scholarly journals Trends in Bleeding Events Among Patients With Acute Coronary Syndrome in China, 2015 to 2019: Insights From the CCC-ACS Project

2021 ◽  
Vol 8 ◽  
Author(s):  
Xiao Wang ◽  
Guanqi Zhao ◽  
Mengge Zhou ◽  
Changsheng Ma ◽  
Junbo Ge ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Major Bleeding ◽  
Anticoagulation Therapy ◽  
Heart Association ◽  
Chinese Society ◽  
Invasive Treatment ◽  
Bleeding Events ◽  
Clinical Trial Registration ◽  
Coronary Syndrome ◽  
Almost All

Objective: Major bleeding is a common complication following treatment for an acute coronary syndrome (ACS) and is associated with increased mortality. We aimed to explore the temporal trend of bleeding events in relation to changes of therapeutic strategies among patients hospitalized for ACS in China.Methods: The CCC-ACS project (Improving Care for Cardiovascular Disease in China–Acute Coronary Syndrome) is a collaborative initiative of the American Heart Association and the Chinese Society of Cardiology. We analyzed 113,567 ACS patients from 241 hospitals in China from 2015 to 2019. Major bleeding was defined as intracranial bleeding, retroperitoneal bleeding, a decline in hemoglobin levels ≥3 g/dL, transfusion with overt bleeding, bleeding requiring surgical intervention, and fatal bleeding. Kruskal–Wallis test was used to examine the trend of major bleeding over time.Results: The rate of in-hospital major bleeding decreased from 6.3% in 2015 to 4.7% in 2019 (unadjusted OR = 0.74, 95% CI: 0.68–0.80, and P < 0.001). The relative changes were consistent across almost all subgroups including patients with NSTE-ACS and STEMI, although the trend was more pronounced in NSTE-ACS patients. The decrease in bleeding was accompanied by a decrease in use of GP IIb/IIIa inhibitors and parenteral anticoagulation therapy during hospitalization. The annual reduced risk of bleeding (OR = 0.91, 95% CI: 0.89–0.93) was attenuated after stepwise adjusting for baseline characteristics and antithrombotic treatments (OR = 0.95, 95% CI: 0.93–0.97), but did not change after adjusting for invasive treatment (OR = 0.95, 95% CI: 0.93–0.97).Conclusions: There was a temporal reduction in in-hospital bleeding among Chinese ACS patients during the last 5 years, which was associated with more evidence-based use of antithrombotic therapies.Clinical Trial Registration:https://www.clinicaltrials.gov, identifier: NCT02306616.

scholarly journals Relationship of PRECISE-DAPT and DAPT scores with mortality in patients admitted with acute coronary syndrome who undergo coronary stent implantation

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
C Alak ◽  
E Ozpelit ◽  
D Cirgamis ◽  
M Abusharekh ◽  
N Baris
Keyword(s):  
Acute Coronary Syndrome ◽  
Major Bleeding ◽  
Coronary Intervention ◽  
Bleeding Events ◽  
Coronary Syndrome ◽  
Coronary Stent Implantation ◽  
Number Of Patients ◽  
Percutaneous Coronary ◽  
Significant Difference ◽  
Relationship Of

