Towards personalized antithrombotic management with drugs and devices across the cardiovascular spectrum

Abstract

Intravascular thrombus formation and embolization are among the most frequent events leading to a number of cardiovascular conditions with high morbidity and mortality. The underlying causes are stasis of the circulating blood, genetic and acquired coagulation disorders, and reduced antithrombotic or prothrombotic properties of the vascular wall (Virchow’s triad). In the venous system, intravascular thrombi can cause venous thrombosis and pulmonary and even peripheral embolism including ischaemic stroke [through a patent foramen ovale (PFO)]. Thrombi in the left atrium and its appendage or ventricle form in the context of atrial fibrillation and infarction, respectively. Furthermore, thrombi can form on native or prosthetic aortic valves, within the aorta (in particular at sites of ulcers, aortic dissection, and abdominal aneurysms), and in cerebral and peripheral arteries causing stroke and critical limb ischaemia, respectively. Finally, thrombotic occlusion may occur in arteries supplying vital organs such the heart, brain, kidney, and extremities. Thrombus formation and embolization can be managed with anticoagulants and devices depending on where they form and embolize and on patient characteristics. Vitamin K antagonists are preferred in patients with mechanical valves, while novel oral anticoagulants are first choice in most other cardiovascular conditions, in particular venous thromboembolism and atrial fibrillation. As anticoagulants are associated with a risk of bleeding, devices such as occluders of a PFO or the left atrial appendage are preferred in patients with an increased bleeding risk. Platelet inhibitors such as aspirin and/or P2Y12 antagonists are preferred in the secondary prevention of coronary artery disease, stroke, and peripheral artery disease either alone or in combination depending on the clinical condition. A differential and personalized use of anticoagulants, platelet inhibitors, and devices is recommended and reviewed in this article.

Factor XI Inhibition With Heparin Reduces Clot Formation in Simulated Pediatric Extracorporeal Membrane Oxygenation

“…21,22 Anticoagulant and antiplatelet drugs can reduce device-initiated thrombus formation. 23 However, “breakthrough thrombosis” still occurs despite large doses of these drugs. Moreover, serious bleeding remains the dose-limiting toxicity of all current antithrombotic agents, 24 limiting the therapeutic range of anticoagulation therapy.…”

Correlation between Coronary Artery Disease with Other Arterial Systems: Similar, Albeit Separate, Underlying Pathophysiologic Mechanisms

“…Table 1 shows the ubiquitous indication of the guidelines for different arterial locations. Such guidelines also recommend active training and lifestyle modification as being at least as important (Class Ia recommendation) [21].…”

“…Of note, these are chronic long-term default strategies-there are other recommendations for patients requiring anticoagulants for other indications or if they received recent percutaneous or surgical revascularization. According to the recent guidelines [21][22][23]. Green signifies a strong recommendation, yellow means that "it may be considered", and red represents "no benefit".…”