RESUMEN
The efficacy and safety of dual antiplatelet therapy (DAPT) relative to intravenous (IV) alteplase in patients with acute minor ischemic stroke are insufficiently established. Therefore, we aimed to perform a meta-analysis to compare DAPT with IV alteplase in patients with acute minor stroke. MEDLINE, Embase, and Cochrane were searched for studies comparing DAPT with IV alteplase in patients with minor stroke. Functional and safety outcomes in 90 days were analyzed. Statistical analysis was performed using Rstudio 4.3.1. Subanalyses were performed restricted to non-disabling minor strokes and NIHSS score ≤ 3. PROSPERO (CRD42023440986). We included five studies with a total of 6,340 patients, of whom 4,050 (63.9%) received DAPT. The follow-up period for all included studies was 90 days. There was no significant difference for individual outcomes of mRS 0-1 (OR 1.26; 95% CI 0.85-1.89; p = 0.25), mRS 0-2 (OR 0.99; 95% CI 0.69-1.43; p = 0.97), or all-cause mortality (OR 0.80; 95% CI 0.20-3.13; p = 0.75) between groups. Symptomatic intracranial hemorrhage (sICH) was significantly lower (OR 0.11; 95% CI 0.003-0.36; p < 0.001) in patients treated with DAPT compared with IV alteplase. In terms of mRS 0-1 and mRS 0-2, we found no significant difference in both subgroup analyses. We found no statistically significant difference between DAPT and IV alteplase regarding functional outcome (mRS scores of 0-1 and 0-2) or all-cause mortality at 90 days in patients with minor ischemic stroke. Additionally, DAPT was associated with a significantly lower rate of sICH.
Asunto(s)
Terapia Antiplaquetaria Doble , Fibrinolíticos , Accidente Cerebrovascular Isquémico , Activador de Tejido Plasminógeno , Humanos , Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Activador de Tejido Plasminógeno/uso terapéutico , Activador de Tejido Plasminógeno/administración & dosificación , Activador de Tejido Plasminógeno/efectos adversos , Fibrinolíticos/uso terapéutico , Fibrinolíticos/administración & dosificación , Fibrinolíticos/efectos adversos , Terapia Antiplaquetaria Doble/métodos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Inhibidores de Agregación Plaquetaria/efectos adversos , Inhibidores de Agregación Plaquetaria/administración & dosificación , Resultado del Tratamiento , AdultoRESUMEN
BACKGROUND: Dual antiplatelet therapy (DAPT) with clopidogrel plus aspirin is a well-established practice after a minor stroke or transient ischemic attack (TIA). However, ticagrelor plus aspirin may be an alternative. AIMS: We systematically searched PubMed, Embase, and Cochrane Central from inception to January 2024. We included randomized controlled trials (RCTs) enrolling adults with acute minor stroke or TIA within 72 hours of the onset of the symptoms. RESULTS: A total of 8 RCTs were included in our meta-analysis. Ticagrelor plus aspirin (RR, 0.70; 95% CrI 0.52, 0.91) and clopidogrel plus aspirin (RR, 0.79; 95% CrI 0.64, 0.98) were superior to aspirin in preventing stroke recurrence in overall analysis. Excluding studies with dual antiplatelet up to 90 days, ticagrelor plus aspirin was the only strategy that maintained superiority compared with aspirin regarding stroke recurrence (RR, 0.70; 95% CrI 0.51, 0.95) and ischemic stroke (RR, 0.68; 95% CrI 0.47, 0.94). There was no significant difference between treatment groups regarding hemorrhagic stroke, functional disability, and mortality. CONCLUSIONS: DAPTs were superior to aspirin in preventing recurrence or ischemic stroke. Although no significant difference was observed between DAPTs, ticagrelor plus aspirin may be related to worse major bleeding results, including intracranial bleeding. Ticagrelor plus aspirin is a considerable option for patients after a minor stroke or TIA.
