Uninterrupted Dual Antiplatelet Therapy Research Articles

Stepwise Approach for Transvenous Lead Extraction in a Large Single Centre Cohort.

Infection, lead dysfunction and system upgrades are all reasons that transvenous lead extraction is being performed more frequently. Many centres focus on a single method for lead extraction, which can lead to either lower success rates or higher rates of major complications. We report our experience with a systematic approach from a less invasive to a more invasive strategy without the use of laser sheaths. Consecutive extraction procedures performed over a period of seven years in our electrophysiology laboratory were included. We performed a stepwise approach with careful traction, lead locking stylets (LLD), mechanical non-powered dilator sheaths, mechanical powered sheaths and, if needed, femoral snares. In 463 patients (age 69.9 ± 12.3, 31.3% female) a total of 780 leads (244 ICD leads) with a mean lead dwelling time of 5.4 ± 4.9 years were identified for extraction. Success rates for simple traction, LLD, mechanical non-powered sheaths and mechanical powered sheaths were 31.5%, 42.7%, 84.1% and 92.6%, respectively. A snare was used for 40 cases (as the primary approach for 38 as the lead structure was not intact and stepwise approach was not feasible) and was successful for 36 leads (90.0% success rate). Total success rate was 93.1%, clinical success rate was 94.1%. Rate for procedural failure was 1.1%. Success for less invasive steps and overall success for extraction was associated with shorter lead dwelling time (p < 0.001). Major procedure associated complications occurred in two patients (0.4%), including one death (0.2%). A total of 36 minor procedure-associated complications occurred in 30 patients (6.5%). Pocket hematoma correlated significantly with uninterrupted dual antiplatelet therapy (p = 0.001). Pericardial effusion without need for intervention was associated with long lead dwelling time (p = 0.01) and uninterrupted acetylsalicylic acid (p < 0.05). A stepwise approach with a progressive invasive strategy is effective and safe for transvenous lead extraction.

Procedural outcomes in patients with dual versus single antiplatelet therapy prior to transcatheter aortic valve replacement

The impact of uninterrupted dual antiplatelet therapy (DAPT) on bleeding events among patients undergoing transcatheter aortic valve replacement (TAVR) has not been well studied. We conducted an analysis of 529 patients who underwent transfemoral TAVR in our centre and were receiving either DAPT or single antiplatelet therapy (SAPT) prior to the procedure. Accordingly, patients were grouped into a DAPT or SAPT group. Following current guidelines, patients in the SAPT group were switched to DAPT for 90 days after the procedure. The primary endpoint of our analysis was the incidence of bleeding events at 30 days according to the VARC-2 classification system. Any VARC-2 bleeding complications were found in 153 patients (28.9%), while major/life-threatening or disabling bleeding events occurred in 60 patients (11.3%). Our study revealed no significant difference between the DAPT vs. SAPT group regarding periprocedural bleeding complications. Based on multivariable analyses, major bleeding (HR 4.59, 95% CI 1.64–12.83, p = 0.004) and life-threatening/disabling bleeding (HR 8.66, 95% CI 3.31–22.65, p < 0.001) events were significantly associated with mortality at 90 days after TAVR. Both pre-existing DAPT and SAPT showed a comparable safety profile regarding periprocedural bleeding complications and mortality at 90 days. Thus, DAPT can be safely continued in patients undergoing transfemoral TAVR.

Post-extraction bleeding complications in patients on uninterrupted dual antiplatelet therapy-a prospective study.

Dental surgeons consider patients on antiplatelet therapy (APT) to be at a risk for perioperative bleeding during dental extraction. This fear often prompts them to consider a temporary withdrawal of the medication for a few days before extraction. Such withdrawal can have serious consequences, especially in patients on dual antiplatelet therapy (DAPT). The purpose of this study was to analyze if patients on uninterrupted DAPT undergoing dental extractions had an increased risk of bleeding complications when compared with patients on no antiplatelet therapy. This prospective study included 120 DAPT patients and an equal number of age- and gender-matched non-APT patients undergoing dental extractions. Immediate and delayed bleeding complications in both groups were recorded. Interventions required to control the post-extraction hemorrhage were also analyzed. Duration of DAPT medication ranged from 6months to 13years. Post-percutaneous coronary intervention was the most common cause for DAPT. A vast majority of patients in both groups underwent extraction of one or two teeth. Patients on DAPT had a 7-fold increased risk of immediate bleeding complications when compared with control group. All bleeding episodes were controlled with local hemostatic measures. Transalveolar extractions and localized periodontitis had a significant relationship to bleeding complications. This study observed an increase in the risk of prolonged bleeding in uninterrupted DAPT patients undergoing dental extractions. Bleeding episodes were amenable to local hemostatic measures with favorable outcomes. Dental extractions in patients on uninterrupted DAPT can be done safely. Resorting to temporary withdrawal of DAPT due to a fear of excessive bleeding is unnecessary.

