A real-world study of effectiveness and safety of generic and original clopidogrel in the treatment of acute coronary syndrome / 中国药房

OBJECTIVE To evaluate the clinical effectiveness and safety of domestic generic and imported original clopidogrel for antiplatelet therapy in patients with acute coronary syndrome （ACS）. METHODS The clinical data of ACS patients in Nanjing Drum Tower Hospital of China Pharmaceutical University from January 2020 to June 2021 were retrospectively collected by using electronic medical record system， and the patients were divided into original drug group （321 cases） and generic drug group （328 cases） according to the drug use. Both groups were given dual antiplatelet therapy with clopidogrel and aspirin. The effectiveness and safety outcomes of the two groups were followed up for 12 months and compared， the related influential factors were analyzed. RESULTS Major adverse cardiovascular events （MACE） occurred in 16 and 22 patients in original drug group and generic drug group respectively， including nonfatal myocardial infarction （4 and 5 cases）， stroke （2 and 4 cases）， revascularization （8 and 3 cases）， cardiovascular related death （2 and 4 cases）， and all-cause death （4 and 6 cases）. There were 12 and 7 patients with major bleeding events， 38 and 29 patients with minor bleeding events， and 33 and 21 patients with non-bleeding adverse events. There was no statistically significant difference in the cumulative incidence of related events （P values of Log-Rank tests were all greater than 0.05）. Cox regression analysis showed that the use of generic clopidogrel did not increase the risk of MACE and major bleeding events in ACS patients [hazard ratio of 1.305 and 0.416， 95% confidence interval of （0.678， 2.512） and （0.155， 1.117）， respectively， P＞0.05]， and the combination of proton pump inhibitors （PPI） could reduce the risk of major bleeding events [hazard ratio of 0.196， 95% confidence interval of （0.063， 0.611）， P＜0.05]. CONCLUSIONS Compared with imported original drug， domestic generic clopidogrel has similar clinical effectiveness and good safety. Combined use of PPI may be a beneficial factor to reduce the occurrence of major bleeding events in patients.

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

Abstract Objective: To investigate the safety and efficacy of short-term (7-day) Dual Antiplatelet Therapy (DAPT) with intensive rosuvastatin in Acute Ischemic Stroke (AIS). Methods: In this study, patients with AIS in the emergency department of the hospital from October 2016 to December 2019 were registered and divided into the control group (Single Antiplatelet Therapy [SAPT] + rosuvastatin) and the study group (7-day DAPT + intensive rosuvastatin) according to the therapy regimens. The generalized linear model was used to compare the National Institute of Health Stroke Scale (NIHSS) scores between the two groups during the 21-day treatment. A Cox regression model was used to compare recurrent ischemic stroke, bleeding events, Statin-Induced Liver Injury (SILI), and Statin-Associated Myopathy (SAM) between the two groups during the 90-day follow-up. Results: Comparison of NIHSS scores after 21-day treatment: NIHSS scores in the study group decreased significantly, 0.273-times as much as that in the control group (Odds Ratio [OR] 0.273; 95% Confidence Interval [95% CI] 0.208-0.359; p < 0.001). Comparison of recurrent ischemic stroke during the 90-day follow-up: The therapy of the study group reduced the risk of recurrent stroke by 65% (7.76% vs. 22.82%, Hazard Ratio [HR] 0.350; 95% CI 0.167-0.730; p = 0.005). Comparison of bleeding events: There was no statistical difference between the two groups (7.79% vs. 6.71%, HR = 1.076; 95% CI 0.424-2.732; p = 0.878). No cases of SILI and SAM were found. Conclusions: Short-term DAPT with intensive rosuvastatin effectively relieved the clinical symptoms and significantly reduced the recurrent stroke for patients with mild-to-moderate AIS within 90 days, without increasing bleeding events, SILI and SAM.

Positioning of the fixed dose combination of Rosuvastatin + Clopidogrel + Aspirin in the Treatment of Cardiovascular Diseases

Dual anti-platelet therapy (DAPT) and statins are recommended by guidelines for the management of cardiovascular diseases (CVDs), even though the duration of treatment is guided by ischemic and bleeding risk. Clopidogrel and aspirin are the most commonly used DAPT in CVDs. Adding a statin to DAPT is helpful in reducing the thrombosis risk. Fixed-dose combination (FDC) therapy in CVD can help to address the factors of convenience, compliance, control, cost, and complication better than free drug combinations. Therefore, the FDC of rosuvastatin (10 mg or 20 mg) + clopidogrel (75 mg) + aspirin (75 mg) is likely to improve compliance in CVD patients, thereby reducing adverse cardiovascular outcomes and cost of treatment. There is lack of awareness on long term benefits of this FDC in Indian patients.

