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.

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.

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.

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 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.

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.

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.

In-Stent Thrombosis after Antiplatelet Therapy Conversion while Awaiting Coronary Bypass

In-stent thrombosis(IST)is a rare yet dangerous complication that may occur despite optimized coronary intervention in the cardiac catheterization laboratory.This is a case of an 81-year-old man who presented with ST-elevation myocardial infarction.Right coronary artery(RCA)occlusion was suspected.RCA angiography and percutaneous coronary intervention were performed.Complicated left coronary artery disease was subsequently discovered.Per cardiothoracic surgeon request,the patient was transitioned from ticagrelor to clopidogrel therapy in preparation for coronary artery bypass grafting.The patient experienced IST the day before surgery while receiving clopidogrel.We examine this case,which highlights the complexity of antiplatelet therapy choice and the role of genetic testing in evaluation of IST risk.

Shortened dual antiplatelet therapy in contemporary percutaneous coronary intervention era

Percutaneous coronary intervention with stenting is followed by a duration of dual antiplatelet therapy(DAPT)to reduce stent thrombosis and avoid target lesion failure.The period of DAPT recommended in international guidelines following drug-eluting stent implantation is 12 mo for most patients with acute coronary syndrome,and 6 mo for patients with chronic coronary syndrome or high bleeding risk.The new generation of drug-eluting stents have metallic platforms with thinner struts,associated with significantly less stent thrombosis.Shortened DAPT has been investigated with these stents,with evidence from randomised clinical trials for some individual stents showing non-inferior safety and efficacy outcomes.This has to be balanced by the effect of DAPT on secondary prevention of systemic cardiovascular disease especially in high-risk populations.This review will outline the current evidence for individual stents with regards to DAPT duration for both acute coronary syndrome and chronic coronary syndrome and discuss further directions for research and personalised medicine in this contemporary percutaneous coronary intervention era.

Should antiplatelet therapy be interrupted in drug eluting stent recipients throughout the periendoscopic period？ A very late stent thrombosis case re-port and review of the literature

In-stent thrombosis after cessation of antiplatelet medications in patients with drug-eluting stents （DES） is a significant problem in medical practice, particularly in the perioperative period. We report a case of an 87-year-old man with a medical history of hypertension, coronary artery disease and chronic atrophic gastritis. Very late thrombosis of a sirolimus-eluting stent occurred 1207 days after implantation, seven months after discontinuation of clopidogrel, and the interruption of aspirin 13 days in preparation of an elective endoscopic gastroin-testinal procedure presented with acute myocardial infarction. The patient was treated with thrombectomy and successfully revascularized with superimposition of two sirolimus-eluting stents. Medications administered in the catheterization laboratory included low molecular weight heparin and nitroglycerin. Flow was defined as grade 2 according to the thrombolysis in myocardial infarction scale. Electrocardio-gram after the procedure revealed persistent, but decreased, ST-segment elevation in the anterolateral leads. The patient recovered and was discharged on aspirin and clopidogrel indefinitely. There was no cardiac event during the two year follow-up period. This case underlines the importance of maintaining the balance of thrombosis and bleeding during perioperation of non-cardiac procedure and the possible need for continuation of aspirin therapy during periendoscopic procedures among patients with low bleeding risks who received DES.

Efficacy and safety of triple-antiplatelet therapy after percutaneous coronary intervention： a meta-analysis

