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İsikay Aİ, Cekic E, Charehsaz A, Uyaniker ZA, Cakmakli GY, Gocmen R, Hanalioglu S, Elibol B. The impact of perioperative aspirin utilization on postoperative hemorrhagic complications in idiopathic normal pressure hydrocephalus: a single-center retrospective analysis. Neurosurg Rev 2025; 48:304. [PMID: 40091061 PMCID: PMC11911258 DOI: 10.1007/s10143-025-03459-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Revised: 01/24/2025] [Accepted: 03/08/2025] [Indexed: 03/19/2025]
Abstract
BACKGROUND AND OBJECTIVES Idiopathic normal pressure hydrocephalus (iNPH) primarily affects older patients. Ventriculoperitoneal (VP) shunt surgery is a standard treatment. Many iNPH patients have high cardiovascular risks and require aspirin (ASA) therapy to prevent thromboembolic events. Discontinuing ASA increases the risk of these events. This study evaluates the impact of perioperative ASA use on hemorrhagic complications in iNPH patients undergoing VP shunt surgery. METHODS This retrospective cohort study included patients who underwent VP shunt surgery for iNPH from January 2020 to September 2024. Patients were divided into two groups based on perioperative ASA use: no ASA (n = 50) and ASA continued (n = 51). Data collected included demographics, surgery details, ASA dosage, and indications for ASA use. Primary outcomes were early and late postoperative hemorrhage incidences. Postoperative follow-up included MRI or CT scans at regular intervals (mean ≈ one year). Statistical analyses were performed using SPSS version 23.0, with Chi-square tests and independent samples t-tests or Mann-Whitney U tests used to analyze differences between groups. RESULTS The study cohort had 101 patients with a mean age of 69.5 ± 7.6 years, 41.6% female and 58.4% male. Early postoperative hemorrhage occurred in 5% of patients, including epidural (1), intraparenchymal(3), and intraventricular hematoma(1). Late postoperative hemorrhages occurred in 4% of patients ( 4 patients in the no-ASA group), with two cases each of unilateral and bilateral subdural hematoma. No significant differences in hemorrhagic outcomes were observed between the ASA continuation and non-use groups (p = 0.092). The mean follow-up period was 300 days. One patient died in non-ASA group due to neurodegenerative disease. CONCLUSION Perioperative ASA use does not significantly impact the incidence of postoperative hemorrhages in iNPH patients undergoing VP shunt surgery. These findings suggest that ASA can be safely continued without increasing hemorrhagic risks. This is a particularly significant issue for patients with high cardiovascular risk.
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Affiliation(s)
| | - Efecan Cekic
- Department of Neurosurgery, Hacettepe University, Ankara, Turkey
| | - Amin Charehsaz
- Department of Neurosurgery, Hacettepe University, Ankara, Turkey.
| | | | | | - Rahsan Gocmen
- Department of Radiology, Hacettepe University, Ankara, Türkiye
| | - Sahin Hanalioglu
- Department of Neurosurgery, Hacettepe University, Ankara, Turkey
| | - Bulent Elibol
- Department of Neurology, Hacettepe University, Ankara, Türkiye
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Kristensen AMD, Pareek M, Kragholm KH, McEvoy JW, Torp-Pedersen C, Prescott EB. Long-term aspirin adherence following myocardial infarction and risk of cardiovascular events. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:612-622. [PMID: 38305132 DOI: 10.1093/ehjqcco/qcae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/24/2024] [Accepted: 01/31/2024] [Indexed: 02/03/2024]
Abstract
AIMS Aspirin is considered mandatory after myocardial infarction (MI). However, its long-term efficacy has been questioned. This study investigated the effectiveness of long-term aspirin after MI. METHODS AND RESULTS Patients ≥40 years with MI from 2004 to 2017 who were adherent to aspirin 1 year after MI were included from Danish nationwide registries. At 2, 4, 6, and 8 years after MI, continued adherence to aspirin was evaluated. Absolute and relative risks of MI, stroke, or death at 2 years from each time point were calculated using multivariable logistic regression analysis with average treatment effect modelling standardized for age, sex, and comorbidities. Subgroup analyses were stratified by sex and age > and ≤65 years. Among 40 116 individuals included, the risk of the composite endpoint was significantly higher for non-adherent patients at all time points. The absolute risk was highest at 2-4 years after MI for both adherent [8.34%, 95% confidence interval (CI): 8.05-8.64%] and non-adherent patients (10.72%, 95% CI: 9.78-11.66%). The relative risk associated with non-adherence decreased from 4 years after index-MI and onwards: 1.41 (95% CI: 1.27-1.55) at 4-6 years and 1.21 (95% CI: 1.06-1.36) at 8-10 years (Ptrend = 0.056). Aspirin non-adherence in women and individuals >65 years was not associated with increased risk. Pinteraction at each of the time points: Age - <0.001, <0.001, 0.002, 0.51; Sex - 0.25, 0.02, 0.02, 0.82. CONCLUSION Non-adherence to long-term aspirin was associated with increased risk of MI, stroke, or death, but not in women or individuals >65 years. The risk decreased from 4 years after MI with near statistical significance.
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Affiliation(s)
- Anna Meta Dyrvig Kristensen
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, 2000 Frederiksberg, Copenhagen, Denmark
| | - Manan Pareek
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2870 Gentofte, Denmark
| | | | - John William McEvoy
- National Institute for Prevention and Cardiovascular Health, School of Medicine, University of Galway, H91 Galway, Ireland
| | - Christian Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital-North Zealand Hospital, 3400 Hillerød, Denmark
- Department of Public Health, University of Copenhagen, 1353 Copenhagen, Denmark
| | - Eva Bossano Prescott
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, 2000 Frederiksberg, Copenhagen, Denmark
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Rosca CI, Lighezan DF, Cozma GV, Branea HS, Nisulescu DD, Zus AS, Morariu SI, Kundnani NR. To Be, or Not to Be … Pectoral Angina? The Pain Is the Same, but the Etiology Is Different-A Case Report. Life (Basel) 2024; 14:1066. [PMID: 39337851 PMCID: PMC11432985 DOI: 10.3390/life14091066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 08/18/2024] [Accepted: 08/23/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Chest pain is one of the most common causes of emergency room visits and also accounts for numerous visits to the family physician's office or Outpatient Clinics of cardiology or internal medicine. CASE REPORT Here we present a case of a 48-year-old female patient who presented to our hospital emergency unit but refused hospital admission. She presented in our Outpatient Clinic with a complaint of typical chest pain indicating it to be of coronary origin. A computed tomography (CT) coronary angiography for the evaluation of this chest pain was indicated. While ruling out the coronary origin of this chest pain, we were surprised to have incidentally identified the presence of an esophageal tumor mass that had intimate contact with carina of the trachea. After the diagnosis of esophageal leiomyoma was made and its surgical treatment was performed, the patient was asymptomatic. Approximately one year after the surgical intervention was performed, following the cessation of antiplatelet therapy and statin, the patient returned to our Outpatient Clinic complaining of chest pain again with the same characteristics as previously presented, being terrified by the possibility of the recurrence of the esophageal leiomyoma. Upon resuming investigations, it was proven through coronary angio-CT evaluation that the etiology of the chest pain was indeed coronary this time. However, the patient still refused hospital admission and the performance of percutaneous coronary angiography with the potential implantation of a coronary stent. CONCLUSIONS Chest pain can be due to various underlying pathologies and should not be neglected. A thorough investigation and timely management are key to treating this possible fatal symptom. In our case, the patient presented twice with the complaint of typical chest pain indicating a possible coronary event, but at the first presentation, it was due to esophageal leiomyoma, while a year later, the patient had similar pain, which was indeed this time due to coronary blockage. Hence, it is of utmost importance to think of all possible scenarios and to investigate accordingly, leaving no stone unturned.
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Affiliation(s)
- Ciprian Ilie Rosca
- Department of Internal Medicine I—Medical Semiotics I, Centre for Advanced Research in Cardiovascular Pathology and Haemostasis, “Victor Babeș” University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania; (C.I.R.); (D.F.L.)
| | - Daniel Florin Lighezan
- Department of Internal Medicine I—Medical Semiotics I, Centre for Advanced Research in Cardiovascular Pathology and Haemostasis, “Victor Babeș” University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania; (C.I.R.); (D.F.L.)
| | - Gabriel Veniamin Cozma
- Department of Surgery I, Surgical Semiotics I and Thoracic Surgery, “Victor Babeș” University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania;
| | - Horia Silviu Branea
- Department of Internal Medicine I—Medical Semiotics II, “Victor Babeș” University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania
| | - Daniel Dumitru Nisulescu
- General Medicine Faculty, “Victor Babeș” University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania;
- General Medicine Faculty, ”Vasile Goldiș” West University Arad, 473223 Arad, Romania
| | - Adrian Sebastian Zus
- Department VI—Cardiology, “Victor Babeș” University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania;
| | - Stelian I. Morariu
- General Medicine Faculty, ”Vasile Goldiș” West University Arad, 473223 Arad, Romania
| | - Nilima Rajpal Kundnani
- Discipline of Internal Medicine and Ambulatory Care, Prevention and Cardiovascular Recovery, Department of VI Cardiology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania;
- Research Centre of Timisoara Institute of Cardiovascular Diseases, “Victor Babeș” University of Medicine and Pharmacy, 3000041 Timișoara, Romania
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4
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Houben AM, Crepy M, Senard M, Bonhomme V, Tchana-Sato V, Hans G. Preoperative continuation of aspirin before isolated heart valve surgery and postoperative bleeding and transfusion: a single-center retrospective study. Acta Chir Belg 2024; 124:274-280. [PMID: 38146908 DOI: 10.1080/00015458.2023.2298097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 12/18/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND The risks and benefits of preoperative aspirin continuation in patients undergoing isolated heart valve replacement surgery are unclear. We investigated the effect of aspirin continuation on the risk of bleeding and transfusion in these patients. METHODS In this single center, retrospective study, among 474 adult patients who underwent isolated heart valve surgery between April 2013 and June 2018, 269 continued aspirin within 5 days before surgery (aspirin group) and 205 patients did not take or stopped aspirin no later than 5 days before surgery (non-aspirin group). The chi-square test, the Mann-Whitney U-test, and the Student's T-test were used to compare data between the groups. Univariate and Multivariate logistic regressions were used to assess crude and adjusted relationships between outcome and exposure. RESULTS The primary outcome, red blood cell (RBC) transfusion, occurred in 59 patients (22%) of the aspirin group and in 24 patients (12%) of the non-aspirin group (p = 0.004). After adjustment for confounding factors, continuation of aspirin was no longer associated with RBC transfusion (aOR1.8;95%CI,0.98-3.2;p = 0.06). The amount of allogenic blood products, the incidence of surgical re-exploration for bleeding, the volume of re-transfused cell-saved blood, and the cumulative chest tube drainage during the first 24 postoperative hours were similar between groups. CONCLUSION Preoperative continuation of aspirin in patients undergoing isolated heart valve surgery is neither associated with a higher incidence of RBC transfusion, nor with larger perioperative blood loss, or more frequent surgical revision for bleeding. TRIAL REGISTRATION Clinicaltrials.gov (NCT05151796).
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Affiliation(s)
- Alan M Houben
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
| | - Margaux Crepy
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
| | - Marc Senard
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
| | - Vincent Bonhomme
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Anesthesia and Perioperative Neuroscience Laboratory, GIGA-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Vincent Tchana-Sato
- Department of Cardiovascular Surgery, Liege University Hospital, Liege, Belgium
| | - Gregory Hans
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
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Shubietah ARM, Marin MP, Rajab IM, Oweidat MH, Zayed A, Hmeedan A. A Thorough Literature Review of the Potential Benefits and Drawbacks of Long-Term Aspirin Use for the Primary Prevention of Cardiovascular Disease. Cardiol Rev 2024:00045415-990000000-00271. [PMID: 38785443 DOI: 10.1097/crd.0000000000000722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
This article examines the role of aspirin in the primary prevention of cardiovascular disease. It highlights findings from major studies such as ASPREE (ASPirin in Reducing Events in the Elderly), ARRIVE (Aspirin to Reduce Risk of Initial Vascular Events), and ASPREE-XT (ASPirin in Reducing Events in the Elderly - eXTension) , among others. The review focuses on aspirin's role in primary prevention for specific populations including older adults, diabetics, hypertension patients, rheumatoid arthritis patients, kidney transplant recipients, and those with specific lipoprotein(a) genotypes, among other groups. We review these studies, noting aspirin's role in reducing events such as myocardial infarctions and its potential for increasing bleeding risks. The review also considers the implications for patients with kidney disease, referencing the Chronic Renal Insufficiency Cohort (CRIC) study and the International Polycap Study-3 (TIPS-3) trial. Additionally, it addresses the shifting paradigms in guidelines from the US Preventive Services Task Force and other entities, underscoring the importance of individualized aspirin use by balancing benefits against bleeding risks. The article further explores the concept of platelet reactivity, discusses strategies for improving adherence to aspirin therapy, and identifies existing research gaps, such as the phenomenon of aspirin resistance. It concludes by suggesting potential areas for future investigation to enhance understanding and application of aspirin in cardiovascular disease prevention.
