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Zhu LY, Li Q, Yu LY, Liu Y, Chen YN, Wang Z, Zhang SY, Li J, Liu Y, Zhao YL, Xi Y, Pi L, Sun YH. [Anticoagulation status and adherence in patients with atrial fibrillation hospitalized for ACS and the impact on 1-year prognosis: a multicenter cohort study]. Zhonghua Xin Xue Guan Bing Za Zhi 2023; 51:731-741. [PMID: 37460427 DOI: 10.3760/cma.j.cn112148-20230314-00138] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Objective: For patients with atrial fibrillation (AF) complicated with acute coronary syndrome (ACS), both anticoagulant and antiplatelet therapy should be applied, but the use of anticoagulation therapy is still poor in these patients in China. The purpose of this study was to explore the status and adherence of antithrombotic therapy in AF patients with ACS and the impact on 1 year clinical outcomes. Methods: Patients with AF hospitalized for ACS were retrospectively included from 6 tertiary hospitals in China between July 2015 and December 2020. According to the use of anticoagulant drugs at discharge, patients were divided into two groups: anticoagulant treatment group and non-anticoagulant treatment group. Logistic regression model was used to analyze the main factors influencing the use of anticoagulant drugs in patients with atrial fibrillation complicated with ACS. Major adverse cardiac events (MACEs) were defined as all-cause death, non-fatal myocardial infarction or coronary revascularization, and ischemic stroke and Bleeding Academic Research Consortium (BARC) 3 bleeding events were also collected at 1 year after discharge. After propensity score matching, Cox proportional hazards models and Kaplan-Meier analysis were used to evaluate the effect of anticoagulant treatment and non-anticoagulant treatment on 1-year prognosis. The patients were divided into different groups according to whether anticoagulation was performed at discharge and follow-up, and the sensitivity of the results was analyzed. Results: A total of 664 patients were enrolled, and 273 (41.1%) were treated with anticoagulant therapy, of whom 84 (30.8%) received triple antithrombotic therapy, 91 (33.3%) received double antithrombotic therapy (single antiplatelet combined with anticoagulant), and 98 (35.9%) received single anticoagulant therapy. Three hundred and ninety-one (58.9%) patients were treated with antiplatelet therapy, including 253 (64.7%) with dual antiplatelet therapy and 138 (35.3%) with single antiplatelet therapy. After 1∶1 propensity score matching between the anticoagulant group and the non-anticoagulant group, a total of 218 pairs were matched. Multivariate logistic regression analysis showed that history of diabetes, HAS-BLED score≥3, and percutaneous coronary intervention were predictors of the absence of anticoagulant therapy, while history of ischemic stroke and persistent atrial fibrillation were predictors of anticoagulant therapy. At 1-year follow-up, 218 patients (79.9%) in the anticoagulant group continued to receive anticoagulant therapy, and 333 patients (85.2%) in the antiplatelet group continued to receive antiplatelet therapy. At 1-year follow-up, 36 MACEs events (13.2%) occurred in the anticoagulant group, and 81 MACEs events (20.7%) in the non-anticoagulant group. HR values and confidence intervals were calculated by Cox proportional risk model. Patients in the non-anticoagulant group faced a higher risk of MACEs (HR=1.802, 95%CI 1.112-2.921, P=0.017), and the risk of bleeding events was similar between the two group (HR=0.825,95%CI 0.397-1.715, P=0.607). Conclusions: History of diabetes, HAS-BLED score≥3, and percutaneous coronary intervention are independent factors for the absence of anticoagulant therapy in patients with AF complicated with ACS. The incidence of MACEs, death and myocardial infarction is lower in the anticoagulant group, and the incidence of bleeding events is similar between the two groups. The risk of bleeding and ischemia/thrombosis should be dynamically assessed during follow-up and antithrombotic regiments should be adjusted accordingly.
