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.

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.

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.

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.

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.

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.

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

到 clopidogrel (纵向冗余码校验) 的 BackgroundLow 应答与 ischemic 事件的增加的风险被联系。这研究被瞄准根据应答探索定制的 antiplatelet 治疗的可行性到 305 clopidogrel na&#x000ef 全部的 clopidogrel.MethodsA；有经历冠的 stenting 的急性冠的症候群(交流) 的 ve 病人随机被分配收到标准(n = 151 ) 或定制(n = 154 ) antiplatelet 治疗。由轻传播 aggregometry 的导致自动数据处理的血小板聚集测试被执行识别分到定制的组的纵向冗余码校验病人。标准 antiplatelet 政体是有阿司匹林和 clopidogrel 的双 antiplatelet 治疗。定制的 antiplatelet 治疗为纵向冗余码校验病人是为非纵向冗余码校验病人和另外的 6 月的 cilostazol 治疗的标准政体。主要功效结果是在一 year.ResultsLCR 的心血管的死亡，心肌的梗塞或击合成在 26.6% 是在场的(41/154 ) 在定制的组的病人。为 LCR 病人的百分比血小板聚集显著地在附属 cilostazol 治疗以后在三天被减少(77.5%&#x000b1；12.1% 对 64.5%&#x000b1；12.1% ， P &#x0003c；0.001 ) 。在一年后续，一不重要主要事件的 37% 相对风险减小作为与标准组相比在定制的组被观察(5.8% 对 9.3% ， P = 0.257 ) 。在冠的 stenting 根据到 clopidogrel 的应答是可行的以后，处于在为交流病人的二 groups.ConclusionsTailored antiplatelet 治疗之间的 stent 血栓和出血性的事件的率没有差别。然而，它的功效和安全需要与更大的样品尺寸由临床的试用推进证实。

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.

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

ObjectiveTo 在心律调整器估计流血复杂并发症的流行收到不同 antiplatelet 政体的植入的病人，和在设备 implantation.MethodsWe 以后的医院停留上的每政体的影响有希望地注册了从 2012 年 7 月在 Fuwai 医院里收到心脏的节奏设备培植到 2013 年 12 月的 364 个病人。包括袖珍 hematoma， hemothorax，心脏的 tamponade 和输血要求的流血复杂并发症作为端点被测量。波斯特手术医院停留也在 endpoints.ResultsBleeding 复杂并发症被包括在 15 个病人被检测(14 与 hematoma，有 hemothorax 的) 从所有 364 个病人(4.12%) 。双 antiplatelet 治疗(DAT ) 显著地与阿司匹林治疗(ASA ) 相比增加了 hematoma (19.3%)(3.2% ， P = 0.001 ) 并且没有 antiplatelet 治疗(1.9% ， P &#x0003c；0.001 ) 。在在 ASA 组和控制组之间的袖珍 hematoma 的发生没有重要差别(P = 0.45 ) 。柱子过程医院停留在 DAT 组是更长的(5.45 &#x000b1；2.01 天) 与那些相比在 ASA 组(3.65 &#x000b1；1.37 天， P &#x0003c；0.05 ) 或控制组(3.99 &#x000b1；2.27 天， P &#x0003c；0.05 ) 。袖珍 hematoma 被认为医院停留延伸的一个独立预言者(或：5.26；95% CI：1.56 &#x02212； 16.64；P = 0.007 ) 在这经历设备培植的中国病人学习的 .ConclusionsAmong，双 antiplatelet 代理人的使用显著地增加了袖珍 hematoma 复杂并发症的风险并且导致了更长的医院停留。阿司匹林的使用独自没增加风险。

Safety and efficacy of dual antiplatelet therapy after percutaneous coronary interventions in patients with end-stage liver disease

The prevalence of coronary artery disease(CAD)increases in patients with endstage liver disease,with part of them receiving the percutaneous coronary intervention(PCI)as a treatment option.Dual antiplatelet therapy(DAPT),a standard of care after PCI,could result in catastrophic consequences in this population.Before PCI and the start of DAPT,it is recommended to assess patient bleeding risk.Based on novel findings,liver cirrhosis does not necessarily lead to a significant increase in bleeding complications.Furthermore,conventional methods,such as the international normalized ratio,might not be appropriate in assessing individual bleeding risk.The highest bleeding risk among cirrhotic patients has a subgroup with severe thrombocytopenia(<50×10^(9)/L)and elevated portal pressure.Therefore,every effort should be made to maintain thrombocyte count above>50×10^(9)/L and prevent variceal bleeding.There is no solid evidence for DAPT in patients with cirrhosis.However,randomized trials investigating short(one month)DAPT duration after PCI with new drug-eluting stents(DES)in a high bleeding risk patient population can be implemented in patients with cirrhosis.Based on retrospective studies(with older stents and protocols),PCI and DAPT appear to be safe but with a higher risk of bleeding complications with longer DAPT usage.Finally,novel methods in assessing CAD severity should be performed to avoid unnecessary PCI and potential risks associated with DAPT.When indicated,PCI should be performed over radial artery using contemporary DES.Complementary medical therapy,such as proton pump inhibitors and beta-blockers,should be prescribed for lower bleeding risk patients.Novel approaches,such as thromboelastography and“preventive”upper endoscopies in PCI circumstances,warn clinical confirmation.

