Individualized antithrombotic therapy in high risk patients after coronary stenting. A double-edged sword between thrombosis and bleeding

2008 ◽  
Vol 99 (03) ◽  
pp. 487-493 ◽  
Author(s):  
Tobias Geisler ◽  
Meinrad Gawaz ◽  
Andreas May
Keyword(s):  
High Risk ◽  
Antiplatelet Therapy ◽  
Stent Thrombosis ◽  
Antithrombotic Therapy ◽  
Bleeding Complications ◽  
Severe Bleeding ◽  
High Risk Patients ◽  
Coronary Stent Implantation ◽  
Risk Patients ◽  
The Individual

SummaryDual antiplatelet therapy with aspirin and clopidogrel is currently the standard therapy after coronary stent implantation to prevent a life-threatening stent thrombosis. However, a variety of procedural and individual factors contribute to the individual patient risk and have to be taken into account to allow for an individual recommendation for both the duration and intensity of the antiplatelet therapy. Obviously, the benefit of the prevention of stent thrombosis by antithrombotic therapy has to outweigh the risk of severe bleeding complications. Depending on the individual clinical situation and procedural characteristics (stent type, length, angiographic result etc.), the recommended duration of the combined antiplatelet therapy currently varies from four weeks to at least one year.These recommendations are mainly based on large, prospective, randomized trials and evidence-based guidelines. However, in a subgroup of high-risk patients there is insufficient evidence for the benefit of conventional dual antiplatelet regimen.These include i) patients with an indication for anticoagulation, ii) patients with urgent need for an operation requiring a perioperative withholding of antiplatelet therapy, as well as iii) clopidogrel low responders.This review aims to provide a stratification to define patient collectives who may benefit from more individualized antithrombotic regimens on behalf of currently available literature and guidelines.

scholarly journals Randomized Evaluation of Anticoagulation Versus Antiplatelet Therapy After Coronary Stent Implantation in High-Risk Patients

Circulation ◽  
1998 ◽  
Vol 98 (20) ◽  
pp. 2126-2132 ◽  
Author(s):  
Philip Urban ◽  
Carlos Macaya ◽  
Hans-Jürgen Rupprecht ◽  
Ferdinand Kiemeneij ◽  
Hakan Emanuelsson ◽  
...  
Keyword(s):  
High Risk ◽  
Antiplatelet Therapy ◽  
Stent Implantation ◽  
Coronary Stent ◽  
High Risk Patients ◽  
Randomized Evaluation ◽  
Coronary Stent Implantation ◽  
Risk Patients

TWILIGHT: A Randomized Trial of Ticagrelor Monotherapy Versus Ticagrelor Plus Aspirin Beginning at 3 Months in High-risk Patients Undergoing Percutaneous Coronary Intervention

2020 ◽  
Vol 14 ◽  
Author(s):  
Johny Nicolas ◽  
Usman Baber ◽  
Roxana Mehran
Keyword(s):  
Percutaneous Coronary Intervention ◽  
High Risk ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Coronary Intervention ◽  
Bleeding Events ◽  
High Risk Patients ◽  
Risk Of Death ◽  
Percutaneous Coronary ◽  
Risk Patients

A P2Y12 inhibitor-based monotherapy after a short period of dual antiplatelet therapy is emerging as a plausible strategy to decrease bleeding events in high-risk patients receiving dual antiplatelet therapy after percutaneous coronary intervention. Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention (TWILIGHT), a randomized double-blind trial, tested this approach by dropping aspirin at 3 months and continuing with ticagrelor monotherapy for an additional 12 months. The study enrolled 9,006 patients, of whom 7,119 who tolerated 3 months of dual antiplatelet therapy were randomized after 3 months into two arms: ticagrelor plus placebo and ticagrelor plus aspirin. The primary endpoint of interest, Bleeding Academic Research Consortium type 2, 3, or 5 bleeding, occurred less frequently in the experimental arm (HR 0.56; 95% CI [0.45–0.68]; p<0.001), whereas the secondary endpoint of ischemic events was similar between the two arms (HR 0.99; 95% CI [0.78–1.25]). Transition from dual antiplatelet therapy consisting of ticagrelor plus aspirin to ticagrelor-based monotherapy in high-risk patients at 3 months after percutaneous coronary intervention resulted in a lower risk of bleeding events without an increase in risk of death, MI, or stroke.

