scholarly journals French vascular physicians’ practices in indicating antiplatelet and anticoagulation therapy in venous thromboembolism

VASA ◽  
2019 ◽  
Vol 48 (4) ◽  
pp. 355-360 ◽  
Author(s):  
Antoine Fayol ◽  
Damien Lanéelle ◽  
Clément Hoffmann ◽  
Guillaume Mahé ◽  
Isabelle Mahé
Keyword(s):  
Venous Thromboembolism ◽  
Antiplatelet Therapy ◽  
Anticoagulation Therapy ◽  
Antiplatelet Agents ◽  
Bleeding Risk ◽  
French Society ◽  
Vascular Medicine ◽  
Online Questionnaire ◽  
Full Dose ◽  
Reduced Dose

Summary. Background: As antiplatelet therapy becomes widespread, physicians face the issue patients being treated with antiplatelet agents (APA) and anticoagulants for venous thromboembolism (VTE). Bleeding risk of this combination is increased 1.5–2.5-fold. The aim of this survey is to assess French vascular physician’s management of this combination at the beginning of the treatment and at 6 months of treatment for VTE. Patients and methods: French vascular physicians were surveyed between September and December 2017, using 4 fictional scenarios regarding a VTE event diagnosed in a patient under antiplatelet therapy plus isolated questions in an online questionnaire, sent by the French Society of Vascular Medicine to its members. Out of 1812 physicians, 179 returned valid questionnaires: the response rate was 9.9%. Results: Firstly 97.2% of respondents acknowledged extra risk with this combination; and 63% ceased antiplatelet therapy when initiating anticoagulants; while 36% did not. Secondly, four strategies emerged: 31.4% ceased APA and prescribed full-dose anticoagulants at initiation and at 6 months; 32% associated reduced-dose anticoagulation with APA at 6 months, regardless of what they decided at initiation; 16.5% prescribed isolated full-dose anticoagulants at initiation and reduced-dose at 6 months; lastly 11.2% associated full-dose anticoagulant with antiplatelet therapy at initiation and at 6 months. Conclusions: French vascular physicians adopted different strategies according to estimated risk/benefit ratio. Prospective randomized controlled trials should compare these strategies in order to make recommendations.

scholarly journals Antithrombotic Therapy in Myocardial Infarction: Historic Perils and Current Challenges—A 70-Year Journey

2020 ◽  
Vol 120 (10) ◽  
pp. 1352-1356
Author(s):  
Dion Stub ◽  
Himawan Fernando ◽  
James D. McFadyen ◽  
Jathushan Palasubramaniam ◽  
James Shaw ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
Dual Pathway ◽  
Pathway Inhibition ◽  
Direct Acting

AbstractThere have been numerous and intriguing advancements in antithrombotic therapy for myocardial infarction since it was described in the earliest issues of Thrombosis and Haemostasis. In this article, we revisit historical breakthroughs and describe the four most challenging contemporary themes relating to antithrombotic therapy in myocardial infarction. In all four, the challenge is to find the best balance of reducing specific levels of ischaemic risks without increasing bleeding risk. The first is the question of the optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). This includes discussion of monotherapy after a period of DAPT. The second relates to the role of genotype and phenotype-guided individualisation of antiplatelet therapy. There is emerging evidence for a role of pheno/genotyping in identifying individuals at high risk for recurrent ischaemic events or in guiding the timing of cardiac surgery for patients on DAPT. The third addresses the increasing evidence for dual pathway inhibition, for example, with rivaroxaban in addition to aspirin in patients where high ischaemic and low bleeding risk is demonstrated. Finally the fourth highlights the challenge of the most appropriate combination of antiplatelet and anticoagulation therapy for patients with known atrial fibrillation after PCI. In most individuals, oral P2Y12 inhibitor therapy combined with a direct acting oral anticoagulant appears to be the best strategy based on the available evidence. Overall, the progress in antithrombotic therapy achieved over the last seven decades is remarkable, however, there are important issues to address and progress still to be made.

