Search Results (348)

Complex percutaneous coronary intervention (PCI) represents a growing proportion of contemporary coronary revascularization, driven by aging populations, increasing comorbidity burden, and advances in interventional techniques. Complex PCI encompasses a spectrum of anatomically and procedurally challenging lesions, including left main disease, bifurcation lesions requiring two-stent strategies, chronic total occlusions, long stent lengths, severe calcification requiring atherectomy, and multivessel revascularization. Antithrombotic therapy, comprising antiplatelet and anticoagulant agents, is essential for preventing stent thrombosis and other ischemic events in both the early and long-term phases after PCI. While antithrombotic therapy mitigates ischemic risks associated with complex PCI, these patients frequently carry a high bleeding risk, thus making the choice of antithrombotic regimen challenging. Recent guideline recommendations emphasize balancing ischemic and bleeding risks rather than relying solely on procedural complexity. This review synthesizes contemporary evidence, guideline recommendations, and clinical considerations for antithrombotic therapy after complex PCI. Full article

This article presents recommendations aimed at reducing the risk of bleeding during bronchoscopy. The document was developed by a working group convened by the Polish Respiratory Society, which included pulmonologists experienced in bronchoscopic procedures, an anesthesiologist, a thoracic surgeon, a cardiologist, a hematologist, a nurse, and methodologists. Clinical questions were formulated according to the PICO (Population, Intervention, Comparison, Outcome) framework, followed by a systematic literature search and critical appraisal of the selected studies. Based on these data, 13 recommendations/good clinical practice points were developed addressing bronchoscopy in patients with thrombocytopenia, abnormal activated partial thromboplastin time or international normalized ratio results, and in those receiving antiplatelet agents, oral anticoagulants, or low-molecular-weight heparin. Full article

Shiga toxin-producing Escherichia coli (STEC) infections are a major cause of hemolytic uremic syndrome (HUS), a thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. The pathogenesis of STEC-HUS is primarily driven by Shiga toxins (Stx), which induce endothelial injury, inflammation, platelet activation, and microvascular thrombosis. Hemolysis associated with thrombotic microangiopathy leads to the release of hemoglobin and free heme into the circulation. Free heme, an iron-containing molecule with potent pro-oxidative, pro-inflammatory, and cytotoxic properties, contributes to oxidative stress, endothelial dysfunction, complement activation, and further tissue injury. Oxidative stress plays a crucial role in both host and bacterial cells, influencing disease progression and the expression of bacterial virulence factors, including Shiga toxin. N-acetyl-L-cysteine (NAC), a precursor of glutathione (GSH) and a well-established antioxidant, has attracted attention as a potential adjunctive therapeutic agent due to its antioxidant, anti-inflammatory, antiplatelet, and cytoprotective properties. In addition, NAC may influence iron- and heme-mediated oxidative damage and improve erythrocyte resistance to oxidative stress. This review summarizes current knowledge regarding the roles of oxidative stress and free heme in STEC-HUS and examines the mechanistic rationale and current evidence supporting NAC as a potential adjunctive strategy. The available evidence remains largely indirect and preclinical; therefore, the potential role of NAC in STEC-HUS should be considered hypothesis-generating and requires further investigation in clinical studies. Full article

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor remains the cornerstone of antithrombotic management after myocardial revascularization. However, the traditional “one-size-fits-all” approach to DAPT duration and intensity fails to account for marked interindividual variability in drug response—driven by genetic polymorphisms, notably CYP2C19 variants like CYP2C19*2, which reach a frequency of up to 75% in specific groups like the Melanesian population—comorbidities such as diabetes and chronic kidney disease, and dynamic clinical factors including age and concomitant medications. We examine the current landscape of precision medicine tools for individualizing DAPT, including platelet function testing, point-of-care genotyping, validated clinical risk scores, and emerging artificial intelligence (AI)–based predictive models. Evidence from landmark trials is synthesized to evaluate escalation, de-escalation, and duration-tailoring strategies within the ischemic–bleeding trade-off framework. Special populations requiring individualized approaches are reviewed, including patients with atrial fibrillation, the elderly, and those requiring urgent noncardiac surgery with perioperative bridging. Future directions, including multi-omics integration, novel antiplatelet agents, and AI-driven clinical decision support systems, are also explored. As a narrative review, conclusions should be interpreted as reflective of current evidence synthesis rather than systematic-review-grade evidence, given the absence of formal risk-of-bias scoring or meta-analytic pooling. Personalized DAPT guided by complementary genetic and phenotypic testing, integrated with dynamic risk stratification, offers a paradigm shift from empiric therapy toward precision-guided antithrombotic management with the potential to simultaneously reduce ischemic and bleeding complications. Full article