Antiplatelet therapy for the prevention of peri-coiling thromboembolism in high-risk patients with ruptured intracranial aneurysms

2017 ◽  
Vol 127 (6) ◽  
pp. 1326-1332 ◽  
Author(s):  
Nancy J. Edwards ◽  
Wesley H. Jones ◽  
Aditya Sanzgiri ◽  
Juan Corona ◽  
Mark Dannenbaum ◽  
...  
Keyword(s):  
High Risk ◽  
Antiplatelet Therapy ◽  
Intracranial Aneurysms ◽  
Treated Group ◽  
Parent Artery ◽  
Aneurysm Neck ◽  
High Risk Patients ◽  
Ruptured Aneurysms ◽  
Hemorrhagic Complications ◽  
Risk Patients

OBJECTIVEThe most frequent procedural complication of the endovascular treatment of intracranial aneurysms is a thromboembolic event (TEE); in a subset of patients, such events will cause permanent neurological disability. In patients with unruptured aneurysms, increasing evidence supports the use of periprocedural antiplatelet therapy to prevent TEEs. The object of this study was to evaluate whether patients with ruptured aneurysms and subarachnoid hemorrhage would also benefit from periprocedural antiplatelet therapy.METHODSThe authors reviewed a prospective registry of 169 patients with endovascularly treated intracranial aneurysms to delineate angiographic features associated with periprocedural TEEs. They then performed a controlled before-and-after study in 79 patients with ruptured aneurysms who were deemed to be at high risk for TEEs (for example, patients with at least 1 angiographic feature associated with TEEs) to evaluate whether selective aspirin administration would reduce the rate of periprocedural thromboembolism without increasing major hemorrhagic complications.RESULTSSix angiographic features were associated with periprocedural TEEs in the study cohort: wide aneurysm neck, coil or loop protrusion, small parent artery diameter, an incorporated branch, intraprocedural thrombus formation, and intracranial parent vessel atherosclerosis. Aspirin administration to high-risk patients significantly decreased the rate of periprocedural TEEs, from 53.8% in the control group to 10.6% in the aspirin-treated group (p = 0.001). The reduction in TEEs in the aspirin-treated group continued to be statistically significant even when adjusted for age, sex, cardiovascular risk factors (smoking, diabetes, hypertension, dyslipidemia, coronary artery disease), and factors associated with TEEs in other large studies (wide aneurysm neck, aneurysm size ≥ 10 mm), with an adjusted OR of 0.16 (95% CI 0.03–0.8). There were no major systemic hemorrhagic complications, and aspirin did not increase the risk of aneurysm rebleeding, symptomatic intracranial hemorrhage, or major external ventricular drain (EVD)–associated hemorrhage (p = 0.3), though there was an increase in asymptomatic, minor (< 1 cm) EVD-associated hemorrhage in the aspirin-treated group (p = 0.02).CONCLUSIONSThe study findings suggest that for ruptured aneurysm patients with high-risk features, antiplatelet therapy can significantly reduce the rate of periprocedural TEE without increasing major systemic or intracranial hemorrhages.