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Affiliation(s)
- L Y Zhu
- Peking University Health Science Center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Q Li
- Peking University Health Science Center, China-Japan Friendship Hospital, Beijing 100029, China
| | - L Y Yu
- Peking University Health Science Center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Y Liu
- Peking University Health Science Center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Y N Chen
- Peking University Health Science Center, China-Japan Friendship Hospital, Beijing 100029, China
| | - Z Wang
- Department of Cardiology, China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100029, China
| | - S Y Zhang
- Department of Cardiology, China-Japan Friendship Hospital, Beijing 100029, China
| | - J Li
- Department of Cardiology, Capital Medical University, Xuanwu Hospital, Beijing 100053, China
| | - Y Liu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
| | - Y L Zhao
- Department of Cardiology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou 450014, China
| | - Y Xi
- Department of Hypertension, Peking University People's Hospital, Beijing 100044, China
| | - L Pi
- Department of Cardiology, Chui Yang Liu Hospital Affiliated to Tsinghua University, Beijing 100021, China
| | - Y H Sun
- Department of Cardiology, China-Japan Friendship Hospital, Beijing 100029, China
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152
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Rallidis LS, Tsamoulis D, Leventis I, Kalogeras P, Delakis I, Samiotis E, Kalantzis C, Malkots B, Tasoulas D, Bouratzis V, Eleutheriou D, Daios S, Potoupni V, Zervakis S, Xygka G, Miliotou A, Papathanasiou KA, Vlachopoulos C. Extremely high-risk patients with acute coronary syndrome: How "extreme" should lipid-lowering therapy be if the LDL-C target <40 mg/dl is considered? Kardiol Pol 2023; 81:1012-1014. [PMID: 37401581 DOI: 10.33963/kp.a2023.0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/22/2023] [Indexed: 07/05/2023]
Affiliation(s)
- Loukianos S Rallidis
- 2nd Department of Cardiology, Medical School, National and Kapodistrian University of Athens, University General Hospital ATTIKON, Athens, Greece
| | - Donatos Tsamoulis
- Department of Cardiology, Thriasio General Hospital, Elefsina, Greece
| | - Ioannis Leventis
- Department of Cardiology, University General Hospital of Larissa, Larissa, Greece
| | - Petros Kalogeras
- 2nd Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
| | - Iosif Delakis
- 1st Department of Cardiology, General Hospital of Nikea, Piraeus, Greece
| | - Elefterios Samiotis
- 2nd Department of Cardiology, Medical School, National and Kapodistrian University of Athens, University General Hospital ATTIKON, Athens, Greece
| | - Charalampos Kalantzis
- 1st Department of Cardiology, Medical School, National and Kapodistrian, University of Athens, Hippokration Hospital, Athens, Greece
| | - Belkis Malkots
- Department of Cardiology, Medical School, Democritus University of Thrace, Dragana, Alexandroupolis, Greece
| | - Dimitrios Tasoulas
- 2nd Department of Cardiology, General Hospital of Nikea, Piraeus, Greece
| | - Vasileios Bouratzis
- 2nd Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
| | - Dimitris Eleutheriou
- 2nd Department of Cardiology, General Hospital of Athens "Evangelismos", Athens, Greece
| | - Stylianos Daios
- 1st Department of Cardiology, University General Hospital of Thessaloniki, AHEPA, Thessaloniki, Greece
| | - Victoria Potoupni
- 3rd Department of Cardiology, Hippokration University Hospital, Aristotle University, Thessaloniki, Greece
| | - Stelios Zervakis
- Department of Cardiology, Heraklion University Hospital, Crete, Greece
| | - Georgia Xygka
- Department of Cardiology, Patras University Hospital, Patras, Greece
| | - Argyro Miliotou
- Department of Clinical Therapeutics, University of Athens, Alexandra Hospital, Athens, Greece
| | - Konstantinos A Papathanasiou
- 2nd Department of Cardiology, Medical School, National and Kapodistrian University of Athens, University General Hospital ATTIKON, Athens, Greece.
| | - Charalambos Vlachopoulos
- 1st Department of Cardiology, Medical School, National and Kapodistrian, University of Athens, Hippokration Hospital, Athens, Greece
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153
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Wu H, Jia S. A Comparative Study on Ticagrelor and Clopidogrel in Patients With Acute Coronary Syndrome Treated With Primary Percutaneous Coronary Intervention. J Clin Pharmacol 2023; 63:776-783. [PMID: 37017131 DOI: 10.1002/jcph.2239] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/23/2023] [Indexed: 04/06/2023]
Abstract
This study was conducted to compare the efficacy and safety of ticagrelor and clopidogrel in patients with acute coronary syndrome (ACS) treated with primary percutaneous coronary intervention (PPCI). A total of 3528 consecutive patients with ACS treated with PPCI were divided into the ticagrelor and clopidogrel groups based on their dual antiplatelet therapy regimen at hospital discharge. Patient follow-up visits were completed 1, 6, and 12 months after PPCI treatment. Major adverse cardiac events (MACEs) and Bleeding Academic Research Consortium (BARC) bleeding events were assessed in both groups. In total, 2501 cases were included in the ticagrelor group, and 817 cases were included in the clopidogrel group. The incidence of MACEs was lower in the ticagrelor group than in the clopidogrel group (P < .05). The ticagrelor group had lower incidence of all-cause death and cardiac death compared with the clopidogrel group, and the difference was significant (P < .05). The incidences of study end points, including recurrent myocardial infarction and repeat revascularization, were not significantly different between the groups (P > .05). The incidences of BARC total and major bleeding events were not significantly different between the groups (P > .05). However, the incidences of BARC type 1 and 2 bleeding events were lower in the ticagrelor group than in the clopidogrel group (P < .05). The multivariate Cox regression analysis suggested that ticagrelor could decrease all-cause death compared with clopidogrel (P = .021). In patients with ACS treated with PPCI, ticagrelor could significantly reduce the risk of MACEs compared with clopidogrel, without increasing the risk of bleeding.
