Proximal femur fractures (PFF) pose a major challenge in elderly patients with severe comorbidities and receiving antithrombotic therapy since according to the latest guidelines the surgery should be performed as soon as possible, preferably within 24 hours, to reduce mortality and morbidity. This review outlines the practical approach to surgical management of PFF that relies on increasing evidence of safety of early surgery in patients with PFF receiving antiplatelet and anticoagulant therapy. We have also used information from the existing evidence-based guidelines for elective/planned surgery in patients with antithrombotic therapy. The practical approach can be summarised as follows: • Antiplatelet therapy - discontinuation of acetylsalicylic acid (ASA) and clopidogrel in monotherapy or in combination is not necessary prior to surgery. In case of bleeding, antifibrinolytic therapy is recommended as well as administration of platelet concentrate which is rarely needed. • In patients taking warfarin, reversal of its effects is recommended by early administration of vitamin K to allow surgery to be performed within 24 hours. Prothrombin complex concentrate (PCC) as a second-line drug is reserved for extreme cases only. Warfarin therapy is resumed 24 hours after surgery. • Direct oral anticoagulants must be discontinued 24-48 hours prior to surgery, possibly longer depending on the type of drug, time of administration of the last dose, and renal function. In extreme cases, an antidote (idarucizumab, off-label andexanet) can be administered prior to surgery, or PCC in case they are unavailable. Anticoagulation therapy is resumed in 24-48 hours. • Neuraxial anaesthesia is possible when ASA is taken by the patient and in case of effective warfarin reversal. • In early surgery and rapid restart of anticoagulant therapy, bridging therapy with LMWH is not indicated except for in cases with extreme risk of thrombosis. Key words: proximal femur fracture, antiplatelet therapy, anticoagulant therapy, perioperative management.
- MeSH
- antikoagulancia * škodlivé účinky aplikace a dávkování terapeutické užití MeSH
- Aspirin škodlivé účinky terapeutické užití aplikace a dávkování MeSH
- fraktury femuru chirurgie MeSH
- fraktury proximálního femuru MeSH
- inhibitory agregace trombocytů * škodlivé účinky terapeutické užití MeSH
- lidé MeSH
- warfarin škodlivé účinky terapeutické užití aplikace a dávkování MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- anglický abstrakt MeSH
- časopisecké články MeSH
- přehledy MeSH
Cardiogenic shock (CS) is a devastating and fatal complication of acute myocardial infarction (AMI). CS can affect the pharmacokinetics and pharmacodynamics of medications. The unique properties of cangrelor make it the optimal P2Y12 inhibitor for CS-AMI, in terms of both efficacy and safety. The DAPT-SHOCK-AMI trial (ClinicalTrials.gov: NCT03551964; EudraCT: 2018-002161-19) will assess the benefits of cangrelor in patients with an initial CS-AMI undergoing primary angioplasty. This randomised, multicentre, placebo-controlled trial of approximately 550 patients (with an allowed 10% increase) in 5 countries using a double-blind design will compare initial P2Y12 inhibitor treatment strategies in patients with CS-AMI of (A) intravenous cangrelor and (B) ticagrelor administered as crushed tablets at a loading dose of 180 mg. The primary clinical endpoint is a composite of all-cause death, myocardial infarction (MI), or stroke within 30 days. The main secondary endpoints are (1) the net clinical endpoint, defined as death, MI, urgent revascularisation of the infarct-related artery, stroke, or major bleeding as defined by the Bleeding Academic Research Consortium criteria; (2) cardiovascular-related death, MI, urgent revascularisation, or heart failure; (3) heart failure; and (4) cardiovascular-related death, all (1-4) within 1 year after study enrolment. A platelet reactivity study that tests the laboratory antiplatelet benefits of cangrelor, when given in addition to standard antiplatelet therapy, will be conducted using vasodilator-stimulated phosphoprotein phosphorylation. The primary laboratory endpoints are the periprocedural rate of onset and the proportion of patients who achieve effective P2Y12 inhibition. The DAPT-SHOCK-AMI study is the first randomised trial to evaluate the benefits of cangrelor in patients with CS-AMI.
