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Lincoff AM, Mehran R, Povsic TJ, Zelenkofske SL, Huang Z, Armstrong PW, Steg PG, Bode C, Cohen MG, Buller C, Laanmets P, Valgimigli M, Marandi T, Fridrich V, Cantor WJ, Merkely B, Lopez-Sendon J, Cornel JH, Kasprzak JD, Aschermann M, Guetta V, Morais J, Sinnaeve PR, Huber K, Stables R, Sellers MA, Borgman M, Glenn L, Levinson AI, Lopes RD, Hasselblad V, Becker RC, Alexander JH. Effect of the REG1 anticoagulation system versus bivalirudin on outcomes after percutaneous coronary intervention (REGULATE-PCI): a randomised clinical trial. Lancet 2016; 387:349-356. [PMID: 26547100 DOI: 10.1016/s0140-6736(15)00515-2] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND REG1 is a novel anticoagulation system consisting of pegnivacogin, an RNA aptamer inhibitor of coagulation factor IXa, and anivamersen, a complementary sequence reversal oligonucleotide. We tested the hypothesis that near complete inhibition of factor IXa with pegnivacogin during percutaneous coronary intervention, followed by partial reversal with anivamersen, would reduce ischaemic events compared with bivalirudin, without increasing bleeding. METHODS We did a randomised, open-label, active-controlled, multicentre, superiority trial to compare REG1 with bivalirudin at 225 hospitals in North America and Europe. We planned to randomly allocate 13,200 patients undergoing percutaneous coronary intervention in a 1:1 ratio to either REG1 (pegnivacogin 1 mg/kg bolus [>99% factor IXa inhibition] followed by 80% reversal with anivamersen after percutaneous coronary intervention) or bivalirudin. Exclusion criteria included ST segment elevation myocardial infarction within 48 h. The primary efficacy endpoint was the composite of all-cause death, myocardial infarction, stroke, and unplanned target lesion revascularisation by day 3 after randomisation. The principal safety endpoint was major bleeding. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, identifier NCT01848106. The trial was terminated early after enrolment of 3232 patients due to severe allergic reactions. FINDINGS 1616 patients were allocated REG1 and 1616 were assigned bivalirudin, of whom 1605 and 1601 patients, respectively, received the assigned treatment. Severe allergic reactions were reported in ten (1%) of 1605 patients receiving REG1 versus one (<1%) of 1601 patients treated with bivalirudin. The composite primary endpoint did not differ between groups, with 108 (7%) of 1616 patients assigned REG1 and 103 (6%) of 1616 allocated bivalirudin reporting a primary endpoint event (odds ratio [OR] 1·05, 95% CI 0·80-1·39; p=0·72). Major bleeding was similar between treatment groups (seven [<1%] of 1605 receiving REG1 vs two [<1%] of 1601 treated with bivalirudin; OR 3·49, 95% CI 0·73-16·82; p=0·10), but major or minor bleeding was increased with REG1 (104 [6%] vs 65 [4%]; 1·64, 1·19-2·25; p=0·002). INTERPRETATION The reversible factor IXa inhibitor REG1, as currently formulated, is associated with severe allergic reactions. Although statistical power was limited because of early termination, there was no evidence that REG1 reduced ischaemic events or bleeding compared with bivalirudin. FUNDING Regado Biosciences Inc.
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Affiliation(s)
- A Michael Lincoff
- Cleveland Clinic Coordinating Center for Clinical Research (C5Research), Cleveland, OH, USA.
| | | | - Thomas J Povsic
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
| | | | - Zhen Huang
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
| | - P Gabriel Steg
- Université Paris-Diderot, Sorbonne Paris Cité, Paris, France
| | | | | | | | | | - Marco Valgimigli
- University Hospital of Ferrara, Institute of Cardiology, Ferrara, Italy
| | | | - Viliam Fridrich
- National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | | | - Bela Merkely
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
| | | | | | | | | | - Victor Guetta
- Heart Institute Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | | | - Peter R Sinnaeve
- University Hospitals Leuven Campus Gasthuisberg, Leuven, Belgium
| | | | - Rod Stables
- Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mary Ann Sellers
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
| | - Marilyn Borgman
- Cleveland Clinic Coordinating Center for Clinical Research (C5Research), Cleveland, OH, USA
| | | | - Arnold I Levinson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
| | - Vic Hasselblad
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
| | - Richard C Becker
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - John H Alexander
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
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102
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Yu J, Mehran R, Clayton T, Gibson CM, Brodie BR, Witzenbichler B, Lincoff AM, Deliargyris EN, Gersh BJ, Pocock SJ, Stone GW, Dangas GD. Prediction of 1-year mortality and impact of bivalirudin therapy according to level of baseline risk: A patient-level pooled analysis from three randomized trials. Catheter Cardiovasc Interv 2015; 87:391-400. [DOI: 10.1002/ccd.26146] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 07/18/2015] [Indexed: 12/22/2022]
Affiliation(s)
- Jennifer Yu
- Mount Sinai Medical Center; Cardiovascular Institute; New York New York
- Prince of Wales Hospital Clinical School; University of New South Wales; NSW Australia
| | - Roxana Mehran
- Mount Sinai Medical Center; Cardiovascular Institute; New York New York
- Cardiovascular Research Foundation; New York New York
| | - Tim Clayton
- London School of Hygiene and Tropical Medicine; London United Kingdom
| | - C. Michael Gibson
- Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Bruce R. Brodie
- LeBauer Cardiovascular Research Foundation; Greensboro North Carolina
| | | | | | | | | | - Stuart J. Pocock
- London School of Hygiene and Tropical Medicine; London United Kingdom
| | - Gregg W. Stone
- Cardiovascular Research Foundation; New York New York
- Columbia University Medical Center; New York New York
| | - George D. Dangas
- Mount Sinai Medical Center; Cardiovascular Institute; New York New York
- Cardiovascular Research Foundation; New York New York
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103
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Nicholls SJ, Lincoff AM, Barter PJ, Brewer HB, Fox KAA, Gibson CM, Grainger C, Menon V, Montalescot G, Rader D, Tall AR, McErlean E, Riesmeyer J, Vangerow B, Ruotolo G, Weerakkody GJ, Nissen SE. Assessment of the clinical effects of cholesteryl ester transfer protein inhibition with evacetrapib in patients at high-risk for vascular outcomes: Rationale and design of the ACCELERATE trial. Am Heart J 2015; 170:1061-9. [PMID: 26678626 DOI: 10.1016/j.ahj.2015.09.007] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 09/14/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Potent pharmacologic inhibition of cholesteryl ester transferase protein by the investigational agent evacetrapib increases high-density lipoprotein cholesterol by 54% to 129%, reduces low-density lipoprotein cholesterol by 14% to 36%, and enhances cellular cholesterol efflux capacity. The ACCELERATE trial examines whether the addition of evacetrapib to standard medical therapy reduces the risk of cardiovascular (CV) morbidity and mortality in patients with high-risk vascular disease. STUDY DESIGN ACCELERATE is a phase 3, multicenter, randomized, double-blind, placebo-controlled trial. Patients qualified for enrollment if they have experienced an acute coronary syndrome within the prior 30 to 365 days, cerebrovascular accident, or transient ischemic attack; if they have peripheral vascular disease; or they have diabetes with coronary artery disease. A total of 12,092 patients were randomized to evacetrapib 130 mg or placebo daily in addition to standard medical therapy. The primary efficacy end point is time to first event of CV death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary revascularization. Treatment will continue until 1,670 patients reached the primary end point; at least 700 patients reach the key secondary efficacy end point of CV death, myocardial infarction, and stroke, and the last patient randomized has been followed up for at least 1.5 years. CONCLUSIONS ACCELERATE will establish whether the cholesteryl ester transfer protein inhibition by evacetrapib improves CV outcomes in patients with high-risk vascular disease.
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Affiliation(s)
- Stephen J Nicholls
- South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, Australia
| | - A Michael Lincoff
- Cleveland Clinic Coordinating Center for Clinical Research and Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | | | | | | | | | | | - Venugopal Menon
- Cleveland Clinic Coordinating Center for Clinical Research and Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | | | | | | | - Ellen McErlean
- Cleveland Clinic Coordinating Center for Clinical Research and Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | | | | | | | | | - Steven E Nissen
- Cleveland Clinic Coordinating Center for Clinical Research and Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
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104
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Mennuni MG, Dangas GD, Mehran R, Ben-Gal Y, Xu K, Généreux P, Brener SJ, Feit F, Lincoff AM, Ohman EM, Hamon M, Stone GW. Coronary Artery Bypass Surgery Compared With Percutaneous Coronary Intervention for Proximal Left Anterior Descending Artery Treatment in Patients With Acute Coronary Syndrome: Analysis From the ACUITY Trial. J Invasive Cardiol 2015; 27:468-473. [PMID: 26121708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The optimal revascularization strategy in patients with acute coronary syndrome (ACS) and proximal left anterior descending (pLAD) coronary artery lesions is not well defined. The aim of this study was to compare the outcomes of ACS patients with pLAD culprit lesions receiving percutaneous coronary intervention (PCI) vs coronary artery bypass graft (CABG). METHODS The ACUITY trial was a multicenter, prospective trial of patients with ACS treated with an early invasive strategy. Major adverse cardiac event (MACE; defined as death, myocardial infarction [MI], and repeat revascularization) and stroke were compared at 30 days and 1 year between PCI and CABG in patients with significant stenosis of the pLAD undergoing revascularization. Postprocedural major bleeding was evaluated at 30 days. RESULTS Among patients with a significant pLAD stenosis (n = 842), a total of 562 (66.7%) underwent PCI and 280 (33.3%) underwent CABG. Baseline characteristics, including age, sex, diabetes, and TIMI risk score, were well matched between groups; however, patients undergoing PCI were more likely to have had previous CABG (21.9% vs 6.4%; P<.001). Death, MI, MACE, and stroke rates did not differ between groups at 1 year. PCI patients had lower bleeding rates (8.1% vs 52.4%; P<.001) and blood product transfusion at 30 days (4.5% vs 41.3%; P<.001), but higher rates of unplanned revascularization at 1 year (12.7% vs 5.2%; P<.01). These results were consistent in patients with single vs multivessel disease and in diabetics vs non-diabetics. CONCLUSIONS Among ACS patients with pLAD culprit lesions, an initial revascularization strategy of PCI compared with CABG yields similar 1-year death, MI, and MACE rates, although unplanned revascularization is more common after PCI.
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Affiliation(s)
- Marco G Mennuni
- Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029 USA.
