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- Chest pain in a patient with a tall R wave in V1. [Journal Article]
- BMJ Case Rep 2014.
An 83-year-old man 2 days postoperative from L3 to L5 laminectomy developed sudden onset of chest pain. Initial ECGs demonstrated a tall R wave in V1 and ST-segment depression in leads V2-V5. A posterior ECG was performed, but failed to demonstrate ST elevations. The patient was initially treated as an non-ST-segment elevation myocardial infarction with weight-based enoxaparin. On further review, the patient's ECG was identified as a STEMI equivalent, and he underwent cardiac catheterisation. He was noted to have a near complete occlusion of the posterior descending branch of the right coronary artery (RCA). Bare-metal stents were placed in the proximal and distal RCA, with restored flow distal to the lesions. The patient was transferred to the intensive care unit for observation, and was noted to develop atrial fibrillation. Rate control was achieved with diltiazem, and the patient was started on dabigatran. Medical therapy including aspirin and clopidogrel was initiated, and the patient was discharged home.
- Association between Peak Neutrophil Count, Clopidogrel Loading Dose, and Left Ventricular Systolic Function in Patients with Primary Percutaneous Coronary Intervention. [Journal Article]
- Mediators Inflamm 2014.:482763.
Inflammation plays an important role in plaque development and left ventricular remodeling during acute myocardial infarction (AMI). Clopidogrel may exhibit some anti-inflammatory properties and high loading dose of clopidogrel results in improved clinical outcomes in patients with AMI. 357 patients who received successful primary percutaneous coronary intervention from January 2008 to March 2011 in Peking University Third Hospital were included in this study. Different loading dose of clopidogrel (300 mg, 450 mg, or 600 mg) was given at the discretion of the clinician. Neutrophils reached their peak values on the first day after AMI. Higher levels of peak neutrophil and lower left ventricular ejection fraction (LVEF) were found in patients of low clopidogrel loading dose group (300 mg or 450 mg). After adjusting for the related confounders, a logistic regression model showed that low clopidogrel loading dose remained an independent predictor of low LVEF (LVEF ≤ 50%) [OR: 1.97, 95% CI: 1.03-3.79, P = 0.04]. Low clopidogrel loading dose was associated with higher peak neutrophil count and poor left ventricular systolic function, suggesting an important role of clopidogrel loading dose in the improvement of left ventricular function and high loading dose may exhibit better anti-inflammatory properties.
- [Retrospective analysis of correlative factors between digestive system injury and anticoagulant or antiplatelet-agents]. [English Abstract, Journal Article]
- Zhonghua Yi Xue Za Zhi 2014 May 27; 94(20):1553-8.
To explore the correlative factors and clinical characteristics of digestive system injury during the treatment of anticoagulant and (or) antiplatelet-agents.A total of 1 443 hospitalized patients on anticoagulant and (or) antiplatelet-agents from January 2010 to December 2013 at Renmin Hospital of Wuhan University were analyzed retrospectively.Their length of hospital stay was from 5 to 27 days. Most of them were elderly males (n = 880, 61.0%) with an average age of (62 ± 6) years. 1 138 patients (78.9%) were farmers, workers or someone without a specific occupation. During the treatment of anticoagulant/antiplatelet-agents, statistical difference existed (P = 0.01) between positively and negatively previous digestive disease groups for actively newly occurring digestive system injury (16.0% (41/256) vs 15.9% (189/1 187)). After the dosing of anticoagulant and (or) antiplatelet-agents, 57 (66.3%, 57/86) patients were complicated by hemorrhage of digestive tract, taking 62.9% (61/97) of all positive result patients for Helicobacter pylori test. Comparing preventive PPI group with no PPI group, there was no marked statistical differences (P = 2.67) for digestive system complication (including hemorrhage of digestive tract) while receiving anticoagulant and (or) antiplatelet-agents (13.9% (74/533) vs 17.1% (156/910)). During anticoagulant and/or antiplatelet-agent therapy, 185 patients (12.8%) were complicated by peptic ulcer or peptic ulcer with bleeding, 40 patients (2.8%) had erosive gastritis and 5 (0.3%) developed acute gastric mucosal lesions. And 42 of 76 patients complicated by hemorrhage of digestive tract underwent endoscopic hemostasis while 2 patients were operated. Ninety-seven patients (6.7%) died, including 61 (62.9%, 61/97) from hemorrhage of digestive tract. The remainder became cured, improved and discharged. Moreover, no significant statistical differences existed (P = 2.29) among three combination group (aspirin, clopidogrel, warfarin), two combination group (aspirin, clopidogrel), exclusive aspirin group and exclusive warfarin group in short-term (<27 d) mortality.It is necessary to clearly dictate the details of medication to the patients not highly educated. Elder, male, history of digestive system disease and Helicobacter pylori infection are possibly highly risk correlative factors for digestive system complications during anticoagulant/antiplatelet-agent therapy. The short-term protective effect of routine dose of PPI is inconspicuous. No significant correlation exists between short-term mortality and the dosage (or type) of anticoagulant/antiplatelet-agents.