- MeSH
- adenosinmonofosfát * analogy a deriváty terapeutické užití škodlivé účinky aplikace a dávkování MeSH
- dvojitá slepá metoda MeSH
- fosfoproteiny MeSH
- infarkt myokardu * komplikace MeSH
- inhibitory agregace trombocytů * škodlivé účinky terapeutické užití aplikace a dávkování MeSH
- kardiogenní šok * mortalita MeSH
- koronární angioplastika škodlivé účinky MeSH
- lidé středního věku MeSH
- lidé MeSH
- multicentrické studie jako téma MeSH
- purinergní receptory P2Y - antagonisté aplikace a dávkování škodlivé účinky terapeutické užití MeSH
- randomizované kontrolované studie jako téma MeSH
- senioři MeSH
- ticagrelor * terapeutické užití aplikace a dávkování škodlivé účinky MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- protokol klinické studie MeSH
The story of aspirin is exciting and complicated. We tried to decipher the role of the main characters, as well as a wide field of pharmacological roles of acetylsalicylic acid, a super-drug, which would not be approved by responsible institutions today but which is still one of the most used medicines on the Earth, as well as in the space (it was used by the astronauts in the Apollo project). Original literature sources were used as much as possible to clean up some misinformation around the topic. The authors are aware that Aspirin is a trademarked name but it has become "popular" in common human speech.
- MeSH
- analgetika chemie MeSH
- antipyretika chemie MeSH
- Aspirin * farmakologie terapeutické užití MeSH
- fytoterapie * metody MeSH
- inhibitory agregace trombocytů chemie MeSH
- léčivé přípravky * chemie dějiny MeSH
- lidé MeSH
- salicylany chemie farmakologie terapeutické užití MeSH
- Salix chemie fyziologie MeSH
- Check Tag
- lidé MeSH
Koronární angioplastika (PCI) je zavedenou metodou léčby ischemické choroby srdeční, jejíž bezpečnost je zásadně zvýšena správně vedenou antitrombotickou léčbou. Vlastní provedení PCI je zajištěno kombinací antikoagulační léčby a kyseliny acetylsalicylové. Inhibitory destičkového receptoru P2Y12 se ukázaly být klíčové pro bezpečné používání koronárních stentů jak v perioperačním období, tak v dlouhodobé léčbě po provedení PCI. Volba inhibitoru P2Y12 a doba jeho podávání se řídí především podle rizika krvácení.
Percutaneous coronary angioplasty (PCI) is an established method of treating chronic coronary syndrome, the safety of which is fundamentally increased by properly administered antithrombotic treatment. The actual performance of PCI is ensured by a combination of anticoagulant treatment and acetylsalicylic acid. Platelet P2Y12 receptor inhibitors have been shown to be crucial for the safe use of coronary stents both in the perioperative period and in long-term treatment after PCI. The choice of a P2Y12 inhibitor and the duration of its administration are governed primarily by the risk of bleeding.
- Klíčová slova
- chronický koronární syndrom (CCS),
- MeSH
- antikoagulancia terapeutické užití MeSH
- Aspirin terapeutické užití MeSH
- heparin terapeutické užití MeSH
- hodnocení rizik MeSH
- inhibitory agregace trombocytů * terapeutické užití MeSH
- ischemická choroba srdeční * terapie MeSH
- klopidogrel terapeutické užití MeSH
- koronární angioplastika * metody MeSH
- lidé MeSH
- Check Tag
- lidé MeSH
Prevence a léčba krvácení nebo trombózy je u pacientů s jaterní cirhózou spojena s řadou úskalí, zažitých představ a zavedených stereotypů. V odborné veřejnosti přetrvává falešné paradigma, že změny hemostázy provázející jaterní cirhózu mají apriori krvácivý charakter. Ve skutečnosti se spolu s jaterním onemocněním vyvíjí nová hemostatická rovnováha. Problém je, že je křehká a snadno se vlivem vnitřních pohnutek nebo vnějších zásahů bortí. Výsledkem může být krvácení stejně jako trombóza. K těmto neblahým důsledkům mohou přispět i neadekvátní lékařské intervence vedené ve snaze upravit patologické výsledky koagulačních testů nebo trombocytopenii. Předložené doporučení pro klinickou praxi bylo vypracováno s cílem poskytnout praktické pokyny pro interpretaci výsledků laboratorních vyšetření hemostázy a počtu destiček, resp. shrnout současné názory na hemostázu u jaterní cirhózy, pravidla úpravy trombocytopenie a změn v koagulačním systému před invazivními výkony a pravidla tromboprofylaxe u hospitalizovaných pacientů. Hlavním východiskem je doporučení Evropské asociace pro studium jater „Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis“.