Abstract Introduction International guidelines recommend using risk score tools that allow us to assess the risk of bleeding and ischemia when deciding on DAPT. In our research, we aimed to examine the mortality relationship of new risk scores, DAPT and PRECISE-DAPT scores. Method Between 2013–2014, 948 patients admitted to our clinic with ACS were included in our study. We excluded 688 patient (no contact number,CABG, medical treatment, use of oral anticoagulation, active malignant cancer). 260 patients admitted with acute coronary syndrome (58%, 8 STEMI, 35%, 4 non-STEMI, 5%, 4 Unstable angina pectoris) who undergo coronary stent implantation were included in the study. We aimed to focus on the patients who undergo percutaneous coronary intervention and their risk of mortality. The patients' records were retrospectively analyzed through the hospital information system and archive records. Laboratory results, echocardiography and CAG reports of the patients, disease histories were obtained from the information recorded through the system. With these data, PRECISE-DAPT and DAPT scores of patients were calculated. Results The number of patients with a PRECISE-DAPT Score ≥25 was 62 (23.8%). The number of patients with DAPT Score ≥2 was 193 (74.2%). Mortality occurred in 49 (18.8%) patients. Patients with PRECISE-DAPT ≥25 and those with PRECISE-DAPT <25 were compared in terms of mortality and mortality was significantly higher in the high-scoring group [P <0.001 OR 6.94 C (3.53–13.62)]. The patients were divided into 4 groups (PRECISE-DAPT 25 and DAPT ≥2, PRECISE-DAPT ≥25 and DAPT ≥2, PRECISE-DAPT 25 and DAPT 2, PRECISE-DAPT ≥25 and DAPT 2) according to PRECISE-DAPT and DAPT score. Mortality was significantly higher regardless of DAPT score in patients with high PRECISE-DAPT scores (p<0.001). We evaluated the relationship between PRECISE-DAPT score and major bleeding and all bleeding. Compared to the group there was no significant difference in all bleeding events (P=0.56) and major bleeding events (P=0.23). The relationship between bleeding events and mortality was evaluated. There was no significant difference in mortality (p=0.689) with all bleeding events; but mortality was significantly increased in patients with major bleeding [P=0.025 OR 6.16 (1,33–28,49)]. Conclusion In our study, we observed that the patient group with a high PRECISE-DAPT score had a high mortality rate regardless of the DAPT score. The PRECISE-DAPT score is a useful tool in determining the group with high long-term mortality in patients who present with acute coronary syndrome and undergo percutaneous coronary intervention. The clinician should use the PRECISE-DAPT score when deciding on the duration of dual antiplatelet therapy in this patient group and these patients with high scores need to be monitored more closely. The data we have obtained from our study is retrospective and these results need to be supported by prospective and large studies. FUNDunding Acknowledgement Type of funding sources: None.

scholarly journals Clinical impact of CREDO-kyoto risk score on in-hospital bleeding in patients with acute coronary syndrome

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
Y Minematsu ◽  
M Natsuaki ◽  
G Yoshioka ◽  
K Shinzato ◽  
Y Nishimura ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
High Risk ◽  
Risk Score ◽  
Major Bleeding ◽  
Bleeding Risk ◽  
Risk Groups ◽  
University Hospital ◽  
Severe Bleeding ◽  
Bleeding Events ◽  
Coronary Syndrome

Abstract Background/Introduction CREDO-Kyoto bleeding risk score was developed to predict the post-discharge bleeding events in patients with percutaneous coronary intervention. However, there were limited reports of the effectiveness of this score to predict the in-hospital bleeding events in patients with acute coronary syndrome (ACS). Methods We evaluated 562 consecutive ACS patients in Saga university hospital between 2014 and 2019. Primary outcome was major bleeding during hospitalization. Major bleeding was defined as the GUSTO moderate/severe bleeding. Patients were classified into three groups according to the CREDO-Kyoto bleeding risk score (low, intermediate and high). Results Major bleeding events occurred in 12.1% of all patients during hospitalization. Patients in the high risk group (n=22) had significantly higher incidence of major bleeding than those in the intermediate (n=113) and the low risk groups (n=427) (22.7%, 18.6%, versus 9.8%, respectively, p=0.018, see figure). Multivariate analysis showed that intermediate and high risk groups were independent predictors for the in-hospital major bleeding. Conclusions CREDO-Kyoto risk score successfully identified high risk ACS patients for the major bleeding during hospitalization. FUNDunding Acknowledgement Type of funding sources: None. Results

scholarly journals Mild renal insufficiency and attributable risk of adverse In-hospital outcomes in patients with Acute Coronary Syndrome from the improving care for Cardiovascular Disease in China (CCC) project

2022 ◽  
Vol 23 (1) ◽  
Author(s):  
Fengbo Xu ◽  
Guoqin Wang ◽  
Nan Ye ◽  
Weijing Bian ◽  
Lijiao Yang ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Acute Coronary Syndrome ◽  
Renal Insufficiency ◽  
Collaborative Study ◽  
Heart Association ◽  
Attributable Risk ◽  
Major Adverse Cardiovascular Events ◽  
Chinese Society ◽  
Hospital Outcomes ◽  
Coronary Syndrome