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Affiliation(s)
- Abdalhakim R M Shubietah
- From the Department of Internal Medicine, An-Najah National University Hospital, Nablus, Palestine
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Monica Pernia Marin
- Neuro-Oncology Department, Columbia University, Irving Medical Center, New York, NY
| | - Islam M Rajab
- Columbia University, Irving Medical Center, New York, NY
| | - Majd H Oweidat
- Department of Medicine, Hebron University, College of Medicine, Hebron, Palestine
| | - Alaa Zayed
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Alaa Hmeedan
- From the Department of Internal Medicine, An-Najah National University Hospital, Nablus, Palestine
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
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Hozman M, Hassouna S, Grochol L, Waldauf P, Hracek T, Pazdiorova BZ, Adamec S, Osmancik P. Previous antithrombotic therapy does not have an impact on the in-hospital mortality of patients with upper gastrointestinal bleeding. Eur Heart J Suppl 2023; 25:E25-E32. [PMID: 37234230 PMCID: PMC10206644 DOI: 10.1093/eurheartjsupp/suad103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The association between antithrombotics (ATs) and the risk of gastrointestinal bleeding is well known; however, data regarding the influence of ATs on outcomes are scarce. The goals of this study are: (i) to assess the impact of prior AT therapy on in-hospital and 6-month outcomes and (ii) to determine the re-initiation rate of the ATs after a bleeding event. All patients with upper gastrointestinal bleeding (UGB) who underwent urgent gastroscopy in three centres from 1 January 2019 to 31 December 2019 were retrospectively analysed. Propensity score matching (PSM) was used. Among 333 patients [60% males, mean age 69.2 (±17.3) years], 44% were receiving ATs. In multivariate logistic regression, no association between AT treatment and worse in-hospital outcomes was observed. Development of haemorrhagic shock led to worse survival [odds ratio (OR) 4.4, 95% confidence interval (CI) 1.9-10.2, P < 0.001; after PSM: OR 5.3, 95% CI 1.8-15.7, P = 0.003]. During 6-months follow-up, higher age (OR 1.0, 95% CI 1.0-1.1, P = 0.002), higher comorbidity (OR 1.4, 95% CI 1.2-1.7, P < 0.001), a history of cancer (OR 3.6, 95% CI 1.6-8.1, P < 0.001) and a history of liver cirrhosis (OR 2.2, 95% CI 1.0-4.4, P = 0.029) were associated with higher mortality. After a bleeding episode, ATs were adequately re-initiated in 73.8%. Previous AT therapy does not worsen in-hospital outcomes in after UGB. Development of haemorrhagic shock predicted poor prognosis. Higher 6-month mortality was observed in older patients, patients with more comorbidities, with liver cirrhosis and cancer.
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Affiliation(s)
- Marek Hozman
- Cardiocenter, Hospital Karlovy Vary, 360 01 Karlovy Vary, Czech Republic
| | - Sabri Hassouna
- Cardiocenter, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Ruska 87, 100 00 Prague, Czech Republic
| | - Lukas Grochol
- 2nd Department of Internal Medicine, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady,100 00 Prague, Czech Republic
| | - Petr Waldauf
- Department of Anaesthesia and Intensive Care, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, 100 00 Prague, Czech Republic
| | - Tomas Hracek
- Department of General Surgery, 3rd Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 00 Prague, Czech Republic
| | | | - Stanislav Adamec
- Department of Gastroenterology, Hospital Cheb, 350 02 Cheb, Czech Republic
| | - Pavel Osmancik
- Corresponding author. Tel: 00420-721544447, Fax: 00420-267162817,
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Relvas M, Gonçalves J, Castro I, Diniz H, Mendonça L, Coentrão L. Effects of Aspirin on Kidney Biopsy Bleeding Complications: A Systematic Review and Meta-Analysis (PROSPERO 2021 CRD42021261005). KIDNEY360 2023; 4:700-710. [PMID: 36951435 PMCID: PMC10278841 DOI: 10.34067/kid.0000000000000091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 01/27/2023] [Indexed: 03/24/2023]
Abstract
Postprocedural bleeding is the main complication of percutaneous kidney biopsy (PKB). Therefore, aspirin is routinely withheld in patients undergoing PKB to reduce the bleeding risk. The authors aimed to examine the association between aspirin use and bleeding during PKB. This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The article search was performed on MEDLINE and Scopus using queries specific to each database. Article inclusion was limited to primary studies. The meta-analysis compared the risk of major bleeding events between the aspirin-exposed versus nonexposed group. Pooled effect estimate was examined using random effects presented as odds ratio with 95% confidence intervals. Heterogeneity was assessed through Cochrane I 2 test statistics. Sensitivity and subgroup analyses were also performed according to kidney type. Ten studies were included in the review and four studies were included in the meta-analysis, reviewing a total of 34,067 PKBs. Definitions for significant aspirin exposure were inconsistent between studies, limiting comparisons. Studies with broader definitions for aspirin exposure mostly showed no correlation between aspirin use and postbiopsy bleeding. Studies with strict definitions for aspirin exposure found an increased risk of hemorrhagic events in the aspirin-exposed group. No significant differences were found between the aspirin-exposed and comparison groups regarding major bleeding events (odds ratio 1.72; 95% confidence interval 0.50 to 5.89, I 2 =84%). High-quality evidence on the effect of aspirin on the bleeding risk is limited. Our meta-analysis did not show a significantly increased risk of major bleeding complications in aspirin-exposed patients. Further studies are needed to define a more comprehensive approach for clinical practice.
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Affiliation(s)
- Miguel Relvas
- Nephrology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Joana Gonçalves
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Inês Castro
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Hugo Diniz
- Nephrology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Luís Mendonça
- Nephrology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Luís Coentrão
- Nephrology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
- Nephrology & Infectious Diseases R&D, i3S—Institute for Research & Innovation in Health, Porto, Portugal
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Rychen J, Saemann A, Fingerlin T, Guzman R, Mariani L, Greuter L, Soleman J. Risks and benefits of continuation and discontinuation of aspirin in elective craniotomies: a systematic review and pooled-analysis. Acta Neurochir (Wien) 2023; 165:39-47. [PMID: 36376767 PMCID: PMC9840583 DOI: 10.1007/s00701-022-05416-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/29/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIM Discontinuation of aspirin (ASA) prior to elective craniotomies is common practice. However, patients treated with ASA for secondary prevention bear a higher risk for thromboembolic complications. Aim of this systematic review is to investigate the risks and benefits of perioperative continuation and discontinuation of ASA in elective craniotomies. METHODS PubMed and Embase databases were searched. Inclusion criteria were retro- and prospective studies, reporting hemorrhagic and thromboembolic complications in patients in whom ASA was either continued or discontinued perioperatively in elective craniotomies. We excluded shunt operations and emergency cases. The MINORS (Methodological index for non-randomized studies) score was used to quantify the methodological quality of the eligible studies. RESULTS Out of 523 publications, 7 met the eligibility criteria (cumulative cohort of 646 patients). The mean MINORS score for the comparative studies was 18.7/24 (± SD 2.07, range: 17-22) and 9/16 for the unique non-comparative study, indicating an overall weak methodological quality of the included studies. 57.1% of the patients underwent craniotomy for intra- and extra-axial tumor removal, 39.0% for bypass surgery and 3.9% for neurovascular lesions (other than bypass). In 31.0% of the cases, ASA was prescribed for primary and in 69.0% for secondary prevention. ASA was continued perioperatively in 61.8% and discontinued in 38.2% of the cases. The hemorrhagic complication rate was 3% (95% CI [0.01-0.05]) in the ASA continuation group (Con-Group) and 3% (95% CI [0.01-0.09]) in the discontinuation group (Disc-Group) (p = 0.9). The rate of thromboembolic events in the Con-Group was 3% (95% CI [0.01-0.06]) in comparison to 6% (95% CI [0.02-0.14]) in the Disc-Group (p = 0.1). CONCLUSION Perioperative continuation of ASA in elective craniotomies does not seem to be associated with an increased hemorrhagic risk. The potential beneficial effect of ASA continuation on thromboembolic events needs to be further investigated in patients under ASA for secondary prevention.
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Affiliation(s)
- Jonathan Rychen
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
| | - Attill Saemann
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
| | - Tamara Fingerlin
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Ladina Greuter
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland.
- Faculty of Medicine, University of Basel, Basel, Switzerland.
- Department of Clinical Studies, University Hospital of Basel, Basel, Switzerland.
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9
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Reynard ME, Dufour J. Elective percutaneous liver biopsy and use of aspirin. United European Gastroenterol J 2022; 10:538-543. [PMID: 35652196 PMCID: PMC9278580 DOI: 10.1002/ueg2.12254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/02/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES Percutaneous liver biopsy is an essential diagnostic investigation in hepatology. Among complications, which are rare, bleeding is the most feared. Many patients scheduled for a liver biopsy are taking aspirin. Surprisingly no information is available in the literature on this frequent clinical situation. The American Association for the Study of Liver Diseases (AASLD) position paper on percutaneous liver biopsy does not specifically recommend stopping low dose aspirin prior to an elective percutaneous liver biopsy. The European Association for the Study of the Liver also remains unspecific without giving clear recommendation on stopping or not low dose aspirin before the procedure. The aim of this study is to document current practice concerning the management of patients scheduled for an elective percutaneous biopsy and taking low dose aspirin. DESIGN An online questionnaire was designed to gather data on current practice on the perioperative management of percutaneous liver biopsy and use of aspirin. SETTINGS The questionnaire was emailed to AASLD members in September 2018. PARTICIPANTS Four hundred sixty six responses were collected. RESULTS Seventy eight percent postpone elective percutaneous liver biopsy if International Normalised Ratio is ≥1.5 or Quick ≤50%. Ninety five percent postpone biopsy if platelet count is ≤50,000 × 106 /L. Seventy five percent stop low dose aspirin, on average, 6 days prior to the percutaneous liver biopsy. This choice of management does not seem to be related to previous complications since 86% report not having experienced any bleeding in patients taking low dose aspirin. Nevertheless, this practice has logistic consequences since 61% of the respondents postponed a liver biopsy due to intake of low dose aspirin. CONCLUSIONS Despite the lack of clear statement in guidelines and evidence supporting this practice, three quarters of physicians practicing in hepatology stop low dose aspirin before elective percutaneous liver biopsy.
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Affiliation(s)
| | - Jean‐François Dufour
- Department for Biomedical Research DBMRUniversity of BernBernSwitzerland
- Centre des Maladies DigestivesLausanneSwitzerland
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10
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Vora P, Soriano-Gabarró M, Russell B, Morgan Stewart H. Long-Term Adherence and Persistence to Low-Dose Aspirin for the Prevention of Cardiovascular Disease: A Population-Based Cohort Study. Int J Clin Pract 2022; 2022:7786174. [PMID: 36540065 PMCID: PMC9734008 DOI: 10.1155/2022/7786174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 12/03/2022] Open
Abstract
METHODS Using information from electronic health records in Germany and the United Kingdom (UK) in a common data model, we followed adults with ≥2 low-dose aspirin prescriptions (75-100 mg) during 2007-2018 for up to 10 years. Included individuals had no low-dose aspirin prescriptions in the year before the follow-up started (date of first low-dose aspirin prescription) and ≥12 months' observation. Adherence was determined using the medication possession ratio (MPR), and persistence was defined as continuous treatment disregarding gaps between prescriptions of <60 days; analyses were undertaken according to indication (primary/secondary CVD prevention). RESULTS We identified 144,717 low-dose aspirin users from Germany and 190,907 from the UK. Among patients with 5-10 years' follow-up, median adherence among secondary CVD prevention users was 60% in Germany and 75% in the UK. Among primary prevention users, median adherence was 50% for both countries. Persistence among secondary CVD prevention users was 58.3% at 2 years, 47.0% at 5 years, 35.2% at 10 years (Germany), and 67.5% at 2 years, 58.0% at 5 years, and 46.8% at 10 years (UK). Among primary CVD prevention users, persistence was 52.8% at 2 years, 41.6% at 5 years, 32.1% at 10 years (Germany), 56.3% at 2 years, 45.4% at 5 years, and 33.8% at 10 years (UK). CONCLUSIONS Long-term adherence and persistence to low-dose aspirin are suboptimal; efforts for improvement could translate into a lower CVD burden in the general population.
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Affiliation(s)
- Pareen Vora
- Integrated Evidence Generation, Bayer AG, Berlin, Germany
| | | | - Beth Russell
- Comprehensive Cancer Centre, Kings College London, London, UK
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11
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Jia RJ, Wang XP, Zhang ZH, Cui HH, Qin R, Du DY, Liu Y. Effect of Rabeprazole and Rebamipide in the Treatment of Upper Gastrointestinal Hemorrhage Associated with Dual Antiplatelet Therapy in Elderly Patients with Coronary Heart Disease. Clin Appl Thromb Hemost 2022; 28:10760296221130746. [PMID: 36411982 PMCID: PMC9703470 DOI: 10.1177/10760296221130746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 08/27/2023] Open
Abstract
To investigate the therapeutic effect of rabeprazole and rebamipide on patient age over 60 with dual antiplatelet therapy (DAPT)-related upper gastrointestinal hemorrhage following percutaneous coronary intervention (PCI). A total of 360 patients age over 60 undergoing PCI were recruited for antiplatelet therapy involving a combined treatment of aspirin (100 mg/d) and clopidogrel (75 mg/d). The enrolled patients were divided into 4 groups: the control group, the rabeprazole group, the rebamipide group, and the rabeprazole + rebamipide group. The incidence and severity of any upper gastrointestinal hemorrhage and the incidence of major adverse cardiac events (MACEs) were observed 6 months after the operation. The incidence of upper gastrointestinal hemorrhage in the 4 groups was 11.1%, 3.3%, 8.9%, and 1.1%, respectively, and the differences were statistically significant (P < 0.05). On comparing the groups, the differences between the control group and the rabeprazole group, those between the control group and the rabeprazole + rebamipide group, and those between the rebamipide group and the rabeprazole + rebamipide group were found to be statistically significant (P < 0.05). The severity of the upper gastrointestinal hemorrhage in the rabeprazole group and the rabeprazole + rebamipide group was significantly lower than that in the control group. The 4 groups exhibited no significant differences in the incidence of MACEs (P > 0.05). For patients age over 60 receiving DAPT following PCI in our study population, treatment with rabeprazole or a combination of rabeprazole and rebamipide could reduce the risk of upper gastrointestinal hemorrhage, as well as reduce its severity.
