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Background Surgical bleeding is associated with postoperative cardiovascular complications. The efficacy and safety of tranexamic acid (TXA) in noncardiac surgery are still uncertain. Statins may prevent perioperative cardiovascular complications. We conducted a pilot to assess the feasibility of a perioperative trial of TXA and rosuvastatin. Methods Using a factorial design, we randomized patients at cardiovascular risk undergoing noncardiac surgery to intravenous TXA (1 g at the start and end of surgery) or placebo, and oral rosuvastatin (40 mg before and 20 mg daily for 30 days after surgery) or placebo. Feasibility outcomes included recruitment rates, follow-up, and compliance to interventions. Clinical outcomes were secondarily explored. Results After 3 months, we changed the design to a partial factorial due to the difficult recruitment of statin-naive patients. Over 6 months, 100 patients were randomized in the TXA trial (49 TXA, 51 placebo), 34 in the rosuvastatin trial (18 rosuvastatin, 16 placebo). Ninety-two percent (95% CI 80–98) of TXA and 86% (95% CI 74–94) of TXA-placebo patients received the 2 study doses. Thirty-three percent (95% CI 13–59) of rosuvastatin patients and 37% (95% CI 15–65) of rosuvastatin-placebo patients discontinued the study drug. A major cardiovascular complication occurred at 30 days in 1 TXA and 6 TXA-placebo patients, and 1 rosuvastatin and no rosuvastatin-placebo patients. Conclusions Our pilot study supports the feasibility of a perioperative TXA trial in noncardiac surgery. Feasibility of a perioperative rosuvastatin trial is uncertain because of a high prevalence of statin use in the target population and concerns about compliance. Trial registration ClinicalTrials.govNCT02546648.

Background It is unclear how to appropriately manage discontinuation and resumption of antiplatelet therapy in patients with coronary stents who need noncardiac surgery. We undertook a systematic review of the literature to identify practice guideline statements regarding antiplatelet therapy in patients with coronary stents undergoing noncardiac surgery. Methods We used six search strategies to identify practice guideline statements that comment on perioperative antiplatelet management for patients with coronary stents undergoing noncardiac surgery. Two independent reviewers assessed study eligibility, abstracted data, and completed quality assessment. Results We identified 11 practice guidelines that met the eligibility criteria; these were included in the review. These guidelines advised that elective noncardiac surgery be delayed for at least 4 weeks after bare-metal stent implantation and at least 6 months after drug-eluting stent implantation. For elective surgery, all guidelines advised continuing acetylsalicylic acid (ASA) therapy whenever possible. If interruption of antiplatelet therapy was required, four guidelines advised to discontinue ASA/clopidogrel at least 5 days before surgery, while two guidelines advised to discontinue 7 to 10 days before surgery. Five guidelines provided varying guidance for the use of perioperative bridging during antiplatelet therapy interruption. Conclusions Most current recommendations are based on expert opinion. This review highlights the need for well-designed prospective studies to identify optimal management strategies in patients with coronary stents who are on antiplatelet therapy and who need noncardiac surgery.

The novel oral anticoagulant drugs, comprising dabigatran, rivaroxaban, and apixaban, have emerged as compelling alternatives to vitamin K antagonists for stroke prevention in atrial fibrillation, and low‑molecular‑weight heparin for thromboprophylaxis following hip and knee arthroplasty. Rivaroxaban has also been approved for treatment of venous thromboembolism. However, the role of these drugs for the management of patients with an acute coronary syndrome (ACS) is less certain. The purpose of this review was to summarize the randomized trials evaluating novel oral anticoagulants in patients with an ACS and consider the reasons why these drugs have not been incorporated into routine clinical practice. In addition, the situation involving rivaroxaban, which has been approved for use in patients with an acute coronary syndrome in Europe but not in North America, is discussed.

Patients receiving anticoagulant or antiplatelet therapy who require noncardiac surgery represent a common yet challenging clinical problem. Clinicians must balance the risk of thromboembolic and major adverse cardiovascular events that are associated with interrupting these therapies, against the risk of bleeding from continuing these drugs in the perioperative period. Identifying patients at highest risk for such complications requires particular attention to the role of bridging therapy and the optimal timing and duration of drug withdrawal and resumption with surgery. Patients with coronary stents represent a population that requires specific considerations, due to the added risk and significant mortality associated with perioperative stent thrombosis. Minimizing this risk is dependent on several patient- and stent-specific factors. This review provides clinicians with a summary of the available evidence to facilitate a practical approach to the management of these patients while highlighting the need for continued research in this field.