Thrombophylaxis in Patients Undergoing Bariatric Surgery

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 2080-2080
Author(s):  
Addie A Hill ◽  
Poy P Theprungsirikul ◽  
Maureen T Quigley ◽  
Mary E Menduni ◽  
Thadeus L Trus ◽  
...  
Keyword(s):  
Bariatric Surgery ◽  
High Risk ◽  
Risk Stratification ◽  
Postoperative Bleeding ◽  
Bleeding Complications ◽  
Severe Bleeding ◽  
Delayed Bleeding ◽  
Vte Prophylaxis ◽  
Risk Patients ◽  
History Of

Abstract Background: Patients undergoing bariatric surgery are at increased risk for symptomatic venous thromboembolism (VTE). Although the incidence of clinical VTE is lower than in other general and orthopedic surgical procedures, pulmonary embolism is an independent predictor of death after gastric bypass surgery. The optimal strategy for postoperative thrombophylaxis in bariatric surgery has yet to be elucidated. In 2010 our institution proposed a guideline for postoperative thrombophylaxis for bariatric surgery based on risk stratification. Patients were considered high risk if they had history of VTE or a BMI >/= 60 kg/m2 or if they had two or more of the following: age > 50, BMI >/= 50 kg/m2, male sex, recent history of smoking, obstructive sleep apnea, varicose veins, or hormone therapy within 30 days. All patients undergoing bariatric surgery received enoxaparin 40 mg SC twice daily in addition to mechanical thrombophylaxis including venodynes and compression stockings during the hospital stay. Prophylactic IVC filter insertion was not recommended. High-risk patients received an extended course of anticoagulation for 10 days after discharge. Methods: We retrospectively reviewed the medical charts of 692 patients who underwent bariatric surgery at Dartmouth-Hitchcock Medical Center from 2009 to 2014. We analyzed the incidence of VTE and bleeding complications under two different institutional thrombophylaxis protocols: an earlier protocol of VTE prophylaxis based on surgeon's preference (n = 62) and our subsequent protocol based on risk stratification (n = 630). Results: Prior to implementing our protocol the incidence of VTE and bleeding complications in patients who underwent bariatric surgery was 1.6% (1 in 62) for each. After 2010, with the implementation of extended VTE prophylaxis for high-risk patients, the incidence of postoperative VTE was 0% (0 in 630) and the incidence of postoperative bleeding was 2.7% (17 in 630). Of 17 patients who developed postoperative bleeding, 14 (82%) developed bleeding before postoperative day 3 during the hospitalization and 3 (18%) experienced delayed bleeding after hospital discharge. Of 3 patients with delayed bleeding, only 1 was on the extended thrombophylaxis protocol. Severe bleeding, defined as the need for packed red blood cell transfusions or re-operation, occurred in 1.6% (10 in 630). Conclusion: Our study demonstrates that a protocol based on risk stratification is effective at reducing the risk of symptomatic VTE in patients undergoing bariatric surgery. Although the incidence of all postoperative bleeding appears to have increased slightly after implementation of the protocol, the incidence of severe bleeding appears unchanged. As most of the post-operative bleeding events occurred during the hospitalization period, extending the length of pharmacologic thromboprophylaxis was not associated with an increase in bleeding. This study is limited by its retrospective design and the small number of patients studied prior to implementing the extended VTE prophylaxis protocol. Nevertheless, the findings are promising with respect to VTE risk reduction after bariatric surgery and suggest that prospective evaluation of the thromboprophylaxis protocol is in order. Disclosures No relevant conflicts of interest to declare.

T1963 High-Risk Patients for GI Bleeding On Dual Antiplatelet Therapy in Spain Are More Like to Receive PPI Therapy Than Their American Peers

2009 ◽  
Vol 136 (5) ◽  
pp. A-610
Author(s):  
Angel Lanas ◽  
Liz Guastello ◽  
Ruben Casado ◽  
Sameer D. Saini ◽  
Monica Polo-Tomas ◽  
...  
Keyword(s):  
High Risk ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Gi Bleeding ◽  
High Risk Patients ◽  
Risk Patients ◽  
To Receive

scholarly journals Diabetic foot and its serial treatment in high-risk patients: focusing on the individual