Carotid artery stenting is safe and effective for symptomatic patients with acute coronary syndrome

Patients with symptomatic carotid stenosis recently treated with percutaneous transluminal coronary angioplasty (PTCA) for acute coronary syndrome (ACS) are always classified as at high risk for surgery, given that they are required uninterrupted dual antiplatelet therapy. In this regard, carotid artery stenting (CAS) may represent a valid alternative. The purpose of this study is to overview CAS outcomes in symptomatic patients with and without ACS. One hundred fifty-one consecutive symptomatic patients who underwent CAS between 2010 and 2017 in a single institution were included in this study, of which 66 (43.7%) were identified as having ACS. All patients were followed-up with carotid duplex ultrasound scan and a neurological assessment of symptoms status at 30-day postprocedure and at 3, 6, and 12 months, with annual follow-up after that for 3 years. Among symptomatic ACS patients, common risks factors were active smoking, metabolic syndrome, diabetes, and hypertension. In the short-term follow-up, no significant differences were observed among rates of death, stroke, myocardial infarction (MI), and restenosis, between patients with and without ACS. Mean clinical follow-up was 28.2 (12.3) months. In the long-term follow-up, higher rates of death and MI were recorded in patients with ACS (death: 11.4% vs. 5.4%, p = .04; MI: 11.4% vs. 3.6%, p = .02), owing to the complexity of these patients. This single-center study suggested that CAS is a safe and effective treatment for patients with symptomatic carotid artery stenosis, who recently underwent PTCA for ACS, requiring uninterrupted dual antiplatelet therapy.

Influence of Baseline Anemia on Dual Antiplatelet Therapy Cessation and Risk of Adverse Events After Percutaneous Coronary Intervention.

Anemia is a well-recognized risk factor for both bleeding and ischemic events after percutaneous coronary intervention (PCI). We sought to determine the impact of baseline anemia on dual antiplatelet therapy (DAPT) cessation patterns ≤2 years after PCI and the subsequent risk of clinical adverse events. PARIS (Patterns of Non-Adherence to Dual Anti-Platelet Regimen in Stented Patients) was a prospective multicenter observational registry of PCI-treated patients (n=5018). Anemia was defined as baseline Hb (hemoglobin) <12 g/dL for men and <11 g/dL for women. DAPT cessation modes included physician-recommended discontinuation, temporary interruption (≤14 days), and disruption due to bleeding or noncompliance. The primary end point was 2-year major adverse cardiovascular events (MACE), a composite of cardiac death, myocardial infarction, or target vessel revascularization. We identified 824 (18%) anemic and 4194 (82%) nonanemic patients. Anemic patients were older and had a higher rate of diabetes mellitus, hypertension, and prior PCI. DAPT interruption and disruption were significantly more common in anemic patients throughout 2 years after PCI, whereas physician-recommended discontinuation occurred more often in anemic patients during the first year after PCI and in nonanemic patients during the second year. The 2-year adjusted risks of MACE and Bleeding Academic Research Consortium 3 or 5 bleeding events were significantly higher in anemic patients. Compared with uninterrupted DAPT, disruption, but not interruption and physician-recommended discontinuation, was associated with a higher risk of myocardial infarction in nonanemic patients and a higher risk of both myocardial infarction and MACE in anemic patients. There was no significant interaction between anemia and risk of clinical outcomes associated with each DAPT cessation mode. Baseline anemia was associated with a significantly higher adjusted risk of MACE and major bleeding. Physicians more frequently recommend DAPT discontinuation to anemic patients during the first year, and to nonanemic patients during the second year after PCI. DAPT disruption was associated with a higher risk of MACE outcomes.

To revascularize or not before transcatheter aortic valve implantation?

