Guided Antithrombotic Therapy: Current Status and Future Research Direction: Report on a National Heart, Lung and Blood Institute Working Group

Perspective:

The following are 10 points to remember about this report on guided antithrombotic therapy:

1. Atrial fibrillation, many forms of stroke, acute and chronic coronary artery disease (CAD), prosthetic heart valves, and venous thromboembolism are all large areas of cardiovascular medicine in which thrombosis is a major part of the pathology.

2. There is a need for comparative trials of oral direct thrombin inhibitors and factor Xa inhibitors in patients with atrial fibrillation.

3. Studies to assess mechanical versus pharmacological approaches for stroke reduction and maintenance of sinus rhythm in atrial fibrillation are indicated.

4. Optimal medical therapy versus revascularization for asymptomatic carotid stenosis, with consideration of better brain and carotid imaging for risk stratification, needs further study.

5. Catheter-directed therapy trials for stroke (as has been done with ST-segment elevation myocardial infarction) need to be performed.

6. There is a need for identification of molecular targets that dissociate thrombosis from bleeding, to the extent possible.

7. Anticoagulation bridging for invasive procedures—who, when, and how—needs further research.

8. Predictors of recurrent venous thromboembolism and determination of appropriate length of therapy need additional study.

9. For genetics to be readily incorporated into clinical practice, genotyping must move from research laboratories and send-out tests to rapid-turnaround or even rapid point-of-care testing.

10. There are four key areas to consider in antithrombotic development: 1) basic research into the biology of thrombosis, 2) preclinical development, 3) definitive clinical trials, and 4) comparative effectiveness and advances in these areas, which will need multi–stakeholder collaboration.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease, Interventions and Vascular Medicine

Keywords: Thromboembolism, Heart Valve Prosthesis, Coronary Artery Disease, Myocardial Infarction, Stroke, Endarterectomy, Carotid, Venous Thromboembolism, Fibrinolytic Agents


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