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Affiliation(s)
- Rong-Jie Jia
- Department of Gastroenterology and Hepatology, The 305 Hospital of
Chinese PLA, Beijing, China
| | - Xiao-Peng Wang
- Department of Gastroenterology and Hepatology, The 305 Hospital of
Chinese PLA, Beijing, China
| | - Zhen-Hua Zhang
- Department of Gastroenterology and Hepatology, The 305 Hospital of
Chinese PLA, Beijing, China
| | - Hai-Hong Cui
- Department of Gastroenterology and Hepatology, The 305 Hospital of
Chinese PLA, Beijing, China
| | - Rui Qin
- Department of Gastroenterology and Hepatology, The 305 Hospital of
Chinese PLA, Beijing, China
| | - Da-Yong Du
- Department of Cardiology, The 305 Hospital of Chinese PLA, Beijing,
China
| | - Yang Liu
- Department of Cardiology, The 305 Hospital of Chinese PLA, Beijing,
China
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12
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Insani WN, Whittlesea C, Alwafi H, Man KKC, Chapman S, Wei L. Prevalence of adverse drug reactions in the primary care setting: A systematic review and meta-analysis. PLoS One 2021; 16:e0252161. [PMID: 34038474 PMCID: PMC8153435 DOI: 10.1371/journal.pone.0252161] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/11/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Adverse drug reactions (ADRs) represent a major cause of iatrogenic morbidity and mortality in patient care. While a substantial body of work has been undertaken to characterise ADRs in the hospital setting, the overall burden of ADRs in the primary care remains unclear. OBJECTIVES To investigate the prevalence of ADRs in the primary care setting and factors affecting the heterogeneity of the estimates. METHODS Studies were identified through searching of Medline, Embase, CINAHL and IPA databases. We included observational studies that reported information on the prevalence of ADRs in patients receiving primary care. Disease and treatment specific studies were excluded. Quality of the included studies were assessed using Smyth ADRs adapted scale. A random-effects model was used to calculate the pooled estimate. Potential source of heterogeneity, including age groups, ADRs definitions, ADRs detection methods, study setting, quality of the studies, and sample size, were investigated using sub-group analysis and meta-regression. RESULTS Thirty-three studies with a total study population of 1,568,164 individuals were included. The pooled prevalence of ADRs in the primary care setting was 8.32% (95% CI, 7.82, 8.83). The percentage of preventable ADRs ranged from 12.35-37.96%, with the pooled estimate of 22.96% (95% CI, 7.82, 38.09). Cardiovascular system drugs were the most commonly implicated medication class. Methods of ADRs detection, age group, setting, and sample size contributed significantly to the heterogeneity of the estimates. CONCLUSION ADRs constitute a significant health problem in the primary care setting. Further research should focus on examining whether ADRs affect subsequent clinical outcomes, particularly in high-risk therapeutic areas. This information may better inform strategies to reduce the burden of ADRs in the primary care setting.
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Affiliation(s)
- Widya N. Insani
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
- Department of Pharmacology and Clinical Pharmacy, Center of Excellence for Pharmaceutical Care Innovation, Padjadjaran University, Bandung, Indonesia
| | - Cate Whittlesea
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
| | - Hassan Alwafi
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
- Faculty of Medicine, Umm Al Qura University, Mecca, Saudi Arabia
| | - Kenneth K. C. Man
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
- Department of Pharmacology and Pharmacy, University of Hong Kong, Hong Kong, Hong Kong
| | - Sarah Chapman
- Department of Pharmacy and Pharmacology, University of Bath, Bath, United Kingdom
| | - Li Wei
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
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13
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Min YJ, Ling EA, Li F. Immunomodulatory Mechanism and Potential Therapies for Perinatal Hypoxic-Ischemic Brain Damage. Front Pharmacol 2020; 11:580428. [PMID: 33536907 PMCID: PMC7849181 DOI: 10.3389/fphar.2020.580428] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/13/2020] [Indexed: 12/13/2022] Open
Abstract
Hypoxia-ischemia (HI) is one of the most common causes of death and disability in neonates. Currently, the only available licensed treatment for perinatal HI is hypothermia. However, it alone is not sufficient to prevent the brain injuries and/or neurological dysfunction related to HI. Perinatal HI can activate the immune system and trigger the peripheral and central responses which involve the immune cell activation, increase in production of immune mediators and release of reactive oxygen species. There is mounting evidence indicating that regulation of immune response can effectively rescue the outcomes of brain injury in experimental perinatal HI models such as Rice-Vannucci model of newborn hypoxic-ischemic brain damage (HIBD), local transient cerebral ischemia and reperfusion model, perinatal asphyxia model, and intrauterine hypoxia model. This review summarizes the many studies about immunomodulatory mechanisms and therapies for HI. It highlights the important actions of some widely documented therapeutic agents for effective intervening of HI related brain damage, namely, HIBD, such as EPO, FTY720, Minocycline, Gastrodin, Breviscapine, Milkvetch etc. In this connection, it has been reported that the ameboid microglial cells featured prominently in the perinatal brain represent the key immune cells involved in HIBD. To this end, drugs, chemical agents and herbal compounds which have the properties to suppress microglia activation have recently been extensively explored and identified as potential therapeutic agents or strategies for amelioration of neonatal HIBD.
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Affiliation(s)
- Ying-Jun Min
- Department of Pathology and Pathophysiology, School of Basic Medical Sciences, Kunming Medical University, Kunming, China
| | - Eng-Ang Ling
- Department of Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Fan Li
- Department of Pathology and Pathophysiology, School of Basic Medical Sciences, Kunming Medical University, Kunming, China
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14
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Dangers L, Giovannelli J, Mangiapan G, Alves M, Bigé N, Messika J, Morawiec E, Neuville M, Cracco C, Béduneau G, Terzi N, Huet I, Dhalluin X, Bautin N, Quiot JJ, Appere-de Vecchi C, Similowski T, Chenivesse C. Antiplatelet Drugs and Risk of Bleeding After Bedside Pleural Procedures: A National Multicenter Cohort Study. Chest 2020; 159:1621-1629. [PMID: 33290789 DOI: 10.1016/j.chest.2020.10.092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 09/10/2020] [Accepted: 10/29/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The decision-making on antiplatelet drug withdrawal or continuation before performing a pleural procedure is based on the balance between the risk of bleeding associated with the antiplatelet therapy and the risk of arterial thrombosis due to its interruption. Knowledge on antiplatelet therapy-associated risk of bleeding after pleural procedures is lacking. RESEARCH QUESTION Is the risk of bleeding associated with antiplatelet drugs increased in patients undergoing pleural procedures? STUDY DESIGN AND METHODS We conducted a French multicenter cohort study in 19 centers. The main outcome was the occurrence of bleeding, defined as hematoma, hemoptysis, or hemothorax, during the 24 h following a pleural procedure. Serious bleeding events were defined as bleeding requiring blood transfusion, respiratory support, endotracheal intubation, embolization, or surgery, or as death. RESULTS A total of 1,124 patients was included (men, 66%; median age, 62.6 ± 27.7 years), of whom 182 were receiving antiplatelet therapy and 942 were not. Fifteen patients experienced a bleeding event, including eight serious bleeding events. The 24-h incidence of bleeding was 3.23% (95% CI, 1.08%-5.91%) in the antiplatelet group and 0.96% (95% CI, 0.43%-1.60%) in the control group. The occurrence of bleeding events was significantly associated with antiplatelet therapy in univariate analysis (OR, 3.44; 95% CI, 1.14-9.66; P = .021) and multivariate analysis (OR, 4.13; 95% CI, 1.01-17.03; P = .044) after adjusting for demographic data and the main risk factors for bleeding. Likewise, antiplatelet therapy was significantly associated with serious bleeding in univariate analysis (OR, 8.61; 95% CI, 2.09-42.3; P = .003) and multivariate analysis (OR, 7.27; 95% CI, 1.18-56.1; P = .032) after adjusting for the number of risk factors for bleeding. INTERPRETATION Antiplatelet therapy was associated with an increased risk of post-pleural procedure bleeding and serious bleeding. Future guidelines should take into account these results for patient safety.
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Affiliation(s)
- Laurence Dangers
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Jonathan Giovannelli
- CHU Lille, Clinique de Pneumologie, Lille, France; Univ Lille, INSERM, LIRIC UMR U995, Lille, France
| | - Gilles Mangiapan
- Centre Hospitalier Intercommunal de Créteil, Service de Pneumologie et Pathologies Professionnelles, Créteil, France
| | - Mikael Alves
- APHP, Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France; Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye, Service de Réanimation, Poissy, France
| | - Naïke Bigé
- Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye, Service de Réanimation, Poissy, France
| | - Jonathan Messika
- APHP, Hôpital Louis Mourier, Service de Réanimation Médico-Chirurgicale, Colombes, France; Sorbonne Paris Cité, Univ Paris Diderot, INSERM, IAME, UMR 1137, Paris, France
| | - Elise Morawiec
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Mathilde Neuville
- APHP, Hôpital Bichat-Claude Bernard, Service de Pneumologie, Paris, France
| | - Christophe Cracco
- Centre Hospitalier d'Angoulême Saint-Michel, Service de Réanimation Médicale, Saint-Michel, France
| | - Gaëtan Béduneau
- Centre Hospitalier Universitaire de Rouen, Service de Réanimation Médicale, Rouen, France
| | - Nicolas Terzi
- Centre Hospitalier Universitaire de Caen, Service de Réanimation Médicale, Caen, France
| | - Isabelle Huet
- Centre Hospitalier Universitaire de Toulouse, Service de Pneumologie, Toulouse, France
| | | | - Nathalie Bautin
- CHU Lille, Clinique de Pneumologie, Lille, France; Centre Hospitalier de Roubaix, Service de Pneumologie et Allergologie, Roubaix, France
| | - Jean-Jacques Quiot
- Centre Hospitalier Régional Universitaire de Brest, Département de Médecine Interne et de Pneumologie, Brest, France
| | | | - Thomas Similowski
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Cécile Chenivesse
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Paris, France; CHU Lille, Clinique de Pneumologie, Lille, France; Univ Lille, INSERM, CNRS, Institut Pasteur de Lille, CIIL, U1019, UMR 8204, Lille, France.
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15
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Zhirov IV. [Decreasing cardiovascular morbidity: how to improve adherence to the treatment in the translational era]. TERAPEVT ARKH 2020; 92:49-53. [PMID: 33346431 DOI: 10.26442/00403660.2020.09.000835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 11/22/2022]
Abstract
Cardiovascular diseases are the main drivers of the morbidity and mortality in Russian Federation. We briefly discussed the poor adherence of the patients and outlined the solutions of this problem.
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Affiliation(s)
- I V Zhirov
- National Medical Research Center for Cardiology.,Russian Medical Academy of Continuous Professional Education
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16
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Gerstein NS, Albrechtsen CL, Mercado N, Cigarroa JE, Schulman PM. A Comprehensive Update on Aspirin Management During Noncardiac Surgery. Anesth Analg 2020; 131:1111-1123. [PMID: 32925332 DOI: 10.1213/ane.0000000000005064] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aspirin is considered critical lifelong therapy for patients with established cardiovascular (CV) disease (including coronary artery, cerebrovascular, and peripheral arterial diseases) and is consequently one of the most widely used medications worldwide. However, the indications for aspirin use continue to evolve and recent trials question its efficacy for primary prevention. Although one third of patients undergoing noncardiac surgery and at risk for a major adverse CV event receive aspirin perioperatively, uncertainty still exists about how aspirin should be optimally managed in this context, and significant practice variability remains. Recent trials suggest that the risks of continuing aspirin during the perioperative period outweigh the benefits in many cases, but data on patients with high CV risk remain limited. We performed a comprehensive PubMed and Medline literature search using the following keywords: aspirin, aspirin withdrawal, perioperative, coronary artery disease, cerebrovascular disease, peripheral artery disease, and CV disease; we manually reviewed all relevant citations for inclusion. Patients taking aspirin for the primary prevention of CV disease should likely discontinue it during the perioperative period, especially when there is a high risk of bleeding. Patients with established CV disease but without a coronary stent should likely continue aspirin during the perioperative period unless undergoing closed-space surgery. Patients with a history of coronary stenting also likely need aspirin continuation throughout the perioperative period for nonclosed space procedures. Perioperative clinicians need to balance the risks of ceasing aspirin before surgery against its continuation during the perioperative interval using a patient-specific strategy. The guidance on decision-making with regard to perioperative aspirin cessation or continuation using currently available clinical data from studies in high-risk patients along with nonclinical aspirin studies is conflicting and does not enable a simplified or unified answer. However, pertinent guidelines on CV disease management provide a basic framework for aspirin management, and large trial findings provide some insight into the safety of perioperative aspirin cessation in some contexts, although uncertainty on perioperative aspirin still exists. This review provides an evidence-based update on perioperative aspirin management in patients undergoing noncardiac surgery with a focus on recommendations for perioperative clinicians on continuing versus holding aspirin during this context.
