Use Of Antiplatelet Agents Research Articles

Time trends in antithrombotic therapy prescription patterns: Real-world monocentric study in hospitalized patients with atrial fibrillation.

Since 2010, the European Society of Cardiology has extended prescription criteria for oral antithrombotic therapy (OAT) in atrial fibrillation (AF). Direct oral anticoagulants (DOACs) were upgraded from an IIAa recommendation in 2012 to an IA in 2016. In real-world scenarios, however, OAC prescription is still suboptimal, mainly for DOACs. To evaluate OAT temporal prescription patterns in a cohort of patients hospitalized with AF in a Cardiology Department. A retrospective observational study was conducted on a cohort of hospitalized patients in a secondary setting (Trapani, Italy) from 2010 to 2021 with AF as the main or secondary diagnosis. For 4089 consecutive patients, the variables extracted from the Cardiology department database were: Sex, age, time of hospitalization, antithrombotic therapy (warfarin, acenocoumarol, apixaban, dabigatran, edoxaban, rivaroxaban, aspirin, clopidogrel, other antiplatelet agents, low molecular weight heparin, and fondaparinux), diagnosis at discharge and used resources. Basal features are presented as percentage values for categorized variables and as mean +/- SD for categorized once. From January 1st, 2010 to October 6th, 2021, 25132 patients were hospitalized in our department; 4089 (16.27%, mean age 75.59+/-10.82) were discharged with AF diagnosis; of them, 2245 were males (54.81%, mean age 73.56+/-11.45) and 1851 females (45.19%, mean age 78.06+/-9.47). Average length of stay was 5.76+/-4.88 days; 154 patients died and 88 were moved to other Departments/Structures. AF was the main diagnosis in 899 patients (21.94%). The most frequent main diagnosis in patients with AF was acute myocardial infarction (1973 discharges, 48.19%). The most frequent secondary cardiac diagnosis was chronic coronary syndrome (1864 discharges, 45.51%), and the most frequent secondary associated condition was arterial hypertension (1010 discharges, 24.66%). For the analysis of antithrombotic treatments, the final sample included 3067 patients, after excluding in-hospital deaths, transferred out or self-discharged patients, as well as discharges lacking indications for prescribed treatments. OAC treatment increased significantly (35.63% in 2010-2012 vs 61.18% in 2019-2021, +25.55%, P < 0.0001), in spite of any antiplatelet agent use. This rise was due to increasing use of DOACs, with or without antiplatelet agents, from 3.04% in 2013-2015 to 50.06% in 2019-2021 (+47.02%, P < 0.0001) and was greater for factor Xa inhibitors, especially apixaban. In addition, treatment with a vitamin K antagonist, in spite of any antiplatelet agent use, decreased from 35.63% in 2010-2012 to 11.12% in 2019-2021 (-24.48%, P < 0.0001), as well as any antiplatelet therapy, alone or in double combination, (49.18% in 2010-2012 vs 34.18% in 2019-2021, -15.00%, P < 0.0001); and patients not receiving antithrombotic therapy declined with time (14.58% in 2010-2012 vs 1.97% in 2021, P < 0.0001). Real-world patients with AF are elderly and affected by cardiovascular and non-cardiovascular diseases. The percentage of patients on OAT and DOACs increased. These data suggest a slow, gradual guidelines implementation process.

Assessing the Relationship between Thrombosis and Immune-Related Adverse Events in Patients with Lung Cancer Treated with Immune Checkpoint Inhibitors

Introduction: Venous thromboembolisms (VTE) frequently occur in cancer patients, and the role of immune checkpoint inhibitors on thrombotic risk has been a rising concern for clinicians. Identifying pro-thrombotic risk factors could guide primary prophylaxis strategies in patients receiving immunotherapy. Immune checkpoint blockade can induce inflammatory side effects known as immune-related Adverse Events (irAE). Inflammatory states are known to be associated with a hypercoagulable state. It is not established whether patients treated with immunotherapy experience a higher risk of thrombotic events during periods of increased inflammation surrounding irAE occurrence. Similarly, while immune checkpoint inhibitors have been shown to be associated with increased bleeding events, it is not clear whether irAE occurrence affects incidence of hemorrhage. Our primary objective was to determine the association between irAE and thrombosis in patients with non-small cell lung cancer treated with immune checkpoint inhibitors in order to better elucidate potential risk factors for thrombosis in patients on immunotherapy. Our secondary objective was to evaluate the association between irAE and clinically significant bleeding events. Methods: We identified all patients with non-small cell lung cancer treated with pembrolizumab at an academic medical center between 2016 and 2021. Outcomes of interest were VTE and clinically relevant bleeding (a composite of major bleeding and clinically-relevant non-major bleeds). We collected information regarding concurrent chemotherapy use with immunotherapy, frequency and type of irAE, steroid use for treatment for irAE, and use of anticoagulation or antiplatelet agents. We used logistic regression to calculate the odds ratios (OR) and 95% confidence intervals (CI) of VTE and clinically-relevant bleeding among patients who had an irAE prior to the outcome of interest compared to those who did not. We calculated the odds of VTE associated with use of concurrent chemotherapy (vs. no concurrent chemotherapy). Results: Of 102 patients included, 46.1% were female, and average age at diagnosis was 66.8 ± 10.5 years. Thirty-four patients were treated with pembrolizumab alone, with the remainder receiving concurrent chemotherapy and/or targeted therapy with pembrolizumab. Overall, 21 patients experienced thrombotic events (20.6%), 7 (6.9%) experienced clinically-relevant bleeding events, and 28 (27%) experienced an irAE. (Table 1). Overall, occurrence of irAE was not associated with increased odds of VTE (OR: 1.07, 95% CI: 0.37-3.11, P=0.90). (Figure 1). Similarly, among those with an irAE, steroid treatment was not associated with increased odds of VTE (OR: 1.14, 95% CI: 0.17-7.69, P=0.89). The combination of chemotherapy with pembrolizumab did not result in a statistically significant increase in odds of VTE (OR: 1.37, 95% CI: 0.52-3.60, P=0.53). The odds of clinically-relevant bleeding was not statistically higher among those with an irAE (OR: 2.10, 95% CI: 0.44-10.0, P=0.35). Conclusions: The development of irAE in patients with NSCLC treated with pembrolizumab does not appear to predict the development of VTE. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abstract 9789: Geriatric Nutritional Risk Index Predicts Bleeding Event in Patients With Heart Failure

