The addition of Tirofiban infusión to heparin for intraoperative heparin resistance associated with Marfan Syndrome / Adición de una infusión de Tirofiban a heparina en caso de resistencia intraoperatoria a la heparina asociada al Síndrome de Marfan

Abstract Marfan syndrome classically presents with aortic root aneurysms. Aortic ectasia causes diverse blood flow alterations, influencing the behavior of coagulation factors and platelet activity. Heparin resistance has also been reported associated with Marfan Syndrome in a small number of patients, probably due to antithrombin III (ATIII) deficiency or various mutations. The ascending aorta and the aortic valve are replaced with prosthetic material during Bentall- de Bonno procedures. Resistance to anticoagulation during extracorporeal circulation, represents a significant challenge for both anesthesiologists and the surgical team. Resistance to heparin was observed in a patient with Marfan syndrome undergoing a Bentall procedure. ATIII concentrate was not available, and Activated Coagulation Time did not increase despite high doses of heparin. An alternate anticoagulation approach was used successfully.

Resumen El síndrome de Marfan clásicamente se presenta con aneurismas de la raíz de la aorta. La ectasia aórtica produce alteraciones en el flujo sanguíneo que influyen sobre el comportamiento de los factores de la coagulación y la actividad de las plaquetas. También se ha reportado resistencia a la heparina asociada al Síndrome de Marfan en un menor número de pacientes, probablemente debido a deficiencia de antitrombina III (ATIII) o a diversas mutaciones. La aorta ascendente y la válvula aórtica se reemplazan con material prostético en los procedimientos Bentall- de Bonno. La resistencia a la anticoagulación durante circulación extracorpórea significa un enorme desafío tanto para los anestesiólogos, como para el equipo quirúrgico. Se observó resistencia a la heparina en un paciente con Síndrome de Marfan sometido a un procedimiento de Bentall. No había disponibilidad de concentrado ATIII y no aumentó el Tiempo de Coagulación Activada a pesar de las elevadas dosis de heparina. Se utilizó exitosamente un abordaje alterno de anticoagulación.

Drogas antiagregantes plaquetárias e anticoagulantes em pacientes que se submeterão à cirurgia oral: conduta / Antiagregant platelet and anticoagulant drugs in patients who will submit oral surgery: conduct

Objetivo: Como a frequência de pacientes em uso de anticoagulantes e antiagragantes plaquetários nos consultórios odontológicos é crescente, este trabalho objetivou avaliar através de Revisão de Literatura, qual o melhor manejo desses medicamentos na prática odontológica perioperatória. Metodologia: Trata-se de uma revisão integrativa da literatura, utilizadas as bases de dados Scielo e PubMed. Foram escolhidos os seguintes descritores disponíveis na BVs e PubMed em inglês "Platelet Aggregation Inhibitors", "Oral Surgical Procedures" e "Antigoagulants" no período de 2016 a 2021. Também foram consultados livros e sites de diretrizes do Governo. Foram escolhidos 20 artigos para elaboração da pesquisa. Resultados: doenças cardiovasculares e outras condições clínicas pró-coagulantes tem prevalência crescente e são conhecidos fatores de risco para a ocorrência de fenômenos tromboembólicos graves. A terapia antitrombótica tem papel definido nesses casos. No perioperatorio de cirurgias orais, a decisão por suspender ou manter a terapia deve ser individualizada e pode ser orientada por guidelines. Conclusão: procedimentos orais de baixo risco de sangramento podem ser conduzidos sem a descontinuação da terapia antitrombótica. Cirurgias de moderado a alto risco frequentemente requerem suspensão temporária das medicações para fins de minimizar os riscos de complicações hemorrágicas... (AU)

Objective: As the frequency of patients using anticoagulants and antiplatelet agents in dental offices is increasing, this study aimed to evaluate, through a Literature Review, which is the best management of these medications in dental perioperative practice. Methodology: This is an integrative literature review, being used Scielo and PubMed databases. The following descriptors available in BVs and PubMed "Platelet aggregation inhibitors", "Oral Surgical Procedures" and "Antigoagulants" were used, from 2016 to 2021. In addition, the search was also performed in guideline books and Government websites. Twenty articles were chosen for research elaboration. Results: established cardiovascular disease and other procoagulant clinical conditions have an increasing prevalence, especially among the elderly, and are known risk factors for the occurrence of severe thromboembolic phenomena. Antithrombotic therapy has defined role in these cases. In the perioperative period of oral surgery, the decision to suspend or maintain therapy must be individualized and may be guided by guidelines. Age appears as a clinical criterion in the main ones used. Conclusion: oral procedures with low risk of bleeding can be carried out without discontinuing antithrombotic therapy. Moderate to high-risk surgeries usually require its temporary suspension in order to minimize the risk of bleeding complications... (AU)