Abstract Background Renal insufficiency (RI) is a frequent comorbidity among patients with acute coronary syndrome (ACS). We aimed to evaluate the attributable risk associated with mild RI for the in-hospital outcomes in patients with ACS. Methods The Improving Care for Cardiovascular Disease in China-ACS (CCC-ACS) Project was a collaborative study of the American Heart Association and the Chinese Society of Cardiology. A total of 92,509 inpatients with a discharge diagnosis of ACS were included. The attributable risk was calculated to investigate the effect of mild RI (eGFR 60-89 ml / min · 1.73 m2) on major adverse cardiovascular events (MACEs) during hospitalization. Results The average age of these ACS patients was 63 years, and 73.9% were men. The proportion of patients with mild RI was 36.17%. After adjusting for other possible risk factors, mild RI was still an independent risk factor for MACEs in ACS patients. In the ACS patients, the attributable risk of eGFR 60-89ml/min·1.73m2 to MACEs was 7.78%, 4.69% of eGFR 45-59 ml/min·1.73m2, 4.46% of eGFR 30-44 ml/min·1.73m2, and 3.36% of eGFR<30 ml/min·1.73m2. Conclusion Compared with moderate to severe RI, mild RI has higher attributable risk to MACEs during hospitalization in Chinese ACS population.

scholarly journals Efficacy and safety of low dose ticagrelor in patients with acute coronary syndrome: a systematic review and meta-analysis

2020 ◽  
Vol 96 (1141) ◽  
pp. 693-702
Author(s):  
Qing Chen ◽  
Yuanyuan Zhang ◽  
Zhen Wang ◽  
Shuai Wang ◽  
Hao Zhang ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Platelet Aggregation ◽  
Major Bleeding ◽  
Low Dose ◽  
Standard Dose ◽  
Left Ventricular ◽  
Efficacy And Safety ◽  
Bleeding Events ◽  
Coronary Syndrome ◽  
Major Bleeding Events

Our aim was to examine clinical trials, provide guidance to practitioners and estimate the efficacy and safety of two agents by comparing low dose ticagrelor with standard dose clopidogrel in patients with acute coronary syndrome. We systematically looked through Pubmed, Embase, the Cochrane Library, Wanfang data and CNKI for trials comparing low dose ticagrelor with standard dose clopidogrel for the treatment of patients with ACS since the database was created. The primary endpoint for efficacy was the rate of major adverse cardiac events (MACEs). The primary endpoint for safety was the rate of major bleeding events. We also evaluated platelet function between low dose ticagrelor and standard dose clopidogrel in ACS patients. From 6744 articles, 16 studies including 1629 patients met the inclusion criteria. In contrast with standard dose clopidogrel, low dose ticagrelor significantly reduced MACEs (OR 0.39, 95% CI 0.26, 0.58) and the difference was statistically significant (p<0.01). No difference was noted for major bleeding events (OR 1.16, 95% CI 0.43, 3.08) between the two agents (p=0.77). In addition, low dose ticagrelor showed lower platelet aggregation rate than clopidogrel (standardised mean difference (SMD) −0.68, 95% CI −0.83 to 0.53) (p<0.01). Platelet reaction units for low dose ticagrelor were much lower than those for standard dose clopidogrel (SMD −2.46, 95% CI −2.85 to −2.07) (p<0.01). In comparison with standard dose clopidogrel, low dose ticagrelor significantly lowered the incidence of MACEs, improved left ventricular ejection fraction, decreased left ventricular end diastolic dimension and did not expand the risk of major bleeding events or minor or minimal bleeding events in ACS patients with a considerable safety and efficacy profile. In addition, low dose ticagrelor was associated with dramatically lower platelet aggregation compared with standard dose clopidogrel.