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Affiliation(s)
- Hui Wu
- Heart Centre & Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
- Clinical Medical College, Ningxia Medical University, Yinchuan, Ningxia, China
| | - Shaobin Jia
- Heart Centre & Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
- Clinical Medical College, Ningxia Medical University, Yinchuan, Ningxia, China
- Ningxia Key Laboratory of Vascular Injury and Repair Research, Ningxia Medical University, Yinchuan, China
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154
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Guo T, Chu C, Wang Y, He M, Jia H, Sun Y, Wang D, Liu Y, Huo Y, Mu J. Lipid goal attainment in diabetes mellitus patients after acute coronary syndrome: a subanalysis of Dyslipidemia International Study II-China. BMC Cardiovasc Disord 2023; 23:337. [PMID: 37393236 PMCID: PMC10315034 DOI: 10.1186/s12872-023-03312-w] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 05/18/2023] [Indexed: 07/03/2023] Open
Abstract
BACKGROUND Lipid management with a low-density lipoprotein cholesterol (LDL-C) goal of < 1.4 mmol/L is recommended for patients with acute coronary syndrome (ACS) and diabetes mellitus (DM) due to a high risk for adverse cardiovascular events. This study evaluated the lipid-lowering treatment (LLT) pattern and the LDL-C goal attainment rate in this special population. METHODS DM patients were screened from the observational Dyslipidemia International Study II-China study which assessed LDL-C goal attainment in Chinese ACS patients. The baseline characteristics between the LLT and no pre-LLT groups were compared. The proportions of patients obtaining LDL-C goal at admission and at 6-months, the difference from the goal, and the pattern of the LLT regimen were analyzed. RESULTS Totally 252 eligible patients were included, with 28.6% taking LLT at admission. Patients in the LLT group were older, had a lower percentage of myocardial infarction, and had decreased levels of LDL-C and total cholesterol compared to those in the no pre-LLT group at baseline. The overall LDL-C goal attainment rate was 7.5% at admission and increased to 30.2% at 6 months. The mean difference between the actual LDL-C value and LDL-C goal value dropped from 1.27 mmol/L at baseline to 0.80 mmol/L at 6 months. At 6 months, 91.4% of the patients received statin monotherapy, and only 6.9% received a combination of statin and ezetimibe. The atorvastatin-equivalent daily statin dosage was moderate during the study period. CONCLUSION The low rate of lipid goal attainment observed was in line with the outcomes of other DYSIS-China studies.
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Affiliation(s)
- Tongshuai Guo
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, 710061, Xi'an, China
| | - Chao Chu
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, 710061, Xi'an, China
| | - Yang Wang
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, 710061, Xi'an, China
| | - Mingjun He
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, 710061, Xi'an, China
| | - Hao Jia
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, 710061, Xi'an, China
| | - Yue Sun
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, 710061, Xi'an, China
| | - Dan Wang
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, 710061, Xi'an, China
| | - Yan Liu
- Medical Affairs, Organon, China
| | - Yong Huo
- Department of Cardiovascular Medicine, Peking University First Hospital, Beijing, China.
- Department of Cardiology, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, 100034, Beijing, China.
| | - Jianjun Mu
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, 710061, Xi'an, China.
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155
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Laudani C, Capodanno D, Angiolillo DJ. Bleeding in acute coronary syndrome: from definitions, incidence, and prognosis to prevention and management. Expert Opin Drug Saf 2023; 22:1193-1212. [PMID: 38048099 DOI: 10.1080/14740338.2023.2291865] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION In patients with acute coronary syndrome (ACS), the ischemic benefit of antithrombotic treatment is counterbalanced by the risk of bleeding. The recognition that bleeding events have prognostic implications (i.e. mortality) similar to recurrent ischemic events led to the development of treatment regimens aimed at balancing both ischemic and bleeding risks. AREAS COVERED This review aims at describing definitions, incidence, and prognosis related to bleeding events in ACS patients as well as bleeding-avoidance strategies for their prevention and management of bleeding complications. EXPERT OPINION Management of ACS patients has witnessed remarkable progress after the shift in focusing on the trade-off between ischemia and bleeding. Efforts in standardizing bleeding definitions will allow for better defining the prognostic impact of different types of bleeding events and enable to identify the high-bleeding risk patient. Such efforts will allow to balance the trade-off between the thrombotic and bleeding risk of the individual patient translating into better downward diagnostic and therapeutic decision-making. Novel strategies aiming at maximizing the safety and efficacy of antithrombotic regimens as well as the development of novel antithrombotic drugs and reversal agents and technological advances will allow for optimization of bleeding-avoidance strategies and management of bleeding complications.