Concomitant coronary artery disease (CAD) and aortic stenosis occur in approximately 60-75% of patients referred for surgical or transcatheter aortic valve replacement (TAVR). Current guidelines support simultaneous surgical aortic valve replacement and bypass surgery with a class IIa recommendation, based on observational, non-randomized data. With the inception of TAVR, this strategy has been challenged, as observational studies have not shown significant outcome differences in patients with and without CAD treated with TAVR. Performing percutaneous coronary intervention (PCI) in patients with aortic stenosis is safe, but the indication and timing remain controversial. Complete revascularization before TAVR with low residual Syntax score (<8) may be considered in selected cases with extensive, proximal, and severe CAD to improve outcomes. PCI before TAVR may require less contrast and reduce the risk of acute kidney injury, but uninterrupted dual antiplatelet therapy may increase the risk of bleeding during TAVR. Combined PCI and TAVR can be considered for unstable patients with simple lesions or ostial lesions, with risk of coronary occlusion after deployment of the transcatheter heart valve. PCI after TAVR may be considered in patients who remain symptomatic with significant residual ischemia despite optimal medical therapy. In the near future, it is expected that randomized clinical trials will further clarify the indications and role of revascularization in patients undergoing TAVR. In this article we provide an extensive review on the management of CAD in TAVR candidates, including additional considerations on technical aspects, device selection, and adjunctive pharmacological therapies.

Percutaneous Endoscopic Gastrostomy (PEG) Tubes can be Safely Placed in Geriatric Patients on Uninterrupted Dual Anti-Platelet Therapy (DAPT)

Percutaneous Endoscopic Gastrostomy (PEG) Tubes can be Safely Placed in Geriatric Patients on Uninterrupted Dual Anti-Platelet Therapy (DAPT)

Mo1160 Peg Tube Can Be Successfully Placed in Patients on Uninterrupted Dual-Antiplatelet Therapy Without any Complications: Time to Change Clinical Practice

Anti-platelet drugs such as aspirin and clopidogrel can cause increased bleeding by inhibiting the formation of the initial platelet plug. Consequently, anti-platelet therapy is often stopped prior to placement of a percutaneous endoscopic gastrostomy (PEG) tube due to fear of internal bleeding. Current guidelines suggest holding clopidogrel for 5-7 days prior to elective PEG placement. Our study aims to study the experience of our high-volume center (>320 PEGs/year) regarding bleeding episodes after PEG placement in patients on uninterrupted anti-platelet therapy.

Incidence, Patterns, and Associations Between Dual-Antiplatelet Therapy Cessation and Risk for Adverse Events Among Patients With and Without Diabetes Mellitus Receiving Drug-Eluting Stents: Results From the PARIS Registry

ObjectivesThe aim of this study was to examine the frequency and clinical impact of different cessation patterns of dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention with drug-eluting stents among patients with and those without diabetes mellitus (DM). BackgroundEarly DAPT suspension after percutaneous coronary intervention increases the risk for major adverse cardiac events. However, temporal variability in risk and relation to DAPT cessation patterns among patients with DM remain unclear. MethodsUsing data from the PARIS (Patterns of Non-Adherence to Anti-Platelet Regimens in Stented Patients) registry, 1,430 patients with DM (34%) and 2,777 without DM (66%) treated with drug-eluting stents were identified. DAPT cessation modes were classified as temporary interruption (<14 days), disruption because of bleeding or poor compliance, and physician-recommended discontinuation. ResultsDuring 2-year follow-up, DM was associated with an increased risk for thrombotic events but a similar risk for bleeding. The cumulative incidence of DAPT cessation was significantly lower in patients with versus those without DM (50.1% vs. 55.4%; p < 0.01), driven largely by less frequent physician-guided discontinuation beyond 1 year. In contrast, 2-year rates of interruption and disruption were similar between groups. When DAPT was interrupted or discontinued under physician guidance, the risk for major adverse cardiac events was unchanged compared with patients with DM on uninterrupted DAPT. Conversely, when DAPT was disrupted, the risk for major adverse cardiac events increased compared with uninterrupted DAPT, regardless of diabetic status, with no evidence of statistical interaction. ConclusionsDAPT cessation patterns vary according to diabetic status, with less frequent physician-guided discontinuation among patients with DM. The presence of DM does not emerge as a modifier of cardiovascular risk after DAPT cessation.

International patterns of dual antiplatelet therapy duration after acute coronary syndromes

ObjectiveTo describe international patterns of dual antiplatelet therapy (DAPT) duration after acute coronary syndrome (ACS), and explore its determinants and correlation with clinical events.MethodsEPICOR (long-tErm follow-uP of anti-thrombotic management patterns...

