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- Differences in thrombus structure and kinetics in patients with type 2 diabetes mellitus after non ST elevation acute coronary syndrome. [JOURNAL ARTICLE]
- Thromb Res 2014 Feb 1.
Despite optimal secondary prevention therapy following non-ST elevation acute coronary syndrome (NSTE-ACS), recurrent thrombotic events are more frequent in patients with type 2 diabetes mellitus (T2DM).This exploratory study was aimed to evaluate quantitative and qualitative aspects of thrombus. In 28 patients with and without T2DM treated with aspirin and clopidogrel we assessed thrombus quantity using an ex-vivo chamber, platelet reactivity, thrombus ultrastructure and thrombus kinetics one week after NSTE-ACS.T2DM was associated with increased thrombus [14861 (8003 to 30161) vs 8908 (6812 to 11996), μ(2)/mm, median (IQR), p=0.045] and platelet reactivity. In addition, diabetic thrombus showed lower visco-elastic tensile strength [(-0.2(-1.7 to 0.7) vs 1.0(-0.9 to 3.3), p=0.044)] and was more resistant to autolysis [(27.8(11.7 to 70.7) vs 78.8(68.5 to109.6) mm/min, p=0.002)]. On SEM, fibrin fibres in diabetes were thinner, with higher lateral interlinkage and mesh-like organisation. Thrombus quantity correlated inversely with thrombus retraction (r=-0.450 p=0.016) but not with platelet reactivity (r=0.153, p=0.544).Despite optimal antiplatelet therapy, T2DM patients after NSTE-ACS developed increased thrombus of lower tensile strength and slower retraction. SEM revealed loosely arranged fibrin fibres. Our data showed significant differences in the magnitude as well as structural and mechanistic characteristics of thrombus in patients with T2DM.
- [Effect of drug interaction between clopidogrel and omeprazole in hospital readmision of patients by a recurrent acute coronary syndrome: A case-control study.] [JOURNAL ARTICLE]
- Aten Primaria 2014 Feb 26.
To evaluate the effect of drug interaction between omeprazol and clopidogrel in hospital readmission of patients with acute coronary syndrome (ACS).Case-control study.University Clinic LeonXIII, Medellin, Colombia. Participants: We selected from a prevalent population, between 2009-2010, use of clopidogrel patients on an outpatient basis (less than one year and more than 30days), and hospital stay for ACS or the presence of a previous ACS.A case-patient was defined as one who had a recurrence of ACS and a patient-control is defined as one that no recurrence of ACS. Both groups used ambulatory prior clopidogrel due to ACS. As defined risk factor the joint use of omeprazole and clopidogrel outpatients.During the study, 1680patients clopidogrel formulated. This group identified 50cases readmitted with ACS and 76controls. No statistically significant association was found between use of clopidogrel-omeprazole and increased risk of hospital readmission for ACS (OR: 1.05; 95%CI: 0.516-2.152; P=.8851).In this small group of patients with previous SCA, the simultaneous use of clopidogrel with omeprazole does not increase the risk of a readmission by recurrence of this type of coronary event.
- Bronchoscopic intratumoral injection of tranexamic acid to prevent excessive bleeding during multiple forceps biopsies of lesions with a high risk of bleeding: a prospective case series. [JOURNAL ARTICLE]
- BMC Cancer 2014 Mar 1; 14(1):143.
Significant bleeding may occur following endobronchial forceps biopsy or brushing of necrotic or hypervascular tumors in the airways. In some cases, methods such as endobronchial instillation of iced saline lavage and epinephrine may fail to control bleeding. The present study evaluated the efficacy and safety of a new bronchoscopic technique using intratumoral injection of tranexamic acid (IIT) for control of bleeding during forceps biopsy in patients with endobronchial tumors with a high risk of bleeding.The study was a prospective case series carried out in a single center. Bronchoscopic IIT was performed in those patients who had endoscopically visible tumoral lesions with persistent active bleeding following the first attempt at bronchoscopic sampling. Tranexamic acid (TEA) was injected through a 22-gauge Wang cytology needle into the lesion in nominal doses of 250-500 mg. After 2-3 minutes, multiple forceps biopsy specimens were obtained from the lesion.Of the 57 consecutive patients included in the study, 20 patients (35.1%) underwent bronchoscopic IIT. The first attempt in 18 patients was endobronchial forceps biopsy (EBB), and because of a high risk of bleeding, the first attempt for the remaining two patients, who were on continuous dual antiplatelet therapy (aspirin and clopidogrel), employed endobronchial needle aspiration (EBNA) as a precautionary measure. Following IIT, subsequent specimens were obtained using EBB in all patients. Multiple forceps biopsy specimens (3-10) were obtained from the lesions (8 necrotic and 12 hypervascular) without incurring active bleeding. The following histopathologic diagnoses were made: squamous cell carcinoma (n = 14), adenocarcinoma (n = 2), small-cell lung cancer (n = 3), and malignant mesenchymal tumor (n = 1). No side effects of TEA were observed.Bronchoscopic IIT is a useful and safe technique for controlling significant bleeding from a forceps biopsy procedure and can be considered as a pre-biopsy injection for lesions with a high risk of bleeding.Trial registration: ISRCTN23323895.