Introduction: The relationship between malnutrition and bleeding event has been unclear in patients with heart failure (HF). Method and Results: We evaluated the nutritional status of patients with HF (n = 2,044) using Geriatric Nutritional Risk Index (GNRI). The primary endpoint was composite bleeding event of hemorrhagic stroke or gastrointestinal bleeding. According to the survival classification and regression tree analysis, the accurate cut-off point of GNRI for predicting the primary endpoint was 106.2. We divided patients into two groups based on GNRI levels: the High GNRI group (GNRI ≥ 106.2, n = 606, 29.6%) and the Low GNRI group (GNRI &lt; 106.2, n = 1,438, 70.4%), and compared patients’ characteristics and prognosis between the two groups. The Low GNRI group showed higher age (72.0 vs. 63.0 years, P &lt; 0.001) and lower prevalence of male sex (56.9% vs. 64.5%, P = 0.001) than the High GNRI group. There were no differences in use of antiplatelet agents and anticoagulants between the groups. In laboratory data, levels of B-type natriuretic peptide were higher in the Low GNRI group (321.1 vs. 111.6 pg/mL, P &lt; 0.001). Left ventricular ejection fraction was comparable between the groups. The Kaplan-Meier analysis demonstrated that bleeding event rates were higher in the Low GNRI group than in the High GNRI group (Figure, log-rank P &lt; 0.001). The multivariable Cox proportional hazard analysis revealed that the Low GNRI was independently associated with bleeding events (hazard ratio 1.795, P = 0.047). Conclusions: Malnutrition assessed by GNRI predicts bleeding events in patients with HF.

Abstract 14027: Use of Anticoagulation or Antiplatelets in Patients With Cardiac Arrest Without ST-Segment-Elevation or Percutaneous Coronary Intervention

Introduction: There are limited data on the use of anticoagulation (AC) and anti-platelet (AP) agents in addition to aspirin compared to standard of care (aspirin alone) in cardiac arrest (CA) patients without ST-segment-elevation and not undergoing a percutaneous coronary intervention. Hypothesis: We hypothesized that use of AC/AP agents in CA is associated with lower mortality compared to aspirin alone. Methods: A comprehensive literature search was performed from inception to 09/30/2021 of the PubMed/EMBASE databases. Studies of adult patients comparing AC/AP to aspirin alone were evaluated for short-term mortality (30-days survival/survival to hospital discharge), significant bleeding, and return of spontaneous circulation (ROSC). Odds ratio (OR) with 95% confidence intervals (CI) were calculated using DerSimonian-Laird method. Results: Of a total 5337 studies, five studies (2 randomized trials and 3 observational studies) with 3,696 subjects (1,196 intervention and 2,500 placebo arm) were included. Overall, there was no evidence of publication bias using either funnel plot or eggers test. For RCT studies, mean age was 60.8 years (males 79.2%), while for observational study mean age was between 58 to 62.3 years (males 58-62.3%). Use of AP/AC was associated with higher rates of major bleeding (odds ratio [OR] = 2.43 [95% confidence interval {CI} 1.35- 4.37]; p=0.003; I2=7%; 4 studies) compared with aspirin alone. There was no significant difference in ROSC (OR= 1.24 [95% CI 0.68-2.26]; p=0.49; I2=57%; 3 studies) and short-term mortality [OR= 1.24 [95% CI 0.87-1.76]; p=0.24; I2=69%; 3 studies) between intervention and placebo arm. Conclusions: In this meta-analysis, use of concomitant AC/AP therapy with aspirin in CA without ST-segment-elevation or percutaneous coronary intervention was associated with higher rates of bleeding without improvement in short-term mortality or ROSC.