Endoprótesis coronaria y doble terapia antiplaquetaria prolongada. Un estudio longitudinal / Coronary stent and prolonged dual antiplatelet therapy. A longitudinal study

Resumen Introducción: En las guías actuales europeas para el manejo del infarto de miocardio posterior a la colocación de endoprótesis coronaria (stent), no existe consenso sobre la duración ideal de la terapia antiagregante plaquetaria dual (DAPT, dual antiplatelet therapy) para prevenir la trombosis-reestenosis del stent sin aumentar el riesgo significativo de sangrado. Objetivo: Reportar el porcentaje de sangrado mayor y de eventos cardiovasculares mayores asociados a la DAPT prolongada en pacientes atendidos en el Instituto Nacional de Cardiología y tratados con intervención coronaria percutánea primaria y stent. Métodos: Se realizó un estudio longitudinal, prospectivo observacional y descriptivo no experimental. Los pacientes fueron captados de noviembre de 2016 a diciembre de 2017. Resultados: Fueron seleccionados 135 pacientes con una media de edad de 57 ± 10 años, quienes cumplieron un seguimiento clínico por tres años. La obesidad y la hipertensión destacaron como principales factores de riesgo. Posterior al uso de DAPT durante tres años, se registró 3.7 % de mortalidad, 1.48 % de sangrado mayor y 4.4 % de trombosis-reestenosis. Conclusiones: El uso prolongado de DAPT estaría justificado por la alta incidencia de trombosis-reestenosis, sin incremento significativo en el riesgo de sangrado y con disminución de los eventos cardiovasculares mayores.

Abstract Introduction: In current European guidelines for the management of myocardial infarction after coronary stent placement, there is no consensus on dual antiplatelet therapy (DAPT) ideal duration to prevent stent thrombosis-restenosis without significantly increasing the bleeding risk. Objective: To report the percentage of major bleeding and presence of major cardiovascular events associated with prolonged DAPT in patients recruited at the National Institute of Cardiology, treated with primary percutaneous coronary intervention and stent. Methods: A longitudinal, prospective, observational, non-experimental, descriptive study was carried out. Patients were recruited from November 2016 to December 2017. Results: One-hundred and thirty-five patients with a mean age of 57 ± 10 years who completed the three-year follow-up were selected. Obesity and hypertension stood out as the main risk factors. After using DAPT for three years, 3.7% of mortality, 1.48% of major bleeding, and 4.4% of thrombosis-restenosis were recorded. Conclusions: Prolonged use of DAPT would be justified by the high incidence of thrombosis-restenosis, without a significant increase in bleeding risk, as well as a decrease in major cardiovascular events.

Antiagregación plaquetaria: stents, isquemia y sangrado ¿Qué sabemos al respecto? / Platelet antiaggregation: stents, ischemia and bleeding What do we know about it?

Antiplatelet therapy and percutaneous coronary intervention are two of the most important interventions in the management of coronary artery disease. In the last 20 years there has been groundbreaking advances in the pharmacotherapy and stent technology. Bleeding is the most feared complication of antiplatelet therapy, mainly due to the increase in major adverse cardiovascular events besides the bleeding itself. Different clinical decision tools have developed with the aim to define which patients have a high ischemic or bleeding risk, thus individualizing treatment.

Analysis of risk factors impacting antiplatelet medication adherence following stenting for atherosclerosis obliterans and development of prediction model / 中国实用护理杂志

Objective:To explore the risk factors of antiplatelet drug compliance after stent implantation in patients with lower extremity arteriosclerosis obliterans, and to construct an online prediction model tool.Methods:Retrospective analysis of the clinical data of patients with lower extremity arteriosclerosis obliterans who received lower extremity arterial stent implantation in Department of Vascular Surgery, Provincial Hospital Affiliated to Shangdong First Medical University from January 2019 to January 2021 was carried out. 90 patients with poor compliance and 90 patients with good compliance were selected into the observation group and the control group, respectively. Univariate analysis was used to screen the influencing factors of antiplatelet drug compliance, and the variables with statistical significance were substituted into the binary Logistic regression to carry out independent risk factor test to screen the risk factors of cross-over antiplatelet drug compliance and establish the prediction model.Results:Married ( OR = 0.316, 95% CI 0.135-0.738), number of follow-up visits during the follow-up period ( OR = 0.866, 95% CI 0.760-0.987), the amount of medication ( OR = 0.755, 95% CI 0.654-0.919) were the protective factors for the compliance of antiplatelet drugs in patients with lower extremity arteriosclerosis obliterans after stent implantation. Advanced age ( OR = 1.136, 95% CI 1.066-1.211), male ( OR = 3.727, 95% CI 1.533-9.060), junior high school and below education level ( OR = 4.949, 95% CI 1.501-16.313), the average monthly income less than 3 000 yuan ( OR = 15.774, 95% CI 4.487-55.495) and the monthly expenditure on medicine more than 500 yuan ( OR = 15.323, 95% CI 3.527-66.569) were the risk factors for the compliance of antiplatelet drugs in patients with lower extremity arteriosclerosis obliterans after stent implantation. The consistency index of this prediction model was 0.895, the area under the ROC curve was 0.875. Conclusion:The antiplatelet medication adherence prediction model established has high accuracy and good clinical application values.