Background: Drug-coated balloons (DCBs) have emerged as a “leave-nothing-behind” strategy in percutaneous coronary intervention (PCI), with potential advantages over drug-eluting stents (DES) in selected patients with acute coronary syndrome (ACS). Methods: We performed a narrative review of randomized controlled trials, registries, and meta-analyses evaluating DCB therapy in ACS, including PEPCAD NSTEMI, REVELATION, BASKET-SMALL 2, AGENT IDE, REC-CAGEFREE I/II, and the ongoing TRANSFORM II trial. Articles were identified through searches of PubMed/MEDLINE, Embase, Scopus, Web of Science, and Cochrane CENTRAL covering January 2005 to February 2026. Results: Across published studies, DCBs have shown outcomes that are non-inferior to those of DES in selected ACS subsets, together with a lower risk of major bleeding attributable to shorter dual antiplatelet therapy (DAPT) requirements. Advances in intravascular imaging and lesion preparation, alongside emerging applications of artificial intelligence (AI) and robotic-assisted PCI, may further improve DCB performance, although evidence specific to DCB use in ACS remains limited for these adjunctive technologies. Conclusions: DCBs are a reasonable alternative to DES in selected patients with ACS, particularly those at high bleeding risk or with lesion subsets in which DES perform less well (small vessels, in-stent restenosis, bifurcations, diffuse disease). Adequately powered randomized trials with long-term follow-up are required before broader recommendations can be made. Full article

Over the past two decades, the combined use of long-term anticoagulation and antiplatelet therapy following percutaneous coronary intervention has been extensively investigated. Efforts to define an optimal antithrombotic strategy—balancing protection against thrombotic and thromboembolic events with minimization of bleeding risk—have led to the design and conduct of randomized clinical trials. This narrative review synthesizes the main evidence comparing different antithrombotic approaches in this setting, with particular focus on regimens stratified by oral anticoagulant type and on the direct comparison between aspirin- and clopidogrel-based double antithrombotic therapy, as evaluated in a limited number of recent studies. Further large-scale randomized data comparing these two regimens are needed to strengthen the current evidence and clarify this issue, as well as to evaluate the role of platelet function and/or genetic testing in guiding the selection of the optimal antiplatelet agent. Full article

Background/Objectives: While standardized guidelines have been established for the evaluation and management of blunt cerebrovascular injuries (BCVIs) in adults, there remains a paucity of standardized guidelines for BCVIs in pediatric populations. Shortcomings in treatment algorithms also persist as uncertainty remains about the optimal approach to manage these cases. A review of the literature was performed to compile the current evidence and provide recommendations based on current overarching trends. Methods: PubMed was queried for studies related to the diagnosis and management of BCVIs in the pediatric population. Prevalence, mechanism of injury (MOI), screening criteria, diagnostic modality, vascular injuries identified, associated injuries, treatment, and patient risk factors were analyzed. Results: The Utah and McGovern criteria were the first tools developed for screening BCVIs in pediatric patients. Among all screening tools, the high sensitivity and specificity of the McGovern criteria support its use as the optimal screening strategy to date for pediatric patients. Given the high prevalence of high-energy MOI, observation is the most common approach chosen due to contraindications to medical therapy. Antiplatelet agents showed no significant differences in stroke prevention or hemorrhagic complications compared to anticoagulation. Strokes represent the primary source of morbidity among pediatric patients with BCVIs. Conclusions: Pediatric BCVIs represent an uncommon but clinically significant consequence of blunt trauma, with a significant risk for ischemic stroke and neurologic morbidity. Early recognition through appropriate screening with pediatric-specific screening criteria, CTA imaging, and timely initiation of grade-based treatment can help mitigate injury progression and complications. Full article