Background The combination of cilostazol, aspirin and clopidogrel （triple antiplatelet therapy, TAT） after a percutaneous coronary intervention has been used as an alternative therapy. We performed a meta-analysis to evaluate the efficacy and safety of TAT for patients after percutaneous coronary intervention （PCI）. Methods We systematically searched Pubmed, Embase and Web of Science databases to identify all randomized controlled trials （RCTs） that compared dual antiplatelet therapy （DAT） with and without cilostazol after PCI. All analyses were conducted using Review Manager 5.0. Results The final analysis consisted of 4474 patients from ten studies. The combined results suggested that there was a lower risk of cardiac death （relative risk （RR）=0.55, 95% confidence interval （Cl）： 0.31-0.98, P 〈0.05） and major adverse cardiac events （MACEs） （RR=0.63, 95% Cl： 0.54-0.74, P 〈0.05） in patients treated with TAT as compared to those with DAT follow-ups after six months to one year; no significant difference was observed in bleeding and non-fatal myocardial infarction （MI） （RR=1.14, 95% Cl： 0.80-1.64, P 〉0.055 RR=0.87, 95% Cl： 0.42-1.83, P 〉0.05）. However, the rate of adverse drug reaction was higher in patients receiving TAT than in patients receiving DAT （RR=2.21, 95% Cl： 1.84-2.66, P 〈0.05）. Moreover, there was a lower risk of stent thrombosis in patients treated with TAT as compared to those treated with DAT （RR=0.44, 95% Cl： 0.21-0.94, P 〈0.05）. The TAT group had a reduced risk of target lesion revascularization （TLR） （RR=0.60, 95% Cl： 0.43-0.82, P=-0.001） and target vessel revascularization （TVR） than the DAT group （RR=0.56, 95% Cl： 0.45-0.71, P 〈0.05）. The number of MACEs was lower for patients in the TAT group than in the DAT group with diabetes mellitus sub-analysis （RR=0.41, 95% Cl： 0.28-0.61, P 〈0.05）. But no significant difference was observed between the two groups regarding MACEs in patients with drug-eluting stent implantations （RR=0.82, 95% Cl： 0.65-1.03, P 〉0.05）. Conclusion TAT could significantly reduce the rates of MACEs and cardiac death in comparison to DAT, but more attention should be paid to adverse side effects of the drugs.

Efficacy of Dual Antiplatelet Therapy Combined with Naoxintong Capsules(脑心通胶囊) Following Coronary Microembolization Induced by Homologous Microthrombi in Rats

Objective： To evaluate the efficacy of dual antiplatelet therapy combined with Naoxintong Capsule （脑心通胶囊, NXTC） in a rat model of coronary microembolization （CME）. Methods： A total of 95 rats were randomly divided into 6 groups： control, sham-operation, CME model, NXTC, dual antiplatelet （clopidogrel and aspirin） intervention （DA）, and NXTC combined with DA （NDA） groups. The complete data in 69 rats were obtained. The number of CME, myocardial apoptosis rate, bleeding time, clotting time, and adensosine diphosphate （ADP）-induced platelet aggregation were assessed. Results： Compared with the CME group, the number of CME and myocardial apoptosis rates were significantly decreased in the NXTC, DA, and NDA groups （P〈0.01）. Compared with other intervention groups, the number of CME and myocardial apoptosis rates were the least in the NDA group （P〈0.01）, and the incidence of surgical bleeding was the highest in the DA group （P〈0.01）. Compared with the CME group, ADP-induced maximum platelet aggregation rate was significantly inhibited in the NXTC, DA, and NDA groups （P〈0.01）, both bleeding time and clotting time were significantly increased in the NXTC, DA, and NDA groups （P〈0.01）, while the above parameters were the highest in the DA group （P〈0.05）. Conclusion： The combination therapy of NXTC and DA enhanced the anti-CME effect of either therapy alone and reduced the risk of the DA therapy-associated bleeding, demonstrating an improved benefit/ risk ratio in the rat model of CME.

Shorter- versus Longer-duration Dual Antiplatelet Therapy in Patients with Diabetes Mellitus Undergoing Drug-eluting Stents Implantation： A Meta-analysis of Randomized Controlled Trials