Antiplatelet and myocardial protective effect of Shexiang Tongxin Dropping Pill in patients undergoing percutaneous coronary intervention: A randomized controlled trial / 中西医结合学报

BACKGROUND@#High on-clopidogrel platelet reactivity could be partially explained by loss-of-function alleles of CYP2C19, the enzyme that converts clopidogrel into its active form. Shexiang Tongxin Dropping Pill (STDP) is a traditional Chinese medicine to treat angina pectoris. STDP has been shown to improve blood flow in patients with slow coronary flow and attenuate atherosclerosis in apolipoprotein E-deficient mice. However, whether STDP can affect platelet function remains unknown.@*OBJECTIVE@#The purpose of this study is to examine the potential effects of STDP on platelet function in patients undergoing percutaneous coronary intervention (PCI) for unstable angina. The interaction between the effects of STDP with polymorphisms of CYP2C19 was also investigated.@*DESIGN, PARTICIPANTS AND INTERVENTION@#This was a single-center, randomized controlled trial in patients undergoing elective PCI for unstable angina. Eligible subjects were randomized to receive STDP (210 mg per day) plus dual antiplatelet therapy (DAPT) with clopidogrel and aspirin or DAPT alone.@*MAIN OUTCOME MEASURES@#The primary outcome was platelet function, reflected by adenosine diphosphate (ADP)-induced platelet aggregation and platelet microparticles (PMPs). The secondary outcomes were major adverse cardiovascular events (MACEs) including recurrent ischemia or myocardial infarction, repeat PCI and cardiac death; blood biomarkers for myocardial injury including creatine kinase-MB isoenzyme (CK-MB) and high-sensitive troponin I (hsTnI); and biomarkers for inflammation including intercellular cell adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), monocyte chemoattractant protein-1 (MCP-1) and galectin-3.@*RESULTS@#A total of 118 subjects (mean age: [66.8 ± 8.9] years; male: 59.8%) were included into analysis: 58 in the control group and 60 in the STDP group. CYP2C19 genotype distribution was comparable between the 2 groups. In comparison to the control group, the STDP group had significantly lower CK-MB (P < 0.05) but similar hsTnI (P > 0.05) at 24 h after PCI, lower ICAM-1, VCAM-1, MCP-1 and galectin-3 at 3 months (all P < 0.05) but not at 7 days after PCI (P > 0.05). At 3 months, the STDP group had lower PMP number ([42.9 ± 37.3] vs. [67.8 ± 53.1] counts/μL in the control group, P = 0.05). Subgroup analysis showed that STDP increased percentage inhibition of ADP-induced platelet aggregation only in slow metabolizers (66.0% ± 20.8% in STDP group vs. 36.0% ± 28.1% in the control group, P < 0.05), but not in intermediate or fast metabolizers. The rate of MACEs during the 3-month follow-up did not differ between the two groups.@*CONCLUSION@#STDP produced antiplatelet, anti-inflammatory and cardioprotective effects. Subgroup analysis indicated that STDP inhibited residual platelet reactivity in slow metabolizers only.@*TRIAL REGISTRATION@#This study was registered on www.chictr.org.cn: ChiCTR-IPR-16009785.

Anestesia regional en la paciente embarazada antiagregada o anticoagulada / Regional anesthesia in the antiplatelet or anticoagulated pregnant patient / Anestesia regional em paciente grávida antiplaquetária ou anticoagulada

Resumen: La anestesia regional es la técnica de elección debida a la menor morbimortalidad. Una de las complicaciones más temidas es el hematoma espinal, teniendo las pacientes que reciben antiagregantes y/o anticoagulantes mayor riesgo de desarrollarlo. El cuadro clínico es variable, y no siempre están todos los elementos presentes (dolor lumbar, déficit motor y/o sensitivo y/o vesical). El diagnóstico se realiza por resonancia nuclear magnética y el tratamiento es la descompresión por laminectomía. Estando el pronóstico neurológico vinculado al tiempo en que se realiza ésta. Se realiza una revisión sobre los distintos fármacos antiagregantes y anticoagulantes utilizados en el embarazo - puerperio y las recomendaciones necesarias para las pacientes que recibirán una anestesia regional.

Abstract: Regional anesthesia is the technique of choice due to lower morbidity and mortality. One of the most feared complications is spinal hematoma, with patients receiving antiplatelet and / or anticoagulants having a greater risk of developing it. The clinical picture is variable, and not all the elements are always present (lumbar pain, motor and / or sensory and / or bladder deficits). Diagnosis is made by magnetic resonance imaging and treatment is laminectomy decompression. Being the neurological prognosis linked to the time in which it is performed. A review is made of the different antiplatelet and anticoagulant drugs used in pregnancy - puerperium and the necessary recommendations for patients who will receive regional anesthesia.

