Use Of Antithrombotic Medications Research Articles

Impact of antithrombotic agents on outcomes in patients requiring surgery for chronic subdural haematoma: a systematic review and meta-analysis.

A chronic subdural haematoma (CSDH) is a collection of aged blood between the dura and the brain, typically treated with surgical evacuation. Many patients with CSDH have comorbidities requiring the use of antithrombotic medications. The optimal management of these medications in the context of CSDH remains unknown, as the risk of recurrence must be carefully weighed against the risk of vaso-occlusive events. To better understand these risks and inform the development of clinical practice guidelines, we conducted a systematic review and meta-analysis. A systematic review was conducted in accordance with the PRISMA guidelines, searching Medline and Embase databases. The study was registered with PROSPERO (CRD42023397061). A total of 44 studies were included, encompassing 1 prospective cohort study and 43 retrospective cohort studies. Pooled odds ratios (ORs) were calculated for CSDH recurrence and vaso-occlusive events in patients taking anticoagulant or antiplatelet medications compared to patients not receiving antithrombotic therapy. GRADE was used to assess the quality of evidence. In patients on anticoagulant therapy at CSDH diagnosis, the pooled OR for CSDH recurrence was 1.41 (95% CI 1.11 to 1.79; I2 = 28%). For patients on antiplatelet therapy, the pooled OR was 1.31 (95% CI 1.08 to 1.58; I2 = 32%). Patients taking antithrombotic medications had a significantly higher risk of vaso-occlusive events, with a pooled OR of 3.74 (95% CI 2.12 to 6.60; I2 = 0%). There was insufficient evidence to assess the impact of time to recommence antithrombotic medication on CSDH outcomes. We found that baseline antithrombotic use is associated with the risk of CSDH recurrence and vaso-occlusive events following surgical evacuation. The evidence base is of low quality, and decisions regarding antithrombotic therapy should be individualised for each patient. Further high-quality, prospective studies or registry-based designs are needed to better inform clinical decision-making and establish evidence-based guidelines.

A Practical Guide to Understanding and Treating Peripheral Artery Disease.

Peripheral arterial disease (PAD) is the third leading cause of atherosclerotic morbidity after coronary heart disease and stroke yet is widely underdiagnosed and undertreated. Treatment of risk factors such as diabetes and cigarette smoking can benefit patients with PAD. Patients should have adequate blood pressure and lipid control to decrease clinical manifestations and symptoms of PAD. Use of antithrombotic medications should be individualized to the patient depending on presence of symptoms, revascularization, and comorbidities. All patient care providers, including physicians, pharmacists, nurse practitioners, and physician assistants should incorporate PAD screening in their at-risk patients to improve access for appropriate earlier diagnosis, initiation of guideline directed therapy, and risk factor modification in order to reduce both major adverse CV and limb outcomes. The purpose of this narrative review is to provide an overview of PAD, summarize clinical trial evidence and guideline recommendations for screening and treatment in order to increase awareness among health care providers to ultimately have a positive impact on patient care.

Prescriber decision-making on antithrombotic therapy after endovascular intervention for peripheral artery disease: a protocol for a discrete choice experiment

IntroductionPeripheral artery disease (PAD) is a major risk factor for cardiovascular morbidity and mortality, despite surgical and endovascular treatments. Emerging evidence supports the use of immediate antithrombotic medications after endovascular...

COVID-19 and pregnancy: A European study on pre- and post-infection medication use.

