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.

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.

Monitoring anticoagulant therapy with new oral agents

Thromboembolic disease is a major leading cause of mortality and morbidity in industrialized countries. Currently, the management of these patients is challenging due to the availability of new drugs with proven efficacy and security compared to traditional oral vitamin K antagonists. These compounds are characterized by a predictable pharmacokinetic profile for which blood monitoring is not routinely needed. Nevertheless, some data have suggested inter-patient variability in the anticoagulant effect of these drugs, raising concerns about their effectiveness and safety. Although mass-spectrometry is the gold standard to determine drug plasma concentrations, this method is not widely available in every-day practice and some coagulation assays are commonly used to determine the anticoagulant effect of these drugs. The present review aims to summarize the current knowledge regarding the clinical question of how and when to monitor patients with new anticoagulant oral agents.

Anticoagulation and antiplatelet management in gastrointestinal endoscopy: A review of current evidence

The role of endoscopic procedures,in both diagnostic and therapeutic purposes is continually expanding and evolving rapidly.In this context,endoscopists will encounter patients prescribed on anticoagulant and antiplatelet medications frequently.This poses an increased risk of intraprocedural and delayed gastrointestinal bleeding.Thus,there is now greater importance on optimal pre,peri and post-operative management of anticoagulant and/or antiplatelet therapy to minimise the risk of post-procedural bleeding,without increasing the risk of a thromboembolic event as a consequence of therapy interruption.Currently,there are position statements and guidelines from the major gastroenterology societies.These are available to assist endoscopists with an evidenced-based systematic approach to anticoagulant and/or antiplatelet management in endoscopic procedures,to ensure optimal patient safety.However,since the publication of these guidelines,there is emerging evidence not previously considered in the recommendations that may warrant changes to our current clinical practices.Most notably and divergent from current position statements,is a growing concern regarding the use of heparin bridging therapy during warfarin cessation and its associated risk of increased bleeding,suggestive that this practice should be avoided.In addition,there is emerging evidence that anticoagulant and/or antiplatelet therapy may be safe to be continued in cold snare polypectomy for small polyps(<10 mm).

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.

Protein extract of kenaf seed exhibits anticoagulant,antiplatelet and antioxidant activities

Objective:To explore the anticoagulant,antiplatelet and antioxidant activities of protein extract of kenaf seed(PEKS).Methods:Sodium dodecyl sulphate polyacrylamide gel electrophoresis and reverse-phase high-performance liquid chromatography techniques were employed for protein characterization.Antioxidant activity of PEKS was assessed using 1,1-diphenyl-2-picrylhydrazyl(DPPH)assay.The protective effect of PEKS on sodium nitrite(NaNO2)induced oxidative stress was evaluated using the in vitro red blood cell model,while the effect of PEKS on diclofenacinduced oxidative stress was examined in vivo in rats.Platelet-rich plasma and platelet-poor plasma were used for anticoagulant and antiplatelet activities of PEKS.Results:PEKS revealed similar protein bands on SDS-PAGE under reduced and non-reduced conditions.Several acidic proteins were present in native PAGE.PEKS showed antioxidant properties by scavenging DPPH with an IC50 of 24.58μg.PEKS exhibited a protective effect on NaNO2 induced oxidative stress in red blood cells by restoring the activity of stress markers.In addition,PEKS alleviated diclofenac-induced tissue damage of the liver,kidney,and small intestine.PEKS showed an anticoagulant effect in both in vivo and in vitro experiments by enhancing normal clotting time.PEKS did not affect prothrombin time but increase activated partial thromboplastin time.Furthermore,PEKS inhibited adenosine diphosphate and epinephrine-induced platelet aggregation.Conclusions:PEKS protects tissues from oxidative stress and exhibits antithrombotic activity.

Anticoagulant, Antiplatelet and Antianemic Effects of Citrus paradisi (Grape Fruit) Juice in Rabbits

Medicinal plants are under continuous analysis worldwide to explore new medication to treat atherosclerosis and cardiovascular diseases. Citrus fruits have displayed utmost antioxidant activity, particularly flavonoids in Citrus paradisi have exhibited strong antioxidant and anti-inflammatory characteristics. This study was intended to examine effects of C. paradisi on blood coagulation and anticoagulation at doses of 0.1, 0.3 and 0.5 ml/kg. Highly significant increase in thrombin time (TT) and substantial decline in fibrinogen (Fb) level was noticed as related to control. There was substantial increase in TT, prothrombin time (PT) and activated partial thromboplastin time (aPTT) and noteworthy decrease in Fb level by warfarin. C. paradisi at 0.3 ml/kg considerably inhibited aggregation of platelet by collagen, adenosine phosphate, arachidonic acid and epinephrine, while there was also substantial rise in Protein C, TAT complex, RBC and hemoglobin concentration. In conclusion, these results suggest that the addition of C. paradisi to the diet of patients at risk of developing cardiovascular events could significantly decrease the morbidity or mortality in these patients due to high contents of phytochemicals like naringin, hesperidin, limonene and other flavonoids.