Mechanisms of platelet activation: Need for new strategies to protect against platelet-mediated atherothrombosis

2009 ◽  
Vol 102 (08) ◽  
pp. 248-257 ◽  
Author(s):  
Lisa Jennings
Keyword(s):  
Antiplatelet Therapy ◽  
Platelet Activation ◽  
Platelet Reactivity ◽  
Thrombus Formation ◽  
Antiplatelet Agents ◽  
Bleeding Risk ◽  
Adenosine Diphosphate ◽  
Adp Receptor ◽  
Activation Pathways ◽  
New Strategies

SummaryPlatelets are central mediators of haemostasis at sites of vascular injury, but they also mediate pathologic thrombosis. Activated platelets stimulate thrombus formation in response to rupture of an atherosclerotic plaque or endothelial cell erosion, promoting atherothrombotic disease. They also interact with endothelial cells and leukocytes to promote inflammation, which contributes to atherosclerosis. Multiple pathways contribute to platelet activation, and current oral antiplatelet therapy with aspirin and a P2Y12 adenosine diphosphate (ADP) receptor antagonist target the thromboxane A2 and ADP pathways, respectively. Both can diminish activation by other factors, but the extent of their effects depends upon the agonist, agonist strength, and platelet reactivity status. Although these agents have demonstrated significant clinical benefit, residual morbidity and mortality remain high. Neither agent is effective in inhibiting thrombin, the most potent platelet activator. This lack of comprehensive inhibition of platelet function allows continued thrombus formation and exposes patients to risk for recurrent thrombotic events. Moreover, bleeding risk is a substantial limitation of antiplatelet therapy, because these agents target platelet activation pathways critical for both protective haemostasis and pathologic thrombosis. Novel antiplatelet therapies that provide more complete inhibition of platelet activation without increasing bleeding risk could considerably decrease residual risk for ischemic events. Inhibition of the protease-activated receptor (PAR)-1 platelet activation pathway stimulated by thrombin is a novel, emerging approach to achieve more comprehensive inhibition of platelet activation when used in combination with current oral antiplatelet agents. PAR-1 inhibition is not expected to increase bleeding risk, as this pathway does not interfere with haemostasis.

scholarly journals Prevention of stroke in patients with chronic coronary syndromes or peripheral arterial disease

2020 ◽  
Vol 22 (Supplement_M) ◽  
pp. M26-M34
Author(s):  
William A E Parker ◽  
Diana A Gorog ◽  
Tobias Geisler ◽  
Gemma Vilahur ◽  
Dirk Sibbing ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Stroke Risk ◽  
Density Lipoprotein ◽  
Bleeding Risk ◽  
Haemorrhagic Stroke ◽  
Major Adverse Cardiovascular Events ◽  
Full Dose ◽  
Increased Risk ◽  
Coronary Syndromes

Abstract Stroke is a common and devastating condition caused by atherothrombosis, thromboembolism, or haemorrhage. Patients with chronic coronary syndromes (CCS) or peripheral artery disease (PAD) are at increased risk of stroke because of shared pathophysiological mechanisms and risk-factor profiles. A range of pharmacological and non-pharmacological strategies can help to reduce stroke risk in these groups. Antithrombotic therapy reduces the risk of major adverse cardiovascular events, including ischaemic stroke, but increases the incidence of haemorrhagic stroke. Nevertheless, the net clinical benefits mean antithrombotic therapy is recommended in those with CCS or symptomatic PAD. Whilst single antiplatelet therapy is recommended as chronic treatment, dual antiplatelet therapy should be considered for those with CCS with prior myocardial infarction at high ischaemic but low bleeding risk. Similarly, dual antithrombotic therapy with aspirin and very-low-dose rivaroxaban is an alternative in CCS, as well as in symptomatic PAD. Full-dose anticoagulation should always be considered in those with CCS/PAD and atrial fibrillation. Unless ischaemic risk is particularly high, antiplatelet therapy should not generally be added to full-dose anticoagulation. Optimization of blood pressure, low-density lipoprotein levels, glycaemic control, and lifestyle characteristics may also reduce stroke risk. Overall, a multifaceted approach is essential to best prevent stroke in patients with CCS/PAD.

scholarly journals Discontinuation of Oral Antiplatelet Agents before Dental Extraction - Necessity or Myth?

