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Dual Antiplatelet Therapy Prior to Expedited Carotid Surgery Reduces Recurrent Events Prior to Surgery without
A Batchelder1, J Hunter1, V Cairns1
1Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK.
Insights
Introducing dual antiplatelet therapy significantly reduced recurrent neurological events and embolization in patients awaiting carotid endarterectomy (CEA). This approach improved patient outcomes without increasing major bleeding risks.
Area of Science:
- Neurology
- Vascular Surgery
- Pharmacology
Background:
- A Rapid-Access Transient Ischemic Attack (TIA) Clinic initiated in 2008 treated patients with aspirin and simvastatin.
- Patients with significant carotid stenosis (50-99%) were referred for carotid endarterectomy (CEA).
- Previous audits showed a 3-day delay to CEA resulted in 13% recurrent neurological events.
Purpose of the Study:
- To evaluate the efficacy of early dual antiplatelet therapy (DAPT) in reducing recurrent events.
- To assess the impact of DAPT on spontaneous embolization prior to CEA.
- To determine the rate of hemorrhagic complications associated with DAPT.
Main Methods:
- A prospective audit of 100 consecutive patients receiving DAPT (aspirin + clopidogrel).
- Patients received DAPT after parenchymal hemorrhage exclusion in the TIA clinic.
- Endpoints included recurrent events, spontaneous embolization, and hemorrhagic complications between TIA clinic transfer and CEA.
Main Results:
- The median delay from TIA clinic transfer to CEA was 3 days.
- Recurrent TIAs occurred in 3% of patients, a fivefold reduction from previous data.
- Spontaneous embolization reduced fourfold (21% to 5%), with a 1% 30-day death/stroke rate.
- Three hemorrhagic complications were noted, including stroke, neck hematoma exploration, and skin grafting for shin hematoma.
Conclusions:
- Early DAPT significantly reduced recurrent neurological events and spontaneous embolization before CEA.
- The introduction of DAPT did not lead to a significant increase in major peri-operative bleeding.
- DAPT is a safe and effective strategy for managing patients with high-grade carotid stenosis awaiting CEA.
Objective:
A daily Rapid-Access TIA Clinic was introduced in 2008, where symptomatic patients were started on 75 mg aspirin + 40 mg simvastatin by the referring doctor, before attending the clinic. Following clinic assessment, patients with 50-99% stenoses were transferred to the vascular unit for carotid endarterectomy (CEA). In two audits (n = 212 patients), the median delay from transfer to the vascular unit to undergoing CEA was 3 days, during which time 28 patients (13%) suffered recurrent neurological events. It was hypothesized that early introduction of dual antiplatelet therapy (by adding clopidogrel 75 mg once parenchymal haemorrhage was excluded in the TIA clinic) might significantly reduce recurrent events between transfer to the surgical unit and undergoing CEA.
Methods:
Prospective audit in 100 consecutive, recently symptomatic patients receiving dual antiplatelet therapy. Endpoints were: prevalence of recurrent events between transfer from the TIA clinic and undergoing CEA; rates of spontaneous embolization prior to undergoing CEA; and prevalence of haemorrhagic complications
Results:
The median delay from symptom to CEA was 8 days (IQR 5-15). The median delay between transfer from the TIA clinic to CEA was 3 days (IQR 2-5), during which time three patients (3%) suffered recurrent TIAs. This represents a fivefold reduction compared with previous audit data (OR 4.9, 95% CI 1.5-16.6, p = .01) and was matched by a fourfold reduction in the prevalence of spontaneous embolization from 39/189 (21%) previously to 5/83 (5%) in the current audit (OR 4.1, 95% CI 1.5-10.7, p = .0047). The 30-day death/stroke rate was 1%. There were three haemorrhagic complications: stroke caused by haemorrhagic transformation of an infarct; exploration for neck haematoma; and debridement and skin grafting for spontaneous shin haematoma.
Conclusion:
Early introduction of dual antiplatelet therapy was associated with a significant reduction in recurrent neurological events and spontaneous embolization prior to CEA, without incurring a significant increase in major peri-operative bleeding complications.
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