Prevention and treatment of bleeding or thrombosis in patients with liver cirrhosis is associated with a number of pitfalls, perceived ideas and established stereotypes. A false paradigm persists in the professional community that changes in haemostasis accompanying liver cirrhosis are a priori bleeding. In fact, a new haemostatic balance develops along with liver disease. The problem is that it is fragile and easily disrupted by internal drives or external interventions. The result can be bleeding as well as thrombosis. Inadequate medical interventions conducted in an attempt to correct pathological coagulation abnormalities or thrombocytopenia may contribute to these unfortunate consequences. The present guideline for clinical practice was developed to provide practical guidelines for the interpretation of the results of laboratory tests of haemostasis and platelet count, to summarize current views on haemostasis in liver cirrhosis, rules for the correction of thrombocytopenia and changes in the coagulation system before invasive procedures as well as rules for thromboprophylaxis in hospitalized patients. The main starting point is the recommendation of the European Association for the Study of the Live "Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis".
- MeSH
- hemostáza * účinky léků MeSH
- hodnocení rizik metody MeSH
- inhibitory agregace trombocytů terapeutické užití MeSH
- jaterní cirhóza * komplikace MeSH
- krvácení při operaci * ošetřování prevence a kontrola MeSH
- lidé MeSH
- směrnice pro lékařskou praxi jako téma MeSH
- trombocytopenie etiologie terapie MeSH
- trombotická příhoda farmakoterapie MeSH
- vyšetření krevní srážlivosti metody MeSH
- Check Tag
- lidé MeSH
BACKGROUND: There are dated and conflicting data about the optimal timing of initiation of P2Y12 inhibitors in elective percutaneous coronary intervention (PCI). Peri-PCI myocardial necrosis is associated with poor outcomes. We aimed to assess the impact of the P2Y12 inhibitor loading time on periprocedural myocardial necrosis in the population of the randomized Assessment of Loading With the P2Y12 Inhibitor Ticagrelor or Clopidogrel to Halt Ischemic Events in Patients Undergoing Elective Coronary Stenting (ALPHEUS) trial, which compared ticagrelor with clopidogrel in high-risk patients who received elective PCI. METHODS: The ALPHEUS trial divided 1809 patients into quartiles of loading time. The ALPHEUS primary outcome was used (type 4 [a or b] myocardial infarction or major myocardial injury) as well as the main secondary outcome (type 4 [a or b] myocardial infarction or any type of myocardial injury). RESULTS: Patients in the first quartile group (Q1) presented higher rates of the primary outcome (P = 0.01). When compared with Q1, incidences of the primary outcome decreased in patients with longer loading times (adjusted odds ratio [adjOR], 0.70 [0.52.-0.95]; P = 0.02 for Q2; adjOR 0.65 [0.48-0.88]; P < 0.01 for Q3; adjOR 0.66 [0.49-0.89]; P < 0.01 for Q4). Concordant results were found for the main secondary outcome. There was no interaction with the study drug allocated by randomization (clopidogrel or ticagrelor). Bleeding complications (any bleeding ranging between 4.9% and 7.3% and only 1 major bleeding at 48 hours) and clinical ischemic events were rare and did not differ among groups. CONCLUSIONS: In elective PCI, administration of the oral P2Y12 inhibitor at the time of PCI could be associated with more frequent periprocedural myocardial necrosis than an earlier administration. The long-term clinical consequences remain unknown.
