Early antiplatelet therapy used for acute ischemic stroke and intracranial hemorrhage

In this editorial we comment on the article published by Zhang et al in the recent issue of World Journal of Clinical Cases.We evaluate their claims on the benefit of use of Aspirin in the early management of patients with ischemic stroke.We also comment on their contention of using aspirin in the early management of patients with intracranial hemorrhage,a practice not seen in modern medicine.Large clinical trials such as the International Stroke Trial and the Chinese Acute Stroke Trial have shown the benefit of Aspirin use within 48 h of patients with Acute Ischemic Stroke.The findings were corroborated in the open-label trial performed by Zhang et al in a smaller sample group of 25 patients where they showed improvement in functional scores at 90 days without an increase in adverse events.As such,this intervention is also recommended by the American Heart Association stroke guidelines from 2021.With regard to Intracranial hemorrhage,traditional practice has been to discontinue or avoid antiplatelet therapy in these patient groups.However,no studies have been done to evaluate this management strategy that is more borne out of the mechanism behind Aspirin’s effect on the coagulation pathway.Zhang et al evaluate the benefits of Aspirin on patients with low-volume intracranial hemorrhage,i.e.,less than 30 mL on computed tomo-graphy imaging,and show no increase in mortality.The caveat of this finding is that all outcomes were pooled into one group for results,and the number of patients was low.While more studies with larger patient groups are required,the data from Zhang et al suggests that patients with small-volume intracranial hemorrhages may benefit from Aspirin administration in the acute phase of management.

Distribution of gene polymorphisms associated with aspirin antiplatelet in the Han NSTEMI population

Objective:To analyze the genotype and allele distribution characteristics of GPⅢa PLA2(rs5918),PEAR1(rs12041331),and PTGS1(rs10306114)genes related to the antiplatelet pharmacological effects of aspirin,providing reference for individualized treatment of Chinese Han NSTEMI patients.Methods:A total of 107 Han patients with NSTEMI in Beijing Luhe Hospital affiliated to Capital Medical University from January 2016 to December 2022 were selected as the research subjects.The genotypes of GPⅢa PLA2(rs5918),PEAR1(rs12041331)and PTGS1(rs10306114)were detected by fluorescence staining in situ hybridization.The frequency distribution and allele distribution of genotype were analyzed.The results were analyzed whether there were statistical differences in the distribution of related alleles between the Han NSTEMI population and some populations in the 1000 Genomes database.Results:In the Han NSTEMI population,the genotype frequencies of GPⅢa PLA2(rs5918)locus were TT 97.20%,TC 2.80%and CC 0%,the allele frequencies were T 98.60%and C 1.40%.The genotype frequencies of PEAR1(rs12041331)locus were GG 42.06%,GA 44.86%and AA 13.08%,the allele frequencies were G 64.49%and A 35.51%.The genotypes at the PTGS1(rs10306114)locus were all AA(100%),no AG or GG genotype was found.Conclusion:In the NSTEMI population of Han nationality,the mutation at GPⅢa PLA2(rs5918)site related to aspirin antiplatelet pharmacology is rare,and there is no mutation at PTGS1(rs10306114)site.Wild homozygotes are dominant in these two gene loci,while mutations in PEAR1(rs12041331)are more common.Some of the findings in this study are similar to those in previous reports or other populations included in the relevant database;however,some results differ from previous reports or other populations。

Prolonged dual antiplatelet therapy after drug-eluting stent implantation improves long-term prognosis for acute coronary syndrome:five-year results from a large cohort study