Abstract 14712: PCI is Safe and Increasing Among Cancer Patients: Nationally Representative Propensity Score Adjusted and Machine Learning Augmented Study of 100 Million Hospitalizations

Introduction: The greater use of antithrombotic and antiplatelet agents in the growing population of patients with cardiovascular disease and cancer contrasts with the limited evidence-base on appropriate revascularization management for these patients. Methods: This is the first nationally representative multi-year cardio-oncology mortality study of thrombocytopenia (platelets &lt;150,000) and coronary intervention including percutaneous coronary intervention (PCI), and the first such study using machine learning augmentation and propensity score (PS). Utilizing the 2016-2018 National Inpatient Sample (NIS), the PS for receiving PCI was generated, balance confirmed, and regression adjustment completed (also including age, sex, race, income, urban, region, metastasis, NIS-calculated mortality risk by disease-related group), and multivariable regression model performance was optimized using backward propagation neural networks. Results: Of the 101,521,656 hospitalized adult patients, 6,456,777 (6.36%) had active cancer of whom 6.14% had thrombocytopenia. Among thrombocytopenia patients, patients with versus without active cancer were significantly (p&lt;0.001) less likely to receive left heart catheterization (1.88 vs. 5.41%) and PCI (0.48 vs. 1.35%). Among cancer patients, patients with versus without thrombocytopenia were more likely to have acute myocardial infarction (4.06 vs. 2.35%) and to receive intravascular ultrasound (62.65 vs. 56.75%) but had comparable rates of fractional flow reserve and optical coherence tomography. PCI nearly doubled from 2016 to 2018 among patients with thrombocytopenia (10.33 vs. 6.16%). In multivariable regression in PCI, neither active cancer (OR 0.89, 95%CI 0.45-1.75; p=0.738) nor any of the 32 tested primary malignancies significantly increased mortality. Conclusions: This nationally representative longitudinal study suggests inpatient PCI is safe and is increasing among patients with active cancer regardless of their primary malignancy.

Antiplatelet Drugs on the Recurrence of Hepatocellular Carcinoma after Liver Transplantation.

Previous studies reported suppressive effects of antiplatelet agents on hepatocellular carcinoma (HCC); however, this has never been assessed in patients who underwent liver transplantation (LT). This retrospective observational study used data from LT recipients with pre-transplant HCC in a single tertiary hospital. The study population was divided into two groups according to the use of antiplatelet agents for &gt;90 days within the study period (377 antiplatelet groups versus 91 non-antiplatelet groups). Matched groups containing 79 patients in each group were also compared regarding HCC-recurrence and HCC-related mortality, which were analyzed by treating non-HCC death as a competing risk. In Kaplan-Meier analyses of the matched cohort, the 5-year cumulative incidences of HCC recurrence and HCC-specific death were similar between the antiplatelet (p = 0.876) and non-antiplatelet groups (p = 0.701). All-cause and non-HCC deaths were also similar between the two groups (p = 0.867 and p = 0.413, respectively). In multivariable analyses of the entire cohort, antiplatelet use was not associated with HCC recurrence (hazard ratio [HR] 1.37, p = 0.300) or HCC-specific death (HR 1.54, p = 0.310). Therefore, unlike the usual setting with liver disease, antiplatelet therapy did not affect HCC recurrence or HCC-specific mortality when used after LT.

Acute Myocardial Infarction Complicating Coronavirus Infection (Case Report)

Coronavirus infection caused by the SARS-CoV-2 virus is a multifaceted disease due to generalized vascular endothelial damage. Endothelial damage also underlies COVID-associated coagulopathy.The paper presents a case of coagulopathy causing myocardial infarction in a 43-year-old patient with no history of coronary disease. We have reviewed the available literature for the pathophysiological rationale of the assumed possibility of coronary thrombosis resulting from coagulopathy with the intact intima of the coronary arteries.Conclusion. The present observation of coronary thrombosis with radiographically intact coronary artery intima confirms the important role of coronavirus infection in triggering endothelial dysfunction. Currently, the most effective strategy for this type of coronary lesions is the use of anticoagulants and antiplatelet agents along with ECG, echocardiography and troponin level monitoring.

COVID-19 IN PATIENTS WITH MYELOPROLIFERATIVE NEOPLASMS: THE RISK OF THROMBOEMBOLIC EVENTS AND CURRENT OPTIONS FOR ANTITHROMBOTIC PROPHYLAXIS