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105
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Geisler T, Droppa M, Gawaz M, Steinhubl SR, Bertrand ME, Lincoff AM, Cequier AR, Desmet W, Rasmussen LH, Hoekstra JW, Bernstein D, Deliargyris EN, Mehran R, Stone GW. Impact of anticoagulation regimen prior to revascularization in patients with non-ST-segment elevation acute coronary syndromes: The ACUITY trial. Catheter Cardiovasc Interv 2015; 88:174-81. [DOI: 10.1002/ccd.26232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 08/15/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Tobias Geisler
- Department of Cardiology; University Hospital Tübingen; Tübingen Germany
| | - Michal Droppa
- Department of Cardiology; University Hospital Tübingen; Tübingen Germany
| | - Meinrad Gawaz
- Department of Cardiology; University Hospital Tübingen; Tübingen Germany
| | | | | | | | - Angel R. Cequier
- Hospital Universitari De Bellvitge, IDIBELL, Universitat De Barcelona; Barcelona Spain
| | | | | | - James W. Hoekstra
- Wake Forest University Baptist Medical Center, Wake Forest University; Winston-Salem North Carolina
| | | | | | - Roxana Mehran
- Cardiovascular Research Foundation; New York New York
- Icahn School of Medicine at Mount Sinai; New York New York
| | - Gregg W. Stone
- Cardiovascular Research Foundation; New York New York
- Columbia University Medical Center/NewYork-Presbyterian Hospital; New York New York
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106
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Udell JA, Bonaca MP, Collet JP, Lincoff AM, Kereiakes DJ, Costa F, Lee CW, Mauri L, Valgimigli M, Park SJ, Montalescot G, Sabatine MS, Braunwald E, Bhatt DL. Long-term dual antiplatelet therapy for secondary prevention of cardiovascular events in the subgroup of patients with previous myocardial infarction: a collaborative meta-analysis of randomized trials. Eur Heart J 2015; 37:390-9. [PMID: 26324537 DOI: 10.1093/eurheartj/ehv443] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 08/12/2015] [Indexed: 12/20/2022] Open
Abstract
AIMS Recent trials have examined the effect of prolonged dual antiplatelet therapy (DAPT) in a variety of patient populations, with heterogeneous results regarding benefit and safety, specifically with regard to cardiovascular and non-cardiovascular mortality. We performed a meta-analysis of randomized trials comparing more than a year of DAPT with aspirin alone in high-risk patients with a history of prior myocardial infarction (MI). METHODS AND RESULTS A total of 33 435 patients were followed over a mean 31 months among one trial of patients with prior MI (63.3% of total) and five trials with a subgroup of patients that presented with, or had a history of, a prior MI (36.7% of total). Extended DAPT decreased the risk of major adverse cardiovascular events compared with aspirin alone (6.4 vs. 7.5%; risk ratio, RR 0.78, 95% confidence intervals, CI, 0.67-0.90; P = 0.001) and reduced cardiovascular death (2.3 vs. 2.6%; RR 0.85, 95% CI 0.74-0.98; P = 0.03), with no increase in non-cardiovascular death (RR 1.03, 95% CI 0.86-1.23; P = 0.76). The resultant effect on all-cause mortality was an RR of 0.92 (95% CI 0.83-1.03; P = 0.13). Extended DAPT also reduced MI (RR 0.70, 95% CI 0.55-0.88; P = 0.003), stroke (RR 0.81, 95% CI 0.68-0.97; P = 0.02), and stent thrombosis (RR 0.50, 95% CI 0.28-0.89; P = 0.02). There was an increased risk of major bleeding (1.85 vs. 1.09%; RR 1.73, 95% CI 1.19-2.50; P = 0.004) but not fatal bleeding (0.14 vs. 0.17%; RR 0.91, 95% CI 0.53-1.58; P = 0.75). CONCLUSION Compared with aspirin alone, DAPT beyond 1 year among stabilized high-risk patients with prior MI decreases ischaemic events, including significant reductions in the individual endpoints of cardiovascular death, recurrent MI, and stroke. Dual antiplatelet therapy beyond 1 year increases major bleeding, but not fatal bleeding or non-cardiovascular death.
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Affiliation(s)
- Jacob A Udell
- Peter Munk Cardiac Centre and Cardiovascular Division, University Health Network, Heart and Stroke Richard Lewar Centre of Excellence, University of Toronto, 76 Grenville Street, Toronto, Canada ON M5S 1B1 Women's College Research Institute and Cardiovascular Division, Department of Medicine, Women's College Hospital, University of Toronto, Toronto, Canada
| | - Marc P Bonaca
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Jean-Philippe Collet
- ACTION Study Group, Institut de Cardiologie Hôpital Pitié-Salpêtrière (APHP), Université Paris 6, INSERM, Paris, France
| | - A Michael Lincoff
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, OH, USA
| | - Dean J Kereiakes
- The Christ Hospital Heart and Vascular Center and The Lindner Center for Research and Education at the Christ Hospital, Cincinnati, OH, USA
| | - Francesco Costa
- Thoraxcenter, Erasmus Medical Center, Rotterdam 3015 CE, The Netherlands
| | - Cheol Whan Lee
- The Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Laura Mauri
- Harvard Clinical Research Institute and Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marco Valgimigli
- Thoraxcenter, Erasmus Medical Center, Rotterdam 3015 CE, The Netherlands University Hospital of Bern, Bern, Switzerland
| | - Seung-Jung Park
- The Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Gilles Montalescot
- ACTION Study Group, Institut de Cardiologie Hôpital Pitié-Salpêtrière (APHP), Université Paris 6, INSERM, Paris, France
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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107
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Warren J, Mehran R, Yu J, Xu K, Bertrand ME, Cox DA, Lincoff AM, Manoukian SV, Ohman EM, Pocock SJ, White HD, Stone GW. Incidence and impact of totally occluded culprit coronary arteries in patients presenting with non-ST-segment elevation myocardial infarction. Am J Cardiol 2015; 115:428-33. [PMID: 25542393 DOI: 10.1016/j.amjcard.2014.11.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 11/17/2014] [Accepted: 11/17/2014] [Indexed: 12/13/2022]
Abstract
The accuracy of the 12-lead electrocardiogram in detecting coronary artery occlusion is limited. We sought to determine the incidence, distribution, and outcomes of patients who have total occlusion of the culprit artery but present with non-ST-segment elevation myocardial infarction (NSTEMI). The randomized Acute Catheterization and Urgent Intervention Triage Strategy trial enrolled 13,819 patients presenting with non-ST-segment elevation acute coronary syndromes who underwent an early invasive strategy. The present study includes 1,319 patients with baseline biomarker elevation (NSTEMI) and no history of coronary artery bypass graft who underwent percutaneous coronary intervention of a single culprit vessel. We compared the baseline characteristics and outcomes according to whether the culprit vessel was occluded (baseline Thrombolysis In Myocardial Infarction [TIMI] 0 to 1) or patent (TIMI 2 to 3 flow) by angiographic core laboratory assessment. TIMI 0 to 1 flow in the culprit artery was present in 262 of 1,319 (19.9%) patients. The incidence of coronary occlusion was 28.4%, 19.3%, and 12.6% in patients with NSTEMI because of right coronary, left circumflex, and left anterior descending artery disease, respectively. Patients with an occluded culprit artery were more commonly men and had ST-segment deviation ≥1 mm. One-year outcomes, including death (3.5% vs 3.0%, p = 0.68) and myocardial infarction (8.4% vs 9.6%, p = 0.47), did not differ significantly between patients with versus without occluded culprit arteries, respectively. In conclusion, the present study demonstrates that the culprit artery is totally occluded in approximately 1 in 5 patients presenting with NSTEMI and single-vessel disease; however, the presence of total occlusion in NSTEMI was not associated with an incremental hazard of death or reinfarction at 1 year.
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108
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Hall TS, Hallén J, Krucoff MW, Roe MT, Brennan DM, Agewall S, Atar D, Lincoff AM. Cardiac troponin I for prediction of clinical outcomes and cardiac function through 3-month follow-up after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Am Heart J 2015; 169:257-265.e1. [PMID: 25641535 DOI: 10.1016/j.ahj.2014.10.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 10/27/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Circulating levels of cardiac troponin I (cTnI) after ST-segment elevation myocardial infarction (STEMI) are associated with infarct size and chronic left ventricular dysfunction, but the relation to clinical end points and biochemical measures of global cardiac function remains less well defined. METHODS One thousand sixty-six patients receiving primary percutaneous coronary intervention (PCI) in the PROTECTION AMI trial were studied in a post hoc analysis. Cardiac troponin I was measured at several time points during the index hospitalization, and patients were followed up for 3 months before reassessment including N-terminal pro-B-type natriuretic peptide (NT-proBNP) and left ventricular ejection fraction (LVEF) measurements. RESULTS The median (quartile 1-3) cTnI levels were 0.4 (0.1-0.4) μg/L at admission, 33.1 (12.8-72.1) μg/L after 16 to 24 hours, and 9.1 (3.9-17.5) μg/L after 70 to 80 hours. In adjusted models, all post-PCI single points, peak, and area under curve were found to be independently associated with clinical events, NT-proBNP >118 pmol/L, or LVEF <40% (P for all <.001). When cTnI was added to a baseline risk model for prediction of clinical events, the C statistic improved from 0.779 to 0.846 (16-24 hours) and 0.859 (70-80 hours). Quantified by integrated discrimination improvement, the addition of cTnI significantly augmented prediction ability (relative integrated discrimination improvement 44%-154%; P for all ≤.001). Consistent improvements in discrimination of NT-proBNP >118 pmol/L and LVEF <40% were observed. CONCLUSIONS Cardiac troponin I measured after primary PCI for STEMI is independently associated with clinical outcomes and cardiac function through 3-month follow-up. These results suggest that cTnI levels are a useful risk stratification tool in STEMI patients.
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109
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Kunadian V, Mehran R, Lincoff AM, Feit F, Manoukian SV, Hamon M, Cox DA, Dangas GD, Stone GW. Effect of anemia on frequency of short- and long-term clinical events in acute coronary syndromes (from the Acute Catheterization and Urgent Intervention Triage Strategy Trial). Am J Cardiol 2014; 114:1823-9. [PMID: 25438908 DOI: 10.1016/j.amjcard.2014.09.023] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 09/14/2014] [Accepted: 09/14/2014] [Indexed: 11/25/2022]
Abstract
There are limited data on the impact of anemia on clinical outcomes in unstable angina and non-ST-segment elevation myocardial infarction treated with an early invasive strategy. We sought to determine the short- and long-term clinical events among patients with and without anemia enrolled in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. Anemia was defined as baseline hemoglobin of <13 g/dl for men and <12 g/dl for women. The primary end points were composite ischemia (death, myocardial infarction, or unplanned revascularization for ischemia) and major bleeding assessed in-hospital, at 1 month, and at 1 year. Among the 13,819 patients in the ACUITY trial, information regarding anemia was available in 13,032 (94.3%), 2,199 of whom (16.9%) had anemia. Patients with anemia compared with those without anemia had significantly increased adverse event rates in-hospital (composite ischemia 6.6% vs 4.8%, p = 0.0004; major bleeding 7.3% vs 3.3%, p <0.0001), at 1 month (composite ischemia 10% vs 7.2%, p <0.0001, major bleeding 8.8% vs 3.9%, p <0.0001), and 1 year (composite ischemia 21.7% vs 15.3%, p <0.0001). Anemia was an independent predictor of death at 1 year (hazard ratio 1.77, 95% confidence interval [CI] 1.29 to 2.44, p = 0.0005). Composite ischemia was significantly more common among patients who developed in-hospital non-coronary artery bypass surgery major bleeding compared with those who did not (anemic patients 1-year relative risk 2.19, 95% CI 1.67 to 2.88, p <0.0001; nonanemic patients relative risk 2.16, 95% CI 1.76 to 2.65, p <0.0001). In conclusion, in the ACUITY trial, baseline anemia was strongly associated with adverse early and late clinical events, especially in those who developed major bleeding.
