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Previous randomized trials, such as CHANCE and POINT, have shown that dual antiplatelet therapy (DAPT) reduces ischemic event recurrence. However, its effectiveness depends on accurate dosage and timely administration. This study is a comprehensive quality assessment of the implementation of the DAPT protocol-specifically, treatment initiation within 48 h of symptom onset in patients with mild stroke or high-risk TIA-at our center. For this single-center, retrospective analysis we screened all 11,180 consecutive patients from the Helsinki Stroke Quality Registry (HSQR) treated at the emergency department between 1st of January 2019 and 25th of January 2023. Patients with DAPT (ASA and clopidogrel) within 2 weeks of admission were included. Patients treated with i.v. thrombolysis, thrombectomy or if already on DAPT prior to admission were excluded. We analyzed the time of DAPT initiation, patient diagnoses and risk scores (NIHSS and ABCD ). Of 11,180 patients screened, 299 met the inclusion criteria. Among them, 263 (88.0%) had a final diagnosis of ischemic stroke or TIA, supporting DAPT use. Risk scores were documented in 193 (73.4%), and 197 (65.9%) initiated DAPT within 48 h of symptom onset per our institutional protocol. Overall, 137 (45.8%) fully adhered to all protocol criteria. Fewer than half (45.8%) of patients fully adhered to the HUS protocol, and 65.9% initiated DAPT within 48 h from symptom onset. We propose that DAPT should be considered as part of the acute stroke treatment protocol for eligible patients to minimize delays in treatment initiation.

A novel smartphone‐based patient support tool was developed to increase the adherence to antiplatelet therapy and lifestyle changes in patients after coronary angioplasty for acute coronary syndrome (ACS). The eMocial study (ClinicalTrials.gov Identifier: NCT02615704) investigates whether an electronic support tool will improve adherence to comedication and lifestyle changes in ACS patients. The primary hypothesis of this trial is that an electronic support tool can increase adherence to comedication (primary endpoint) thereby supporting positive lifestyle changes (secondary endpoints). Patients hospitalized with ACS (ST elevation myocardial infarction [STEMI], non‐ST elevation myocardial infarction [NSTEMI], or unstable angina pectoris) and treated with ticagrelor coadministered with low‐dose acetylsalicylic acid will be randomized 1:1 to an active group receiving the patient support tool via a smartphone‐based application or to a control group without the patient support tool. Patient questionnaires to evaluate lifestyle changes and quality of life will be used at baseline and at the end of the 48‐week observation phase. Patients are asked to fill out questionnaires to determine their adherence, treatment attitudes, health‐care utilization and risk factors on a monthly basis. The study was started in February 2016 and the completion date is scheduled for October 2019. For final analysis 664 patients are expected be available. Preliminary baseline demographics were unstable angina pectoris (13.7%), NSTEMI (49.9%), STEMI (36.4%), male gender (86.3%), and diabetes mellitus (17.6%). Our study could significantly help to understand how inadequate adherence to antiplatelet therapy in ACS patients could be improved with a smartphone‐based application.

BackgroundIt remains unclear whether type of antiplatelet (AP) therapy, AP combination therapy, and AP continuing or switching strategy affect the risk of post-polypectomy bleeding (PPB). In this study, we sought to elucidate this risk.MethodsWe analyzed 1050 patients who underwent colonoscopic polypectomy: 525 AP users and 525 controls matched for age, sex, comorbidities, concomitant non-steroidal anti-inflammatory drugs use, and polyp characteristics who did not receive antithrombotics. PPB risk was evaluated by AP number, type, and continuing or switching strategies during the peri-endoscopic period.ResultsIn multivariate analysis, bleeding risk increased significantly as the number of AP agents used increased (monotherapy, adjusted odds ratio [aOR], 3.7; dual antiplatelet therapy (DAPT), 4.6; triple antiplatelet therapy (TAPT), 11.1) compared with controls. With monotherapy, significantly increased PPB risk was found for aspirin (aOR 4.3), thienopyridine (aOR 6.3), and cilostazol (aOR 5.9), but not for eicosapentaenoic acid or other APs (beraprost, limaprost, sarpogrelate, dilazep, or dipyridamole). With DAPT, significantly increased PPB risk was found for combination aspirin plus cilostazol, but not aspirin plus other APs. Bleeding rates for continuing monotherapy were 4.3% for aspirin and 0% for thienopyridine, cilostazol, and other APs, respectively.ConclusionsAnalysis of this large polypectomy dataset showed that the use of low-dose aspirin, thienopyridine, or cilostazol and a combination of these is associated with increased PPB risk. Although PPB risk was high with DAPT or TAPT, PPB rate in any antiplatelet monotherapy even with a continuing strategy was low at < 5%.

