death. Our findings highlight the need for pharmacovigilance and corroborate with current guidelines for PPI deprescription, especially in patients treated with thienopyridines for the prevention of cerebrovascular events.

Cerebrovascular Outcomes With Proton Pump Inhibitors and Thienopyridines: A Systematic Review and Meta-Analysis.

Pharmacokinetic and prior studies on thienopyridine and proton pump inhibitors (PPI) coadministration provide conflicting data for cardiovascular outcomes, whereas there is no established evidence on the association of concomitant use of PPI and thienopyridines with adverse cerebrovascular outcomes. We conducted a systematic review and meta-analysis of randomized controlled trials and cohort studies from inception to July 2017, reporting following outcomes among patients treated with thienopyridine and PPI versus thienopyridine alone (1) ischemic stroke, (2) combined ischemic or hemorrhagic stroke, (3) composite outcome of stroke, myocardial infarction (MI), and cardiovascular death, (4) MI, (5) all-cause mortality, and (6) major or minor bleeding events. After the unadjusted analyses of risk ratios, we performed additional analyses of studies reporting hazard ratios adjusted for potential confounders. We identified 22 studies (12 randomized controlled trials and 10 cohort studies) comprising 131 714 patients. Concomitant use of PPI with thienopyridines was associated with increased risk of ischemic stroke (risk ratio, 1.74; 95% confidence interval [CI], 1.41-2.16; P<0.001), composite stroke/MI/cardiovascular death (risk ratio, 1.14; 95% CI, 1.01-1.29; P=0.04), and MI (risk ratio, 1.19; 95% CI, 1.00-1.40; P=0.05). Likewise, in adjusted analyses concomitant use of PPI with thienopyridines was again associated with increased risk of stroke (hazard ratios adjusted, 1.30; 95% CI, 1.04-1.61; P=0.02), composite stroke/MI/cardiovascular death (hazard ratios adjusted, 1.23; 95% CI, 1.03-1.47; P=0.02), but not with MI (hazard ratios adjusted, 1.19; 95% CI, 0.93-1.52; P=0.16). Co-prescription of PPI and thienopyridines increases the risk of incident ischemic strokes and composite stroke/MI/cardiovascular death. Our findings corroborate the current guidelines for PPI deprescription and pharmacovigilance, especially in patients treated with thienopyridines.

Clopidogrel in a combined therapy with anticancer drugs-effect on tumor growth, metastasis, and treatment toxicity: Studies in animal models.

Clopidogrel, a thienopyridine derivative with antiplatelet activity, is widely prescribed for patients with cardiovascular diseases. In addition to antiplatelet activity, antiplatelet agents possess anticancer and antimetastatic properties. Contrary to this, results of some studies have suggested that the use of clopidogrel and other thienopyridines accelerates the progression of breast, colorectal, and prostate cancer. Therefore, in this study, we aimed to evaluate the efficacy of clopidogrel and various anticancer agents as a combined treatment using mouse models of breast, colorectal, and prostate cancer. Metastatic dissemination, selected parameters of platelet morphology and biochemistry, as well as angiogenesis were assessed. In addition, body weight, blood morphology, and biochemistry were evaluated to test toxicity of the studied compounds. According to the results, clopidogrel increased antitumor and/or antimetastatic activity of chemotherapeutics such as 5-fluorouracil, cyclophosphamide, and mitoxantrone, whereas it decreased the anticancer activity of doxorubicin, cisplatin, and tamoxifen. The mechanisms of such divergent activities may be based on the modulation of tumor vasculature via factors, such as transforming growth factor β1 released from platelets. Moreover, clopidogrel increased the toxicity of docetaxel and protected against mitoxantrone-induced toxicity, which may be due to the modulation of hepatic enzymes and protection of the vasculature, respectively. These results demonstrate that antiplatelet agents can be useful but also dangerous in anticancer treatment and therefore use of thienopyridines in patients undergoing chemotherapy should be carefully evaluated.

Risk Factors for Upper Gastrointestinal Bleeding in Patients Taking Selective COX-2 Inhibitors: A Nationwide Population-Based Cohort Study.

Cyclooxygenase-2 inhibitors (coxibs) are associated with less upper gastrointestinal bleeding (UGIB) than traditional nonsteroidal anti-inflammatory drugs (tNSAIDs). However, they also increase the risk of UGIB in high-risk patients. We aimed to identify the risk factors of UGIB in coxibs users. Retrospective cohort study. 2000-2010 National Health Insurance Research Database of Taiwan. Patients taking coxibs as the study group and patients not taking any coxibs as controls. After age, gender, and comorbidity matching by propensity score, 12,145 coxibs users and 12,145 matched controls were extracted for analysis. The primary end point was the occurrence of UGIB. Cox multivariate proportional hazard regression models were used to determine the risk factors for UGIB among all the enrollees and coxibs users. During a mean follow-up of three years, coxibs users had significantly higher incidence of UGIB than matched controls (P < 0.001, log-rank test). Cox regression analysis showed that coxibs increased risk of UGIB in all participants (hazard ratio = 1.37, 95% confidence interval = 1.19-1.55, P < 0.001). Independent risk factors for UGIB among coxibs users were age, male gender, diabetes, chronic renal disease, cirrhosis, history of peptic ulcer disease, PU bleeding (PUB), Helicobacter pylori (H. pylori) infection, and concomitant use of tNSAIDs, acetylsalicylic acid, or thienopyridines. Among coxibs users, H. pylori infection and history of PUB were especially important risk factors for UGIB. Further studies are needed to determine whether proton pump inhibitors might play a protective role in these at-risk patients.