Folia Medica ◽  
2017 ◽  
Vol 59 (3) ◽  
pp. 336-343 ◽  
Author(s):  
Atanaska S. Dinkova ◽  
Dimitar T. Atanasov ◽  
Ludmila G. Vladimirova-Kitova
Keyword(s):  
Acetylsalicylic Acid ◽  
Antiplatelet Therapy ◽  
Local Anaesthesia ◽  
Antiplatelet Agents ◽  
Bleeding Risk ◽  
Major Haemorrhage ◽  
Excessive Bleeding ◽  
Significant Difference ◽  
Patients At Risk ◽  
Experimental Group

AbstractBackground:The risk of excessive bleeding often prompts physicians to interrupt the antiplatelet agents as acetylsalicilyc acid and clopidogrel before dental extractions which puts patients at risk of adverse thrombotic events.Aim:To assess the bleeding risk during dental extractions in patients with continued antiplatelet therapy.Materials and methods:The study included 130 patients (64 men and 66 women) aged between 18 and 99 years old. Sixty-eight of the patients received 100 mg acetilsalicilic acid (ASA); these were divided into two groups: 34 patients continued taking ASA and 34 patients stopped it 72 hours before extraction. Sixty-two of the patients were treated with 75 mg clopidogrel; these were also divided into two groups: 31 continued taking clopidogrel and 31 patients stopped it 72 hours before extractions. Extraction was performed under local anaesthesia as no more than 3 teeth per visit were extracted. Local haemostasis with gelatine sponge and/or suturing was used to control bleeding.Results:Mild bleeding was observed most frequently in the first 30 minutes, successfully managed by local haemostasis. Only 1 patient in the control and 1 in the experimental group receiving ASA reported mild bleeding in the first 24 hours, controlled by compression with gauze. No major haemorrhage requiring emergency or more than local haemostasis occurred. No statistically significant difference in bleeding between two groups was found.Conclusion:Single and multiple dental extractions in patients receiving acetylsalicylic acid or clopidogrel can be safely performed without discontinuation of the therapy with provided appropriate local haemostasis.

Review of the Target-Specific Oral Anticoagulants in Development for the Treatment and Prevention of Venous Thromboembolism

2016 ◽  
Vol 29 (4) ◽  
pp. 392-405 ◽  
Author(s):  
Sandeep Devabhakthuni ◽  
Connie H. Yoon ◽  
Kathleen J. Pincus
Keyword(s):  
Venous Thromboembolism ◽  
Clinical Decision Making ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Clinical Decision ◽  
Thrombin Inhibitors ◽  
Direct Thrombin Inhibitors ◽  
Treatment And Prevention

Anticoagulation therapy is often indicated for the treatment and prevention of venous thromboembolism (VTE). Despite advances in anticoagulant management with parenteral anticoagulants and vitamin K antagonists, limitations to their use still exists, leading to investigation of alternative anticoagulants such as factor Xa inhibitors and direct thrombin inhibitors. To date, 3 target-specific oral anticoagulants (TSOACs) are Food and Drug Administration approved; several other agents are currently in development to optimize VTE management and minimize bleeding risks. The objective of this systematic review article is to provide clinicians an overview of the clinical evidence on the investigational TSOACs for the treatment and prevention of VTE. Of the agents in development, edoxaban holds the most promise due to robust data supporting its clinical benefit with a similar bleeding risk to currently approved agents. Clinicians should understand the TSOACs under investigation, since differences in pharmacokinetics and pharmacodynamics may influence clinical decision making and agent selection for management of VTE. Currently, no direct comparisons between TSOACs have been conducted. Agents under investigation have yet to overcome the major limitations of the currently existing TSOACs. Further studies are necessary to clarify which TSOAC agent is best for management of VTE in clinical practice.