Asunto(s)
Clopidogrel , Terapia Antiplaquetaria Doble , Ataque Isquémico Transitorio , Metaanálisis en Red , Inhibidores de Agregación Plaquetaria , Accidente Cerebrovascular , Ticagrelor , Humanos , Ticagrelor/administración & dosificación , Clopidogrel/administración & dosificación , Ataque Isquémico Transitorio/tratamiento farmacológico , Inhibidores de Agregación Plaquetaria/administración & dosificación , Inhibidores de Agregación Plaquetaria/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , Aspirina/administración & dosificación , Aspirina/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como Asunto , Quimioterapia Combinada , Accidente Cerebrovascular Isquémico/tratamiento farmacológicoRESUMEN
Em pacientes que apresentam síndromes coronárias agudas e são tratados com intervenção coronária percutânea, a prescrição do esquema antiplaquetário duplo, composto de ácido acetilsalicílico e um inibidor dos receptores P2Y12, é mandatória, contribuindo para a redução de eventos cardíacos maiores. No entanto, ao mesmo tempo em que previne eventos isquêmicos, essa associação pode precipitar complicações hemorrágicas maiores, o que é mais comumente observado quando são prescritos os medicamentos mais potentes, como o prasugrel ou o ticagrelor. Essas constatações levaram à procura de alternativas terapêuticas capazes de manter a proteção contra eventos isquêmicos e, ao mesmo tempo, prevenir a ocorrência de hemorragias. Uma das estratégias que está em estudo é a de-escalação dos inibidores P2Y12, que consiste no uso dos medicamentos mais potentes numa fase precoce após o procedimento, com substituição deles pelo clopidogrel, após um período de, em geral, 30 dias de evolução; outra possibilidade seria a simples redução da dose do fármaco de maior potência, algo que, até o momento, só pode ser cogitado com o prasugrel. A de-escalação pode ser feita de forma guiada, utilizando testes de mensuração objetiva da agregação plaquetária ou exames para avaliar o perfil genético dos pacientes, ou não guiada, na qual o cardiologista simplesmente faz a substituição ou redução da dose ao fim do período estipulado, sem o auxílio de exames complementares. A literatura contempla ensaios clínicos com essas duas opções de estratégia, os quais são discutidos nesta revisão. Até o momento, nenhuma diretriz médica recomenda de forma explícita o uso regular dessa alternativa terapêutica.
In patients who have acute coronary syndromes and are treated with percutaneous coronary intervention, the prescription of a dual antiplatelet regimen, consisting of acetylsalicylic acid and a P2Y12 receptor inhibitor, is mandatory, contributing to the reduction of major cardiac events. However, while preventing ischemic events, this association may precipitate major bleeding complications, which is more commonly seen when more potent drugs, such as prasugrel or ticagrelor, are prescribed. These findings led to the search for therapeutic alternatives that could maintain the protection against ischemic events and, at the same time, prevent the occurrence of hemorrhages. One of the strategies being studied is de-escalation of P2Y12 inhibitors, which consists of the use of more potent drugs in an early phase after the procedure, replacing them with clopidogrel, after a period of, in general, 30 days of clinical course. Another possibility would be to simply reduce the dose of the most potent drug, which so far can only be considered with prasugrel. De-escalation can be done in a guided way, using objective measuring tests of platelet aggregation or exams to assess the genetic profile of patients, or unguided, in which the cardiologist simply replaces or reduces the dose at the end of the stipulated period, with no ancillary tests. The literature includes clinical trials with these two strategy options, which are discussed in this review. So far, no medical guideline explicitly recommends the regular use of this therapeutic alternative.
Asunto(s)
Agonistas del Receptor Purinérgico P2Y , Terapia Antiplaquetaria Doble , Angina Inestable , Infarto del Miocardio , Clorhidrato de PrasugrelRESUMEN
Antiplatelet therapy and percutaneous coronary intervention are two of the most important interventions in the management of coronary artery disease. In the last 20 years there has been groundbreaking advances in the pharmacotherapy and stent technology. Bleeding is the most feared complication of antiplatelet therapy, mainly due to the increase in major adverse cardiovascular events besides the bleeding itself. Different clinical decision tools have developed with the aim to define which patients have a high ischemic or bleeding risk, thus individualizing treatment.