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110
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Ruilope L, Hanefeld M, Lincoff AM, Viberti G, Meyer-Reigner S, Mudie N, Wieczorek Kirk D, Malmberg K, Herz M. Effects of the dual peroxisome proliferator-activated receptor-α/γ agonist aleglitazar on renal function in patients with stage 3 chronic kidney disease and type 2 diabetes: a Phase IIb, randomized study. BMC Nephrol 2014; 15:180. [PMID: 25407798 PMCID: PMC4364102 DOI: 10.1186/1471-2369-15-180] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 09/22/2014] [Indexed: 02/07/2023] Open
Abstract
Background Type 2 diabetes is a major risk factor for chronic kidney disease, which substantially increases the risk of cardiovascular disease mortality. This Phase IIb safety study (AleNephro) in patients with stage 3 chronic kidney disease and type 2 diabetes, evaluated the renal effects of aleglitazar, a balanced peroxisome proliferator-activated receptor-α/γ agonist. Methods Patients were randomized to 52 weeks’ double-blind treatment with aleglitazar 150 μg/day (n = 150) or pioglitazone 45 mg/day (n = 152), followed by an 8-week off-treatment period. The primary endpoint was non-inferiority for the difference between aleglitazar and pioglitazone in percentage change in estimated glomerular filtration rate from baseline to end of follow-up. Secondary endpoints included change from baseline in estimated glomerular filtration rate and lipid profiles at end of treatment. Results Mean estimated glomerular filtration rate change from baseline to end of follow-up was –2.7% (95% confidence interval: –7.7, 2.4) with aleglitazar versus –3.4% (95% confidence interval: –8.5, 1.7) with pioglitazone, establishing non-inferiority (0.77%; 95% confidence interval: –4.5, 6.0). Aleglitazar was associated with a 15% decrease in estimated glomerular filtration rate versus 5.4% with pioglitazone at end of treatment, which plateaued to 8 weeks and was not progressive. Superior improvements in high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and triglycerides, with similar effects on glycosylated hemoglobin were observed with aleglitazar versus pioglitazone. No major safety concerns were identified. Conclusions The primary endpoint in AleNephro was met, indicating that in stage 3 chronic kidney disease patients with type 2 diabetes, the decrease in estimated glomerular filtration rate after 52 weeks’ treatment with aleglitazar followed by 8 weeks off-treatment was reversible and comparable (non-inferior) to pioglitazone. Trial registration NCT01043029 January 5, 2010. Electronic supplementary material The online version of this article (doi:10.1186/1471-2369-15-180) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luis Ruilope
- Hospital 12 de Octubre, Clinical Science, Madrid, Spain.
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Bangalore S, Bhatt DL, Steg PG, Weber MA, Boden WE, Hamm CW, Montalescot G, Hsu A, Fox KAA, Lincoff AM. β-blockers and cardiovascular events in patients with and without myocardial infarction: post hoc analysis from the CHARISMA trial. Circ Cardiovasc Qual Outcomes 2014; 7:872-81. [PMID: 25271049 DOI: 10.1161/circoutcomes.114.001073] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The long-term efficacy of β-blockers in patients with and without myocardial infarction (MI) is controversial. METHODS AND RESULTS This is post hoc analysis from the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial of 4772 patients with prior MI, 7804 patients with known atherothrombosis, and 2101 patients with risk factors alone but without heart failure. Primary outcome was a composite of nonfatal MI, stroke, or cardiovascular mortality. The cohorts were divided into 2 groups based on baseline β-blocker use. In the propensity score-matched prior MI cohort, after 28 months of follow-up, β-blocker use was associated with a 31% lower risk of the primary outcome (70 [7.1%] versus 100 [10.2%]; hazards ratio, 0.69; 95% confidence interval, 0.50-0.94; P=0.021), driven by a lower risk of recurrent MI (33 [3.4%] versus 48 [4.9%]; hazards ratio, 0.62; 95% confidence interval, 0.39-1.00; P=0.049) with no difference in mortality (52 [5.3%] versus 66 [6.7%]; P=0.20). In the known atherothrombotic disease and the risk factors alone cohorts, β-blocker use was not associated with lower ischemic outcomes, whereas a trend toward a higher risk of stroke (3.5% versus 1.5%; hazards ratio, 2.13; 95% confidence interval, 0.92-4.92; P=0.079) was observed in the risk factors alone cohort. This higher stroke risk was significant in the regression model adjusted to the propensity score (hazards ratio, 2.69; 95% confidence interval, 1.33-5.44; P=0.006) and in the multivariable models. CONCLUSIONS β-blocker use in patients with prior MI but no heart failure was associated with a lower composite cardiovascular outcome driven by lower risk of recurrent MI with no difference in mortality. However, β-blocker use was not associated with lower cardiovascular events in those without MI, with a suggestion of inferior outcome with regard to stroke risk. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00050817.
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Affiliation(s)
- Sripal Bangalore
- From the New York University School of Medicine (S.B.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); AP-HP, Hôpital Bichat, Paris, France (P.G.S.); State University of New York, Downstate College of Medicine, Brooklyn (M.A.W.); Samuel Stratton VA Medical Center, Albany Medical College, NY (W.E.B.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France (G.M.); Cleveland Clinic, OH (A.H., A.M.L.); and Centre for Cardiovascular Science, University of Edinburgh Duke of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
| | - Deepak L Bhatt
- From the New York University School of Medicine (S.B.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); AP-HP, Hôpital Bichat, Paris, France (P.G.S.); State University of New York, Downstate College of Medicine, Brooklyn (M.A.W.); Samuel Stratton VA Medical Center, Albany Medical College, NY (W.E.B.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France (G.M.); Cleveland Clinic, OH (A.H., A.M.L.); and Centre for Cardiovascular Science, University of Edinburgh Duke of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Ph Gabriel Steg
- From the New York University School of Medicine (S.B.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); AP-HP, Hôpital Bichat, Paris, France (P.G.S.); State University of New York, Downstate College of Medicine, Brooklyn (M.A.W.); Samuel Stratton VA Medical Center, Albany Medical College, NY (W.E.B.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France (G.M.); Cleveland Clinic, OH (A.H., A.M.L.); and Centre for Cardiovascular Science, University of Edinburgh Duke of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Michael A Weber
- From the New York University School of Medicine (S.B.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); AP-HP, Hôpital Bichat, Paris, France (P.G.S.); State University of New York, Downstate College of Medicine, Brooklyn (M.A.W.); Samuel Stratton VA Medical Center, Albany Medical College, NY (W.E.B.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France (G.M.); Cleveland Clinic, OH (A.H., A.M.L.); and Centre for Cardiovascular Science, University of Edinburgh Duke of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - William E Boden
- From the New York University School of Medicine (S.B.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); AP-HP, Hôpital Bichat, Paris, France (P.G.S.); State University of New York, Downstate College of Medicine, Brooklyn (M.A.W.); Samuel Stratton VA Medical Center, Albany Medical College, NY (W.E.B.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France (G.M.); Cleveland Clinic, OH (A.H., A.M.L.); and Centre for Cardiovascular Science, University of Edinburgh Duke of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Christian W Hamm
- From the New York University School of Medicine (S.B.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); AP-HP, Hôpital Bichat, Paris, France (P.G.S.); State University of New York, Downstate College of Medicine, Brooklyn (M.A.W.); Samuel Stratton VA Medical Center, Albany Medical College, NY (W.E.B.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France (G.M.); Cleveland Clinic, OH (A.H., A.M.L.); and Centre for Cardiovascular Science, University of Edinburgh Duke of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Gilles Montalescot
- From the New York University School of Medicine (S.B.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); AP-HP, Hôpital Bichat, Paris, France (P.G.S.); State University of New York, Downstate College of Medicine, Brooklyn (M.A.W.); Samuel Stratton VA Medical Center, Albany Medical College, NY (W.E.B.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France (G.M.); Cleveland Clinic, OH (A.H., A.M.L.); and Centre for Cardiovascular Science, University of Edinburgh Duke of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Amy Hsu
- From the New York University School of Medicine (S.B.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); AP-HP, Hôpital Bichat, Paris, France (P.G.S.); State University of New York, Downstate College of Medicine, Brooklyn (M.A.W.); Samuel Stratton VA Medical Center, Albany Medical College, NY (W.E.B.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France (G.M.); Cleveland Clinic, OH (A.H., A.M.L.); and Centre for Cardiovascular Science, University of Edinburgh Duke of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - Keith A A Fox
- From the New York University School of Medicine (S.B.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); AP-HP, Hôpital Bichat, Paris, France (P.G.S.); State University of New York, Downstate College of Medicine, Brooklyn (M.A.W.); Samuel Stratton VA Medical Center, Albany Medical College, NY (W.E.B.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France (G.M.); Cleveland Clinic, OH (A.H., A.M.L.); and Centre for Cardiovascular Science, University of Edinburgh Duke of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
| | - A Michael Lincoff
- From the New York University School of Medicine (S.B.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); AP-HP, Hôpital Bichat, Paris, France (P.G.S.); State University of New York, Downstate College of Medicine, Brooklyn (M.A.W.); Samuel Stratton VA Medical Center, Albany Medical College, NY (W.E.B.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France (G.M.); Cleveland Clinic, OH (A.H., A.M.L.); and Centre for Cardiovascular Science, University of Edinburgh Duke of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.)
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112
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Bagai A, Schulte PJ, Granger CB, Mahaffey KW, Christenson RH, Bell G, Lopes RD, Green CL, Lincoff AM, Armstrong PW, Roe MT. Prognostic implications of creatine kinase-MB measurements in ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention. Am Heart J 2014; 168:503-511.e2. [PMID: 25262260 DOI: 10.1016/j.ahj.2014.06.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 06/05/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Peak creatine kinase (CK)-MB concentration is related to reperfusion success and clinical outcomes after fibrinolytic therapy for acute myocardial infarction. However, prognostic implications of CK-MB measurements after primary percutaneous coronary intervention (PCI), which provides more predictable and consistent reperfusion, are unknown. METHODS We pooled 2,042 primary PCI-treated ST-segment elevation myocardial infarction (STEMI) patients from 3 trials with serial core laboratory-determined CK-MB measurements; 1,799 patients (88.1%) who survived to 36 hours and had ≥4 CK-MB measurements were studied. Cox regression modeling was performed to quantify the association between peak CK-MB concentration (and area under the time-concentration curve [AUC]) and mortality at 6 months, and death or congestive heart failure at 90 days. RESULTS The median (25th-75th percentiles) peak CK-MB concentration and AUC measurement through 36 hours were 239 (109-429) ng/mL and 4,263 (2,081-7,124) ng/(mL h), respectively. By multivariable analysis, peak CK-MB concentration and AUC measurement were independently associated with 6-month mortality (adjusted hazard ratio [HR] 1.15, 95% CI 1.05-1.25, per 100-ng/mL increase, P = .002; and adjusted HR 1.09, 95% CI 1.03-1.14, per 1,000-ng/[mL h] increase, P < .001, respectively) and 90-day death or congestive heart failure (adjusted HR 1.26, 95% CI 1.18-1.34, P < .001; and adjusted HR 1.15, 95% CI 1.11-1.19, P < .001, respectively). CONCLUSIONS Peak CK-MB concentration and AUC measurement are independent predictors of 3- to 6-month cardiovascular outcomes in primary PCI-treated STEMI patients. Our findings guide application of these measurements as efficacy end points in early-phase studies evaluating new therapies for STEMI.