BACKGROUND:To investigate the most appropriate dual antiplatelet therapy(DAPT)duration for patients with acute coronary syndrome(ACS)after drug-eluting stent(DES)implantation in the largest cardiovascular center of China.METHODS:We enrolled 5,187 consecutive patients with ACS who received DES from January to December 2013.Patients were divided into four groups based on DAPT duration:standard DAPT group(11-13 months,n=1,568)and prolonged DAPT groups(13-18 months[n=308],18-24 months[n=2,125],and>24 months[n=1,186]).Baseline characteristics and 5-year clinical outcomes were recorded.RESULTS:Baseline characteristics were similar across the four groups.Among the four groups,those with prolonged DAPT(18-24 months)had the lowest incidence of major adverse cardiovascular and cerebrovascular events(MACCEs)(14.1%vs.11.7%vs.9.6%vs.24.2%,P<0.001),all-cause death(4.8%vs.3.9%vs.2.1%vs.2.6%,P<0.001),cardiac death(3.1%vs.2.6%vs.1.4%vs.1.9%,P=0.004),and myocardial infarction(MI)(3.8%vs.4.2%vs.2.5%vs.5.8%,P<0.001).The incidence of bleeding was not different among the four groups(9.9%vs.9.4%vs.11.0%vs.9.4%,P=0.449).Cox multivariable analysis showed that prolonged DAPT(18-24 months)was an independent protective factor for MACCEs(hazard ratio[HR]0.802,95%confidence interval[CI]0.729-0.882,P<0.001),all-cause death(HR 0.660,95%CI 0.547-0.795,P<0.001),cardiac death(HR 0.663,95%CI 0.526-0.835,P<0.001),MI(HR 0.796,95%CI 0.662-0.957,P=0.015),and target vessel revascularization(HR 0.867,95%CI 0.755-0.996,P=0.044).Subgroup analysis for high bleeding risk showed that prolonged DAPT remained an independent protective factor for all-cause death and MACCEs.CONCLUSION:For patients with ACS after DES,appropriately prolonging the DAPT duration may be associated with a reduced risk of adverse ischemic events without increasing the bleeding risk.

Efficacy and safety of aspirin antiplatelet therapy within 48 h of symptom onset in patients with acute stroke

BACKGROUND Aspirin is a widely used antiplatelet agent that reduces the risk of recurrent ischemic stroke and other vascular events.However,the optimal timing and dose of aspirin initiation after an acute stroke remain controversial.AIM To evaluate the efficacy and safety of aspirin antiplatelet therapy within 48 h of symptom onset in patients with acute stroke.METHODS We conducted a randomized,open-label,controlled trial in 60 patients with acute ischemic or hemorrhagic stroke who were admitted to our hospital within 24 h of symptom onset.Patients were randomly assigned to receive either aspirin 300 mg daily or no aspirin within 48 h of stroke onset.The primary outcome was the occurrence of recurrent stroke,myocardial infarction,or vascular death within 90 d.The secondary outcomes were functional outcomes at 90 d measured using the modified Rankin Scale(mRS),incidence of bleeding complications,and mortality rate.RESULTS The mean age of the patients was 67.8 years and 55%of them were male.The median time from stroke onset to randomization was 12 h.The baseline characteristics were well balanced between the two groups.The primary outcome occurred in 6.7%of patients in the aspirin group and 16.7%of patients in the no aspirin group(relative risk=0.40,95%confidence interval:0.12-1.31,P=0.13).The mRS score at 90 d was significantly lower in the aspirin group than in the no aspirin group(median,2 vs 3,respectively;P=0.04).The incidence of bleeding complications was similar between the groups(6.7%vs 6.7%,P=1.00).The mortality rates were also comparable between the two groups(10%vs 13.3%,P=0.69).CONCLUSION Aspirin use is associated with favorable functional outcomes but does not significantly reduce the risk of recurrent vascular events.Its acceptable safety profile is comparable to that of no aspirin.Further studies with larger sample sizes and longer follow-up periods are needed to confirm these findings.

Dissolvable polymeric microneedles loaded with aspirin for antiplatelet aggregation

To reduce mucosal damage in the gastrointestinal tract caused by aspirin,we developed a dissolvable polymeric microneedle(MN)patch loaded with aspirin.Biodegradable polymers provide mechanical strength to the MNs.The MN tips punctured the cuticle of the skin and dissolved when in contact with the subcutaneous tissue.The aspirin in the MN patch is delivered continuously through an array of micropores created by the punctures,providing a stable plasma concentration of aspirin.The factors affecting the stability of aspirin during MNs fabrication were comprehensively analyzed,and the hydrolysis rate of aspirin in the MNs was less than 2%.Compared to oral administration,MN administration not only had a smoother plasma concentration curve but also resulted in a lower effective dose of antiplatelet aggregation.Aspirin-loaded MNs were mildly irritating to the skin,causing only slight erythema on the skin and recovery within 24 h.In summary,aspirin-loaded MNs provide a new method to reduce gastrointestinal adverse effects in patients requiring aspirin regularly.