The COVID-19 pandemic has impacted medication needs and prescribing practices, including those affecting pregnant women. Our goal was to investigate patterns of medication use among pregnant women with COVID-19, focusing on variations by trimester of infection and location. We conducted an observational study using six electronic healthcare databases from six European regions (Aragon/Spain; France; Norway; Tuscany, Italy; Valencia/Spain; and Wales/UK). The prevalence of primary care prescribing or dispensing was compared in the 30-day periods before and after a positive COVID-19 test or diagnosis. The study included 294,126 pregnant women, of whom 8943 (3.0%) tested positive for, or were diagnosed with, COVID-19 during their pregnancy. A significantly higher use of antithrombotic medications was observed particularly after COVID-19 infection in the second and third trimesters. The highest increase was observed in the Valencia region where use of antithrombotic medications in the third trimester increased from 3.8% before COVID-19 to 61.9% after the infection. Increases in other countries were lower; for example, in Norway, the prevalence of antithrombotic medication use changed from around 1-2% before to around 6% after COVID-19 in the third trimester. Smaller and less consistent increases were observed in the use of other drug classes, such as antimicrobials and systemic corticosteroids. Our findings highlight the substantial impact of COVID-19 on primary care medication use among pregnant women, with a marked increase in the use of antithrombotic medications post-COVID-19. These results underscore the need for further research to understand the broader implications of these patterns on maternal and neonatal/fetal health outcomes.

Abstract WP279: Stroke in Young Adults With Congenital Heart Disease a Single Center Case Control Study

Introduction: Adults with congenital heart disease (ACHD) are at risk for stroke, but risk factors within this population are not well characterized. Methods: We reviewed medical records of patients evaluated in an ACHD clinic from 8/1/1995- 3/1/2022 who underwent brain imaging for any reason. We categorized patients by anatomical complexity based on American Heart Association guidelines (simple, moderate or high complexity). The primary outcome was ischemic or hemorrhagic stroke. TIA and silent infarcts were excluded. We created logistic regression models to calculate odds ratios (OR) and 95% confidence intervals (CI) for the association between anatomic complexity and stroke. Results: Out of 184 patients, 48 (26.1%) had any stroke (62% ischemic, 38% hemorrhagic). Median age at first stroke was 26.2 years (IQR 19.2-38.5) (Figure). Those with stroke had higher proportion of Black race, more major cardiac surgeries, and more use of antithrombotic medications prior to stroke (see Table). Adjusting for age, sex, race, number of cardiac surgeries, and use of antithrombotic medications, those with highly complex lesions had a trend towards higher odds of any stroke (adjusted OR 2.0, 95% CI 0.89 - 4.4). Effect size was higher for ischemic stroke (adjusted OR 2.6, 95% CI 0.99-6.7). Conclusion: In our sample of 184 ACHD patients who underwent brain imaging, stroke was common with half of strokes occurring before the age of 26 years. High complexity cardiac lesions were associated with more than double the odds of ischemic stroke. Larger studies are needed to develop effective stroke prevention strategies in this growing young adult population.

No contraindication to internal jugular central venous catheter insertion in patients at increased risk of bleeding: Results from a prospective observational study in a internal medicine department.

Implantation of centrally inserted central venous catheter (CICC) may be complicated by bleedings particularly in patients with severe coagulopathy or taking antithrombotic drugs. It has been shown that the application of the Italian Group for Venous Access Devices (GAVeCeLT) bundle reduces the incidence of bleeding in patients admitted to intensive care units (ICU), but its effectiveness has never been demonstrated in different contexts. In this study we evaluated the incidence of bleeding after urgent internal jugular CICC (J-CICC) implantation in patients with increased or no risk of bleeding complications when recommended preventive strategies are applied systematically. We included 185 patients admitted to Internal Medicine Units who underwent urgent J-CICC implantation from April 2016 to December 2018. The incidence of major and minor bleeding immediately after the procedure and in the following 30 days was recorded. None of the enrolled patients showed major bleeding. The incidence of minor bleedings was 2.1% (95% IC: 0.03-4.2) with two patients requiring line removal and repositioning (1.1%; 95% IC: -0.45 to 2.6). Bleeds were not correlated with age or sex, although they all occurred in female subjects. The incidence of bleeds was not increased in patients with increased risk of bleeding compared with those without (5.0% vs 1.3%; p = 0.16). The use of anti-thrombotic medications was significantly associated with increased risk of minor bleedings (p = 0.03). In this study we demonstrated that the application of the GAVeCeLT suggested bundle can minimize the number of bleeding complications even in patients hospitalized in Internal Medicine Units. Further data are needed in patients taking antithrombotic drugs who appear to be more prone to minor bleeding, however the benefit of completing the procedure appears to significantly outweigh the risk of mechanical complications.

