Risk of Serious Bleeding with Antiplatelet Therapy for Secondary Prevention Post Ischemic Stroke in Middle East Population.

Introduction Stroke is a devastating disease, causing significant mortality and long-term disability worldwide. Since the bulk of ischemic strokes is attributed to atherothrombosis, secondary prevention with antiplatelet agents is essential to decrease the recurrence of stroke. Aspirin, as well as clopidogrel monotherapy, has been shown to reduce the relative risk of recurrent stroke. However, concerns regarding the efficacy and safety of dual antiplatelet approach still exist. Stroke patients are particularly susceptible to bleeding complications, which might be due to advanced age and comorbidities. Our study assessed the risk of serious bleeding among adult patients on antiplatelet therapy for secondary prevention after stroke who were admitted to Mount Lebanon Hospital (MLH) between 2010 and 2015. It also studied the effect of the antiplatelet therapy, including dose and combination in increasing the risk of bleed. Methods A retrospective monocentric study included 454 patients who were admitted for ischemic cerebrovascular accident (CVA) between 2010 and 2015, and discharged on antiplatelet therapy for secondary prevention. Those patients' records were followed to assess the percentage of patients who developed a major bleed after initiation of antiplatelet therapy. Results The risk of serious bleed was highest with aspirin 100 mg monotherapy and dual antiplatelet therapy (DAPT) (Aspirin 100 mg + Clopidogrel 75 mg). Bleeding risk was high during the first three months of therapy. However, the highest risk of bleed exists during the duration extending between three months and one year for both aspirin 100 mg monotherapy and DAPT. Moreover, there was an established relation between patients' related factors and bleeding risk. Advanced age and smoking were found to contribute to increasing this risk. Conclusion Aspirin 100 mg monotherapy and DAPT are associated with the highest risk of bleeding. Although this exists regardless of the duration of antiplatelet therapy, it is highest during the duration extending between three months and one year post initiation of antiplatelet therapy.

Recurrent Asymptomatic Sigmoid Diverticular Perforation in a Patient with Pemphigus Vulgaris on Immunosuppressive Therapy: A Case Report.

BACKGROUND Perforation of the colon is associated with high mortality and requires early diagnosis. However, the diagnosis of perforation from atypical causes can be a diagnostic challenge. This report is of a rare case of recurrent sigmoid colonic perforation in a patient with diverticular disease who did not present with an acute abdomen but who had pemphigus vulgaris treated with immunosuppressive therapy. CASE REPORT A 57-year-old man with pemphigus vulgaris was treated with steroids, non-steroidal anti-inflammatory drugs (NSAIDS), and azathioprine. He had episodes of abdominal bloating but denied any other symptoms. He was diagnosed with spontaneous sigmoid diverticular perforation without presenting with an acute abdomen. CONCLUSIONS Diverticular perforation can be asymptomatic in patients on immunosuppressive therapy. Therefore, there should be a high index of suspicion for bowel perforation in patients with abdominal symptoms who are treated for skin diseases, such as pemphigus vulgaris, and are on steroids and other immunosuppressive treatments.