Background: Bleeding is the most important complication of percutaneous liver biopsy. However, there are many unknowns regarding the management of antithrombotic agents in percutaneous liver biopsy. We investigated whether percutaneous liver biopsy could be performed safely by withdrawal of antithrombotic agents in accordance with the criteria of gastroenterological endoscopy guidelines. Methods: A retrospective study was conducted on patients who underwent percutaneous liver biopsy. Antithrombotic agents were discontinued in accordance with the withdrawal criteria in the Japan Gastroenterological Endoscopy Society guidelines for gastroenterological endoscopy. Results: A total of 630 cases were enrolled, including 64 cases receiving antithrombotic therapy. Bleeding complications occurred in 6.7% of cases with antithrombotic therapy and 2.1% of patients without antithrombotic therapy, with no significant difference between the two groups (p = 0.069). Major bleeding requiring surgical intervention or transarterial embolization was not observed in cases with antithrombotic therapy. Only one case (1.6%) developed thromboembolism after withdrawal of antithrombotic agents. Even after propensity score matching, there was no significant difference in the bleeding complication rates between the cases with and without antithrombotic therapy in either tumor biopsy (p = 0.599) and non-tumor biopsy (p = 0.440). Univariate and multivariate analysis revealed that low platelet count (≤10 × 10⁴/μL) was a significant risk factor for bleeding complications (OR = 1.07, 95%CI 1.01–1.15, p = 0.034), whereas antithrombotic therapy was not a significant factor (OR = 2.7, 95%CI 0.79–9.22, p = 0.114). Conclusions: This study suggests that percutaneous liver biopsy may be performed safely in cases receiving antithrombotic therapy by discontinuation of antithrombotic agents in accordance with the withdrawal criteria of Japan Gastroenterological Endoscopy Society guidelines for gastroenterological endoscopy. Full article

Aspirin has been the default backbone of antiplatelet therapy after percutaneous coronary intervention (PCI) for over two decades, anchored by landmark trials that established 12-month dual antiplatelet therapy (DAPT) as the standard of care. Three developments have prompted reassessment of this paradigm: the markedly lower thrombotic risk of contemporary drug-eluting stents, the greater potency and consistency of potent P2Y₁₂ inhibitors (ticagrelor, prasugrel), and increasing recognition that major bleeding independently worsens outcomes after PCI. Recent randomised trials have systematically tested aspirin withdrawal at varying time points. Immediate aspirin-free strategies (NEO-MINDSET, STOPDAPT-3) demonstrated an early signal of excess ischaemic events in the ACS component of enrolled populations, suggesting that aspirin remains important during the earliest post-PCI period in ACS. One-month strategies (T-PASS, ULTIMATE-DAPT, TARGET-FIRST) and three-month strategies (TWILIGHT, TICO, DUAL-ACS) showed that transition to P2Y₁₂ monotherapy after an initial DAPT period significantly reduces bleeding without increasing ischaemic events in selected populations. Beyond one year, long-term randomised trials including the HOST-EXAM 10-year follow-up (Lancet 2026) and the STOPDAPT-2 5-year landmark analysis (Circ Cardiovasc Interv 2026), together with study-level meta-analyses (PANTHER) and recent individual patient data meta-analyses, provide converging evidence that clopidogrel monotherapy outperforms aspirin for chronic secondary prevention without excess bleeding. The choice of P2Y₁₂ agent is critical: clopidogrel monotherapy in ACS during the first post-procedural year carries excess thrombotic risk owing to CYP2C19 pharmacogenomic variability, whereas ticagrelor and prasugrel provide more reliable protection. This review synthesises the mechanistic rationale, trial evidence across all time points, special clinical contexts (oral anticoagulation, coronary artery bypass grafting, high bleeding risk), guideline evolution, and methodological considerations, providing a practical framework for individualising post-PCI antiplatelet therapy. Full article

Background/Objectives: Atrial fibrillation (AF) is highly prevalent among older adults and is associated with increased thromboembolic risk. Although anticoagulant therapy (AC) is strongly recommended, its use in elderly and multimorbid patients remains suboptimal. This study aimed to describe long-term trends in AC prescribing patterns among hospitalized older patients with AF. Methods: We conducted a retrospective observational analysis using data from the Italian REPOSI registry, including patients aged ≥65 years hospitalized with AF between 2010 and 2023. AC at admission and discharge was analyzed, including vitamin K antagonists (VKAs), direct oral anticoagulants (DOACs), and antiplatelet agents. Temporal trends, admission-to-discharge treatment changes, and patient characteristics associated with therapy modification were assessed descriptively. Results: The study included 2061 AF patients, characterized by multimorbidity and high thromboembolic risk. A marked shift from VKAs to DOACs was observed over time. However, a substantial proportion of cases remained without AC or received only antiplatelet therapy at both admission and discharge, with untreated individuals being generally older and more clinically complex. DOAC use increased steadily but showed a slight decline at discharge after 2020. Clinical variables available in the registry only partially explained AC changes during hospitalization. Conclusions: Despite increasing adoption of DOACs, AC underuse remains frequent among elderly hospitalized patients with AF. These real-world data highlight persistent challenges in AC management in complex older adults and underscore the need for more comprehensive clinical information and data-driven tools to support individualized therapeutic decision-making. Full article