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Affiliation(s)
- Neal S Gerstein
- From the Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | - Nestor Mercado
- Division of Cardiology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | - Peter M Schulman
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
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17
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Zhu J, Shi Y, Li J, Zhang Z. Role of risk attitude and time preference in preventive aspirin use adherence. J Eval Clin Pract 2020; 26:819-825. [PMID: 31478307 DOI: 10.1111/jep.13274] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/19/2019] [Accepted: 08/19/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Poor adherence to medication that is taken chronically for the prevention of cardiovascular disease (CVD) continues to occur. Poor adherence is a primary barrier to treatment success and affects not only the patient but also the health care system. OBJECTIVE We aim to explore the impacts of risk attitudes and time preferences on the decisions of patients to begin and comply with aspirin therapy for CVD prevention. METHODS Three hundred fifty-seven patients who used low-dose aspirin for CVD prevention under the guidance of their doctors completed the survey. The risk attitudes and time preferences of the patients were elicited using a multiple price list experiment. Logistic regression models were used to examine the predictors of adherence to aspirin use. RESULTS Risk-seeking behaviours were significantly associated with both nonparticipation (P < .01) and lower compliance (P < .05) in patients. The coefficient for time preference was only significant at the 0.05 level for the decision to initiate aspirin use, which indicated that more impatient patients were less likely to begin with the use of aspirin. Forgetfulness in using aspirin on time and a lack of knowledge (as well as a lack of belief in the use of aspirin) could largely explain the poor adherence to aspirin therapy. CONCLUSIONS The identification of risk seekers and of those individuals who discount the future to a lesser degree may help providers to formulate tailored strategies to their patients, thus effectively enhancing their adherence to treatment.
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Affiliation(s)
- Jingrong Zhu
- School of Management and Economics, Beijing Institute of Technology, Beijing, China.,College of Health and Human Development, Pennsylvania State University, State College, Pennsylvania
| | - Yunfeng Shi
- School of Management and Economics, Beijing Institute of Technology, Beijing, China
| | - Jinlin Li
- School of Management and Economics, Beijing Institute of Technology, Beijing, China
| | - Zengbo Zhang
- School of Management and Economics, Beijing Institute of Technology, Beijing, China
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18
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Wei J, Wood MJ, Dubreuil M, Tomasson G, LaRochelle MR, Zeng C, Lu N, Lin J, Choi HK, Lei G, Zhang Y. Association of tramadol with risk of myocardial infarction among patients with osteoarthritis. Osteoarthritis Cartilage 2020; 28:137-145. [PMID: 31629022 PMCID: PMC7047659 DOI: 10.1016/j.joca.2019.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/26/2019] [Accepted: 10/02/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Tramadol has been widely used among patients with osteoarthritis (OA); however, there is paucity of information on its cardiovascular risk. We aimed to examine the association of tramadol with risk of myocardial infarction (MI) among patients with OA. DESIGN Among OA patients aged 50-90 years without history of MI, cancer, or opioid use disorder in The Health Improvement Network database in the United Kingdom (2000-2016), three sequential propensity-score matched cohort studies were assembled, i.e., (1) patients who initiated tramadol or naproxen (negative comparator); (2) patients who initiated tramadol or diclofenac (positive comparator); and (3) patients who initiated tramadol or codeine (a commonly used weak opioid). The outcome was incident MI over six-months. RESULTS Among tramadol and naproxen initiators (n = 33,024 in each cohort), 77 (4.8/1000 person-years) and 46 (2.8/1000 person-years) incident MI occurred, respectively. The rate difference (RD) and hazard ratios (HR) for incident MI with tramadol initiation were 1.9 (95% confidence interval [CI] 0.6 to 2.3)/1000 person-years and 1.68 (95% CI 1.16 to 2.41) relative to naproxen initiation, respectively. Among tramadol and diclofenac initiators (n = 18,662 in each cohort), 58 (6.4/1000 person-years) and 47 (5.1/1000 person-years) incident MIs occurred, respectively. The corresponding RD and HR for incident MI were 1.2 (95%CI -2.1 to 14.1)/1000 person-years and 1.24 (95%CI 0.84 to 1.82), respectively. Among tramadol and codeine initiators (n = 42,722 in each cohort), 127 (6.1/1000 person-years) and 103 (5.0/1000 person-years) incident MI occurred, respectively, and the corresponding RD and HR were 1.1 (95%CI:-0.3 to 2.5)/1000 person-years and 1.23 (95%CI:0.95 to 1.60), respectively. CONCLUSIONS In this population-based cohort of patients with OA, the six-month risk of MI among initiators of tramadol was higher than that of naproxen, but comparable to, if not lower than, those of diclofenac or codeine.
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Affiliation(s)
- Jie Wei
- Health Management Center, Xiangya Hospital, Central South University, Changsha, Hunan, China,Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,The Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Malissa J Wood
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maureen Dubreuil
- Boston University School of Medicine, Boston, Massachusetts, USA,VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Gunnar Tomasson
- Department of Public Health Sciences, University of Iceland, Stapi Hringbraut, 101 Reykjavik, Iceland
| | - Marc R. LaRochelle
- Clinical Addiction Research and Education Unit at Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Chao Zeng
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,The Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Na Lu
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,Arthritis Research Canada, Richmond, British Columbia, Canada
| | - Jianhao Lin
- Department of Orthopaedic Surgery, Peking University People’s Hospital, Beijing, China
| | - Hyon K. Choi
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,The Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Guanghua Lei
- Department of Orthopaedic Surgery, Peking University People’s Hospital, Beijing, China,National Clinical Research Center of Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China,Correspondence to: Guanghua Lei, Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, China, 410008, ; Yuqing Zhang, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts, USA, 02114,
| | - Yuqing Zhang
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,The Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,Correspondence to: Guanghua Lei, Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, China, 410008, ; Yuqing Zhang, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts, USA, 02114,
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19
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Vogt C, Allo G, Buerger M, Kasper P, Chon SH, Gillessen J, Goeser T, Schramm C. Assessing guideline adherence in patients with non-variceal upper gastrointestinal bleeding receiving antiplatelet and anticoagulant therapy. Scand J Gastroenterol 2019; 54:1357-1363. [PMID: 31718330 DOI: 10.1080/00365521.2019.1688384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background & aims: Non-variceal upper gastrointestinal bleeding (NVUGIB) occurs frequently and is associated with a significant morbidity and mortality, especially in patients receiving antiplatelet or anticoagulant therapy (APT and ACT, respectively). We aimed to evaluate adherence to guideline recommendations published by European Society of Gastrointestinal Endoscopy (ESGE).Methods: Retrospective analysis of patients with NVUGIB und prior exposition to APT or ACT at a single university hospital between 01 January 2016 and 31 December 2017.Results: 270 patients were identified (70.4% male, median age 72 years). 6/17 (35.3%) patients receiving APT for primary cardiovascular prophylaxis, 39/71 (54.9%) and 35 (49.3%) patients receiving APT for secondary cardiovascular prophylaxis (using strict and liberal definition, respectively) and 13/25 (52%) patients receiving dual antiplatelet therapy (DAPT) were not managed according to current recommendations. Management of ACT for secondary thromboembolic prophylaxis did not follow guideline recommendations in 59/93 (63.4%) and 34/93 (36.6%) patients (using strict and liberal definition, respectively). 23.7% of patients with NVUGIB were exposed to combined APT and ACT for whom no guideline recommendations exist. Mortality for any reason was twice as high in patients who were not managed according to guideline recommendations (18.8% vs. 8% using strict definition, 20.5% vs. 10.2% using liberal definition), which did not remain significant after adjusting for comorbidities, whereas cardiovascular events were observed at similar rates.Conclusion: A significant number of patients with NVUGIB receiving APT or ACT is not managed according to current ESGE guideline recommendations. Strategies to implement these guidelines into daily practice need to be developed.
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Affiliation(s)
- Carolin Vogt
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Gabriel Allo
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Martin Buerger
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Philipp Kasper
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Johannes Gillessen
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Christoph Schramm
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
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MacGinley R, Champion De Crespigny PJ, Gutman T, Lopez-Vargas P, Manera K, Menahem S, Saunders J, See E, Voss D, Wong J. KHA-CARI Guideline recommendations for renal biopsy. Nephrology (Carlton) 2019; 24:1205-1213. [PMID: 31490584 DOI: 10.1111/nep.13662] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 08/13/2019] [Accepted: 08/17/2019] [Indexed: 01/17/2023]
Affiliation(s)
- Rob MacGinley
- Department of Renal and General Medicine, Eastern Health Clinical School, Monash University Melbourne, Melbourne, Victoria, Australia
| | - Paul J Champion De Crespigny
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Talia Gutman
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Pamela Lopez-Vargas
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Karine Manera
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Solomon Menahem
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - John Saunders
- Renal Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Emily See
- Department of Nephrology, Monash Health, Melbourne, Victoria, Australia
| | - David Voss
- Counties Manukau Health, Auckland, New Zealand
| | - Jeffrey Wong
- Department of Nephrology, Liverpool Hospital, Liverpool, New South Wales, Australia
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21
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Rizelio V, Macuco ALB, Sato HK, Nascimento MTDMS, Souza RKMD, Kowacs PA. Stroke and transient ischemic attacks related to antiplatelet or warfarin interruption. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:456-459. [PMID: 31365636 DOI: 10.1590/0004-282x20190066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 02/14/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Patients on anticoagulant or antiplatelet therapy are often required to discontinue these medications before and during surgical or invasive procedures. In some cases, the patient stops the treatment without medical supervision. These situations may increase stroke risk. To identify the ischemic stroke and transient ischemic attack (TIA) prevalence related to length of time of discontinuation of antiplatelet or vitamin K antagonist therapy, in a group of inpatients from a specialized neurological hospital in Brazil. METHODS Cross-sectional, retrospective and descriptive study of stroke inpatients for three years. Medical reports were reviewed to find study participants, stroke characteristics, risk factors, reasons and time of drug interruption. RESULTS In three years, there were 360 stroke and TIA inpatients, of whom 27 (7.5%) had a history of antiplatelet or vitamin K antagonist interruption correlated with the time of the event (81% ischemic stroke, 19% TIA). The median time between antiplatelet interruption and an ischemic event was five days, and 62% of events occurred within seven days after drug suspension. For vitamin K antagonists, the average time to the ischemic event was 10.4 days (SD = 5.7), and in 67% of patients, the time between drug discontinuation and the event was 7-14 days. The most frequent reason for drug suspension was patient negligence (37%), followed by planned surgery or invasive examination (26%) and side effects, including hemorrhage (18.5%). CONCLUSION Antiplatelet or vitamin K antagonist suspension has a temporal relationship with the occurrence of stroke and TIA. Since these events are preventable, it is crucial that healthcare professionals convince their patients that drug withdrawal can cause serious consequences.
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Affiliation(s)
| | | | | | | | | | - Pedro André Kowacs
- Instituto de Neurologia de Curitiba; Curitiba PR, Brasil.,Universidade Federal do Paraná, Curitiba PR, Brasil
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22
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Adhikari K, Patten SB, Lee S, Metcalfe A. Adherence to and Persistence with Antidepressant Medication during Pregnancy: Does It Differ by the Class of Antidepressant Medication Prescribed? CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2019; 64:199-208. [PMID: 30252505 PMCID: PMC6405814 DOI: 10.1177/0706743718802809] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Pregnant women are often concerned about the impact of medication use on their pregnancy, such as congenital abnormalities. This study examined the rate of adherence to and persistence with antidepressant medications during pregnancy based on the class of antidepressants prescribed. METHODS Women who gave birth between 2012 and 2015 in Alberta, Canada; had ≥1 diagnosis of depression within 1 year of preconception in outpatient physician claims, emergency department, or hospitalization administrative data; and were adherent (medication possession ratio ≥80%) to ≥2 consecutive antidepressant prescriptions during the preconception year ( n = 1865) were included in this retrospective cohort study. The rates of adherence and persistence (prescription refill gap ≤30 days) were calculated by antidepressant class and were compared using chi-square tests. RESULTS During pregnancy, 834 (44.7%; 95% CI, 42.4% to 47.0%) women discontinued antidepressants. Among those continuing antidepressants, the overall rate of adherence was 62.6% (95% CI, 59.4% to 65.7%). The rate differed significantly by medication class ( P < 0.0001), with a rate of 75.1% (95% CI, 68.3% to 80.9%) for serotonin-norepinephrine inhibitors, 60.9% (95% CI, 57.2% to 64.5%) for selective serotonin reuptake inhibitors, 42.8% (95% CI, 19.9% to 69.3%) for nonselective monoamine reuptake inhibitors, and 37.5% (95% CI, 22.5% to 55.4%) for atypical antidepressants. Only, 40.7% (95% CI, 37.5 to 44.1) of women were persistent with antidepressants for the full pregnancy period-the rate differed significantly by medication class ( P < 0.0001). CONCLUSIONS Adherence to and persistence with antidepressants is low during pregnancy and varies by medication class. Low adherence and persistence can interfere with a therapeutic effect of antidepressants, which may contribute to the worsening of depression symptoms.