Aim: to provide a literature review of the presently available data on the risk of thromboembolic events and current options for antithrombotic prophylaxis in patients with myeloproliferative neoplasms (MPN) patients with concomitant coronavirus disease 2019 (COVID-19).&#x0D; Material and methods. The thematic scientific papers, published predominantly during the last decade (including the references regarding SARS-CoV-2 infection (COVID-19) of the last three years), constituted the study material. The research methodology involved bibliosemantic method and structural and logical analysis.&#x0D; Results and discussion. MPN and SARS-CoV-2 infection (COVID-19) are both conditions with inherently enhanced susceptibility to thromboembolic events (venous and arterial). Along with the specific pathophysiological pathways, MPN and COVID-19, in case of their constellation, share overlapping pathomechanisms of hypercoagulability. As of today, the antithrombotic prophylaxis in MPN/COVID-19 patients (primary and secondary) is carried out according to the guidelines and algorithms, including those regarding general principles of the use of anticoagulants (oral or parenteral) and antiplatelet agents, and those specifically addressed to MPN or SARS-CoV-2 infection. These documents are constantly updating as the results of ongoing trials become available. Considering the relatively low prevalence of MPN, and the absence of specific guidelines, devoted to MPN in tandem with SARS-CoV-2 infection, the conduction of global registry studies is of crucial importance, aiming to provide a continuous and thorough collection and analysis of the data, related to the characteristics of this particular patients` population, pathological background and clinical features of thromboembolic complications, as well as short- and long-term outcomes.&#x0D; Conclusion. The comprehensive study of basic, epidemiological and clinical data regarding various aspects of thrombosis/thromboembolism in case of MPN/COVID-19 constellation, is a multidisciplinary task, which should be performed with an ultimate goal to improve already implemented and develop novel approaches to antithrombotic management of such patients.

Navigating Antiplatelet Treatment Options for Stroke: Evidence-Based and Pragmatic Strategies.

The benefit of using antiplatelet monotherapy in acute ischemic stroke and secondary stroke prevention is well established. In the last few years, several large randomized trials showed that the use of short-term dual antiplatelet therapy in particular stroke subtypes may reduce the risk of recurrent ischemic events. The aim of this article is to provide a critical analysis of the current evidence and recommendations for the use of antiplatelet agents for stroke prevention. Long-term therapy with aspirin, clopidogrel, or aspirin plus extended-release dipyridamole is recommended for secondary stroke prevention in patients with noncardioembolic ischemic stroke. Short-term dual antiplatelet therapy with aspirin and clopidogrel is superior to antiplatelet monotherapy in secondary stroke prevention when used in patients with mild noncardioembolic stroke or high-risk transient ischemic attack. Dual therapy, however, is associated with an increased risk of major bleeding, particularly when the treatment is extended for greater than 30days. Similarly, aspirin plus ticagrelor is superior to aspirin monotherapy for the prevention of recurrent ischemic stroke, although this combination is associated with a higher risk of hemorrhagic complications when compared to other dual antiplatelet regimens. Among patients who carry CYP2C19 genetic polymorphisms associated with a slow bioactivation of clopidogrel, short-term treatment with aspirin plus ticagrelor is superior to aspirin plus clopidogrel for the reduction of recurrent stroke; however, the use of ticagrelor is associated with a higher risk of any bleeding. In patients with symptomatic intracranial stenosis, aggressive medical management in addition to dual antiplatelet therapy up to 90days is recommended. Antiplatelet therapy has an essential role in the management of ischemic stroke. The specific antiplatelet regimen should be individualized based on the stroke characteristics, time from symptom onset, and patient-specific predisposition to develop hemorrhagic complications.

The new 2022 ESC Guidelines on Cardio-oncology and their impact on the Acute Cardiovascular Care Society.

In this perspective piece on the recently published ESC Guidelines on Cardio-oncology and the Consensus Statements from the Acute Cardiovascular Care Association, we summarize key learning points regarding the management of acute cardiovascular disease in patients with cancer. This document outlines where other pre-existing ESC Guidelines can be applied to the management of acute cardiovascular disease in patients with cancer while simultaneously highlighting important gaps in knowledge that require further research. Cancer and cardiovascular disease share common risk factors and often co-exist, especially in older patients. In addition, patients with cancer undergoing active treatment are exposed to multiple, potentially cardiotoxic drugs, which may manifest as a variety of cardiovascular events, including left-ventricular systolic dysfunction and heart failure, arrhythmias, hypertension, or acute venous and arterial vascular events. Knowledge about potential causative cancer therapeutics is necessary for rapid recognition and management to improve cardiovascular outcomes and guide ongoing cancer treatment. Specifically, the importance of rapidly interrupting culprit cancer drugs is highlighted, as well as instituting standard guideline-based therapies for conditions such as acute heart failure and acute coronary syndromes [ST-elevation myocardial infarction and high-risk non-ST-elevation acute coronary syndrome (ACS)]. Given the high prevalence of thrombocytopenia and increased bleeding risk in patients with cancer, we are provided with platelet cut-offs for the use of different antiplatelet agents and anticoagulants for patients with ACS and atrial arrhythmias. In contrast, given the hypercoagulable milieu of cancer, we are provided information regarding types of anticoagulants, drug-drug interactions, and duration of anticoagulation in patients with acute venous thromboembolism, as well as for atrial fibrillation. They also discuss the diagnostic and treatment strategies for the unique cardiotoxicities seen with novel cancer therapeutics such as immune checkpoint inhibitors and chimeric receptor antigen T-cell therapy. Last, but not least, the authors emphasize that the care of these patients requires close collaboration between cardiology and oncology to maximize both cardiovascular and cancer outcomes.