2020 ◽  
Vol 66 (11) ◽  
pp. 1542-1547
Author(s):  
Eli Ávila Souza Júnior ◽  
Raul Silva Simões de Camargo ◽  
Tiago Soares Baumfeld ◽  
Daniel Soares Baumfeld ◽  
Benjamin Dutra Macedo
Keyword(s):  
High Risk ◽  
Diabetic Foot ◽  
Tertiary Hospital ◽  
Cross Sectional Study ◽  
High Risk Group ◽  
Foot Care ◽  
Cross Sectional ◽  
High Risk Patients ◽  
Risk Patients ◽  
The Individual

SUMMARY Objectives: To assess knowledge about diabetic foot, care measures, and the importance attached to serial treatment in a group of high-risk diabetic foot patients. METHODS: This is a cross-sectional study, carried out in a tertiary hospital, with 25 patients undergoing serial treatment for diabetic foot. The tabulation of the data occurred through the use of three methodological figures: core idea, key expressions, and the collective subject discourse. RESULTS: It became evident that even among high-risk patients with diabetic foot, there is no complete knowledge about the definition of the disease. Despite this, all participants reported practicing daily care measures, including frequent inspection of the feet, food care, and attention to footwear. Regarding the importance of serial treatment, there was unanimous recognition of the relevance of this practice, which improves self-care discipline, optimizes the understanding of the disease, and helps to prevent progression. CONCLUSIONS: Authentic speeches in the context of a pathology of considerable prevalence manifested, in an unprecedented way, with conceptions about its definition, care measures, and importance of serial treatment in a high-risk group.

P1852The clinical experience of J valve transapical transcatheter aortic valve replacement system in high-risk patients with severe pure aortic regurgitation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
W Liu ◽  
Y J Zhou ◽  
H B Zhang ◽  
X U Meng ◽  
Y N Gao
Keyword(s):  
High Risk ◽  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Aortic Regurgitation ◽  
Valve Replacement ◽  
Clinical Experience ◽  
Bleeding Complications ◽  
High Risk Patients ◽  
Transcatheter Aortic Valve ◽  
Risk Patients

Abstract Objective Patients with severe pure aortic regurgitation (PAR) undergoing transcatheter aortic valve implantation (TAVI) is still under controversial. J valve™, a China Food and Drug Administration (CFDA) certified device, has specific positioning and anchoring system, which makes this device indicated in PAR patients. We aim to introduce the clinical experience of J valve in the treatment of PAR in high risk patients. Methods A total of 53 severe PAR patients (STS score 6,3±1.8, mean age, 76.4±5.2 years) who underwent TAVI using J valve™ in our Hospital from June 2017 to December 2018 were retrospectively enrolled. All patients underwent echocardiography and contrast-enhanced computed tomography to evaluate their baseline and follow-up characteristics. The 30 days outcomes were reported according to the Valve Academic Research Consortium-2 (VARC) definitions. Results All patients underwent transapical TAVI, and J valve was in implanted successfully in 51 patients (96,2%). J valve was dislodged in two patients, one patient was successful implanted with another J valve and the dislodged valve placed in descending aorta. The other patient was converted to urgent surgery for aortic valve replacement. One patient was converted to surgery due to severe aortic regurgitation after J-valve placement. The 30 days mortality was 9.2% (n=5), 1 patient died of acute heart failure and 2 patients died of infection. During the hospitalization, none of the patients had stroke or transient ischemic attack (TIA) and periprocedural myocardial infarction (MI). There were 5 (n=14.3%) patients presenting with bleeding complications (BARC 4 definition of major bleeding). 1 (2.9%). Pacemaker implantation was performed in 2 (5.7%) patients. Paravalvular regurgitation was none or trace in 90.7% (n=49), mild to moderate in 5.6% (n=3), and moderate to severe 1.8% (n=1) after the procedure. Mean intensive care unit stay was 29.30±15.30 h. Working illustration of J valve Conclusion TAVI by J valve™ can be an alternative option for high risk patients with PAR, but more evidences are still needed to further prove its safety and feasibility.

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