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Affiliation(s)
- Kamala Adhikari
- 1 Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Scott B Patten
- 1 Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sangmin Lee
- 1 Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Amy Metcalfe
- 1 Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,2 Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada.,3 Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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23
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Plümer L, Seiffert M, Punke MA, Kersten JF, Blankenberg S, Zöllner C, Petzoldt M. Aspirin Before Elective Surgery-Stop or Continue? DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:473-480. [PMID: 28764836 DOI: 10.3238/arztebl.2017.0473] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 10/02/2016] [Accepted: 04/13/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cessation of long-term aspirin treatment before noncardiac surgery can cause adverse cardiac events in patients at risk, particularly in those with previous percutaneous coronary interventions (PCI) with stent implantation. The factors influencing the clinical decision to stop aspirin treatment are currently unknown. METHODS In a single-center, cross-sectional study (retrospective registration: NCT03049566) carried out from February to December 2014, we took a survey among patients scheduled for noncardiac surgery who were under long-term aspirin treatment, and among their treating anesthesiologists using standardized questionnaires on preoperative aspirin use, comorbidities, and risk-benefit assessments. The main objective was to identify factors associated with the decision to stop aspirin treatment. The results of multivariable logistic regressions and intraclass correlations are presented. RESULTS 805 patients were included in the study, and 636 questionnaires were returned (203 of which concerned patients with coronary stents). 46.8% of the patients stopped their long-term aspirin treatment before surgery; 38.7% of these patients stopped it too early (>10 days before surgery) or too late (≤ 3 days before surgery). A prior PCI with stent implantation lowered the probability of aspirin cessation (odds ratio [OR] = 0.47 [0.31; 0.72]; p <0.001). On the other hand, patients were more likely to stop their long-term aspirin treatment if it had already been discontinued once before (OR = 4.58 [3.06; 6.84]; p <0.001), if there was a risk of bleeding into a closed space (OR = 4.54 [2.02; 10.22]; p <0.001), if they did not know why they were supposed to take aspirin (OR = 2.12 [1.05; 4.28]; p = 0.036), or if the preoperative consultation with the anesthesiologist occurred <2 days before surgery (OR = 1.60 [1.08; 2.37]; p = 0.018). Patients often assessed the risks related to aspirin cessation lower than their physicians did. CONCLUSION This study reveals discordance between guideline recommendations and everyday clinical practice in patients with coronary stents. The early integration of cardiologists and anesthesiologists and a more widespread use of stent implant cards could promote adherence to the guidelines.
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Affiliation(s)
- Lili Plümer
- Department of Anesthesiology, Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany; Department of General and Interventional Cardiology, University Heart Center Hamburg (UHZ), Hamburg, Germany; Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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Screening for Gastric and Small Intestinal Mucosal Injury with Magnetically Controlled Capsule Endoscopy in Asymptomatic Patients Taking Enteric-Coated Aspirin. Gastroenterol Res Pract 2018; 2018:2524698. [PMID: 30581462 PMCID: PMC6276468 DOI: 10.1155/2018/2524698] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/26/2018] [Accepted: 10/14/2018] [Indexed: 02/06/2023] Open
Abstract
Objective To investigate gastric and small intestinal mucosal injury in asymptomatic patients taking enteric-coated aspirin using magnetically controlled capsule endoscopy. Methods Patients taking enteric-coated aspirin (aspirin group) and healthy controls (control group) were recruited from Beijing Anzhen Hospital, Capital Medical University, between September 2017 and May 2018, and undertook magnetically controlled capsule endoscopy. Results Twenty-six subjects were recruited to the aspirin group and twenty-six to the control group; the median Gastrointestinal Symptom Rating Scale scores were 3.50 and 3.00 (P = 0.200), the median gastric Lanza scores were 2.50 and 1.00 (P < 0.001), the small intestinal Lanza scores were 1.00 and 0.00 (P < 0.001), the gastric controlled examination times were 50.0 and 51.0 min (P = 0.171), the small intestinal transit times were 240.0 and 238.0 min (P = 0.654), and the capsule excretion times were 24.0 and 24.0 hours (P = 0.956), respectively. Conclusions Rates of gastric and small intestinal mucosal injuries were significantly higher in patients without obvious gastrointestinal symptoms taking enteric-coated aspirin compared to healthy controls. Magnetically controlled capsule endoscopy constitutes a safe, real-time screening modality for gastric and small intestinal mucosal injury in patients taking enteric-coated aspirin.
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25
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Jones MR, Howard G, Roubin GS, Blackshear JL, Cohen DJ, Cutlip DE, Leimgruber PP, Rhodes D, Prineas RJ, Glasser SP, Lal BK, Voeks JH, Brott TG. Periprocedural Stroke and Myocardial Infarction as Risks for Long-Term Mortality in CREST. Circ Cardiovasc Qual Outcomes 2018; 11:e004663. [PMID: 30571337 PMCID: PMC6309309 DOI: 10.1161/circoutcomes.117.004663] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) previously reported increased mortality in patients who sustained a periprocedural stroke or cardiac event (myocardial infarction [MI] or biomarker only) in follow-up to 4 years. We now extend these observations to 10 years. METHODS AND RESULTS CREST is a randomized controlled trial designed to compare the outcomes of carotid stenting versus carotid endarterectomy. Proportional hazards models were used to assess the association between mortality and periprocedural stroke, MI, or biomarker-only events. For 10-year follow-up, patients with periprocedural stroke were at 1.74× the risk of death compared with those without stroke (adjusted hazard ratio [HR]=1.74; 95% CI, 1.21-2.50; P<0.003). This increased risk was driven by increased early (between 0 and 90 days) mortality (adjusted HR=14.41; 95% CI, 5.33-38.94; P<0.0001), with no significant increase in late (between 91 days and 10 years) mortality (adjusted HR=1.40; 95% CI, 0.93-2.10; P=0.11). Patients with a protocol MI were at 3.61× increased risk of death compared with those without MI (adjusted HR=3.61; 95% CI, 2.28-5.73; P<0.0001), with an increased hazard both early (adjusted HR=8.20; 95% CI, 1.86-36.2; P=0.006) and late (adjusted HR=3.40; 95% CI, 2.09-5.53; P<0.0001). Patients with a biomarker-only event were at 2.04× increased risk overall (adjusted HR=2.04; 95% CI, 1.09-3.84; P=0.03) than those without MI, with an increased early hazard (adjusted HR=8.44; 95% CI, 1.09-65.5; P=0.04) and a suggestive but nonsignificant association toward higher 91-day to 10-year risk (1.88; 95% CI, 0.97-3.64; P=0.062) contributing to the increased risk. CONCLUSIONS In the CREST trial, patients with periprocedural events demonstrate a substantial increase in future mortality to 10 years. For stroke, this risk is largely confined to an early time frame while periprocedural MI or biomarker-only events confer a continuous increased mortality for 10 years. Strategies to reduce periprocedural events and to optimize the evaluation and management of patients with cardiac events should be considered in efforts to reduce not only early but also long-term mortality. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT00004732.
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Affiliation(s)
- Michael R. Jones
- Department of Cardiology, Baptist Health Lexington, Lexington, KY
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Gary S. Roubin
- Cardiovascular Associates of the Southeast, Birmingham, AL
| | - Joseph L. Blackshear
- Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FL
| | - David J. Cohen
- St. Luke’s Mid America Heart Institute, University of Missouri, Kansas City, MO
| | | | | | - David Rhodes
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Ronald J. Prineas
- Department of Public Health Services, Wake Forest School of Medicine, Winston Salem, NC
| | - Stephen P. Glasser
- Department of Medicine, Division of Cardiology, University of Kentucky School of Medicine, Lexington, KY
| | - Brajesh K. Lal
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore MD
| | - Jenifer H. Voeks
- College of Medicine, Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - Thomas G. Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL for the CREST Investigators
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Nouraei SM, Gholipour Baradari A, Emami Zeydi A. Does Early Post-operative Administration of Aspirin Influence the Risk of Bleeding After Coronary Artery Bypass Graft Surgery? A Prospective Observational Study. Med Arch 2018; 69:381-3. [PMID: 26843729 PMCID: PMC4720471 DOI: 10.5455/medarh.2015.69.381-383] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Aspirin has a proven role in preventing thrombotic diseases. However, given its anti-platelet activity, it is often assumed that its early post-operative administration significantly increase the amount of post-operative bleeding. Aim: The aim of this study was to determine whether early post-operative administration of aspirin influence the risk of bleeding in patients undergoing coronary artery bypass graft (CABG) surgery. Methods: In a prospective observational study, 100 consecutive patients undergoing first time elective CABG surgery were include in the study. Patients received a low dose of aspirin (75-150 mg per day) either 1 hours (the early aspirin group; n=43) or 6 hours after surgery (the late aspirin group; n=57). Total mediastinal blood drainage, blood drainage after 6 hours, incidences of re-operation for the control of bleeding and transfusion of red blood cells (RBCs) and blood products were recorded and followed until chest tube removal. Results: The groups were found to be matched for the confounding variables and no significant differences were found between post-aspirin bleeding (p=0.37), RBCs and blood product usage (p=0.90) or incidences of re-operation for control of bleeding (p=1.00) between the two groups. Conclusions: Early administration (1 hour after surgery) of aspirin did not appear to increase the risk of post-operative bleeding in patients undergoing CABG. Thereby, its early administration in such cases may be considered. Although further well-designed randomized controlled trials to confirm the safety and efficacy of early administration of aspirin after CABG surgery are warranted.
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Affiliation(s)
- Seyed Mahmood Nouraei
- Department of Cardiac Surgery, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Afshin Gholipour Baradari
- Department of Anesthesiology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Amir Emami Zeydi
- Student research Committee, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
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Iwasawa M, Wada K, Takada M. Gastrointestinal risk factors and prescribing pattern of antiulcer agents in patients taking low-dose aspirin in Japan. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2018; 26:369-372. [DOI: 10.1111/ijpp.12412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 10/02/2017] [Indexed: 11/29/2022]
Abstract
Abstract
Objectives
To identify prescribing patterns of antiulcer agents in patients on low-dose aspirin (LDA) and to evaluate the number of gastrointestinal (GI) risk factors of the patients.
Methods
A retrospective chart review of patients taking LDA was conducted at the National Cerebral and Cardiovascular Center in Japan. The rate of concomitant use of antiulcer agents and the risk of each patient to develop GI complications were evaluated.
Results
Of the 314 patients, 64 were not on antiulcer agents and 55 of them had >1 risk factor. More patients not on antiulcer agents had started LDA before hospitalization.
Conclusion
The rate of coprescribing antiulcer agents with LDA was high. However, the timing of initiating LDA therapy affected the prescribing pattern of antiulcer agents.
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Affiliation(s)
- Makiko Iwasawa
- Division of Drug Information, School of Pharmacy, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Kyoichi Wada
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Mitsutaka Takada
- Division of Clinical Drug Informatics, School of Pharmacy, Kindai University, Higashi-osaka, Osaka, Japan
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Khan TS, Sharma E, Singh B, Jammu B, Chadha A, Markanday D, Wu YY, Bajaj HS. Aspirin Increases the Risk of Nondiagnostic Yield of Fine-Needle Aspiration and Biopsy of Thyroid Nodules. Eur Thyroid J 2018; 7:129-132. [PMID: 30023344 PMCID: PMC6047498 DOI: 10.1159/000488451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 03/09/2018] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The link between the diagnostic yield of thyroid fine-needle aspiration and biopsy (FNAB) in patients taking antithrombotic or anticoagulant medications (AT/AC) remains poorly characterized. OBJECTIVES We studied the risk of obtaining a nondiagnostic sample with ultrasound-guided thyroid FNAB in patients taking AT/AC medications. METHODS This is a retrospective cohort study using medical rec-ords of 556 patients who underwent thyroid FNAB. All cytology samples were reported using the Bethesda classification. For patients with a nondiagnostic cytology, logistic regression was used to calculate OR for patients taking AT/AC medications. Multivariate regression was used to adjust for potential confounding variables including age, cystic ultrasound features, presence of eggshell calcifications, number of passes performed, cystic aspirate on FNAB, and position of the nodule. RESULTS Out of 556 patients, cytology results were available for 547 patients. Of these, 46 subjects were taking aspirin and 1 was on warfarin. Among the entire cohort, 17.5% of the subjects had a nondiagnostic cytology. Among the patients on AT/AC medications, 34% had a nondiagnostic result compared to 16% for those not taking them (OR = 2.70, p = 0.003). The subgroup of patients taking aspirin had similarly higher odds of a nondiagnostic cytology (OR = 2.78, p = 0.002). These differences remained statistically significant after multivariate adjustment. CONCLUSIONS This is the first study to demonstrate a 3-fold independently greater risk of a nondiagnostic FNAB cytology in patients taking aspirin. Our results highlight the importance of evaluating the need for continuation of aspirin in patients undergoing thyroid FNAB as this may impact the diagnostic yield of the procedure.