Efficacy of Short-term Dual Antiplatelet Therapy after Implantation of Second-generation Drug-eluting Stents:A Meta-analysis and Systematic Review

Objective The benefit of short-term dual antiplatelet therapy(DAPT) following second-generation drug-eluting stents implantation has not been systematically evaluated. To bridge the knowledge gap,we did a meta-analysis to assess the efficacy of ≤6 months versus ≥12 months DAPT among patients with second-generation drug-eluting stents. Methods We searched online databases and identified randomized controlled trials that assess the clinical impact of short-term DAPT(≤6 months) published before March 3,2016. The efficacy endpoints included the incidence of all-cause death,myocardial infarction,cerebrovascular accidents,and definite or probable stent thrombosis. Safety endpoint defined as major bleeding was also evaluated and discussed. Results We included 5 trials that randomized 9473 participants(49.8%,short-term DAPT duration vs. 50.2%,standard duration). A total of 9445(99.7%) patients reported the efficacy endpoints,and the safety endpoint was available from 4 studies(n=8457). There was no significant difference in efficacy endpoints between short-term and standard DAPT duration(≥12 months) [risk ratio(RR) 0.96; 95% confidence intervals(CI),0.80-1.15]. Short-term DAPT duration did not significantly increase the individual risk of all-cause death,myocardial infarction,cerebrovascular accidents,or definite or probable stent thrombosis. Although short-term DAPT obviously reduced risk of major bleeding compared with standard DAPT(RR 0.53; 95% CI,0.29-0.96),significant publication bias was found when accessing the safety endpoint of the 4 studies(Egger's test,P=0.009). Conclusions The efficacy of short-term DAPT was comparable with that of standard duration DAPT.DAPT less than 6 months may be appropriate for patients receiving second-generation drug-eluting stents implantation.

Optimal duration for dual antiplatelet therapy with COMBO dual therapy stent

The COMBO stent(OrbusNeich Medical BV,the Netherlands)is a stainless-steel platform with the biodegradable abluminal coating containing antiproliferative sirolimus(5 mg/mm)and the luminal stent surface covered with anti-CD-34 antibody.The CD-34 antibodies essentially capture endothelial progenitor cells resulting in rapid re-endothelialization of the treated segment.

Knowledge,attitude and perception of antiplatelet therapy among dentists in Central Eastern Turkey

AIM:To survey the dentists in Central Eastern Turkey,testing their knowledge on coronary interventions and assessing perception of antecedent dual antiplatelet therapy.METHODS:Two hundred and ninety-eight dentists were surveyed face-to-face by completing questionnaires,including 16 structured questions focused on general knowledge of coronary stents,and assessing periprocedural practice with regard to antiplatelet therapy.RESULTS:All respondents were aware of such devices as coronary stents,but only one-third of the respondents knew the differences between a bare metal and a drug-eluting stent design,and associated vascularoutcomes.Awareness about stent thrombosis was limited to 34%,while consequences of interrupting antiplatelet therapy were known to only 30% of surveyed dentists.Importantly,the attitudes of surveyed respondents differed substantially depending on the location of their practice,where dentists working in the urban environment(population over 10 000) were more aware of antiplatelet recommendations when compared to their colleagues from the rural areas.CONCLUSION:Knowledge about coronary stents,associated clinical outcomes,and current guidelines with regard to surgical management of antecedent antiplatelet therapy in Central Eastern Turkey is inconsistent,and heavily dependent on the location of dental practice.Rural areas around the globe should be in a focus of continuous medical education to improve the quality of medical care.

Study on the Guidance of Platelet Inhibition Rate Detected with Thrombelastogram in Antiplatelet Therapy for Acute Non-Cardiogenic Stroke

Objective:To investigate the application value of thrombelastogram(TEG)in the detection of platelet inhibition rate for antiplatelet therapy for acute non-cardiogenic stroke.Methods:A total of 100 patients with ischemic non-cardiogenic stroke were selected for this study from September 2020 to October 2021.Patients were randomly divided into experimental group and control group,with 50 cases for each group.Before and after 1 week of antiplatelet drug treatment,the platelet inhibition rate in the experimental group was measured with arachidonic acid(AA)and adenosine diphosphate(ADP)by TEG;no platelet inhibition rates detection was conducted for the control group.The dose and type of drugs were adjusted for the experimental group according to the platelet functions and medication based on the clinical experience conducted for the control group.The neurological deficits of the discharged patients were scored with NIHSS score,mRS score,stroke recurrence,hemorrhage,and other events were followed up at the 3rd month of discharge.Results:In the experimental group,the inhibition rates of AA and ADP were significantly higher than those before treatment(both P<0.05).After treatment,the inhibition rates of AA and ADP in dual antiplatelet patients were higher than those of monoclonal antiplatelets(both P<0.05).The NIHSS score at discharge and the mRS score at the 3rd-month-follow-up in the experimental group were lower than those in the control group(both P<0.05).The incidences of stroke recurrence and hemorrhage events in the experimental group were lower than those in the control group(P<0.05).Conclusion:The application of a thrombelastogram in the detection of platelet inhibition rate to guide antiplatelet therapy in patients with acute non-cardiogenic stroke reduces the recurrences of cerebral infarction and the risk of hemorrhage and improves patients’clinical prognosis.