Síndrome de vena cava superior: una serie de casos consecutivos en pacientes internados en un hospital terciario universitario / Superior vena cava syndrome: a consecutive case series of in-hospital patients in a tertiary teaching hospital

Introducción: el síndrome de vena cava superior resulta de la obstrucción del flujo sanguíneo a través de este vaso. Casi la totalidad de los casos en la actualidad se asocian con tumores malignos. Existen controversias acerca del manejo apropiado de este cuadro. Actualmente, las terapias endovasculares son consideradas de elección. Materiales y métodos: se recolectaron y describieron, a partir de datos de la historia clínica electrónica, los casos de pacientes mayores de 18 años internados ­de forma consecutiva, que desarrollaron el síndrome­ en el Hospital Italiano de Buenos Aires en 2021. Se constataron las características basales, los tratamientos recibidos y los desenlaces clínicos intrahospitaliarios de cada uno de ellos. Resultados: un total de cinco pacientes fueron incluidos en el presente estudio y seguidos durante su instancia intrahospitalaria. Todos los casos descriptos fueron secundarios a enfermedades oncológicas. La mayoría de los pacientes presentaron un cuadro de moderada gravedad según las escalas utilizadas. En cuatro de cinco pacientes se optó por terapias endovasculares y dos de ellos fallecieron durante la internación. Discusión: existen controversias respecto del tratamiento óptimo del síndrome de vena cava superior, y heterogeneidad en la práctica clínica. Los estudios futuros deberían centrarse en identificar a aquellos pacientes que más probablemente se beneficien de las estrategias terapéuticas endovasculares, anticoagulantes o antiagregantes. (AU)

Introduction: superior vena cava syndrome results from an obstruction of blood flow through this vessel. Currently, almost all cases are associated with malignancies. There are controversies about the optimal management of this syndrome. Endovascular therapies are considered the first-line therapy. Material and methods: we collected clinical, laboratory and pharmacological data from patients admitted at the Hospital Italiano de Buenos Aires, between January 1st and November 1st 2021 with a diagnosis o superior vein cava syndrome. Baseline characteristics, treatment strategies and clinical outcomes were recorded. Results: a total of five patients were included in the present study. All cases were malignancy-related. Most of the patientsdeveloped moderate symptoms. Four out of five patients were treated with endovascular therapies and two patients died during hospitalization. Discussion: controversies regarding optimal management of the superior vena cava syndrome remain. Future research should focus on identifying those patients who are most likely to benefit from endovascular, anticoagulant or antiplatelet therapeutic strategies. (AU)

Effect of anticoagulant or antiplatelet drugs on bleeding and cardio-cerebral vascular events in perioperative period of catherization for peritoneal dialysis / 中华肾脏病杂志