Asunto(s)
Humanos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Quimioterapia Combinada/métodos , Intervención Coronaria Percutánea/tendencias , Stents , Terapia Antiplaquetaria Doble , Hemorragia/tratamiento farmacológico , Isquemia , Anticoagulantes/uso terapéuticoRESUMEN
Abstract ST elevation myocardial infarction (STEMI) is a highly prevalent condition worldwide. Reperfusion therapy is strongly associated with the prognosis of STEMI and must be performed with a high standard of quality and without delay. A systematic review of different reperfusion strategies for STEMI was conducted, including randomized controlled trials that included major cardiovascular events (MACE), and systematic reviews in the last 5 years through the PRISMA ( Preferred Reporting Items for Systematic Reviews and Meta-Analysis) methodology. The research was done in the PubMed and Cochrane Central Register of Controlled Trials databases, in addition to a few manual searches. After the exclusion criteria were applied, 90 articles were selected for this review. Despite the reestablishment of IRA patency in PCI for STEMI, microvascular lesions occur in a significant proportion of these patients, which can compromise ventricular function and clinical course. Several therapeutic strategies - intracoronary administration of nicorandil, nitrates, melatonin, antioxidant drugs (quercetin, glutathione), anti-inflammatory substances (tocilizumab [an inhibitor of interleukin 6], inclacumab, P-selectin inhibitor), immunosuppressants (cyclosporine), erythropoietin and ischemic pre- and post-conditioning and stem cell therapy - have been tested to reduce reperfusion injury, ventricular remodeling and serious cardiovascular events, with heterogeneous results: These therapies need confirmation in larger studies to be implemented in clinical practice
Asunto(s)
Pronóstico , Reperfusión Miocárdica/métodos , Daño por Reperfusión , Infarto del Miocardio con Elevación del ST/terapia , Stents , Terapia Trombolítica , Estrategias de Salud , Trombectomía , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Electrocardiografía/métodos , Antagonistas del Receptor Purinérgico P2Y , Poscondicionamiento Isquémico , Fibrinolíticos/uso terapéutico , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/rehabilitación , Terapia Antiplaquetaria Doble , Revascularización MiocárdicaRESUMEN
BACKGROUND: Dual antiplatelet therapy (DAT) is a therapeutic option for patients with minor ischemic stroke (IS) or transient ischemic attack (TIA). No study has evaluated the incidence of early bleeding in patients with moderate to major ischemic stroke. The current study aimed to analyze both the frequency of early bleeding and hospital morbidity related to DAT for either acute IS or TIA regardless of admission National Institute of Health Stroke Scale (NIHSS) score. METHODS: This was a retrospective analysis based on data collected from a prospective data bank of a single center. We included patients who underwent DAT in the first 24 hours of symptom onset with a loading dose (aspirin 300 mgâ¯+â¯clopidogrel 300 mg) on the first day, followed by a maintenance dose (aspirin 100 mgâ¯+â¯clopidogrel 75 mg). We analyzed intracranial and/or extracranial hemorrhage that had occurred during the hospital admission, symptomatic bleeding, modified Rankin Scale (mRS) score at discharge, and death rates as outcomes. RESULTS: Of the 119 patients analyzed, 94 (79 %) had IS and 25 (21 %) had TIA. Hemorrhage occurred in 11 (9.2 %) and four (3.4 %) patients with TIA or NIHSS ≤ 3, respectively, although none were symptomatic. Patients with bleeding as a complication had higher admission NIHSS [4 (3-7) vs. 2 (1-4), pâ¯=â¯0.044] and had higher mRS at discharge (mRS 2 [1-5] vs. mRS 1 [0-2], pâ¯=â¯0.008). These findings did not indicate increased mortality, as one (9 %) patient died from bleeding and two (1.8 %) patients died without bleeding (pâ¯=â¯0.254). CONCLUSION: DAT seems to be a safe therapy in patients regardless of admission NIHSS if started within the first 24 h after symptom onset because only 1.6 % of patients had symptomatic bleeding.