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Affiliation(s)
- Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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156
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Occhipinti G, Greco A, Angiolillo DJ, Capodanno D. Gender differences in efficacy and safety of antiplatelet strategies for acute coronary syndromes. Expert Opin Drug Saf 2023; 22:669-683. [PMID: 37542468 DOI: 10.1080/14740338.2023.2245331] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/15/2023] [Accepted: 08/03/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT) represents the cornerstone of secondary prevention in patients presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention. Despite its undisputed efficacy in reducing thrombotic events, DAPT increases the risk of bleeding, which is associated with higher morbidity and mortality. Novel antiplatelet strategies (i.e. in terms of timing, selection of drugs and their combinations, and modulation strategies) have been tested in randomized trials, suggesting the utility of tailored approaches in selected populations (i.e. patients at high bleeding or ischemic risk). It remains uncertain whether the effect of these strategies is influenced by sex. AREAS COVERED This narrative review provides an overview of available evidence surrounding sex differences in the efficacy and safety of antiplatelet strategies for ACS and analyzes the potential reasons behind these findings. Relevant content was searched for in PubMed. EXPERT OPINION Significant differences between women and men exist in terms of clinical presentation, pharmacotherapies, interventional management, and prognosis of ACS. However, these observations do not appear to be attributed to different pharmacodynamic effects of antiplatelet therapies between women and men. Unfortunately, a critical issue depends on women being often underrepresented in clinical trials, leading to a substantial lack of sex-specific evidence.
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Affiliation(s)
- Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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157
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Galli M, Bernardi M, Ortega-Paz L, Nerla R, D'Amario D, Franchi F, Biondi-Zoccai G, Angiolillo DJ. Bivalirudin in acute coronary syndromes. Expert Rev Cardiovasc Ther 2023; 21:901-911. [PMID: 37919937 DOI: 10.1080/14779072.2023.2273902] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION Bivalirudin, a bivalent direct thrombin inhibitor, has been developed to reduce bleeding without any trade-off in thrombotic events in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). AREAS COVERED Despite showing a superior safety profile compared with unfractionated heparin (UFH), bivalirudin is not considered the anticoagulant of choice in ACS patients undergoing PCI, mainly because of an increased rate of acute stent thrombosis (ST) shown by several randomized controlled trials (RCTs), in addition to limited availability in certain countries and increased costs. However, RCTs on bivalirudin have been characterized by several confounding factors hindering the interpretation of its safety and efficacy compared with UFH among the spectrum of ACS patients. Furthermore, a significant body of evidence has demonstrated that the risk of acute ST can be mitigated by a full-dose infusion regimen following PCI, without compromising the favorable safety profile compared to UFH. EXPERT OPINION In light of the increased understanding of the prognostic relevance of bleeding events and the excellent safety profile of bivalirudin, recent trial evidence may allow for this anticoagulant agent to reemerge and have a more prominent role in the management of ACS patients undergoing PCI.
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Affiliation(s)
- Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Marco Bernardi
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Roberto Nerla
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Domenico D'Amario
- Dipartimento Universitario di Medicina Traslazionale, Università Piemonte Orientale, Azienda Ospedaliero-Universitaria Maggiore della Carità di Novara, Novara, Italy
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Mediterranea Cardiocentro, Napoli, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
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158
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Yuan X, Chu Q, Chen K, Wang Y, Zhang L, Zheng Y, Hu S. Multicentre, randomised, double-blind, parallel controlled trial to investigate timing of platelet inhibition after coronary artery bypass grafting: TOP-CABG trial study. BMJ Open 2023; 13:e070823. [PMID: 37385747 PMCID: PMC10314523 DOI: 10.1136/bmjopen-2022-070823] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 05/24/2023] [Indexed: 07/01/2023] Open
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT), referred to as the combination of aspirin and P2Y12 receptor antagonist (clopidogrel or ticagrelor), potentially improves patency of saphenous vein grafts (SVG) after coronary artery bypass grafting (CABG), while it is further proposed that DAPT potentially increases bleeding risk. Compared with DAPT, de-escalated DAPT (De-DAPT) is an effective antiplatelet strategy for acute coronary syndrome treatment, which significantly reduces the risk of bleeding without increasing the incidence of major adverse cardiovascular events. However, insufficient evidence is available to determine the timing of DAPT after CABG. METHODS AND ANALYSIS ETHICS AND DISSEMINATION: The Ethics Committee in Fuwai hospital approved this study (2022-1774). Fifteen centres agreed to participate the TOP-CABG trial, and the study has been approved in these 15 centres by whose ethics committee. The results of the trial will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT05380063.
