Interindividual variability in response to aspirin remains a major challenge in antiplatelet therapy. Identification of patients with high platelet reactivity (HPR) and optimal or low platelet reactivity remains challenging and may be influenced by both biological and methodological factors, including interlaboratory variability. We report results of a large cohort of aspirin-treated patients to assess the gold standard light transmission aggregometry (LTA). We retrospectively analyzed 3065 patients treated with aspirin (ASA; 75-150 mg/d) who sequentially underwent LTA assessment using multiple agonists (adenosine diphosphate [ADP] 2μM, collagen 2 μg/mL, arachidonic acid [AA] 0.75mM, and epinephrine 10μM). Patients were stratified according to AA-induced platelet aggregation using a 16% cutoff (third quartile). Patients with AA >16% showed significantly higher platelet aggregation across all agonists (P < .0001). However, a substantial proportion of patients with AA ≤16%, consistent with effective COX-1 inhibition, still exhibited HPR when stimulated with ADP, epinephrine, or collagen. Collagen-induced aggregation was particularly informative in identifying residual platelet reactivity. Sex-related differences were observed, with female patients showing HPR, especially to ADP and collagen. Platelet reactivity in aspirin-treated patients is highly heterogeneous, with hyperreactive or hyporeactive phenotype potentially affecting the safety and efficacy of antiplatelet therapy. AA-induced aggregation alone is insufficient to fully characterize platelet responsiveness. A multiagonist approach, particularly including collagen, may improve identification of patients with residual platelet reactivity and support personalized antiplatelet strategies. These data support ongoing strategies of guided selection of antiplatelet therapy in patients with cardiovascular disease.

Acute pancreatitis may cause electrocardiographic abnormalities and troponin elevation that mimic acute myocardial infarction. True coronary thrombosis is less common. The development of disseminated intravascular coagulation shortly after percutaneous coronary intervention creates a difficult balance between bleeding control and prevention of early stent thrombosis. A 68-year-old man with no previous pancreatitis presented with acute interstitial pancreatitis. Evaluation did not identify biliary disease, alcohol use, hypertriglyceridemia, hypercalcemia, medication exposure, autoimmune pancreatitis, pancreatic duct abnormalities, or malignancy, and the episode was classified as idiopathic. Coronary CT angiography performed five months earlier had shown an Agatston calcium score of 0 and Coronary Artery Disease Reporting and Data System (CAD-RADS) category 0, with no visible coronary plaque or stenosis. On day two of hospitalization, he developed inferior ST-elevation myocardial infarction caused by a 99% thrombotic subtotal occlusion of the mid-right coronary artery. Primary percutaneous coronary intervention with drug-eluting stent implantation restored normal coronary flow. Approximately 48 hours later, he developed bleeding-predominant disseminated intravascular coagulation with severe thrombocytopenia, hypofibrinogenemia, prolonged coagulation parameters, and mucocutaneous bleeding. Aspirin was continued, ticagrelor was changed to clopidogrel, and targeted blood-component replacement was administered. Acquired and inherited thrombophilia testing performed after recovery was negative. Acute pancreatitis may mimic myocardial infarction, but true coronary thrombosis should be suspected when ischemic symptoms, reciprocal electrocardiographic changes, dynamic troponin elevation, regional wall-motion abnormality, and a culprit coronary lesion are present. A recent normal coronary CT angiogram does not exclude a later acute thrombotic event. Bleeding-predominant disseminated intravascular coagulation shortly after percutaneous coronary intervention requires individualized antiplatelet adjustment and targeted hemostatic support.

Background and objective Venous thromboembolism (VTE) after reverse total shoulder arthroplasty (RTSA) is uncommon but potentially fatal, and there is no consensus on extended pharmacological prophylaxis after discharge. This study described symptomatic VTE and other acute complications within 90 days of RTSA under the three extended prophylaxis strategies used in routine practice (rivaroxaban, aspirin, or no extended prophylaxis) and compared them descriptively. Methods We retrospectively reviewed all RTSAs performed by four shoulder and elbow surgeons at a single orthopedic referral center between January 2021 and April 2024. Patients with preoperative oral anticoagulation, follow-up shorter than three months, or a post-discharge regimen other than the three studied or not completed were excluded. All patients received intraoperative mechanical prophylaxis, enoxaparin 40 mg daily until discharge, and early mobilization. After discharge, in the absence of an institutional protocol, the treating surgeon chose rivaroxaban 10 mg once daily for 15 or 30 days, aspirin 81 mg once daily for 30 days, or no extended prophylaxis. Pulmonary embolism (PE) was confirmed by computed tomography pulmonary angiography. The primary outcome, symptomatic VTE, was compared with the exact Freeman-Halton test, Holm-adjusted pairwise Fisher's exact tests, and risk differences with Newcombe hybrid score 95% confidence intervals (CIs); other complications were described without inferential testing. Results Of 84 patients screened, 68 were included (52 women, 76.5%; median age 76 years, interquartile range 71-79), and all completed in-person follow-up at three months. No extended prophylaxis was given to 28 patients (41.2%), aspirin to 17 (25.0%), and rivaroxaban to 23 (33.8%). No symptomatic deep vein thrombosis occurred. Symptomatic PE occurred in one of 28 patients without extended prophylaxis (3.6%, 95% CI: 0.6-17.7; postoperative day 35, fatal), one of 17 receiving aspirin (5.9%, 95% CI: 1.0-27.0; day 22), and none of 23 receiving rivaroxaban (0%, 95% CI: 0-14.3) (p=0.717); no pairwise comparison approached significance after adjustment. Three non-thromboembolic complications occurred, all with rivaroxaban. Groups differed at baseline in age (p=0.019) and length of stay (p=0.019), and prophylaxis was almost entirely determined by the operating surgeon (p<0.001). Conclusions Because extended prophylaxis was chosen by the operating surgeon and was almost entirely collinear with surgeon identity, the observed differences cannot be attributed to the drugs themselves. No symptomatic PE occurred with rivaroxaban, but with only two events the estimates are highly imprecise and no comparison approached significance. These hypothesis-generating data describe institutional practice and do not establish the superiority of any strategy; extended thromboprophylaxis after RTSA should remain an individualized decision until adequately powered prospective studies are available.