Asunto(s)
Aspirina/efectos adversos , Clopidogrel/efectos adversos , Evaluación de la Discapacidad , Terapia Antiplaquetaria Doble/efectos adversos , Hemorragias Intracraneales/inducido químicamente , Ataque Isquémico Transitorio/tratamiento farmacológico , Admisión del Paciente , Inhibidores de Agregación Plaquetaria/efectos adversos , Accidente Cerebrovascular/tratamiento farmacológico , Tiempo de Tratamiento , Anciano , Aspirina/administración & dosificación , Brasil/epidemiología , Clopidogrel/administración & dosificación , Bases de Datos Factuales , Esquema de Medicación , Terapia Antiplaquetaria Doble/mortalidad , Femenino , Estado Funcional , Humanos , Incidencia , Hemorragias Intracraneales/diagnóstico , Hemorragias Intracraneales/mortalidad , Ataque Isquémico Transitorio/diagnóstico , Ataque Isquémico Transitorio/mortalidad , Masculino , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/administración & dosificación , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
Resumo A ponte de tirofiban é uma alternativa à suspensão da terapia antiplaquetária dupla no perioperatório de pacientes com alto risco de trombose de stent e de sangramento. Objetivamos avaliar a eficácia e a segurança deste protocolo em pacientes submetidos à cirurgia em até 12 meses após intervenção coronária percutânea com stent. Realizamos uma revisão sistemática por meio de pesquisa nas bases PubMed, Web of Science, Cochrane, EMBASE, LILACS e SciELO e nas referências de artigos relevantes ao tema. Dos 107 trabalhos encontrados, cinco foram incluídos após análise dos critérios de elegibilidade e da qualidade metodológica, totalizando 422 pacientes, sendo 227 do grupo controle. Apesar das limitações reportadas, quatro dos cinco estudos incluídos indicam que a ponte de tirofiban é eficaz em reduzir eventos cardíacos adversos e segura ao não interferir no risco de eventos hemorrágicos ou sangramentos. Todavia, são necessários ensaios clínicos randomizados para evidências robustas.
Abstract Use of a tirofiban bridge is an alternative to simply withdrawing dual antiplatelet therapy prior to operating on patients at high risk of stent thrombosis and bleeding. We aimed to evaluate the efficacy and safety of this protocol in patients undergoing surgery within 12 months of a percutaneous coronary intervention involving stenting. We performed a systematic review based on searches of the PubMed, Web of Science, Cochrane, Embase, Lilacs, and Scielo databases and of the references of relevant articles on the topic. Five of the 107 studies identified were included after application of eligibility criteria and analysis of methodological quality, totaling 422 patients, 227 in control groups. Notwithstanding the limitations reported, four of the five studies included indicate that the tirofiban bridge technique is effective for reducing adverse cardiac events and is safe in terms of not interfering with the risk of hemorrhagic events or bleeding. However, randomized clinical trials are needed to provide robust evidence.
Asunto(s)
Stents , Periodo Perioperatorio/efectos adversos , Tirofibán/uso terapéutico , Terapia Antiplaquetaria Doble , Complicaciones Posoperatorias/prevención & control , Inhibidores de Agregación Plaquetaria/uso terapéuticoAsunto(s)
Humanos , Femenino , Persona de Mediana Edad , Anciano , Cardiomiopatía Hipertrófica/diagnóstico por imagen , Accidente Cerebrovascular/tratamiento farmacológico , Embolia Intracraneal/etiología , Enfermedad de Moyamoya/terapia , Enfermedad de Moyamoya/diagnóstico por imagen , Fibrilación Atrial/complicaciones , Tomografía Computarizada por Rayos X/métodos , Ecocardiografía Doppler en Color , Inhibidores de Hidroximetilglutaril-CoA Reductasas/farmacología , Accidente Cerebrovascular/complicaciones , Electrocardiografía , Valsartán/farmacología , Terapia Antiplaquetaria Doble/métodos , Anticoagulantes/farmacologíaRESUMEN
ABSTRACT: In recent decades, the increasing complexity of arterial bypasses in the management of chronic limb-threatening ischemia has spurred the development of alternative techniques, such as revascularization of genicular arteries. Few publications on this technique can be found in the literature, and its use has been restricted to specialized vascular groups. This article describes the case of a patient with extensive femorotibial occlusive disease who received a collateral artery bypass, using the deep femoral artery as a donor, the cephalic vein as an alternative autogenous substitute and the descending genicular artery as a recipient. Bypass to the descending genicular artery, although underutilized, is an effective option and increases the possibility of limb salvage in the management of chronic limb-threatening ischemia.