Combined anticoagulant and antiplatelet therapy is associated with an improved outcome in hospitalised patients with COVID-19: a propensity matched cohort study

Abstract Background COVID-19 is a respiratory disease that results in a prothrombotic state manifesting as thrombotic, microthrombotic and thromboembolic events. As a result, several antithrombotic modalities have been implicated in the treatment of this disease. Purpose Currently, prophylactic dose anticoagulation is considered the standard of care antithrombotic regimen in hospitalised patients with COVID-19. However, high-quality data about the subject is unavailable. This study aimed to identify if therapeutic anticoagulation (TAC) or concurrent use of antiplatelet and anticoagulants was associated with an improved outcome in this patient population. Methods A retrospective observational cohort study of adult patients admitted to a single university hospital for COVID-19 infection was performed. The primary outcome was a composite of in-hospital mortality, intensive care unit (ICU) admission or the need for mechanical ventilation. The secondary outcomes were each of the components of the primary outcome, in-hospital mortality, ICU admission, or the need for mechanical ventilation. Results 242 patients were included in the study and divided into four subgroups: Therapeutic anticoagulation (TAC), prophylactic anticoagulation+antiplatelet (PACAP), TAC+antiplatelet (TACAP) and prophylactic anticoagulation (PAC) which was the reference for comparison. Multivariable Cox regression analysis and propensity matching were done and showed when compared with PAC, TACAP and TAC were associated with less in-hospital all-cause mortality with an adjusted HR (aHR) of 0.113 (95% CI 0.028 to 0.449) and 0.126 (95% CI 0.028 to 0.528), respectively. The number needed to treat in both subgroups was 11. Furthermore, PACAP was associated with a reduced risk of invasive mechanical ventilation with an aHR of 0.07 (95% CI 0.014 to 0.351). However, the was no statistically significant difference in the occurrence of major or minor bleeds, ICU admission or the composite outcome of in-hospital mortality, ICU admission or the need for mechanical ventilation. Conclusion The use of combined anticoagulant and antiplatelet agents or TAC alone in hospitalised patients with COVID-19 was associated with a better outcome in comparison to PAC alone without an increase in the risk of major and minor bleeds. Sufficiently powered randomised controlled trials are needed to further evaluate the safety and efficacy of combining antiplatelet and anticoagulants agents or using TAC in the management of patients with COVID-19 infection. Funding Acknowledgement Type of funding sources: None.

Complications After Transthoracic Needle Biopsy of Pulmonary Nodules: A Population-Level Retrospective Cohort Analysis.

To provide recent population-based estimates of transthoracic needle biopsy (TTNB) complications and risk factors associated with these complications. This retrospective cohort analysis included adults from a nationally representative longitudinal insurance claims data set who underwent TTNB in 2017 or 2018. Complications that were evaluated included pneumothorax, hemorrhage, and air embolism. Separate logistic regression models estimated the association of pneumothorax or hemorrhage with the setting of care (ie, inpatient or outpatient) and selected baseline patient demographic and clinical characteristics including age, gender, history of chronic obstructive pulmonary disease, diagnosis of pleural effusion, tobacco use, use of oral anticoagulants and antiplatelet agents, prior lung cancer screening, previous bronchoscopy within 1 year, and Elixhauser comorbidity index. Among 16,971 patients who underwent TTNB, 25.8% experienced a complication within 3 days of the procedure (pneumothorax 23.3%, hemorrhage 3.6%, and air embolism 0.02%). Among patients who experienced pneumothorax, 31.9% required chest tube drainage. Among patients undergoing an outpatient TTNB (n= 12,443), 6.9% were hospitalized within 7 days. Biopsy in an inpatient setting, chronic obstructive pulmonary disease diagnosis, and prior bronchoscopy were associated with higher rates of both pneumothorax and hemorrhage. Prior lung cancer screening was associated with an increased risk of pneumothorax, and prior use of oral anticoagulants or antiplatelets was associated with higher rates of hemorrhage. This contemporary population-based cohort study demonstrated that approximately one-quarter of patients undergoing TTNB experienced a complication. Pneumothorax was the most frequent complication, and hemorrhage and air embolism were rare. Among outpatients, complications from TTNB are an important cause of hospitalization.

S998 Predictors and Outcomes of 90-Day Readmission in Inflammatory Bowel Disease Patients Admitted for Percutaneous Coronary Intervention