Resumo: A anestesia regional é a técnica de escolha devido à menor morbimortalidade. Uma das complicações mais temidas é o hematoma espinhal, com pacientes em uso de antiagregantes plaquetários e / ou anticoagulantes com maior risco de desenvolvê-lo. O quadro clínico é variável e nem sempre os elementos estão presentes (dor lombar, déficits motores e / ou sensoriais e / ou vesicais). O diagnóstico é feito por ressonância magnética e o tratamento é a descompressão por laminectomia. Sendo o prognóstico neurológico ligado ao tempo em que é realizado. É feita uma revisão das diferentes drogas antiplaquetárias e anticoagulantes utilizadas na gravidez - puerpério e as recomendações necessárias para as pacientes que receberão anestesia regional.

The clinical profile of patients with intracerebral hemorrhage after receiving acute coronary syndrome regimen in a tertiary hospital: A case series

@#Coronary heart disease, which includes acute coronary syndromes (ACS) is a major cause of death and morbidity. Treatment for this condition includes dual anti-platelet treatment combined with an anti-coagulant and an anti-dyslipidemic. Bleeding complications may occur and one fatal adverse event is intracerebral hemorrhage (ICH). ACS cases in a tertiary hospital for the years 2014-2018 showed that there were 7 patients who presented with symptomatic ICH after treatment administration that accounts for 0.01% of a total of 1,097 patients. These patients were over the age of 50, but with no sex predilection. Common comorbidities were hypertension and malignancy. All patients presented with acute onset neurologic deficits within 1-4 days after administration of ACS regimen, with ICH scores of 3-4 signifying a high mortality rate of 72-90%. 6 out 7 patients had significant volume of ICH with mass effects, and 1 with subarachnoid hemorrhage. This lead to poor outcome in all patients with 6 out of 7 mortalities and 1 left with substantial disability. It was found that given the total number of patients administered with the said treatment, there is a low incidence of ICH.

Analysis of premature ticagrelor discontinuation in patients with acute coronary syndrome during dual antiplatelet therapy / 第二军医大学学报

Objective To explore the incidence, causes and influencing factors of premature ticagrelor discontinuation (PTD) in patients with acute coronary syndrome (ACS). Methods A total of 400 hospitalized ACS patients who were treated with aspirin and ticagrelor in the Department of Cardiovasology, Changhai Hospital, Naval Medical University (Second Military Medical University) from Jan. to Oct. 2018 were retrospectively enrolled. Baseline data were collected and patients were followed up to analyze the incidence, causes and influencing factors of PTD in ACS patients. Results At 12 months after discharge, PTD occurred in 49 patients (12.2%), and was free in 351 patients (87.8%). The proportions of patients with age>75 years, heart failure history or previous percutaneous coronary intervention (PCI) and the levels of serum potassium and urea in PTD group were significantly higher than those in non-PTD group (P=0.004, 0.031, 0.028, 0.037, 0.001). The proportion of patients using β-blocker and the severity of vascular stenosis in PTD group were significantly lower than those in non-PTD group (P=0.041, 0.018). Dyspnea (22.4%, 11/49), drug unavailability (18.4%, 9/49) and bleeding (12.2%, 6/49) were the three most common causes of PTD. PTD occurred in all dyspnea patients with modified British Medical Research Council (mMRC) being grade 2 or higher (two cases with grade 1, six cases with grade 2, two cases with grade 3, and one case with grade 4). Kaplan-Meier curve analysis showed that 67.3% (33/49) of patients with PTD occurred within 90 days after discharge. Multivariate logistic regression analysis showed that age>75 years old (odds ratio [OR]=2.58, 95% confidence interval[ CI] 1.26-5.26, P=0.009) and elevated urea (OR=1.17, 95% CI 1.04-1.30, P=0.007) were independent predictors of PTD in ACS patients, while severity of vascular stenosis (OR=0.95, 95% CI 0.92-0.98, P=0.001) was the related factor of adherence to ticagrelor. Conclusion The incidence of PTD in ACS patients during dual antiplatelet therapy is 12.2%. For dyspnea patients with mMRC score of grade 2 or higher, P2Y12 receptor antagonist should be replaced in time. Age> 75 years old is an independent predictor of PTD in ACS patients and more attention is needed for elderly patients taking ticagrelor whether they have dyspnea or PTD.

Comparison of short-term and long-term dual antiplatelet therapy after implantation of drug-eluting stents—Meta analysis / 药学实践杂志