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Affiliation(s)
- Akshay Bagai
- St. Michael's Hospital, University of Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | - A Michael Lincoff
- Cleveland Clinic Foundation/Cleveland Clinical Coordinating Center for Clinical Research (C5Research), Cleveland, OH
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
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Affiliation(s)
- A Michael Lincoff
- Cleveland Clinic Coordinating Center for Clinical Research (C5Research), Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA.
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Sharma PK, Agarwal S, Ellis SG, Goel SS, Cho L, Tuzcu EM, Lincoff AM, Kapadia SR. Association of Glycemic Control With Mortality in Patients With Diabetes Mellitus Undergoing Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2014; 7:503-9. [DOI: 10.1161/circinterventions.113.001107] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Praneet K. Sharma
- From the Department of Interventional Cardiology, Saint Luke’s Mid America Heart Institute, Kansas City, MO (P.K.S.); and Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH (S.A., S.G.E., S.S.G., L.C., E.M.T., A.M.L., S.R.K.)
| | - Shikhar Agarwal
- From the Department of Interventional Cardiology, Saint Luke’s Mid America Heart Institute, Kansas City, MO (P.K.S.); and Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH (S.A., S.G.E., S.S.G., L.C., E.M.T., A.M.L., S.R.K.)
| | - Stephen G. Ellis
- From the Department of Interventional Cardiology, Saint Luke’s Mid America Heart Institute, Kansas City, MO (P.K.S.); and Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH (S.A., S.G.E., S.S.G., L.C., E.M.T., A.M.L., S.R.K.)
| | - Sachin S. Goel
- From the Department of Interventional Cardiology, Saint Luke’s Mid America Heart Institute, Kansas City, MO (P.K.S.); and Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH (S.A., S.G.E., S.S.G., L.C., E.M.T., A.M.L., S.R.K.)
| | - Leslie Cho
- From the Department of Interventional Cardiology, Saint Luke’s Mid America Heart Institute, Kansas City, MO (P.K.S.); and Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH (S.A., S.G.E., S.S.G., L.C., E.M.T., A.M.L., S.R.K.)
| | - E. Murat Tuzcu
- From the Department of Interventional Cardiology, Saint Luke’s Mid America Heart Institute, Kansas City, MO (P.K.S.); and Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH (S.A., S.G.E., S.S.G., L.C., E.M.T., A.M.L., S.R.K.)
| | - A. Michael Lincoff
- From the Department of Interventional Cardiology, Saint Luke’s Mid America Heart Institute, Kansas City, MO (P.K.S.); and Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH (S.A., S.G.E., S.S.G., L.C., E.M.T., A.M.L., S.R.K.)
| | - Samir R. Kapadia
- From the Department of Interventional Cardiology, Saint Luke’s Mid America Heart Institute, Kansas City, MO (P.K.S.); and Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH (S.A., S.G.E., S.S.G., L.C., E.M.T., A.M.L., S.R.K.)
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Aggarwal B, Randhawa MS, Shah G, Goel SS, Ellis SG, Lincoff AM, Menon V. Abstract 387: Utility of Glycated Hemoglobin for Assessment of Glucose Metabolism in Patients with ST segment elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2014. [DOI: 10.1161/circoutcomes.7.suppl_1.387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The performance of glucose tolerance test (OGTT) in patients with STEMI results in the new recognition of diabetes mellitus (DM) in over 25% of subjects. However, due to presence of stress hyperglycemia and critical patient condition, diagnosis of DM using traditional tests (fasting glucose and OGTT) during initial hospital stay is challenging. The ADA definition now enables use of HbA1c for diagnosis of DM. We sought to evaluate the incidence and trends in newly diagnosed DM utilizing HbA1c in patients with STEMI.
Methods:
Consecutive patients (N=1,812) undergoing primary PCI for STEMI at the Cleveland Clinic between Jan 05-Dec 12 were included. Medical charts were queried to identify patients with an established history of DM. Admission HbA1c was used to identify patients with previously undiagnosed DM (HbA1c ≥ 6.5) and pre DM (HbA1c ≥ 5.7 and < 6.5).
Results:
Mean age was 60 years with 68% males. Overall, 428 patients (23.6%) had an established history of DM. Of the remainder, only 118 (8.5%) were diagnosed with DM while 593 patients (42.9%) had pre-DM based on admission HbA1c (Figure 1). There was no significant increase in mean body mass index (BMI) and incidence of DM over time (p=0.5).
Conclusions:
Utilization of admission HBA1c in patients with STEMI enables cardiologists to establish a new diagnosis of DM in a significant minority of subjects. Although convenient, HbA1c appears to under diagnose DM when compared to historical data with OGTT. Despite the increasing prevalence of obesity and DM in overall US population, we did not observe differences in mean BMI and prevalence of DM over time. The manifest cardiovascular consequences of DM may yet represent the exposed tip of the iceberg.
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Affiliation(s)
| | | | | | | | | | | | - Venu Menon
- Cleveland Clinic Foundation, Cleveland, OH
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116
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Affiliation(s)
- Venu Menon
- From the Robert & Suzanne Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - A. Michael Lincoff
- From the Robert & Suzanne Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
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117
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Lincoff AM, Roe M, Aylward P, Galla J, Rynkiewicz A, Guetta V, Zelizko M, Kleiman N, White H, McErlean E, Erlinge D, Laine M, Dos Santos Ferreira JM, Goodman S, Mehta S, Atar D, Suryapranata H, Jensen SE, Forster T, Fernandez-Ortiz A, Schoors D, Radke P, Belli G, Brennan D, Bell G, Krucoff M. Inhibition of delta-protein kinase C by delcasertib as an adjunct to primary percutaneous coronary intervention for acute anterior ST-segment elevation myocardial infarction: results of the PROTECTION AMI Randomized Controlled Trial. Eur Heart J 2014; 35:2516-23. [PMID: 24796339 DOI: 10.1093/eurheartj/ehu177] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Delcasertib is a selective inhibitor of delta-protein kinase C (delta-PKC), which reduced infarct size during ischaemia/reperfusion in animal models and diminished myocardial necrosis and improved reperfusion in a pilot study during primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI). METHODS AND RESULTS A multicentre, double-blind trial was performed in patients presenting within 6 h and undergoing primary PCI for anterior (the primary analysis cohort, n = 1010 patients) or inferior (an exploratory cohort, capped at 166 patients) STEMI. Patients with anterior STEMI were randomized to placebo or one of three doses of delcasertib (50, 150, or 450 mg/h) by intravenous infusion initiated before PCI and continued for ∼2.5 h. There were no differences between treatment groups in the primary efficacy endpoint of infarct size measured by creatine kinase MB fraction area under the curve (AUC) (median 5156, 5043, 4419, and 5253 ng h/mL in the placebo, delcasertib 50, 150, and 450 mg/mL groups, respectively) in the anterior STEMI cohort. No treatment-related differences were seen in secondary endpoints of infarct size, electrocardiographic ST-segment recovery AUC or time to stable ST recovery, or left ventricular ejection fraction at 3 months. No differences in rates of adjudicated clinical endpoints (death, heart failure, or serious ventricular arrhythmias) were observed. CONCLUSIONS Selective inhibition of delta-PKC with intravenous infusion of delcasertib during PCI for acute STEMI in a population of patients treated according to contemporary standard of care did not reduce biomarkers of myocardial injury.
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Affiliation(s)
- A Michael Lincoff
- Cleveland Clinic Coordinating Center for Clinical Research (C5Research), Cleveland, OH, USA
| | - Matthew Roe
- Duke Clinical Research Institute, Durham, NC, USA
| | - Philip Aylward
- Flinders University and Medical Centre, Adelaide, Australia
| | - John Galla
- Cleveland Clinic Coordinating Center for Clinical Research (C5Research), Cleveland, OH, USA
| | - Andrzej Rynkiewicz
- Department of Cardiology and Cardiosurgery, University of Warmia and Mazury, Olsztyn, Poland
| | - Victor Guetta
- Heart Institute, Sheba Medical Center, Tel Hashomer, Israel
| | - Michael Zelizko
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Neal Kleiman
- Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Harvey White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Ellen McErlean
- Cleveland Clinic Coordinating Center for Clinical Research (C5Research), Cleveland, OH, USA
| | - David Erlinge
- Department of Cardiology, Lund University, Lund, Sweden
| | - Mika Laine
- Division of Cardiology, Helsinki University Central Hospital, Helsinki, Finland
| | | | - Shaun Goodman
- Canadian Heart Research Centre and St. Michael's HospitalUniversity of Toronto, Toronto, Ontario, Canada
| | - Shamir Mehta
- Department of Cardiology, Hamilton General Hospital Hamilton, Ontario, Canada
| | - Dan Atar
- Department of Cardiology B, Oslo University Hospital, Norway, and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Harry Suryapranata
- Department of Cardiology, Radboud University Nijmegen Medical Center, The Netherlands
| | | | - Tamas Forster
- Medical Faculty, University of Szeged and Albert Szent-Gyorgyi Medical and Pharmaceutical Center, Szeged, Hungary
| | | | - Danny Schoors
- Interventional Department, Universitair Ziekenhuis Brussel, Belgium
| | - Peter Radke
- Department of Cardiology, Angiology, Intensive Care Medicine, University of Schleswig Holstein, Lübeck, Germany
| | - Guido Belli
- Unita Operativa di Emodinamica e Cardiologia Invasiva Istitutio Clinico Humanitas, Milano, Italy
| | - Danielle Brennan
- Cleveland Clinic Coordinating Center for Clinical Research (C5Research), Cleveland, OH, USA
| | - Gregory Bell
- KAI Phamaceuticals and Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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Geisler T, Müller K, Karathanos A, Bocksch W, Gawaz M, Deliargyris E, Bernstein D, Lincoff AM, Mehran R, Dangas G, Stone GW. Impact of antithrombotic treatment on short-term outcomes after percutaneous coronary intervention for left main disease: a pooled analysis from REPLACE-2, ACUITY, and HORIZONS-AMI trials. EUROINTERVENTION 2014; 10:97-104. [DOI: 10.4244/eijv10i1a16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Lincoff AM, Tardif JC, Schwartz GG, Nicholls SJ, Rydén L, Neal B, Malmberg K, Wedel H, Buse JB, Henry RR, Weichert A, Cannata R, Svensson A, Volz D, Grobbee DE. Effect of aleglitazar on cardiovascular outcomes after acute coronary syndrome in patients with type 2 diabetes mellitus: the AleCardio randomized clinical trial. JAMA 2014; 311:1515-25. [PMID: 24682069 DOI: 10.1001/jama.2014.3321] [Citation(s) in RCA: 182] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
IMPORTANCE No therapy directed against diabetes has been shown to unequivocally reduce the excess risk of cardiovascular complications. Aleglitazar is a dual agonist of peroxisome proliferator-activated receptors with insulin-sensitizing and glucose-lowering actions and favorable effects on lipid profiles. OBJECTIVE To determine whether the addition of aleglitazar to standard medical therapy reduces cardiovascular morbidity and mortality among patients with type 2 diabetes mellitus and a recent acute coronary syndrome (ACS). DESIGN, SETTING, AND PARTICIPANTS AleCardio was a phase 3, multicenter, randomized, double-blind, placebo-controlled trial conducted in 720 hospitals in 26 countries throughout North America, Latin America, Europe, and Asia-Pacific regions. The enrollment of 7226 patients hospitalized for ACS (myocardial infarction or unstable angina) with type 2 diabetes occurred between February 2010 and May 2012; treatment was planned to continue until patients were followed-up for at least 2.5 years and 950 primary end point events were positively adjudicated. INTERVENTIONS Randomized in a 1:1 ratio to receive aleglitazar 150 µg or placebo daily. MAIN OUTCOMES AND MEASURES The primary efficacy end point was time to cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke. Principal safety end points were hospitalization due to heart failure and changes in renal function. RESULTS The trial was terminated on July 2, 2013, after a median follow-up of 104 weeks, upon recommendation of the data and safety monitoring board due to futility for efficacy at an unplanned interim analysis and increased rates of safety end points. A total of 3.1% of patients were lost to follow-up and 3.2% of patients withdrew consent. The primary end point occurred in 344 patients (9.5%) in the aleglitazar group and 360 patients (10.0%) in the placebo group (hazard ratio, 0.96 [95% CI, 0.83-1.11]; P = .57). Rates of serious adverse events, including heart failure (3.4% for aleglitazar vs 2.8% for placebo, P = .14), gastrointestinal hemorrhages (2.4% for aleglitazar vs 1.7% for placebo, P = .03), and renal dysfunction (7.4% for aleglitazar vs 2.7% for placebo, P < .001) were increased. CONCLUSIONS AND RELEVANCE Among patients with type 2 diabetes and recent ACS, use of aleglitazar did not reduce the risk of cardiovascular outcomes. These findings do not support the use of aleglitazar in this setting with a goal of reducing cardiovascular risk. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01042769.
