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Mehran R, Edens M, Sartori S, Spirito A, Vogel B, Nicolas J, Smith K, Baber U, Yan R, Kamaleldin K, Vijay P, Guthrie J, Khera S, Sweeny JM, Sharma SK, Kini AS, Krishnamoorthy PM, Dangas GD. IMPACT OF BODY SURFACE AREA ON OUTCOMES IN WOMEN AND MEN UNDERGOING PERCUTANEOUS CORONARY INTERVENTION. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01415-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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van Bergeijk KH, Wykrzykowska JJ, Sartori S, Snyder C, Vogel B, Tchetche D, Petronio AS, Mehilli J, Lefèvre T, Presbitero P, Capranzano P, Iadanza A, Sardella G, Van Mieghem NM, Meliga E, Dumonteil N, Fraccaro C, Trabattoni D, Mikhail G, Ferrer-Gracia MC, Naber C, Kievit P, Sharma SK, Morice MC, Dangas GD, Chieffo A, Voors AA, Mehran R. Pre-procedural oral anticoagulant use is associated with cardiovascular events in women after transcatheter aortic valve replacement: An analysis from the WIN-TAVI cohort. Int J Cardiol 2023; 372:40-45. [PMID: 36455701 DOI: 10.1016/j.ijcard.2022.11.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/01/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) has become an accepted treatment for patients with severe aortic stenosis (AS). Predicting which patients are at risk for adverse clinical outcomes after TAVI remains difficult, especially in women. AIM To identify predictors of adverse events in the WIN-TAVI cohort. METHODS The WIN-TAVI study is an observational registry of 1019 women undergoing TAVI for severe symptomatic AS. Follow-up was 1 year. The primary outcome was defined according to VARC-2: a composite of mortality, stroke, myocardial infarction or hospitalization for valve-related symptoms or heart failure. The secondary outcome was a composite of cardiovascular mortality or hospitalization for valve-related symptoms or heart failure. RESULTS We included 1019 women with severe AS (mean age of 82.5 ± 6.3 years). At 1 year, 16.4% of the patients experienced the primary endpoint and 12.6% the secondary endpoint. The use of oral anticoagulants (OAC) was the strongest independent predictor of the primary outcome (adjusted hazard ratio [aHR] 1.51, 95% confidence interval [CI] 1.079-2.106, p = 0.016). Independent predictors of the secondary endpoint were age (aHR 1.04 per year, 95% CI 1.01-1.074, p = 0.016) and use of OAC (aHR: 1.79, 95% CI 1.24-2.60, p = 0.002). OAC use was not associated with higher bleeding risk. CONCLUSION Pre-procedural use of OAC was the strongest predictor of adverse outcomes during 1-year follow-up, likely reflecting a combination of high-risk factors and comorbidities, but was not related to increased bleeding risk.
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Chen H, Spirito A, Sartori S, Nicolas J, Cao D, Zhang Z, Baber U, Kamaleldin K, Guthrie J, Vogel B, Sweeny J, Krishnan P, Sharma SK, Kini A, Dangas G, Mehran R. Impact of complex percutaneous coronary intervention features on clinical outcomes in patients with or without chronic kidney disease. Catheter Cardiovasc Interv 2023; 101:511-519. [PMID: 36691863 DOI: 10.1002/ccd.30569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) are at higher risk of ischemic and bleeding events after percutaneous coronary intervention (PCI). Complex PCI (CPCI) is associated with higher rates of ischemic complications. Whether CPCI confers an additive risk of adverse events in CKD patients is unclear. METHODS Patients who underwent PCI at a single tertiary-care-center between 2012 and 2019 were stratified by CKD status and CPCI. The primary outcome was major adverse cardiac events (MACE), a composite of all-cause death, myocardial infarction (MI), and target-vessel revascularization (TVR) at 1-year follow-up. Secondary outcomes included the individual components of the primary outcome and major bleeding. RESULTS Out of 15,071 patients, 4537 (30.1%) had CKD and 10,534 (69.9%) had no CKD. Patients undergoing CPCI were 1151 (25.4%) and 2983 (28.3%) in the two cohorts, respectively. At one year, CPCI compared with no CPCI was associated with higher risk of MACE in both CKD (Adj. HR 1.72, 95% confidence interval [CI] 1.45-2.06, p < 0.001) and no-CKD patients (Adj. hazard ratios [HR] 2.19, 95% CI 1.91-2.51, p < 0.001; p of interaction 0.057), determined by an excess of death, MI and TVR in CKD patients and of TVR and MI only in no-CKD. CPCI was related with a consistent increase of major bleeding in the CKD (Adj. HR 1.49, 95% CI 1.18-1.87, p < 0.001) and no-CKD group (Adj. HR 1.23, 95% CI 0.98-1.54, p = 0.071, p of interaction 0.206). CONCLUSION At 1-year follow-up, CPCI was associated with higher risk of MACE and major bleeding irrespective of concomitant CKD. CPCI predicted mortality in CKD patients only.