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Affiliation(s)
- Xin Yuan
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiac Surgery, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| | - Qing Chu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiac Surgery, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| | - Kai Chen
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiac Surgery, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| | - Yang Wang
- National Clinical Research Centre of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Lihua Zhang
- National Clinical Research Centre of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yingli Zheng
- Department of Pharmacy, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| | - Shengshou Hu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiac Surgery, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
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159
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Sabouret P, Puymirat E, Kownator S, Abdennbi K, Lebeau F, Meltz M, Angoulvant D, Schiele F. Lipid-lowering treatment up to one year after acute coronary syndrome: guidance from a French expert panel for the implementation of guidelines in practice. Panminerva Med 2023; 65:244-249. [PMID: 36222543 DOI: 10.23736/s0031-0808.22.04777-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
The management of patients with coronary artery disease (CAD) is complex, especially after they have been discharged from hospital after an acute coronary syndrome (ACS), because each patient may have numerous healthcare providers, and follow-up after discharge may be disjointed, or even incomplete. During follow-up after ACS, few patients have treatment intensification; rather, there is actually a major tendency towards reductions in treatment intensity, to the potential detriment of outcomes. We present here guidance from a French expert panel for the optimal management of lipid-lowering therapy up to 1 year after ACS. A French expert panel provides a practical guide for the implementation of guidelines for the management of post-ACS patients in routine practice, from hospital discharge up to one year after the index event, focusing in particular on the achievement of target LDL cholesterol (LDL-C) levels. We discuss the early follow-up (up to 6 months after discharge) and review the lipid-lowering treatment strategies that should be implemented. We discuss the evidence underpinning the prescription of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors as well as recent evidence about icosapent ethyl. This review should facilitate implementation of a clear and effective lipid-lowering strategy for all patients after ACS. The panel recommends early use of high-intensity statins, in combination with ezetimibe for patients with LDL-c above 100 mg/dL at baseline. PCSK9i should be rapidly added during the first 3 months in high-risk diabetic patients with residual LDL-C above 70 mg/dL (with further benefit for those with residual LDL-C above ≥100 mg/dL) despite maximal tolerated dose statin and ezetimibe, patients with recent ACS, and patients with recurrent ischemic events under optimal medical therapy, multivessel coronary disease (MVD) and/or polyvascular disease (PVD), especially symptomatic PAD diabetic patients. Concerning icosapent ethyl (EPA), this drug should be introduced in patients ≥45 years of age with clinical atherosclerotic cardiovascular disease (ASCVD) or already on high-intensity or maximally tolerated statin therapy or with fasting triglycerides 135-499 mg/dL (with or without ezetimibe). Lipid-lowering treatment should be introduced as early as possible to obtain a rapid and profound decrease of LDL-c from baseline, using high-intensity statins (atorvastatin or rosuvastatin) and ezetimibe in fixed combination before discharge. Then, the strategy should be rapidly intensified by adding a PCSK9 inhibitor if the patient does not reach LDL-c levels below 55 mg/dL. We advocate this intensive strategy, which has demonstrated a further reduction in ischemic events, without safety concerns, even for patients who reach very low LDL-cholesterol levels. This approach, comprising few therapeutic steps, aims to rapidly reach LDL-c goals, improve patient compliance, and is an efficient method to fight therapeutic inertia, which remains a major issue.