Objective:To analyze the effect of anticoagulant or antiplatelet drugs on bleeding and cardio-cerebral vascular events in perioperative period of catherization for peritoneal dialysis.Methods:The clinical data of patients undergoing peritoneal dialysis catheterization in Peking University Third Hospital from July 1, 2010 to December 31, 2020 were collected and analyzed retrospectively. The patients were divided into drugs discontinuation group and drugs continuation group according to whether the anticoagulant drugs or antiplatelet drugs were discontinued or not. Baseline clinical data and bleeding and cardio-cerebral events after surgery were compared between the two groups. Multivariate logistic regression model was used to analyze the influencing factors for bleeding and cardio-cerebral events.Results:A total of 57 patients were included in the study, with 34 males and 23 females. The age was (67.37±13.93) years old (range from 27 to 97 years old). There were 37 patients in drugs discontinuation group and 20 patients in drugs continuation group. The proportions of acute myocardial infarction events in drugs continuation group were higher than those in drugs discontinuation group in 3 months and 6 months before surgery (10/20 vs 3/37, χ2=10.671, P=0.001; 11/20 vs 3/37, χ2=12.980, P<0.001 respectively). The median drugs discontinuation time was 5.0(2.0, 14.0) d (range from 1 to 30 d) before surgery, and median restore medication time was 4.0(3.0, 7.0) d (range from 1 to 14 d) after surgery in drugs discontinuation group. There was no significant difference in the proportion of bleeding (10/37 vs 8/20, χ2=1.011, P=0.315) and cardio-cerebral events (4/37 vs 0/20, χ2=0.964, P=0.326) between drugs discontinuation group and drugs continuation group within 2 weeks after surgery. The results of multivariate logistic regression analysis showed that drugs discontinuation before surgery was not an independent influencing factor for bleeding events ( OR=0.656, 95% CI 0.195-2.206, P=0.496), however combination of aspirin and clopidogrel before surgery was an independent influencing factor for bleeding events ( OR=4.038, 95% CI 1.044-15.626, P=0.043). All cardio-cerebral events (4 cases) happened in drugs discontinuation group, and myocardial angina in 6 months before surgery ( OR=9.764, 95% CI 0.928-102.682, P=0.058) and increased serum calcium concentration ( OR=1.491, 95% CI 0.976-2.278, P=0.065) were related with an elevated trend for cardio-cerebral events. Conclusions:Whether anticoagulant or antiplatelet drugs are discontinued before catherization surgery for peritoneal dialysis is not an independent influencing factor for bleeding events after surgery. The risk of postoperative bleeding in patients using combination of aspirin and clopidogrel should be paid attention. Myocardial angina in 6 months before surgery and higher serum calcium are related with an elevated trend for cardio-cerebral events after drugs discontinuation.

Low platelet reactivity in patients with myocardial infarction treated with aspirin plus ticagrelor

ABSTRACT Objective: Low platelet reactivity levels are associated with higher risk of bleeding in patients receiving dual antiplatelet therapy relative to patients with optimal platelet blockade. This study set out to evaluate the prevalence of low platelet reactivity in patients with acute myocardial infarction treated with ticagrelor and aspirin. Methods: Patients admitted with acute myocardial infarction who were already undergoing dual antiplatelet therapy with aspirin and ticagrelor were enrolled. Blood samples were collected 1 hour before and 2 hours after the maintenance dose of ticagrelor to investigate trough and the peak effects of the drug respectively. Platelet reactivity was measured by three methods: Multiplate®, PFA-100® with Innovance® PFA-P2Y cartridge and PFA-100® with Collagen/ADP cartridge. Platelet reactivity was assessed in the presence of peak levels of ticagrelor and defined according to previously validated cut-offs for each method (<19 AUC, >299 seconds and >116 seconds respectively). The level of significance was set at p<0.05. Results: Fifty patients were enrolled (44% with ST-elevation). Median duration of DAPT was 3 days (interquartile range, 2-5 days). On average, peak and trough platelet reactivity were markedly low and did not differ between different methods. Low platelet reactivity was common, but varied according to analytic method (PFA-100®/Innovance®PFA-P2Y: 86%; Multiplate®: 74%; PFA-100®/Collagen/ADP: 48%; p<0.001). Conclusion: Low platelet reactivity was very common in patients with acute myocardial infarction submitted to dual antiplatelet therapy with ticagrelor and aspirin. Findings of this study justify the investigation of less intensive platelet inhibition strategies aimed at reducing the risk of bleeding in this population, such as lower dose regimens or monotherapy with P2Y12 inhibitors.

Antiplatelet therapy of patients with intracranial aneurysms undergoing stent-assisted coil embolization / 国际脑血管病杂志

Stent-assisted coil embolization is a common endovascular treatment for ruptured/unruptured intracranial aneurysms. Stent implantation process can damage vascular endothelium, activate platelet and coagulation cascade, and then increase the risk of thrombosis. In order to reduce the risk of postoperative embolism, antiplatelet therapy is required. Among them, aspirin combined with clopidogrel dual antiplatelet therapy is a commonly used strategy. For patients with low response to clopidogrel, tigrelol or cilostazol can be used as an alternative drug. Although the scheme has been considered to be effective and safe, it is still controversial.