Impact of Cancer Diagnosis on Appropriate Use of Antithrombotic Medications in Individuals with Cardiovascular Diseases

Introduction: Cancer and Cardiovascular disease (CVD) often coexist and CVD is the leading cause of non-cancer mortality in people with cancer. Antithrombotic medications used to manage CVD are associated with increased bleeding risk, particularly in people with cancer. Appropriate management of CVD is therefore essential in individuals with cancer, both to decrease recurrent CVD as well as to prevent bleeding. In this study, we assessed utilization patterns of antithrombotic medications for CVD following a new diagnosis of cancer. Methods: Among people receiving primary care at the University of Vermont Medical Center from 2010 to 2019, we identified a cohort of 4,010 subjects with baseline CVD, identified from problem lists or billing codes within the first year of follow-up. Exclusion criteria included baseline cancer diagnosis (cancer known at the time of inclusion in the cohort or within the first year of follow-up) or a known history of venous thrombosis. Incident cancer was defined as new diagnosis of cancer after the first year of follow-up and did not include people with non-melanomatous skin cancers. We used the National Cancer Institute list of ICD-9 and ICD-10 codes for different cancer diagnoses. Patient's use of antithrombotics, prescribed or non-prescribed, were captured using computable phenotypes developed from the electronic outpatient medication reconciliation record and validated using chart review. People with baseline CVD who were diagnosed with cancer after the first year of follow up were matched 1:1 by sex and age with people with CVD and no cancer. We used logistic regression to estimate the odds ratio (OR) and 95% confidence intervals (95% CI) of persistent guideline-directed use of antithrombotic medications for 6 months after a new cancer diagnosis versus a matched time-period in those without incident cancer (use of antiplatelets in those with a history of atherosclerotic CVD and use of anticoagulation in those with a history of atrial fibrillation). Results: We identified 4,010 individuals with baseline CVD, 841 of whom (20%) developed incident cancer during follow-up. Distribution of CVD and antithrombotic use in the age- and sex-matched population are presented in Table 1. 2/3 of the population had coronary artery disease and about 30% had atrial fibrillation or flutter. About 65% of individuals were on any antiplatelet therapy and 18% were on anticoagulation for CVD. 41% of people with baseline CVD, and incident cancer diagnosis were still on antiplatelet therapy 6 months after their cancer diagnosis as opposed to 38 % in the matched population without a cancer diagnosis. 33% of individuals with incident cancer were still on anticoagulation for atrial fibrillation or flutter as opposed to 28% of the matched population without cancer. Both of these differences were statistically significant with OR=1.55 (95% CI, 1.15-2.1) for antiplatelets, and OR=1.56 (95% CI, 1.05,2.31) for anticoagulants, compared to those with no cancer diagnosis (Table 2). Conclusion: Surprisingly, our study found that incident cancer in individuals with baseline CVD was associated with increased adherence to antithrombotic therapy. We had hypothesized that incident cancer would be associated with lower use of antithrombotic therapy. This result could be related to increased interaction with medical specialists following a cancer diagnosis. The impact of increased adherence to antithrombotics on bleeding however, will need to be further investigated.

Analysis of the Factors of Wound Healing Problems After Transtibial Amputation in Diabetic Patients.