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Affiliation(s)
- Pierre Sabouret
- Cardiovascular Prevention Institute, Paris, France -
- National College of French Cardiologists, Paris, France -
| | - Etienne Puymirat
- Department of Cardiology, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
- Hôpital Européen Georges Pompidou, Paris, France
- University of Paris, Paris, France
- Université Paris Cité, Paris, France
| | - Serge Kownator
- Centre Cardiologique et Vasculaire "Cœur de Lorraine", Thionville, France
| | | | | | - Michel Meltz
- Association des Rencontres Médicales Pluridisciplinaires (ARMP), Claude Bernard University Lyon1, Villeurbanne, France
| | - Denis Angoulvant
- EA4245 Transplantation, Immunologie, Inflammation, University of Tours, Tours, France
- Service of Cardiology, University Hospital of Tours, Tours, France
| | - François Schiele
- Department of Cardiology, University Hospital of Besancon, Besancon, France
- EA3920, University of Franche-Comté, Besancon, France
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Pérez de Isla L, Díaz-Díaz JL, Romero MJ, Muñiz-Grijalvo O, Mediavilla JD, Argüeso R, Sánchez Muñoz-Torrero JF, Rubio P, Álvarez-Baños P, Ponte P, Mañas D, Suárez Gutierrez L, Cepeda JM, Casañas M, Fuentes F, Guijarro C, Ángel Barba M, Saltijeral Cerezo A, Padró T, Mata P. Alirocumab and Coronary Atherosclerosis in Asymptomatic Patients with Familial Hypercholesterolemia: The ARCHITECT Study. Circulation 2023; 147:1436-1443. [PMID: 37009731 PMCID: PMC10158600 DOI: 10.1161/circulationaha.122.062557] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 03/01/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND The effect of alirocumab, a PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor, on coronary plaque burden in patients with familial hypercholesterolemia has not been addressed. Our aim was to assess changes in coronary plaque burden and its characteristics after treatment with alirocumab by quantification and characterization of atherosclerotic plaque throughout the coronary tree on the basis of a noninvasive analysis of coronary computed tomographic angiography in asymptomatic subjects with familial hypercholesterolemia receiving optimized and stable treatment with maximum tolerated statin dose with or without ezetimibe. METHODS This study is a phase IV, open-label, multicenter, single-arm clinical trial to assess changes in coronary plaque burden and its characteristics after 78 weeks of treatment with alirocumab in patients with familial hypercholesterolemia without clinical atherosclerotic cardiovascular disease. Participants underwent an initial coronary computed tomographic angiography at baseline and another at 78 weeks. Every patient received 150 mg of alirocumab subcutaneiously every 14 days in addition to high-intensity statin therapy. The main outcome was the change on coronary plaque burden and its characteristics by quantification and characterization of atherosclerotic plaque throughout the coronary tree on the basis of analysis of coronary computed tomographic angiography. RESULTS The study was completed by 104 patients. The median age was 53.3 (46.2-59.4) years. Of these patients, 54 were women (51.9%). Median low-density lipoprotein cholesterol was 138.9 (117.5-175.3) mg/dL at entry and 45.0 (36.0-65.0) mg/dL at follow-up (P<0.001). Coronary plaque burden changed from 34.6% (32.5%-36.8%) at entry to 30.4% (27.4%-33.4%) at follow-up (P<0.001). A significant change in the characteristics of the coronary atherosclerosis was also found: an increase in the proportion of calcified (+0.3%; P<0.001) and mainly fibrous (+6.2%; P<0.001) plaque, accompanied by a decrease in the percentage of fibro-fatty (-3.9%; P<0.001) and necrotic plaque (-0.6%; P<0.001). CONCLUSIONS Treatment with alirocumab in addition to high-intensity statin therapy resulted in significant regression of coronary plaque burden and plaque stabilization on coronary computed tomographic angiography over 78 weeks in these groups of patients with familial hypercholesterolemia without clinical atherosclerotic cardiovascular disease. ARCHITECT (Effect of Alirocumab on Atherosclerotic Plaque Volume, Architecture and Composition) could link and explain ODYSSEY OUTCOMES (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) results. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT05465278.
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Affiliation(s)
| | - Jose L. Díaz-Díaz
- Internal Medicine Department, Hospital Abente y Lago, A Coruña, Spain (J.L.E.-D.)
| | - Manuel J. Romero
- Internal Medicine Department, Hospital Infanta Elena, Huelva, Spain M.J.R.)
| | | | - Juan D. Mediavilla
- Internal Medicine Department, Hospital Universitario Virgen de las Nieves, Granada, Spain (J.D.M.)
| | - Rosa Argüeso
- Endocrinology Department, Hospital Universitario Lucus Augusti, Lugo, Spain (R.A.)
| | | | - Patricia Rubio
- Internal Medicine Department, Hospital Universitario Jerez de la Frontera, Spain (P.R.)
| | | | - Paola Ponte
- Internal Medicine Department, Hospital Santa Creu i Sant Pau, Barcelona, Spain (P.P.)
| | - Dolores Mañas
- Internal Medicine Department, Hospital General Universitario de Ciudad Real, Spain (D.M.)
| | | | - José María Cepeda
- Internal Medicine Department, Hospital Comarcal Vega Baja, Orihuela, Alicante, Spain (J.M.C.)
