Dual antiplatelet therapy (clopidogrel and aspirin) is associated with increased all-cause mortality after carotid revascularization for asymptomatic carotid disease

Alcocer, Francisco; Novak, Zdenek; Combs, Bart R.; Lowman, Bruce G.; Passman, Marc A.; Mujib, Marjan; Jordan, William D.

doi:10.1016/j.jvs.2013.10.087

Cited by 18 publications

(10 citation statements)

References 17 publications

(12 reference statements)

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“…If clopidogrel is initiated at the time of CEA, there is currently no evidence establishing the duration of therapy. Alcocer et al 20 reported that patients on dual therapy after CEA for asymptomatic disease demonstrated higher rates of all-cause mortality over a median follow-up of >4 years, suggesting that the risks of dual antiplatelet therapy may extend beyond the perioperative beneficial effects observed in this report.…”

Section: Discussionmentioning

confidence: 60%

Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy

Jones¹,

Goodney

Conrad

et al. 2016

Journal of Vascular Surgery

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Objective Controversy persists regarding the perioperative management of clopidogrel among patients undergoing carotid endarterectomy (CEA). This study examined the effect of preoperative dual antiplatelet therapy (aspirin and clopidogrel) on in-hospital CEA outcomes. Methods Patients undergoing CEA in the Vascular Quality Initiative were analyzed (2003–2014). Patients on clopidogrel and aspirin (dual therapy) were compared with patients taking aspirin alone preoperatively. Study outcomes included reoperation for bleeding and thrombotic complications defined as transient ischemic attack (TIA), stroke, or myocardial infarction. Secondary outcomes were in-hospital death and composite stroke/death. Univariate and multivariable analyses assessed differences in demographics and operative factors. Propensity score-matched cohorts were derived to control for subgroup heterogeneity. Results Of 28,683 CEAs, 21,624 patients (75%) were on aspirin and 7059 (25%) were on dual therapy. Patients on dual therapy were more likely to have multiple comorbidities, including coronary artery disease (P < .001), congestive heart failure (P < .001), and diabetes (P < .001). Patients on dual therapy were also more likely to have a drain placed (P < .001) and receive protamine during CEA (P < .001). Multivariable analysis showed that dual therapy was independently associated with increased reoperation for bleeding (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.20–2.42; P = .003) but was protective against TIA or stroke (OR, 0.61; 95% CI, 0.43–0.87; P = .007), stroke (OR, 0.63; 95% CI, 0.41–0.97; P = .03), and stroke/death (OR, 0.66; 95% CI, 0.44–0.98; P = .04). Propensity score matching yielded two groups of 4548 patients and showed that patients on dual therapy were more likely to require reoperation for bleeding (1.3% vs 0.7%; P = .004) but less likely to suffer TIA or stroke (0.9% vs 1.6%; P = .002), stroke (0.6% vs 1.0%; P = .04), or stroke/death (0.7% vs 1.2%; P = .03). Within the propensity score-matched groups, patients on dual therapy had increased rates of reoperation for bleeding regardless of carotid symptom status. However, asymptomatic patients on dual therapy demonstrated reduced rates of TIA or stroke (0.6% vs 1.5%; P < .001), stroke (0.4% vs 0.9%; P = .01), and composite stroke/death (0.5% vs 1.0%; P = .02). Among propensity score-matched patients with symptomatic carotid disease, these differences were not statistically significant. Conclusions Preoperative dual antiplatelet therapy was associated with a 40% risk reduction for neurologic events but also incurred a significant increased risk of reoperation for bleeding after CEA. Given its observed overall neurologic protective effect, continued dual antiplatelet therapy throughout the perioperative period is justified. Initiating dual therapy in all patients undergoing CEA may lead to decreased neurologic complication rates.

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Section: Discussionmentioning

confidence: 60%

Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy

Jones¹,

Goodney

Conrad

et al. 2016

Journal of Vascular Surgery

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“…10,11 On the contrary, other studies demonstrated an increased mortality or higher bleeding rates for dual antiplatelet therapy. 12,13 In addition, a recent metaanalysis could not demonstrate an advantage of dual antiplatelet therapy over monotherapy in terms of prevention of stroke and death after CEA, but there was an increased risk of bleeding complications. 14 Thus, there is still some uncertainty about the use of dual antiplatelet therapy in the perioperative period of CEA.…”

Section: Date Of Release December 1 2018 Expiration December 31 2019mentioning

confidence: 99%

Different perioperative antiplatelet therapies for patients treated with carotid endarterectomy in routine practice

Zimmermann

Knappich

Tsantilas

et al. 2018

Journal of Vascular Surgery

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This study shows that the risk of stroke or death was significantly higher in patients without any perioperative antiplatelet therapy. In contrast, dual antiplatelet therapy vs aspirin monotherapy was associated with a lower risk only of perioperative death but with a higher risk of neck bleeding until discharge. Perioperative antiplatelet therapy was significantly associated with a decreased in-hospital stroke and death risk. Further studies are needed to evaluate the risk-benefit ratio of single vs dual antiplatelet therapy.

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“…Only two studies investigated the effect of dual versus single antiplatelet therapy in patients with symptomatic and asymptomatic carotid disease undergoing CEA. Alcocer et al 10 demonstrated an increased mortality rate in patients with asymptomatic carotid disease receiving dual antiplatelet therapy as compared with aspirin alone (47% vs. 40%; p ¼ .05). In patients with symptomatic carotid disease, dual antiplatelet therapy was associated with a nonsignificant decrease in all-cause mortality (38% vs. 39%; p ¼ .53).…”

Section: Discussionmentioning

confidence: 98%

“…Although monotherapy (aspirin or clopidogrel) is widely accepted during the perioperative period of carotid intervention for stroke prevention, the role of dual antiplatelet therapy (aspirin and clopidogrel), which has a pivotal role in coronary artery disease (CAD), is less clear. 10 The objective was to undertake a comprehensive literature review and perform a meta-analysis to assess the effects of dual antiplatelet therapy in carotid interventions.…”

Section: Introductionmentioning

confidence: 99%

Systematic Review and Meta-analysis of Dual Versus Single Antiplatelet Therapy in Carotid Interventions

Barkat

Hajibandeh

Torella

et al. 2017

European Journal of Vascular and Endovascular Surgery

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Dual antiplatelet therapy (clopidogrel and aspirin) is associated with increased all-cause mortality after carotid revascularization for asymptomatic carotid disease

Cited by 18 publications

References 17 publications

Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy

Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy

Different perioperative antiplatelet therapies for patients treated with carotid endarterectomy in routine practice

Systematic Review and Meta-analysis of Dual Versus Single Antiplatelet Therapy in Carotid Interventions

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