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Affiliation(s)
- Tayyab S. Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - Esha Sharma
- LMC Diabetes and Endocrinology, Brampton, Ontario, Canada
| | - Baldev Singh
- LMC Diabetes and Endocrinology, Brampton, Ontario, Canada
| | - Bikram Jammu
- LMC Diabetes and Endocrinology, Brampton, Ontario, Canada
| | | | | | - Yan Yan Wu
- Office of Public Health Studies, University of Hawai'i at Manoa, Honolulu, Hawaii, USA
| | - Harpreet S. Bajaj
- LMC Diabetes and Endocrinology, Brampton, Ontario, Canada
- Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, Ontario, Canada
- *Harpreet S. Bajaj, MD, MPH, ECNU, FACE, LMC Diabetes and Endocrinology, 2130 North Park Dr., Suite 238, Brampton, ON L6S 0C9 (Canada), E-Mail
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Otto BJ, Terry RS, Lutfi FG, Syed JS, Hamann HC, Gupta M, Bird VG. The Effect of Continued Low Dose Aspirin Therapy in Patients Undergoing Percutaneous Nephrolithotomy. J Urol 2018; 199:748-753. [DOI: 10.1016/j.juro.2017.10.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2017] [Indexed: 12/23/2022]
Affiliation(s)
- Brandon J. Otto
- Department of Urology, University of Florida College of Medicine, Gainesville, Florida
| | - Russell S. Terry
- Department of Urology, University of Florida College of Medicine, Gainesville, Florida
| | - Forat G. Lutfi
- University of Florida College of Medicine, Gainesville, Florida
| | - Jamil S. Syed
- University of Florida College of Medicine, Gainesville, Florida
| | | | - Mohit Gupta
- Department of Urology, University of Florida College of Medicine, Gainesville, Florida
| | - Vincent G. Bird
- Department of Urology, University of Florida College of Medicine, Gainesville, Florida
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Mattioli AV, Manenti A, Farinetti A. Sex differences in adherence to guidelines in aspirin prescription in a population of low-risk cardiovascular patients. Eur J Prev Cardiol 2018; 25:606-607. [DOI: 10.1177/2047487318758433] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Anna Vittoria Mattioli
- Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine University of Modena and Reggio Emilia, Italy
| | - Antonio Manenti
- Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine University of Modena and Reggio Emilia, Italy
| | - Alberto Farinetti
- Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine University of Modena and Reggio Emilia, Italy
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Elliott RA, Tanajewski L, Gkountouras G, Avery AJ, Barber N, Mehta R, Boyd MJ, Latif A, Chuter A, Waring J. Cost Effectiveness of Support for People Starting a New Medication for a Long-Term Condition Through Community Pharmacies: An Economic Evaluation of the New Medicine Service (NMS) Compared with Normal Practice. PHARMACOECONOMICS 2017; 35:1237-1255. [PMID: 28776320 PMCID: PMC5684280 DOI: 10.1007/s40273-017-0554-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND The English community pharmacy New Medicine Service (NMS) significantly increases patient adherence to medicines, compared with normal practice. We examined the cost effectiveness of NMS compared with normal practice by combining adherence improvement and intervention costs with the effect of increased adherence on patient outcomes and healthcare costs. METHODS We developed Markov models for diseases targeted by the NMS (hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, asthma and antiplatelet regimens) to assess the impact of patients' non-adherence. Clinical event probability, treatment pathway, resource use and costs were extracted from literature and costing tariffs. Incremental costs and outcomes associated with each disease were incorporated additively into a composite probabilistic model and combined with adherence rates and intervention costs from the trial. Costs per extra quality-adjusted life-year (QALY) were calculated from the perspective of NHS England, using a lifetime horizon. RESULTS NMS generated a mean of 0.05 (95% CI 0.00-0.13) more QALYs per patient, at a mean reduced cost of -£144 (95% CI -769 to 73). The NMS dominates normal practice with a probability of 0.78 [incremental cost-effectiveness ratio (ICER) -£3166 per QALY]. NMS has a 96.7% probability of cost effectiveness compared with normal practice at a willingness to pay of £20,000 per QALY. Sensitivity analysis demonstrated that targeting each disease with NMS has a probability over 0.90 of cost effectiveness compared with normal practice at a willingness to pay of £20,000 per QALY. CONCLUSIONS Our study suggests that the NMS increased patient medicine adherence compared with normal practice, which translated into increased health gain at reduced overall cost. TRIAL REGISTRATION ClinicalTrials.gov Trial reference number NCT01635361 ( http://clinicaltrials.gov/ct2/show/NCT01635361 ). Current Controlled trials: Trial reference number ISRCTN 23560818 ( http://www.controlled-trials.com/ISRCTN23560818/ ; DOI 10.1186/ISRCTN23560818 ). UK Clinical Research Network (UKCRN) study 12494 ( http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=12494 ). FUNDING Department of Health Policy Research Programme.
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Affiliation(s)
- Rachel A Elliott
- Manchester Centre for Health Economics, Room 4.318, 4th floor, Jean Mcfarlane Building, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
| | - Lukasz Tanajewski
- Division of Pharmacy Practice and Policy, The School of Pharmacy, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Georgios Gkountouras
- Division of Pharmacy Practice and Policy, The School of Pharmacy, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Anthony J Avery
- Primary Care Research, Division of Primary Care, School of Medicine, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Nick Barber
- Emeritus Professor of Pharmacy, UCL School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - Rajnikant Mehta
- Research Design Service, East Midlands (RDS EM), School of Medicine, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Matthew J Boyd
- Division of Pharmacy Practice and Policy, The School of Pharmacy, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Asam Latif
- School of Health Sciences, Faculty of Medicine and Health Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Antony Chuter
- Patient and Public Representative, 68 Brighton Cottages, Copyhold Lane, Lindfield, Haywards Heath, RH16 1XT, UK
| | - Justin Waring
- Organisational Sociology and Improvement Science, Centre for Health Innovation, Leadership and Learning, Nottingham University Business School, Jubilee Campus, University of Nottingham, Nottingham, NG8 2BB, UK
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Rodríguez L, Johansson S, Soriano LC. Use of clopidogrel and proton pump inhibitors after a serious acute coronary event: Risk of coronary events and peptic ulcer bleeding. Thromb Haemost 2017; 110:1014-24. [DOI: 10.1160/th13-03-0225] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 06/26/2013] [Indexed: 12/13/2022]
Abstract
SummarySome pharmacokinetic studies have reported that proton pump inhibitors (PPIs) reduce the activity of clopidogrel, but the results of studies assessing clinical outcomes in patients receiving both drugs are inconsistent. We have therefore carried out a population-based cohort study with nested case–control analysis, in order to evaluate changes in the risk of cardiovascular and peptic ulcer bleeding (PUB) events associated with PPI use in patients receiving clopidogrel. A total of 42,542 patients aged 50–84 years in 2000–2007 who survived an acute coronary event were identified in two UK-based primary care databases (The Health Improvement Network and the General Practice Research Database). Individuals were followed up to identify incident cases of non-fatal myocardial infarction/coronary death (n = 2,546) and PUB (n = 194). Controls were frequency matched to cases by age, sex and calendar year. Compared with PPI non-use, current continuous PPI use was not associated with a significant change in risk of non-fatal myocardial infarction/coronary death among current continuous users of clopidogrel monotherapy (relative risk [RR], 1.06; 95% confidence interval [95% CI], 0.47 to 2.36) or dual antiplatelet therapy (DAT; RR, 0.80; 95% CI, 0.47 to 1.37) who initiated their antiplatelet therapy shortly after their coronary event. Among patients prescribed DAT at the start date, the RR of PUB events associated with current PPI use initiated at the start date was 0.66 (95% CI, 0.27 to 1.60).
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Johansson S, Nagy P, Soriano LC, Rodríguez LAG. Use of proton pump inhibitors and the risk of coronary events in new users of low-dose acetylsalicylic acid in UK primary care. Thromb Haemost 2017; 111:131-9. [DOI: 10.1160/th13-07-0542] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 09/23/2013] [Indexed: 11/05/2022]
Abstract
SummaryThis study evaluated the risk of cardiovascular events associated with the use of proton pump inhibitors (PPIs) in new users of acetylsalicylic acid (ASA) for the secondary prevention of cardiovascular events. Two cohorts of patients aged 50–84 years were identified from UK primary care databases: individuals with a first prescription for ASA (75−300 mg/day) for secondary prevention of cardiovascular events (n = 39,513; CVD cohort) or with a record of hospitalisation for an acute coronary event (n = 42,542; ACS cohort) in 2000–2007. Cases of nonfatal myocardial infarction (MI) and coronary death were identified: 1,222 in the CVD cohort and 604 among new users of ASA in the ACS cohort. A nested case–control analysis estimated the relative risk (RR) of non-fatal MI or coronary death associated with use vs non-use of PPI therapy. Current continuous use of PPI therapy was not associated with a significant increase in RR overall: in the CVD cohort (RR = 1.14 [95% confidence interval = 0.91−1.43]); in the ACS cohort (0.88 [0.66−1.18]); or among current continuous users of ASA as antiplatelet monotherapy (CVD cohort: 1.15 [0.80−1.66]; ACS cohort: 0.73 [0.43−1.23]; pooled analysis of both cohorts: 0.96 [0.62−1.48]). In conclusion, among first-time users of ASA for the secondary prevention of cardiovascular events, PPI use was not shown to be associated with an increased risk of non-fatal MI or coronary death.
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Aspirin Use in Secondary Cardiovascular Protection and the Development of Aspirin-Associated Erosions and Ulcers. J Cardiovasc Pharmacol 2017; 68:121-6. [PMID: 27002280 DOI: 10.1097/fjc.0000000000000387] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Aspirin for secondary cardiovascular disease prevention is well established, but treatment discontinuation, often because of gastrointestinal mucosal injury or symptoms, can lead to increased risk for cardiovascular events. Proton pump inhibitor therapy is recommended for aspirin-treated patients at gastrointestinal risk. PA32540 [enteric-coated aspirin (EC-ASA) 325 mg + immediate-release omeprazole 40 mg] was compared with EC-ASA 325 mg alone once daily for 6 months in 2 duplicate, randomized double-blind trials in gastrointestinal-risk patients taking aspirin for ≥3 months for secondary prevention. In this post hoc analysis, we determined the prevalence of endoscopic upper gastrointestinal ulcers at screening and whether baseline endoscopic gastric erosions impacted subsequent ulcer development. At the screening endoscopy, 6% of subjects had upper gastrointestinal ulcers (not eligible for randomization) and 40% had gastric erosions. Conditional logistic regression modeling showed that baseline gastric erosions are significantly associated with endoscopic gastric ulcer development (OR = 2.12, 95% confidence interval, 1.26-3.57). In subjects with baseline gastric erosion, 4.2% of PA32540-treated versus 13.0% of EC-ASA-treated subjects (P = 0.001) subsequently developed endoscopic gastric ulcers. These data suggest that gastric injury predisposes to gastric ulcer development when taking EC-ASA, and exposure to immediate-release omeprazole in the presence of aspirin therapy significantly reduces the likelihood of progressing to gastric ulcers.
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Fradkov E, Goldowsky A, Quiles K, Williams R. A Quality Improvement Educational Intervention to Increase Knowledge of Cardiogastroenterology Amongst Medical Trainees and Nursing Staff. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2017; 13:10642. [PMID: 30800843 PMCID: PMC6338142 DOI: 10.15766/mep_2374-8265.10642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 09/28/2017] [Indexed: 06/09/2023]
Abstract
Introduction The American Society of Gastrointestinal Endoscopy recommends continuing aspirin prior to routine endoscopy. National data show that few endoscopists follow the current guidelines due to concern about bleeding and perceived minimal downside to stopping aspirin. Utilizing the Kern model, we implemented an educational quality improvement initiative aimed at increasing knowledge of antithrombotic management periendoscopy and during acute gastrointestinal (GI) bleeding. Methods We implemented an interactive lecture incorporating a large-group discussion to help residents learn to define low- versus high-risk procedures, distinguish thrombotic risk in medical conditions, present the procedural risks associated with use of antiplatelets, and list current practice guidelines. Nursing staff received a tailored lecture with the goal of learning proper management of current antiplatelets and holding parameters for anticoagulants prior to endoscopy. Both groups received pre-and posttest questionnaires evaluating their knowledge. Results Eighteen nurses and 75 medical trainees received this intervention. Significant score improvement was noted in both groups. The greatest change was seen in aspirin management (30.5% vs. 95.0% for group 1, 43.7% vs. 91.9% for group 2; p < .0001). For management of antiplatelets after aspirin-induced GI bleed, the medical trainees improved from 50.7% to 93.3%. Chi-square analysis showed a statistically significant difference in knowledge across all areas among medical trainees pre-and posttest (p < .001). Discussion This quality-based educational intervention significantly increased the knowledge of nurses and medical trainees in management guidelines that directly impact patient care. Similar educational programs may be very effective in improving quality and safety.
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Affiliation(s)
- Elena Fradkov
- Categorical Resident, Department of Medicine, New York University Langone Medical Center
| | | | - Kirsten Quiles
- Research Assistant, New York University Langone Medical Center
| | - Renee Williams
- Assistant Professor of Medicine, Division of Gastroenterology, New York University Langone Medical Center
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Sundström J, Hedberg J, Thuresson M, Aarskog P, Johannesen KM, Oldgren J. Low-Dose Aspirin Discontinuation and Risk of Cardiovascular Events. Circulation 2017; 136:1183-1192. [DOI: 10.1161/circulationaha.117.028321] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 07/06/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Johan Sundström
- From Department of Medical Sciences (J.S., J.O.), Uppsala Clinical Research Center (J.S., J.O.), and Department of Surgical Sciences (J.H), Uppsala University, Sweden; Statisticon AB, Uppsala, Sweden (M.T.); AstraZeneca Nordic Baltic, Södertälje, Sweden (P.A.); and Linköping University, Sweden (K.M.J.)
| | - Jakob Hedberg
- From Department of Medical Sciences (J.S., J.O.), Uppsala Clinical Research Center (J.S., J.O.), and Department of Surgical Sciences (J.H), Uppsala University, Sweden; Statisticon AB, Uppsala, Sweden (M.T.); AstraZeneca Nordic Baltic, Södertälje, Sweden (P.A.); and Linköping University, Sweden (K.M.J.)
| | - Marcus Thuresson
- From Department of Medical Sciences (J.S., J.O.), Uppsala Clinical Research Center (J.S., J.O.), and Department of Surgical Sciences (J.H), Uppsala University, Sweden; Statisticon AB, Uppsala, Sweden (M.T.); AstraZeneca Nordic Baltic, Södertälje, Sweden (P.A.); and Linköping University, Sweden (K.M.J.)
| | - Pernilla Aarskog
- From Department of Medical Sciences (J.S., J.O.), Uppsala Clinical Research Center (J.S., J.O.), and Department of Surgical Sciences (J.H), Uppsala University, Sweden; Statisticon AB, Uppsala, Sweden (M.T.); AstraZeneca Nordic Baltic, Södertälje, Sweden (P.A.); and Linköping University, Sweden (K.M.J.)
| | - Kasper Munk Johannesen
- From Department of Medical Sciences (J.S., J.O.), Uppsala Clinical Research Center (J.S., J.O.), and Department of Surgical Sciences (J.H), Uppsala University, Sweden; Statisticon AB, Uppsala, Sweden (M.T.); AstraZeneca Nordic Baltic, Södertälje, Sweden (P.A.); and Linköping University, Sweden (K.M.J.)
| | - Jonas Oldgren
- From Department of Medical Sciences (J.S., J.O.), Uppsala Clinical Research Center (J.S., J.O.), and Department of Surgical Sciences (J.H), Uppsala University, Sweden; Statisticon AB, Uppsala, Sweden (M.T.); AstraZeneca Nordic Baltic, Södertälje, Sweden (P.A.); and Linköping University, Sweden (K.M.J.)