- Benefit of clopidogrel therapy in patients with myocardial infarction and chronic kidney disease-a danish nation-wide cohort study. [Journal Article]
- J Am Heart Assoc 2014; 3(4)
The aim of the present study was to evaluate clopidogrel treatment after incident myocardial infarction (MI) in patients with and without chronic kidney disease (CKD).By linking nation-wide registries, information about patients admitted with incident MI was found. Primary endpoints were all-cause and cardiovascular (CV) mortality, a composite of all-cause mortality and recurrent MI, and a composite of fatal and nonfatal bleedings. Effect of clopidogrel use versus clopidogrel nonuse was estimated using an adjusted Cox's regression model stratified according to percutaneous coronary intervention (PCI) treatment.A total of 69 082 incident MI patients in the period 2002-2011 were included. Clopidogrel treatment was associated with hazard ratios (HRs) for the combined endpoint of all-cause mortality and recurrent MI in PCI-treated patients of 0.90 (95% confidence interval [CI], 0.47 to 1.72) in renal replacement therapy (RRT) patients, 0.59 (95% CI: 0.40 to 0.88) in non-end-stage CKD patients and 0.69 (95% CI, 0.61 to 0.77) in patients without kidney disease (P for interaction=0.60). In patients not treated with PCI, HRs were 0.90 (95% CI, 0.68 to 1.21) in RRT patients, 0.86 (95% CI, 0.75 to 0.99) in non-end-stage CKD patients, and 0.91 (95% CI, 0.87 to 0.95) in patients without kidney disease (P for interaction=0.74). An increase in bleeding events (not significant) was noted for clopidogrel-treated patients not undergoing PCI and for non-end-stage CKD patients undergoing PCI, whereas clopidogrel was associated with less bleedings in PCI-treated RRT patients and patients without kidney disease.During a 1-year follow-up, after MI, clopidogrel was associated with improved outcomes in patients with non-end-stage CKD. Even though no effect difference, compared to patients without CKD, was observed, the benefit associated with the use of clopidogrel after MI in patients requiring RRT is less clear.
- Cardiovascular drugs in environmental waters and wastewaters: method optimization and real sample analysis. [Journal Article, Research Support, Non-U.S. Gov't]
- J AOAC Int 2014 Jul-Aug; 97(4):1167-74.
A sensitive method for determination of the eight most prescribed drugs used in combined cardiovascular therapy in Serbia was developed and optimized. The method was based on SPE followed by LC/ion trap-MS/MS with positive electrospray ionization. Parameters that affect the SPE were optimized, such as the eluent, sample pH, and sample volume. Good recoveries from groundwater (87.6-120.9%) as well as wastewater (84.5-106.6%) were achieved with this method, except in the case of atorvastatin (26.1 and 45.2%, respectively). The method was applied in the analysis of four river water samples collected in Serbia, as well as nine corresponding groundwater samples. Residues of the P-blockers metoprolol and bisoprolol as well as the anticoagulant clopidogrel were detected for the first time in river water. Groundwater samples did not contain drug residues. Influents and effluents of two wastewater treatment plants showed the predominant presence of metoprolol and enalapril. The removal rate of metoprolol was generally low, whereas enalapril was eliminated with the highest efficiency. Atorvastatin was detected in influents and completely removed in the treatment.
- Safety of low-dose aspirin in endovascular treatment for intracranial atherosclerotic stenosis. [Journal Article]
- PLoS One 2014; 9(8):e105252.
To evaluate the safety of low-dose aspirin plus clopidogrel versus high-dose aspirin plus clopidogrel in prevention of vascular risk within 90 days of duration of dual antiplatelet therapy in patients treated with intracranial endovascular treatment.From January 2012 to December 2013, this prospective and observational study enrolled 370 patients with symptomatic intracranial atherosclerotic stenosis of ≥70% with poor collateral undergoing intracranial endovascular treatment. Antiplatelet therapy consists of aspirin, at a low-dose of 100 mg or high-dose of 300 mg daily; clopidogrel, at a dose of 75 mg daily for 5 days before endovascular treatment. The dual antiplatelet therapy continued for 90 days after intervention. The study endpoints include acute thrombosis, subacute thrombosis, stroke or death within 90 days after intervention.Two hundred and seventy three patients received low-dose aspirin plus clopidogrel and 97 patients received high-dose aspirin plus clopidogrel before intracranial endovascular treatment. Within 90 days after intervention, there were 4 patients (1.5%) with acute thrombosis, 5 patients (1.8%) with subacute thrombosis, 17 patients (6.2%) with stroke, and 2 death (0.7%) in low-dose aspirin group, compared with no patient (0%) with acute thrombosis, 2 patient (2.1%) with subacute thrombosis, 6 patients (6.2%) with stroke, and 2 death (2.1%) in high-dose aspirin group, and there were no significant difference in all study endpoints between two groups.Low-dose aspirin plus clopidogrel is comparative in safety with high-dose aspirin plus clopidogrel within 90 days of duration of dual antiplatelet therapy in patients treated with intracranial endovascular treatment.