Carotid Artery Stenting in Patients With Acute Coronary Syndrome: A Possible Primary Therapy for Symptomatic Carotid Stenosis

To report the results of carotid artery stenting (CAS) in symptomatic patients (stroke/transient ischemic attack) after recent percutaneous transluminal coronary angioplasty (PTCA) for acute coronary syndrome (ACS). Between January 2009 and July 2011, 28 consecutive patients (18 women; mean age 66 years, range 42-82) underwent protected CAS for symptomatic carotid stenosis following recent PTCA that included bare or drug-eluting stents requiring uninterrupted dual antiplatelet therapy. Primary technical success, neurological complications, major adverse cardiovascular events, and death were evaluated at 30 days and over midterm follow-up. Technical success was 96%; 1 patient suffered a nonfatal major stroke (3.5% 30-day stroke rate) during the procedure. During a median 21.6-month follow-up, 4 (14%) patients died of myocardial infarction (all diabetic smokers with ejection fractions <40%), but there were no new neurological events. Estimated survival was 89.3% at 2 years. Further coronary interventions were performed in 2 diabetic patients with a body mass index >34 kg/m(2). This preliminary experience demonstrated that CAS is a reasonable, safe, and effective treatment for patients with symptomatic carotid artery stenosis who were recently treated with coronary stents requiring uninterrupted dual antiplatelet therapy.

Dual Antiplatelet Therapy With Aspirin and Clopidogrel: What Is the Risk in Noncardiac Surgery? A Narrative Review

Clopidogrel is one of the most commonly prescribed medications and is currently recommended along with aspirin as treatment to be used for 1 year in all patients without contraindications following an acute coronary syndrome. Patients who are committed to clopidogrel therapy due to recent coronary artery stent implantation may require noncardiac surgery during this recommended period of dual antiplatelet therapy (DAPT). Due to differing rates of endothelialization, patients who undergo bare-metal stent implantation generally require ≥ 1 month of uninterrupted DAPT, and those who undergo drug-eluting stent implantation require ≥ 12 months. Many surgeons ask their patients to stop taking clopidogrel in advance of their procedure to decrease perioperative bleeding. This practice is based largely on anecdotal experience and extrapolated from limited data in cardiac surgery. Premature cessation of aspirin and/or clopidogrel following coronary artery stenting, however, has been associated with acute stent thrombosis, myocardial infarction, and death. We searched PubMed for English language articles published from 1960 to 2012, using the keywords aspirin, clopidogrel, surgery, general, vascular, genitourinary, thoracic, orthopedic, ophthalmologic, dermatologic, endoscopy, colonoscopy, cardiac device implantation, pacemaker, defibrillator, bronchoscopy, bridging, bleeding complications, and transfusion, including various combinations. s were reviewed to confirm relevance, and then the full articles were extracted. References from extracted articles were also reviewed for relevant articles. Literature regarding perioperative clopidogrel continuation is predominantly composed of small, nonrandomized data, but suggests that most noncardiac surgeries or procedures can be performed safely while patients are taking clopidogrel. In this article, we review the current best evidence on the risk for bleeding with clopidogrel therapy in noncardiac surgery, summarize recent guidelines on appropriate duration of DAPT, and make recommendations on the management of perioperative DAPT.

Safety of Temporary and Permanent Suspension of Antiplatelet Therapy After Drug Eluting Stent Implantation in Contemporary “Real‐world” Practice

To define the incidence of stent thrombosis (ST) and/or AMI (ST/AMI) associated with temporary or permanent suspension of dual antiplatelet therapy (DAPT) after coronary drug-eluting stent (DES) implantation in "real-world" patients, and additional factors influencing these events. Adherence to DAPT is critical for avoiding ST following DES implantation. However, the outcomes of patients undergoing antiplatelet therapy withdrawal following DES implantation remain to be clearly described. Patients receiving DES from 05/01/2003 to 05/01/2008 were identified from a single-center registry. Complete follow-up data were available for 5,681 patients (67% male, age 66 ± 11 years, duration 1,108 ± 446 days) who were included in this analysis. Uninterrupted DAPT was maintained in 4,070/5,681 (71.6%) patients, with an annual ST/AMI rate of 0.43%. Antiplatelet therapy was commonly ceased for gastrointestinal-related issues, dental procedures or noncardiac/nongastrointestinal surgery. Temporary DAPT suspension occurred in 593/5,681 (10.4%) patients for 17.6 ± 74.1 days, with 6/593 (1.0%) experiencing ST/AMI during this period. Of patients permanently ceasing aspirin (n = 187, mean 338 ± 411 days poststenting), clopidogrel (n = 713, mean 614 ± 375 days) or both agents (n = 118, mean 459 ± 408 days), ST/AMI was uncommon with an annual rate of 0.1-0.2%. Overall, independent predictors of ST/AMI were unstable initial presentation, uninterrupted DAPT and lower left ventricular ejection fraction. Factors predicting uninterrupted DAPT included diabetes, unstable presentation, prior MI, left main coronary PCI, and multivessel coronary disease. In real-world practice, rates of ST/AMI following DES implantation are low, but not insignificant, following aspirin and/or clopidogrel cessation. Use of uninterrupted DAPT appears more common in high-risk patients.