Background： Patients with diabetes mellitus （DM） have a higher risk of thromboembolic events： however, the optimal duration of dual antiplatelet therapy （DAPT） remains unclear. The goal of this study was to assess the efficacy and safety of various DAPT durations in patients with DM undergoing drug-eluting stent implantation. Methods： We conducted a literature search for randomized controlled trials （RCTs）. We searched databases including EMBASE, PubMed, Cochrane Library, and Scopus up to June 2016. Investigators extracted data independently, including outcomes, characteristics, and study quality. A random-effect model was used to pool odds ratios （ORs） with 95% confidence intervals （C/s） of the clinical outcomes. Results： Six RCTs totaling 6040 patients with DM were included in the study. Shorter-duration DAPT resulted in an increased rate of stent thrombosis （ST） （OR, 1.83, 95% CI： 1.03-3.26, P = 0.04）, but did not increase the risk of myocardial inihrction （OR. 1.33, 95% CI： 0.71 2.47, P=0.37）, stroke （OR, 0.96, 95% CI： 0.52-1.77, P 0.90）, target vessel revascularization （OR, 1.19, 95% CI： 0.46-3.07, P = 0.71 ）, all-cause death （OR： 0.72, 95% CI： 0.48-1.09, P = 0.12）, or cardiac death （OR, 0.82, 95% CI： 0.49-1.36, P= 0.44） significantly. Shorter-duration DAPT was associated with a decreased risk of major bleeding （OR. 0.60, 95% CI： 0.38-0.94, P = 0.02）. Conclusion： In patients with DM, longer-duration DAPT had a lower risk of ST, but was associated with an increased bleeding risk.

Triple antithrombotic therapy versus double antiplatelet therapy after percutaneous coronary intervention with stent implantation in patients requiring chronic oral anticoagulation： a meta-analysis

Background Whether an addition of OAC to double antiplatelet therapy for patients with an indication of chronic oral anticoagulation undergoing PCI-S may improve clinical outcomes is still debated. This meta-analysis aimed to update and re-compare the benefits and risks of triple antithrombotic therapy （TT） with double anti-platelet therapy （DAPT） after in patients who requiring oral anticoagulation after percutaneous coronary interventions with stenting （PCI-s）. Methods Ten reports of observational retrospective or prospective studies were retrieved, including a total of 6296 patients, follow-up period ranging from 1 year to 2 years. Results Baseline characteristics were similar in both groups. The main finding of this study is the overall incidence of major adverse cardiovascular events （MACE）, myocardial infarction （MI） and stent thrombosis was comparable between two groups. Patients with TT was associated with significant reduction in ischemic stroke （OR： 0.27; 95% CI： 0.13-0.57; P=0.0006） as compared to DAPT. We reaffirmed triple therapy significantly increased the risk of major bleeding （OR： 1.47; 95% CI： 1.22-1.78; P 〈0.0001） and minor bleeding （OR： 1.55; 95% CI： 1.07-2.24; P=-0.02）. Conclusions Triple therapy is more efficacious in reducing the occurrence of ischemic stroke in PCI-s patients with an indication of chronic oral anticoagulation （OAC）, compared with DAPT. However, it significantly increased major and minor risk of bleeding. It is imperative that further prospective randomized controlled trials are required to define the best therapeutic strateav for patients with an indication of chronic OAC underaoina PCI-s.

Platelet function monitoring guided antiplatelet therapy in patients receiving high-risk coronary interventions

Background Large-scale clinical trials have shown that routine monitoring of the platelet function in patients after percutanous coronary intervention （PCI） is not necessary. However, it is still unclear whether patients received high-risk PCI would benefit from a therapy which is guided by a selective platelet function monitoring. This explanatory study sought to assess the benefit of a therapy guided by platelet function monitoring for these patients. Methods Acute coronary syndrome （ACS） patients （n=384） who received high-risk, complex PCI were randomized into two groups. PCI in the two types of lesions described below was defined as high-risk, complex PCI： lesions that could result in severe clinical outcomes if stent thrombosis occurred or lesions at high risk for stent thrombosis. The patients in the conventionally treated group received standard dual antiplatelet therapy. The patients in the platelet function monitoring guided group received an antiplated therapy guided by a modified thromboelastography （TEG） platelet mapping： If inhibition of platelet aggregation （IPA） induced by arachidonic acid （AA） was less than 50% the aspirin dosage was raised to 200 mg/d; if IPA induced by adenosine diphosphate （ADP） was less than 30% the clopidogrel dosage was raised to 150 mg/d, for three months. The primary efficacy endpoint was a composite of myocardial infarction, emergency target vessel revascularization （eTVR）, stent thrombosis, and death in six months. Results This study included 384 patients; 191 and 193 in the conventionally treated group and platelet function monitoring guided group, respectively. No significant differences were observed in the baseline clinical characteristics and interventional data between the two groups. In the platelet function monitoring guided group, the mean IPA induced by AA and ADP were （69.2＋24.5）% （range, 4.8% to 100.0%） and （51.4＋29.8）% （range, 0.2% to 100.0%）, respectively. The AA- induced IPA of forty-three （22.2%） patients was less than 50% and the ADP-induced IPA of fifty-seven （29.5%） patients was less than 30%; therefore, their drug dosages were adjusted. The TEG was rechecked one to four weeks after PCI, and the results indicated that the IPAs had significantly improved （P 〈0.01）. However, no significant differences were found in the rates of the primary efficacy endpoint. Rates in the conventionally treated group and platelet function monitoring guided group were 4.7% and 5.2%, respectively （hazard ratio： 1.13; P=0.79）. Conclusion An antiplatelet therapy guided by TEG monitored platelet function could not improve clinical efficacy even in ACS patients treated with high-risk complex PCI.