Diabetes mellitus has a global impact, necessitating surgical intervention when conservative methods fail. Transtibial amputation (TTA) is commonly performed on diabetic patients, yet surgical site complications can lead to more procedures. This study aimed to identify factors linked to wound healing issues post-TTA in diabetics.A total of 181 patients who underwent TTA between 2004 and 2021 at a single hospital were included in the study. Exclusion criteria comprised trauma, non-diabetic mellitus, follow-up duration of less than 1 year, incomplete medical records, and surgeries performed by different surgeons. The comparison focused on underlying diseases other than diabetes between the group with wound problems and the group without. Additionally, factors impacting blood flow, such as presurgery hemoglobin levels, intraoperative blood transfusion, the use of antithrombotic or anticoagulant drugs, and the presence of procedures like percutaneous transluminal angioplasty (PTA) and bypass surgery, were analyzed.Among the 181 cases, 22.1% experienced problems at the surgical site while 77.9% did not. Statistical analysis revealed that age was a significant variable affecting wound healing problems after TTA in diabetic patients (p = .007). However, there were no significant differences in wound problems based on comorbidities other than diabetes (p = .209), gender (p = .677), preoperative anemia (p = .102), intraoperative blood transfusion (p = .633), the use of antithrombotic or anticoagulant medications (p = .556), and the performance of PTA or bypass surgery (p = .6).In conclusion, this study found that age was a significant variable affecting wound healing problems after TTA in diabetic patients. Although no association was observed between underlying diseases and wound healing problems, further investigation and cautious management of factors such as preoperative anemia, intraoperative blood transfusion, the use of antithrombotic or anticoagulant drugs, and the performance of PTA or bypass surgery are warranted to prevent complications and optimize wound healing outcomes in diabetic patients undergoing TTA.

Antithrombotics and Gastrointestinal Prophylaxis: A Systematic Review.

Antithrombotic medications include both antiplatelet and anticoagulants and are used for a wide variety of cardiovascular conditions. A common complication of antithrombotic use is gastrointestinal bleeding. As a result, gastrointestinal prophylaxis is a common consideration for patients on a single or combination antithrombotic regimen. Prophylaxis is typically achieved through use of either proton pump inhibitors or histamine 2 receptor antagonists. Current recommendations for use of gastrointestinal prophylaxis with concomitant use of antithrombotic medications are scarce. In this systematic review, we explore the current evidence and recommendations regarding gastrointestinal prophylaxis for patients on antiplatelet or anticoagulant therapy as well as combination regimens.

Continuous use of antithrombotic medications during peri-endoscopic submucosal dissection period for colorectal lesions: A propensity score matched study.

The aim of this study was to elucidate the continuous use of antithrombotic medications during the peri-colorectal endoscopic submucosal dissection (ESD) period. This study included 468 patients with colorectal epithelial neoplasms treated by ESD, consisting of 82 under antithrombotic medications and 386 patients without the medications. Among patients taking antithrombotic medications, antithrombotic agents were continued during the peri-ESD period. Clinical characteristics and adverse events were compared after propensity score matching. Before and after propensity score matching, post-colorectal ESD bleeding rate was higher in patients continuing antithrombotic medications (19.5% and 21.6%, respectively) than in those not taking antithrombotic medications (2.9% and 5.4%, respectively). In the Cox regression analysis, continuation of antithrombotic medications was associated with post-ESD bleeding risk (hazard ratio, 3.73; 95% confidence interval, 1.2-11.6; P<0.05) compared with patients without antithrombotic therapy. All patients who experienced post-ESD bleeding were successfully treated by endoscopic hemostasis procedure or conservative therapy. Continuation of antithrombotic medications during the peri-colorectal ESD period increases the risk of bleeding. However, the continuation may be acceptable under careful monitoring for post-ESD bleeding.

Practical Guide for Anticoagulant and Antiplatelet Reversal in Clinical Practice

In recent years, anticoagulant and antiplatelet use have increased over the past years for the prevention and treatment of several cardiovascular conditions. Due to the rising use of antithrombotic medications and the complexity of specific clinical cases requiring such therapies, bleeding remains the primary concern among patients using antithrombotics. Direct oral anticoagulants (DOACs) include rivaroxaban, apixaban, edoxaban, and betrixaban. Direct thrombin inhibitors (DTIs) include argatroban, bivalirudin, and dabigatran. DOACs are associated with lower rates of fatal, life-threatening, and significant bleeding risks compared to those of warfarin. The immediate reversal of these agents can be indicated in an emergency setting. Antithrombotic reversal recommendations are still in development. Vitamin K and prothrombin complex concentrate (PCCs) can be used for warfarin reversal. Andexanet alfa and idarucizumab are specific reversal agents for DOACs and DTIs, respectively. Protamine sulfate is the solely approved reversal agent for unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH). However, there are no specific reversal agents for antiplatelets. This article aims to provide a practical guide for clinicians regarding the reversal of anticoagulants and antiplatelets in clinical practice based on the most recent studies.