Background/Objectives: Acute carotid tandem lesions (TLs), defined by concurrent cervical internal carotid artery (ICA) stenosis or occlusion and intracranial large vessel occlusion, occur in 10–20% of patients undergoing mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Optimal periprocedural antiplatelet management during emergent carotid artery stenting (eCAS) remains uncertain, particularly regarding the balance between preventing stent thrombosis and avoiding hemorrhagic complications. Methods: A narrative review was conducted using PubMed and Scopus (until 6 March 2026) to identify English-language studies evaluating antiplatelet therapies during eCAS for TLs. We included seven real-world studies and registry analyses. Data on study design, patient characteristics, procedural strategies, angiographic results, functional outcomes, and safety metrics were extracted. Results: No randomized controlled trials (RCTs) were identified. The available evidence is derived exclusively from observational studies. Across these cohorts, glycoprotein IIb/IIIa inhibitors (GPIs), particularly tirofiban, were generally associated with lower rates of in-stent thrombosis and higher reperfusion success, with symptomatic intracranial hemorrhage (sICH) rates that appeared comparable to or lower than those reported with acetylsalicylic acid (ASA). Cangrelor, an intravenous (IV) P2Y₁₂ inhibitor, was associated with improved stent patency and increased likelihood of complete reperfusion, although reported effects on clinical outcomes were inconsistent when compared with GPIs or ASA. Aside from abciximab, potent IV antiplatelet agents did not consistently show an increased sICH signal. Oral dual antiplatelet therapy was also associated with improved technical outcomes without a clear excess in bleeding complications. Conclusions: Current real-world observational data suggest that rapid-acting IV antiplatelet agents—particularly GPIs and, increasingly, cangrelor—may represent feasible periprocedural options during eCAS for TLs, with potential benefits for technical success and no consistent evidence of increased hemorrhagic risk. However, interpretation is limited by study heterogeneity and non-randomized designs. The absence of RCTs highlights the need for prospective comparative studies and standardized periprocedural antiplatelet protocols. Full article

Patient Blood Management (PBM) has evolved from a transfusion-centered practice to a structured, patient-focused perioperative strategy aimed at improving surgical outcomes while preserving blood resources. In the operating room, where bleeding risk is anticipated and modifiable, PBM requires proactive intervention rather than reactive transfusion. This review synthesizes current evidence on perioperative blood conservation strategies specifically relevant to surgeons and anesthesiologists. Preoperative optimization begins with systematic identification and correction of anemia, most commonly iron deficiency, using appropriately timed oral or intravenous iron therapy and, in selected cases, erythropoiesis-stimulating agents. Careful management of anticoagulant and antiplatelet therapies, early recognition of acquired or inherited coagulopathies, and protocol-driven reversal strategies further reduce perioperative hemorrhagic risk. Intraoperatively, blood conservation depends on meticulous surgical technique, respect for anatomical planes, minimally invasive approaches, and the judicious use of advanced energy devices and topical hemostatic agents. Pharmacologic interventions—particularly tranexamic acid administered with appropriate timing and dosing—have demonstrated consistent reductions in blood loss and transfusion requirements across multiple surgical disciplines. Goal-directed coagulation management guided by viscoelastic testing allows targeted correction of specific hemostatic deficits while minimizing unnecessary blood product exposure. Acute normovolemic hemodilution and intraoperative cell salvage provide additional benefit in selected high-blood-loss procedures. Collectively, these multimodal strategies shift perioperative care from product-driven transfusion toward physiology-based blood conservation. When embedded within institutional protocols and supported by multidisciplinary collaboration, perioperative PBM reduces transfusion exposure, decreases morbidity, shortens hospital stay, and promotes sustainable stewardship of blood resources without compromising patient safety. Full article

