Does Dual Antiplatelet Therapy Affect Blood Loss and Transfusion Requirements in Robotic-Assisted Coronary Artery Surgery?

2012 ◽  
Vol 7 (6) ◽  
pp. 399-402 ◽  
Author(s):  
Jonathan M. Hemli ◽  
Lincoln S. Darla ◽  
Christopher R. Panetta ◽  
Joan Jennings ◽  
Valavanur A. Subramanian ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Antiplatelet Agents ◽  
Coronary Surgery ◽  
Robotic Assisted ◽  
Coronary Syndrome ◽  
Perioperative Bleeding ◽  
Transfusion Requirements ◽  
The Impact

Objective Patients who present for coronary surgery often receive preoperative dual antiplatelet therapy with aspirin and a thienopyridine derivative (clopidogrel or prasugrel), especially after a recent acute coronary syndrome. Studies have shown that patients on aspirin and clopidogrel are at increased risk for perioperative bleeding and related events. We sought to examine the impact of dual antiplatelet therapy on bleeding and transfusion requirements in patients undergoing robotic-assisted minimally invasive coronary artery bypass grafting. Methods From January 2010 to November 2011, a total of 110 patients underwent robotic-assisted off-pump coronary surgery at our institution. All patients underwent robotic-assisted harvest of the left internal mammary artery from the chest wall. Some patients then underwent direct coronary anastomosis to the left anterior descending coronary artery via a left minithoracotomy, whereas others had a complete robotic endoscopic procedure within the closed chest. The patients were divided into two groups for outcome analysis on the basis of preoperative antiplatelet therapy: group 1 (either aspirin alone or no antiplatelet agents at all; n = 53) and group 2 (aspirin plus clopidogrel or prasugrel; n = 57). Results Perioperative chest tube drainage was not significantly different between the patient groups, irrespective of the preoperative antiplatelet agents used. Transfusion requirements and other morbidities were also similar in both groups of patients. Conclusions Preoperative dual antiplatelet therapy does not result in significantly increased bleeding or perioperative transfusion requirements. If clinically indicated, it is reasonable to continue preoperative combination antiplatelet therapy in patients undergoing robotic-assisted coronary surgery.

scholarly journals Impact of Diabetes Mellitus on Antithrombotic Management Patterns and Long‐Term Clinical Outcomes in Patients With Acute Coronary Syndrome: Insights From the EPICOR Asia Study

2020 ◽  
Vol 9 (22) ◽  
Author(s):  
Shaoyi Guan ◽  
Xiaoming Xu ◽  
Yi Li ◽  
Jing Li ◽  
Mingzi Guan ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Acute Coronary Syndrome ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Antiplatelet Agents ◽  
Coronary Syndrome ◽  
Increased Risk ◽  
Antithrombotic Management

Background Long‐term use of antiplatelet agents after acute coronary syndrome in diabetic patients is not well known. Here, we describe antiplatelet use and outcomes in such patients enrolled in the EPICOR Asia (Long‐Term Follow‐up of Antithrombotic Management Patterns in Acute Coronary Syndrome Patients in Asia) registry. Methods and Results EPICOR Asia is a prospective, observational study of 12 922 patients with acute coronary syndrome surviving to discharge, from 8 countries/regions in Asia. The present analysis included 3162 patients with diabetes mellitus (DM) and 9602 patients without DM. The impact of DM on use of antiplatelet agents and events (composite of death, myocardial infarction, and stroke, with or without any revascularization; individual components, and bleeding) was evaluated. Significant baseline differences were seen between patients with DM and patients without DM for age, sex, body mass index, cardiovascular history, angiographic findings, and use of percutaneous coronary intervention. At discharge, ≈90% of patients in each group received dual antiplatelet therapy. At 2‐year follow‐up, more patients with DM tended to still receive dual antiplatelet therapy (60% versus 56%). DM was associated with increased risk from ischemic but not major bleeding events. Independent predictors of the composite end point of death, myocardial infarction, and stroke in patients with DM were age ≥65 years and use of diuretics at discharge. Conclusions Antiplatelet agent use is broadly comparable in patients with DM and patients without DM, although patients with DM are more likely to be on dual antiplatelet therapy at 2 years. Patients with DM are at increased risk of ischemic events, suggesting an unmet need for improved antithrombotic treatment. Registration URL: https://www.clini​caltr​ials.gov ; Unique identifier: NCT01361386.