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Farhan S, Enzmann FK, Bjorkman P, Kamran H, Zhang Z, Sartori S, Vogel B, Tarricone A, Linni K, Venermo M, van der Veen D, Moussalli H, Mehran R, Reijnen MMPJ, Bosiers M, Krishnan P. Revascularization Strategies for Patients With Femoropopliteal Peripheral Artery Disease. J Am Coll Cardiol 2023; 81:358-370. [PMID: 36697136 DOI: 10.1016/j.jacc.2022.10.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/06/2022] [Accepted: 10/26/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND No adequately powered studies exist to compare major clinical outcomes after endovascular therapy (EVT) with stent implantation vs bypass surgery (BSx) for symptomatic femoropopliteal peripheral artery disease. OBJECTIVES This study sought to perform a pooled analysis of individual patient data from all randomized controlled trials comparing EVT vs BSx. METHODS Principal investigators of 5 of 6 available randomized controlled trials agreed to pool individual patient data. The primary endpoint was major adverse limb events, a composite of all-cause death, major amputation, or target limb reintervention. Secondary endpoints included amputation-free survival, individual major adverse limb event components, and primary patency. Early complications were bleeding, infection, or all-cause death within 30 days. RESULTS A total of 639 patients were analyzed with a mean age of 68.1 ± 9.1 years and 29.0% women. Baseline characteristics were comparable between groups. At 2 years, there were no significant differences between patients who received EVT and those who received BSx regarding major adverse limb events (40.1% vs 36.4%; log-rank P = 0.447; adjusted HR [aHR]: 1.04; 95% CI: 0.80-1.36), amputation-free survival (88.1% vs 90.0%; log-rank P = 0.455; aHR for death or amputation: 1.04; 95% CI: 0.63-1.71) and the other secondary endpoints except for primary patency, which was lower in patients who received EVT vs those who received BSx (51.2% vs 61.3%; log-rank P = 0.024; aHR for loss of primary patency: 1.31; 95% CI: 1.02-1.69). EVT was associated with significantly lower rates of early complications (6.8% vs 22.6%; P < 0.001) and shorter hospital stay (3.1 ± 4.2 days vs 7.4 ± 4.9 days; P < 0.001). CONCLUSIONS These findings further support the efficacy and safety of EVT as an alternative to BSx in patients with symptomatic femoropopliteal peripheral artery disease.
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Spirito A, Kastrati A, Cao D, Baber U, Sartori S, Angiolillo DJ, Briguori C, Cohen DJ, Dangas G, Dudek D, Escaned J, Gibson CM, Zhang Z, Huber K, Kaul U, Kornowski R, Kunadian V, Han YL, Mehta SR, Sardella G, Sharma S, Shlofmitz RA, Vogel B, Collier T, Pocock S, Mehran R. Ticagrelor With or Without Aspirin in High-Risk Patients With Anemia Undergoing Percutaneous Coronary Intervention: a subgroup analysis of the TWILIGHT trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023:6989842. [PMID: 36649694 DOI: 10.1093/ehjcvp/pvad006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
AIM The aim of this study was to assess the effect of ticagrelor monotherapy among high-risk patients with anemia undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS In the TWILIGHT trial (Ticagrelor With Aspirin or Alone in High-Risk Patients after Coronary Intervention), after 3 months of ticagrelor plus aspirin, high-risk patients were maintained on ticagrelor and randomized to aspirin or placebo for 1 year. Anemia was defined as hemoglobin <13 g/dL for men and <12 g/dL for women. The primary endpoint was Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding. The key secondary endpoint was a composite of all-cause death, myocardial infarction, or stroke.Out of 6 828 patients, 1 329 (19.5%) had anemia and were more likely to have comorbidities, multivessel disease, and to experience bleeding or ischemic complications than non-anemic patients. Among anemic patients, BARC 2, 3, or 5 bleeding occurred less frequently with ticagrelor monotherapy than with ticagrelor plus aspirin (6.4% vs. 10.7%; HR 0.60; 95% CI 0.41 to 0.88; p = 0.009); the rate of the key secondary endpoint was similar in the two arms (5.2% vs. 4.8%; HR 1.07; 95% CI 0.66 to 1.74; p = 0.779). These effects were consistent in patients without anemia (interaction p-value 0.671 and 0.835, respectively). CONCLUSIONS In high-risk patients undergoing PCI, ticagrelor monotherapy after 3 months of ticagrelor-based DAPT was associated with a reduced risk of clinically relevant bleeding without any increase in ischemic events irrespective of anemia status. (TWILIGHT: NCT02270242).
