• International Journal of Arrhythmia
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• v.17 no.1
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• pp.41-45
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• 2016

Atrial fibrillation (AF) can occur in acute coronary syndrome (ACS), which is a serious medical condition and may require the use of antiplatelet agents in addition to anticoagulants for stroke prevention. Recently, novel or non-vitamin K antagonist oral anticoagulants (NOACs) have been increasingly used for stroke prevention in patients with AF instead of traditional OACs. The duration of treatment or treatment with a stepwise approach (e.g. triple, double, or monotherapy) is determined depending on the clinical setting and the balance between the risks of ischemic stroke and bleeding. However, some concerns and controversies in the use of NOACs in patients with AF and ACS need to be addressed. Here, the current management for NOAC therapy in patients with ACS and AF will be reviewed based on recently published guidelines.

• Journal of Korean Neurosurgical Society
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• v.65 no.1
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• pp.123-129
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• 2022

Objective : Chronic subdural hematoma (CSDH) is one of the most common pathology in daily neurosurgical practice and incidence increases with age. The aim of this study was to evaluate the prognostic factors and surgical outcome of CSDH in patients aging over 90 years compared with a control group of patients aging under 90 years. Methods : This study reviewed 25 patients with CSDH aged over 90 years of age treated in our department. This group was compared with a younger group of 25 patients aged below their eighties. At admission past medical history was recorded concerning comorbidities (hypertension, dementia, ictus cerebri, diabetes, and heart failure or attack). History of alcohol abuse, anticoagulant and antiplatelet therapy, head trauma and seizures were analyzed. Standard neurological examination and Markwalder score at admission, 48 hours after surgery and 1-6 months follow-up, radiologic data including location and CSDH maximum thickness were also evaluated. Results : Their mean age was 92.8 years and the median was 92.4 years (range, 90-100 years). In older group, the Markwalder evaluation at one month documented the complete recovery of 24 patients out of 25 without statistical difference with the younger group. This data was confirmed at 6-month follow-up. One patient died from cardiovascular failure 20 days after surgery. The presence of comorbidities, risk factors (antiplatelet therapy, anticoagulant therapy, history of alcohol abuse, and head trauma), preoperative symptoms, mono or bilateral CSDH, maximum thickness of hematoma, surgical time and recurrence were similar and statistically not significant in both groups. Conclusion : In this study, we demonstrate that surgery for very old patients above 90 years of age affected by CSDH is safe and allows complete recovery. Comparing two groups of patients above and under 90 years old we found that complication rate and recovery were similar in both groups.

• Journal of Korean Neurosurgical Society
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• v.63 no.5
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• pp.539-549
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• 2020

The efficacy of P2Y12 reaction unit (PRU) of VerifyNow still remains as a controversial issue in neurointervention. So we investigated the usefulness of PRU of VerifyNow to predict the peri-procedural thromboembolic events (TE) and hemorrhagic events (HE). And we evaluated the safety of modified dual antiplatelet therapy (DAPT) or triple antiplatelet therapy (TAPT) for clopidogrel hyporesponders. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science and Scopus on August 19 2018. Data was collected the 1) incidence of TE between clopidogrel responder and clopidogrel hypo-responder, 2) incidence of HE between clopidogrel hyper-responder and clopidogrel responder and hypo-responder, and 3) incidence of TE and HE between modified DAPT or TAPT and standard DAPT in clopidogrel hypo-responder. High cut-off value of PRU was defined as PRU >40% or <220. Fifteen studies were enrolled. Clopidogrel responder showed lower incidence of TE than hypo-responder (risk ratio [RR], 0.32; 95% confidence interval [CI], 0.17-0.61; p<0.001). With the high cut-off value of PRU, clopidogrel responder showed more lower incidence of TE than hypo-responder (RR, 0.11; 95% CI, 0.02-0.45; p=0.002). The incidence of periprocedural HE have higher on clopidogrel hyper-responder than clopidogrel responder and hypo-responder (RR, 4.26; 95% CI, 1.10-16.44; p=0.04; I²=66%). The incidence of periprocedural TE after changing regimen of DAPT for clopidogrel hypo-responder have a tendency to reduce, but there was no significant difference between modified DAPT or TAPT group and standard DAPT group (p>0.05). The incidence of periprocedural HE after changing regimen of DAPT for clopidogrel hypo-responder was no significant difference between modified DAPT or TAPT group and standard DAPT group (p>0.05). PRU is a useful tool as a predictor of peri-procedural TE or HE on neurointervention. PRU has a threshold effect of cut-off value to predict the peri-procedural TE. Modified DAPT or TAPT to prevent TE in clopidogrel hypo-responders could not reduce the incidence of TE. We should investigate the further research about modification of regiment on neurointervention.

