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.

• Authors: Thomas F Lüscher, Allan Davies, Juerg H Beer, Marco Valgimigli, Christoph A Nienaber, John A Camm, Iris Baumgartner, Hans-Christoph Diener, Stavros V Konstantinides
• Journal: European heart journal (Eur Heart J) Vol. 43 Issue 10 Pg. 940-958 (03 07 2022) ISSN: 1522-9645 [Electronic] England
• PMID: 34624084 (Publication Type: Journal Article)
• Copyright: Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected].

Chemical References

• Anticoagulants
• Fibrinolytic Agents
• Platelet Aggregation Inhibitors

Topics

• Anticoagulants (therapeutic use)
• Atrial Fibrillation (complications)
• Brain Ischemia (chemically induced)
• Fibrinolytic Agents (therapeutic use)
• Foramen Ovale, Patent (complications, drug therapy)
• Humans
• Platelet Aggregation Inhibitors (therapeutic use)
• Stroke (prevention & control)