INTRODUCTION: After transcatheter aortic valve replacement (TAVR), ischemic/embolic complications and bleeding remain important because it correlates with mortality. The optimal antithrombotic regimen after successful TAVR remains unclear. This study compared the efficacy and safety of single antiplatelet therapy (SAPT) versus dual antiplatelet therapy (DAPT) among post-TAVR patients.

METHODS: Extensive search of PubMed, MEDLINE, Cochrane, and Ovid was done for articles published until November 20, 2020. Studies were limited to randomized controlled trials. Outcome measures include stroke, myocardial infarction (MI), all-cause mortality, and major bleeding. Two reviewers independently reviewed the studies. Results were gathered from published articles, journals, and clinical trials. Studies were critically appraised with regard to methods of minimizing bias. All four studies included received a quality scale for meta-analysis overall score of not less than B. Statistical analysis was done using Review Manager V5.4.

RESULTS: Four randomized controlled trials with 1086 patients were included in this meta-analysis. Overall, the risk of stroke (odds ratio [OR], 0.94 [0.54-1.64]), MI (OR, 0.50 [0.18-1.40]), and overall mortality (OR, 1.01 [0.65-1.57]) did not differ significantly between DAPT and SAPT. There was increased risk of bleeding noted with DAPT, thus favoring SAPT (OR, 0.44 [0.30- 0.65]).

CONCLUSION: Among patients who underwent TAVR, DAPT compared with SAPT had similar rates of stroke, MI, and death. Because of lower rates of bleeding, we recommend using single antiplatelet therapy after TAVR.

KEYWORDS: TAVR, TAVI, antiplatelet, single antiplatelet therapy, antithrombotic, DAPT

INTRODUCTION: The development of pneumonia after cardiac surgery is a significant postoperative complication that may lead to worse clinical outcomes. We aimed to identify risk factors associated with it and determine its clinical impact in terms of in-hospital mortality and morbidity.

METHODS: This was a cross-sectional study among all adult patients who underwent cardiac surgery from 2014 to 2019 in a tertiary hospital in the Philippines. Baseline characteristics and risk factors for pneumonia were retrieved from medical records. Nosocomial pneumonia was based on the Centers for Disease Control and Prevention criteria. Odds ratios from logistic regression were computed to determine risk factors and clinical outcomes for pneumonia using STATA 15.0 (StataCorp, College Station, Texas).

RESULTS: Of 373 patients included, 104 (28%) acquired pneumonia. Most surgeries were ere coronary artery bypass grafting (71.58%). Age, sex, body mass index, diabetes, left ventricular/ renal dysfunction, chronic obstructive pulmonary disease/asthma, surgical urgency, surgical time, and smoking did not show association with pneumonia development. However, preoperative stay of >2 days was associated with 92.3% increased odds of having pneumonia (P = 0.009). Also, every additional hour on mechanical ventilation conferred 0.8% greater odds of acquiring pneumonia (P = 0.003). Patients who developed pneumonia had 3.9-times odds of mortality (95% confidence interval [CI], 1.51-9.89; P = 0.005), 3.8-times odds of prolonged hospitalization (95% CI, 1.81-7.90; P < 0.001), 6.4-times odds of prolonged intensive care unit stay (95% CI, 3.59-11.35; P < 0.001), and 9.5-times odds of postoperative reintubation (95% CI, 3.01-29.76; P < 0.001).

CONCLUSION: Among adult patients undergoing cardiac surgeries, prolonged preoperative hospital stay and prolonged mechanical ventilation were associated with an increased risk of nosocomial pneumonia. Those who developed pneumonia had worse outcomes with significantly increased in-hospital mortality, prolonged hospitalization/intensive care unit stay, and increased postoperative reintubation. Clinicians should therefore minimize delays in surgery and encourage timely liberation from mechanical ventilation after surgery.

BACKGROUND

Dual-antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the standard for the prevention of thrombotic events in patients undergoing percutaneous coronary intervention (PCI). Type 2 diabetes mellitus (DM) patients are a subgroup with a higher risk of bleeding and thrombotic events after PCI.

OBJECTIVES

This meta-analysis aimed to determine whether ticagrelor monotherapy after an initial short-course DAPT is an effective and safe option in preventing thrombotic events among DM patients undergoing PC.

METHODS

A systematic review and meta-analysis was done on randomized controlled trials (RCT) comparing ticagrelor monotherapy following short-course DAPT versus conventional DAPT in T2DM patients who underwent PCI. Outcome measures for major bleeding, myocardial infarction, and all-cause mortality were extracted and analyzed using a random-effects model via RevMan version 5.3.

RESULTS

A total of three RCTs, with 7482 patients, were analyzed. There were no significant differences in major bleeding (P = 0.26) and myocardial infarction (P = 0.66) events between the ticagrelor and DAPT groups. However, there was a higher rate of all-cause mortality in the DAPT group, which was statistically significant (risk ratio, 0.76; 95% confidence interval, 0.59–0.98; P = 0.03).

CONCLUSION

Ticagrelor monotherapy following short course DAPT and conventional DAPT have similar rates of major bleeding and myocardial infarction among DM patients undergoing PCI with DES. However, conventional DAPT has a higher incidence of all-cause mortality, which suggests that ticagrelor monotherapy after short-course DAPT may be a preferable antiplatelet strategy in DM patients undergoing PCI.

Bleeding ; Hemorrhage ; Diabetes Mellitus ; Percutaneous Coronary Intervention ; Thrombosis ; Ticagrelor