This study compares ticagrelor and clopidogrel on major adverse cardiovascular events (MACE) and bleeding risk in Chinese CAD patients. Conducted at the Chinese PLA General Hospital from June 2017 to October 2020, it involved patients on DAPT, divided into A + C (aspirin + clopidogrel) and A + T (aspirin + ticagrelor) groups. The primary endpoint was MACE, including all-cause mortality, non-fatal myocardial infarction, and stroke. The secondary endpoint was BARC type 2, 3, and 5 bleeding events. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) adjusted confounders. Weighted outcomes and Cox models assessed treatment and outcomes. Of 844 patients, 631 were in A + C (470 males, median age 65) and 213 in A + T (178 males, median age 60). Covariates balanced using IPTW or PSM showed no significant baseline differences ( P  > 0.05, SMD < 0.2). No significant differences in MACE or BARC type 3/5 bleeding were found between groups. However, the A + T group had a higher risk of BARC type 2 bleeding (HR: 4.16, 95% CI: 2.18–7.90). The incidence rates of MACE events were 2.38% (15/631) in the A + C group and 3.29% (7/213) in the A + T group. This study indicates ticagrelor and clopidogrel have similar MACE and BARC type 3/5 bleeding incidence, but ticagrelor shows higher BARC type 2 bleeding risk.

•High bleeding risk patients receiving cobalt-chromium everolimus-eluting stents were enrolled.•Chronic kidney disease (CKD) was highly prevalent.•CKD patients had higher risk of ischemic events and major bleeding at 1 year.•One- versus 3-month DAPT was associated with a similar risk of ischemic events.•There was a trend toward fewer bleeding with 1-month DAPT, regardless of CKD status. Shortening the duration of dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) was shown to be effective and safe in patients at high bleeding risk (HBR). We aimed to investigate the effect of 1 versus 3-month DAPT on outcomes after drug-eluting stent in HBR patients with or without chronic kidney disease (CKD). Data from 3 prospective single-arm studies (XIENCE Short DAPT Program) enrolling HBR patients after successful coronary implantation of cobalt-chromium everolimus-eluting stent (XIENCE, Abbott) were analyzed. Subjects were eligible for DAPT discontinuation at 1 or 3 months if free from ischemic events. The primary end point was all-cause death or any myocardial infarction. The key secondary end point was Bleeding Academic Research Consortium Type 2 to 5 bleeding. Outcomes were assessed from 1 to 12 months after PCI. CKD was defined as baseline creatinine clearance <60 ml/min. Of 3,286 patients, 1,432 (43.6%) had CKD. One-month versus 3-month DAPT was associated with a similar 12-month risk of the primary outcome irrespective of CKD status (CKD: 9.5% vs 10.9%, adjusted hazard ratio 0.86, 95% confidence interval 0.60 to 1.22; no-CKD: 6.6% vs 5.6%, adjusted hazard ratio 1.15, 95% confidence interval 0.77 to 1.73; p interaction 0.299). Bleeding Academic Research Consortium 2 to 5 bleeding rates were numerically but not significantly lower with 1-month versus 3-month DAPT in both CKD (9.9% vs 12%) and no-CKD (6.4% vs 9.0%) patients. In conclusion, in HBR patients, 1-month versus 3-month DAPT was associated with a similar risk of ischemic complications and a trend toward fewer bleeding events at 12 months after PCI, irrespective of CKD status.