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Nardin M, Pivato CA, Cao D, Sartori S, Zhang Z, Vogel B, Nicolas J, Chiarito M, Qiu H, Chandrasekhar J, Spirito A, Abizaid A, Christiansen EH, Colombo A, de Winter RJ, Haude M, Jakobsen L, Jensen LO, Krucoff MW, Landmesser U, Saito S, Suryapranata H, De Luca G, Dangas G, Mehran R. The mega COMBO collaboration: An individual patient data pooled analysis of patients undergoing PCI with COMBO stent. Int J Cardiol 2023; 370:149-155. [PMID: 36270496 DOI: 10.1016/j.ijcard.2022.10.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 10/11/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND COMBO (OrbusNeich Medical, Hong Kong) is a dual-therapy coronary stent featuring sirolimus as antiproliferative drug and an anti-CD34+ antibody coating to attract endothelial progenitor cells favoring rapid stent re-endothelization. The Mega COMBO collaboration aimed to evaluate the performance of the COMBO stent in a large contemporary cohort of patients undergoing percutaneous coronary intervention (PCI). METHODS Patient-level data of subjects undergoing PCI with the COMBO stent from the REMEDEE-Trial, REMEDEE-OCT, HARMONEE, REDUCE, SORT OUT X, REMEDEE-Registry and MASCOT studies were pooled together. The primary endpoint was 1-year target lesion failure (TLF), a composite of cardiovascular death, target vessel myocardial infarction (TV-MI) or clinically driven target lesion revascularization (CD-TLR). Secondary outcomes were the individual components of the primary endpoint and stent thrombosis (ST). Endpoints were evaluated against performance goals based on the EAPCI (the European Association of Percutaneous Coronary Intervention) recommendations for new drug-eluting stents. RESULTS A total of 6753 patients (mean age 63.7 ± 11.4 years, 23% women) were included. At 1-year follow-up, TLF occurred in 303 (4.6%) patients. The rates of cardiovascular death, TV-MI, and CD-TLR were 1.3%, 1.8%, and 2.5%, respectively. The rate of definite/probable ST was 0.73%, early ST (<1 month) was 0.48%, while late ST (1-12 months) was 0.26%. The performance goals were met for all of the evaluated endpoints. CONCLUSIONS This large patient-level pooled analysis provides a comprehensive outline of the performance of the dual-therapy COMBO stent. The low rates of primary and secondary endpoints suggest that this stent technology may be a good alternative to other contemporary drug eluting coronary stent platforms.
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Nicolas J, Dangas G, Chiarito M, Pivato CA, Spirit A, Cao D, Giustino G, Beerkens F, Camaj A, Vogel B, Sartori S, Yamamoto K, Kimura T, Kim BK, Baber U, Mehran R. Efficacy and Safety of P2Y12 Inhibitor Monotherapy After Complex PCI: A Collaborative Systematic Review and Meta-Analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 9:240-250. [PMID: 36564015 DOI: 10.1093/ehjcvp/pvac071] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/28/2022] [Accepted: 12/22/2022] [Indexed: 12/25/2022]
Abstract
AIMS Complex percutaneous coronary intervention (C-PCI) is associated with an increased risk of ischemic and bleeding complications. We aimed to assess the safety and efficacy of a 1-3-month dual antiplatelet therapy (DAPT) regimen followed by P2Y12 inhibitor monotherapy after C-PCI. METHODS AND RESULTS We conducted a meta-analysis of randomized trials comparing a 1-3-month DAPT regimen followed by P2Y12 inhibitor monotherapy with standard (≥12 months) DAPT in patients undergoing C-PCI. C-PCI criteria and the co-primary bleeding and ischemic outcomes were determined according to each trial. Secondary outcomes included major bleeding, all-cause death, myocardial infarction, and stent thrombosis. All outcomes were evaluated at 12 months after randomization. We used hazard ratios (HRs) and 95% confidence interval (CI) as a metric of choice for treatment effects with random-effects models. Among 8299 screened studies, five randomized trials fulfilled the eligibility criteria. In the pooled population of 34 615 patients, 8818 (25.5%) underwent C-PCI. As compared with standard DAPT, a 1-3-month DAPT regimen followed by P2Y12 inhibitor monotherapy reduced the bleeding risk in C-PCI (HR:0.66, 95% CI:0.44-0.98) and non-C-PCI (HR:0.60, 95% CI:0.45-0.79) patients (p-interaction = 0.735). Furthermore, the risk for the primary ischemic endpoint was similar in patients randomized to either arm, with significant effect modification by PCI complexity showing an enhanced benefit of 1-3-month DAPT in patients undergoing C-PCI (C-PCI, HR:0.69, 95% CI:0.48-1.00; non-C-PCI, HR:1.04, 95% CI:0.84-1.30; p-interaction = 0.028). CONCLUSION As compared with a standard DAPT, a 1-3-month DAPT regimen followed by P2Y12 inhibitor monotherapy reduced bleeding complications after C-PCI without increasing the risk of ischemic events.