Introduction: The outcome of patients with Inflammatory bowel disease (IBD) presenting with coronary artery disease (CAD) requiring percutaneous coronary intervention (PCI) has limited evidence in the literature. The aim of this study is to examine the predictors and outcomes of 90-day readmissions in IBD patients requiring PCI. Methods: The International Classification of Diseases Code,10th Revision Clinical Modification (ICD-10) was used to identify patients who were hospitalized for PCI. Patients were identified from the Healthcare Cost and Utilization Project databases (HCUP) using the National readmission database (NRD) between 2016 and 2019. Patients were classified into 2 groups depending on whether they have IBD or not. Outcomes were all-cause and cause-specific 90-day readmissions and mortality rate during readmission. Multiple logistic regression model was used to identify the factors associated with readmission Results: 1,851,473 patients underwent PCI between 2016 and 2019. 9295 (0.5%) patients had IBD. The mean age was 65.3 in patients with no IBD and 67.7 in patients with IBD. Total of 239105 readmissions were identified, 1522 (0.6%) were patients with IBD. The rate of admission for patients with IBD was 16.3% as compared to 12.9 % for patient without IBD (p< 0.001). Multivariate logistic regression was performed and showed OR of 1.31 (95% CI 1.18,1.455) (P< 0.001) for 90 days readmission for patients with IBD who underwent PCI as compared to those without IBD. Gastrointestinal bleed occurred in 7 % in patients readmitted who had IBD as compared to 3 % in patients without IBD, OR 1.89 (95% CI 1.57,2.27) (P< 0.001). Most important predictors of readmission were history of coronary artery disease (CAD), Congestive heart failure (CHF) and renal failure. Conclusion: It appears that IBD is an independent risk factor for re-admission in patients undergoing PCI. Bleeding is a major cause of readmission which might be related to use of anticoagulation and antiplatelet agents in patients undergoing PCI. Further studies are needed to identify other possible causes of readmission and optimal means to control them.

Тромбоз вен нижних конечностей и его последствия в восстановительном периоде инсульта

Post-stroke lower extremity vein thrombosis can be the reason behind complications of embolic nature and death. This study aimed to investigate the influence of provoking factors, frequency and localization of acute thrombosis, post-thrombotic changes in the lower extremity veins during stroke recovery period. The study involved 1315 patients, 885 (67.3%) male and 430 (32.7%) female, ages 18–94 years, mean age 59.23 ± 13.7 years. All participants underwent lower extremity venous duplex scanning in the early and late stages of stroke recovery period. We found no evidence of interconnections between presence of signs of thrombosis and/or its consequences and the pathogenetic variant of stroke the patient had. Acute deep vein thrombosis was diagnosed significantly more often (p &lt; 0.05) in the early stage of stroke recovery period. The frequency of acute lower extremity vein thrombosis was 7.8%, post-thrombotic changes — 5.6%. Isolated lesion of the lower leg veins was the most common complication associated with deep veins (49.6%). We have discovered a significant relationship between the side of lower extremity paresis (plegia) of and the side of deep vein thrombosis (p &lt; 0.001). No relationship was found between lower extremity superficial and deep vein thrombosis and use of anticoagulants and antiplatelet agents (p &gt; 0.05). Excess body weight was associated with damage to the lower extremity proximal veins (p &lt; 0.05). Women had lower extremity vein thrombosis significantly more often (p &lt; 0.05). Repeated lower extremity venous duplex scanning upon admission to the rehabilitation hospital allowed reducing the risk of venous thromboembolic complications that may develop during the stroke recovery period.

S176 Cold Snare Polypectomy in Pedunculated Colorectal Polyps: A Systematic Review and Meta-Analysis

Introduction: Colonoscopy remains an vital tool for colorectal cancer screening and allows for early detection and removal of adenomatous polyps. While several studies have reported on cold snare polypectomy (CSP) and hot snare polypectomy (HSP) in sessile and flat elevated polyps; limited data exists on outcomes in pedunculated polyps. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of CSP for pedunculated polyps. Methods: Multiple databases were searched till June 2022 to identify studies involving the removal of pedunculated polyps with CSP and HSP. (Table) A random effects model was used to calculate outcomes and 95% confidence intervals (CI). Heterogeneity was assessed using I2 test. Our primary goal was to assess pooled rates of immediate and delayed bleeding with CSP. Secondary outcomes included pooled rates of en-bloc & piecemeal resection as well as prophylactic and post resection clipping. Meta-regression was performed to assess if bleeding was affected by polyp location and use of antithrombotics. Results: Six studies including 1025 patients (1,111 polyps with a mean size 4 – 8.5 mm) were analyzed. 116 and 995 polyps were removed with HSP and CSP, respectively. The overall pooled rate of immediate bleeding following CSP was 49.8% (CI 46.8-52.91; I2 98%), which was significantly higher than HSP, RR 7.89 (CI 4.36-14.29; I20%), p< 0.00001 (Figure 1A). The overall pooled rate of delayed bleeding following CSP was 0% (CI 0.00-0.00; I2 0%), which was significantly lower than HSP, RR 0.05 (CI 0.01-0.43; I20%), p=0.006 (Figure 1B). Pooled rate of en-bloc and piecemeal resection with CSP were 99.7% and 0.3%, respectively. Pooled rate of prophylactic clipping and post procedure clipping (to control immediate bleeding) after CSP was 55.3% and 47.2%, respectively. We found no statistical difference in these outcomes when compared to HSP, RR 0.19 (CI 0.01-6.35; I2 85%), p=0.35 and RR 1.73 (CI 0.12-25.5; I2 98%), p=0.69. Meta-regression showed that concurrent use of antithrombotic and/or antiplatelet agents did not have any effect on immediate bleeding following CSP. Right colon polyp location (proximal to the hepatic flexure) significantly correlated with frequency of immediate bleeding. Conclusion: Our analysis shows that CSP is safe and effective for resection of pedunculated colorectal polyps, especially those less than 10 mm in size. While CSP may increase the risk of immediate bleeding, HSP has a higher risk of delayed bleeding.Figure 1.: Forest plots demonstrating the relative risk of immediate (1A) and delayed (1B) bleeding following polypectomy Table 1. - Characteristics of included studies Author, year Study Design Study Country Total Polyps Arimoto, 2022 Prospective, single center Japan 114 Fatima, 2022 Prospective, single center United States 239 Kaltenbach, 2019 Retrospective, multicenter United States 94 Arimoto, 2021 Retrospective, single center Japan 188 Kudo 2021 Retrospective, single center Japan 444 Arimoto, 2020 Retrospective, single center Japan 90 Kaltenbach, 2019 Retrospective, multicenter United States 94