Asunto(s)
Inhibidores de Agregación Plaquetaria/efectos adversos , Intervención Coronaria Percutánea , Toma de Decisiones Clínicas , Terapia Antiplaquetaria Doble/normas , Complicaciones Posoperatorias/inducido químicamente , Enfermedad Crónica , Duración de la Terapia , Hemorragia/inducido químicamenteRESUMEN
BACKGROUND: We evaluated the association of pulse pressure (PP) and different antiplatelet regimes with clinical and safety outcomes in an all-comers percutaneous coronary intervention (PCI) population. METHODS: In this analysis of GLOBAL LEADERS (n = 15,936) we compared the experimental therapy of 23 months of ticagrelor after 1 month of dual-antiplatelet therapy (DAPT) vs standard DAPT for 12 months followed by aspirin monotherapy in subjects who underwent PCI and were divided into 2 groups according to the median PP (60 mm Hg). The primary end point (all-cause death or new Q-wave myocardial infarction) and the composite end points: patient-oriented composite end points (POCE), Bleeding Academic Research Consortium (BARC) 3 or 5, and net adverse clinical events (NACE) were evaluated. RESULTS: At 2 years, subjects in the high-PP group (n = 7971) had similar rates of the primary end point (4.3% vs 3.9%; P = 0.058), POCE (14.9% vs 12.7%; P = 0.051), and BARC 3 or 5 (2.5% vs 1.7%; P = 0.355) and higher rates of NACE (16.4% vs 13.7%; P = 0.037) compared with the low-PP group (n = 7965). Among patients with PP < 60 mm Hg, the primary end point (3.4% vs 4.4%, adjusted hazard ratio [aHR] 0.77, 95% confidence interval [CI] 0.61-0.96), POCE (11.8% vs 13.5%, aHR 0.86, 95% CI 0.76-0.98), NACE (12.8% vs 14.7%, aHR 0.85, 95% CI 0.76-0.96), and BARC 3 or 5 (1.4% vs 2.1%, aHR 0.69, 95% CI 0.49-0.97) were lower with ticagrelor monotherapy compared with DAPT. The only significant interaction was for BARC 3 or 5 (P = 0.008). CONCLUSIONS: After contemporary PCI, subjects with high PP levels experienced high rates of NACE at 2 years. In those with low PP, ticagrelor monotherapy led to a lower risk of bleeding events compared with standard DAPT.
Asunto(s)
Presión Sanguínea , Terapia Antiplaquetaria Doble , Intervención Coronaria Percutánea , Ticagrelor/uso terapéutico , Anciano , Femenino , Hemorragia/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Mortalidad , Infarto del Miocardio/epidemiología , Inhibidores de Agregación Plaquetaria/uso terapéuticoRESUMEN
INTRODUCTION: Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) reduces the rate of ischemic events but increases bleeding risk. DAPT score helps identify patients who benefit from prolonged DAPT. Nevertheless, its accuracy in patients with acute myocardial infarction (AMI) remains uncertain. The aim of this study was to validate the use of DAPT score to predict ischemic and bleeding events in patients undergoing PCI for AMI and who received prolonged DAPT. MATERIAL AND METHODS: This study included a cohort of patients with AMI who underwent PCI with stent placement and were treated with DAPT for more than 12 months. RESULTS: Two hundred thirty subjects were included in the final analysis (age: 64 ± 12 years, 78% men, median follow-up: 31 months). Ischemic event (reinfarction or revascularization of target vessel or lesion) occurred in 17% and bleeding occurred in 5% of patients. DAPT score demonstrated modest prediction performance for ischemic events (C-statistic: 0.59, 95% confidence interval [CI]: 0.50-0.68, p<0.001) and a good prediction performance for bleeding events (C-statistic: 0.79, 95% CI: 0.66-0.92, p<0.001). Subjects with a DAPT score ≥2 had a greater risk of ischemic events (hazard risk [HR]: 3.1, 95% CI: 1.2-7.8, p = 0.019) and a lower risk of bleeding (HR: 0.23, 95% CI: 0.07-0.79, p = 0.019). Kaplan-Meier curves at 4 years showed that patients with a DAPT score ≥2 had lower ischemic-free survival rates (79% ± 4 vs. 90% ± 5, p = 0.0137) and higher bleeding-free survival rates (97% ± 2 vs. 90% ± 4, p = 0.0106). CONCLUSIONS: DAPT score is useful in patients with AMI, and a cut-off value of 2 identifies patients with a higher risk of ischemic events who might benefit from prolonged DAPT.