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Affiliation(s)
- A Michael Lincoff
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - Jean-Claude Tardif
- Montreal Heart Institute Coordinating Center, Université de Montréal, Montreal, Canada
| | - Gregory G Schwartz
- Veterans Affairs Medical Center and University of Colorado School of Medicine, Denver
| | - Stephen J Nicholls
- South Australian Health and Medical Research Institute, University of Adelaide, Adelaide
| | - Lars Rydén
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Bruce Neal
- George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Klas Malmberg
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden7F. Hoffman-La Roche Ltd, Basel, Switzerland
| | - Hans Wedel
- Nordic School of Public Health, Frolunda, Sweden
| | - John B Buse
- University of North Carolina School of Medicine, Chapel Hill
| | | | | | - Ruth Cannata
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | | | | | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care and Julius Clinical, University Medical Center Utrecht, Utrecht, the Netherlands
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Lincoff AM. Managing acute coronary syndromes: decades of progress. Cleve Clin J Med 2014; 81:233-42. [PMID: 24692442 DOI: 10.3949/ccjm.81gr.13002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
In managing acute coronary syndromes, physicians can draw on a large body of evidence from clinical trials. This article reviews clinical trials that inform current standards of practice regarding reperfusion, aggressive vs conservative initial approaches, and the appropriate use of aspirin, dual antiplatelet therapy, glycoprotein IIb/IIIa antagonists, anticoagulants, and statins.
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Affiliation(s)
- A Michael Lincoff
- Director, C5 Research (Cleveland Clinic Coordinating Center for Clinical Research); Vice Chairman for Clinical Research, Lerner Research Institute; Vice Chairman of Cardiovascular Medicine, Cleveland Clinic; Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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Robertson JO, Ebrahimi R, Lansky AJ, Mehran R, Stone GW, Lincoff AM. Impact of cigarette smoking on extent of coronary artery disease and prognosis of patients with non-ST-segment elevation acute coronary syndromes: an analysis from the ACUITY Trial (Acute Catheterization and Urgent Intervention Triage Strategy). JACC Cardiovasc Interv 2014; 7:372-9. [PMID: 24630881 DOI: 10.1016/j.jcin.2013.11.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 11/07/2013] [Accepted: 11/21/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This study sought to evaluate the short- and long-term outcomes for smokers with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). BACKGROUND Smoking has been associated with the "paradox" of reduced mortality after acute myocardial infarction (MI). This is thought to be due to favorable baseline characteristics and less diffuse coronary artery disease (CAD) among smokers. METHODS In the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial, 13,819 patients (29.1% smokers) with moderate- to high-risk NSTE-ACS underwent angiography and, if indicated, revascularization. RESULTS Smokers were significantly younger and had fewer comorbidities than nonsmokers. Incidence of death and MI were comparable at 30 days, although smokers had significantly reduced risks of 30-day major bleeding (hazard ratio [HR]: 0.80, 95% confidence interval [CI]: 0.67 to 0.96; p = 0.016) and 1-year mortality (HR: 0.797, 95% CI: 0.65 to 0.97; p = 0.027). After correction for baseline and clinical differences, smoking was no longer predictive of major bleeding (odds ratio: 1.06, 95% CI: 0.86 to 1.32; p = 0.56) and was associated with higher 1-year mortality (HR: 1.37, 95% CI: 1.07 to 1.7; p = 0.013). This pattern of reversed risk after multivariable correction held true for those smokers requiring percutaneous coronary intervention. Core laboratory angiographic analysis showed that smokers and nonsmokers were comparable in terms of the extent of CAD, Thrombolysis In Myocardial Infarction flow, myocardial blush, and the presence of thrombi. CONCLUSIONS In contrast to the paradox previously described in ST-segment elevation MI, our analysis finds smoking to be an independent predictor of higher 1-year mortality in patients presenting with NSTE-ACS, and our angiographic study demonstrates CAD in smokers that is comparable to that in nonsmokers but evident ∼1 decade earlier. (Acute Catheterization and Urgent Intervention Triage Strategy [ACUITY]; NCT00093158).
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Affiliation(s)
- Jason O Robertson
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Ramin Ebrahimi
- University of California Los Angeles and the Greater Los Angeles VA Medical Center, Los Angeles, California
| | | | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Gregg W Stone
- Cardiovascular Research Foundation, New York, New York; Columbia University Medical Center, New York, New York
| | - A Michael Lincoff
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
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Mahaffey KW, Wojdyla DM, Pieper KS, Tricoci P, Alexander JH, Lincoff AM, Brennan DM, Bhatt DL, Wallentin L, Harrington RA. Comparison of clinical trial outcome patterns in patients following acute coronary syndromes and in patients with chronic stable atherosclerosis. Clin Cardiol 2014; 37:337-42. [PMID: 24615711 DOI: 10.1002/clc.22255] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 01/06/2014] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The transition of patients with atherosclerotic vascular disease from the acute phase of the disease to the chronic stable atherosclerosis (CSA) phase has not been well characterized. We sought to compare ischemic and bleeding outcomes in hospitalized patients enrolled in clinical trials of non-ST-elevation acute coronary syndrome (ACS) with patients enrolled in outpatient trials of CSA. HYPOTHESIS The risk for recurrent events will differ between the 2 populations. METHODS Patient-level outcome data were evaluated from 3 consecutive trials of patients with ACS with long-term follow-up and 2 trials of patients with CSA. Kaplan-Meier curves were generated for ischemic and bleeding outcomes. RESULTS In total, 37 370 patients were included in these analyses. Of these, 28 489 (76.2%) were from ACS trials and 8881 (23.8%) from chronic trials. During the first year of follow-up, 1353 deaths, 1081 cardiovascular (CV) deaths, 2113 myocardial infarctions (MIs), and 397 strokes occurred across the trials. Six-month Kaplan-Meier event rates for CV death, MI, or stroke were higher in the ACS trials compared with the CSA trials (8.6% vs 2.7%), as were the 1-year CV death rate (3.6% vs 1.7%) and 1-year rates for GUSTO moderate or severe bleeding (6.0% vs 1.3%). Qualitatively, the Kaplan-Meier curves appear to show an early increased risk as well as a continued increased risk over time. CONCLUSIONS Patients with ACS enrolled while in the hospital appear to have different risk profiles for ischemic and bleeding outcomes compared with outpatients enrolled with CSA, including those patients with ACS after the acute phase.
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Affiliation(s)
- Kenneth W Mahaffey
- Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine, Stanford University, Stanford, California
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Raymond T, Raymond R, Lincoff AM. Management of the patient with diabetes and coronary artery disease: a contemporary review. Future Cardiol 2014; 9:387-403. [PMID: 23668743 DOI: 10.2217/fca.13.22] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Diabetes mellitus is a metabolic disease with microvascular and macrovascular complications, and is well known to increase the risk of coronary atherosclerosis. Despite recent reductions in the prevalence of coronary artery disease and cardiovascular events in the USA, persons with diabetes remain up to four-times as likely to die of cardiovascular disease than the general population. Diabetes is associated with an atherogenic lipid profile, induces a hypercoagulable state, and increases coronary plaque volume, progression and instability. Medicinal and procedural treatments in the patient with diabetes should be multifactorial, targeting and managing the many coexisting risk factors that contribute to atherosclerosis. This type of treatment is complex and should be individualized, and guided by a careful review of recent literature. Here we discuss important clinical data and their impact on up-to-date recommendations for the management of coronary artery disease in the patient with Type 2 diabetes mellitus.