Optimal Medical Therapy on Top of Dual-Antiplatelet Therapy: 1-Year Clinical Outcome in Patients With Acute Coronary Syndrome: The START Antiplatelet Registry

Angiology ◽  
2019 ◽  
Vol 71 (3) ◽  
pp. 235-241 ◽  
Author(s):  
Plinio Cirillo ◽  
Luigi Di Serafino ◽  
Vittorio Taglialatela ◽  
Paolo Calabrò ◽  
Emilia Antonucci ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Clinical Outcome ◽  
Antiplatelet Therapy ◽  
Medical Therapy ◽  
Real World ◽  
Dual Antiplatelet Therapy ◽  
Optimal Medical Therapy ◽  
Cerebrovascular Event ◽  
Coronary Syndrome ◽  
The Impact

Optimal medical therapy (OMT) at discharge is recommended after acute coronary syndrome (ACS). Few studies report the impact of OMT on long-term clinical outcome in a real-world scenario. We evaluated the impact of discharge OMT on top of dual-antiplatelet therapy (DAPT) on clinical outcome in the real-world ACS population of the Survey on anTicoagulated pAtients RegisTer ANTIPLATELET registry. The primary end point was major adverse cardiac and cerebrovascular event (MACCE), a composite of death, myocardial infarction, stroke, or target vessel revascularization. The co-primary end point was net adverse cardiac and cerebrovascular event (NACE), based on MACCE plus major bleeding. Consecutive patients with ACS with 1-year follow-up were enrolled. They were evaluated at discharge for the use of a β-blocker, angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers and statins. Optimal medical therapy was defined as the use of ≥2 of 3 medications. At multivariate analysis, both MACCE and NACE were significantly higher in non-OMT patients than in OMT patients (MACCE 18 [19] vs 59 [9], hazard ratio [HR] = 0.44 [0.26-0.75], P = .002, NACE 19 [20] vs 67 [10], HR = 0.47 [0.28-0.79], P = .004). In this real-world scenario, OMT at discharge on top of DAPT seems associated with a better clinical outcome compared with patients discharged on non-OMT.

Differential effects of dual antiplatelet therapy in patients presented with acute coronary syndrome vs. stable ischaemic heart disease after coronary artery bypass grafting

2020 ◽  
Author(s):  
Ki Hong Choi ◽  
Young Bin Song ◽  
Dong Seop Jeong ◽  
Yong Ho Jang ◽  
David Hong ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Heart Disease ◽  
Coronary Artery ◽  
Antiplatelet Therapy ◽  
Lower Risk ◽  
Dual Antiplatelet Therapy ◽  
Artery Bypass ◽  
Cardiovascular Death ◽  
Bypass Grafting ◽  
Coronary Syndrome