Evidence from Cochrane systematic reviews for effects of antithrombotic drugs for lower-limb revascularization. A narrative review

ABSTRACT BACKGROUND: Peripheral arterial disease (PAD) is characterized by progressive narrowing of the arterial lumen, resulting from atherosclerotic plaques. Treatment for PAD aims to control atherosclerosis and improve blood flow. Use of antiplatelet agents and anticoagulants has played important roles in helping to prevent occlusions and stenosis. OBJECTIVE: To evaluate the evidence from Cochrane systematic reviews regarding the accuracy, effectiveness and safety of use of anticoagulants and antiplatelets in lower-limb revascularization, in patients with peripheral arterial disease. METHODS: Systematic reviews found through searches in the Cochrane Library were included. Two authors evaluated whether the reviews found were in line with the inclusion criteria for this investigation. A qualitative synthesis of their findings was presented. RESULTS: Three systematic Cochrane reviews were included. Patients who underwent prosthetic bypass surgery probably presented greater benefit from use of antiplatelets, and patients who underwent vein revascularization probably presented greater benefit from use of anticoagulants. Patients who received endovascular treatment benefited from both antiplatelet and anticoagulant treatment. However, the reliability of the results found was impaired because at the time when these reviews were published, there was no mandatory assessment using the GRADE criteria. CONCLUSION: Despite the evidence found, it is necessary for these reviews to be updated in order to evaluate the degree of certainty of the results found.

Estrategias de antiagregación en síndromes coronarios agudos sin elevación del segmento ST / Antiplatelet Strategies in Non-ST-Segment Elevation Acute Coronary Syndrome

RESUMEN Introducción: Existe información limitada sobre estrategias de tratamiento con inhibidores del receptor P2Y12 (iP2Y12) en síndromes coronarios agudos sin elevación del segmento ST (SCASEST) en la vida real. Objetivos: Determinar la incidencia de eventos cardíacos adversos mayores (MACE)y sangrado BARC ≥2, según la estrategia de tratamiento con iP2Y12 a 6 meses. Material y métodos: Subanálisis preespecificado del registro BUENOS AIRES I (n = 1100). Se estratificó la cohorte según "pretratamiento" con iP2Y12 (antes de conocer la anatomía coronaria), o "tratamiento en sala" (luego de conocer la anatomía coronaria) y se analizó la incidencia de eventos clínicos, según: pretratamiento con clopidogrel/ticagrelor, tratamiento en sala con clopidogrel/ticagrelor. Resultados: La edad media fue 65,4 ± 11,5 años, con 77,2% de sexo masculino. El 79,72% recibió iP2Y12, el 75% como pretratamiento y 25% como tratamiento en sala. Los pacientes con pretratamiento fueron más jóvenes y con más infarto agudo de miocardio (IAM), en comparación con el subgrupo de tratamiento en sala. A los 6 meses, no hubo diferencias significativas en la incidencia de MACE (16,4% vs. 14,4%; p = 0,508), o sangrado BARC ≥2 (14,7% vs. 11,1%; p = 0,205), entre los distintos momentos de administración del iP2Y12. El tratamiento con ticagrelor presentó menos MACE en comparación con el clopidogrel (p = 0,044), sin diferencias en sangrados. No se observaron diferencias en MACE entre ticagrelor en pretratamiento o tratamiento en sala (p = 0,893). Conclusiones: El subgrupo de pacientes seleccionados para recibir pretratamiento con iP2Y12 no presentó diferencias en MACE ni sangrado en relación con los tratados en sala. Los pacientes seleccionados para su tratamiento con ticagrelor en sala presentaron un balance beneficioso entre eventos isquémicos y hemorrágicos.