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Chiarito M, Cao D, Sartori S, Zhang Z, Vogel B, Nicholas J, Pivato CA, Spirito A, Tavenier A, Effron M, Stefanini GG, Baber U, Kapadia S, Rao S, Henry TD, Pocock S, Dangas G, Kini A, Mehran R. 761 PRASUGREL OR CLOPIDOGREL IN PATIENTS WITH ACUTE CORONARY SYNDROMES AT DIFFERENT THROMBOTIC RISK: RESULTS FROM THE PROMETHEUS STUDY. Eur Heart J Suppl 2022. [DOI: 10.1093/eurheartjsupp/suac121.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Background
Potent P2Y12 inhibitors are recommended in patients with acute coronary syndrome (ACS), although the optimal antithrombotic strategy should be tailored based on patients thrombotic and hemorrhagic risk profile. We evaluated if the benefits associated with prasugrel vs. clopidogrel in ACS patients undergoing percutaneous coronary intervention (PCI) are similar in patients with different thrombotic risk profiles.
Methods
PROMETHEUS was a multicenter observational study comparing prasugrel vs. clopidogrel in ACS patients undergoing PCI. Patients were defined at high thrombotic risk if presenting with a clinical and a procedural risk feature. The primary endpoint was major adverse cardiac events (MACE), composite of death, myocardial infarction, stroke, or unplanned revascularization. Hazard ratio (HR) and 95% confidence intervals (CI) were calculated using propensity-stratified analysis and with multivariable Cox regression.
Results
Among 16,065 patients, 4,293 were defined at high and 11,772 at low-to-moderate thrombotic risk. Patients receiving prasugrel had less comorbidities and risk factors than those treated with clopidogrel, both in the high and low-to-moderate thrombotic risk strata. High thrombotic risk patients had increased rates of ischemic and bleeding events at 90-day and 1-year follow-up. Patients treated with prasugrel had a lower adjusted 1-year risk of MACE (HR 0.86, 95% CI 0.77-0.96), irrespective of their thrombotic risk (pinteraction =0.32). Stratifying the study population by number of risk factors there was a significant interaction (pinteraction =0.026) for a greater reduction in MACE with prasugrel among patients with ≤1 thrombotic risk factor. The risk of clinically significant bleeding was similar in patients treated with prasugrel and clopidogrel.
Conclusions
Patients with ACS at high thrombotic risk who undergo PCI are at increased risk of adverse events at 1 year. Prasugrel, mainly reserved to patients with less comorbidities, reduced the risk of ischemic events both in patients at high and low-to-moderate thrombotic risk as compared with clopidogrel.
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Farhan S, Silbiger JJ, Halperin JL, Zhang L, Dukkipati SR, Vogel B, Kini A, Sharma S, Lerakis S. Pathophysiology, Echocardiographic Diagnosis, and Treatment of Atrial Functional Mitral Regurgitation: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 80:2314-2330. [PMID: 36480974 DOI: 10.1016/j.jacc.2022.09.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/12/2022] [Indexed: 12/07/2022]
Abstract
The conventional view holds that functional mitral regurgitation (MR) is caused by restriction of leaflet motion resulting from displacement of the papillary muscle-bearing segments of the left ventricle. In the past decade, evidence has accrued suggesting functional MR can also be caused by left atrial enlargement. This underrecognized cause of secondary MR-atrial functional MR (AF-MR)-is mechanistically linked to annular enlargement, perturbations of annular contraction, and atriogenic leaflet tethering. AF-MR has been described in patients with atrial fibrillation and heart failure with preserved ejection fraction. Preliminary data suggest rhythm control may decrease MR severity in patients with atrial fibrillation. Additionally, several studies have reported reductions in MR and symptomatic improvement with restrictive annuloplasty and transcatheter edge-to-edge repair. This review discusses the pathophysiology, echocardiographic diagnosis, and treatment of AF-MR. AF-tricuspid regurgitation is also discussed.