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Affiliation(s)
- Timothy Raymond
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Nicholls SJ, Kastelein JJP, Schwartz GG, Bash D, Rosenson RS, Cavender MA, Brennan DM, Koenig W, Jukema JW, Nambi V, Wright RS, Menon V, Lincoff AM, Nissen SE. Varespladib and cardiovascular events in patients with an acute coronary syndrome: the VISTA-16 randomized clinical trial. JAMA 2014; 311:252-62. [PMID: 24247616 DOI: 10.1001/jama.2013.282836] [Citation(s) in RCA: 230] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Secretory phospholipase A2 (sPLA2) generates bioactive phospholipid products implicated in atherosclerosis. The sPLA2 inhibitor varespladib has favorable effects on lipid and inflammatory markers; however, its effect on cardiovascular outcomes is unknown. OBJECTIVE To determine the effects of sPLA2 inhibition with varespladib on cardiovascular outcomes. DESIGN, SETTING, AND PARTICIPANTS A double-blind, randomized, multicenter trial at 362 academic and community hospitals in Europe, Australia, New Zealand, India, and North America of 5145 patients randomized within 96 hours of presentation of an acute coronary syndrome (ACS) to either varespladib (n = 2572) or placebo (n = 2573) with enrollment between June 1, 2010, and March 7, 2012 (study termination on March 9, 2012). INTERVENTIONS Participants were randomized to receive varespladib (500 mg) or placebo daily for 16 weeks, in addition to atorvastatin and other established therapies. MAIN OUTCOMES AND MEASURES The primary efficacy measure was a composite of cardiovascular mortality, nonfatal myocardial infarction (MI), nonfatal stroke, or unstable angina with evidence of ischemia requiring hospitalization at 16 weeks. Six-month survival status was also evaluated. RESULTS At a prespecified interim analysis, including 212 primary end point events, the independent data and safety monitoring board recommended termination of the trial for futility and possible harm. The primary end point occurred in 136 patients (6.1%) treated with varespladib compared with 109 patients (5.1%) treated with placebo (hazard ratio [HR], 1.25; 95% CI, 0.97-1.61; log-rank P = .08). Varespladib was associated with a greater risk of MI (78 [3.4%] vs 47 [2.2%]; HR, 1.66; 95% CI, 1.16-2.39; log-rank P = .005). The composite secondary end point of cardiovascular mortality, MI, and stroke was observed in 107 patients (4.6%) in the varespladib group and 79 patients (3.8%) in the placebo group (HR, 1.36; 95% CI, 1.02-1.82; P = .04). CONCLUSIONS AND RELEVANCE In patients with recent ACS, varespladib did not reduce the risk of recurrent cardiovascular events and significantly increased the risk of MI. The sPLA2 inhibition with varespladib may be harmful and is not a useful strategy to reduce adverse cardiovascular outcomes after ACS. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01130246.
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Affiliation(s)
- Stephen J Nicholls
- South Australian Health and Medical Research Institute and University of Adelaide, Adelaide, Australia
| | | | - Gregory G Schwartz
- Veterans Affairs Medical Center and University of Colorado, Colorado, Denver
| | - Dianna Bash
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | | | | | - Danielle M Brennan
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | | | - J Wouter Jukema
- Leiden University Medical Center, Leiden, and Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands
| | - Vijay Nambi
- Michael E. DeBakey Veterans Affairs Hospital and Baylor College of Medicine, Houston, Texas
| | | | - Venu Menon
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - A Michael Lincoff
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
| | - Steven E Nissen
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio
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Herz M, Malmberg K, Hanefeld M, Ruilope L, Lincoff AM, Viberti G, Mudie N, Urbanowska T, Reigner SM. Effects of aleglitazar on cardiovascular risk factors in patients with stage 3 chronic kidney disease and type 2 diabetes. Atherosclerosis 2013. [DOI: 10.1016/j.atherosclerosis.2013.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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126
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Lincoff AM, Tardif JC, Neal B, Nicholls SJ, Rydén L, Schwartz GG, Malmberg K, Buse JB, Henry RR, Wedel H, Weichert A, Cannata R, Grobbee DE. Evaluation of the dual peroxisome proliferator-activated receptor α/γ agonist aleglitazar to reduce cardiovascular events in patients with acute coronary syndrome and type 2 diabetes mellitus: rationale and design of the AleCardio trial. Am Heart J 2013; 166:429-34. [PMID: 24016490 DOI: 10.1016/j.ahj.2013.05.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 05/21/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Peroxisome proliferator-activated receptors (PPARs) regulate transcription of genes involved in glucose uptake, lipid metabolism, and inflammation. Aleglitazar is a potent dual PPAR agonist with insulin-sensitizing and glucose-lowering actions and favorable effects on lipid profiles and biomarkers of cardiovascular risk. The AleCardio trial examines whether the addition of aleglitazar to standard medical therapy reduces the risk of cardiovascular morbidity and mortality in patients with type 2 diabetes mellitus and recent acute coronary syndrome. STUDY DESIGN AleCardio is a phase 3, multicenter, randomized, double-blind, placebo-controlled trial. A total of 7,228 patients were randomized to aleglitazar 150 μg or placebo daily in addition to standard medical therapy. The primary efficacy end point is time to the first event of cardiovascular death, myocardial infarction, or stroke. Principal safety end points are hospitalization due to heart failure and changes in renal function. Treatment will continue until 7,000 patients are followed up for at least 2.5 years and 950 primary end point events are adjudicated. CONCLUSIONS AleCardio will establish whether the PPAR-α/γ agonist aleglitazar improves cardiovascular outcomes in patients with diabetes and high-risk coronary disease.
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Affiliation(s)
- A Michael Lincoff
- Cleveland Clinic Coordinating Center for Clinical Research (C5Research), Cleveland, OH.
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Herz M, Malmberg K, Hanefeld M, Michael Lincoff A, Mudie N, Nicholls S. GW24-e3085 The dual PPAR alpha/gamma agonist aleglitazar has a beneficial effect on atherogenic dyslipidemia in patients with type 2 diabetes. Heart 2013. [DOI: 10.1136/heartjnl-2013-304613.699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Aggarwal B, Ellis SG, Lincoff AM, Kapadia SR, Cacchione J, Raymond RE, Cho L, Bajzer C, Nair R, Franco I, Simpfendorfer C, Tuzcu EM, Whitlow PL, Shishehbor MH. Cause of Death Within 30 Days of Percutaneous Coronary Intervention in an Era of Mandatory Outcome Reporting. J Am Coll Cardiol 2013; 62:409-15. [DOI: 10.1016/j.jacc.2013.03.071] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 02/15/2013] [Accepted: 03/05/2013] [Indexed: 11/24/2022]
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Zoghbi WA, Arend TE, Oetgen WJ, May C, Bradfield L, Keller S, Ramadhan E, Tomaselli GF, Brown N, Robertson RM, Whitman GR, Bezanson JL, Hundley J. 2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. Circulation 2013; 127:e663-828. [DOI: 10.1161/cir.0b013e31828478ac] [Citation(s) in RCA: 181] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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130
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Jneid H, Ettinger SM, Ganiats TG, Philippides GJ, Jacobs AK, Halperin JL, Albert NM, Creager MA, DeMets D, Guyton RA, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 61:e179-347. [PMID: 23639841 DOI: 10.1016/j.jacc.2013.01.014] [Citation(s) in RCA: 373] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Wu WM, Lincoff AM. Pharmacotherapy During Saphenous Vein Graft Intervention. Interv Cardiol Clin 2013; 2:273-282. [PMID: 28582135 DOI: 10.1016/j.iccl.2012.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Coronary revascularization using saphenous vein grafts is an important treatment modality for patients with severe coronary artery disease. Percutaneous intervention of these grafts is often the best option for patients who develop severe stenosis of the vein grafts. Use of adjunctive glycoprotein IIb/IIIa inhibitors does not confer added benefit with ischemic endpoints as compared with heparin alone, but it increases the risk of bleeding. Bivalirudin used as the primary anticoagulant lowers the risk of bleeding. No-reflow frequently complicates vein graft interventions but can be treated with vasoactive agents such as calcium channel blockers, adenosine, and nitroprusside.
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Affiliation(s)
- Willis M Wu
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue Desk J2-3, Cleveland, OH 44195, USA
| | - A Michael Lincoff
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, 9500 Euclid Avenue Desk J2-3, Cleveland, OH 44195, USA.
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Kumbhani DJ, Wells BJ, Lincoff AM, Jain A, Arrigain S, Yu C, Goormastic M, Ellis SG, Blackstone E, Kattan MW. Predictive models for short- and long-term adverse outcomes following discharge in a contemporary population with acute coronary syndromes. Am J Cardiovasc Dis 2013; 3:39-52. [PMID: 23467552 PMCID: PMC3584647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 01/23/2013] [Indexed: 06/01/2023]
Abstract
Although numerous risk-prediction models exist in patients presenting with acute coronary syndromes (ACS), they are subject to important short-comings, including lack of contemporary information. Short-term models are frequently biased by in-hospital events. Accordingly, we sought to create contemporary risk-prediction models for clinical outcomes following ACS up to 1 year following discharge. Models were constructed for death at 30 days and 1 year, death/myocardial infarction (MI)/revascularization at 30 days and death/MI at 1 year in consecutive patients presenting with ACS at our institution between 2006 and 2008, and discharged alive. Logistic regression was used to model the 30 day outcomes and Cox proportional hazards were used to model the 1 year outcomes. No linearity assumptions were made for continuous variables. The final model coefficients were used to create a prediction nomogram, which was incorporated into an online risk calculator. A total of 2,681 patients were included, of which about 9.5% presented with ST-elevation MI. All-cause mortality was 2.6% at 30 days and 13% at 1 year. Demographic, past medical history, laboratory, pharmacological and angiographic parameters were identified as being predictive of adverse ischemic outcomes at 30 days and 1 year. The c-indices for these models ranged from 0.73 to 0.82. Our study thus identified risk factors that are predictive of short- and long-term ischemic and revascularization outcomes in contemporary patients with ACS, and incorporated them into an easy-to-use online calculator, with equal or better discriminatory power than currently available models.