Antiplatelet Aggregation and Vasodilation Effects of RGDS

In an attempt to demonstrate the biological activities of a short peptide.Arg-Gly-Asp- Ser (RGDS) was synthesized and used for bioassay,The data obtained here proved that RGDS ob- viously inhibited PAF- and/or ADP-induced platelet aggregation.The present paper revealed that RG- DS had vasodilative action and the cGMP accumulation may be one of the mechanisms of RGDS exer- ting bioactivities.

Feasibility of gastric endoscopic submucosal dissection with continuous low-dose aspirin for patients receiving dual antiplatelet therapy

BACKGROUND Endoscopic submucosal dissection(ESD) for gastric neoplasms during continuous low-dose aspirin(LDA) administration is generally acceptable according to recent guidelines. This retrospective study aimed to investigate the effect of continuous LDA on the postoperative bleeding after gastric ESD in patients receiving dual antiplatelet therapy(DAPT).AIM To investigate the feasibility of gastric ESD with continuous LDA in patients with DAPT.METHODS A total of 597 patients with gastric neoplasms treated with ESD between January2010 and June 2017 were enrolled. The patients were categorized according to type of antiplatelet therapy(APT).RESULTS The postoperative bleeding rate was 6.9%(41/597) in all patients. Patients were divided into the following two groups: no APT(n = 443) and APT(n = 154). APT included single-LDA(n = 95) and DAPT(LDA plus clopidogrel, n = 59)subgroups. In the single-LDA and DAPT subgroups, 56 and 39 patients were received continuous LDA, respectively. The bleeding rate with continuous singleLDA(10.7%) was similar to that with discontinuous single-LDA(10.3%)(P >0.99). Although the bleeding rate with continuous LDA in patients receiving DAPT(23.1%) was higher than that with discontinuous LDA in patients receiving DAPT(5.0%), no significant difference was observed(P = 0.141).CONCLUSION The bleeding rate with continuous LDA in patients receiving DAPT was not statistically different from that with discontinuous LDA in patients receiving DAPT. Therefore, continuous LDA administration may be acceptable for ESD in patients receiving DAPT, although patients should be carefully monitored for possible bleeding.

Efficacy and safety of individually tailored antiplatelet therapy in patients with acute coronary syndrome after coronary stenting： a single center, randomized, feasibility study

Background Low responsiveness to clopidogrel （LRC） is associated with increased risk of ischemic events. This study was aimed to explore the feasibility of tailored antiplatelet therapy according to the responsiveness to clopidogrel. Methods A total of 305 clopidogrel naive patients with acute coronary syndromes （ACS） undergoing coronary stenting were randomly assigned to receive standard （n = 151） or tailored （n = 154） antiplatelet therapy. The ADP-induced platelet aggregation tests by light transmission aggregometry were performed to identify LRC patients assigned to the tailored group. The standard antiplatelet regimen was dual antiplatelet therapy with aspirin and clopidogrel. The tailored antiplatelet therapy was standard regimen for non-LRC patients and an additional 6-month cilostazol treatment for LRC patients. The primary efficacy outcome was the composite of cardiovascular death, myocardial infarction or stroke at one year. Results LCR was present in 26.6% （41/154） of patients in the tailored group. The percentage platelet aggregation for LCR patients was significantly decreased at three days after adjunctive cilostazol treatment （77.5% ± 12.1% vs. 64.5% ± 12.1%, P 〈 0.001）. At one year follow-up, a non-significant 37% relative risk reduction of primary events were observed in the tailored group as compared to the standard group （5.8% vs. 9.3%, P = 0.257）. There were no differences in the rates of stent thrombosis and hemorrhagic events between the two groups. Conclusions Tailored antiplatelet therapy for ACS patients after coronary stenting according to responsiveness to clopidogrel is feasible. However, its efficacy and safety need further confirmation by clinical trials with larger sample sizes.