Thrombosis in hereditary hemorrhagic telangiectasia

Thrombosis in hereditary hemorrhagic telangiectasia

Creation of a novel specialty residency in thrombosis and hemostasis management

AbstractAntithrombotic and hemostatic medications are essential, yet high‐risk therapies commonly used for the prevention and treatment of thrombosis and bleeding. Since first demonstrating the ability to improve the safety and quality of heparin and warfarin‐related care many years ago, pharmacists now play an important expanded role in more comprehensive and complex thrombosis and hemostasis management programs. Such programs encompass the prevention and treatment of thrombosis and bleeding across care settings, medical indications, and professional services. These programs impact not only appropriate use of antithrombotic medications, but also of antidotes, blood products, medical devices, laboratory testing, and other important aspects of care. In addition to providing direct patient care, pharmacists are increasingly involved in the development and implementation of system‐level processes and quality improvement activities that require technical knowledge, leadership skills, and effective multidisciplinary collaboration. Evolution in health care regulation and accreditation standards, along with national efforts to advance the concept of Anticoagulation Stewardship, will likely accelerate the growth and expansion of thrombosis and hemostasis management programs, increasing the demand for well‐trained and experienced clinical pharmacists. However, none of the existing accredited specialty pharmacy residency programs encompasses the full range of skills and experiences necessary for new pharmacists to practice effectively in this complex and rapidly evolving field. This manuscript describes the evolution of the Hemostasis and Antithrombotic Stewardship program at Brigham and Women's Hospital and the development of a novel postgraduate year 2 (PGY2) pharmacy residency in this specialty area. It provides details of the new PGY2 residency program curriculum and puts forth a vision of success for such programs at the local and national levels.

Safety of cholecystectomy in patients under antithrombotic Drugs: A systematic review and meta-analysis.

This review aimed to assess evidence on the safety of cholecystectomy in patients under antithrombotic therapy. PubMed, Embase, Science Direct, CENTRAL, and Google Scholar databases were searched from inception up to 20th January 2022 for studies comparing outcomes of patients undergoing cholecystectomy surgeries with or without concomitant antithrombotic therapy. Nine studies were included. Meta-analysis revealed that the use of antithrombotic medications had no statistically significant effect on intra-operative blood loss in patients undergoing cholecystectomy (MD: 82.31 95% CI: -283.38, 448 I2=98% p=0.66). However, incidence of blood transfusion (OR: 5.65 95% CI: 1.10, 28.86 I2=83% p=0.04) and bleeding complications (OR: 8.02 95% CI: 1.71, 37.58 I2 = 71% p=0.008) were significantly increased in patients under antithrombotic therapy. Pooled analysis indicated that cholecystectomy patients under antithrombotic are at an increased risk of conversion to open surgery (OR: 2.02 95% CI: 1.21, 3.36 I2=0% p=0.007). Meta-analysis revealed significantly shorter LOS in patients under antithrombotic (MD: -5.01 95% CI: -8.29, -1.73 I2=97% p=0.03). Current evidence from a limited number of studies indicates that the use of antithrombotic may be associated with an increased risk of bleeding-related complications in patients undergoing cholecystectomies. Antithrombotic use may also increase the risk of conversion to open surgery in patients undergoing laparoscopic cholecystectomies.

