Safety and Necessity of Antiplatelet Therapy on Patients Underwent Endovascular Aortic Repair with Both Stanford Type B Aortic Dissection and Coronary Heart Disease

Background： Acute aortic dissection is known as the most dangerous aortic disease, with management and prognosis determined as the disruption of the medial layer provoked by intramural bleeding. The objective of this study was to evaluate the safety and necessity of antiplatelet therapy on patients with Stanford Type B aortic dissection （TBAD） who underwent endovascular aortic repair （EVAR）. Methods： The present study retrospectively analyzed 388 patients with TBAD who underwent EVAR and coronary angiography. The primary outcomes were hemorrhage, death, endoleak, recurrent dissection, myocardial infarction, and cerebral infarction in patients with and without aspirin antiplatelet therapy at 1 month and 12 months. Results： Of those 388 patients, 139 （35.8%） patients were treated with aspirin and 249 （64.2%） patients were not treated with aspirin. Patients in the aspirin group were elderly （57.0 ± 10.3 years vs. 52.5 ± 11.9 years, respectively, χ2 = 3.812, P 〈 0.001） and had more hypertension （92.1% vs. 83.9%, respectively, χ2 = 5.191, P = 0.023） and diabetes （7.2% vs. 2.8%, respectively, χ2 = 4.090, P = 0.043） than in the no-aspirin group. Twelve patients （aspirin group vs. no-aspirin group; 3.6% vs. 2.8%, respectively, χ2 = 0.184, P = 0.668） died at 1-month follow-up, while the number was 18 （4.6% vs. 5.0%, respectively, χ2 = 0.027, P = 0.870） at 12-month follow-up. Hemorrhage occurred in 1 patient （Bleeding Academic Research Consortium [BARC] Type 2） of the aspirin group, and 3 patients （1 BARC Type 2 and 2 BARC Type 5） in the no-aspirin group at 1-month follow-up （ χ2 = 0.005, P = 0.944）. New hemorrhage occurred in five patients in the no-aspirin group at 12-month follow-up. Three patients in the aspirin group while five patients in the no-aspirin group had recurrent dissection for endoleak at 1-month follow-up （2.3% vs. 2.2%, respectively, χ2 = 0.074, P = 0.816）. Four patients had new dissection in the no-aspirin group at 12-month follow-up （2.3% vs. 3.8%, respectively, χ2 = 0.194, P = 0.660）. Each group had one patient with myocardial infarction at 1-month follow-up （0.8% vs. 0.4%, respectively, χ2 = 0.102, P = 0.749） and one more patient in the no-aspirin group at 12-month follow-up. No one had cerebral infarction in both groups during the 12-month follow-up. In the percutaneous coronary intervention （PCI） subgroup, 44 （31.7%） patients had taken dual-antiplatelet therapy （DAPT, aspirin ＋ clopidogrel） and the other 95 （68.3%） patients had taken only aspirin. There was no significant difference in hemorrhage （0% vs. 1.1%, respectively,χ2 = 0.144, P = 0.704）, death （4.8% vs. 4.5%, respectively, χ2 = 0.154, P = 0.695）, myocardial infarction （2.4% vs. 0%, respectively,χ2 = 0.144, P = 0.704）, endoleak, and recurrent dissection （0% vs. 3.4%, respectively, χ2 = 0.344, P = 0.558） between the two groups at 12-month follow-up. Conclusions： The present study indicated that long-term oral low-dose aspirin was safe for patients with both TBAD and coronary heart disease who underwent EVAR. For the patients who underwent both EVAR and PCI, DAPT also showed no increase in hemorrhage, endoleak, recurrent dissection, death, and myocardial infarction.

Sex-Related Differences in Short- and Long-Term Outcome among Young and Middle-Aged Patients for ST-Segment Elevation Myocardial Infarction Underwent Percutaneous Coronary Intervention

