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Acute coronary syndromes
Published in Henry J. Woodford, Essential Geriatrics, 2022
This dual antiplatelet therapy is continued for at least one month and often longer, depending on the balance of ischaemic and haemorrhagic event risks. The combination of aspirin plus ticagrelor or prasugrel results in a greater reduction in ischaemic events but this is offset by increased bleeding events compared to aspirin plus clopidogrel. The combination of therapy chosen is partly determined by bleeding risk. Aspirin plus ticagrelor or prasugrel is the standard treatment following NSTEMI for younger and non-frail people.2 The risk of bleeding with antiplatelet drugs, including intracerebral haemorrhage, is higher for older people.13 Shortening the duration of dual antiplatelet therapy reduces the risk of major bleeding complications, possibly without an increase in ischaemic events. People at very high bleeding risk may be given aspirin and clopidogrel for one month, followed by clopidogrel alone thereafter (seeFigure 20.1).2 Gastric protection with a proton pump inhibitor is recommended for at-risk groups, including older people.
Stroke and Transient Ischemic Attacks of the Brain and Eye
Published in Philip B. Gorelick, Fernando D. Testai, Graeme J. Hankey, Joanna M. Wardlaw, Hankey's Clinical Neurology, 2020
Dual antiplatelet therapy is more effective than monotherapy in reducing early recurrent stroke. The most effective combination is aspirin and clopidogrel (a P2Y12 ADP receptor antagonist) in patients with high-risk acute TIA or minor ischemic stroke (NIHSS score <3), who are at low risk of hemorrhagic complications and who are not carriers of CYP2C19 loss-of-function alleles (*2, *3). In three RCTs involving 10,447 patients with acute minor ischemic stroke or TIA, dual antiplatelet therapy with clopidogrel and aspirin, started within 24 hours of symptom onset, reduced the risk of nonfatal recurrent stroke by 30% compared with aspirin monotherapy (relative risk [RR]: 0.70, 95% CI: 0.61–0.80, I2 = 0%, absolute risk reduction [ARR] 1.9%), but at the expense of a likely increase in moderate or severe extracranial bleeding (1.71, 0.92–3.20, I2 = 32%, absolute risk increase 0.2%).70 Most stroke events, and the separation in recurrent stroke incidence curves between dual and single therapy arms, occurred within 10 days of randomization; any benefit after 21 days is extremely unlikely. Discontinuation of dual antiplatelet therapy within 21 days, and possibly as early as 10 days, of initiation is likely to maximize benefit and minimize harms.
Major Adverse Limb Events and Mortality in Patients with Peripheral Artery Disease: The COMPASS Trial
Published in Juan Carlos Jimenez, Samuel Eric Wilson, 50 Landmark Papers Every Vascular and Endovascular Surgeon Should Know, 2020
Juan Carlos Jimenez, Samuel Eric Wilson
Prior to the COMPASS trial, the data on medical therapy for the prevention of adverse cardiovascular events in PAD patients was ambiguous. Currently, the standard antithrombotic regimen includes antiplatelet therapy typically with a single agent. There have been a variety of trials comparing single and dual antiplatelet therapy with a variety of agents including aspirin, clopidogrel, ticagrelor, and vorapaxar. Results from these trials have shown modest risk reduction with single antiplatelet therapy and no net benefit in reduction of adverse cardiovascular event rate or death with dual antiplatelet therapy in PAD subgroup analysis.4–7 Combination antiplatelet and anticoagulants have also shown no net benefit in PAD patients. Combination anticoagulant therapy has shown an increase in major bleeding events with a small to no difference in risk reduction.8,9 However, the COMPASS trial proposed an antithrombotic regimen that combined low-dose anticoagulant (rivaroxaban 2.5 mg twice daily) and antiplatelet (aspirin 100 mg daily) and found such a profound risk reduction benefit that the trial was prematurely concluded. It is the first trial that has shown a substantial net benefit in preventing MALE, adverse cardiac events, and death in PAD patients.
Are P2Y12 inhibitors superior to aspirin for long-term secondary prevention of cardiovascular disease?