Abstract Aims The current study sought to evaluate whether long-term clinical outcomes according to the use of dual antiplatelet therapy (DAPT) or single antiplatelet therapy (SAPT) differed between acute coronary syndrome (ACS) and stable ischaemic heart disease (SIHD) patients who underwent coronary artery bypass grafting surgery (CABG). Methods and results Between January 2001 and December 2017, 3199 patients with ACS (55.3%) and 2583 with SIHD (44.7%) who underwent isolated CABG were enrolled. The study population was stratified using DAPT or SAPT in ACS patients and SIHD patients. The primary outcome was a cardiovascular death or myocardial infarction (MI) at 5 years. After CABG, DAPT was more frequently used in patients with ACS than in those with SIHD [n = 1960 (61.3%) vs. n = 1313 (50.8%), P < 0.001]. Among patients with ACS, the DAPT group showed a significantly lower risk of cardiovascular death or MI at 5 years than the SAPT group [DAPT vs. SAPT, 4.0% vs. 7.8%, hazard ratio (HR) 0.521, 95% confidence interval (CI) 0.339–0.799; P = 0.003]. In contrast, among patients with SIHD, there was no significant difference in the rate of cardiovascular death or MI at 5 years between the use of DAPT and SAPT (4.0% vs. 4.0%, HR 0.991, 95% CI 0.604–1.626; P = 0.971). These findings were robust to multiple sensitivity analyses and competing risk analysis. In the subgroup analysis, the use of DAPT was associated with a significantly lower risk of cardiovascular death or MI among SIHD patients with a previous percutaneous coronary intervention (PCI), with a significant interaction between the use of DAPT and PCI history (interaction P = 0.011). Conclusion Among ACS patients who underwent CABG, the use of DAPT was associated with lower cardiovascular death or MI than the use of SAPT, but this was not the case in SIHD patients. Trial registration ClinicalTrials.gov, NCT03870815.

scholarly journals Impact of bleeding during dual antiplatelet therapy in patients with coronary artery disease

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Ying-Chang Tung ◽  
Lai-Chu See ◽  
Shu-Hao Chang ◽  
Jia-Rou Liu ◽  
Chi-Tai Kuo ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
East Asian ◽  
Asian Population ◽  
Adverse Outcomes ◽  
Research Database ◽  
Coronary Syndrome ◽  
Asian Patients ◽  
Increased Risk ◽  
The Impact

AbstractThis nationwide retrospective cohort study used the National Health Insurance Research Database of Taiwan to compare the impact of bleeding on clinical outcomes in patients with acute myocardial infarction (AMI) versus chronic coronary syndrome (CCS). Between July 2007 and December 2010, patients with AMI (n = 15,391) and CCS (n = 19,724) who received dual antiplatelet therapy after coronary stenting were identified from the database. AMI was associated with increased risks of MI (AMI vs. CCS: 0.38 vs. 0.16 per 100 patient-months; p < 0.01), all-cause death (0.49 vs. 0.32 per 100 patient-months; p < 0.01), and BARC type 3 bleeding (0.22 vs. 0.13 per 100 patient-months; p < 0.01) at 1 year compared with CCS, while the risk of BARC type 2 bleeding was marginally higher in the CCS patients than in the AMI patients (1.32 vs. 1.4 per 100 person-months; p = 0.06). Bleeding was an independent predictor of MI, stroke, and all-cause death in this East Asian population, regardless of the initial presentation. Among the patients with bleeding, AMI was associated with a higher risk of ischemic events at 1 year after bleeding compared with CCS (MI: 0.34 vs. 0.25 per 100 patient-months; p = 0.06; ischemic stroke: 0.22 vs. 0.13 per 100 patient-months; p = 0.02). The 1-year mortality after bleeding was comparable between the two groups after propensity score weighting. In conclusion, bleeding conferred an increased risk of adverse outcomes in East Asian patients with AMI and CCS.

The Dual Antiplatelet Therapy Trial after the FDA Update: Noncardiovascular Deaths, Cancer and Optimal Treatment Duration

Cardiology ◽  
2015 ◽  
Vol 132 (2) ◽  
pp. 74-80 ◽  
Author(s):  
Victor L. Serebruany ◽  
Vasily Cherepanov ◽  
Elena Z. Golukhova ◽  
Moo Hyun Kim
Keyword(s):  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Antiplatelet Agents ◽  
Clinical Event ◽  
Cancer Risks ◽  
Full Disclosure ◽  
Cancer Data ◽  
Coronary Syndrome ◽  
Coronary Syndromes