Antiplatelet Therapy Considerations in Women

Coronary artery disease(CAD)is the leading cause of death worldwide,but because of several factors,one of which is antiplatelet therapy,the mortality rates have steadily declined.However,women continue to experience higher CAD mortality rates than men.This may be explained by differences in comorbidities,increased time to presentation,higher bleeding rates,and differences in management.There are numerous landmark trials in the field of antiplatelet therapy;however,women are consistently underrepresented in these trials.The results of these trials reveal that women experience the same benefit as men from antiplatelet therapy but experience higher bleeding rates;therefore bleeding-reduction strategies are imperative in this patient population.This review provides an overview of the available evidence on CAD in women and its implications for antiplatelet medications.

Risk Factors for Gastrointestinal Injuries in Acute Coronary Syndrome Patients with Double Antiplatelet Therapy in One-Year Follow-Up

Background: The goal is to determine the incidence of symptomatic gastrointestinal (GI) injuries in acute coronary syndrome (ACS) patients receiving double antiplatelet therapy (DAPT). The risk factors for serious GI complications are also evaluated. Methods: 603 eligible patients from the Department of Cardiology at Zhongda Hospital between January 2014 and August 2015 were enrolled and the occurrence of GI injuries within one year assessed. The risk factors for serious GI complications were identified using cox regression analysis. Results: After one-year follow-up, 108 (17.9%) out of 603 patients developed symptomatic GI injuries: 22 (3.65%) with serious GI complications and 86 (14.2%) with GI symptoms. Drinking habit (95% CI: 1.512 - 8.796;P = 0.004) and previous peptic injury (95% CI: 2.307 - 18.080;P = 0.001) are independent predictors of serious GI complications, while proton pump inhibitor (PPI) was protective (95% CI: 0.120 - 0.699;P = 0.006) per cox regression analysis. Additionally, GI injuries of both serious GI complications and GI symptoms peaked in the first three months. Conclusions: Symptomatic GI injuries were relatively common in ACS patients with DAPT, especially in the first three months. Previous peptic injury and drinking habit were significant independent risk factors for serious GI complications, while PPI played a protective role in ACS with DAPT.

What is the Optimal Duration of Dual Antiplatelet Therapy After Stenting?

The optimal duration of dual antiplatelet therapy(DAPT)of aspirin and a P2Y12 receptor blocker after stenting is still being debated.The current recommendations for DAPT duration are signifi cantly focused on reducing stent thrombosis;a less frequent event with later than earlier generation drug eluting stents(DES).A persistent occurrence of late and very late stent thrombosis with first generation DES supported extended use of DAPT beyond one year.However,recent studies have demonstrated that extended duration DAPT is associated with increased bleeding;an independent predictor for poor outcomes,including long-term mortality.Second-generation DES are associated with less late and very late stent thrombosis.Some recent studies have supported a shorter duration of DAPT for second generation DES.However,these studies were inadequately powered to assess signifi cant differences in stent thrombosis.Furthermore,extended duration DAPT has been associated with a reduced risk of thrombotic events in non-culprit vessels in addition to stent thrombosis in patients with acute coronary syndromes(ACS).The higher risk of bleeding associated with extended DAPT therapy provides a strong rationale for personalized DAPT based on patient risk factors(e.g.ACS vs.non-ACS),type of stents,and cost-benefit analyses.

Modern Antiplatelet Therapy:When Is Clopidogrel the Right Choice?

Platelet inhibition with aspirin is the cornerstone of medical therapy for coronary artery disease.In the era of percutaneous coronary intervention with drug-eluting stents,dual anti-platelet therapy with the addition of clopidogrel(Plavix,Bristol-Myers Squibb,New York,NY)became the mainstay of therapy.However,with the advent of newer oral antiplatelet medications,including prasugrel(Effient?,Eli Lilly,Indianapolis,Indiana)and ticagrelor(Brilinta?,Astra-Zeneca,Cambridge,United Kingdom),choosing the appropriate platelet inhibitor has become more nuanced.The optimal regimen differs based on patient characteristics,clinical situation,and the condition being treated,with differing risk and safety profiles for these medications.This review explores the appropriate use of antiplatelet therapy for stable ischemic heart disease,acute coronary syndrome,stroke,and peripheral vascular disease.Furthermore,we evaluate the data behind the use of antiplatelet therapy in patients on oral anticoagulation.By understanding the biochemistry of platelet aggregation,the pharmacology of platelet inhibitors,and the extensive clinical trial data that informs current guideline recommendations we aim to better understand the role of clopidogrel in patients with cardiovascular disease.