Koroner Yoğun Bakımda Yatan Akut Koroner Sendrom Hastalarında Tienopiridin ve Proton Pompa İnhibitör Kullanımı

Koroner Yoğun Bakımda Yatan Akut Koroner Sendrom Hastalarında Tienopiridin ve Proton Pompa İnhibitör Kullanımı

Acute Middle Gastrointestinal Bleeding Risk Associated with NSAIDs, Antithrombotic Drugs, and PPIs: A Multicenter Case-Control Study.

BackgroundMiddle gastrointestinal bleeding (MGIB) risk has not been fully investigated due to its extremely rare occurrence and the need for multiple endoscopies to exclude upper and lower gastrointestinal bleeding. This study investigated whether MGIB is associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs), low-dose aspirin (LDA), thienopyridines, anticoagulants, and proton-pump inhibitors (PPIs), and whether PPI use affects the interactions between MGIB and antithrombotic drugs.MethodsIn this multicenter, hospital-based, case-control study, 400 patients underwent upper and lower endoscopy, 80 had acute overt MGIB and 320 had no bleeding and were matched for age and sex as controls (1:4). MGIB was additionally evaluated by capsule and/or double-balloon endoscopy, after excluding upper and lower GI bleeding. Adjusted odds ratios (AOR) for MGIB risk were calculated using conditional logistic regression. To estimate the propensity score, we employed a logistic regression model for PPI use.ResultsIn patients with MGIB, mean hemoglobin level was 9.4 g/dL, and 28 patients (35%) received blood transfusions. Factors significantly associated with MGIB were chronic kidney disease (p<0.001), liver cirrhosis (p = 0.034), NSAIDs (p<0.001), thienopyridines (p<0.001), anticoagulants (p = 0.002), and PPIs (p<0.001). After adjusting for these factors, NSAIDs (AOR, 2.5; p = 0.018), thienopyridines (AOR, 3.2; p = 0.015), anticoagulants (AOR, 4.3; p = 0.028), and PPIs (AOR; 2.0; p = 0.021) were independently associated with MGIB. After adjusting for propensity score, the use of PPIs remained an independent risk factors for MGIB (AOR, 1.94; p = 0.034). No significant interactions were observed between PPIs and NSAIDs (AOR, 0.7; p = 0.637), LDA (AOR, 0.3; p = 0.112), thienopyridine (AOR, 0.7, p = 0.671), or anticoagulants (AOR, 0.5; p = 0.545).ConclusionsOne-third of patients with acute small intestinal bleeding required blood transfusion. NSAIDs, thienopyridines, anticoagulants, and PPIs increased the risk of acute small intestinal bleeding. However, there were no significant interactions found between antithrombotic drugs and PPI use for bleeding risk.

Efficacy and Safety of Vorapaxar in Non-ST-Segment Elevation Acute Coronary Syndrome Patients Undergoing Noncardiac Surgery.

BackgroundPerioperative antiplatelet agents potentially increase bleeding after non–ST‐segment elevation (NSTE) acute coronary syndromes (ACS). The protease‐activated receptor 1 antagonist vorapaxar reduced cardiovascular events and was associated with increased bleeding versus placebo in NSTE ACS, but its efficacy and safety in noncardiac surgery (NCS) remain unknown. We aimed to evaluate ischemic, bleeding, and long‐term outcomes of vorapaxar in NCS after NSTE ACS.Methods and ResultsIn the TRACER trial, 2202 (17.0%) patients underwent major or minor NCS after NSTE ACS over 1.5 years (median); continuing study treatment perioperatively was recommended. The primary ischemic end point for this analysis was cardiovascular death, myocardial infarction, stent thrombosis, or urgent revascularization within 30 days of NCS. Safety outcomes included 30‐day NCS bleeding and GUSTO moderate/severe bleeding. Overall, 1171 vorapaxar and 1031 placebo patients underwent NCS. Preoperative aspirin and thienopyridine use was 96.8% versus 97.7% (P=0.235) and 89.1% versus 86.1% (P=0.036) for vorapaxar versus placebo, respectively. Within 30 days of NCS, no differences were observed in the primary ischemic end point between vorapaxar and placebo groups (3.4% versus 3.9%; adjusted odds ratio 0.81, 95% CI 0.50 to 1.33, P=0.41). Similarly, no differences in NCS bleeding (3.9% versus 3.4%; adjusted odds ratio 1.41, 95% CI 0.87 to 2.31, P=0.17) or GUSTO moderate/severe bleeding (4.2% versus 3.7%; adjusted odds ratio 1.15, 95% CI, 0.72 to 1.83, P=0.55) were observed. In a 30‐day landmarked analysis, NCS patients had a higher long‐term risk of the ischemic end point (adjusted hazard ratio 1.62, 95% CI 1.33 to 1.97, P<0.001) and GUSTO moderate/severe bleeding (adjusted hazard ratio 5.63, 95% CI 3.98 to 7.97, P<0.001) versus patients who did not undergo NCS, independent of study treatment.Conclusion NCS after NSTE ACS is common and associated with more ischemic outcomes and bleeding. Vorapaxar after NSTE ACS was not associated with increased perioperative ischemic or bleeding events in patients undergoing NCS.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Risk factors for small bowel bleeding in chronic nonsteroidal anti-inflammatory drug users.