- CYP 450 2C19 polymorphisms in Indian patients with coronary artery disease. [Journal Article]
- Indian Heart J 2014 Jan-Feb; 66(1):16-24.
Dual antiplatelet therapy is the cornerstone in the management of acute coronary syndromes (ACS) and prevention of stent thrombosis (ST). Genetic polymorphisms in CYP2C19 gene involved in hepatic activation of clopidogrel leads to clopidogrel non-responsiveness and may influence clinical outcomes. These polymorphisms in CYP2C19 gene and their impact on clinical outcome in coronary artery disease (CAD) have not been studied in Indian population.We studied 110 consecutive patients (mean age 55.7 ± 10.7 years; 90% male) taking clopidogrel with angiographically proven CAD for various genetic polymorphisms in CYP2C19 gene. Relationship between loss of function mutation and clinical presentation with recurrent ACS including ST was analyzed.Out of 110 patients, 26 (23.64%) had normal genotype, 52 (47.23%) had loss of function mutation *2 and 39 (35.45%) had a gain of function mutation *17, 7 (6.36%) patients were undefined metabolizers (*2/*17) which were excluded from analyses. Final analyses included 103 patients, with 45 (40.90%) having loss of function. Overall 51 patients had ACS, with 27 developing recurrence while on clopidogrel. The prevalence of loss of function mutation was no different between the group with recurrences and those without recurrences (55.6% vs. 50%, p = 0.7). Two patients developed ST while on clopidogrel; both had loss of function mutation.CYP2C19 gene polymorphisms are common in Indian population. Loss of function mutation status did not affect the clinical outcomes. A larger study also considering P2Y12 receptor polymorphisms together with platelet activity testing, may be required to establish the role of CYP2C19 gene polymorphisms in clinical practice.
- Prevalence of CYP2C19 variant alleles and pharmacodynamic variability of aspirin and clopidogrel in Native Americans. [Journal Article]
- Am Heart J 2014 Mar; 167(3):413-8.
The prevalence of variant alleles of the CYP2C19 gene has been determined for most population groups, but not Native Americans. Furthermore, the overall effectiveness of clopidogrel and aspirin has not been well studied in Native Americans, although this group has high mortality rates for cardiovascular disease and diabetes.We recruited 50 volunteers from the Oglala Sioux Tribe with coronary artery disease taking aspirin and clopidogrel. Whole blood was collected for analysis using the VerifyNow P2Y12 and aspirin tests. Samples from the coronary artery disease patients and 50 additional tribal volunteers (n = 100 total) were genotyped for CYP2C19 variants *2, *3, and *17.The allele frequencies for CYP2C19*2 and CYP2C19*17 in the population group were 11% (95% CI 7%-16%) and 9% (95% CI 5%-13%), respectively. No subjects carried the CYP2C19*3 allele. The median PRU (P2Y12 reaction units) in the population group was 194 with wide variability (range 29-400). There was no significant effect of genotype on platelet aggregation as measured by the VerifyNow P2Y12 test (P = .77). The median ARU (aspirin reaction units) for the group was 437 (range 350-659), and 73% had aspirin reaction unit values <550.The prevalence of variant CYP2C19 alleles is low in Native Americans of the Oglala Sioux Tribe compared with certain HapMap populations. The variable response to aspirin and clopidogrel in the Oglala Sioux Tribe is consistent with reported values for other groups as measured by the VerifyNow assay (Accumetrics, San Diego, CA).
- Cardiac arrest during percutaneous coronary intervention in a patient 'resistant' to clopidogrel - successful 50-minute mechanical chest compression. [Journal Article]
- Postepy Kardiol Interwencyjnej 2013; 9(4):394-6.
We report a case of 72-year-old female patient with end-stage chronic kidney disease, undergoing percutaneous coronary intervention (PCI) that resulted in a cardiac arrest caused by a thrombus mediated flow limitation in the left coronary artery. With mechanical cardiopulmonary resuscitation (CPR) PCI of the left main artery was performed successfully during 50 min cardiac arrest. The patient was discharged from the hospital without compromising cardiac function and neurological deficits.
- New oral anticoagulants - will they be used with antiplatelet drugs in patients with atrial fibrillation after acute coronary syndrome? [Journal Article]
- Postepy Kardiol Interwencyjnej 2013; 9(4):348-52.