Automated left atrial strain after electrical cardioversion for atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Evidence shows that atrial dysfunction and stunning occur, after successful cardioversion from persistent atrial fibrillation (AF) to sinus rhythm (SR). Electrical and mechanical recovery of the left atrium (LA), do not seem to coincide. Traditional Doppler parameters show reduced atrial contractility immediately after cardioversion, while mechanical improvement in atrial function mainly occurs within the first 4 weeks after sinus rhythm restoration. Purpose This study aimed to determine whether automated left atrial strain (auto-LA strain) could be used to measure global LA function and the time required for mechanical improvement to be seen in LA after cardioversion. Methods Auto-LA strain was measured via transthoracic echocardiography in 20 patients with persistent AF who had been cardioverted to SR and followed up for 3 months, and in a cohort of 20 healthy individuals. Conventional measures of atrial function derived from transmitral pulsed Doppler and tissue Doppler imaging of lateral mitral annulus were included, such as transmitral A wave velocity, A wave velocity-time integral, atrial fraction, A" wave velocity, and A" velocity-time integral. Results Immediately after cardioversion auto-LA strain was significantly lower than in control subjects. Atrial function improved over time with maximal change observed at 1 month after cardioversion. Doppler tissue imaging parameters were also normalised after 1 month of restoration to SR. Despite this initial improvement in LA function, the values of auto-LA strain remained stable for the following 3 months. Conclusion Although the electrical function of LA is immediately restored after successful cardioversion in AF patients, there remains a persistent degree of atrial dysfunction for at least 3 months. This difference could explain the increased propensity for these patients to develop recurrent atrial fibrillation. Additionally, this dysfunction could indicate longer-term use of anti-arrhythmic and antithrombotic medications in the AF cohort. Abstract Figure.

A Population Cohort Study to Evaluate the Risk of Ischemic Stroke Among Individuals with a New Diagnosis of Cancer Compared to Matched Cancer-Free Controls: Impact of Prior Stroke History

▪Cancer is a risk factor for thrombosis, but unlike venous thrombosis, its association with ischemic stroke, and its impact on stroke management and post-stroke outcomes are not well characterized. The primary objective of this study was to measure and compare the risk of ischemic stroke in individuals with a new diagnosis of cancer and those without a history of cancer in two separate matched cohorts based on the absence (Matched Cohort 1) or presence (Matched Cohort 2) of a prior diagnosis of ischemic stroke (Figure 1).Methods: We conducted a population-based matched cohort study of adults ≥18 years using linked clinical and administrative health databases in Ontario, Canada (2010 to 2019). Individuals with a new diagnosis of cancer were matched (1:1) to cancer-free controls by age and sex. Cancer diagnoses were determined using ICD-O-3 diagnostic codes (basal and squamous cell carcinoma and primary central nervous system tumors were excluded). For cancer patients, the index date was the diagnosis date and a corresponding dummy index date was assigned to the matched cancer-free control. The primary outcome was the incidence of ischemic stroke (time to ischemic stroke following index) determined using validated ICD-9 or -10 diagnostic codes from hospitalizations or emergency department visits. Analyses were conducted separately, in parallel, for each cohort. Standardized differences were used to compare the distributions of baseline characteristics. Cumulative incidence function (CIF) curves were generated for ischemic stroke and all-cause mortality. Competing risk methods were used to calculate sub-distribution adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for ischemic stroke, where death was treated as a competing event. Interactions with the timeline at 1.5 years after index were incorporated to assess if the hazard ratio for the main exposure (cancer vs cancer-free) varied before and after the 1.5-year mark. Regression analyses were adjusted using baseline characteristics for which there was imbalance between groups.Results: Matched Cohort 1 included 620,647 individuals with cancer and 620,647 controls. Matched Cohort 2 included 13,924 individuals with cancer and 13,924 controls. Baseline characteristics were generally well balanced (Table 1). Use of antithrombotic medications (prior to index) among individuals ≥66 years was similar between the groups (data not shown). CIF curves for ischemic stroke and mortality are shown in Figure 2.In Matched Cohort 1 (no history of stroke), the risk of ischemic stroke was increased in cancer patients compared to cancer-free controls 1.5 years post-index (aHR 1.40, 95%CI 1.34-1.47). From 1.5 years to 5 years, the risk of ischemic stroke was lower in cancer patients compared to controls (aHR 0.72, 95%CI 0.69-0.74). In Matched Cohort 2 (prior history of ischemic stroke), the risk of ischemic stroke was similar at 1.5 years after the index date in individuals with and without cancer (aHR 1.00, 95%CI 0.88-1.14). From 1.5 to 5 years, the risk of ischemic stroke was reduced (aHR 0.53, 95%CI 0.46-0.62) in cancer patients compared to controls.Conclusions:Compared to cancer-free controls, the risk of ischemic stroke among individuals with a new cancer diagnosis depended on the presence or absence of prior history of ischemic stroke, a novel finding not previously reported. In individuals without a prior history of stroke, those with cancer had a 1.5-fold higher risk of ischemic stroke at 1.5 years compared to controls. In individuals with a prior history of stroke, those with cancer had a similar risk of stroke compared to controls. At 5 years post-index, the risk of ischemic stroke was lower in cancer patients in both cohorts which may reflect high early mortality rates and lower stroke risk among long-term survivors of cancer. The risk of death among cancer patients was highest during the first 1.5 years after the index date in both cohorts. However, the magnitude of the risk increase was higher in individuals without a prior history of stroke (10-fold) compared to those with a prior history of cancer (5-fold). Limitations include unknown causes of death and unavailability of some covariates (e.g. smoking and antithrombotic use in individuals aged <65 years). Future analyses will explore risk of ischemic stroke within common cancer subtypes (breast, prostate, colon, pancreas, lymphoma), and assess stroke risk factors, treatments and outcomes. [Display omitted] DisclosuresSiegal: BMS-Pfizer: Honoraria; Leo Pharma: Honoraria; Novartis: Honoraria; Portola: Honoraria; Servier: Honoraria. Carrier: Pfizer: Honoraria, Research Funding; BMS: Honoraria, Research Funding; Servier: Honoraria; Leo Pharma: Honoraria, Research Funding; Bayer: Honoraria; Sanofi: Honoraria. Gross: Valeo: Honoraria; Leo Pharma: Honoraria; Bayer: Honoraria; BMS-Pfizer: Honoraria.