Historical Evolution of the Anticoagulant-Antiplatelet Therapy in Patients with Mitral Valve Disease Associated to Atrial Fibrillation or Mechanical Valve Prosthesis. Role of Omeprazole

In this review article we analyze the historical evolution of anticoagulant and antiplatelet therapies in the treatment of atrial fibrillation plus complicated heart diseases. Its combined use, compared with anticoagulation alone, has been widely used to significantly reduce thromboembolic risk. Major bleeding risk has been usually registered during combined antithrombotic therapy, which is mainly due to gastric bleeding, but enteric coating antiplatelet tablets can effectively protect against gastric mucosal damage, and the addition of proton-pump inhibitors (omeprazole) can avoid it.

甲状腺功能异常对凝血系统的影响及治疗药物相互作用研究进展

甲状腺功能异常患者的凝血指标可出现异常,存在潜在发生血栓或出血的风险。甲状腺功能亢进患者存在显著的血管内皮功能紊乱并引起血栓风险,但关于甲状腺功能减退对凝血功能的影响仍存在争议。甲状腺功能异常对凝血系统的潜在风险可能干扰抗凝药物治疗安全性,同时甲状腺疾病治疗药物与抗凝药物之间的相互作用也对患者的用药安全造成影响。该文基于既往研究文献分析甲状腺功能异常与凝血功能相关性,评估和探讨甲状腺功能异常对凝血系统的影响及相关治疗药物相互作用,以期为甲状腺功能紊乱合并凝血功能异常患者的诊治提供参考。

颅内破裂动脉瘤介入栓塞术后抗凝及抗血小板聚集药物应用下腰椎穿刺致急性椎管内血肿2例并文献复习

目的探讨腰椎穿刺(LP)导致椎管内血肿(ISH)形成的临床表现、诊断、治疗及预后。方法回顾性分析新乡医学院第一附属医院2020年7月—2020年10月收治的2例在使用抗血小板聚集及抗凝药物情况下LP导致急性ISH形成患者的临床资料,并复习相关文献。结果此2例均为脑动脉瘤破裂合并蛛网膜下腔出血患者,在支架辅助弹簧圈栓塞动脉瘤术后使用抗血小板聚集及抗凝药物预防支架内血栓形成。在行LP术后均出现急性ISH,并进一步行血肿清除及椎管减压术治疗,出院时均遗留不同程度的神经功能障碍。结论抗凝及抗血小板聚集药物的应用使LP导致ISH形成的可能性较前增加。其诊断主要依靠患者的临床表现、体征及影像学检查,治疗以外科手术减压为主,预后主要与发病时神经功能缺失的程度相关。

急性缺血性卒中急性期药物治疗进展

卒中是我国成人致死、致残的第一位病因。急性缺血性卒中(acute ischemic stroke,AIS)是卒中最常见的类型,严重影响患者生活质量,造成沉重的疾病负担,其防治是医学领域亟待解决的重大问题。AIS的发病机制复杂,治疗上应基于对患者的整体评估进行综合决策,并遵循规范的诊治流程。目前针对AIS急性期的治疗策略主要有两方面,一是尽早开通阻塞血管恢复脑组织灌注,挽救缺血半暗带;二是多靶点抑制缺血性病理生理级联反应,保护脑细胞。近年来,AIS在溶栓、抗血小板以及细胞保护各领域的药物治疗发展迅速,本文结合目前国内外的相关研究成果,对AIS急性期药物治疗进展做一综述,为更多有效治疗药物的研发提供科学依据和思路。

Spinal cord hemorrhage: a rare complication of dual antiplatelet therapy for non-ST elevation myocardial infarction

Dual antiplatelet therapy(DAPT)with aspirin and clopidogrel has been widely used after percutaneous coronary intervention(PCI).The bleeding complications caused by it cannot be ignored and the incidence is as high as 32.4%.[1]Among them,spinal cord hemorrhage is rare,acute and life-threatening.We herein report a case of spinal cord hemorrhage caused by DAPT with aspirin and clopidogrel used after PCI for non-ST elevation myocardial infarction(NSTEMI).