- MeSH
- infarkt myokardu * etiologie MeSH
- inhibitory agregace trombocytů terapeutické užití MeSH
- klopidogrel terapeutické užití MeSH
- koronární angioplastika * metody MeSH
- lidé MeSH
- purinergní receptory P2Y - antagonisté terapeutické užití MeSH
- ticagrelor terapeutické užití MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
- MeSH
- chronická kritická ischemie končetin diagnóza farmakoterapie MeSH
- hydroxymethylglutaryl-CoA-reduktasy imunologie škodlivé účinky MeSH
- imunosupresiva aplikace a dávkování terapeutické užití MeSH
- inhibitory agregace trombocytů aplikace a dávkování terapeutické užití MeSH
- komorbidita MeSH
- lidé MeSH
- myozitida chemicky indukované terapie MeSH
- nemoci svalů * chemicky indukované terapie MeSH
- senioři MeSH
- statiny * škodlivé účinky terapeutické užití MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- Publikační typ
- kazuistiky MeSH
Dual antiplatelet therapy (DAPT) remains the gold standard in patients who underwent percutaneous coronary intervention (PCI). This meta-analysis aims to evaluate the clinical safety of 1-month DAPT followed by aspirin or a P2Y12 receptor inhibitor after PCI with drug-eluting stents (DES). We searched PubMed, MEDLINE, Embase, Scopus, Google Scholar, Cochrane Central Registry, and ClinicalTrials.gov databases and identified 5 randomized controlled trials with 29,831 patients who underwent PCI with DES and compared 1-month versus >1-month DAPT. The primary end point was major bleeding, and the co-primary end point was stent thrombosis. The secondary end point included all-cause mortality, cardiovascular death, myocardial infarction, stroke, and major adverse cardiovascular or cerebrovascular events. Compared with >1-month DAPT, the 1-month DAPT was associated with a lower rate of major bleeding (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.45 to 0.97, p = 0.03, I2 = 71%), whereas stent thrombosis had a similar rate in both study groups (OR 1.08, 95% CI 0.81 to 1.44, p = 0.60, I2 = 0.0%). The study groups had similar risks for all-cause mortality (OR 0.89, 95% CI 0.77 to 1.04, p = 0.14, I2 = 0.0%), cardiovascular death (OR 0.84, 95% CI 0.59 to 1.19, p = 0.32, I2 = 0.0%), myocardial infarction (OR 1.04, 95% CI 0.89 to 1.21, p = 0.62, I2 = 0.0%), and stroke (OR 0.82, 95% CI 0.64 to 1.05, p = 0.11, I2 = 6%). The risk of major adverse cardiovascular or cerebrovascular events was lower (OR 0.86, 95% CI 0.76 to 0.97, p = 0.02, I2 = 25%) in the 1-month DAPT compared with >1-month DAPT. In conclusion, in patients who underwent PCI with DES, 1-month DAPT followed by aspirin or a P2Y12 receptor inhibitor reduced major bleeding with no risk of increased thrombotic risk compared with longer-term DAPT.
- MeSH
- Aspirin aplikace a dávkování škodlivé účinky MeSH
- časové faktory MeSH
- duální protidestičková léčba * škodlivé účinky metody MeSH
- inhibitory agregace trombocytů * aplikace a dávkování škodlivé účinky MeSH
- koronární angioplastika * škodlivé účinky MeSH
- koronární trombóza prevence a kontrola epidemiologie MeSH
- krvácení * chemicky indukované epidemiologie MeSH
- lidé MeSH
- randomizované kontrolované studie jako téma MeSH
- stenty uvolňující léky * škodlivé účinky MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- metaanalýza MeSH
- systematický přehled MeSH
BACKGROUND: Endovascular treatment (EVT) of tandem lesion (TL) in the anterior circulation acute ischemic stroke (IS) usually requires periprocedural antithrombotic treatment and early initiation of dual antiplatelet therapy (DAPT) after carotid stenting. However, it may contribute to an occurrence of symptomatic intracerebral hemorrhage (SICH) in some cases. We investigated factors influencing the SICH occurrence and assessed the possible predictors of SICH after EVT. METHODS: IS patients with TL in the anterior circulation treated with EVT were enrolled in the multicenter retrospective ASCENT study. A good three-month clinical outcome was scored as 0-2 points in modified Rankin Scale (mRS) and recanalization using the TICI scale. SICH was assessed using the SITS-MOST criteria. Logistic regression analysis was used for the assessment of possible predictors of SICH with adjustment for potential confounders. RESULTS: In total, 300 (68.7 % males, mean age 67.3 ± 10.2 years) patients with median of admission NIHSS 17 were analyzed. Recanalization (TICI 2b-3) was achieved in 290 (96.7 %) patients and 176 (58.7 %) had mRS 0-2. SICH occurred in 25 (8.3 %) patients. Patients with SICH did not differ from those without SICH in the rate of periprocedural antithrombotic treatment (64 vs. 57.5 %, p = 0.526) and in the rate of DAPT started within the first 12 h after EVT (20 vs. 42.2 %, p = 0.087). After adjustment, admission NIHSS and admission glycemia were found as the only predictors of SICH after EVT. CONCLUSION: Admission NIHSS and glycemia were found as the only predictors of SICH after EVT for TL. No associations between periprocedural antithrombotic treatment, early start of DAPT after EVT and SICH occurrence were found.