Gut dysbiosis is associated with chronic immune activation in people with HIV (PWH), but is not well-characterized in elite controllers (ECs) or PWH receiving aspirin or statins. We analyzed gut microbiota among 22 virally-suppressed PWH and 12 ECs before and 9-months after randomization to aspirin or atorvastatin. There were no differences in microbiota between PWH and EC at baseline. There was a significant change in beta diversity after aspirin administration, but no difference in microbiota after atorvastatin. These findings suggest that ECs have gut microbiota resembling virally-suppressed PWH, and aspirin but not atorvastatin may impact gut microbiota diversity in PWH.

Pituitary apoplexy (PA) is an acute, potentially life-threatening neuroendocrine emergency caused by hemorrhage or infarction within the pituitary gland, most often arising in a previously unrecognized pituitary neuroendocrine tumor (PitNET). Reported precipitants include surgery, anticoagulation, dynamic pituitary testing, hypertension, and head trauma; alcohol is rarely implicated. We report a 61-year-old man with long-standing hypertension, type 2 diabetes mellitus and coronary artery disease (on aspirin after coronary stenting) who developed sudden thunderclap headache and complete right oculomotor nerve palsy the morning after consuming approximately 250 ml of distilled liquor (baijiu). Magnetic resonance imaging showed a 2.7 cm × 1.9 cm × 1.9 cm sellar mass with heterogeneous hemorrhagic signal, suprasellar extension and optic chiasm contact. Perioperative endocrine evaluation demonstrated secondary adrenal insufficiency, central hypothyroidism and low gonadotropins, consistent with multi-axis hypopituitarism. After aspirin withdrawal and immediate parenteral hydrocortisone, the patient underwent endoscopic endonasal transsphenoidal resection on day 8. Histopathology confirmed an SF-1 lineage gonadotroph PitNET with extensive infarction (Ki-67 2%; FSH+, SF-1+, PIT-1-, T-PIT-). At 3 months, the right oculomotor palsy had partially recovered, with improvement in ptosis and ocular motility but incomplete resolution. Follow-up contrast-enhanced magnetic resonance imaging showed no residual or recurrent tumor, a decompressed optic chiasm and a midline pituitary stalk, and the markedly elevated presenting 24h urinary free cortisol had returned to the laboratory reference range. Anterior pituitary function nonetheless remained deficient across the corticotroph, thyrotroph, and gonadotroph axes, and the patient continued stable hydrocortisone and levothyroxine replacement. This case adds to the limited literature on PA temporally associated with alcohol intake, illustrates the value of World Health Organization 2022 lineage-based PitNET classification, and supports individualized, semi-elective surgery in haemodynamically stable patients without acute visual-pathway compromise.

Background The use of oral anticoagulants (OACs), especially direct oral anticoagulants (DOACs), for thromboprophylaxis in atrial fibrillation (AF) has increased over the last decade, and an increasing number of generic DOAC medications (particularly regarding rivaroxaban and apixaban) have been marketed recently. The aim of the present study was to prospectively observe clinical event rates and patient satisfaction with a generic rivaroxaban for thromboprophylaxis in patients with AF. Methods Adult patients with AF in whom long-term OAC was indicated for thromboprophylaxis were included in this international, prospective, non-interventional, observational study with 1-year follow-up, conducted in the Republic of Serbia and Bosnia and Herzegovina. Data were collected at baseline and 3-, 6-, and 12-month follow-up visits. The primary endpoints were stroke/systemic embolism (SE), major bleeding, and all-cause mortality. Secondary endpoints included adverse events and patient satisfaction with generic rivaroxaban therapy. Results Of 1092 patients (mean age 67.9 ± 9.8, 42.9% female), 72 (6.6%) discontinued the treatment due to different reasons. The mean value of the CHA 2 DS 2 -VASc score (Congestive heart failure, Hypertension, Age > 75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category) and HAS-BLED (Hypertension [uncontrolled], Abnormal renal and/or liver function, Stroke history, Bleeding history, Labile International Normalised Ratio, Elderly [>65 years], Drugs [non-steroidal anti-inflammatory drugs, aspirin]/Alcohol use [>8 drinks per week]) score was 3.15 ± 1.55 and 1.18 ± 0.92, respectively. Overall, seven patients (0.64%) experienced a symptomatic thromboembolic event (two strokes, three transient ischaemic attack, and two SE), and major bleeding occurred in two patients (0.18%). At the 3-, 6- and 12-month follow-up visits, 1068 (97.8%), 1031 (94.4%) and 1014 participants (92.9%), respectively, were still taking generic rivaroxaban. At 3 and 12 months, 1024/1071 patients (95.6%) and 1005/1020 (98.5%), respectively, were very satisfied or satisfied with generic rivaroxaban. Conclusions The observed clinical event rates during the use of generic rivaroxaban in AF patients were low, with very good 1-year persistence to treatment and persistently high level of patient satisfaction with generic rivaroxaban, including those previously taking another OAC. More studies with larger sample size are needed to allow additional analyses of factors associated with specific outcomes, including non-persistence to treatment with generic rivaroxaban.