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Chandrasekhar J, Baber U, Sartori S, Goel R, Nicolas J, Vogel B, Snyder C, Kini A, Briguori C, Witzenbichler B, Iakovou I, Sardella G, Marzo K, DeFranco A, Stuckey T, Chieffo A, Colombo A, Shlofmitz R, Capodanno D, Dangas G, Pocock S, Mehran R. Antithrombotic strategy variability in atrial fibrillation and obstructive coronary disease revascularised with percutaneous coronary intervention: primary results from the AVIATOR 2 international registry. EUROINTERVENTION 2022; 18:e656-e665. [PMID: 35656720 PMCID: PMC10241278 DOI: 10.4244/eij-d-21-01044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/06/2022] [Indexed: 10/09/2023]
Abstract
BACKGROUND Managing percutaneous coronary intervention (PCI) patients with atrial fibrillation (AF) presents challenges given that there are several potential antithrombotic therapy (ATT) strategies. AIMS We examined ATT patterns, agreement between subjective physician ratings and validated risk scores, physician-patient perceptions influencing ATT and 1-year outcomes. METHODS The AVIATOR 2 prospective registry enrolled 514 non-valvular AF-PCI patients from 11 sites. Treating physicians selected ATT and completed smartphone surveys rating stroke and bleeding risks, compared against CHA2DS2-VASc and HAS-BLED scores. Patients completed surveys regarding treatment understanding. Primary outcomes were 1-year major adverse cardiac or cerebrovascular events (MACCE: composite of death, myocardial infarction, definite/probable stent thrombosis, stroke, target lesion revascularisation) and actionable bleeding (Bleeding Academic Research Consortium 2, 3 or 5). RESULTS The mean patient age was 73.2±9.0 years, including 25.8% females. Triple therapy (TT: 1 anticoagulant and 2 antiplatelet agents) was prescribed in 66.5%, dual antiplatelet therapy (DAPT) in 20.7% and dual therapy (1 anticoagulant+1 antiplatelet agent) in 12.8% of patients. Physician ratings and validated risk scores showed poor agreement (stroke: kappa=0.03; bleeding: kappa=0.07). Physicians rated bleeding-related safety (93.8%) as the main factor affecting ATT choice. Patients worried about stroke over bleeding (50.6% vs 14.8%). No group differences by ATT strategy were observed in 1-year MACCE (TT 14.1% vs dual therapy 12.7% vs DAPT 18.5%; p=0.25), or actionable bleeding (14.7% vs 7.9% vs 15.1%, respectively; p=0.89). CONCLUSIONS The AVIATOR 2 study is the first digital health study examining physician-patient perspectives on ATT choices after AF-PCI. TT was the most common strategy without differences in 1-year outcomes in ATT strategy. Physicians rated safety first when prescribing ATT; patients feared stroke over bleeding. CLINICALTRIALS gov: NCT02362659.
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Spirito A, Koh WJ, Sartori S, Snyder C, Nicholas J, Cao D, Vogel B, Rezvanizadeh V, Jones D, Baber U, Sweeny J, Sharma S, Kini A, Dangas G, Mehran R. Prevalence and impact of TWILIGHT criteria in all-comer patients undergoing percutaneous coronary intervention. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The Ticagrelor with Aspirin or Alone in High-Risk Patients after Coronary Intervention (TWILIGHT) randomized clinical trial demonstrated that in selected high risk patients who took ticagrelor and aspirin for 3 months after percutaneous coronary intervention (PCI), continuing ticagrelor alone was associated with significantly less bleeding events than ticagrelor plus aspirin and did not lead to ischemic harm over a period of 1 year (1).
The prevalence and risk of adverse events of patients fulfilling the TWILIGHT inclusion criteria in real-world setting is unclear.
Purpose
To elucidate the prevalence and prognosis of patients fulfilling the TWILIGHT inclusion criteria.
Methods
Patients that received at least one drug eluting stent in a coronary artery at a large tertiary center (Mount Sinai Hospital, New York) were considered for inclusion. As in the TWILIGHT trial, individuals on chronic oral anticoagulation treatment, with STEMI, cardiogenic shock, on dialysis, with prior stroke, or platelet count <100,000 were excluded. Patients were stratified in two groups: 1) TWILIGHT-like patients, who met at least one clinical (age ≥65 years, female sex, established vascular disease, diabetes mellitus, estimated glomerular fraction rate <60mL/min, acute coronary syndrome with troponin increase) and one angiographic (multivessel coronary artery disease [CAD], stent length >30mm, thrombotic target lesion, bifurcation requiring 2 stents, left main or proximal left anterior descending artery lesion, atherectomy device use, SYNTAX score ≥23) TWILIGHT inclusion criterion; 2) Non-TWILIGHT-like patients, who did not fulfil at least one clinical and one angiographic TWILIGHT inclusion criterion.
The primary outcome was a composite of death, myocardial infarction (MI), stroke. Secondary outcomes included bleeding, components of the primary outcome, target vessel and target lesion revascularization, stent thrombosis. All events were assessed at 1 year after PCI.
Results
Out of 30,470 patients undergoing PCI between 2012 and 2019, 13,236 were included in the current analysis. TWILIGHT criteria were met in 11,018 (83%) patients. Established vascular disease and multivessel CAD were the most frequently fulfilled criteria. At 1 year, TWILIGHT-like patients were at higher risk for the primary outcome (3.2% vs 1.1%, HR 2.85, 95% CI 1.83–4.44), severe bleeding (3.3% vs 1.8%, HR 1.86, 95% CI 1.32–2.62), all-cause death (1.4% vs 0.4%, HR 3.63, 95% CI 1.70–7.77), myocardial infarction (1.8% vs 0.6%, HR 2.81 95% CI 1.56–5.04), TVR (7.8% vs 4.1%, HR 1.94, 95% CI 1.53–2.47), TLR (5.1% vs 1.7%, HR 2.98 95% CI 2.07–4.29). Stent thrombosis and stroke rate were generally low and did not differ between patients meeting or not the TWILIGHT inclusion criteria.