- Peri-operative management of and recommendations for antithrombotic medications in dermatological surgery. [JOURNAL ARTICLE]
- Br J Dermatol 2014 Aug 21.
With the ever increasing number of patients on anticoagulant or antiplatelet medications presenting for a dermatological surgical procedure, dermatological surgeons are facing the challenge of managing these drugs in order to balance the bleeding complications against the risk of thromboembolic events. The difficulty results from the scarce available recommendations, the literature data that is in part contradictory and the rate of emergence of newer agents that have not been thoroughly studied and widely used. Although the common approach in the past was to stop any antithrombotic medications, including warfarin and aspirin, several days prior to cutaneous surgery, recent data suggest that this practice should be changed as the relatively low risk of bleeding does not justify the life-threatening nature of a likely thrombosis. For patients on warfarin surgery should be avoided if INR>3.5; aspirin should not be stopped prior to dermatological surgery and in most other circumstances patients taking long term antithrombotic medication should not stop this prior to dermatological surgery. In more complicated cases liaison with the prescriber is indispensable even when the therapy should be discontinued for a short period of time. This review studies the available data and presents the dermatological surgeon with a up-to-date information about all studies concerning the old and new antithrombotic agents in the setting of dermatological surgery procedures. Our aim was to propose our recommendations based on the most recent evidence and our experience and provide a comprehensive approach to the dermatological surgeon without excluding the need for individual assessment of each case. This article is protected by copyright. All rights reserved.
- Impact of aspirin and clopidogrel interruption on platelet function in patients undergoing major vascular surgery. [Journal Article]
- PLoS One 2014; 9(8):e104491.
To investigate functional platelet recovery after preoperative withdrawal of aspirin and clopidogrel and platelet function 5 days after treatment resumption.We conducted an observational study, which prospectively included consecutive patients taking aspirin, taking clopidogrel, and untreated controls (15 patients in each group). The antiplatelet drugs were withdrawn five days before surgery (baseline) and were reintroduced two days after surgery. Platelet function was evaluated by optical aggregation in the presence of collagen, arachidonic acid (aspirin) and ADP (clopidogrel) and by VASP assay (clopidogrel). Platelet-leukocyte complex (PLC) level was quantified at each time-point. At baseline, platelet function was efficiently inhibited by aspirin and had recovered fully in most patients 5 days after drug withdrawal. PLC levels five days after aspirin reintroduction were similar to baseline (+4±10%; p = 0.16), in line with an effective platelet inhibition. Chronic clopidogrel treatment was associated with variable platelet inhibition and its withdrawal led to variable functional recovery. PLC levels were significantly increased five days after clopidogrel reintroduction (+10±15%; p = 0.02), compared to baseline.Aspirin withdrawal 5 days before high-bleeding-risk procedures was associated with functional platelet recovery, and its reintroduction two days after surgery restored antiplaletet efficacy five days later. This was not the case of clopidogrel, and further work is therefore needed to define its optimal perioperative management.
- [Long-term cost-effectiveness of ticagrelor versus clopidogrel in acute coronary syndrome in Spain]. [English Abstract, Journal Article]
- Farm Hosp 2014 Jul-Aug; 38(4):266-75.
To assess the cost-effectiveness relationship of Ticagrelor versus Clopidogrel for the management of acute coronary syndrome in Spain.The data from the PLATO study were used for the calculation of the events rate and health-related quality of life for Ticagrelor and Clopidogrel for the first 12 months, whereas the costs were obtained from Spanish sources. Quality of lifeadjusted survival and costs were estimated according to the fact that the patients did not suffer any thrombotic event (myocardial infarction or ictus) or this one was not fatal. The lifetime cots, life years gained, and the quality of life-adjusted survival were estimated for both treatment arms. Incremental costeffectiveness ratios were assessed through the perspective of the Spanish healthcare system for 2013, by using a macro-costs strategy based on published literature and the survival tables for the Spanish population.Treatment with Ticagrelor was associated to an incremental cost of 1,228 per year, an increase in 0.1652 life years gained, and 0.1365 years adjusted by quality of life, as compared to Clopidogrel. The cost for one quality of life-adjusted life year was 8,997 and the cost per one gained life year of 7,435 . The sensitivity analysis showed consistent results.Treatment of acute coronary syndrome for 12 months with Ticagrelor was associated with a cost per 1 life year of quality of life-adjusted cost below the cost-effectiveness limits generally accepted in Spain.