Published in Expert Review of Cardiovascular Therapy, 2023
Stephanie Carlin, John Eikelboom
With the advent of more potent P2Y12 inhibitors and growing concerns about the risk of bleeding with dual antiplatelet therapy, attention has shifted back to the potential for P2Y12 inhibitors to replace aspirin. With respect to clopidogrel, a post-hoc analysis of the Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack (CHANCE) trial suggested that after completion of 21 days of DAPT or aspirin (n = 4,696), patients receiving clopidogrel monotherapy may achieve greater benefit from continuing clopidogrel in preference to aspirin monotherapy (HR, 0.72; 95% CI, 0.46–1.14; p = 0.16) although this result was not statistically significant [14]. Most recently, the Aspirin Versus Clopidogrel for Long-Term Maintenance Monotherapy After Percutaneous Coronary Intervention (HOST-EXAM) trial conducted at 37 South Korean sites in 5,438 patients with CAD who were 6–18 months post PCI found that clopidogrel substantially reduced the risk of CV death, non-fatal MI, ischemic stroke, readmission due to ACS and definite or probable stent thrombosis (RR, 0.68; 95% CI, 0.52–0.87; p = 0.003) as well as Bleeding Academic Research Consortium (BARC) type >3 major bleeding (HR, 0.63; 95% CI, 0.41–0.97; p = 0.035) [15]. The benefit of clopidogrel over aspirin persisted during a mean follow-up of 5.8 years [16]. Further, the HOST-EXAM results may underestimate the benefits in non-East Asian populations as East Asians have a higher prevalence of CYP2C19 loss of function alleles that may reduce the efficacy of clopidogrel.
Impact of cardiac and noncardiac cirrhosis on coronary revascularization outcomes from the National Inpatient Sample, 2016 to 2018
Published in Baylor University Medical Center Proceedings, 2023
Dae Yong Park, Seokyung An, Muhammad-Sheharyar Warraich, Ziad Sad Aldeen, Ibrahim Maghari, Smriti Khanal, Abdul Wahab Arif, Anas Almoghrabi
However, our findings showed that even with PCI, patients with liver cirrhosis have a significantly higher odds of mortality and morbidities. Patients undergoing PCI are administered anticoagulants and sometimes glycoprotein IIb/IIIa inhibitors periprocedurally, exacerbating the bleeding risk in the setting of underlying deficiencies in coagulation factors, thrombocytopenia, and consumptive coagulopathy in liver cirrhosis.17 In addition, after a drug-eluting stent has been placed, dual antiplatelet therapy typically ensues for at least 1 to 3 months, which further increases the risk of bleeding and need for transfusion.18 The increased bleeding tendency in this vulnerable population was well demonstrated in a nationwide cohort study of 150,887 patients, which showed that dual antiplatelet therapy in patients with cirrhosis who underwent PCI for acute myocardial infarction was associated with a lower recurrence of myocardial infarction but an increased risk of gastrointestinal bleeding.19
The prognostic value of C-reactive protein to albumin ratio in patients undergoing transcatheter aortic valve implantation
Published in Acta Cardiologica, 2022
Yalcin Avci, Ali Riza Demir, Mustafa Duran, Umit Bulut, Gökhan Demirci, Begum Uygur, Omer Tasbulak, Arda Can Doğan, Omer Celik, Mehmet Erturk
All TAVI procedures were performed under local anaesthesia with transfemoral (TF) access using either first-generation self-expanding Medtronic CoreValve (Medtronic, Minneapolis, MN, USA) or either first- or second-generation Edwards SAPIEN-SAPIEN XT balloon-expandable valve (Edwards Lifesciences, Irvine, CA). Valve size was determined from the aortic annular diameter measured by CT scan before the planned procedure. The type and size of the valve prosthesis, pre-dilatation, and post-dilatation were at the discretion of the operator. All patients were treated with dual antiplatelet therapy including aspirin (81–100 mg) and clopidogrel (75 mg). Aspirin was continued indefinitely and clopidogrel was recommended for 6 months. Other medications, including beta-blockers, ACE inhibitors, nitrates, and statins were prescribed according to standardised protocols.