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37
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García Rodríguez LA, Soriano-Gabarró M, Bromley S, Lanas A, Cea Soriano L. New use of low-dose aspirin and risk of colorectal cancer by stage at diagnosis: a nested case-control study in UK general practice. BMC Cancer 2017; 17:637. [PMID: 28882113 PMCID: PMC5590216 DOI: 10.1186/s12885-017-3594-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 08/23/2017] [Indexed: 02/06/2023] Open
Abstract
Background Evidence from clinical trial populations suggests low-dose aspirin reduces the risk of colorectal cancer (CRC). Part of this reduction in risk might be due to protection against metastatic disease. Methods We investigated the risk of CRC among new-users of low-dose aspirin (75–300 mg), including risk by stage at diagnosis. Using The Health Improvement Network, we conducted a cohort study with nested case–control analysis. Two cohorts (N = 170,336 each) aged 40–89 years from 2000 to 2009 and free of cancer were identified: i) new-users of low-dose aspirin, ii) non-users of low-dose aspirin, at start of follow-up, matched by age, sex and previous primary care practitioner visits. Patients were followed for up to 12 years to identify incident CRC. 10,000 frequency-matched controls were selected by incidence density sampling where the odds ratio is an unbiased estimator of the incidence rate ratio (RR). RRs with 95% confidence intervals were calculated. Low-dose aspirin use was classified ‘as-treated’ independent from baseline exposure status to account for changes in exposure during follow-up. Results Current users of low-dose aspirin (use on the index date or in the previous 90 days) had a significantly reduced risk of CRC, RR 0.66 (95% CI 0.60–0.74). The reduction in risk was apparent across all age groups, and was unrelated to dose, indication, gender, CRC location or case-fatality status. Reduced risks occurred throughout treatment duration and with all low-dose aspirin doses. RRs by aspirin indication were 0.71 (0·63–0·79) and 0.60 (0.53–0.68) for primary and secondary cardiovascular protection, respectively. Among cases with staging information (n = 1421), RRs for current use of low-dose aspirin were 0.94 (0.66–1.33) for Dukes Stage A CRC, 0.54 (0.42–0.68) for Dukes B, 0.71 (0.56–0.91) for Dukes C, and 0.60 (0.48–0.74) for Dukes D. After 5 years’ therapy, the RR for Dukes Stage A CRC was 0.53 (0.24–1.19). Conclusions Patients starting low-dose aspirin therapy have a reduced risk of Stages B–D CRC, suggesting a role for low-dose aspirin in the progression of established CRC; a substantial reduction in the risk of Dukes A CRC may occur after 5 years’ therapy. Electronic supplementary material The online version of this article (10.1186/s12885-017-3594-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luis A García Rodríguez
- Spanish Centre for Pharmacoepidemiologic Research, c/ Almirante 28, 2°, 28004, Madrid, Spain
| | | | - Susan Bromley
- EpiMed Communications Ltd, Abingdon, Oxford, OX14 1QS, UK.,London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT, UK
| | - Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico, University of Zaragoza, IIS Aragón, Zaragoza, Spain.,CIBERehd, Av. Monforte de Lemos, 3-5. Pabellón 11. Planta 0, 28029, Madrid, Spain
| | - Lucía Cea Soriano
- Spanish Centre for Pharmacoepidemiologic Research, c/ Almirante 28, 2°, 28004, Madrid, Spain.,Department of Preventive Medicine and Public Health, Faculty of Medicine, Complutense University of Madrid, Av. Séneca, 2, 28040, Madrid, Spain
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38
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Wen L. Upper Gastrointestinal Complications and Cardiovascular/Gastrointestinal Risk Calculator in Patients with Myocardial Infarction Treated with Aspirin. Chin Med J (Engl) 2017; 130:1909-1913. [PMID: 28776541 PMCID: PMC5555123 DOI: 10.4103/0366-6999.211889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Aspirin is widely used for the prevention of cardiovascular and cerebrovascular diseases for the past few years. However, much attention has been paid to the adverse effects associated with aspirin such as gastrointestinal bleeding. How to weigh the benefits and hazards? The current study aimed to assess the feasibility of a cardiovascular/gastrointestinal risk calculator, AsaRiskCalculator, in predicting gastrointestinal events in Chinese patients with myocardial infarction (MI), determining unique risk factor(s) for gastrointestinal events to be considered in the calculator. METHODS The MI patients who visited Shapingba District People's Hospital between January 2012 and January 2016 were retrospectively reviewed. Based on gastroscopic data, the patients were divided into two groups: gastrointestinal and nongastrointestinal groups. Demographic and clinical data of the patients were then retrieved for statistical analysis. Univariate and multiple logistic regression analyses were used to identify independent risk factors for gastrointestinal events. The receiver operating characteristic (ROC) curves were used to assess the predictive value of AsaRiskCalculator for gastrointestinal events. RESULTS A total of 400 MI patients meeting the eligibility criteria were analyzed, including 94 and 306 in the gastrointestinal and nongastrointestinal groups, respectively. The data showed that age, male gender, predicted gastrointestinal events, and Helicobacter pylori (HP) infection were positively correlated with gastrointestinal events. In multiple logistic regression analysis, predicted gastrointestinal events and HP infection were identified as risk factors for actual gastrointestinal events. HP infection was highly predictive in Chinese patients; the ROC curve indicated an area under the curve of 0.822 (95% confidence interval: 0.774-0.870). The best diagnostic cutoff point of predicted gastrointestinal events was 68.0‰, yielding sensitivity and specificity of 60.6% and 93.1%, respectively, for predicting gastrointestinal events in Chinese patients with MI. CONCLUSIONS AsaRiskCalculator had a predictive value for gastrointestinal events in Chinese patients with MI. HP infection seemed to be an independent risk factor for gastrointestinal events caused by long-term aspirin treatment in Chinese patients with MI, and it should be included in the risk calculator adapted for Chinese patients.
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Affiliation(s)
- Lei Wen
- Department of Gastroenterology, Shapingba District People's Hospital, Chongqing 400030, China
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39
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Durán J, Peloquin C, Zhang Y, Felson DT. Primary Prevention of Myocardial Infarction in Rheumatoid Arthritis Using Aspirin: A Case-crossover Study and a Propensity Score–matched Cohort Study. J Rheumatol 2017; 44:418-424. [DOI: 10.3899/jrheum.160930] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2017] [Indexed: 11/22/2022]
Abstract
Objective.Subjects with rheumatoid arthritis (RA) are at higher risk of developing cardiovascular disease, which is their leading cause of death. Conflicting evidence exists regarding the efficacy of aspirin (ASA) as primary prevention. We evaluated whether a protective association exists between ASA and myocardial infarction (MI) in RA subjects.Methods.In the United Kingdom, persons age ≥ 60 years receive free ASA by prescription and 75% of use is by prescription. Subjects ≥ 60 years with RA in the population-based The Health Improvement Network database constituted our study population. We excluded patients with history of MI, angina, stroke, peripheral vascular disease, or coronary artery procedures. Our main outcome was the occurrence of fatal and nonfatal MI. We performed a case-crossover study with each subject contributing a hazard period and a control period 90 days prior to the MI. In addition, to minimize confounding by indication, a propensity score (PS)–matched cohort study was performed, considering all patients with RA with an incident prescription of low-dose ASA as our exposed group.Results.We did not find a protective effect in the case-crossover study (OR 1.83, 95% CI 0.71–4.71), with 55 subjects exposed in the hazard period and 44 in the control period. Similarly, among 1836 subjects included in the PS-matched cohort study (918 ASA users and 918 ASA non-users), we did not find a protective effect of low ASA on MI (HR 1.39, 95% CI 0.87–2.23).Conclusion.We did not find a protective effect of ASA on MI in patients with RA when used as primary prophylaxis.
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Witteman HO, Presseau J, Nicholas Angl E, Jokhio I, Schwalm JD, Grimshaw JM, Bosiak B, Natarajan MK, Ivers NM. Negotiating Tensions Between Theory and Design in the Development of Mailings for People Recovering From Acute Coronary Syndrome. JMIR Hum Factors 2017; 4:e6. [PMID: 28249831 PMCID: PMC5352859 DOI: 10.2196/humanfactors.6502] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 12/19/2016] [Accepted: 12/19/2016] [Indexed: 11/13/2022] Open
Abstract
Background Taking all recommended secondary prevention cardiac medications and fully participating in a formal cardiac rehabilitation program significantly reduces mortality and morbidity in the year following a heart attack. However, many people who have had a heart attack stop taking some or all of their recommended medications prematurely and many do not complete a formal cardiac rehabilitation program. Objective The objective of our study was to develop a user-centered, theory-based, scalable intervention of printed educational materials to encourage and support people who have had a heart attack to use recommended secondary prevention cardiac treatments. Methods Prior to the design process, we conducted theory-based interviews and surveys with patients who had had a heart attack to identify key determinants of secondary prevention behaviors. Our interdisciplinary research team then partnered with a patient advisor and design firm to undertake an iterative, theory-informed, user-centered design process to operationalize techniques to address these determinants. User-centered design requires considering users’ needs, goals, strengths, limitations, context, and intuitive processes; designing prototypes adapted to users accordingly; observing how potential users respond to the prototype; and using those data to refine the design. To accomplish these tasks, we conducted user research to develop personas (archetypes of potential users), developed a preliminary prototype using behavior change theory to map behavior change techniques to identified determinants of medication adherence, and conducted 2 design cycles, testing materials via think-aloud and semistructured interviews with a total of 11 users (10 patients who had experienced a heart attack and 1 caregiver). We recruited participants at a single cardiac clinic using purposive sampling informed by our personas. We recorded sessions with users and extracted key themes from transcripts. We held interdisciplinary team discussions to interpret findings in the context of relevant theory-based evidence and iteratively adapted the intervention accordingly. Results Through our iterative development and testing, we identified 3 key tensions: (1) evidence from theory-based studies versus users’ feelings, (2) informative versus persuasive communication, and (3) logistical constraints for the intervention versus users’ desires or preferences. We addressed these by (1) identifying root causes for users’ feelings and addressing those to better incorporate theory- and evidence-based features, (2) accepting that our intervention was ethically justified in being persuasive, and (3) making changes to the intervention where possible, such as attempting to match imagery in the materials to patients’ self-images. Conclusions Theory-informed interventions must be operationalized in ways that fit with user needs. Tensions between users’ desires or preferences and health care system goals and constraints must be identified and addressed to the greatest extent possible. A cluster randomized controlled trial of the final intervention is currently underway.
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Affiliation(s)
- Holly O Witteman
- Department of Family and Emergency Medicine, Faculty of Medicine, Laval University, Quebec City, QC, Canada.,Office of Education and Professional Development, Faculty of Medicine, Laval University, Quebec City, QC, Canada.,Pavillon Ferdinand-Vandry 2881, Quebec City, QC, Canada
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Emily Nicholas Angl
- Patients Canada, Toronto, ON, Canada.,Pivot Design Group Inc, Toronto, ON, Canada
| | | | - J D Schwalm
- Department of Medicine, Division of Cardiology, Hamilton Health Sciences, Hamilton, ON, Canada.,Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Beth Bosiak
- Women's College Research Institute, Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Madhu K Natarajan
- Department of Medicine, Division of Cardiology, Hamilton Health Sciences, Hamilton, ON, Canada.,Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Noah M Ivers
- Women's College Research Institute, Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Family Practice Health Centre, Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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41
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Goldstein JL, Whellan DJ, Scheiman JM, Cryer BL, Eisen GM, Lanas A, Fort JG. Long-Term Safety of a Coordinated Delivery Tablet of Enteric-Coated Aspirin 325 mg and Immediate-Release Omeprazole 40 mg for Secondary Cardiovascular Disease Prevention in Patients at GI Risk. Cardiovasc Ther 2017; 34:59-66. [PMID: 26725920 PMCID: PMC5069577 DOI: 10.1111/1755-5922.12172] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction In two, 6‐month, randomized, double‐blind Phase 3 trials, PA32540 (enteric‐coated aspirin 325 mg and immediate‐release omeprazole 40 mg) compared to aspirin alone was associated with fewer endoscopic gastric and duodenal ulcers in patients requiring aspirin therapy for secondary cardiovascular disease (CVD) prevention who were at risk for upper gastrointestinal (UGI) events. Aims In this 12‐month, open‐label, multicenter Phase 3 study, we evaluated the long‐term cardiovascular and gastrointestinal safety of PA32540 in subjects who were taking aspirin 325 mg daily for ≥3 months for secondary CVD prevention and were at risk for aspirin‐associated UGI events. Enrolled subjects received PA32540 once daily for up to 12 months and were assessed at baseline, month 1, month 6, and month 12. Results The overall safety population consisted of 379 subjects, and 290 subjects (76%) were on PA32540 for ≥348 days (12‐month completers). Adverse events (AEs) caused study withdrawal in 13.5% of subjects, most commonly gastroesophageal reflux disease (1.1%). Treatment‐emergent AEs occurred in 76% of the safety population (11% treatment‐related) and 73% of 12‐month completers (8% treatment‐related). The most common treatment‐related AE was dyspepsia (2%). One subject had a gastric ulcer observed on for‐cause endoscopy. There were five cases of adjudicated nonfatal myocardial infarction, one nonfatal stroke, and one cardiovascular death, but none considered treatment‐related. Conclusions Long‐term treatment with PA32540 once daily for up to 12 months in subjects at risk for aspirin‐associated UGI events is not associated with any new or unexpected safety events.