Current Status and Future Direction of Antithrombotic Therapy for Patients with STEMI Undergoing Primary PCI.

Since the introduction of the first pharmacological therapy for the treatment of patients with acute myocardial infarction in the early 20th century, treatment of myocardial infarction has evolved extensively throughout the years. Mechanical revascularization therapies such as the percutaneous transluminal coronary angioplasty, combined with the ongoing development of pharmacological therapies have successfully improved the survival of patients with acute myocardial infarction. To date, antiplatelet therapy (consisting of aspirin and an oral inhibitor) and anticoagulation therapy represent the main stay of pharmacological treatment in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). The routine use of clopidogrel as antiplatelet agent has been largely replaced by the use of the more potent inhibitors ticagrelor and prasugrel. Unfractionated heparin remains the preferred anticoagulant therapy, despite the development of other anticoagulants, including enoxaparin and bivalirudin. To date, limited evidence exists supporting a pre-hospital initiation of antiplatelet and anticoagulant therapy in STEMI patients. The use of potent intravenous antiplatelet agents, including the glycoprotein IIb/IIIa inhibitors and the intravenous inhibitor cangrelor, is currently restricted to specific clinical settings. While several potent antithrombotic agents already exist, the search for novel potent antithrombotic agents continues, with a focus on balancing antithrombotic properties with an improved safety profile to reduce excess bleeding. This review provides an overview of currently available pharmacological therapies for the treatment of STEMI patients undergoing primary PCI, and an outlook for the ongoing development of novel agents in this field.

Demographic and clinical profile of patients suffering prolonged severe hypoxia in COVID-19

ABSTRACT Background Coronavirus disease 2019 (COVID-19) may result in rapid onset of hypoxemic respiratory failure. This study aimed to characterize the factors and outcomes associated with prolonged hypoxia in patients with COVID-19. Prolonged severe hypoxia (PSH) was defined as hypoxia requiring ≥6 L/min of oxygen by nasal cannula or equivalent for more than 10 days. Research design and methods This study was designed as a single-center retrospective analysis. Multivariable logistic regression was utilized to assess factors associated with PSH. Results The sample included 554 patients with 117 (21%) having PSH. Median length of stay of patients with PSH was significantly longer (median IQR: 18 days vs 6 days, p < 0.0001). Patients with PSH had significantly higher rates of venous thromboembolism (p < 0.0001) and major bleeding (p < 0.004). The presence of cirrhosis (OR 3.32, 95% CI [1.02 to 10.83]) and hypertension (OR 1.99, 95% CI [1.12 to 3.53]) were independently associated with PSH, while outpatient use of anti-platelet agents had an inverse association (OR 0.57, 95% CI [0.36 to 0.91]). Conclusion PSH is associated with increased length of stay, morbidity, and mortality. Hypertension and liver cirrhosis were significantly associated with higher odds of PSH, while use of anti-platelet therapy had a protective effect.

Features of course and treatment of necrotic epifascial phlegmona in children's chicken pox

Introduction. The most life-threatening bacterial complication of chickenpox in children is necrotizing epifascial phlegmon. The incidence of this disease is 0.01-0.2%. Unsatisfactory results of treatment can be associated with late and erroneous diagnosis, as well as insufficient intensive therapy.The aim is to study the features of the course and treatment of necrotizing epifascial phlegmon with chickenpox in children.Material and methods. An analysis of the treatment of 20 children with necrotizing epifascial phlegmon with chickenpox was carried out. Microbiological and histological studies were performed from the lesion focus, the immune status and the state of hemostasis were studied, and a clinical assessment of the wound process was given on the basis of visual observation.Results. In the study, there were 12 boys and 8 girls among all patients. The most frequent localization of necrotizing epifascial phlegmon in chickenpox was the lower and upper extremities. Of the observed 20 patients with necrotizing epifascial phlegmon at the age from 1 to 7 years, there were 16 children. The development of this disease usually occurred on the 3-5th day of the course of chickenpox. The disease proceeded with a clearly pronounced staging, thrombosis in the vessels of the skin and subcutaneous tissue, followed by necrosis. The severity of the patient's condition depended on the area of skin and subcutaneous tissue lesions. Streptococcus pyogenes was the main causative agent in the inoculation of the lesion separatedfrom the focus. Changes in the immune status for the most part corresponded to those in acute purulent inflammation. Complex treatment with systemic antibacterial and intensive syndromic therapy, active intervention in the lesion focus and the use of modern technologies in the management of wounds and wound defects contributed to the healing of patients and a decrease in mortality.Conclusion. The likelihood of developing necrotic epifascial phlegmon in children with chickenpox is quite high when infected with Streptococcus pyogenes. The course of necrotic epifascial phlegmon with chickenpox in children has a certain sequence: a period of progressive course, a period of necrosis and wound defects, a period of repair. Active early complex treatment with targeted antibacterial and intensive post-syndrome therapy, the use of anticoagulants and antiplatelet agents, antibiotic-novocaine blockade and incisions in the lesion focus, the use of modern technologies in the management of wounds and wound defects contributed to the healing of patients and the prevention of deaths.