| | - Marta Casañas
- Internal Medicine Department, Hospital San Pedro, Logroño, Spain (M.C.)
| | - Francisco Fuentes
- Lipid and Atherosclerosis Unit, CIBERObn, IMBIC. Hospital Universitario Reina Sofia, Córdoba, Spain (F.F.)
| | - Carlos Guijarro
- Internal Medicine Department, Hospital Universitario Fundación Alcorcón-Universidad Rey Juan Carlos, Madrid, Spain (C.G.)
| | - Miguel Ángel Barba
- Internal Medicine Department, Complejo Hospitalario Universitario, Albacete, Spain (M.A.B.)
| | | | - Teresa Padró
- Programa-ICCC Cardiovascular, Institut de Recerca Hospital Santa Creu i Sant Pau, IIB-Sant Pau, CIBERCV, Barcelona, Spain (T.P.)
| | - Pedro Mata
- Fundación Hipercolesterolemia Familiar, Madrid, Spain (P.M.)
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Malm CJ, Alfredsson J, Erlinge D, Gudbjartsson T, Gunn J, James S, Møller CH, Nielsen SJ, Sartipy U, Tønnessen T, Jeppsson A. Dual or single antiplatelet therapy after coronary surgery for acute coronary syndrome (TACSI trial): Rationale and design of an investigator-initiated, prospective, multinational, registry-based randomized clinical trial. Am Heart J 2023; 259:1-8. [PMID: 36681173 DOI: 10.1016/j.ahj.2023.01.011] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 01/12/2023] [Accepted: 01/12/2023] [Indexed: 05/11/2023]
Abstract
The TACSI trial (ClinicalTrials.gov Identifier: NCT03560310) tests the hypothesis that 1-year treatment with dual antiplatelet therapy with acetylsalicylic acid (ASA) and ticagrelor is superior to only ASA after isolated coronary artery bypass grafting (CABG) in patients with acute coronary syndrome. The TACSI trial is an investigator-initiated pragmatic, prospective, multinational, multicenter, open-label, registry-based randomized trial with 1:1 randomization to dual antiplatelet therapy with ASA and ticagrelor or ASA only, in patients undergoing first isolated CABG, with a planned enrollment of 2200 patients at Nordic cardiac surgery centers. The primary efficacy end point is a composite of time to all-cause death, myocardial infarction, stroke, or new coronary revascularization within 12 months after randomization. The primary safety end point is time to hospitalization due to major bleeding. Secondary efficacy end points include time to the individual components of the primary end point, cardiovascular death, and rehospitalization due to cardiovascular causes. High-quality health care registries are used to assess primary and secondary end points. The patients will be followed for 10 years. The TACSI trial will give important information useful for guiding the antiplatelet strategy in acute coronary syndrome patients treated with CABG.
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Affiliation(s)
- Carl Johan Malm
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Department of Cardiology, Linköping University Hospital, Linköping, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland; Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Jarmo Gunn
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Christian H Møller
- Department for Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Susanne J Nielsen
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ulrik Sartipy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Theis Tønnessen
- Department of Cardiothoracic Surgery, Oslo University Hospital, Norway; University of Oslo, Oslo, Norway
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
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162
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Landi A. Duration more than type of dual antiplatelet therapy matters in ACS patients with high bleeding risk. Int J Cardiol 2023; 378:10. [PMID: 36812988 DOI: 10.1016/j.ijcard.2023.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023]
Affiliation(s)
- Antonio Landi
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), CH-6900 Lugano, Switzerland; Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland.