Objective To evaluate the clinical effects of short-term (3-6 months) and long-term (12 months) dual antiplatelet therapy (DAPT) after the implantation of coronary drug-eluting stents (DES). Methods The eligibilities of the patients included stable angina, acute coronary syndrome and silent ischemia. The lesions were in a native coronary vessel. The clinical observation endpoints were all-cause death, cardiogenic death, myocardial infarction, stroke, stent thrombosis, target lesion revascularization, severe bleeding, and true adverse clinical events. The clinical observation endpoints were all-cause death, cardiogenic death, myocardial infarction, stroke, stent thrombosis, target lesion revascularization, severe bleeding, and true adverse clinical events. By searching Pubmed, Chinese biomedical literature and other Chinese and English databases and manual search, qualified randomized controlled studies were evaluated and data were extracted for meta-analysis. Results A total of 12 randomized controlled studies were conducted. Detsky scores were all greater than 5 points. There were a total of 25949 patients in the study with a follow-up rate of 97.9%. There were no significantly different in all cause death (OR = 0.86，95%CI 0.71-1.05，P = 0.14), cardiac death (OR = 0.94，95% CI 0.70-1.25，P = 0.67), stent thrombosis (OR = 1.36，95%CI 0.94-1.98，P = 0.11), stroke (OR = 1.01，95%CI 0.71-1.42，P = 0.98), target lesion revascularization (OR = 0.121，95%CI 0.94-1.55，P = 0.14),and true adverse clinical events (OR = 0.98，95%CI 0.83-1.14，P = 0.75). The incident rate of myocardial infarction during the follow-up period was higher in the short-term group than in the long-term group (OR = 1.27, 95% CI 1.02-1.59, P = 0.04). The proportion of severe bleeding in the long-term group increased significantly (OR = 0.69, 95% CI 0.50-0.95, P = 0.02). Asian population studies showed that all-cause mortality was higher in the long-term treatment group than in the short-term group (OR = 0.72, 95% CI 0.53-0.97, P = 0.03), and there was no significant difference in severe bleeding between the two groups. Conclusion According to the defined clinical observation endpoints, the short-term dual antiplatelet effect is not inferior to the long-term group. Seven asian group studies have shown that the long-term group has high all-cause mortality. It can not rule out the deviation and/or population caused by the small sample size or individual variation. The results need to be further verified. This result can be used as a clinical warning to adjust the dual antiplatelet cycle based on the individualized risk of bleeding and coronary lesions.

Analysis and management of coronary heart disease complicated by thrombocytopenia / 药学实践杂志

Objective To summarize the factors and the corresponding treatments for patients with coronary heart disease (CHD) complicated by thrombocytopenia, and provide medical advises for clinical treatment. Methods Literatures and case reports were analyzed and summarized. Results Thrombocytopenia in patient with CHD could be mainly divided into two types, one group was induced by the antithrombotic therapies for CHD, and the other group was caused by some concurrent diseases or combined non-antithrombotic medications. There were different medical decisions and prognoses according to the causes in different groups. Conclusion The treatment strategies of CHD will be considered in the CHD patients with thrombocytopenia. Identifying thrombocytopenia by monitoring the platelet counts in early stage, finding out the causes quickly and providing proper treatments are the key for the prognosis of the patients.

Perioperative Outcomes of Patients Undergoing Pulmonary Resection for Lung Cancer after Coronary Stenting / 中国肺癌杂志

BACKGROUND@#It is common for patients with lung cancer to have concomitant coronary artery disease, some of them have underwent coronary stenting and accepted antiplatelet therapy. Whether antiplatelet agents should be continued in the perioperative period remains controversial, especially in patients requiring lung cancer resection with coronary artery stents. We reviewed the data of our institute to clarify the perioperative outcomes of this specific population.@*METHODS@#We retrospectively analyzed the data on patients who underwent pulmonary resection for lung cancer following coronary stent placement between January 2013 and September 2019 in the Department of Thoracic Surgery in Peking University First Hospital. All of them discontinued oral antiplatelet agents before operation at least 5 days. The primary outcomes were the cardiovascular morbidity and mortality in hospital.@*RESULTS@#111 patients were identified and included in the analysis. The time intervals between stenting and lung surgery were 1-3 months, 3-12 months, and more than 12 months in 6.3%, 13.5% and 80.2% of the patients, respectively. Sublobectomy, lobectomy, biolobectomy, pneumonectomy and sleeve lobectomy were performed in 10.8%, 71.2%, 9.0%, 2.7% and 6.3% of the patients. The overall incidences of cardiovascular complications were 11.6%, including unstable angina (n=1, 0.9%), hypotention (n=1, 0.9%), congestive heart failure (n=2, 1.8%) and new-onset atrial fibrillation (n=10, 9.0%). There was no perioperative death. No major adverse cardiac events (MACE) occurred.@*CONCLUSIONS@#It was safety to discontinued oral antiplatelet agents before operation, with no MACE and death in perioperative period.

Research progress of antithrombotic therapy after transcatheter aortic valve implantation / 中国胸心血管外科临床杂志

@#Traditional surgical aortic valve replacement is associated with a high risk of serious complications, especially in elderly patients with other preoperative diseases and unable to undergo thoracotomy. Therefore, transcatheter aortic valve implantation (TAVI) is now the accepted standard treatment for patients with symptomatic severe aortic stenosis at elevated risk for conventional surgical valve replacement. Currently, guidelines propose the use of dual antiplatelet therapy for the prevention of thromboembolic events after TAVI in the patients without an indication for oral anticoagulation. While, this strategy is empiric and largely based on expert consensus extrapolated from the arena of percutaneous coronary intervention. Antithrombotic therapy is associated with a significant occurrence of both thrombotic and bleeding complications, thus, the balance between thrombotic and bleeding risk is critical. This review summarizes current guidelines and the evidence underpinning them and explores the rational for using antiplatelet and/or anticoagulant strategies after TAVI.