To identify potential confounders and co-interventions systematically to optimise control of confounding for three non-randomized studies of interventions (NRSI) designed to quantify bleeding in populations exposed to different dual antiplatelet therapy (DAPT). Systematic review, interviews, and surveys with clinicians. We searched Ovid Medline, Ovid Embase, and the Cochrane Library to identify randomized-controlled trials and cohort studies of DAPT interventions. Two researchers independently screened citations, identified eligible studies and extracted data. We conducted individual semi-structured interviews with six cardiologists and six cardiac surgeons to elicit factors clinicians consider when they prescribe DAPT. We administered two online surveys for members of professional cardiology and cardiac surgery organisations. We screened 2,544 records, identified 322 eligible studies, and extracted data from 47. We identified 10 co-interventions and 70 potential confounders: review 31 (91%); interviews 19 (56%); surveys 31 (91%). 16/34 (47%) were identified by all three methods while, 3/34 (9%) were picked up by one method only. The review identified the majority of factors, but the interviews identified hard-to-measure factors such as perceived patient adherence and local prescribing culture. The methods could, in principle, be widely applied when designing or reviewing non-randomized studies of interventions (NRSI).

Intravenous thrombolysis (IVT) and dual antiplatelet therapy (DAPT) have been widely used in minor ischemic stroke (MIS) treatment. However, the clinical outcomes and safety of these two treatments have not been compared within the early thrombolytic time window. Here, we conducted a multicenter, ambispective cohort study involving patients with MIS presenting within 4.5 h of symptom onset at 3 affiliated hospitals of Jinan University from 2018–2022. The patients were divided into the IVT group and DAPT group. The primary outcome was a 90-day excellent outcome (mRS ≤ 1). A total of 1,026 patients were enrolled, of whom 492 were assigned to the IVT group and 534 were assigned to the DAPT group. The IVT group had better 90-day excellent outcomes (mRS ≤ 1) than the DAPT group (OR 1.69, 95% CI 1.14–2.52, P = 0.010). Among the 623 patients with nondisabling stroke, the proportion of mRS ≤ 1 in the IVT group was higher than the DAPT group (P = 0.009). In the subtypes of MIS with large vessel occlusion/stenosis and with isolated symptoms, the 90-day outcomes of the IVT group and DAPT group were not different (P > 0.05). In conclusion, compared with DAPT, IVT was associated with better 90-day clinical outcomes in patients with MIS (in particular, for those with mRS > 1), including earlier clinical improvement.IVT also benefited the early neurological improvement of patients with severe stenosis/occlusion of intracranial large vessels, nondisabling mild stroke, nondisabling mild stroke with isolated symptoms.Grapical abstract

PurposeThe predicting bleeding complications in patients undergoing stent implantation and the subsequent dual antiplatelet therapy (PRECISE-DAPT) score predicts the risk of bleeding in patients with dual antiplatelet therapy (DAPT) after percutaneous coronary interventions (PCIs). Patients with carotid artery stenting (CAS) are also treated with DAPT. In this study, we aimed to investigate the performance of the PRECISE-DAPT score in predicting bleeding in patients with CAS.MethodsPatients who had CAS between January 2018 and December 2020 were retrospectively enrolled. The PRECISE-DAPT score was calculated for each patient. The patients were divided into two groups based on their PRECISE-DAPT score: low < 25 and high ≥ 25. Bleeding and ischemia complications and laboratory data among the two groups were compared.ResultsA total of 120 patients with a mean age of 67.3 ± 9.7 years were included. Forty-three patients had high PRECISE-DAPT scores, and 77 patients had low PRECISE-DAPT scores. Six patients developed bleeding events during the six-month follow-up, and five of them were in the PRECISE DAPT score ≥ 25 group. The difference between the two groups regarding bleeding events at six months was significant (P = 0.022).ConclusionThe PRECISE-DAPT score might be used for predicting the bleeding risk in patients with CAS, and the bleeding rate was significantly higher in patients with a PRECISE-DAPT score ≥ 25.