scholarly journals Stroke prevention with non-vitamin K antagonist oral anticoagulants in high risk elderly atrial fibrillation patients at increased bleeding risk

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
T Chao ◽  
G.Y.H Lip ◽  
S.A Chen
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Ischaemic Stroke ◽  
Major Bleeding ◽  
Lower Risk ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Vitamin K Antagonist ◽  
Full Dose ◽  
Reduced Dose

Abstract Background Elderly atrial fibrillation (AF) patients with risk factors of bleeding are often considered ineligible for standard oral anticoagulants (OACs). The ELDERCARE-AF trial recently showed that edoxaban 15mg/day was superior to placebo for preventing stroke or systemic embolism and did not result in a significantly higher incidence of major bleeding. Our aim was to investigate a real-world cohort of AF patients similar to the ELDERCARE-AF cohort, with regard to the impact of non-vitamin K antagonist oral anticoagulant (NOAC) use compared to non-OAC use, in relation to clinical outcomes. Methods From January 1, 2012 to December 31, 2016, 15,183 AF patients aged ≥80 years (mean age 86.63 years [SD 4.79]; 48.7% male) with a CHADS2 score >2 who met the enrollment criteria (generally similar to ELDERCARE-AF) were identified from the Taiwan National Health Insurance Research Database. Patients were categorized into 2 groups according to their stroke prevention strategies, ie. without OACs (n=9,084) and NOACs (n=6,099). Patients receiving NOACs were further stratified into reduced-dose or full-dose regimen groups. Results Compared to the non-OAC group as a reference, NOAC use (whether as reduced dose or full dose) was associated with a lower risk of ischaemic stroke (adjusted hazard ratio [aHR] 0.766, 95% confidence interval [CI] 0.667–0.879) and all-cause mortality (aHR 0.393, 95% CI 0.370–0.418) while the risks of ICH and major bleeding were similar. The risks of composite outcomes of “ischaemic stroke or mortality” (aHR 0.423, 95% CI 0.398–0.449) and “ischaemic stroke or major bleeding or mortality” (aHR 0.490, 95% CI 0.463–0.518) were significantly lower with NOAC use. When compared to non-OAC as the reference groups, NOACs (whether reduced dose or full dose) showed a positive NCB. The results were generally consistent even after the propensity matching (Figure 1). Conclusions In routine clinical care, NOACs (whether reduced or full dose) were associated with a lower risk of ischemic stroke, mortality and the composite endpoint, when compared to non-OAC use in high risk elderly AF patients at increased bleeding risk. Our findings provide complimentary “real world” data to support the generalizability of the results of ELDERCARE-AF trial into daily clinical practice. FUNDunding Acknowledgement Type of funding sources: None. Figure 1

Antiplatelet Agents

2018 ◽  
Author(s):  
Eelco F. M. Wijdicks ◽  
Sarah L. Clark
Keyword(s):  
Antiplatelet Therapy ◽  
Stroke Prevention ◽  
Endovascular Procedures ◽  
Dual Antiplatelet Therapy ◽  
Antiplatelet Agents ◽  
Mechanisms Of Action ◽  
Secondary Stroke Prevention ◽  
Vascular Medicine ◽  
Optimal Duration ◽  
Pharmacologic Management

Antiplatelet agents are commonly used in vascular medicine and cardiology, but also in the pharmacologic management of patients with ischemic stroke. Aspirin alone remains the mainstay of therapy for secondary stroke prevention. Several landmark studies for the optimal duration and dose of antiplatelet therapy in stroke prevention are discussed. Dual antiplatelet therapy is needed after carotid artery stenting. Situations where antiplatelet agents also come into play are endovascular procedures associated with procedure-related thrombi. Antiplatelet agents have different mechanisms of action, and each will be discussed. Testing of platelet function and the issue of antiplatelet resistance and discontinuation of antiplatelet agents before procedures will be discussed in this Chapter.