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Affiliation(s)
- Dharam J Kumbhani
- Department of Cardiovascular Medicine, Cleveland ClinicCleveland, OH
| | - Brian J Wells
- Department of Quantitative Health Sciences, Cleveland ClinicCleveland, OH
| | - A Michael Lincoff
- Department of Cardiovascular Medicine, Cleveland ClinicCleveland, OH
| | - Anil Jain
- Information Technology, Cleveland ClinicCleveland, OH
| | - Susana Arrigain
- Department of Quantitative Health Sciences, Cleveland ClinicCleveland, OH
| | - Changhong Yu
- Department of Quantitative Health Sciences, Cleveland ClinicCleveland, OH
| | | | - Stephen G Ellis
- Department of Cardiovascular Medicine, Cleveland ClinicCleveland, OH
| | - Eugene Blackstone
- Department of Cardiovascular Medicine, Cleveland ClinicCleveland, OH
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Cleveland ClinicCleveland, OH
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Affiliation(s)
- Christopher H May
- Department of Cardiovascular Medicine, Cleveland Clinic, The Cleveland Clinic Foundation, 9500 Euclid Avenue - J2-3, Cleveland, OH 44195, USA
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Aksoy O, Tuzcu EM, Ellis SG, Whitlow PL, Cam A, Batizy L, Agarwal S, Franco I, Bajzer C, Simpfendorfer C, Raymond R, Nair R, Cho L, Shishehbor MH, Lincoff AM, Kapadia SR. Percutaneous coronary revascularization in coronary artery disease: lessons from a single center experience. Catheter Cardiovasc Interv 2013; 81:E1-8. [PMID: 22508442 DOI: 10.1002/ccd.24442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 03/27/2012] [Accepted: 04/09/2012] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To determine the role of percutaneous coronary intervention (PCI) and its impact on mortality in coronary artery disease (CAD). BACKGROUND It's unclear whether PCI provides benefit in patients with CAD outside of acute settings. We sought to determine the role of PCI and its effect on mortality in patients with similar entry criteria to prior RCTs and compare outcomes with medical treatment. METHODS Using institutional diagnostic catheterization database of consecutive patients undergoing coronary angiography from 1/2004 to 1/2010, we examined records for patients with a positive stress test and >70% coronary stenosis or symptoms of angina and >80% coronary stenosis. We excluded those with acute coronary syndromes, low ejection fraction (EF), history of CABG, and CABG following index catheterization. We stratified patients by treatment and performed unadjusted and propensity matched analyses. The outcome was all-cause mortality obtained from the social security death index. RESULTS We identified 3,375 patients using study inclusion criteria. Mean age was 65 ± 11 years and 69% (n = 2,332) were men. Mean EF was 55% ± 8%. In the unadjusted cohort, 1,265 patients received medical management and 2,110 received PCI. The unadjusted analysis revealed significantly better survival in PCI patients (P < 0.0001) (HR: 0.51; 95% confidence interval (CI), 0.41-0.63). Propensity matching was performed for 1,580 patients and analysis showed better survival among patients receiving PCI (0 = 0.04) (HR: 0.74; 95% CI, 0.55-0.98). PCI continued to show better survival after excluding patients with malignancy (P = 0.03) and unstable angina (P = 0.007). CONCLUSIONS This single center registry analysis demonstrated better survival in stable CAD patients undergoing PCI compared to medical management alone. These data suggest there may be a benefit of PCI beyond symptom relief. Future randomized trials are needed to further understand the role of PCI in broader patient populations.
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Affiliation(s)
- Olcay Aksoy
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Eapen ZJ, Tang WHW, Felker GM, Hernandez AF, Mahaffey KW, Lincoff AM, Roe MT. Defining heart failure end points in ST-segment elevation myocardial infarction trials: integrating past experiences to chart a path forward. Circ Cardiovasc Qual Outcomes 2012; 5:594-600. [PMID: 22811505 DOI: 10.1161/circoutcomes.112.966150] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Zubin J Eapen
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012; 60:645-81. [PMID: 22809746 DOI: 10.1016/j.jacc.2012.06.004] [Citation(s) in RCA: 446] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Huff C, Agarwal S, Lai J, Cauthen C, Lincoff AM, Cho L. TCT-727 Meta-analysis Comparing Bleeding Rates After Low Versus High Dose Clopidogrel In Patients Undergoing Percutaneous Coronary Intervention And Receiving A Glycoprotein IIb/IIIa Inhibitor. J Am Coll Cardiol 2012. [DOI: 10.1016/j.jacc.2012.08.768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
INTRODUCTION Ticagrelor is a novel, non-thienopyridine ADP inhibitor that reversibly blocks the P2Y(12) receptor, preventing platelet activation and aggregation. It is the first ADP inhibitor to show a mortality benefit in patients with acute coronary syndromes (ACS). Its major safety concern, as with the other ADP blockers, is bleeding. Other common adverse effects of ticagrelor such as dyspnea and ventricular pauses appear to be mild and self-limited. AREAS COVERED The pharmacological properties of ticagrelor compared with clopidogrel are explored in this article. In addition, the relevant clinical trials in which ticagrelor was investigated are described, with an emphasis on efficacy and safety end points. EXPERT OPINION Although some patients suffer from dyspnea when administered with ticagrelor, there is no evidence of any untoward effects on the cardiovascular or pulmonary systems. Given that the majority of these episodes are mild to moderate and self-limiting, patients should be encouraged to continue the medication, as symptoms may resolve. Furthermore, patients with underlying heart failure or lung disease do not appear to be at an increased risk of developing ticagrelor-induced dyspnea. Its overall mortality benefit among patients with ACS, along with its ability to inhibit platelet aggregation more rapidly and consistently, makes it the preferred agent over clopidogrel.
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Affiliation(s)
- Christopher H May
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue/J2-3, Cleveland, OH 44195, USA
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Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP, Anderson JL. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/Non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2012; 126:875-910. [PMID: 22800849 DOI: 10.1161/cir.0b013e318256f1e0] [Citation(s) in RCA: 356] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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140
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Vandvik PO, Lincoff AM, Gore JM, Gutterman DD, Sonnenberg FA, Alonso-Coello P, Akl EA, Lansberg MG, Guyatt GH, Spencer FA. Primary and secondary prevention of cardiovascular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e637S-e668S. [PMID: 22315274 DOI: 10.1378/chest.11-2306] [Citation(s) in RCA: 332] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND This guideline focuses on long-term administration of antithrombotic drugs designed for primary and secondary prevention of cardiovascular disease, including two new antiplatelet therapies. METHODS The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. RESULTS We present 23 recommendations for pertinent clinical questions. For primary prevention of cardiovascular disease, we suggest low-dose aspirin (75-100 mg/d) in patients aged > 50 years over no aspirin therapy (Grade 2B). For patients with established coronary artery disease, defined as patients 1-year post-acute coronary syndrome, with prior revascularization, coronary stenoses > 50% by coronary angiogram, and/or evidence for cardiac ischemia on diagnostic testing, we recommend long-term low-dose aspirin or clopidogrel (75 mg/d) (Grade 1A). For patients with acute coronary syndromes who undergo percutaneous coronary intervention (PCI) with stent placement, we recommend for the first year dual antiplatelet therapy with low-dose aspirin in combination with ticagrelor 90 mg bid, clopidogrel 75 mg/d, or prasugrel 10 mg/d over single antiplatelet therapy (Grade 1B). For patients undergoing elective PCI with stent placement, we recommend aspirin (75-325 mg/d) and clopidogrel for a minimum duration of 1 month (bare-metal stents) or 3 to 6 months (drug-eluting stents) (Grade 1A). We suggest continuing low-dose aspirin plus clopidogrel for 12 months for all stents (Grade 2C). Thereafter, we recommend single antiplatelet therapy over continuation of dual antiplatelet therapy (Grade 1B). CONCLUSIONS Recommendations continue to favor single antiplatelet therapy for patients with established coronary artery disease. For patients with acute coronary syndromes or undergoing elective PCI with stent placement, dual antiplatelet therapy for up to 1 year is warranted.
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Affiliation(s)
- Per Olav Vandvik
- Norwegian Knowledge Centre for the Health Services and Department of Medicine, Innlandet Hospital Trust Gjøvik, Gjøvik, Norway
| | - A Michael Lincoff
- Department of Cardiovascular Medicine and Cleveland Clinic Coordinating Center for Clinical Research (C5Research), Cleveland Clinic, Cleveland, OH
| | - Joel M Gore
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | | | - Frank A Sonnenberg
- Department of Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Elie A Akl
- Department of Medicine and Department of Clinical Epidemiology and Biostatistics, State University of New York at Buffalo, Buffalo, NY
| | - Maarten G Lansberg
- Stanford Stroke Center, Stanford University Medical Center, Palo Alto, CA
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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141
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Bhatt DL, Paré G, Eikelboom JW, Simonsen KL, Emison ES, Fox KA, Steg PG, Montalescot G, Bhakta N, Hacke W, Flather MD, Mak KH, Cacoub P, Creager MA, Berger PB, Steinhubl SR, Murugesan G, Mehta SR, Kottke-Marchant K, Lincoff AM, Topol EJ. The relationship between CYP2C19 polymorphisms and ischaemic and bleeding outcomes in stable outpatients: the CHARISMA genetics study. Eur Heart J 2012; 33:2143-50. [PMID: 22450429 DOI: 10.1093/eurheartj/ehs059] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Deepak L. Bhatt
- VA Boston Healthcare System, Brigham and Women's Hospital, and Harvard Medical School, 1400 VFW Parkway, Boston, MA 02132, USA
| | | | | | - Katy L. Simonsen
- Department of Statistics, Purdue University, West Lafayette, IN, USA
- Global Biometric Sciences, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Eileen S. Emison
- Clinical Biomarkers, Pharmacogenetics, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Keith A.A. Fox
- University and Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ph. Gabriel Steg
- INSERM U-698, Paris, France
- Université Paris 7, Paris, France
- Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Gilles Montalescot
- Institut de Cardiologie (AP-HP)—INSERM U-937, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France
- Université Paris 6, Paris, France
| | | | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Marcus D. Flather
- Clinical Trials and Evaluation Unit, Royal Brompton Hospital and Imperial College, London, UK
| | | | - Patrice Cacoub
- AP HP Hopital La Pitié Salpetriere, Department of Internal Medicine and UMR 7211 (UPMC/CNRS), U 959 (INSERM) Université Pierre Marie Curie, Paris, France
| | - Mark A. Creager
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Peter B. Berger
- Division of Cardiology, Geisinger Medical Center, Danville, PA, USA
| | | | | | | | | | | | - Eric J. Topol
- Scripps Translational Science Institute and Scripps Clinic, LaJolla, CA, USA
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142
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Good CW, Steinhubl SR, Brennan DM, Lincoff AM, Topol EJ, Berger PB. Is There a Clinically Significant Interaction Between Calcium Channel Antagonists and Clopidogrel? Circ Cardiovasc Interv 2012; 5:77-81. [DOI: 10.1161/circinterventions.111.963405] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background—
Clopidogrel is an inactive prodrug; it is converted to its active metabolite through the cytochrome P450 (CYP3A4) pathway, which also metabolizes calcium channel blockers (CCBs). Several studies have reported that CCBs reduce the ability of clopidogrel to inhibit platelet aggregability; one suggested that CCBs reduce the efficacy of clopidogrel.
Methods and Results—
We performed a post hoc analysis of the Clopidogrel for the Reduction of Events During Observation (CREDO) study to compare the treatment effect of clopidogrel in patients on CCBs versus not on CCBs. In CREDO, 2116 patients were randomly assigned to pretreatment with 300 mg clopidogrel 3–24 hours before a planned percutaneous coronary intervention followed by 1 year of 75 mg/d clopidogrel, versus 75 mg clopidogrel at the time of the procedure and continued for 28 days only. The primary end points were a combined end point of death, myocardial infarction, and stroke at 28 days and 1 year. Among the 580 patients (27%) on CCBs at enrollment, at 28 days, the combined end point was reached in 17 patients (6%) on clopidogrel versus 28 (9%) on placebo (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.39–1.29). At 1 year, the combined end point was reached in 27 patients (10%) on clopidogrel versus 46 (15%) on placebo (HR, 0.68; 95% CI, 0.42–1.09). The treatment effect of clopidogrel was similar in patients not on CCBs at 1 year (HR, 0.78; 95% CI, 0.56–1.09). After adjustment for differences between patients on and not on CCB, there was still no evidence of an interaction between clopidogrel treatment and CCB (HR for patients not on CCBs, 0.87; 95% CI, 0.62–1.23; HR for patients on CCBs, 0.74; 95% CI, 0.45–1.21).