Background： Females with ST-segment elevation myocardial infarction （STEMI） have higher in-hospital and short-term mortality rates compared with males in China, suggesting that a sex disparity exists. The age of onset of STEM1 is ahead of time and tends to be younger. However, there are relatively little data on the significance of sex on prognosis for long-term outcomes for adult patients with STEMI alter percutaneous coronary intervention （PCI） in China. This study sought to analyze the sex differences in 30-day, l-year, and long-term net adverse clinical events （NACEs） in Chinese adult patients with STEMI after PCI. Methods： This study retrospectively analyzed 1920 consecutive STEMI patients （age 〈60 years） treated with PCI fYom January 01, 2006, to December 31,2012. A propensity score analysis between males and females was perfimned to adjust tbr differences in baseline characteristics and comorbidities. The primary endpoint was the incidence of 3-year NACE. Survival curves were constructed with Kaplan- Meier estimates and compared by log-rank tests between the two groups. Multivariate analysis was perforated using a Cox proportional hazards model for 3-year NACE. Results： Compared with males, females had higher risk profiles associated with old age, longer prehospital delay at the onset of STEMI, hypertension, diabetes mellitus, and chronic kidney disease, and a higher Killip class （≥3）, with more multivessel diseases （P 〈 0.05）. The female group had a higher levels of low-density lipoprotein （2.72 [2.27, 3.29] vs. 2.53 [2,12, 3.00], P 〈 （1.001）, high-density lipoprotein （ 1.43 [1.23, 1.71] vs. 1.36 [1.11, 1.63], P - 0.003）, total cholesterol （4.98±1.10 vs. 4.70 ±1.15, t = -3.508, P 〈 0.001）, and estimated glomerular filtration rate （103.12 ± 22.22 vs. 87.55 ±18.03, t = 11.834, P〈 0.001 ） than the male group. In the propensity-matched analysis, being female was associated with a higher risk for 3-year NACE and major adverse cardiac or cerebral events compared with males. In the multivariate model, female gender （hazard ratio [HR]： 2.557, 95% confidence interval [CI]： 1.415-4.620, P=0.002）, hypertension （MR： 2.017, 95% CI： 1.138-3.576, P = 0.016）, and family history of coronary heart disease （HR： 2.256, 95% CI：1.115-4.566, P = 0.024） were independent risk factors for NACE. The number of stents （HR： 0.625, 95% CI：0.437 0.894, P = 0.010） was independent protective factors of NACE. Conclusions： Females with STEMI undergoing PCl have a significantly higher risk for 3-year NACE compared with males in this population. Sex differences appear to be a risk factor and present diagnostic challenges for clinicians.

Optimal strategy of switching from clopidogrel to ticagrelor in Chinese acute coronary syndrome patients with complicated coronary artery disease: the switching from clopidogrel to ticagrelor (SHIFT-CACS) study

Background:The dose and time point for switching from clopidogrel to ticagrelor remain controversial,especially for Chinese acute coronary syndrome(ACS)patients with complicated coronary artery disease(CAD).Hence,the purpose of this study was to further explore the optimal dose and time point for the switching strategy to balance the increase in platelet inhibition and the decrease in adverse events in Chinese ACS patients with complicated CAD managed by percutaneous coronary intervention(PCI).Methods:From July 2017 to December 2017,the prospective,randomized,open-label study(the SwitcHIng from clopidogrel to ticagrelor study)assigned the eligible Chinese ACS patients with complicated CAD managed by PCI(n=102)for 90 mg of ticagrelor at 12 h(T-90 mg-12 h),90 mg of ticagrelor at 24 h(T-90 mg-24h)or 180 mg ticagrelor at 24 h(T-180 mg-24 h)after the last dose of clopidogrel.The primary endpoint was the comparison of maximal platelet aggregation(MPA)values at 2 h after switching strategies among the three groups.In addition,the MPA values at baseline,8 h and before discharge and the rates of high ontreatment platelet reactivity were evaluated,the incidences of bleeding episodes and dyspnea during hospitalization and at 30-day follow-up in our study were also recorded.The MPA was measured by light transmittance aggregometry in our study.A repeatedmeasures analysis of variance(ANOVA)model and one-way ANOVA were used to compare data for the primary endpoint.Results:The MPA values were significantly decreased in the T-180 mg-24 h group compared with the T-90 mg-12 h group(P=0.017)and decreased numerically compared with the T-90 mg-24 h group(P=0.072)at 2 h.In particular,the MPA values were markedly reduced in the T-90 mg-24 h group compared with the T-90 mg-12 h group at 8 h after switching treatment(P=0.002).There was no significant difference among the three groups in all bleedings and dyspnea events.Conclusions:The optimal treatment strategy recommended in this study for Chinese ACS patients with complicated CAD managed by PCI is 180 or 90 mg of ticagrelor at 24 h after the last dose of clopidogrel.In addition,a negative interaction was detected in this study between the overlap for clopidogrel and ticagrelor at 12 h after the last dose of clopidogrel.Trial Registration:ClinicalTrials.gov,NCT03577652;http://clinicaltrials.gov/ct2/show/NCT03577652.