Between the rock of ages and a hard place to cohort

Furthermore, thrombotic events in the TAVR population may have a different mechanistic explanation. Most notably, the role of vWF has not been established in the PCI population, as well as platelet activation and aggregation on the valve surface. These factors included advanced age, diabetes, polypharmacy, and low BMI.

Several ongoing studies discussed below seek to clarify the most appropriate regimens. Pre-procedural P2Y12 loading was found to decrease the severity of thrombocytopenia in a single-center study. As far as intraprocedural antithrombotic management, unfractionated heparin UFH remains the gold standard.

The trial was designed to show superiority of bivalirudin in regard to bleeding events. Bivalirudin for procedural anticoagulation did not significantly reduce the primary outcomes. At 30 days, NACE rates were We use a clopidogrel loading dose of mg on the day of the procedure.

We recommend clopidogrel monotherapy for 3 m onths after TAVR. After that, the patient can be transitioned to aspirin if they have an indication for aspirin. Current Antithrombotic Recommendations after Transcatheter Aortic Valve Replacement The current guidelines for antithrombotic management peri-TAVR have been extrapolated from data obtained from other areas in the field, namely in a post-PCI population.

The Canadian Cardiovascular Society guidelines suggest treating with low-dose aspirin along with 1—3 months of a thienopyridine based on consensus of expert opinion. There are multiple ongoing clinical trials investigating different antithrombotic regimens in patients undergoing TAVR Table 2.

However, this small study was underpowered for clinical endpoints and larger randomized trials are needed to substantiate these results. However, there are several limitations to this study mostly related to the small size of the studies included in the meta-analysis, as well as the non-randomized design.

Given the lack of randomization of these studies, it is also possible that the SAPT arm included a disproportionate number of patients who had greater frailty or were at greater risk of adverse events than those placed on DAPT. Finally, there were inconsistent long-term data from the individual studies, with some only providing in-hospital events, potentially missing or under-reporting events after hospitalization.

Other studies that have tried to further elucidate the best antithrombotic regimens post-TAVR include those looking at various antiplatelet combinations, as well as those investigating anticoagulation versus antiplatelet agents. Specifically, rivaroxaban plus aspirin was compared with standard DAPT treatment.

This trial was prematurely stopped due to an increase in all-cause mortality in the rivaroxaban group 6. Additionally, the increased mortality rate most likely mirrored the increase in bleeding events. During 13 months of follow-up, patients who received warfarin and any combination of antiplatelet therapy had higher rates of major and life-threatening bleeding with no significant reduction in thrombotic events. The main issue with this study is that patients with AF who received antiplatelets alone had lower rates of stroke than those who received anticoagulation alone 4.

At our center, patients who are on any anticoagulant without indications for antiplatelets do not receive any antiplatelet drugs before or after TAVR. The choice of anticoagulation is discussed with each patient individually, given there are no major differences between warfarin and NOACs Figure 1. The optimal antithrombotic regimen in patients undergoing TAVR is yet to be identified.

The rationale for DAPT following TAVR is to decrease the risk of thromboembolic events associated with this procedure, especially cerebrovascular events. As Discussion Inevitably any study of famous people will have limitations. Our choice of music genres table 1 aimed to capture only mainstream genres across both continents but some stars of, for instance, folk, country and jazz that were not included have substantial popular followings eg, Damien Rice.

Our definition of fame, while objective, is also likely to omit key individuals not included in the international polls we used despite success in record sales. Other analyses have chosen performers who topped sales charts 7 but we used a broader definition as specific population groups can influence album purchases. For those performers included, extensive internet coverage of even somewhat forgotten stars meant that mortality could be relatively easily established.

However, the exact cause of death was more difficult to identify. In particular, for some stars deaths from accidents and longer-term conditions may have been due to alcohol and drug use but would not be coded as such unless this was specifically reported in biographical resources.

For the first time we also attempted to extract information from public sources on adverse experiences stars had suffered while children. Two researchers collected such data independently and concordance between them was high. Data collection was limited to those who had died as death often generates greater media coverage and exposure of more sensitive personal details.

Moreover, the extent to which ACEs occur in living pop stars and consequently their relationship with overall risk of mortality is an important research questions for further work. Finally, it is unknown as to whether the impacts of ACEs and fame in other groups eg, film stars and sports stars would show similar relationships with mortality to those identified here.

Consequently, this work on ACEs should be regarded as representing only an initial attempt to examine the impact of early life experiences in a unique group of individuals. However, while the limitations of this study are important to acknowledge, this methodology may currently be the only way to examine individuals who have moved, in some cases, from relative poverty to extreme affluence and who have followings larger than the population of entire countries.

Consistent with our findings, other recent studies have established the longer-term impact of rock and pop stardom on mortality; with reduced survival compared to the general population continuing well beyond the point of fame. As well as confirming the disproportionate mortality suffered by stars overall, here we have examined the impacts of nationality and performer type eg, solo performer on survival and impacts of ACEs on cause of death.

Such findings raise a number of issues regarding the causes of increased mortality in stars that are central to protecting the health of rock and pop stars and addressing the appeal the hedonistic elements of rock and pop may have to their fan bases. However, the difference in NA was substantively greater than that in EU. As previously reported, 11 for both NA and EU samples the survival gap between stars and the population widened up to 25 years postfame.

At this point, however, survival in EU stars only, begins recovery to general population levels.

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Farlex Dictionary of Idioms. I couldn't make up my mind. I was caught between a rock and a hard place. He had a dilemma on his hands. He was clearly between the devil and the deep blue sea. Between two equally difficult or unacceptable choices. For example, Trying to please both my boss and his supervisor puts me between a rock and a hard place. The rock and hard place version is the newest of these synonymous phrases, dating from the early s, and alludes to being caught or crushed between two rocks.

The oldest is Scylla and Charybdis, which in Homer's Odyssey signified a monster on a rock Scylla and a fatal whirlpool Charybdis , between which Odysseus had to sail through a narrow passage. It was used figuratively by the Roman writer Virgil and many writers since. The devil in devil and deep blue sea, according to lexicographer Charles Earle Funk, referred to a seam around a ship's hull near the waterline, which, if a sailor was trying to caulk it in heavy seas, would cause him to fall overboard.

These types of situations have existed as long as the human race has been alive. The actual phrase, between a rock and a hard place, however, was penned much later in our evolutionary history. The phrase can be traced back to Greek mythology. In the tale, the character Odysseus must go through a difficult area on his journey.

The Charybdis, which is a dangerous whirlpool, and the cliff-dwelling monster Scylla that loves to eat men, are the dangers he must face. The phrase between a rock and a hard place was used to explain his plight of having to travel between the cliff and the whirlpool. The Greek saying is more of a translation or inference rather than a direct quote. The phrase was used quite often in the early parts of the 20th century in the USA and other first-world countries.

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