Conclusion
Among all-comer patients undergoing PCI, the fulfillment of the TWILIGHT inclusion criteria is frequent and is associated with a higher risk of death, ischemic and bleeding complications
Funding Acknowledgement
Type of funding sources: None.
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Iruvanti S, Blumfield A, Farhan S, Snyder C, Sartori S, Vogel B, Giustino G, Kyaw H, Dangas G, Mehran R, Kini A, Sharma S. TCT-105 Determinants of Seattle Angina Questionnaire in Multivessel Disease Patients Undergoing Percutaneous Coronary Intervention: Insights From a Single-Center Study. J Am Coll Cardiol 2022. [DOI: 10.1016/j.jacc.2022.08.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Nicolas J, Mehran R, Sartori S, Snyder C, Spirito A, Hermiller J, Makkar R, Bangalore S, Angiolillo D, Ge J, Vogel B, Saito S, Cao D, Guthrie J, Neumann FJ, Bhatt D. TCT-4 Dual Antiplatelet Therapy for 1 Versus 3 Months in Women and Men at High Bleeding Risk Undergoing Drug-Eluting Stent Implantation. J Am Coll Cardiol 2022. [DOI: 10.1016/j.jacc.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jou S, Vogel B, Snyder C, Sartori S, Farhan S, Nicolas J, Cao D, Moreno P, Sweeny J, Krishnan P, Dangas G, Kini A, Sharma S. TCT-566 Impact of Sex on Risk for Adverse Events Associated With Polyvascular Disease in Patients After PCI. J Am Coll Cardiol 2022. [DOI: 10.1016/j.jacc.2022.08.666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Spirito A, Cao D, Sartori S, Zhang Z, Nicolas J, Cohen D, Angiolillo D, Briguori C, Vogel B, Collier T, Dudek D, Escaned J, Sharma S, Farhan S, Huber K, Kastrati A, Kornowski R, Krucoff M, Kunadian V, Mehta S, Moliterno D, Ohman EM, Sardella G, Shlofmitz R, Steg P, Witzenbichler B, Han Y, Pocock S, Dangas G, Mehran R. TCT-13 Ticagrelor Monotherapy in Patients With Peripheral Artery Disease Undergoing PCI. J Am Coll Cardiol 2022. [DOI: 10.1016/j.jacc.2022.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Nicolas J, Edens M, Vogel B, Mehran R. Best Practices for Designing Informative Trials Including Women. Curr Atheroscler Rep 2022; 24:885-888. [PMID: 36018472 DOI: 10.1007/s11883-022-01064-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Despite mandates from funding agencies and professional societies to broaden inclusivity in medical research, women remain underrepresented in cardiovascular clinical trials. This lack of representation limits the generalizability of the findings and results in uncertainty about the safety and efficacy of many cardiovascular therapies in female patients. RECENT FINDINGS Several barriers impact women's participation in clinical trials, including enrollment criteria, common misconceptions, access to tertiary care, and women representation in clinical trial leadership. This short review discusses these barriers and suggests potential solutions to increase women's participation in clinical trials and improve their cardiovascular health.
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Pivato CA, Cao D, Spirito A, Sartori S, Nicolas J, Chiarito M, Snyder C, Mehilli J, Lefèvre T, Stefanini GG, Presbitero P, Capranzano P, Tchetche D, Iadanza A, Vogel B, Sardella G, Van Mieghem NM, Nardin M, Tavenier AH, Meliga E, Dumonteil N, Fraccaro C, Trabattoni D, Mikhail G, Sharma S, Ferrer MC, Naber C, Kievit P, Baber U, Petronio AS, Morice MC, Chieffo A, Dangas G, Mehran R. Impact of Small Valve Size on 1-Year Outcomes After Transcatheter Aortic Valve Implantation in Women (from the WIN-TAVI Registry). Am J Cardiol 2022; 172:73-80. [PMID: 35461697 DOI: 10.1016/j.amjcard.2022.02.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/04/2022] [Accepted: 02/08/2022] [Indexed: 11/16/2022]
Abstract
Although most patients with small aortic annulus are women, there is paucity of data on the prognostic impact of small aortic prosthesis in women who underwent transcatheter aortic valve implantation (TAVI). Therefore, we aimed to evaluate the impact of small valve size on 1-year clinical outcomes after TAVI in women. The Women's INternational Transcatheter Aortic Valve Implantation is an all-women registry evaluating patients with severe aortic stenosis who underwent TAVI. Based on the size of the aortic bioprosthesis implanted, women were stratified into small (≤23 mm) and nonsmall (>23 mm) valve. The primary efficacy endpoint was the Valve Academic Research Consortium-2 composite of all-cause death, stroke, myocardial infarction, hospitalization for valve-related symptoms or heart failure or valve-related dysfunction at 1-year follow-up. Of 934 women who underwent TAVI, 388 (41.5%) received a small valve. Women with a small valve size had a lower body mass index, lower surgical risk scores, were less likely to suffer from atrial fibrillation, less often required postdilation and had a lower rate of residual aortic regurgitation grade ≥2. The occurrence of the Valve Academic Research Consortium-2 efficacy endpoint was similar between women treated with small and nonsmall valve (16.0% vs 16.3%, p = 0.881; adjusted hazard ratio 1.34, 95% confidence interval 0.90 to 2.00). Likewise, there were no significant differences in the occurrence of other secondary endpoints after multivariable adjustment. In conclusion, women with severe aortic stenosis who underwent TAVI with the implantation of a small valve bioprosthesis had similar 1-year outcomes as those receiving a nonsmall bioprosthesis.