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Affiliation(s)
| | | | | | - Byron L Cryer
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Glenn M Eisen
- Oregon Health and Science University, Portland, OR, USA
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Niikura R, Nagata N, Doyama H, Ota R, Ishii N, Mabe K, Nishida T, Hikichi T, Sumiyama K, Nishikawa J, Uraoka T, Kiyotoki S, Fujishiro M, Koike K. Current state of practice for colonic diverticular bleeding in 37 hospitals in Japan: A multicenter questionnaire study. World J Gastrointest Endosc 2016; 8:785-794. [PMID: 28042393 PMCID: PMC5159677 DOI: 10.4253/wjge.v8.i20.785] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 08/20/2016] [Accepted: 11/02/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To clarify the current state of practice for colonic diverticular bleeding (CDB) in Japan.
METHODS We conducted multicenter questionnaire surveys of the practice for CDB including clinical settings (8 questions), diagnoses (8 questions), treatments (7 questions), and outcomes (4 questions) in 37 hospitals across Japan. The answers were compared between hospitals with high and low number of inpatient beds to investigate which factor influenced the answers.
RESULTS Endoscopists at all 37 hospitals answered the questions, and the mean number of endoscopists at these hospitals was 12.7. Of all the hospitals, computed tomography was performed before colonoscopy in 67% of the hospitals. The rate of bowel preparation was 46.0%. Early colonoscopy was performed within 24 h in 43.2% of the hospitals. Of the hospitals, 83.8% performed clipping as first-line endoscopic therapy. More than half of the hospitals experienced less than 20% rebleeding events after endoscopic hemostasis. No significant difference was observed in the annual number of patients hospitalized for CDB between high- (≥ 700 beds) and low-volume hospitals. More emergency visits (P = 0.012) and endoscopists (P = 0.015), and less frequent participation of nursing staff in early colonoscopy (P = 0.045) were observed in the high-volume hospitals.
CONCLUSION Some practices unique to Japan were found, such as performing computed tomography before colonoscopy, no bowel preparation, and clipping as first-line therapy. Although, the number of staff differed, the practices for CDB were common irrespective of hospital size.
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González-Pérez A, Sáez ME, Johansson S, Nagy P, García Rodríguez LA. Mortality in patients who discontinue low-dose acetylsalicylic acid therapy after upper gastrointestinal bleeding. Pharmacoepidemiol Drug Saf 2016; 26:215-222. [DOI: 10.1002/pds.4140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 09/13/2016] [Accepted: 11/03/2016] [Indexed: 01/10/2023]
Affiliation(s)
- Antonio González-Pérez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE); Madrid Spain
- Andalusian Bioinformatics Research Centre (CAEBi); Seville Spain
| | - María Eugenia Sáez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE); Madrid Spain
- Andalusian Bioinformatics Research Centre (CAEBi); Seville Spain
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Sadhasivam G, Bhushan S, Chiang KC, Agarwal N, Vasundhar PL. Clinical Trial Evaluating the Risk of Thromboembolic Events During Dental Extractions. J Maxillofac Oral Surg 2016; 15:506-511. [PMID: 27833344 PMCID: PMC5083703 DOI: 10.1007/s12663-016-0904-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 03/24/2016] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Discontinuation of anti-platelet therapy increases the risk of thrombotic complications whereas its continuation is believed to increase the risk of prolonged post-extraction bleeding. We therefore, performed this study to evaluate the risk of significant bleeding following dental extractions and also to assess the necessity of discontinuing anti-platelet therapy. PATIENTS AND METHODS Three hundred patients requiring dental extraction were included in the study in which 200 patients were on anti-platelet therapy. Patients were divided into three groups of 100 patients each. Group 1 consisted of patients continuing their anti-platelet therapy, Group 2 consisted of patients whose anti-platelet therapy was interrupted and Group 3 comprised of healthy patients not on anti-platelet therapy. Preoperative bleeding and clotting time were determined for all patients. The procedure involved single or multiple teeth (>3 teeth) extractions under local anesthesia with a vasoconstrictor. Pressure pack was given in all cases as in routine dental extractions and bleeding was checked after 15, 30 min, 1, 24, 48 h and 1 week. Immediate post-extraction bleeding was considered to be prolonged if it continued beyond 30 min in spite of the pressure pack. Late and very late bleeding was considered to be clinically significant if it extended beyond 12 and 24 h respectively. RESULTS The mean bleeding time in Groups 1, 2, and 3 were 1 min and 32 s, 1 min and 25 s, and 1 min and 27 s, respectively. Prolonged immediate post-extraction bleeding (bleeding after 30 min) was present among 9 patients in Group 1 (9 %) and 15 patients in Group 2 (15 %) whereas it was not seen in any patient of Group 3. Bleeding after 1 h was present in 9 patients of Group 2 (9 %) and was controlled with gelatin sponge within half an hour thereafter. None of the patients in any group reported with bleeding after 24, 48 h and 1 week. CONCLUSION Dental extractions can be safely carried out in patients on anti-platelet therapy without the risk of significant post-extraction bleeding thus averting the risk of thromboembolic events that might take place on temporary discontinuation of antiplatelet therapy.
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Affiliation(s)
| | - Satya Bhushan
- Department of OMFS, GITAM Dental College & Hospital, Visakhapatnam, India
| | - Kho Chai Chiang
- Department of OMFS, GITAM Dental College & Hospital, Visakhapatnam, India
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Risks associated with permanent discontinuation of blood pressure-lowering medications in patients with type 2 diabetes. J Hypertens 2016; 34:781-7. [PMID: 26938813 DOI: 10.1097/hjh.0000000000000841] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The associations of discontinuation of the study medication on major outcomes were assessed in the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation Trial. METHODS ADVANCE was a factorial randomized controlled trial of blood pressure lowering (a fixed combination of perindopril and indapamide vs. placebo) and intensive glucose control (vs. standard glucose control) in patients with type 2 diabetes. Patients who permanently discontinued the randomized blood pressure-lowering medication during the study period (n = 1557) were compared with others (n = 9583). Cox's proportional hazards models were used to estimate the effects of the discontinuation on the risks of macrovascular events, microvascular events together and separately and all-cause mortality, using discontinuation as a time-dependent covariate. RESULTS In multivariable analyses, discontinuation was associated with increased risks of combined macro and microvascular events (hazard ratio 2.24, 95% CI 1.96-2.57), macrovascular events (3.23, 2.75-3.79), microvascular events (1.38, 1.11-1.71), and all-cause mortality (7.99, 6.92-9.21) compared to continuing administration of randomized medications during the trial period, which were highest in the first year after discontinuation. These associations were similar in active and placebo groups, except in the first year after discontinuation during which event rates were lower in the active group than in the placebo group (P ≤ 0.01). CONCLUSION Discontinuation of study medication is a potent risk marker for identifying high-risk patients. Thus it is important that clinicians seek to identify such patients early after discontinuation of treatment. Although some short-term residual effects of previous active treatment can be expected, patients who discontinue require further urgent investigation and management.
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Cea Soriano L, Soriano-Gabarró M, García Rodríguez LA. The Protective Effect of Low-Dose Aspirin against Colorectal Cancer Is Unlikely Explained by Selection Bias: Results from Three Different Study Designs in Clinical Practice. PLoS One 2016; 11:e0159179. [PMID: 27428004 PMCID: PMC4948817 DOI: 10.1371/journal.pone.0159179] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 06/28/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND We conducted three differently designed nested case-control studies to evaluate whether the protective effect of low-dose aspirin against colorectal cancer (CRC) is explained by selection bias. METHODS Using a large validated UK primary care database, we followed different cohorts of patients, who varied in their demographic and clinical characteristics, to identify first ever cases of CRC. In Studies 1 and 2, two cohorts were followed, i) new users of low-dose aspirin at start of follow-up (N = 170,336 in Study 1, N = 171,527 in Study 2) and either ii) non-users of low-dose aspirin (Study 1, N = 170,336) or new users of paracetamol (Study 2, N = 149,597) at start of follow-up. In Study 3 a single cohort of individuals näive to low-dose aspirin at the start of observation was followed. Controls were selected using incidence sampling and logistic regression used to obtain an unbiased estimate of the incidence rate ratio (RR) with 95% confidence intervals (CIs). Low-dose aspirin exposure was analyzed 'as-treated' before the index date (CRC date for cases, random date for controls). RESULTS In the three studies, median (maximum) follow-up was 5.1 (12), 5.8 (12) and 7.5 (13) years, respectively. 3033 incident CRC cases were identified in Study 1, 3174 in Study 2, and 12,333 in Study 3. Current use of low-dose aspirin was associated with a significantly reduced risk of 34%, 29% and 31% in the three studies, respectively; corresponding RRs (95% CIs) were 0.66 (0.60-0.73), 0.71 (0.63-0.80) and 0.69 (0.64-0.74). In each study, significantly reduced risks of CRC were seen when low-dose aspirin was used for primary or secondary cardiovascular disease prevention, in both sexes, and across all age groups evaluated. CONCLUSION Low-dose aspirin is associated with a significantly reduced risk of CRC. The consistency of our findings across different studies makes selection bias an unlikely explanation.
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Zeymer U, Becher A, Jennings E, Johansson S, Westergaard M. Systematic review of the clinical impact of dual antiplatelet therapy discontinuation after acute coronary syndromes. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:522-531. [DOI: 10.1177/2048872616648467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Uwe Zeymer
- Klinikum Ludwigshafen, Institut für Herzinfarktforschung, Germany
| | - Anja Becher
- Research and Evaluation Unit, Oxford PharmaGenesis Ltd, UK
- School of Medicine, Pharmacy and Health, Durham University, UK
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Abstract
Determining practice parameters for interventional procedures is challenging due to many factors including unreliable laboratory tests to measure bleeding risk, variable usage of standardized terminology for adverse events, poorly defined standards for administration of blood products, and the growing numbers of anticoagulant and antiplatelet medications. We aim to address these and other issues faced by radiologists performing invasive procedures through a review of available literature, and experiential guidance from three academic medical centers. We discuss the significant limitations with respect to using prothrombin-time and international normalized ratio to measure bleeding risk, especially in patients with synthetic defects due to liver function. Factors affecting platelet function including the impact of uremia; recent advances in laboratory testing, including platelet function testing; and thromboelastography are also discussed. A review of the existing literature of fresh-frozen plasma replacement therapy is included. The literature regarding comorbidities affecting coagulation including malignancy, liver failure, and uremia are also reviewed. Finally, the authors present a set of recommendations for laboratory thresholds, corrective transfusions, as well as withholding and restarting medications.
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Proton Pump Inhibitors in Cardiovascular Disease: Drug Interactions with Antiplatelet Drugs. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:325-350. [PMID: 27628008 DOI: 10.1007/5584_2016_124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Aspirin and P2Y12 receptor antagonists are widely used across the spectrum of cardiovascular diseases. Upper gastrointestinal complications, including ulcer and bleeding, are relatively common during antiplatelet treatment and, therefore, concomitant proton pump inhibitor (PPI) treatment is often prescribed.PPIs provide gastroprotection by changing the intragastric milieu, essentially by raising intragastric pH. In recent years, it has been heavily discussed whether PPIs may reduce the cardiovascular protection by aspirin and, even more so, clopidogrel. Pharmacodynamic and pharmacokinetic studies suggested an interaction between PPIs and clopidogrel, and subsequent clinical studies were conducted to evaluate the clinical impact of this interaction. More recently, it was reported that PPIs may also attenuate the antiplatelet effect of aspirin. This may be clinically important, because a fixed combination of aspirin and a PPI (esomeprazole) has recently been approved and because aspirin is the most widely used drug in patients with cardiovascular disease. The antiplatelet effect of the new P2Y12 receptor antagonists, ticagrelor and prasugrel, seems less influenced by PPI co-treatment.Given the large number of patients treated with antithrombotic drugs and PPIs, even a minor reduction of platelet inhibition potentially carries considerable clinical impact. The present book chapter summarizes the evidence regarding the widespread use of platelet inhibitors and PPIs in combination. Moreover, it outlines current evidence supporting or opposing drug interactions between these drugs and discusses clinical implications.
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