Diferencias en el tratamiento antitrombótico y pronóstico en función del sexo en pacientes con síndrome coronario agudo tratados con stent / Sex-specific differences in antithrombotic therapy and prognosis in patients with acute coronary syndrome treated with stent

Resumen Antecedentes y objetivo: El interés sobre la influencia del sexo en pacientes con síndrome coronario agudo (SCA) tratados con stent y nuevos antiagregantes inhibidores de P2Y12 en la práctica clínica es creciente. Se analizan las diferencias en función del sexo en el tratamiento con doble antiagregación plaquetaria (DAPT) y los eventos adversos isquémicos y hemorrágicos Materiales y métodos: Estudio prospectivo de pacientes consecutivos con diagnóstico de SCA tratados con stent coronario desde julio de 2015 hasta enero de 2016. Resultados: De un total de 283 pacientes incluidos, 75 (26.5%) correspondió a mujeres y 208 (73.5%) a hombres. La edad media fue de 71 ± 13 y 66.5 ± 13 años, respectivamente. Un 44% de mujeres se presentó como SCA con elevación del segmento ST contra un 52.4 de los hombres, p = 0.21. Las mujeres mostraron un mayor riesgo de sangrado (CRUSADE), sin diferencias en el riesgo isquémico (GRACE y TIMI). Se usaron stents farmacoactivos con más frecuencia en mujeres (88.9 vs. 75.5%, p = 0.04). Se observó una tendencia de menor prescripción del ticagrelor en mujeres (42.6 vs. 50.9%, p = 0.29) en favor de un mayor uso del clopidogrel. No se identificaron diferencias en cuanto a la prescripción del prasugrel. Las mujeres presentaron al año una menor mortalidad (1.4 vs. 6.7%, p = 0.19), aunque mayor sangrado (23.3 vs. 17.4%, p = 0.27). Conclusiones: En este estudio de pacientes consecutivos con SCA tratados con stent se registró una mayor prescripción de clopidogrel en las mujeres que en los hombres. Las mujeres presentaron una menor incidencia anual de mortalidad, pero mayor sangrado en comparación con los hombres, no significativo.

Abstract Aims and objective: Impact of sex-related differences in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention and treated with new P2Y12 inhibitors is not adequately characterised. We aimed to analyse gender-based differences in dual antiplatelet therapy, and adverse cardiovascular events and bleeding. Materials and methods: Prospective-observational study of the consecutive ACS patients treated with stent from July 2016 to January 2016, with a follow-up of 1 year. Results: We examined 283 patients, 75 (26.5%) women and 208 (73.5%) men. Women were older than men (71 ± 13 vs. 66,5 ± 13 years). There were 44% of women and 52% of men presenting with ST-elevation ACS (p = 0.21). Women had a higher bleeding risk (CRUSADE), without differences in the ischaemic risk (GRACE and TIMI). More women were treated with drug-eluting stent (88.9 vs. 75.5%, p = 0.04). There was a lower rate of ticagrelor prescription in women (42.6 vs. 50.9%, p = 0.29), in favour of clopidogrel. No differences were observed in prasugrel prescription. No significant differences were observed after a year of follow up, but women had a tendency towards lower mortality (1.4 vs. 6.7%, p = 0.19) and higher bleeding rates (23.3 vs. 17.4%, p = 0.27). Conclusions: In our study of patients presenting with ACS treated with stent, clopidogrel was preferred in women, whereas ticagrelor was the most frequent prescription in men. No significant differences were noted in clinical outcomes, but women experienced a tendency towards less mortality and more bleeding events.

Doble terapia antiagregante en pacientes con accidente cerebrovascular isquémico agudo: Recomendación del grupo CIERTO / Dual antiplatelet therapy for secondary stroke prevention in patients with acute ischemic stroke. CIERTO group recommendation

El inicio precoz del tratamiento con antiagregantes plaquetarios es considerado el estándar de cuidado para pacientes con accidente cerebrovascular isquémico agudo. Distintos esquemas de antiagregación se han comparado con resultados que sugieren que la combinación de múltiples antiagregantes se asocian a menor riesgo de recurrencia de accidente cerebrovascular (ACV) pero a expensas de un aumento en el riesgo de sangrado, lo que a largo plazo termina opacando dichos beneficos. Sin embargo, considerando que el riesgo de recurrencia de ACV es mayor en el periodo inmediato al evento, la indicación de doble tratamiento antiagregante por tiempos limitados podría asociarse a beneficios relevantes. Con este concepto, se realizó una revisión sistemática rápida con el objetivo de evaluar el efecto del tratamiento con doble antiagregación por un periodo corto intentando maximizar el beneficio y reducir al mínimo el riesgo de sangrado. Se incluyeron todos los estudios primarios identificados en los que se comparó un esquema de doble antiagregación, iniciado en el periodo agudo del evento índice (ACV o accidente isquémico transitorio - AIT), contra un esquema de simple antiagregación. El cuerpo de la evidencia mostró que la intervención (doble antiagregación) reduce el riesgo de recurrencia de ACV y probablemente se asocie a un aumento marginal en el riesgo de sangrado mayor. Sugerimos indicar doble esquema antiplaquetario para el tratamiento inicial de pacientes con ACV isquémico menor (Score NIH < o igual a 3 o AIT).