Antiplatelet therapy in very elderly and comorbid patients with acute coronary syndromes

With population ageing and rise of life expectancy,a progressively increasing proportion of patients presenting with an acute coronary syndrome(ACS)are older adults,including those at extreme chronological age.Increasing amounts of data,including randomized clinical trials,have shown that the benefits of an early revascularization are maintained also at very old age,resulting in improved outcome after an acute coronary event.On the contrary,the optimal antiplatelet therapy(APT)remains unclear in these patients,because of both safety and efficacy concerns.Indeed,age-related multiple organ dysfunction and high prevalence of comorbidities may on the one hand reduce the therapeutic effects of administered drugs;on the other hand,it leads to increased vulnerability to drug toxicity and side effects.Therefore,management of APT is particularly challenging in elderly patients because of higher risk of both ischemic and bleeding events.The aim of the present paper is to review the current evidence,gaps in knowledge and ongoing research regarding APT in the setting of an ACS in elderly and very elderly patients,and in those with significant comorbidities including chronic kidney disease,diabetes mellitus and frailty.

Effect of early surgery in high surgical risk geriatric patients with femoral neck fracture and taking antiplatelet agents

AIM: To investigate the effect of early surgical intervention on the high surgical risk elderly patients who sustained femoral neck fracture(FNF) and taking concomitant antiplatelet agents. METHODS: Between 2010 and 2012, a prospective study was conducted on 49 geriatric patients, who took antiplatelet agents, sustained FNF and underwent surgery within 72 h [early surgery(ES) group], and these were compared with a retrospective consecutive case series of patients with similar characteristics(45 cases) who had delayed surgery(DS group) after 72 h during an earlier 3-year period. Postoperative outcomeswere followed for one year and compared. RESULTS: There were non-significant differences in perioperative blood loss, blood transfusion, intensive care unit requirement and postoperative mortality(P > 0.05 all). There were 2 patients(4%) in the DS group who died after surgery(P = 0.23). However, the ES group showed a significantly better postoperative outcome in terms of postoperative complications, length of hospital stay, and functional outcome(P < 0.05 all).CONCLUSION: Early hip surgery in geriatric hip fracture patients with ongoing antiplatelet treatment was not associated with a significant increase of perioperative blood loss and postoperative mortality. Moreover, ES resulted in a better postoperative surgical outcome. In early hip surgery protocol, the antiplatelet agents are discontinued and the patient is operated on within 72 h after admission, which is safe and effective for the medically fit patients.

Treatment and prevention of gastrointestinal bleeding in patients receiving antiplatelet therapy

Antiplatelet therapy is the standard of care for the secondary prevention of acute coronary syndrome and ischemic stroke, especially after coronary intervention. However, this therapy is associated with bleeding complications such as gastrointestinal bleeding, which is one of the most common life-threatening complications. Early endoscopy is recommended for most patients with acute upper gastrointestinal bleeding. After successful endoscopic hemostasis, immediate resumption of antiplatelet therapy with proton-pump inhibitors(PPIs) is recommended to prevent further ischemic events. PPI prophylaxis during antiplatelet therapy reduces the risk of upper gastrointestinal bleeding. The potential negative metabolic interaction between PPIs and clopidogrel is still unclear.

Dual antiplatelet therapy increases pocket hematoma complications in Chinese patients with pacemaker implantation

Objective To assess the prevalence of the bleeding complications in pacemaker implanted patients receiving different antiplatelet regimens, and the influence of each regimen on hospital stays after device implantation. Methods We prospectively enrolled 364 patients receiving the cardiac rhythm device implantations in Fuwai Hospital from July 2012 to December 2013. Bleeding complications including pocket hematoma, hemothorax, cardiac tamponade and blood transfusion requirement were measured as endpoints. Post operation hospital stay was also included in the endpoints. Results Bleeding complications were detected in 15 patients （14 with hematoma, one with hemothorax） out of all 364 patients （4.12%）. Dual antiplatelet therapy （DAT） significantly increased hematoma （19.3%） compared with aspi- fin treatment （ASA） （3.2%, P = 0.001） and no antiplatelet therapy （1.9%, P 〈 0.001）. There was no significant difference in incidence of pocket hematoma between the ASA group and the control group （P = 0.45）. The post procedure hospital stay was longer in DAT group （5.45 ± 2.01 days） compared to those in the ASA group （3.65 ± 1.37 days, P 〈 0.05） or control group （3.99 ± 2.27 days, P 〈 0.05）. Pocket hema- toma was considered an independent predictor of hospital stay prolongation （OR： 5.26; 95% CI： 1.56-16.64; P = 0.007）. Conclusions Among the Chinese patients undergoing device implantation in this study, the use of dual antiplatelet agents significantly increased the risk of pocket hematoma complications and led to a longer hospital stay. Use of aspirin alone did not increase the risk.