Novel pharmacological approaches advocate developing multitarget drugs, that is, molecules capable of simultaneously acting on two or more pharmacological targets to produce synergistic effects from a single compound in each disease. This strategy may help reduce required doses and prevent drug–drug interactions typically associated with polypharmacy. Coumarins are natural products with diverse pharmacological activities, including antioxidant, anti-inflammatory, anticancer, neuroprotective, cardioprotective, and antithrombotic effects. The pleiotropic actions of these molecules suggest that modifying the coumarin structure could yield new multi-target antiplatelet agents with greater efficacy and safety than those currently available in clinical practice. In this work, we began with a theoretical approach using molecular docking and designed three coumarins that simultaneously inhibited platelet aggregation induced by epinephrine, collagen, and ADP. Experimentally, we evaluated the structure activity relationship of three coumarins: (A) 6,7-dimethoxy-3-(1H-pyrrol-1-yl)-2H-chromen-2-one, (B) 7,8-dimethoxy-3-(1H-pyrrol-1-yl)-2H-chromen-2-one, and (C) 3-(1H-imidazol-1-yl)-6,7-dimethoxy-2H-chromen-2-one. In silico studies suggest that compounds B and C may exhibit antagonistic interactions at the α₂-adrenergic, GPVI collagen, and P₂Y₁₂ ADP receptors. Additionally, molecular docking indicates essential interactions between the compounds and the GPIIb/IIIa fibrinogen receptor. Full article

Thromboembolic disorders remain a primary cause of mortality globally, with their burden expected to increase due to an aging population. While various antithrombotic agents exist, many patients still rely on traditional gold-standard drugs like heparin, warfarin, and aspirin, which present significant drawbacks. These include the need for injections, frequent monitoring, dietary restrictions, drug interactions, bleeding complications, or other adverse reactions such as thrombocytopenia. In contrast, direct oral anticoagulants offer advantages over warfarin, including fewer interactions and less need for continuous monitoring. However, even with newer drugs, patients face risks of major bleeding events. Current research focuses on novel antithrombotic agents with superior efficacy and enhanced safety compared to existing treatments. Researchers are exploring specific clinical niches, such as factor XI/XII inhibitors for cancer patients, to facilitate evaluation against standard treatments. The development of new antiplatelet drugs, like subcutaneous zalunfiban and selatogrel for pre-hospital therapy of myocardial infarction, and specific reversal agents, such as bentracimab for ticagrelor, exemplify this trend. Future research will likely focus on addressing the unmet needs of specific patient groups. This narrative review aimed to describe the current antithrombotic treatment and the most promising advances in the pharmacological management of thrombosis. Full article

This review presents an innovative and timely exploration of how cytoprotection can serve as a cohesive therapeutic approach by which to address the hemorrhage–thrombosis paradox. Presenting counteraction of both hemorrhage and thrombosis as phase-dependent outcomes of vascular dysregulation, the manuscript synthesizes conceptual, experimental, and clinical evidence into a unified systems-level model focused on the stable gastric pentadecapeptide BPC 157, which acts as a cytoprotective mediator. In rodents, BPC 157 can simultaneously counteract hemorrhage and thrombosis without directly affecting the coagulation cascade (aggregometry, thromboelastometry). This cytoprotective framework (decreased hemorrhage, decreased thrombosis) stands with presentation of both hemorrhage and thrombosis in the wound, arrhythmias, and Virchow triad, and resolution of these disturbances. As proof of the concept (full cytoprotective effect), a vasoprotective cytoprotective mediator capable of bidirectional regulation, BPC 157, is effective for wound healing, arrhythmia control, and normalization of Virchow’s triad (i.e., following major injuries, occlusion/occlusion-like syndromes). As a comparison from a cytoprotective (partial vs. full) standpoint, conventional agents—anticoagulants, antiplatelet drugs, and fibrinolytics—provide only partial protection by targeting isolated components of hemostasis. Beta blockers, calcium channel blockers, prostaglandins, NO modulators, ACE inhibitors, and statins each exert broader cytoprotective effects; however, these actions remain incomplete and context-dependent, typically unidirectional, dose-limited, or are achieved at the expense of opposing pathological risks. Contrarily, for BPC 157, decreased hemorrhage (including both anticoagulants and antiplatelet agents), decreased thrombosis, effective wound healing, arrhythmia control, and normalization of Virchow’s triad involve preservation of endothelial integrity, normalization of microcirculation, modulation of the NO system, stabilization of hemostatic balance, and recruitment of adaptive collateral pathways. Nevertheless, reliance on preclinical models necessitates further clinical validation. Full article