ABSTRACT Background: There is limited real life information on treatment strategies with P2Y12 receptor inhibitors (P2Y12i) in nonST-segment elevation acute coronary syndromes (NSTEACS). Objectives: The aim of this study was to determine the incidence of major adverse cardiac events (MACE) and BARC bleeding ≥2, according to the treatment strategy with P2Y12i at 6 months. Methods: The study used the pre-specified subanalysis of the BUENOS AIRES I registry (n=1100). The cohort was stratified according to P2Y12i "pretreatment" (before knowing the coronary anatomy), or "ward treatment" (after knowing the coronary anatomy), and the incidence of clinical events was analyzed according to pretreatment or ward treatment with clopidogrel/ ticagrelor. Results: Mean age was 65.4 ± 11.5 years and 77.2% were male patients. In 79.72% of cases patients received P2Y12i, 75% as pretreatment and 25% as ward treatment. Pretreatment patients were younger and with greater prevalence of acute myocardial infarction (AMI) compared with the ward treatment subgroup. At 6 months, there were no significant differences in the incidence of MACE (16.4% vs. 14.4%; p = 0.508), or BARC bleeding ≥2 (14.7% vs. 11.1%; p = 0.205), between the different times of P2Y12i administration. Treatment with ticagrelor presented reduced MACE compared with clopidogrel (p = 0.044), with no difference in bleeding. No MACE differences were observed between pretreatment or in ward treatment with ticagrelor (p=0.893). Conclusions: The subgroup of patients selected to receive P2Y12i pretreatment did not present differences in MACE or bleeding relative to those treated in ward. Patients selected for ticagrelor treatment in ward presented a beneficial balance between ischemic and hemorrhagic events.

Effects of a loading dose of clopidogrel hydrogen sulfate on hemorheology and neurological function in patients with acute progressive cerebral infarction / 中国基层医药

Objective:To investigate the effects of a loading dose of clopidogrel hydrogen sulfate on hemorheology and neurological function in patients with acute progressive cerebral infarction.Methods:A total of 110 patients with acute progressive cerebral infarction who received treatment between January 2018 and January 2019 in the Affiliated Hospital of Shaoxing University, China were included in this study. They were randomly assigned to receive either conventional treatment (control group, n = 55) or treatment with a loading dose of clopidogrel hydrogen sulfate based on conventional treatment (study group, n = 55) for 2 weeks. Hemorheological parameters, National Institute Health of Stroke Scale (NIHSS) scores and adverse reactions were compared between the study and control groups. Results:After treatment, the levels of hemorheological parameters in both groups were obviously decreased. Plasma viscosity, high-shear whole blood viscosity, low-shear whole blood viscosity, fibrinogen level and hematocrit in the study group were (1.01± 0.37) mPa/s, (4.23 ± 0.35) mPa/s, (8.36 ± 1.64) mPa/s, (1.23 ± 0.28) g/L, (40.08 ± 5.04) %, respectively, which were significantly lower than those in the control group [(1.84 ± 0.52) mPa/s, (5.44 ± 0.39) mPa/s, (10.54 ± 1.79) mPa/s, (2.30 ± 0.37) g/L, (44.36 ± 5.12) %, t = 5.485, 8.594, 9.523, 7.789, 11.236, P = 0.019, 0.006, 0.004, 0.007, 0.001]. After treatment, NIHSS scores in the study group were significantly lower than those in the control group [(3.11 ± 1.17) points vs. (6.43 ± 2.25) points, t = 10.416, P = 0.003). There was no significant difference in the incidence of adverse reactions between study and control groups [5.45% (3/55) vs. 9.09% (5/55), χ2 = 0.539, P = 0.463). Conclusion:The loading dose of clopidogrel hydrogen sulfate is highly effective in the treatment of acute progressive cerebral infarction and it can greatly improve hemorheological parameters and neurological function.

Effect of renal insufficiency on the treatment of patients with ischemic stroke / 国际脑血管病杂志

Patients with chronic kidney dysfunction (CKD) have abnormal coagulation function and impaired drug metabolism, resulting in increased bleeding risk and decreased drug clearance. Therefore, while receiving treatment, the prognosis of ischemic stroke patients with CKD is different from that of ischemic stroke patients without CKD. For patients with CKD who need anticoagulant treatment, the use of new anticoagulants without renal metabolism can achieve the same anticoagulant effect as warfarin, and the risk of bleeding is lower. When using antiplatelet drugs, due to the increased risk of bleeding in ischemic stroke patients with CKD, the clinical benefits and bleeding risk should be carefully weighed. Although CKD is not an absolute contraindication of intravenous thrombolysis or endovascular treatment in patients with acute ischemic stroke, attention should be paid to the influence of CKD on the increased risk of death in patients with ischemic stroke after treatment.