Background: The landmark Dual Antiplatelet Therapy (DAPT) trial revealed an impressive reduction of stent thrombosis and myocardial infarction after prolonged 30-month DAPT compared to the conventional 12-month regimen. However, aside from the expected extra bleeding risks, more cancers and noncardiovascular deaths (NCVD) were observed in the 30-month DAPT arm. Objective: We aimed to comprehend the totality of DAPT trial evidence in the light of the FDA medical review. Results: A significant excess of solid cancers that was picked up after prasugrel treatment in the TRITON trial (Prasugrel versus Clopidogrel in Patients with Acute Coronary Syndromes) and later observed with vorapaxar treatment in the TRACER trial (Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome) has now been confirmed by the FDA DAPT review for 30-month therapy with prasugrel [hazard ratio (HR) 1.3] and clopidogrel (HR 1.2). The latest randomized evidence with antiplatelet agents rejected the drug-specific cancer risks, clearly indicating the class effect. The NCVD risks were elevated after treatment with both thienopyridines, but were more prominent after clopidogrel treatment (HR 1.91) than prasugrel treatment (HR 1.17). About half of the NCVD were considered to be caused by cancers occurring after the 24 months of extended antiplatelet therapy. Impression: The DAPT trial confirmed that long-term antiplatelet therapy is associated with cancer that contributes to NCVD. Based on the full disclosure of cancer data by the DAPT study, it can be reflected that the optimal duration of antiplatelet therapy with thienopyridines should be limited to no more than 2 years. This duration allows the preservation of most vascular benefits while avoiding additional cancers and NCVD.

scholarly journals Timing of dual antiplatelet therapy in acute coronary syndrome: a problem of coronary artery bypass grafting accessibility for patients

2020 ◽  
Vol 25 (8) ◽  
pp. 3812
Author(s):  
T. S. Golovina ◽  
Yu. N. Neverova ◽  
R. S. Tarasov
Keyword(s):  
Acute Coronary Syndrome ◽  
Coronary Artery ◽  
Antiplatelet Therapy ◽  
Coronary Artery Bypass ◽  
Dual Antiplatelet Therapy ◽  
Artery Bypass ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
St Segment ◽  
Elevation Acute Coronary Syndrome

The feasibility of dual antiplatelet therapy as early as possible in patients with ST-segment elevation acute coronary syndrome, where percutaneous coronary intervention is recommended, has been proven: it improves treatment outcomes by reducing the risk of adverse ischemic events, including stent thrombosis and myocardial infarction.This article provides a detailed analysis of the evidence data and current recommendations on the validity and timing of dual antiplatelet therapy for acute coronary syndrome. The emphasis is made on the controversy regarding the early dual antiplatelet therapy in non-ST-segment elevation acute coronary syndrome. The rationale for using dual antiplatelet therapy only after coronary angiography and determining the revascularization strategy is described, which should increase the accessibility of coronary artery bypass graft surgery for patients.

Improving Adherence to Ticagrelor in Patients After Acute Coronary Syndrome: Results from the PROGRESS Trial

2020 ◽  
Vol 18 (3) ◽  
pp. 294-301 ◽  
Author(s):  
Mario Crisci ◽  
Felice Gragnano ◽  
Marco Di Maio ◽  
Vincenzo Diana ◽  
Elisabetta Moscarella ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Clinical Practice ◽  
Antiplatelet Therapy ◽  
Outpatient Clinic ◽  
Acute Coronary Syndromes ◽  
Dual Antiplatelet Therapy ◽  
Coronary Syndrome ◽  
Coronary Syndromes ◽  
The Impact