scholarly journals Platelet Inhibition in Acute Coronary Syndrome and Percutaneous Coronary Intervention: Insights from the Past and Present

2020 ◽  
Vol 120 (04) ◽  
pp. 565-578 ◽  
Author(s):  
Diana A. Gorog ◽  
Tobias Geisler
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Antiplatelet Therapy ◽  
Antiplatelet Agents ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
Platelet Function Test ◽  
P2y12 Inhibitors ◽  
Coronary Syndrome ◽  
The Past ◽  
Percutaneous Coronary

AbstractPlatelet activation and aggregation have a pivotal role in arterial thrombosis and in the pathogenesis of both acute coronary syndromes (ACS) and in the thrombotic complications that occur in patients undergoing percutaneous coronary intervention (PCI). The past 30 years has seen the progress from early trials of clopidogrel and glycoprotein IIb/IIIa inhibitors to the application of more potent P2Y12 inhibitors prasugrel and ticagrelor. Early enthusiasm for newer and more potent antiplatelet agents, which could reduce ischemic events, has led to the understanding of the importance of bleeding and a desire to individualize and optimize treatment. It has increasingly become apparent that the potency and duration of dual antiplatelet therapy (DAPT) has to reflect the balance between ischemic and bleeding risk. Recently, multiple strategies have been proposed to individualize DAPT intensity and duration to reduce the bleeding and ischemic risks. Strategies of de-escalation of DAPT intensity, as well as shorter (less than a year) or more prolonged (beyond a year) treatment have been proposed, as well as platelet function test and genotype guidance of P2Y12 inhibitor therapy. Herein, we provide an overview of the progress in the field of antiplatelet therapy for ACS and PCI over the years, showing the current directions of travel. Ongoing studies focusing on personalized antiplatelet treatment will hopefully yield further insight into ways of optimizing outcomes for the individual.

scholarly journals Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications?

Medicina ◽  
2021 ◽  
Vol 57 (4) ◽  
pp. 357
Author(s):  
Gabriele Savioli ◽  
Iride Francesca Ceresa ◽  
Sabino Luzzi ◽  
Alice Giotta Lucifero ◽  
Maria Serena Pioli Di Marco ◽  
...  
Keyword(s):  
Risk Factor ◽  
Antiplatelet Therapy ◽  
Head Trauma ◽  
Clinical Condition ◽  
Antiplatelet Agents ◽  
Bleeding Risk ◽  
Control Group ◽  
Risk Of Bleeding ◽  
Level Ii ◽  
Single Center Study

Background and objectives: In patients who receive antiplatelet therapy (APT), the bleeding risk profile after mild head trauma (MHT) still needs clarification. Some studies have demonstrated an association with bleeding risk, whereas others have not. We studied the population of our level II emergency department (ED) trauma center to determine the risk of bleeding in patients receiving APT and whether bleeding results not from antiplatelet agents but rather from age. We assessed the bleeding risk, the incidence of intracranial hemorrhage (ICH) that necessitated hospitalization for observation, the need for cranial neurosurgery, the severity of the patient’s condition at discharge, and the frequency of ED revisits for head trauma in patients receiving APT. Materials and Methods: This retrospective single-center study included 483 patients receiving APT who were in the ED for MHT in 2019. The control group consisted of 1443 patients in the ED with MHT over the same period who were not receiving APT or anticoagulant therapy. Our ED diagnostic therapeutic protocol mandates both triage and the medical examination to identify patients with MHT who are taking any anticoagulant or APT. Results: APT was not significantly associated with bleeding risk (p > 0.05); as a risk factor, age was significantly associated with the risk of bleeding, even after adjustment for therapy. Patients receiving APT had a greater need of surgery (1.2% vs. 0.4%; p < 0.0001) and a higher rate of hospitalization (52.9% vs. 37.4%; p < 0.0001), and their clinical condition was more severe (evaluated according to the exit code value on a one-dimensional quantitative five-point numerical scale) at the time of discharge (p = 0.013). The frequency of ED revisits due to head trauma did not differ between the two groups. Conclusions: The risk of bleeding in patients receiving APT who had MHT was no higher than that in the control group. However, the clinical condition of patients receiving APT, including hospital admission for ICH monitoring and cranial neurosurgical interventions, was more severe.