Effect of Anticoagulant and Antiplatelet Drugs on Outcome of Arterio-Venous Fistula Created for Hemodialysis Access

Background: Arteriovenous fistula (AVF) creation is the primary mode of achieving vascular access for hemodialysis in chronic renal failure (CRF). Because of high complication rates like thrombosis, maintenance of the fistula is a major challenge. Although antiplatelet and anticoagulant drugs are emerging rapidly for improving the outcome of AVF but fear of bleeding, hematoma, subsequent compression of AV fistula and blockade restrict their use in many dialysis centers. Objective: To see the effect of anticoagulant &amp; antiplatelet drugs in improving primary patency rate and reducing early thrombus formation of AVF. Methods: This clinical trial was conducted in the Department of Urology Bangabandhu Sheikh Mujib Medical University, Dhaka from November, 2018 to October, 2019. Ninety six ESRD patients who underwent AV fistula with immediate postoperative had thrill and murmur were included as study population as per selection criteria. Informed written consent was taken from all the patients. Patients were divided into two groups using computer generated random number (group I and group II). In group I, patients anticoagulation and antiplatelet drugs were used and in group II, patients anticoagulation and antiplatelet drugs were not used after creation of AVF. Patients were followed up on 3rd POD, at 2 weeks and at 4 weeks after the operation and re-evaluated with clinical examinations and investigations. The outcome were evaluated and compared between two groups. Results: In this study maximum patients were more than 40 years old in both groups. Mean age was 47.89 ± 12.54 years in group I and 46.29 ± 14.78 in group II. Males were predominant in both groups. Male to female ratio was 3.36:1 and 5.8:1 in group I and group II respectively in this study. In this study 35.4% in Group I and 45.8% in Group II patients had hypertension. 47.9% in Group I and 60.4% in Group II patients had DM. Thrombosis was significantly lower in study group (group I) than control group (group II). Primary patency was significantly higher at 4th week after treatment in group I than group II. Bleeding was observed in one (2.1%) patients at 1rd POD in group I who came with emergency &amp; managed conservatively. Haematoma was observed in 1 (2.1%) patients at 3rd POD in group I. Conclusion: Use of antiplatelet and anticoagulant agents prevented the loss of AV patency. But it still needs to be determined whether the potential benefits of anticoagulant &amp; antiplatelet therapy outweights the risk of adverse events. Bangladesh J. Urol. 2021; 24(1): 90-98

Pre-Injury Antiplatelet Therapy and Risk of Adverse Outcomes after Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

There is an increasing number of trauma patients presenting on pre-injury antiplatelet (AP) agents attributable to an aging population and expanding cardio- or cerebrovascular indications for antithrombotic therapy. The effects of different AP regimens on outcomes after traumatic brain injury (TBI) have yet to be elucidated, despite the implications on patient/family counseling and the potential need for better reversal strategies. The goal of this systematic review and meta-analysis was to assess the impact of different pre-injury AP regimens on outcomes after TBI. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the OVID Medline, Embase, BIOSIS, Scopus, and Cochrane databases were searched from inception to February 2022 using a combination of terms pertaining to TBI and use of AP agents. Baseline demographics and study characteristics as well as outcome data pertaining to intracerebral hematoma (ICH) progression, need for neurosurgical intervention, hospital length of stay, mortality, and functional outcome were extracted. Pooled odds ratios (ORs) and mean differences comparing groups were calculated using random-effects models. Thirteen observational studies, totaling 1244 patients receiving single AP therapy with acetylsalicylic acid or clopidogrel, 413 patients on dual AP therapy, and 3027 non-AP users were included. No randomized controlled trials were identified. There were significant associations between dual AP use and ICH progression (OR, 2.81; 95% confidence interval [CI], 1.19–6.61; I2, 85%; p = 0.02) and need for neurosurgical intervention post-TBI (OR, 1.61; 95% CI, 1.15–2.28; I2, 15%; p = 0.006) compared to non-users, but not between single AP therapy and non-users. There were no associations between AP use and hospital length of stay or mortality after trauma. Pre-injury dual AP use, but not single AP use, is associated with higher rates of ICH progression and neurosurgical intervention post-TBI. However, the overall quality of studies was low, and this association should be further investigated in larger studies.