Individualized Antiplatelet Therapy： A Long Way to Go

Antiplatelet therapy is the cornerstone for the management of patients with coronary artery disease. In the past two decades, the study on individualized antiplatelet therapy has never been more prosperous accompanied with the rapid growth of percutaneous coronary interventions （PCIs）.

Effects of Prior Antiplatelet Therapy on the Prognosis of Primary Intracerebral Hemorrhage： A Meta-analysis

Background：Antiplatelet therapy （APT） was prevalently being used in the prevention of vascular disease,but the influence of prior APT on the prognosis of patients with intracerebral hemorrhage （ICH） remains controversial.This meta-analysis was to explore the effects of prior APT on the prognosis of patients with primary ICH.Methods：PubMed and Embase were searched to identify the eligible studies.The studies comparing the mortality of ICH patients with or without prior APT were included.The quality of these studies was evaluated by the Newcastle-Ottawa quality assessment scale.The adjusted or unadjusted odds ratio （OR） for mortality between ICH patients with and without prior APT were pooled with 95% confidence interval （95% CI） as the effect of this meta-analysis.Results：Twenty-two studies fulfilled the inclusion criteria and exhibited high qualities.The pooled OR was 1.37 （95% CI：1.13-1.66,P =0.001） for univariate analysis and 1.41 （95% CI：1.05-1.90,P =0.024） for multivariate analysis.The meta-regression indicated that for each 1-day increase in the time of assessment,the adjusted OR for the mortality of APT patients decreased by 0.0049 （95% CI：0.0006-0.0091,P =0.026） as compared to non-APT patients.Conclusion：Prior APT was associated with high mortality in patients with ICH that might be attributed primarily to its strong effect on early time.

Impact of prolonged dual antiplatelet therapy on patients after drug-eluting stents implantation

Background Impact of dual antiplatelet therapy beyond 12 months on patients implanted with DES remains unsolved.Methods From January 2010 to June 2011,1873 patients who have been taking DAPT and free from death,myocardial infarction,stroke,repeat coronary revascularization,stent thrombosis,and major or minor bleeding according to TIMI criteria for 12 months after implantation of DES were randomly assigned to continuous （prolonged DAPT group） or discontinuous （standard DAPT group） clopidogrel （75 mg/day）.The primary outcome was major adverse cardiovascular events （MACEs） which compose of death,nonfatal myocardial infarction （MI）,nonfatal stroke,target vessel revascularization （TVR） or stent thrombosis （ST） at 180 days.Results There was no significant difference in the incidence of 180-day MACEs between prolonged DAPT group and standard DAPT group （8.98 % versus 10.13 %,respectively,P=0.400）.The frequency of major bleeding was 0.64 % in prolonged DAPT arm and 0.43% in standard DAPT arm （P=0.523）,that of minor bleeding was 3.32 % versus 2.87 % （P=0.585）,respectively.Conclusions Prolonged DAPT beyond 12 months neither improve prognosis nor increase risk of bleeding in patients implanted with DES.