Background: Dual antiplatelet therapy (DAPT) with aspirin and ticagrelor is recommended for at least 12 months in patients after an acute coronary syndrome (ACS). However, its underuse and premature discontinuation are common in clinical practice. We aimed to investigate the impact of a dedicated follow-up strategy with clinical visits and counselling on adherence levels to ticagrelor in patients after ACS. Methods: PROGRESS (PROmotinG dual antiplatelet therapy adheREnce in the setting of acute coronary Syndromes) is a prospective, randomized trial enrolling 400 ACS patients treated with ticagrelor. Patients were randomized to be followed-up in a dedicated outpatient clinic (In-person follow-up group, [IN-FU], n=200), or with scheduled for phone interviews only (Telephone follow-up group [TEL-FU], n=200), to assess ticagrelor adherence and related complications. DAPT disruption was defined as an interruption of the administration of the drug due to complications or other reasons of non-adherence, and divided according to the duration into short (1-5 days), temporary (6-30 days) and permanent (≥30 days) disruption. The primary endpoint was the rate of DAPT disruption at 1-year follow-up. Results: The rate of ticagrelor disruption at 1 year follow-up was higher in the TEL-FU group than in the IN-FU group (19.6 vs 5.5%; p<0.0001). The IN-FU group reported a significantly lower rate of short (3.0 vs 8.5%; p=0.012) and permanent (2.0 vs 9.6%; p=0.012) disruption than TEL-FU group. The rate of major bleeding did not differ significantly between the 2 groups (p=0.450). Conclusion: The PROGRESS trial showed a net reduction in DAPT disruption in patients followed-up with clinical (in-person) follow-up visits in a dedicated outpatient clinic compared with those scheduled for phone interviews only.

P5535Gender differences with short-term vs 12 months dual antiplatelet therapy in patients with acute coronary syndrome treated with the COMBO dual therapy stent: a 1-year analysis of the REDUCE trial

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Verdoia ◽  
H Suryapranata ◽  
S Damen ◽  
C Camaro ◽  
E Benit ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Antiplatelet Therapy ◽  
Stent Thrombosis ◽  
Primary Endpoint ◽  
Dual Antiplatelet Therapy ◽  
Study Endpoint ◽  
Primary Study ◽  
Coronary Syndrome ◽  
The Impact

Abstract Background Gender differences in the thrombotic and bleeding risk have been suggested to condition the benefits of antithrombotic therapies in Acute Coronary Syndrome (ACS) patients, and mainly among those undergoing percutaneous coronary interventions with drug eluting stents (DES). Therefore, the impact of gender on the optimal duration of dual antiplatelet therapy (DAPT) treated is still unclear and was therefore the aim of the present sub-study. Methods REDUCE is a prospective, multicenter, randomized, investigator-initiated study, designed to enroll 1500 ACS patients after treatment with the COMBO Dual Stent Therapy, based on a non-inferiority design. Patients were randomized in a 1:1 fashion to either 3 or 12 months of DAPT. Primary study endpoint was a composite of all-cause mortality, myocardial infarction, definite/probable stent thrombosis (ST), stroke, target-vessel revascularization (TVR) and bleeding (BARC II, III, V) at 12 months. Secondary endpoints were cardiovascular mortality and the individual components of the primary endpoint. Results From June 2014 to May 2016 300 women and 1196 men were randomized in the trial. Among them 43.7% of females and 51.9% of males were assigned to the 3 months DAPT treatment. Baseline characteristics were well matched between the two arms, but of a lower rate of TIMI flow <3 (p<0.001) and lower systolic blood pressure (p<0.05) among women and a more advanced age (p=0.05) among men receiving a shorted DAPT. At 1 year follow-up, no difference in the primary endpoint was observed according to DAPT duration (females: 6.9% vs 5.9%, HR [95% CI]=1.19 [0.48–2.9], p=0.71; males: 8.2% vs 9%, HR [95% CI]=0.92 [0.63–1.35], p=0.67). Results were confirmed after correction for baseline differences (females: adjusted HR [95% CI]=1.12 [0.45–2.78], p=0.81; males: adjusted HR [95% CI]=0.90 [0.61–1.32], p=0.60). Comparable rates of survival, thrombotic (MI, stent thrombosis, TVR, stroke) and bleeding events were observed with the two DAPT strategies, with no impact of gender. Conclusions The present study shows that among ACS patients randomized in the REDUCE trial, a 3 months DAPT strategy offers comparable results as compared to a standard 12 months DAPT at 1-year follow-up in both male and female gender. Acknowledgement/Funding None

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