Dual antiplatelet therapy for mild stroke and transient ischemic attack / 国际脑血管病杂志

Patients with mild stroke and transient ischemic attack (TIA) have a high risk of early recurrence or deterioration. Antiplatelet therapy has been recognized to reduce the risk of ischemic vascular events. All guidelines recommend antiplatelet therapy for patients with ischemic stroke. Dual antiplatelet therapy (DAPT) refers to the application of two drugs with different mechanisms to block platelet aggregation and prevent thrombosis. There are many combinations of DAPT, and its safety and effectiveness are still uncertain. This article reviews the efficacy and safety of DAPT in patients with mild stroke and TIA.

Cryptogenic stroke in patients with patent foramen ovale: potential mechanisms and prevention strategies / 国际脑血管病杂志

Patent foramen ovale (PFO) is a congenital heart disease that occurs in about 25% of healthy adults. In recent years, more and more studies have shown that PFO is closely associated with cryptogenic stroke (CS). Although it is currently believed that paradoxical embolism is one of the main mechanisms of the pathogenesis of CS, but the exact mechanism is still controversial. In addition, the treatment of CS in patients with PFO is also the focus of controversy. Recent clinical trials have shown that PFO occlusion is significantly better than drug therapy alone in preventing stroke recurrence, especially for patients with a large right-to-left shunt and atrial septal tumor. This article reviews the potential mechanisms and prevention strategies of CS in patients with PFO.

Anticoagulantes, Antiplaquetarios y sus implicaciones en cirugía: una revisión de la literatura / Anticoagulants, Anti-platelets, and their implications in Surgery: A Literature review

All health care providers should be aware of the impact of bleeding disorders on their patients during any surgical procedures. The knowledge of the mechanisms of hemostasis and optimized management are very important. Initial recognition of a bleeding disorder, in such patients with a systemic pathologic process, may occur in surgical practice. The surgical treatment of those patients might be complicated during the surgery due to the use of anticoagulant and/or antiplatelet medications raises a challenge in the daily practice of surgical professionals. Adequate hemostasis is critical for the success of any surgical procedure because bleeding problems can give rise to complications associated with important morbidity-mortality. Besides, prophylactic, restorative, and surgical care of patients with any bleeding disorders is handled skillfully by practitioners who are well educated regarding the pathology, complications which could arise, and surgical options associated with these conditions. The purpose of this paper is to review common bleeding disorders and their effects on the surgical aspect. Many authors consider that patient medication indicated for the treatment of background disease should not be altered or suspended unless so indicated by the prescribing physician. Local hemostatic measures have been shown to suffice for controlling possible bleeding problems resulting from surgery.

Is There Safety in the Use of Clopidogrel Loading Dose in Patients Over 75 Years of Age with Acute Coronary Syndrome?

There is limited evidence in the literature regarding the administration of clopidogrel to acute coronary syndrome (ACS) in patients over 75 years of age. Most studies excluded this age group, making the subject controversial due to the increased risk of bleeding in this population. Objective: This is a retrospective, unicentric, and observational study aimed at assessing whether the administration of clopidogrel loading dose increases bleeding rates in patients over 75 years of age. Methods: Patients were divided into two groups: group I: 75 mg of clopidogrel; group II: 300-to 600-mg loading dose of clopidogrel. A total of 174 patients (129 in group I and 45 in group II) were included between May 2010 and May 2015. Statistical analysis: The primary outcome was bleeding (major and/or minor). The secondary outcome was combined events (cardiogenic shock, reinfarction, death, stroke and bleeding). The comparison between groups was performed through Q-square and T-test. The multivariate analysis was performed by logistic regression, being considered significant p < 0.05. Results: Comparisons between groups I and II showed differences in the prevalence of diabetes (46.5% vs. 24.4%, p = 0.01), arterial hypertension (90.7% vs. 75, p = 0.01), dyslipidemia (62% vs. 42.2%, p = 0.021), ST segment elevation (11.6% vs. 26.6%, p = 0.016) and coronary intervention percutaneous (16.5% vs. 62.2%, p < 0.0001), respectively. In the multivariate analysis, significant differences were observed between groups I and II in relation to the occurrence of bleeding (8.5% vs. 20%, OR = 0.173, 95% CI: 0.049 - 0.614, p = 0.007). Conclusion: A loading dose of 300 mg or more of clopidogrel

Open tracheostomy in patients with dual platelet aggregation inhibitors: case series / Traqueostomía abierta en pacientes con antiagregación plaquetaria dual: Serie de casos