品管圈活动在改善急性缺血性脑卒中患者血管内治疗后抗血小板药物序贯治疗流程中的应用

目的评价问题解决型品管圈活动在规范急性缺血性脑卒中(AIS)患者血管内治疗术后抗血小板药物使用中的应用效果。方法建立品管圈,并将活动主题确定为“缩短AIS患者血管内治疗后抗血小板药物序贯治疗时间”。选择2019年1月至2020年12月(实施品管圈活动前)121例于我中心行机械取栓桥接抗血小板药物序贯治疗的AIS患者,分析影响抗血小板药物序贯治疗时间不达标的主要因素,拟定现状改善品管圈干预措施。另外选择2021年1月至12月(实施品管圈活动后)在我中心行相同治疗的95例AIS患者,实施问题解决型品管圈干预措施,评价和分析应用效果。结果实施品管圈活动前后两组患者的年龄、性别、入院时美国国立卫生研究院卒中量表评分、发病至血管再通时间差异均无统计学意义(P均>0.05)。实施品管圈活动前,药物中断时间为133(110,175)min,序贯治疗时间为367(183,496)min,序贯治疗时间不达标率为45.5%(55/121)。根据柏拉图80/20法则,造成序贯治疗时间不达标的主要原因为等待外出CT检查时间长(36.4%,20/55)、等待CT判读结果时间>60min(27.3%,15/55)、护士不知晓患者口服药物时间(20.0%,11/55)。实施品管圈活动后,药物中断时间为38(25,71)min,序贯治疗时间为257(210,298)min,序贯治疗时间不达标率为7.4%(7/95),与实施品管圈活动前比较差异均有统计学意义(P均<0.001)。实施品管圈活动前后两组分别有3、2例患者在序贯治疗7 d内出现症状性颅内出血,差异无统计学意义(P>0.05);两组患者序贯治疗7 d内均无消化道出血发生。结论应用问题解决型品管圈活动能够规范AIS患者机械取栓术后抗血小板药物给药流程,可以缩短患者药物中断时间,精确口服药物桥接时间,提高患者的用药安全性。

头颈动脉夹层药物治疗前后的高分辨率磁共振成像特征分析

目的分析自发性未破裂头颈动脉夹层(CCAD)患者药物治疗前后高分辨率磁共振成像(HR-MRI)特征变化。方法回顾性连续收集2015年8月至2022年12月于海军军医大学(第二军医大学)第一附属医院确诊并在药物治疗前后行HR-MRI检查的30例CCAD患者资料。根据随访时磁共振血管成像(MRA)图像上夹层血管管腔狭窄的改善情况,将患者分为改善组(随访时管腔狭窄程度较基线减轻1个级别及以上的患者)与未改善组(随访时管腔狭窄程度较基线加重1个级别及以上或无变化的患者)。分析改善组与未改善组患者的临床资料及治疗前后HR-MRI管腔及管壁特征差异。结果30例CCAD患者共计30处夹层,其中改善组14例(11例完全恢复正常,3例管腔狭窄程度改善)、未改善组16例。改善组患者的年龄小于未改善组[(37.86±9.83)岁vs(56.94±9.86)岁,P=0.001],其余临床特征差异均无统计学意义(P均>0.05)。改善组患者中基线壁内血肿比例高、管腔狭窄程度相对较轻,而未改善组患者的基线管腔狭窄程度较严重,内膜瓣与双腔征、假腔内血栓形成更常见(P均<0.05)。治疗后随访时,改善组患者壁内血肿、管腔狭窄程度均改善,未改善组患者壁内血肿、内膜瓣与双腔征、假腔内血栓形成仍有较多残留(P均<0.05)。两组基线夹层血管壁强化程度差异无统计学意义(P>0.05),治疗后随访时改善组患者血管壁强化程度较未改善组降低(P<0.001)。结论HR-MRI可对CCAD药物治疗前后管腔及管壁形态学特征变化进行评估,年龄小、基线管腔狭窄程度相对较轻的患者经药物治疗后夹层恢复好。

抗血小板与抗凝治疗在外周动脉疾病中的应用和研究进展

外周动脉疾病(PAD)的治疗中需要抗血小板和抗凝措施,以防止血栓形成和维持血管通畅,选择合适的抗血小板和抗凝治疗策略对保障疗效和临床预后至关重要。本文归纳整理国内外PAD抗血小板与抗凝治疗方案和临床研究结果,并进行总结和分析。在PAD患者中使用抗血小板药联合抗凝血药的新方案,明显优于传统的单纯抗血小板或抗凝治疗,同时不增加出血风险。新兴的抗血小板联合抗凝治疗(阿司匹林+利伐沙班)是目前最为安全有效的治疗策略,患者临床受益最大,标志着PAD治疗模式进入新时代。