Temporal Trends and Outcomes Associated with Major Bleeding in Acute Coronary Syndromes: A Decade-Long Perspective from the Acute Coronary Syndrome Israeli Surveys 2000-2010

Cardiology ◽  
2015 ◽  
Vol 132 (3) ◽  
pp. 163-171 ◽  
Author(s):  
Avi Sabbag ◽  
Victor Guetta ◽  
Paul Fefer ◽  
Shlomi Matetzky ◽  
Shmuel Gottlieb ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Major Bleeding ◽  
Temporal Trends ◽  
Blood Pressure Level ◽  
Bleeding Events ◽  
Access Site ◽  
Systolic Blood Pressure Level ◽  
Invasive Approach ◽  
Coronary Syndrome ◽  
Increased Risk

Objectives: The implementation of an early invasive approach and the increased use of potent anti-thrombotic drugs have resulted in higher rates of major bleeding events (MBE) in patients with acute coronary syndrome (ACS). There are limited data on the temporal trends for the rates of MBE over the last decade and associated outcomes. Methods: Rates, characteristics, risk factors and clinical outcomes associated with MBE were assessed among 11,538 patients enrolled in the biennial Acute Coronary Syndrome Israeli Surveys (ACSIS) 2000-2010. Results: A total of 143 patients (1.2%) experienced MBE during the index hospitalization for ACS. There was a significant increase in the risk of MBE in the late (2006-2010) versus the early (2000-2004) surveys (0.9 and 1.6% respectively, adjusted OR 1.86, p < 0.001). In the multivariate analysis, factors independently associated with a significant increase in the risk of MBE included undergoing primary percutaneous coronary intervention (OR 2.21, p < 0.005), experiencing renal failure (OR 4.19, p < 0.001) and systolic blood pressure level at admission (OR 1.12, per 10- mm Hg decrement, p = 0.011). Patients who experienced MBE had a >3.5-fold increased risk for 1-year mortality (adjusted HR = 3.52, p < 0.001). Interestingly, the mortality risk associated with MBE was evident only among those who experienced non-access-site bleeding (HR = 1.9; p = 0.001). Conclusions: In the past decade, there has been a significant increase in the rate of MBE. However, we found that only major bleeding that was not related to the vascular access site affected subsequent mortality.

scholarly journals Ticagrelor monotherapy versus dual anti-platelet therapy in patients undergoing percutaneous coronary intervention: a subgroup analysis of safety in multiple comorbidities

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
M M Patel ◽  
K Zerihun
Keyword(s):  
Acute Coronary Syndrome ◽  
Major Bleeding ◽  
Subgroup Analysis ◽  
Coronary Intervention ◽  
The Elderly ◽  
Bleeding Events ◽  
Coronary Syndrome ◽  
Cerebrovascular Events ◽  
Major Bleeding Events ◽  
Post Hoc

Abstract Background The TICO trial evaluated the effectiveness of ticagrelor monotherapy after 3 months of dual antiplatelet therapy (DAPT) versus continued DAPT and measured the risk of major bleeding and adverse cardiac/cerebrovascular events at 12 months, however there are certain subgroups such as the elderly that have higher bleeding risks than the average population. Objective To determine if specific comorbidities or patient demographics increase the risks of major bleeding or major cardiac/cerebrovascular events in patients receiving ticagrelor monotherapy versus aspirin plus ticagrelor in patients post percutaneous coronary intervention with acute coronary syndrome. Methods This was a post-hoc subgroup analysis of multiple cohorts (Age, diabetes, hypertension, chronic kidney disease, and obesity) from the TICO (The ticagrelor monotherapy after 3 months in the patients treated with new generation sirolimus stent for acute coronary syndrome) study. The co-primary outcomes that were measured were major bleeding events and major adverse cardiac and cerebrovascular events. Results Compared to DAPT, ticagrelor monotherapy significantly decreases risk of major bleeding events in patients &gt;65 (HR 0.48; 95% CI 0.24–0.95), without diabetes (HR 0.48; 95% CI 0.25–0.94), without CKD (HR 0.48; 95% CI 0.25–0.95), and non-obese (HR 0.49; 95% CI 0.25–0.95). Ticagrelor monotherapy also decreases risk of major cardiac and cerebrovascular events in patients &gt;65 (HR 0.52; 95% CI 0.29–0.95) compared to DAPT. Conclusion This post-hoc subgroup analysis reveals that, in certain populations, ticagrelor monotherapy after a three month DAPT course significantly decreases risk of major bleeding events and major cardiac and cerebrovascular outcomes in patients with acute coronary syndrome. This is especially seen in the elderly population where risks of adverse events are higher. Nonetheless, larger studies need to be performed for further analysis. FUNDunding Acknowledgement Type of funding sources: None.