Abstract Introduction: Tracheostomy is the most common surgical procedure performed in the intensive care unit (ICU). There is a paucity of evidence regarding complications in patients on dual anti-platelet therapy. Objective: To describe the complications arising in critically ill patients on dual antiplatelet therapy who are subjected to open tracheostomy. Method: Descriptive observational study of a retrospective case series of patients admitted to the ICU between June 2011 and December 2016, scheduled to undergo open tracheostomy. Results: Overall, 52 patients met the inclusion criteria and, of them, 14 were excluded. Postoperatively, 4 patients (10.5%) had major bleeding and 2 (5.3%) had minor bleeding. Only 1 patient (2.6%) required transfusion secondary to tracheostomy-related bleeding. No patient required fiberoptic bronchoscopy due to bleeding. Reintervention was needed in 10.5% of patients (n=4). No tracheostomy-related mortality was reported. Conclusion: Although 10.5% of patients had major bleeding, there was no impact on mortality. This study showed that, in patients with recent major cardiovascular events, there is no need to discontinue dual antiplatelet therapy or delay tracheostomy.

Resumen Introducción: La traqueostomía es el procedimiento quirúrgico más frecuentemente realizado en la Unidad de Cuidado Intensivo. La evidencia respecto a las complicaciones en pacientes con antiagregación plaquetaria dual es escasa. Objetivo: Describir las complicaciones que se presentan en pacientes críticos en manejo con terapia antiagregante plaquetaria dual, sometidos a traqueostomía abierta. Método: Estudio observacional descriptivo, serie de casos retrospectiva de pacientes hospitalizados en la Unidad de Cuidado Intensivo desde junio de 2011 hasta diciembre de 2016, programados para traqueostomía abierta. Resultados: 52 pacientes cumplieron criterios de inclusión, de los cuales se excluyó a 14. No se presentaron complicaciones durante la realización de la traqueostomía. En el posoperatorio, cuatro pacientes (10.5%) presentaron sangrado mayor y dos (5.3%) presentaron sangrado menor. Solo un paciente (2.6%) requirió transfusión secundaria a sangrado por traqueostomía. Ningún paciente requirió fibrobroncoscopia por sangrado. En un 10.5% de los pacientes (n:4) hubo necesidad de reintervención. No se reportó mortalidad por causa de la traqueostomía. Conclusiones: Aunque el 10.5% de los pacientes presentaron sangrado mayor, no hubo impacto en la mortalidad. El presente estudio mostró que en pacientes con evento cardiovascular mayor reciente no es necesario suspender la antiagregación dual ni diferir la realización de la traqueostomía.

Asociación entre el volumen plaquetario medio y la resistencia a aspirina e inhibidores del receptor p2y12 en pacientes ancianos con síndrome coronario agudo / Association between Mean Platelet Volume and Resistance to Aspirin and P2Y12 Receptor Inhibitors in Elderly Patients with Acute Coronary Syndrome

RESUMEN Introducción: La resistencia a antiagregantes y el volumen plaquetario medio (VPM) son predictores de eventos en el síndrome coronario agudo (SCA). La asociación entre ambos ha sido poco estudiada. Objetivos: Evaluar si existe asociación entre la resistencia a la aspirina (AAS) e inhibidores del receptor P2Y12 (iP2Y12) y el VPM en pacientes mayores de 65 años con SCA. Material y métodos: Se incluyeron pacientes mayores de 65 años con diagnóstico de SCA. Se dividieron en: grupo 1 (resistencia a ambos antiagregantes), grupo 2 (a uno de los antiagregantes) y grupo 3 (a ningún antiagregante). Se midió la agregación plaquetaria entre las 12 y 24 horas poscarga (por light transmission aggregometry). Se consideró resistencia a iP2Y12 a un porcentaje máximo de agregación (PMA) con ADP > 60% y a la AAS a un PMA con ARA > 20%. En el seguimiento se consi-deró el punto final combinado de muerte global y reinternación cardiovascular. Resultados: Se incluyeron 195 pacientes que recibieron AAS e iP2y12 (120 recibieron clopidogrel y 75 ticagrelor); grupo 1 (19%), grupo 2 (34,4%) y grupo 3 (46,6%). El VPM se asoció a la resistencia a ambos antiagregantes (OR 1,02 (IC 95% 1,01-1,05), p = 0,03. A su vez, el VPM y el GRACE fueron predictores independientes del punto combinado (HR 1,03 (IC 95% 1,01-1,07), p = 0,04 y HR 1,02 (IC 95% 1,01-1,04), p = 0,02), respectivamente. Conclusiones: El VPM se asoció a la presencia de resistencia a ambos antiagregantes. En el seguimiento el VPM y el score GRACE fueron predictores del punto combinado.