Conclusions—
In CREDO, there was no evidence that CCBs decrease the efficacy of clopidogrel.
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Affiliation(s)
- Christopher W. Good
- From the Geisinger Clinic, Danville, PA (C.W.G., S.R.S., P.B.B.); the Cleveland Clinic, Cleveland, OH (D.M.B., A.M.L.); and the Scripps Clinic, La Jolla, CA (E.J.T.)
| | - Steven R. Steinhubl
- From the Geisinger Clinic, Danville, PA (C.W.G., S.R.S., P.B.B.); the Cleveland Clinic, Cleveland, OH (D.M.B., A.M.L.); and the Scripps Clinic, La Jolla, CA (E.J.T.)
| | - Danielle M. Brennan
- From the Geisinger Clinic, Danville, PA (C.W.G., S.R.S., P.B.B.); the Cleveland Clinic, Cleveland, OH (D.M.B., A.M.L.); and the Scripps Clinic, La Jolla, CA (E.J.T.)
| | - A. Michael Lincoff
- From the Geisinger Clinic, Danville, PA (C.W.G., S.R.S., P.B.B.); the Cleveland Clinic, Cleveland, OH (D.M.B., A.M.L.); and the Scripps Clinic, La Jolla, CA (E.J.T.)
| | - Eric J. Topol
- From the Geisinger Clinic, Danville, PA (C.W.G., S.R.S., P.B.B.); the Cleveland Clinic, Cleveland, OH (D.M.B., A.M.L.); and the Scripps Clinic, La Jolla, CA (E.J.T.)
| | - Peter B. Berger
- From the Geisinger Clinic, Danville, PA (C.W.G., S.R.S., P.B.B.); the Cleveland Clinic, Cleveland, OH (D.M.B., A.M.L.); and the Scripps Clinic, La Jolla, CA (E.J.T.)
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143
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Tricoci P, Huang Z, Held C, Moliterno DJ, Armstrong PW, Van de Werf F, White HD, Aylward PE, Wallentin L, Chen E, Lokhnygina Y, Pei J, Leonardi S, Rorick TL, Kilian AM, Jennings LHK, Ambrosio G, Bode C, Cequier A, Cornel JH, Diaz R, Erkan A, Huber K, Hudson MP, Jiang L, Jukema JW, Lewis BS, Lincoff AM, Montalescot G, Nicolau JC, Ogawa H, Pfisterer M, Prieto JC, Ruzyllo W, Sinnaeve PR, Storey RF, Valgimigli M, Whellan DJ, Widimsky P, Strony J, Harrington RA, Mahaffey KW. Thrombin-receptor antagonist vorapaxar in acute coronary syndromes. N Engl J Med 2012; 366:20-33. [PMID: 22077816 DOI: 10.1056/nejmoa1109719] [Citation(s) in RCA: 581] [Impact Index Per Article: 48.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Vorapaxar is a new oral protease-activated-receptor 1 (PAR-1) antagonist that inhibits thrombin-induced platelet activation. METHODS In this multinational, double-blind, randomized trial, we compared vorapaxar with placebo in 12,944 patients who had acute coronary syndromes without ST-segment elevation. The primary end point was a composite of death from cardiovascular causes, myocardial infarction, stroke, recurrent ischemia with rehospitalization, or urgent coronary revascularization. RESULTS Follow-up in the trial was terminated early after a safety review. After a median follow-up of 502 days (interquartile range, 349 to 667), the primary end point occurred in 1031 of 6473 patients receiving vorapaxar versus 1102 of 6471 patients receiving placebo (Kaplan-Meier 2-year rate, 18.5% vs. 19.9%; hazard ratio, 0.92; 95% confidence interval [CI], 0.85 to 1.01; P=0.07). A composite of death from cardiovascular causes, myocardial infarction, or stroke occurred in 822 patients in the vorapaxar group versus 910 in the placebo group (14.7% and 16.4%, respectively; hazard ratio, 0.89; 95% CI, 0.81 to 0.98; P=0.02). Rates of moderate and severe bleeding were 7.2% in the vorapaxar group and 5.2% in the placebo group (hazard ratio, 1.35; 95% CI, 1.16 to 1.58; P<0.001). Intracranial hemorrhage rates were 1.1% and 0.2%, respectively (hazard ratio, 3.39; 95% CI, 1.78 to 6.45; P<0.001). Rates of nonhemorrhagic adverse events were similar in the two groups. CONCLUSIONS In patients with acute coronary syndromes, the addition of vorapaxar to standard therapy did not significantly reduce the primary composite end point but significantly increased the risk of major bleeding, including intracranial hemorrhage. (Funded by Merck; TRACER ClinicalTrials.gov number, NCT00527943.).
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Affiliation(s)
- Pierluigi Tricoci
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27705, USA.
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144
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Abstract
Antiplatelet therapies have reduced the frequency of adverse events associated with plaque rupture in several clinical situations. These therapies include established antiplatelet agents (such as aspirin, clopidogrel, or glycoprotein IIb/IIIa inhibitors) as well as new agents (such as prasugrel and ticagrelor). In this Review, we address the most important adverse events of antiplatelet therapy, including hemorrhage, hematologic reactions, and dyspnea. We discuss strategies to reduce the incidence of complications and outline potential methods to manage adverse reactions. Interactions between antiplatelet agents and other drugs--such as proton-pump inhibitors, calcium-channel blockers, statins, warfarin, or NSAIDs--are also addressed, as well as specific issues relating to the use of antiplatelet therapies in elderly patients.
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Affiliation(s)
- Arun Kalyanasundaram
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, J2-3 Cleveland, OH 44195, USA
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145
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Ambrosio G, Steinhubl S, Gresele P, Tritto I, Zuchi C, Bertrand ME, Lincoff AM, Moses JW, Ohman EM, White HD, Mehran R, Stone GW. Impact of chronic antiplatelet therapy before hospitalization on ischemic and bleeding events in invasively managed patients with acute coronary syndromes: the ACUITY trial. ACTA ACUST UNITED AC 2011; 18:121-8. [PMID: 20523219 DOI: 10.1097/hjr.0b013e32833bc070] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIMS Presentation with an acute coronary syndrome (ACS) on chronic aspirin therapy is an independent predictor of adverse short-term outcomes. Whether this finding applies to chronic thienopyridine use, and with the contemporary invasive management of ACS, is unknown. METHODS AND RESULTS In ACUITY, 13819 patients with moderate and high-risk ACS were studied; patients transferred from an outside hospital were excluded from the present analysis, given uncertain preadmission antiplatelet status. Endpoints included major adverse cardiovascular events (MACE: death, myocardial infarction, or unplanned revascularization), major bleeding, and net adverse clinical events (NACE). Among 11313 study patients, 31 % were naive for antiplatelet agent, 49% were receiving aspirin alone, and 20% were on dual antiplatelet therapy. Chronic antiplatelet users were older and had a higher risk profile. After adjusting for baseline differences, chronic antiplatelet therapy (single or dual) was not associated with an increased incidence of 30-day MACE, bleeding, or NACE. However, patients on chronic aspirin or dual antiplatelet therapy at presentation had significantly higher 1-year rates of MACE [odds ratio (95% confidence interval) = 1.17 (1.01–1.36), P = 0.03 and 1.29 (1.02–1.64), P = 0.03, respectively]. Patients presenting on dual antiplatelet therapy had significantly greater adjusted MACE at 1-year than those on aspirin alone [odds ratio (95% confidence interval) = 1.34 (1.15–1.56), P < 0.0001]. CONCLUSION Contrary to earlier studies, prior antiplatelet therapy was not associated with an increased risk of adverse outcomes at 30 days in invasively managed patients. Such use did, however, independently predict 1-year ischemic MACE, with outcomes worse for patients presenting on chronic dual antiplatelet therapy compared with aspirin alone.
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Affiliation(s)
- Giuseppe Ambrosio
- Division of Cardiology, University of Perugia School of Medicine, Perugia, Italy.
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146
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Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP, Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Zidar JP. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 57:e215-367. [PMID: 21545940 DOI: 10.1016/j.jacc.2011.02.011] [Citation(s) in RCA: 276] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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147
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Agarwal S, Zaman T, Tuzcu EM, Shishehbor M, Lincoff AM, Whitlow PL, Bajzer C, Franco I, Nair R, Raymond R, Ellis SG, Kapadia SR. Comparison of outcomes of unprotected left main versus multivessel coronary artery interventions. Am J Cardiol 2011; 108:15-20. [PMID: 21529732 DOI: 10.1016/j.amjcard.2011.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 03/03/2011] [Accepted: 03/03/2011] [Indexed: 10/18/2022]
Abstract
Left main coronary artery (LMCA) percutaneous coronary intervention (PCI) has emerged as an appealing alternative to bypass surgery for significant LMCA disease, especially in high-risk candidates. PCI for unprotected LMCA stenosis is currently designated a class IIb indication. Direct comparisons between unprotected LMCA PCI and multivessel PCI are lacking. We aimed to determine the incremental risk associated with unprotected LMCA PCI compared to multivessel PCI. We queried the Cleveland Clinic PCI database to identify patients who underwent unprotected LMCA PCI from 2003 through 2009 and compared these to patients undergoing multivessel PCI in the same period. Patients undergoing PCI for acute myocardial infarction were excluded. Mortality was derived using the Social Security Death Index. Short-term (≤30-day) mortality rates in the LMCA PCI group (n = 468, 1.9%) were similar to the death rate in the multivessel PCI group (n = 1,973, 1.3%, p = 0.3). There was no significant difference in adjusted mortality between the 2 study groups. Stratifying LMCA PCI by the number of concomitant vessel territories treated, there was no significant difference in mortality in any LMCA PCI category (LMCA only, LMCA + 1-vessel PCI, LMCA + multivessel PCI) compared to multivessel PCI. In conclusion, there was comparable short-term and long-term mortality in the LMCA PCI and multivessel PCI groups. LMCA stenting did not appear to incur incremental risk compared to multivessel PCI.
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148
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Krishnaswamy A, Lincoff AM. Percutaneous coronary intervention for acute coronary syndrome: no difference in 48-h bleeding rate or vascular access-site complications with low- or standard-dose unfractionated heparin in patients initially treated with fondaparinux. Evid Based Med 2011; 16:72-73. [PMID: 21228054 DOI: 10.1136/ebm1174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Amar Krishnaswamy
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
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149
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Mehran R, Pocock S, Nikolsky E, Dangas GD, Clayton T, Claessen BE, Caixeta A, Feit F, Manoukian SV, White H, Bertrand M, Ohman EM, Parise H, Lansky AJ, Lincoff AM, Stone GW. Impact of Bleeding on Mortality After Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2011; 4:654-64. [DOI: 10.1016/j.jcin.2011.02.011] [Citation(s) in RCA: 302] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 02/24/2011] [Indexed: 12/13/2022]
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150
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Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP. 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline). J Am Coll Cardiol 2011; 57:1920-59. [PMID: 21450428 DOI: 10.1016/j.jacc.2011.02.009] [Citation(s) in RCA: 230] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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