Study on Antithrombotic and Antiplatelet Activities of Low Molecular Weight Fucoidan from Laminaria japonica

The antithrombotic and antiplatelet effects of two fucoidan fractions with low molecular weight and different sulfate content from Laminaria japonica were compared in order to examine the influence of chemical character on their antithrombotic activity and the possible mechanism. Both LMW fucoidan fractions exhibited favorable antithrombotic activity in an Fecl3-induced arterial thrombosis. The antithrombotic activity of LMW fucoidan was related with decrease of TXB2 and whole blood viscosity and hematocrit. LMW fucoidan showed a correlation between anticoagulant, antiaggregant and antithrombotic effects in vivo. For LMW fucoidan, antithrombotic activity required high dose of 5-10 nmol kg-1, concomitantly with increase in anticoagulant activity and inhibition of platelet aggregation. Administration of LMW fucoidan significantly promoted the 6-keto-PGF1α content and decreased the TXB2 content, indicating its inhibition of tissue factor pathway and regulation of metabolism of arachidonic acid. By comparison, highly sulfated fucoidan LF2 with Mw 3900 seemed to be a more suitable choice for antithrombotic drug for its antithrombotic activity accompanied with specific inhibitory activity on platelet aggregation, low anticoagulant activity and low hemorrhagic risk in vivo.

Anticoagulation and antiplatelets as prophylaxis for hepatic artery thrombosis after liver transplantation

Hepatic artery thrombosis(HAT) is the most serious vascular complication after liver transplantation. Multiple risk factors have been identified to impact its development. Changes in haemostasis associated with end stage liver disease and the disturbance of the coagulation and anticoagulation cascades play an important role in development of this lethal complication. Early recognition and therapeutic intervention is mandatory to avoid its consequences. Pharmacological prophylaxis, by the use of antiplatelet or anticoagulant agents, is an important tool to reduce its incidence and prevent graft loss. Only a few studies have shown a clear benefit of antiplatelet agents in reducing HAT occurrence, however, these studies are limited by being retrospective and by inhomogeneous populations. The use of anticoagulants such as heparin is associated with an improvement in the outcomes mainly when used for a high-risk patients like living related liver recipients. The major concern when using these agents is the tendency to increase bleeding complications in a setting of already unstable haemostasis. Hence, monitoring of their administration and careful selection of patients to be treated are of great importance. Well-designed clinical studies are still needed to further explore their effects and to formulate proper protocols that can be implemented safely.