ABSTRACT Background: Antiplatelet resistance and mean platelet volume (MPV) are event predictors in acute coronary syndrome (ACS). However, the association between both has been poorly studied. Objective: The aim of this study was to evaluate the association between MPV and resistance to aspirin (ASA) and P2Y12 receptor inhibitors (P2Y12i) in elderly patients with ACS. Methods: Patients over 65 years old with diagnosis of ACS were included in the study. They were divided into group 1 (re-sistance to both antiplatelet agents), group 2 (resistance to one antiplatelet agent) and group 3 (no resistance to antiplatelet agents). Platelet aggregation was measured between 12 and 24 hours postload (by light transmission aggregometry). Resis-tance to P2Y12i was considered as maximum percentage of aggregation (MPA) with adenosine diphosphate (ADP) >60% and resistance to ASA as MPA with arachidonic acid (ARA) >20%. The composite endpoint of global death and cardiovascular re-hospitalization was considered during follow-up. Results: One hundred and ninety five patients included in the study received ASA and P2Y12i (120 received clopidogrel and 75 ticagrelor). Nineteen percent of patients belonged to group 1, 34.4% to group 2 and 46.6% to group 3. Mean platelet volume was associated with resistance to both antiplatelet agents [OR 1.02 (95% CI 1.01-1.05), p=0.03], while MPV and the GRACE score were independent predictors of the composite endpoint [HR 1.03 (95% CI 1.01-1.07), p=0.04] and [HR 1.02 (95% CI 1.01-1.04), p=0.02], respectively. Conclusions: Mean platelet volume was associated with the presence of resistance to both antiplatelet agents. During follow-up, MPV and the GRACE score were predictors of the composite endpoint.

Dual platelet antiaggregation therapy after myocardial revascularization surgery

SUMMARY Coronary artery bypass graft (CABG) is a consolidated treatment in patients with coronary artery disease (CAD) for both symptom control and improvement of prognosis. The patency of venous grafts is still the most vulnerable point of the surgical treatment since it presents a high prevalence of occlusion both in the immediate postoperative period and in the long-term follow-up. Aspirin plays a well-established role in this setting, and for a long time, clopidogrel use has been restricted to patients allergic to aspirin. Recently, subgroup analyses of studies with different anti-platelet therapies have shown reduced mortality and cardiovascular events in patients on dual anti-platelet antiplatelet therapy (DAPT) undergoing CABG, although such studies have not been designed to evaluate this patient profile. However, there is still an insufficient number of randomized studies using DAPT in this context, resulting in a disagreement between the European and American cardiology societies guidelines regarding their indication and generating doubts in clinical practice.

RESUMO A cirurgia de revascularização miocárdica (CRM) é tratamento fundamental em pacientes com doença arterial coronariana (DAC) tanto para controle de sintomas quanto para melhora do prognóstico. A patência dos enxertos venosos ainda hoje é o ponto mais vulnerável do tratamento cirúrgico, por apresentar alta prevalência de oclusão tanto no pós-operatório imediato como no seguimento em longo prazo. A aspirina tem papel bem estabelecido neste cenário e, por muito tempo, o uso do clopidogrel ficou restrito a pacientes alérgicos a aspirina. Recentemente, análises de subgrupos de estudos com diferentes terapias antiplaquetárias demonstraram redução de mortalidade e eventos cardiovasculares em pacientes em uso de dupla antiagregação plaquetária (Dapt) submetidos à CRM, ainda que tais estudos não tenham sido desenhados para avaliar este perfil de pacientes. Contudo, há ainda uma quantidade insuficiente de estudos randomizados com uso de Dapt nesse contexto, resultando em uma discordância entre as diretrizes europeia e americana de cardiologia quanto à sua indicação e gerando dúvidas na prática clínica.