One of the main pillars of acute ischemic stroke management is antiplatelet therapy. Different treatment schemes have been compared, suggesting that the combination of multiple antiplatelet drugs is associated with a reduced risk of stroke recurrence. However, it has also been associated with an increased risk of bleeding complications which, in the long term, surpass the mentioned benefits. However, considering that most stroke recurrences occur i n the short term, a time limited double antiplatelet scheme could result in significant benefits to patients with acute ischemic stroke. On this basis, we conducted a rapid systematic review of the literature in order to evaluate the effects of a short-term double antiplatelet therapy both on stroke recurrence and complications. All trials comparing double versus single antiplatelet therapy in patients with acute ischemic stroke were included. Results showed that double therapy reduces recurrence risk but probably marginally increases major bleeding complications. We suggest double antiplatelet therapy for the initial management of patients with minor (Score NIH < or equal to 3 or transient isquemic attack -TIA) acute ischemic stroke.

Anticoagulation Is Associated With Increased Morbidity And Mortality In Concussive Injury Among Elderly Trauma Patients

To study the association between concussive injury in elderly patients on anticoagulation and development of non-bleeding complication. A retrospective data analysis was performed comparing elderly trauma patients with concussion on antiplatelet therapy, anticoagulation or both. Data obtained included age, ISS, likelihood of development mental status alteration, change in CTscan, hospital length of stay, and survival. 1000 patients patients age > 65 years [elderly] with concussion were enrolled, 622 women and 378 men, all on either antiplatelet therapy, anticoagulation or dual therapy. Patients had an average age of 80 years with average ISS of 1.4. Between the 3 groups (antiplatelet, anticoagulation and dual therapy), notable differences were found in alteration of mental status requiring the obtaining of a repeat CTscan (44% vs. 63% vs. 85%, p < .0001), changes noted in CT scan at 24 hours (8% vs. 19% vs. 56%, p< .0001), hospital length of stay (days) (4.5 vs. 5.1 vs. 6.0, p < .0001), and survival (100% vs. 94% vs. 85%, p < .0001). We also noted a signicant difference between patients on aspirin or clopidogrel with regard to hospital length of stay (days) (4.2 vs. 5.4, p < .0001). Elderly patients on antiplatelet therapy with concussive injury were less prone to develop morbidity such mental status changes, changes in CT at 24 hours and prolonged hospital length of stay when compared to patients on anticoagulation or dual therapy. With 100% survival and hospital length of stay ranging between 4.2 to 5.4 days, raises questions with regard to resource allocation in concussed patients on only antiplatelet therapy. In patients on anticoagulation with or without antiplatelet therapy, changes in CT scan were unrelated to bleeding but more commonly found to be due to worsening of chronic conditions -- edema and prior infarction - possibly related to withholding of anticoagulation or antiplatelet therapy. Concussive injury in patients on anticoagulation is associated with a higher morbidity and mortality than patients with similar injury only on antiplatelet therapy. The change in mental status even with antiplatelet therapy would suggest observing these patients for at least 24 hours.

A study on platelet reactivity and associated clinical characteristics in acute coronary syndrome patients treated with Ticagrelor and Clopidogrel