- MeSH
- časové faktory MeSH
- cerebrální krvácení * diagnostické zobrazování etiologie terapie MeSH
- duální protidestičková léčba škodlivé účinky MeSH
- endovaskulární výkony * škodlivé účinky přístrojové vybavení MeSH
- fibrinolytika * aplikace a dávkování škodlivé účinky MeSH
- hodnocení rizik MeSH
- inhibitory agregace trombocytů * škodlivé účinky aplikace a dávkování MeSH
- ischemická cévní mozková příhoda * etiologie terapie diagnóza diagnostické zobrazování MeSH
- lidé středního věku MeSH
- lidé MeSH
- posuzování pracovní neschopnosti * MeSH
- retrospektivní studie MeSH
- rizikové faktory MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- stenty MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- Geografické názvy
- Japonsko MeSH
BACKGROUND: Whether ticagrelor may reduce periprocedural myocardial necrosis after elective percutaneous coronary intervention (PCI) in patients with and without chronic clopidogrel therapy is unclear. OBJECTIVES: This study sought to compare ticagrelor vs clopidogrel in patients with and without chronic clopidogrel therapy before undergoing elective PCI. METHODS: In this prespecified analysis of the ALPHEUS (Assessment of Loading With the P2Y12 Inhibitor Ticagrelor or Clopidogrel to Halt Ischemic Events in Patients Undergoing Elective Coronary Stenting) trial, patients were defined as clopidogrel(+) and clopidogrel(-) according to the presence and absence of clopidogrel treatment for ≥7 days before PCI, respectively. The primary endpoint was the composite of PCI-related myocardial infarction and major injury as defined by the third and fourth universal definition 48 hours after PCI. RESULTS: A total of 1,882 patients were included, 805 (42.7%) of whom were clopidogrel(+). These patients were older, had more comorbidities, and had more frequent features of complex PCI. The primary endpoint was less frequently present in clopidogrel(-) compared to clopidogrel(+) patients (32.8% vs 40.0%; OR: 0.73; 95% CI: 0.60-0.88), but no significant differences were reported for the risk of death, myocardial infarction, stroke, or transient ischemic attack at 48 hours or 30 days. Ticagrelor did not reduce periprocedural myocardial necrosis or the risk of adverse outcomes, and there was no significant interaction regarding the presence of chronic clopidogrel treatment. CONCLUSIONS: Clopidogrel-naive patients presented less periprocedural complications compared to clopidogrel(+) patients, a difference related to a lower risk profile and less complex PCI. The absence of clopidogrel at baseline did not affect the absence of a difference between ticagrelor and clopidogrel in terms of PCI-related complications supporting the use of clopidogrel as the standard of care in elective PCI in patients with or without chronic clopidogrel treatment.
- MeSH
- časové faktory MeSH
- chronická nemoc MeSH
- hodnocení rizik MeSH
- infarkt myokardu * mortalita MeSH
- inhibitory agregace trombocytů * škodlivé účinky terapeutické užití MeSH
- klopidogrel * škodlivé účinky terapeutické užití aplikace a dávkování MeSH
- koronární angioplastika * škodlivé účinky mortalita MeSH
- krvácení chemicky indukované MeSH
- lidé středního věku MeSH
- lidé MeSH
- nekróza MeSH
- nemoci koronárních tepen terapie mortalita diagnostické zobrazování farmakoterapie MeSH
- purinergní receptory P2Y - antagonisté škodlivé účinky terapeutické užití MeSH
- rizikové faktory MeSH
- senioři MeSH
- stenty MeSH
- ticagrelor * škodlivé účinky terapeutické užití MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- randomizované kontrolované studie MeSH
- srovnávací studie MeSH