Atrial fibrillation (AF) is the most frequent indication for oral anticoagulation. Dual antiplatelet treatment with aspirin and clopidogrel is an antithrombotic treatment recommended after acute coronary syndrome and/or coronary artery stenting. The evidence for optimal antiplatelet therapy for patients who underwent a long-term treatment based on oral anticoagulation is strong. A direct thrombin inhibitor, dabigatran, as well as direct factor X inhibitors, apixaban and rivaroxaban, are now being commonly used in the prevention of thromboembolic complications of AF. Given the consistent increase in bleeding and the less consistent reduction in ischaemic events, the overall profile of adding new oral anticoagulants to antiplatelet treatment after acute coronary syndrome is unknown.
- Balancing between bleeding and thromboembolism after percutaneous coronary intervention in patients with atrial fibrillation. Could triple anticoagulant therapy be a solution? [Journal Article]
- Postepy Kardiol Interwencyjnej 2013; 9(3):234-40.
Atrial fibrillation (AF) has nowadays become a common disease as it comes along with medical procedures propagation in the ageing population with coexistent diseases. Hence a need for use of combined anticoagulant and antithrombotic therapy has arisen. According to the 2010 ESC guidelines on myocardial revascularization, short-term triple antithrombotic therapy after percutaneous coronary intervention (PCI) should be given if compelling indications exist.To assess bleeding and thromboembolic events depending on the antithrombotic regimen in short- and long-term follow-up in patients with AF after PCI with stent implantation.A 12-month prospective, non-randomized registry was conducted in the 3(rd) Department of Cardiology in the Upper Silesian Medical Center in Katowice from October 2008 to April 2011. One hundred and four patients in two groups - on triple therapy (TT; aspirin + clopidogrel + vitamin K antagonists (VKA; warfarin or acenocoumarol) n = 44) and on dual therapy (DT; aspirin + clopidogrel; n = 60) - were assessed 30 days and 12 months after angioplasty.All bleeding events occurred more often in the triple anticoagulated group in 30 days (TT 20.5% vs. DT 6.7%; p = 0.03) and after 12 months (TT 38.9% vs. DT 17.2%, p = 0.09). The difference in major bleeding events was not significant after 30 days (TT 9.1% vs. DT 3.3%; p = NS) or 12 months (TT 11.1% vs. DT 6.9%; p = NS). Thromboembolic events after 30 days (DT 5.0% vs. TT 2.3%) and 12 months (TT 11.1% vs. DT 3.4%) were comparable. The percentage of deaths after 30 days (DT 1.7% vs. TT 0.0%, p = NS) increased after 12 months (DT 13.8% vs. TT 0.0%, p = 0.09).Significantly higher risk of bleeding on TT becomes blurred by a tendency to increased mortality in patients on DT.
- Evaluation of Feasible Timing of Elective Noncardiac Procedure After Antiplatelet Discontinuation in Patients Treated With Antiplatelet Agents. [JOURNAL ARTICLE]
- J Investig Med 2014 Feb 24.
The current standard of care is to delay noncardiac procedure (NCP) 5 to 7 days after discontinuation of antiplatelet agents (APAs) in patients with coronary stents. However, it is often difficult to follow because of concerns over stent thrombosis. The point-of-care aspirin/P2Y12 assay (VerifyNow; Accumetrics Inc, San Diego, CA) is useful to evaluate platelet reactivity in conjunction with APAs. In this study, we evaluated the feasible timing after discontinuation of APAs.Sixty-two patients taking APAs, who were scheduled to undergo elective NCP, were enrolled. All patients took either aspirin 100 mg or aspirin 100 mg plus clopidogrel 75 mg daily. The aspirin-reactivity unit (ARU) and P2Y12-reactivity unit (PRU) were measured from 0 days (day 0, no discontinuation) to as long as 5 days (day 5, 5 days after discontinuation) depending on each procedure schedule. For 15 patients, baseline ARU and PRU (592 and 288) before aspirin/clopidogrel loading at index percutaneous coronary intervention were collected as control. For ARU after discontinuation of APA, days 0 to 5 values progressively increased over time (489.4 ± 85.3, 512.6 ± 77.0, 589.9 ± 58.8, 613.6 ± 47.3, 632.6 ± 49.2, 662.0 ± 4.2). Likewise, for PRUs, days 0 to 5 values also increased over time (245.0 ± 96.9, 253.9 ± 80.9, 270.9 ± 45.8, 289.0 ± 68.6, 306.5 ± 29.2, 351.0 ± 8.5). The ARU and PRU well correlated with days after APA discontinuation by linear regression analysis (y = 490.897 + 39.238 * x, R = 0.43, P < 0.001; y = 241.739 + 16.701 * x, R = 0.092, P = 0.018, respectively). Assuming baseline ARU and PRU as 592 and 288, the mean days after complete reversal of platelet reactivity by APAs are 2.6 and 2.8, respectively.The feasible timing of NCP after discontinuation of APAs showed less than 5 days. VerifyNow is useful in the evaluation of antiplatelet reversal after discontinuation of APAs.