Background: The pathophysiology of the acute coronary syndrome (ACS) is characterized by the rupture of an atherosclerotic plaque within the coronary artery, with subsequent platelet aggregation, thrombus formation, and ischemia. Before platelets aggregate, they must first be activated to express activated glycoprotein IIb/IIIa receptors on the cell surface. This activation is the result of stimulation from endogenous platelet agonists, such as thromboxane A2 and adenosine diphosphate (ADP). ADP activates platelets by binding to P2Y12 receptors on the cell surface. Despite clinical efficacy in a broad range of coronary artery disease patients, pharmacodynamic studies conducted in patients undergoing stenting showed that clopidogrel therapy was associated with variable and moderate platelet inhibition (50% inhibition at steady state as demonstrated by ex-vivo ADP-induced platelet aggregation) as well. Ticagrelor, a cyclopentyl-triazolo-pyrimidine acting as an analog of adenosine triphosphate (ATP), constitutes a first non-thienopyridine direct platelet P2Y12 receptor blocker. Aim of the study: To investigate factors linked to HOTPR on ticagrelor and whether they differ from factors linked to HOTPR on clopidogrel. Materials and methods: Totally 300 patients were included in the study Patients presenting to the Department of Cardiology, SRM Medical College Hospital and Research Institute, Kattangulathur, Veeraraghavan Sriram, Venkatesh Munusamy, Dhandapani Vellala Elumalai. A study on platelet reactivity and associated clinical characteristics in acute coronary syndrome patients treated with Ticagrelor and Clopidogrel. IAIM, 2019; 6(8): 26- 34. Page 27 Kanchipuram District, Chennai with an ACS between January 2018 to May 2019 were eligible for inclusion in the study if coronary angiography (±PCI) was planned and they were adequately pretreated with Ticagrelor or clopidogrel and aspirin. An ACS was defined as symptoms suggestive of myocardial ischemia lasting > 15 min with either troponin elevation or new electrocardiogram (ECG) changes consistent with myocardial ischemia. ECG changes consistent with myocardial ischemia included ≥ 1 mm of ST-segment deviation or T wave inversion ≥ 1 mm in at least 2 contiguous leads. Troponin was considered elevated if greater than 14 ng/L, with a rise and/or fall of 50% if 14-50 ng/L or 20% if >50 ng/L in a subsequent measure. Results: The mean age was 63 ± 12 years with 71.9% being male and 18% having diabetes. Patients predominantly presented with NSTEMI 76% and 24% as STEMI. Patients treated with Ticagrelor were younger, more likely to be male, less likely to present with STEMI, have suffered a previous MI, experience atrial fibrillation and be taking proton pump inhibitors or calcium channel blockers. Patients who were administered Ticagrelor demonstrated significantly lower platelet reactivity when stimulated with ADP compared to patients administered clopidogrel (30.3 AU vs 43.7 AU respectively, p<0.0001). Conclusion: This study demonstrates that Ticagrelor provides more potent platelet inhibition than clopidogrel measured by MEA. This is reflected in ticagrelor’s ability to reduce the proportion of ACS patients experiencing HOTPR. Different clinical factors contribute to HOTPR in ACS patients treated with Ticagrelor or clopidogrel. Clopidogrel dose, renal insufficiency, clinical presentation, and platelet count are linked to clopidogrel HOTPR. In contrast, only a history of myocardial infarction is associated with Ticagrelor HOTPR.

Evaluation of platelet activity by multiple electrode impedance aggregometry in acute coronary syndromes: pilot study in a Brazilian tertiary-care public hospital

There is no definite recommendation for testing platelet aggregation (PA) in acute coronary syndromes (ACS) due to inconclusive evidence on the usefulness of platelet function tests to guide therapy and improve clinical outcomes. The evaluation of PA with multiple electrode impedance platelet aggregometry (MEA) may be useful to manage antiplatelet therapy and possibly influence patient outcome. The primary aim of this study was to measure PA with MEA in Brazilian patients with ACS and evaluate the association between PA and adverse clinical outcomes. Forty-seven consecutive patients admitted with ACS to a Brazilian tertiary-care public hospital were studied and PA was evaluated using MEA. Patients were followed for six months for the occurrence of all-cause death, acute myocardial infarction, or stroke. Suboptimal inhibition of PA was found in 7 patients (14.9%); 5 (10.6%) in response to ASA (acetylsalicylic acid), 2 (5.0%) to clopidogrel, and none to ticagrelor. Inadequate PA inhibition in response to ASA was significantly associated with the composite end point, but there was no significant association for insufficient PA inhibition in response to clopidogrel. This study suggested that the evaluation of PA in ACS using MEA may identify non-responders to ASA. Larger studies are necessary to define, in a public health scenario, the value of MEA in the management of ACS.

The impact of preoperative dual antiplatelet therapy on early outcome of acute type A aortic dissection patients undergoing aortic surgery / 中华胸心血管外科杂志

Objective@#To evaluate the impact of preoperative dual antiplatelet therapy on early outcome of acute type A aortic dissection(ATAAD) patients undergoing aortic surgery.@*Methods@#From December 2015 to November 2017, 45 consecutive patients with ingestion of aspirin and clopidogrel underwent aortic repair surgery at our center. 37 out of 45 patients(83%) were propensity-matched with 74 control ATAAD patients without antiplatelet therapy undergoing aortic surgery in 1∶2 fashion. Thereby, bleeding-related outcome(death, reoperation for bleeding, postoperative blood loss within 12 h ≥2 000 ml and usage of rFⅦa) and blood transfusion requirement were compared.@*Results@#Bleeding-related outcome occurred in 14(18.9%) and 9(24.3%) patients in control and antiplatelet group respectively(P=0.51). Postoperative blood loss within 12 hours was 490 ml in control group, compared to 500 ml in the antiplatelet group(P=0.85). There were no significant differences among the two groups in transfusion requirements of red blood cells, platelets and fresh frozen plasma. Multivariate regression analysis identified antiplatelet therapy as an nonsignifcant risk factor for bleeding-related outcome(OR=2.97, 95%CI: 0.87-10.21, P=0.08).@*Conclusion@#Preoperative dual antiplatelet therapy was not associated with increased risk of bleeding-related outcome and transfusion requirement, and was not a contraindication of emergent surgery for ATAAD patients.