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Gaudino M, Di Franco A, Cao D, Giustino G, Bairey Merz CN, Fremes SE, Kirtane AJ, Kunadian V, Lawton JS, Masterson Creber RM, Sandner S, Vogel B, Zwischenberger BA, Dangas GD, Mehran R. Sex-Related Outcomes of Medical, Percutaneous, and Surgical Interventions for Coronary Artery Disease: JACC Focus Seminar 3/7. J Am Coll Cardiol 2022; 79:1407-1425. [PMID: 35393023 DOI: 10.1016/j.jacc.2021.07.066] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/12/2021] [Indexed: 12/15/2022]
Abstract
Biological and sociocultural differences between men and women are complex and likely account for most of the variations in the epidemiology and treatment outcomes of coronary artery disease (CAD) between the 2 sexes. Worse outcomes in women have been described following both conservative and invasive treatments of CAD. For example, increased levels of residual platelet reactivity during treatment with antiplatelet drugs, higher rates of adverse cardiovascular outcomes following percutaneous coronary revascularization, and higher operative and long-term mortality after coronary bypass surgery have been reported in women compared with in men. Despite the growing recognition of sex-specific determinants of outcomes, representation of women in clinical studies remains low and sex-specific management strategies are generally not provided in guidelines. This review summarizes the current evidence on sex-related differences in patients with CAD, focusing on the differential outcomes following medical therapy, percutaneous coronary interventions, and coronary artery bypass surgery.
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Mehran R, Cao D, Vogel B. Rethinking the Role of Impaired Renal Function in Multivessel PCI or CABG. J Am Coll Cardiol 2022; 79:1285-1287. [DOI: 10.1016/j.jacc.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 10/18/2022]
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Tscharre M, Farhan S, Freynhofer MK, Leutner M, Baumgartner-Parzer S, Tentzeris I, Vogel B, Tinhofer F, Rohla M, Weiss TW, Huber K, Kautzky-Willer A. Neurotensin and Adverse Cardiovascular Outcomes in Patients Undergoing Percutaneous Coronary Intervention. Front Cardiovasc Med 2022; 9:782602. [PMID: 35345492 PMCID: PMC8957262 DOI: 10.3389/fcvm.2022.782602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 02/07/2022] [Indexed: 11/26/2022] Open
Abstract
Background Neurotensin is involved in fatty acid and glucose metabolism and promotes the development of obesity and diabetes. These associations appear to be more pronounced in women. We investigated the association of neurotensin with long-term major adverse cardiovascular events (MACE) in patients presenting with acute coronary syndrome (ACS) or chronic coronary syndrome (CCS) undergoing percutaneous coronary intervention (PCI). Methods We included 452 consecutive patients [144 (31.9%) females] undergoing PCI for ACS or CCS. Plasma samples drawn after PCI were analyzed for neurotensin with an enzyme-linked immunoassay. As primary endpoint, a composite of MACE including all-cause death, non-fatal myocardial infarction and non-fatal stroke during 7 years of follow-up was investigated. As secondary endpoint, we investigated all-cause death. Results Neurotensin levels did not differ between male and female patients (p = 0.560). MACE occurred in 150 (33.2%) patients. Restricted cubic splines demonstrated a U-shaped association of log-transformed neurotensin with the primary and secondary endpoint. Therefore, we dichotomized our cohort according to tertiles of log-transformed neurotensin. In Kaplan-Meier analysis including the total cohort and restricted to male patients log- neurotensin tertiles were not associated with MACE (both p > 0.05). Moreover, in the overall cohort and in male patients multivariable Cox regression analysis log-neurotensin tertiles were not associated with MACE or with all-cause death (all p > 0.05). However, in female patients log-neurotensin was associated with MACE in Kaplan-Meier analysis (log-rank p = 0.013). Also, after multivariable adjustment female patients in the first tertile had a significantly increased risk for MACE compared to female patients in the second tertile [HR 3.84 (95% CI 1.71–8.60), p = 0.001]. There was tendency for increased risk in female patients in the third tertile compared to the second tertile [HR 2.14 (95% CI 0.97–4.73), p = 0.058]. Moreover, in female patients the [first and the third tertile of log- neurotensin were associated with all-cause death 1s vs. 2nd tertile: HR 3.03 (95% CI 1.21–7.63), p = 0.018; 3rd vs. 2nd tertile: HR 3.01 (95% CI 1.22–7.44), p = 0.016]. Conclusion In female patients with CAD undergoing PCI, neurotensin has a U-shaped relationship with adverse outcomes. These data suggest a sex specific association between neurotensin and long-term adverse events after PCI.