scholarly journals Cardiovascular outcomes of clopidogrel and aspirin vs ticagrelor and aspirin in geriatric population with acute coronary syndrome-a systematic review and meta analysis

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
A Abdul Razzack ◽  
S Pothuru ◽  
N Hussain ◽  
S Adeel Hassan ◽  
P Panday ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
High Risk ◽  
Major Bleeding ◽  
Efficacy And Safety ◽  
Bleeding Events ◽  
Geriatric Population ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
St Segment ◽  
Major Bleeding Events

Abstract Funding Acknowledgements Type of funding sources: None. Background The current guidelines of the European Society of Cardiology recommends dual antiplatelet treatment (DAPT) including a  new-generation P2Y12-inhibitor ticagrelor and aspirin for patients with acute coronary syndrome (ACS) with or without ST segment elevation (STEMI). However, the efficacy and safety profile of standard DAPT regimen clopidogrel and aspirin (CDAPT) vs. new DAPT regiment ticagrelor and aspirin (TDAPT) is controversial in geriatric population with age &gt;70 years given this population is a high risk for bleeding due to frailty and recurrent of ACS. Objective   To assess the efficacy and safety of DAPT regimens including CDAPT or TDAPT  for elderly patients &gt;70 years presenting with ACS with or without ST-segment elevation.  Methods Electronic databases (PubMed, Embase, Scopus, Cochrane) were searched from inception to November 28th, 2020. Using a generic invariance weighted fixed effects model, Hazard ratios (HRs) and their 95% confidence intervals (CIs) from individual studies were converted to Log HRs and corresponding standard errors, which were then pooled. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE)and was defined as a composite of death, myocardial reinfarction and stroke. The secondary outcome was any major bleeding events.  Results- A total of four studies with 18365 participants was included in our analysis.Mean age was 79.4 and 79.2 in the CDAPT and TDAPT groups respectively.  Average follow up period was 12 months. There is no difference in MACCE among CDAPT and TDAPT( HR 0.93, 95%CI 0.86-1.01;P = 0.10). However, TDAPT is associated with high risk of major bleeding as compared to CDAPT (HR 1.15, 95%CI 1.02-1.29; P = 0.02) (Figure 1). We had no publication bias in our results (Egger’s regression p &gt; 0.05). Conclusion- Amongst geriatric patients aged 70 years or older with ACS with or without STEMI, TDAPT has the same MACCE as compared to CDAPT while TDAPT can have high major bleeding. Abstract Figure. A)MACCE B)Major Bleeding events

Acute coronary syndrome patients with two minor high-bleeding risk criteria have the same bleeding rate that patients with one major criteria

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Cordero ◽  
J.M Garcia-Acuna ◽  
M Rodriguez-Manero ◽  
B Cid ◽  
B Alvarez Alvarez ◽  
...  
Keyword(s):  
Major Bleeding ◽  
Academic Research ◽  
Bleeding Risk ◽  
Bleeding Events ◽  
Post Discharge ◽  
Bleeding Rate ◽  
Coronary Syndrome ◽  
All Cause Mortality ◽  
High Bleeding Risk ◽  
Minor Criteria