Impact of antiplatelet treatment on colorectal cancer staging characteristics

AIM: To evaluate whether antiplatelet medication leads to an earlier stage colorectal cancer (CRC) diagnosis. METHODS: From January 2002 until March 2010, patients that presented to our institution with the initial diagnosis of CRC and were submitted to an open curative CRC resection or a palliative procedure were retrospectively reviewed. Exclusion criteria were the use of antithrombotic medication, i.e., coumarins, and appendiceal malignancies. Data acquired from medical files included age, gender, past medical history, antithrombotic treatment received prior to endoscopic diagnosis, preoperative imaging staging, location of the tumor, surgical and final histopathological report. Patients that did not receive any antithrombotic medication prior to the endoscopic diagnosis comprised the control group of the study, while patients that were on antiplatelet medication comprised the antiplatelet group. Primary end point was a comparison of CRC stage in the two groups of the study. CRC presenting symptoms and the incidence of each cancer stage in the two groups were also evaluated. RESULTS: A total of 387 patients with the diagnosis of CRC were submitted to our department for further surgical treatment. Ninety-eight patients (25.32%), with a median age of 71 years (range 52-91 years), were included in the antiplatelet group, while 289 (74.67%) patients, with a median age of 67 years (range 41-90 years), were not in any thrombosis prophylaxis medication (control group). Thirty-one patients were treated with some kind of palliative procedure, either endoscopic, such as endoscopic stent placement, or surgical, such as de-compressive colostomy or deviation. Coronary disease (77.55% - 76 patients), stroke recurrence prevention (14.28% - 14 patients) and peripheral arterial disease (8.16% - 8 patients) were the indications for the administration of antiplatelet treatment (aspirin, clopidogrel, ticlopidine or dipyridamole) in the antiplatelet group. All patients on aspirin treatment received a dosage of 100 mg/d, while the minimum prophylactic dosages were also used for the rest of the antiplatelet drugs. Investigation of an iron deficiency anemia (147 patients), per rectum blood loss (84 patients), bowel obstruction and/or perforation (81 patients), bowel habits alterations (32 patients), non-specific symptoms, such as weight loss, intermittent abdominal pain and fatigue, (22 patients) or population screening (21 patients) were the indications for the endoscopic investigation in both groups. Bleeding, either chronic presenting as anemia or acute was significantly higher (P = 0.002) for the antiplatelet arm of the study (71 patients - 72.4% of the antiplatelet group vs 160 patients - 55.3% of the control group). The mean tumor, node and metastasis stage was 2.57 ± 0.96 for the control group, 2.27 ± 0.93 for the antiplatelet group (P = 0.007) and 2.19 ± 0.92 for the subgroup of patients taking aspirin (P = 0.003). The incidence of advanced disease (stage IV) was lower for the antiplatelet group of the study (P = 0.033). CONCLUSION: The adverse effect of bleeding that is justifiably attached to this drug category seems to have a favorable impact on the staging characteristics of CRC.

Peripheral interventions and antiplatelet therapy: Role in current practice

Peripheral arterial disease(PAD) is a common disorder associated with a high risk of cardiovascular mortality and continues to be under-recognized. The major risk factors for PAD are similar to those for coronary and cerebrovascular disease. Management includes exercise program, pharmacologic therapy and revascularization including endovascular and surgical approach. The optimal revascularization strategy, endovascular or surgical intervention, is often debated due to the paucity of head to head randomized controlled studies. Despite significant advances in endovascular interventions resulting in increased utilization over surgical bypass, significant challenges still remain. Platelet activation and aggregation after percutaneous transluminal angioplasty of atherosclerotic arteries are important risk factors for re-occlusion/restenosis and life-threatening thrombosis following endovascular procedures. Antiplatelet agents are commonly prescribed to reduce the risk of myocardial infarction, stroke and death from cardiovascular causes in patients with PAD. Despite an abundance of data demonstrating efficacy of antiplatelet therapy in coronary artery disease and cerebrovascular disease, there is a paucity of clinical information, clinical guidelines and randomized controlled studies in the PAD population. Hence, data on antiplatelet therapy in coronary interventions is frequently extrapolated to peripheral interventions. The aim of this review article is to elucidate the current data on revascularization and the role and duration of antiplatelet and anticoagulant therapy in re-vascularized lower limb PAD patients.

Association between antiplatelet medication and cerebral microbleeds in stroke-free population

BACKGROUND Cerebral microbleeds(CMBs)may increase the risk of future intracerebral hemorrhage and ischemic stroke.However,It is unclear whether antiplatelet medication is associated with CMBs.This study aimed to investigate the association between antiplatelet medication and CMBs in a community-based stroke-free population.METHODS In this cross-sectional study,stroke-free participants aged 18-85 years were recruited from a community in Beijing,China.Demographic,clinical,and antiplatelet medication data were collected through a questionnaire,and all participants underwent blood tests and brain magnetic resonance imaging at 3.0T.The presence,count,and location of CMBs were evaluated using susceptibility-weighted imaging.The association between antiplatelet medication and the presence of CMBs was analyzed using multivariable logistic regression.The associations between antiplatelet medication and CMBs by location(lobar,deep brain or infratentorial,and mixed regions)were also analyzed using multinomial logistic regression.A linear regression analysis was conducted to determine the association between antiplatelet medication and the log-transformed number of CMBs.RESULTS Of the 544 participants(mean age:58.65±13.66 years,217 males),119 participants(21.88%)had CMBs,and 64 participants(11.76%)used antiplatelet medication.Antiplatelet medication was found to be associated with CMBs at any location[odds ratio(OR)=2.39,95%CI:1.24-4.58]and lobar region(OR=2.83,95%CI:1.36-5.86),but not with the number of CMBs(β=0.14,95%CI:-0.21-0.48).Among antiplatelet medications,aspirin use was found to be associated with any CMB(OR=3.17,95%CI:1.49-6.72)and lobar CMBs(OR=3.61,95%CI:1.57-8.26).CONCLUSIONS Antiplatelet medication was associated with CMBs in stroke-free participants,particularly lobar CMBs.Among antiplatelet medications,aspirin use was associated with any CMB and lobar CMBs.Our findings suggest that it might be essential to optimize the management of antiplatelet medication in the stroke-free population with a higher burden of vascular risk factors to reduce the potential risk of CMBs.