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Vogel B, Mehran R. Inclusion of women in cardiovascular clinical trials: A path forward. Contemp Clin Trials 2022; 115:106719. [DOI: 10.1016/j.cct.2022.106719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/23/2022] [Accepted: 02/26/2022] [Indexed: 11/28/2022]
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Guedeney P, Giustino G, Sorrentino S, Claessen BE, Camaj A, Kalkman DN, Vogel B, Sartori S, De Rosa S, Baber U, Indolfi C, Montalescot G, Dangas GD, Rosenson RS, Pocock SJ, Mehran R. Efficacy and safety of alirocumab and evolocumab: a systematic review and meta-analysis of randomized controlled trials. Eur Heart J 2022; 43:e17-e25. [PMID: 31270529 DOI: 10.1093/eurheartj/ehz430] [Citation(s) in RCA: 77] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/28/2019] [Accepted: 06/10/2019] [Indexed: 12/30/2022] Open
Abstract
AIMS The effect of low-density lipoprotein cholesterol-lowering therapy with alirocumab or evolocumab on individual clinical efficacy and safety endpoints remains unclear. We aimed to evaluate the efficacy and safety of alirocumab and evolocumab in patients with dyslipidaemia or atherosclerotic cardiovascular disease. METHODS AND RESULTS We performed a review of randomized controlled trials (RCTs) comparing treatment with alirocumab or evolocumab vs. placebo or other lipid-lowering therapies up to March 2018. Primary efficacy endpoints were all-cause death, cardiovascular death, myocardial infarction (MI), and stroke. We estimated risk ratios (RR) and 95% confidence intervals (CI) using random effect models. We included 39 RCTs comprising 66 478 patients of whom 35 896 were treated with proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors (14 639 with alirocumab and 21 257 with evolocumab) and 30 582 with controls. Mean weighted follow-up time across trials was 2.3 years with an exposure time of 150 617 patient-years. Overall, the effects of PCSK9 inhibition on all-cause death and cardiovascular death were not statistically significant (P = 0.15 and P = 0.34, respectively). Proprotein convertase subtilisin-kexin type 9 inhibitors were associated with lower risk of MI (1.49 vs. 1.93 per 100 patient-year; RR 0.80, 95% CI 0.74-0.86; I 2 = 0%; P < 0.0001), ischaemic stroke (0.44 vs. 0.58 per 100 patient-year; RR 0.78, 95% CI 0.67-0.89; I 2 = 0%; P = 0.0005), and coronary revascularization (2.16 vs. 2.64 per 100 patient-year; RR 0.83, 95% CI 0.78-0.89; I 2 = 0%; P < 0.0001), compared with the control group. Use of these PCSK9 inhibitors was not associated with increased risk of neurocognitive adverse events (P = 0.91), liver enzymes elevations (P = 0.34), rhabdomyolysis (P = 0.58), or new-onset diabetes mellitus (P = 0.97). CONCLUSION Proprotein convertase subtilisin-kexin type 9 inhibition with alirocumab or evolocumab was associated with lower risk of MI, stroke, and coronary revascularization, with favourable safety profile.
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Vogel B, Huber K, Mehran R. Sex Difference in Bleeding Risk With P2Y12 Inhibitor Agents After Percutaneous Coronary Intervention-Reply. JAMA Cardiol 2022; 7:360-361. [PMID: 34985499 DOI: 10.1001/jamacardio.2021.5402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Bohra C, Khachadourian V, Vogel B, Leis P, Correa A, Sud K, Govindarajulu U, Narula J, Argulian E. Comparison of Handheld Ultrasound Assisted Physical Examination to Physical Examination Alone in Detecting Isolated Severe Tricuspid Regurgitation. J Am Soc Echocardiogr 2022; 35:525-527. [PMID: 34998965 DOI: 10.1016/j.echo.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 12/31/2021] [Accepted: 01/01/2022] [Indexed: 11/25/2022]
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Pivato CA, Vogel B, Mehran R. Sex disparities continue to characterise the management of non-ST-elevation acute coronary syndrome. Med J Aust 2021; 216:135-136. [PMID: 34499361 DOI: 10.5694/mja2.51253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/22/2021] [Indexed: 11/17/2022]
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