Racial differences in persistence to secondary prevention medication regimens after ischemic stroke

ABSTRACT Background: Prior stroke is one of the biggest risk factors for future stroke events. Effective secondary prevention medication regimens can dramatically reduce recurrent stroke risk. Guidelines recommend the use of antithrombotic, antihypertensive and lipid-lowering medications after stroke. Medication adherence is known to be better in the presence of a caregiver but long-term adherence after stroke is unknown and disparities may persist. Methods: We examined the effects of race and sex on baseline prescription and maintenance of secondary prevention regimens in the presence of a caregiver using the Caring for Adults Recovering from the Effects of Stroke (CARES) study, an ancillary study of the national REasons for Geographic and Racial Differences in Stroke (REGARDS). Results: Incident ischemic stroke survivors (N = 172; 36% Black) with family caregivers had medications recorded at hospital discharge and on average 9.8 months later during a home visit. At discharge, antithrombotic prescription (95.9%), lipid-lowering medications (78.8%) and antihypertensives (89.9%) were common and there were no race or sex differences in discharge prescription rates. One year later, medication persistence had fallen to 86.6% for antithrombotics (p = 0.002) and 69.8% for lipid lowering (p = 0.008) but increased to 93.0% for antihypertensives (p = 0.30). Blacks were more likely to have discontinued antithrombotics than Whites (18.3% v 7.7%, p = 0.04). No significant differences in persistence were seen with age, sex, income, depression, or cognitive impairment. Conclusions: Medication persistence was high in this sample, likely due to the presence of a caregiver. In our cohort, despite similar prescription rates at the time of hospital discharge, Black stroke survivors were more than twice as likely to stop antithrombotics than Whites. The effect of changes in patterns of medication usage on health outcomes in Black stroke survivors warrants continued investigation.

Antithrombotic Therapy for Stroke Patients with Cardiovascular Disease.

Prevention of ischemic stroke relies on the use of antithrombotic medications comprising antiplatelet agents and anticoagulation. Stroke risk is particularly high in patients with cardiovascular disease. This review will focus on the role of antithrombotic therapies in the context of different types of cardiovascular disease. We will discuss oral antiplatelet medications and both IV and parental anticoagulants. Different kinds of cardiovascular disease contribute to stroke via distinct pathophysiological mechanisms, and the optimal treatment for each varies accordingly. We will explore the mechanism of stroke and evidence for antithrombotic therapy in the following conditions: atrial fibrillation, prosthetic heart values (mechanical and bioprosthetic), aortic arch atherosclerosis, congestive heart failure (CHF), endocarditis (infective and nonbacterial thrombotic endocarditis), patent foramen ovale (PFO), left ventricular assist devices (LVAD), and extracorporeal membrane oxygenation (ECMO). While robust data exist for antithrombotic use in conditions such as atrial fibrillation, optimal treatment in many situations remains under active investigation.