Duration of dual antiplatelet treatment in the era of next generation drug-eluting stents

Current percutaneous coronary intervention guidelines recommend dual antiplatelets(aspirin 100 mg + clopidogrel 75 mg daily) for at least 12 mo following drugeluting stent(DES) implantation if patients are not at high risk of bleeding.Several reports have tried to shorten the dual antiplatelet therapy to 3-6 mo,especially following next-generation DES implantation,for cost-effectiveness.However,the clinical results are inconsistent and the data regarding next-generation DESs limited.In this report,recently published important pivotal reports regarding the optimal duration of dual antiplatelets following DES implantation are summarized.

Association of α_(2A)-Adrenergic Receptor Genetic Variants with Platelet Reactivity in Chinese Patients on Dual Antiplatelet Therapy Undergoing Percutaneous Coronary Intervention

Objective The alpha 2A-adrenergic receptor gene （ADRA2A） polymorphism in individuals antiplatelet response to sympathetic stimulation. The aim of this study was to investigate ADRA2A variants on platelet reactivity in Chinese patients on dual antiplatelet therapy undergoing percutaneous coronary intervention （PCI）. modifies the the effect of （DAPT） after Methods From March 2011 to March 2013, 1,024 patients were enrolled in this prospective, single-center, observational study in China. Four single nucleotide polymorphisms （SNPs） of ADRA2A gene （rs11195419, rs3750625, rs13306146, and rs553668） and CYP2C19^＊2 were detected by ligase detection reaction （LDR）, and adenosine diphosphate （ADP） inhibition was detected by thromboelastography （TEG）. Results The minor allele frequencies of ADRA2A SNPs were common. Platelet ADP inhibition was significantly different among patients carrying rs11195419 （adjusted P = 0.022） and rs3750625 （adjusted P = 0.016）. The homozygous allele carriers had the lowest ADP inhibition. However, ADP inhibition was not significantly different in rs553668 and rs13306146. At the multivariate analysis, rs11195419 （P = 0.033）, rs3750625 （P = 0.020） and CYP2C19＂2 （P = 0.002） were independent predictors of ADP inhibition. Subgroups analysis based on sex showed rs11195419 （P = 0.003） and rs3750625 （P = 0.002） were significantly associated with ADP inhibition in males, but not in females. Conclusion ADRA2A genetic variations were associated with ADP-induced platelet aggregation during DAPT in Chinese patients undergoing PCI, and the effect was particularly more pronounced in males.

Management of antiplatelet or anticoagulant therapy in endoscopy: A review of literature

Endoscopic procedures hold a basal risk of bleeding that depends on the type of procedure and patients’comorbidities.Moreover,they are often performed in patients taking antiplatelet and anticoagulants agents,increasing the potential risk of intraprocedural and delayed bleeding.Even if the interruption of antithrombotic therapies is undoubtful effective in reducing the risk of bleeding,the thromboembolic risk that follows their suspension should not be underestimated.Therefore,it is fundamental for each endoscopist to be aware of the bleeding risk for every procedure,in order to measure the risk-benefit ratio for each patient.Moreover,knowledge of the proper management of antithrombotic agents before endoscopy,as well as the adequate timing for their resumption is essential.This review aims to analyze current evidence from literature assessing,for each procedure,the basal risk of bleeding and the risk of bleeding in patients taking antithrombotic therapy,as well as to review the recommendation of American society for gastrointestinal endoscopy,European society of gastrointestinal endoscopy,British society of gastroenterology,Asian pacific association of gastroenterology and Asian pacific society for digestive endoscopy guidelines for the management of antithrombotic agents in urgent and elective endoscopic procedures.