The incidence of nonsteroidal anti-inflammatory drugs (NSAIDs)-induced enteropathy is currently increasing. However, the predictors of small bowel bleeding (SBB) associated with NSAIDs are unknown. This study aimed to assess the risk factors of SBB in chronic NSAIDs users. We retrospectively compared the medical records of 147 patients receiving NSAIDs in a tertiary-care setting (31 with SBB and 116 without previous bleeding events) and analyzed the predictors of SBB. In total, 31 patients underwent video capsule endoscopy to detect SBB, 74.2% of whom showed the evidence of SBB. Non-invasive treatment was performed in 90.3% of the patients. Multivariate logistic regression analysis revealed that the presence of coronary artery disease [adjusted odds ratio (aOR) 12.43, 95% confidence interval (CI) 1.19-130.34, P = 0.04], use of thienopyridine (aOR 16.93, 95% CI 3.78-75.72, P < 0.001) and prior use of rebamipide (aOR 0.31, 95% CI 0.12-0.82, P = 0.02) were independently associated with SBB in NSAIDs users. Coronary artery disease and co-use of thienopyridine were associated with SBB in NSAIDs users. The patients with coronary artery disease co-using thienopyridine need to be monitored for the occurrence of SBB when they were prescribed with NSAIDs.

Thienopyridine use after coronary stenting in low income patients enrolled in medicare part D receiving maintenance dialysis.

BackgroundCoronary stenting in patients on dialysis has increased by nearly 50% over the past decade, despite heightened risks of associated stent thrombosis and bleeding relative to the general population. We examined clopidogrel, prasugrel or ticlopidine use after percutaneous coronary intervention (PCI) with stenting in patients on dialysis. We conducted 3‐, 6‐, and 12‐month landmark analyses to test the hypothesis that thienopyridine discontinuation prior to those time points would be associated with higher risks of death, myocardial infarction, or repeat revascularization, and a lower risk of major bleeding episodes compared with continued thienopyridine use.Methods and ResultsUsing the US Renal Data System, we identified 8458 patients on dialysis with Medicare Parts A+B+D undergoing PCI with stenting between July 2007 and December 2010. Ninety‐nine percent of all thienopyridine prescriptions were for clopidogrel. At 3 months, 82% of patients who received drug‐eluting stents (DES) had evidence of thienopyridine use. These proportions fell to 62% and 40% at 6 and 12 months, respectively. In patients who received a bare‐metal stent (BMS), 70%, 34%, and 26% of patients had evidence of thienopyridine use at 3, 6, and 12 months, respectively. In patients who received a DES, there was a suggestion of higher risks of death or myocardial infarction associated with thienopyridine discontinuation in the 3‐, 6‐, and 12‐months landmark analyses, but no higher risk of major bleeding episodes. In patients who received a BMS, there were no differences in death or cardiovascular events, and possibly lower risk of major bleeding with thienopyridine discontinuation in the 3‐ and 6‐month landmark analyses.ConclusionsThe majority of patients on dialysis who undergo PCI discontinue thienopyridines before 1 year regardless of stent type. While not definitive, these data suggest that longer‐term thienopyridine use may be of benefit to patients on dialysis who undergo PCI with DES.

TCT-121 Relationship Between On-treatment Platelet Reactivity Prior to Coronary Artery Bypass Surgery and In-Hospital Major Bleeding The Surgical Timing based On Platelet Reactivity for Coronary Artery Bypass Graft surgery (STOP-CABG) trial

Use of aspirin plus thienopyridine increases bleeding risk of coronary artery bypass graft (CABG) surgery. In STOP-CABG trial we prospectively evaluated the association between the pre-operative platelet function testing by different assay methods on the occurrence of post CABG bleeding. 81