Association of Recognized and Unrecognized Myocardial Infarction With Depressive and Anxiety Disorders in 125,988 Individuals: A Report of the Lifelines Cohort Study.

No previous study has focused on recognition of myocardial infarction (MI) and the presence of both depressive and anxiety disorders in a large population-based sample. The aim of this study was to investigate the association of recognized MI (RMI) and unrecognized MI (UMI) with depressive and anxiety disorders. Analyses included 125,988 individuals enrolled in the Lifelines study. Current mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) were assessed with the Mini-International Neuropsychiatric Interview. UMI was detected using electrocardiogram in participants who did not report a history of MI. The classification of RMI was based on self-reported MI history together with the use of either antithrombotic medications or electrocardiogram signs of MI. Analyses were adjusted for age, sex, smoking, somatic comorbidities, and physical health-related quality of life as measured by the RAND 36-Item Health Survey in different models. Participants with RMI had significantly higher odds of having any depressive and any anxiety disorder as compared with participants without MI (depressive disorder: odds ratio [OR] = 1.86, 95% confidence interval [CI] = 1.38-2.52; anxiety disorder: OR = 1.60, 95% CI = 1.32-1.94) after adjustment for age and sex. Participants with UMI did not differ from participants without MI (depressive disorder: OR = 1.60, 95% CI = 0.96-2.64; anxiety disorder: OR = 0.73, 95% CI = 0.48-1.11). After additional adjustment for somatic comorbidities and low physical health-related quality of life, the association between RMI with any depressive disorder was no longer statistically significant (OR = 1.18; 95% CI =0.84-1.65), but the association with any anxiety disorder remained (OR = 1.27, 95% CI = 1.03-1.57). Recognition of MI seems to play a major role in the occurrence of anxiety, but not depressive, disorders.

Association between kidney disease measures and intracranial atherosclerosis: The ARIC study.

To test the association between reduced kidney function (assessed by estimated glomerular filtration rate [eGFR] and cystatin C [CysC]) and kidney damage (assessed by urinary albumin-to-creatinine ratio [ACR]) and intracranial atherosclerotic disease (ICAD) by high-resolution vessel wall MRI (VWMRI) in the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS). We conducted a cross-sectional analysis of ARIC participants with data on kidney measures and VWMRI in 2011 to 2013. The main outcomes were presence of intracranial plaques and luminal stenosis. Multivariable models were adjusted for demographics, cardiovascular risk factors, and use of antithrombotic medications. A total of 1,762 participants (mean ± SD age, 76.3 ± 5.3) were included. eGFR based on CysC (eGFRcysc) <60 mL/min/1.73 m2 (vs ≥60 mL/min/1.73 m2) was associated with plaque presence (adjusted odds ratio [OR] 1.29, 95% confidence interval [CI] 1.04-1.60), any detectable stenosis (adjusted OR 1.31, 95% CI 1.04-1.63), and >70% stenosis or occlusion (adjusted OR 2.15, 95% CI 1.32-3.50). Neither ACR nor CysC showed statistically significant associations with ICAD features in adjusted models. In adjusted multinomial models, participants with eGFRcysc <60 mL/min/1.73 m2 (vs ≥60 mL/min/1.73 m2) had an increased OR of 1.41 (95% CI 1.06-1.87) for having 1 plaque (vs none) but no significant increase for multiple plaques; ACR ≥30 was associated with moderate (50%-70%) stenosis (OR 2.01, 95% CI 1.14-3.55) vs absent or less than 50% stenosis. In community-dwelling older adults, reduced kidney function or elevated kidney damage was associated with ICAD measured by VWMRI. This finding may help to better identify a population at high risk for ICAD.