Abstract Background In 2019 the Academic Research Consortium of high-bleeding risk (ARC-HBR) proposed a new and binary definition of high-bleeding risk (HBR) patients based on the presence of 1 major or 2 minor criteria. Methods Prospective study of all consecutive patients admitted for ACS in two different centers. We analyzed bleeding incidence in patients with 1 major criteria (1MC) vs. 2 minor criteria (2mC) using the 2019 ARC-HBR consensus. Bleeding events were collected according those fitting definitions 3 or 5 of the BARC consortium. Results We included 8,724 patients included and 40.9% we classified as HBR; 20.9% for 1MC and 20.0% for 2mC. In-hospital mayor bleeding rate was 8.6%; no-HBR patients had 0.3%, 2mC 15.1% and 1MC 29.7% (p&lt;0.001 for the comparison). In contrast, the statistically highest in-hospital mortality was observed in patients with 2mC (11.4%), followed by patients with 1MC (8.0%) and no-HBR patients (2.0%). During follow-up (median time 57.8 months) all-cause mortality rate was 21.0% and cardiovascular dead 14.2%. The incidence of post-discharge major bleeding was 10.5%. No-HBR patients had the lowest bleeding rate (7.4%) and no difference was observed in patients with 1MC (14.6%) or 2mC (15.8%) (figure). The multivariate analysis, adjusted by age, gender, medical treatment, atrial fibrillation and revascularization and considering all-cause mortality as competing risk, showed independent association of 1MC (sHR: 1.46, 95% 1.22–1.75) and 2mC (sHR: 1.31, 95% CI 1.05–1.63) with post-discharge major bleeding. Conclusions HBR patients according to the 2019 ARC-HBR containing 2mC or 1MC are at similar and higher risk of in-hospital or post-discharge bleeding events Funding Acknowledgement Type of funding source: None

scholarly journals Benefit and Harm of Extended Dual Antiplatelet Therapy After PCI in high-risk TWILIGHT-like patients with acute coronary syndrome

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
HY Wang ◽  
R Zhang ◽  
ZX Cai ◽  
KF Dou
Keyword(s):  
Acute Coronary Syndrome ◽  
High Risk ◽  
Antiplatelet Therapy ◽  
Cardiovascular Death ◽  
Secondary Outcome ◽  
Short Term ◽  
Bleeding Events ◽  
Coronary Syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Background Recent emphasis on reduced duration and/or intensity of antiplatelet therapy following PCI irrespective of indication for PCI may fail to account for the substantial risk of subsequent nontarget lesion events in acute coronary syndrome (ACS) patients. This study sought to investigate the benefits and risks of extended-term (&gt;12-month) DAPT as compared with short-term DAPT in high-risk "TWILIGHT-like" ACS patients undergoing PCI. Methods All consecutive patients fulfilling the "TWILIGHT-like" criteria undergoing PCI from January 2013 to December 2013 were identified from the prospective Fuwai PCI Registry. High-risk "TWILIGHT-like" patients were defined by at least 1 clinical and 1 angiographic feature based on TWILIGHT trial selection criteria. The present analysis evaluated 4,875 high-risk "TWILIGHT-like" patients with ACS who were event-free at 12 months after PCI. The primary outcome was the composite of all-cause death, myocardial infarction (MI), or stroke at 30 months while BARC type 2, 3, or 5 bleeding was key secondary outcome. Results Extended DAPT compared with shorter DAPT reduced the composite outcome of all-cause death, MI, or stroke by 63% (1.5% vs. 3.8%; HRadj: 0.374, 95% CI: 0.256 to 0.548; HRmatched: 0.361, 95% CI: 0.221-0.590). The HR for cardiovascular death was 0.049 (0.007 to 0.362) and that for MI 0.45 (0.153 to 1.320) and definite/probable stent thrombosis 0.296 (0.080-1.095) in propensity-matched analyses. Rates of BARC type 2, 3, or 5 bleeding (0.9% vs. 1.3%; HRadj: 0.668 [0.379 to 1.178]; HRmatched: 0.721 [0.369-1.410]) did not differ significantly in patients treated with DAPT &gt; 12-month or DAPT ≤ 12-month. The effect of long-term DAPT on primary and key secondary outcome across the proportion of ACS patients with 1-3, 4-5, or 6-9 risk factors showed a consistent manner (Pinteraction &gt; 0.05). Conclusion Among high-risk "TWILIGHT-like" patients with ACS after PCI, long-term DAPT reduced ischemic events without increasing clinically meaningful bleeding events as compared with short-term DAPT, suggesting that extended DAPT might be considered in the treatment of ACS patients who present with a particularly higher risk for thrombotic complications. Abstract Figure.

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