Aspirin Plus Clopidogrel and Risk of Infection After Coronary Artery Bypass Surgery

The risks associated with the use of the combination of aspirin and clopidogrel before surgery are incompletely understood. Pharmacologic suppression of platelet function may increase the risk of postoperative infection by inhibiting hemostasis, immunity, or both. We performed a retrospective cohort study of 1677 patients undergoing coronary artery bypass surgery to determine the relationship of the preoperative use of aspirin plus clopidogrel vs aspirin alone to the 30-day incidence of postoperative surgical site infection and bacteremia. The cumulative incidence of infection at 30 days was 23.1% and 16.1% in patients who were receiving dual antiplatelet therapy and aspirin monotherapy, respectively (unadjusted hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.09-2.08). The risk of infection remained higher among patients who were receiving dual antiplatelet therapy after adjustment for demographic, socioeconomic, preoperative, and intraoperative risk factors (HR, 1.42; 95% CI, 1.01-2.00) and propensity score (HR, 1.43; 95% CI, 1.01-2.01]). Transfusion rates were also higher among patients who were receiving dual antiplatelet therapy than among patients who were receiving aspirin monotherapy (68.4% vs 60.4%, P = .04), but transfusion played a modest role in mediating the risk of infection (adjusted HR, 1.37; 95% CI, 0.96-1.93]). Mortality rates at 30 days were 5.2% and 3.1% in patients who were receiving dual antiplatelet and aspirin monotherapy, respectively (adjusted HR, 1.44; 95% CI, 0.70-2.99]). Preoperative use of aspirin plus clopidogrel is associated with an increased risk of infection after coronary artery bypass surgery. These findings merit additional work to clarify the risks and benefits of uninterrupted dual antiplatelet therapy in surgical patients and the impact of platelet inhibition on infectious outcomes in populations that are at heightened infectious risk.

Drug-Eluting or Bare-Metal Stents for ST Elevation Myocardial Infarction Can Observational Data Balance the Risk Benefit Equation?

The randomized clinical trials leading to initial approval of drug-eluting stents (DES) by the United States Food and Drug Administration were conducted by design in a homogeneous group of lower risk patients with mostly noncomplex coronary lesions.1,2 These studies demonstrated a clear benefit in the reduction of restenosis without any evidence of a safety concern during 1 year follow-up. Shortly after approval of the sirolimus and paclitaxel-eluting stents, safety and effectiveness was reported from small nonrandomized studies in a variety of more complex patient and lesion subgroups and resulted in a large proportion of so-called off-label usage.3,4 Article see p 176 Increased concern over the safety of acute DES implantation during primary percutaneous coronary intervention for ST elevation myocardial infarction (MI) left this indication as one of the last to gain widespread usage in favor of bare-metal stents (BMS). A study from Rotterdam comparing 186 consecutive patients receiving a DES from April 2002 to January 2003 with 183 patients receiving a BMS during an immediately preceding time interval demonstrated no increase in subacute stent thrombosis (0% versus 1.6%, P =0.10) and a significantly lower risk for major adverse cardiac events at 300 days (9.4% versus 17.0%, P =0.02) due to a markedly lower risk for target lesion revascularization (TLR) (1.1% versus 8.2%, P 80% penetration of DES among all percutaneous coronary intervention procedures by early 2006.6 Two small randomized trials of DES versus BMS conducted in Europe and published in September 2006, also showed no increase in stent thrombosis for DES within 1 year.7,8 In the summer of 2006, there were new concerns regarding late safety of DES with …