氯吡格雷对比阿司匹林用于缺血性脑卒中二级预防的药物经济学评价

目的评价抗血小板药物氯吡格雷、阿司匹林单药方案用于缺血性脑卒中二级预防的经济性,为临床用药和相关决策提供经济学证据和参考。方法基于CAPRIE试验构建Markov模型,通过查阅相关文献确定风险事件发生概率、健康效用值以及风险事件管理成本等。模型循环周期为6个月,模拟时限为10年,年贴现率为5%。以总成本、质量调整生命年(QALY)和增量-成本效果比(ICER)作为主要计算结果,应用TreeAge Pro软件对上述2种方案进行成本-效用分析,并采用单因素敏感性分析、概率敏感性分析和情境分析来验证基础分析结果的稳健性。结果氯吡格雷方案与CAPRIE试验中325 mg/d剂量阿司匹林方案相比用于脑卒中二级预防在模拟10、20、30年时的ICER值分别为4284.06、4201.20、3986.78元/QALY,均小于以1倍2021年我国人均国内生产总值(GDP)作为的意愿支付(WTP)阈值。而氯吡格雷方案与我国临床常用剂量(100 mg/d)的阿司匹林方案相比用于脑卒中二级预防在模拟10、20、30年时的ICER值分别为58238.27、42164.72、36164.77元/QALY,也均小于WTP阈值。当对比325 mg/d剂量的阿司匹林方案时,单因素敏感性分析结果显示,氯吡格雷周期成本、阿司匹林周期成本、2组治疗方案的脑卒中首次复发概率等为模型敏感因素;概率敏感性分析结果显示,当WTP为1倍2021年我国人均GDP时,氯吡格雷方案具有经济性的概率约为66.5%。情境分析结果显示,无论是10、20、30年3种模拟时限,还是选用不同剂量(50、100、150、200、250 mg/d)阿司匹林方案,均不会使基础分析结果翻转。结论相较于阿司匹林单药方案,氯吡格雷单药方案用于缺血性脑卒中二级预防更具有经济性。

血小板-白细胞聚集体及其在川崎病发病中的研究进展

活化的血小板会与单核细胞、中性粒细胞、树突状细胞和淋巴细胞等各类白细胞相互作用,触发细胞间信号转导,从而导致血栓形成和炎症介质的大量合成。已在多种血栓性疾病和炎症性疾病中发现血液中血小板-白细胞聚集体水平升高,该文综述了最新文献,探讨血小板-白细胞聚集体形成机制、作用、检测方法及其在川崎病发病中的相关作用,为川崎病发病机制的研究提供了新思路。

老年人急性和围手术期及长期抗血栓治疗策略解读

2023年1月,欧洲心脏病学会(ESC)血栓工作组发布了其在2022年更新的老年人急性、围手术期和长期抗血栓治疗共识文件。由于老年人常伴有多器官变化及多种疾病,出血性和血栓性事件风险增加,常服用多种药物,对治疗的依从性差,因此为临床抗栓管理带来很大的挑战。该文对如何评估血栓及出血风险,口服抗血栓药物的治疗策略,胃肠外抗血栓药物的治疗策略,围手术期抗血栓治疗方案进行解读,以期为临床医生治疗老年抗血栓提供参考。

不同抗栓药物并发非静脉曲张性上消化道出血的临床特征及病因分析

目的探讨不同类型口服抗栓药物治疗中并发非静脉曲张性上消化道出血(NVUGIB)的临床特征及病因。方法回顾性分析535例口服抗栓药物治疗中并发NVUGIB患者的临床资料,按抗栓药物种类不同将患者分为抗血小板组和抗凝组,比较分析2组患者的一般资料、临床特点和病因构成。结果抗血小板组男性占比高于抗凝组,差异有统计学意义(P=0.012)。抗血小板组合并冠心病、高血压、糖尿病患者的占比高于抗凝组,合并房颤、心脏瓣膜病、肺栓塞或深静脉血栓的患者占比低于抗凝组,差异有统计学意义(P<0.05);抗血小板组口服药物1个月内发生NVUGIB患者的占比高于抗凝组,差异有统计学意义(P<0.05);抗血小板组出现胸闷、胸痛症状患者的占比高于抗凝组,腹痛症状患者的占比低于抗凝组,差异有统计学意义(P<0.05);抗血小板组使用抑酸药物患者的占比和Hp感染率高于抗凝组,差异有统计学意义(P<0.05)。2组NVUGIB的常见病因为消化性溃疡、急性胃黏膜病变、恶性肿瘤。结论口服抗栓药物并发NVUGIB以老年男性最为多见,前3位的病因为消化性溃疡、急性胃黏膜病变和恶性肿瘤。抗血小板与抗凝并发NVUGIB患者的基础疾病、口服抗栓药时间、症状和病因存在一定差异,临床医生需注意鉴别。

抗血栓形成药物的研究进展

血栓形成是动脉粥样硬化性心血管疾病患者急性表征(心肌梗死,卒中)的主要直接诱因。在全球范围内,血栓栓塞性疾病的发病率近年来有所增加,患者病死率也随之增加。目前,针对血栓栓塞性疾病,已经发展了几种靶向给药策略,其中包括抗血小板药物和抗凝血药物,随着抗血栓形成药物的研究进展,治疗血栓导致的心血管疾病为患者带来了巨大的潜在效益。