Summary Background Rituximab is commonly used as a treatment for primary immune thrombocytopenia to induce and maintain remission. The benefit of adding rituximab to standard-of-care treatment is uncertain. Methods We did a systematic review and meta-analysis of randomised controlled trials assessing the efficacy and safety of rituximab for treatment of adults with primary immune thrombocytopenia. We searched Medline, Embase, and the Cochrane database in duplicate and independently from inception up to July 31, 2014, for relevant studies. Primary outcomes were the proportion of patients achieving a complete platelet count response and a partial platelet count response (as defined in primary studies) that was maintained until the end of follow-up. We also assessed bleeding, infection, and infusion reactions. Findings Our database search returned 468 abstracts, of which five trials (with total of 463 patients) were eligible for analysis. No patients had splenectomy at the time of enrolment. Median follow-up was 6 months (IQR 6–12). Complete response (>100 × 10 9 platelets per L without rescue therapy) was more common with rituximab than with standard of care (weighted proportions: 46·8% vs 32·5%; relative risk [RR] 1·42, 95% CI 1·13–1·77; p=0·0020). Partial response was not significantly different between groups (57·6% vs 46·7%; RR 1·26, 95% CI 0·95–1·67; p=0·11). Rituximab was not associated with a reduction in bleeding (9·2% vs 5·2%; RR 1·34, 95% CI 0·63–2·87; p=0·44) or an increase in infections (20·1% vs 12·1%; RR 1·40, 95% CI 0·87–2·26; p=0·17). Interpretation Rituximab can improve complete platelet count responses by 6 months in patients with immune thrombocytopenia. Evidence for sustained responses beyond 6–12 months is limited. Clinicians must consider the goals of treatment before prescribing rituximab. Funding None.

Background Rituximab, a monoclonal anti-CD20 antibody is commonly used to treat immune thrombocytopenia (ITP). Results of randomized controlled trials (RCTs) evaluating the efficacy of rituximab are conflicting. We conducted a systematic review and meta-analysis of RCTs to determine a more precise estimate of the effect of rituximab on platelet count response in adults with ITP. Methods We searched MEDLINE (from 1946), EMBASE (from 1980), and the Cochrane database using the MeSH terms antibodies, monoclonal, and purpura thrombocytopenia idiopathic and the textwords rituximab, rituxan, mabthera, and immune thrombocytopenic purpura. In duplicate, two reviewers independently assessed study eligibility, abstracted data and assessed each study for methodological quality. Results We identified 4 RCTs (n=360) that met our eligibility criteria. Each trial compared rituximab to placebo combined with other ITP treatments, including dexamethasone, or standard of care. Each trial enrolled non-splenectomized patients only. The likelihood of achieving a platelet count >100 x109/L at 6 months was greater with rituximab than placebo (relative risk [RR] 1.38, 95% CI 1.08-1.76). More patients receiving rituximab achieved a platelet count greater than 50 x109/L at 6 months (RR 1.46, 95% CI 1.18-1.80) compared to placebo. Rituximab was not associated with a reduction in the risk of any bleeding (RR 1.49, 95% CI 0.55-4.04) or an increase in the risk of infection (RR 1.33, 95% CI 0.74-2.38). Conclusions Rituximab is associated with a modest increase in the likelihood of achieving a platelet count greater than >100 x109/L at 6 months compared to placebo. No significant reduction in bleeding or increased risk of infection was observed at 6 months. Randomized trials were generally small, with relatively short follow-up. Large pragmatic multicenter comparative trials are needed to examine durability of response over a longer period of follow-up. Disclosures: Arnold: Amgen: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding, Speakers Bureau; GlaxoSmithKline: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding, Speakers Bureau; Hoffman-LaRoche: Research Funding. Lim:Leo Pharma: Honoraria, Research Funding; Pfizer: Consultancy, Honoraria. Crowther:Asahi Kasai: Membership on an entity’s Board of Directors or advisory committees; Baxter: Membership on an entity’s Board of Directors or advisory committees, Speakers Bureau; Boehringer Ingelheim: Consultancy, Honoraria, Membership on an entity’s Board of Directors or advisory committees; CSL Behring: Speakers Bureau; Leo Pharma: Consultancy, Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding, Speakers Bureau; Merck: Consultancy; Octapharma: Consultancy, Membership on an entity’s Board of Directors or advisory committees; Pfizer: Consultancy, Honoraria, Research Funding; Sanofi-Aventis: Consultancy, Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Viropharma: Membership on an entity’s Board of Directors or advisory committees.