• The Journal of Internal Korean Medicine
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• v.22 no.3
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• pp.393-396
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• 2001

Objectives: We were to assess the effectiveness of combined therapy of Oriental Medicine and Western Medicine on acute stroke. Methods: We selected acute middle cerebral artery territory infarction subjects, within 3 days after stroke onset, who had never have any type of stroke history before. The subjects, admitted to department of Oriental Medicine, received combination therapy of western medical treatment including thrombolytic, anticoagulant, or antiplatelet agents and oriental medical treatment including acupuncture and herbs medication. The other subjects, admitted to department of Neurology, received only modern western medical treatment. The National Institute of Health Stroke Scale (NIHSS) was checked at admission, 1 week and 2 weeks later to assess neurologic improvement. The Modified Barthel Index (MBI) was checked 1 week and 2 weeks after admission to motor function recovery. Results: Comparing the NIHSS between baseline and 1 week later, the combination therapy group showed more improvement than the single-treated with anticoagulants group. However, there was no significant difference between the two groups, comparing 1 week and 2 weeks later with the NIHSS and the MBI. Conclusions: Combination therapy have more beneficial effect on acute stage of stroke.

• Journal of Medicine and Life Science
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• v.20 no.3
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• pp.131-134
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• 2023

Here, we present a case of a 56-year-old man with acute myocardial infarction. The patient underwent percutaneous coronary intervention (PCI) at the left main bifurcation and mid-left anterior descending artery using drugeluting stents. Four months after the PCI, the patient was readmitted for cardiac arrest. Coronary angiography (CAG) revealed stent thrombosis in the left main-to-proximal left anterior descending artery and in-stent restenosis in the left main-to-proximal left circumflex artery. We performed balloon angioplasty at the left main to mid-left anterior descending artery and left main to proximal left circumflex artery stents; subsequently, blood flow was fully restored. However, contrast agent extravasation was observed outside the mid-portion of the left main artery to the proximal left anterior descending artery stent, indicating the presence of a coronary artery aneurysm (CAA) outside the stent. After guideline-directed medical therapy with dual antiplatelet agents and high-intensity statins, follow-up CAG revealed near-resolution of the CAA, absence of stenotic lesions, and good blood flow.

• Journal of the Korean Association of Oral and Maxillofacial Surgeons
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• v.35 no.6
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• pp.426-430
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• 2009

Purpose: Many patients in anti-platelet therapy have been consulted for bleeding risks before minor oral surgery. However, there has not been an established pretreatment protocol for treating these patients. The purpose of this study is to make a protocol for the preoperative management for patients in anti-platelet therapy. Patients and Methods: The existed consultation pattern of patients was examined in the Department of Oral and Maxillofacial Surgery, Yonsei Dental Hospital. Based on the observation, a protocol including classification of medical status of patients and the type of oral surgery in need was introduced. This protocol had been performed for 6 months. Result: Following this protocol, the frequency of consultation for bleeding risk was decreased. The number of minor oral surgeries with concurrent anti-platelet therapy was increased. There was no severe bleeding event observed among minor oral surgeries that were performed while maintaining anti-platelet therapy. Conclusion: This protocol can be used as a guideline for clinical practice of patients in anti-platelet therapy requiring minor oral surgery.

• Korean Circulation Journal
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• v.52 no.4
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• pp.304-319
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• 2022

Background and Objectives: De-escalation of dual-antiplatelet therapy through dose reduction of prasugrel improved net adverse clinical events (NACEs) after acute coronary syndrome (ACS), mainly through the reduction of bleeding without an increase in ischemic outcomes. Whether the benefits of de-escalation are sustained in highly thrombotic conditions such as ST-elevation myocardial infarction (STEMI) is unknown. We aimed to assess the efficacy and safety of de-escalation therapy in patients with STEMI or non-ST-segment elevation ACS (NSTE-ACS). Methods: This is a pre-specified subgroup analysis of the HOST-REDUCE-POLYTECH-ACS trial. ACS patients were randomized to prasugrel de-escalation (5 mg daily) or conventional dose (10 mg daily) at 1-month post-percutaneous coronary intervention. The primary endpoint was a NACE, defined as a composite of all-cause death, non-fatal myocardial infarction, stent thrombosis, clinically driven revascularization, stroke, and bleeding events of grade ≥2 Bleeding Academic Research Consortium (BARC) criteria at 1 year. Results: Among 2,338 patients included in the randomization, 326 patients were diagnosed with STEMI. In patients with NSTE-ACS, the risk of the primary endpoint was significantly reduced with de-escalation (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.48-0.89; p=0.006 for de-escalation vs. conventional), mainly driven by a reduced bleeding. However, in those with STEMI, there was no difference in the occurrence of the primary outcome (HR, 1.04; 95% CI, 0.48-2.26; p=0.915; p for interaction=0.271). Conclusions: Prasugrel dose de-escalation reduced the rate of NACE and bleeding, without increasing the rate of ischemic events in NSTE-ACS patients but not in STEMI patients.