scholarly journals Prediction of Bleeding Risk in Patients on Extended Oral Anticoagulation for Venous Thromboembolism

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 139-139
Author(s):  
Philip S Wells ◽  
Michael J. Kovacs ◽  
David Anderson ◽  
Susan R. Kahn ◽  
Clive Kearon ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Major Bleeding ◽  
Oral Anticoagulation ◽  
Research Funding ◽  
Risk Index ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Annual Rate ◽  
Bleeding Events

Abstract Background: While tools exist to predict the risk of major bleeding in patients on oral anticoagulation therapy (OAT) for venous thromboembolism (VTE), these have focused on the higher risk period during the first 3 months of OAT therapy (risk of major bleeding 2.4% in first 3 months vs. 2% per year thereafter), and have not been developed or evaluated for bleeding risk after the first 3 months of therapy (extended OAT). It is widely considered that a bleeding risk tool that is able to identify patients with an annual rate of major bleeding over 3% is needed, as this is the cut-point at which the risk of continued anticoagulant therapy exceeds the benefit. Aims: We sought to evaluate if the rates of major bleeding were over 3% when four existing, previously published tools (RIETE,outpatient bleeding risk index (OBRI), ACCP and HAS-BLED) classified VTE patients during extended OAT as being high risk for major bleeding, and to assess if the differences in major bleeding risk between high risk and not high risk patients were statistically significantly different. Methods: The Bleeding Risk study was a multicentre, multinational prospective cohort study of patients on extended OAT for unprovoked VTE, or provoked VTE with prior VTE, designed to generate a new prediction tool for major bleeding. Patients were enrolled after at least 3 months of OAT. All major bleeding events during long term OAT were captured and adjudicated. We applied each of the 4 tools above to determine the risk for major bleeding according to patient scores. Not all variables in these tools were collected, including drug and alcohol history, and INR control. Results: 2514 patients enrolled at 12 sites have contributed over 7000 years of observation. The mean patient age was 60.2±14.7 years, 64% were male, 92% Caucasian, average BMI was 31.3, and 9% of patients were on antiplatelet agents. Patients were followed for a mean of 2.8 years (range, 0.1 to 6.8 years. 121 patients (4.8%) experienced at least one episode of major bleeding. The annual rate of bleeding was 1.7 per 100 patient years of observation. The proportion of patients classified as high risk of major bleeding by the RIETE (score of 3 or 4), OBRI (score of 3), ACCP (score ≥ 2) and HAS-BLED (score ≥ 3) scores were 12.3%, 13.3%, 28.0% and 23.1%, with major bleeding rates of 3.9%, 3.2%, 3.4% and 3.4% per year, respectively. The major bleeding rates of patients who were classified as not high risk of bleeding were 1.4%%, 1.5%, 1.1% and 1.2% per year, respectively. All differences were statistically significant with p values < 0.0001. Conclusion: Despite the potential to underestimate risk due to missing variables, all currently available prediction tools are able to identify patients with a 3% or higher risk of major bleeding per year. , The HAS-BLED and ACCP scores were able to identify the highest proportions of patients as high risk for major bleeding. Disclosures Wells: BMS/Pfizer: Research Funding; Bayer Healthcare: Other: Speaker Fees and Advisory Board; Janssen Pharmaceuticals: Consultancy; Itreas: Other: Served on a Writing Committee. Kovacs:Bayer: Honoraria, Research Funding; LEO Pharma: Honoraria; Daiichi Sankyo Pharma: Research Funding; Pfizer: Honoraria, Research Funding. Anderson:Bayer Healthcare: Research Funding. Rodger:Boehringer Ingelheim: Research Funding; Canadian Agency for Drugs and Technologies in Health: Consultancy.

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