• Journal of Korean Neurosurgical Society
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• v.62 no.1
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• pp.27-34
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• 2019

Objective : Stent-assisted coil embolization of intracranial wide-necked aneurysm requires long-term postoperative antiplatelet therapy to prevent in-stent thrombosis. This study aimed to demonstrate results of temporary stent placement for coiling wide necked small intracranial aneurysms, which eliminated need for antiplatelet agents, and to discuss its feasibility and safety. Methods : Data of 156 patients who underwent stent-assisted coil embolization between 2011 and 2014 were retrospectively analyzed. Thirteen cases of temporary stent-assisted coil embolization were included, and their clinical and radiological results were evaluated. Results : The aneurysms treated were all unruptured except one case. All of them had wide neck with mean dome-to-neck ratio of 0.96 and were small-sized aneurysms with mean maximal diameter of 4.2 mm. There was no technical failure in retrieval of stent after completion of embolization of the target aneurysm. Immediate angiography revealed 11 complete and two partial embolization (one residual neck and one residual aneurysm). Two cases encountered thrombosis complication, and they were managed without neurological sequelae. The mean follow-up period was 43 months, angiographic follow-up revealed two cases with minor recurrence, and clinical outcome was good with modified Rankin scale score of 0. Conclusion : Temporary stent-assisted coil embolization of small wide-necked intracranial aneurysm using fully retrievable stent appears safe and effective. Further application and evaluation of this technique in more cases with larger size aneurysm is warranted.

• Clinical Endoscopy
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• v.57 no.2
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• pp.141-157
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• 2024

Antithrombotic agents, including antiplatelet agents and anticoagulants, are widely used in Korea because of the increasing incidence of cardiocerebrovascular disease and the aging population. The management of patients using antithrombotic agents during endoscopic procedures is an important clinical challenge. The clinical practice guidelines for this issue, developed by the Korean Society of Gastrointestinal Endoscopy, were published in 2020. However, new evidence on the use of dual antiplatelet therapy and direct anticoagulant management has emerged, and revised guidelines have been issued in the United States and Europe. Accordingly, the previous guidelines were revised. Cardiologists were part of the group that developed the guideline, and the recommendations went through a consensus-reaching process among international experts. This guideline presents 14 recommendations made based on the Grading of Recommendations, Assessment, Development, and Evaluation methodology and was reviewed by multidisciplinary experts. These guidelines provide useful information that can assist endoscopists in the management of patients receiving antithrombotic agents who require diagnostic and elective therapeutic endoscopy. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.

• Journal of Korean Neurosurgical Society
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• v.67 no.5
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• pp.586-592
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• 2024

Lateral spinal artery (LSA) aneurysms are extremely rare lesions that can rupture and cause subarachnoid hemorrhage (SAH) even though the spinal arteries communicate directly with the subarachnoid space. To date, six cases of LSA aneurysms have been reported in the literature. Herein, three such cases are reported. All patients presented to the emergency department with headaches. The patients in the first two cases were confirmed to have SAH and LSA aneurysms on a brain computed tomography (CT) angiography performed at the hospital. Two patients had prior instances of cerebral infarction and coronary disease, respectively, and were undergoing antiplatelet therapy. The antiplatelet medication was stopped for 2 weeks and 1 week, respectively, while conservative care was provided. Subsequently, a suboccipital craniectomy was performed, followed by aneurysm clipping. Following the surgery, both patients were discharged without any significant neurological deficits. Regarding the third patient, no aneurysm was found on brain CT angiography, and cerebral angiography was performed during the patient's hospital stay. She was hospitalized, where she received medication and conservative care, and was discharged with an improvement in bleeding without neurological symptoms. Subsequently, a LSA aneurysm was identified on a brain CT angiography performed at an outpatient clinic; however, the patient was transferred because she wanted to be treated at another hospital. LSA aneurysms are difficult to visualize using CT angiography; therefore, careful angiographic studies are required. Surgical clipping is the treatment of choice if the aneurysm is inaccessible by the endovascular treatment.