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163
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Harris J, Pouwels KB, Johnson T, Sterne J, Pithara C, Mahadevan K, Reeves B, Benedetto U, Loke Y, Lasserson D, Doble B, Hopewell-Kelly N, Redwood S, Wordsworth S, Mumford A, Rogers C, Pufulete M. Bleeding risk in patients prescribed dual antiplatelet therapy and triple therapy after coronary interventions: the ADAPTT retrospective population-based cohort studies. Health Technol Assess 2023; 27:1-257. [PMID: 37435838 PMCID: PMC10363958 DOI: 10.3310/mnjy9014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Background Bleeding among populations undergoing percutaneous coronary intervention or coronary artery bypass grafting and among conservatively managed patients with acute coronary syndrome exposed to different dual antiplatelet therapy and triple therapy (i.e. dual antiplatelet therapy plus an anticoagulant) has not been previously quantified. Objectives The objectives were to estimate hazard ratios for bleeding for different antiplatelet and triple therapy regimens, estimate resources and the associated costs of treating bleeding events, and to extend existing economic models of the cost-effectiveness of dual antiplatelet therapy. Design The study was designed as three retrospective population-based cohort studies emulating target randomised controlled trials. Setting The study was set in primary and secondary care in England from 2010 to 2017. Participants Participants were patients aged ≥ 18 years undergoing coronary artery bypass grafting or emergency percutaneous coronary intervention (for acute coronary syndrome), or conservatively managed patients with acute coronary syndrome. Data sources Data were sourced from linked Clinical Practice Research Datalink and Hospital Episode Statistics. Interventions Coronary artery bypass grafting and conservatively managed acute coronary syndrome: aspirin (reference) compared with aspirin and clopidogrel. Percutaneous coronary intervention: aspirin and clopidogrel (reference) compared with aspirin and prasugrel (ST elevation myocardial infarction only) or aspirin and ticagrelor. Main outcome measures Primary outcome: any bleeding events up to 12 months after the index event. Secondary outcomes: major or minor bleeding, all-cause and cardiovascular mortality, mortality from bleeding, myocardial infarction, stroke, additional coronary intervention and major adverse cardiovascular events. Results The incidence of any bleeding was 5% among coronary artery bypass graft patients, 10% among conservatively managed acute coronary syndrome patients and 9% among emergency percutaneous coronary intervention patients, compared with 18% among patients prescribed triple therapy. Among coronary artery bypass grafting and conservatively managed acute coronary syndrome patients, dual antiplatelet therapy, compared with aspirin, increased the hazards of any bleeding (coronary artery bypass grafting: hazard ratio 1.43, 95% confidence interval 1.21 to 1.69; conservatively-managed acute coronary syndrome: hazard ratio 1.72, 95% confidence interval 1.15 to 2.57) and major adverse cardiovascular events (coronary artery bypass grafting: hazard ratio 2.06, 95% confidence interval 1.23 to 3.46; conservatively-managed acute coronary syndrome: hazard ratio 1.57, 95% confidence interval 1.38 to 1.78). Among emergency percutaneous coronary intervention patients, dual antiplatelet therapy with ticagrelor, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.47, 95% confidence interval 1.19 to 1.82), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.06, 95% confidence interval 0.89 to 1.27). Among ST elevation myocardial infarction percutaneous coronary intervention patients, dual antiplatelet therapy with prasugrel, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.48, 95% confidence interval 1.02 to 2.12), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.10, 95% confidence interval 0.80 to 1.51). Health-care costs in the first year did not differ between dual antiplatelet therapy with clopidogrel and aspirin monotherapy among either coronary artery bypass grafting patients (mean difference £94, 95% confidence interval -£155 to £763) or conservatively managed acute coronary syndrome patients (mean difference £610, 95% confidence interval -£626 to £1516), but among emergency percutaneous coronary intervention patients were higher for those receiving dual antiplatelet therapy with ticagrelor than for those receiving dual antiplatelet therapy with clopidogrel, although for only patients on concurrent proton pump inhibitors (mean difference £1145, 95% confidence interval £269 to £2195). Conclusions This study suggests that more potent dual antiplatelet therapy may increase the risk of bleeding without reducing the incidence of major adverse cardiovascular events. These results should be carefully considered by clinicians and decision-makers alongside randomised controlled trial evidence when making recommendations about dual antiplatelet therapy. Limitations The estimates for bleeding and major adverse cardiovascular events may be biased from unmeasured confounding and the exclusion of an eligible subgroup of patients who could not be assigned an intervention. Because of these limitations, a formal cost-effectiveness analysis could not be conducted. Future work Future work should explore the feasibility of using other UK data sets of routinely collected data, less susceptible to bias, to estimate the benefit and harm of antiplatelet interventions. Trial registration This trial is registered as ISRCTN76607611. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jessica Harris
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Thomas Johnson
- Department of Cardiology, Bristol Heart Institute, Bristol, UK
| | - Jonathan Sterne
- National Institute for Health Research Biomedical Research Centre, Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Christalla Pithara
- National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), Bristol, UK
| | | | - Barney Reeves
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | | | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Daniel Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Brett Doble
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Sabi Redwood
- National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Mumford
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Rogers
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Maria Pufulete
- Bristol Trials Centre, University of Bristol, Bristol, UK
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Alam M, Kontopantelis E, Mamas MA, Savinova OV, Jhaveri A, Siddiqui E, Jhamnani S. Meta-analysis of the effect of colchicine on C-reactive protein in patients with acute and chronic coronary syndromes. Coron Artery Dis 2023; 34:210-215. [PMID: 36762630 PMCID: PMC10073305 DOI: 10.1097/mca.0000000000001220] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
OBJECTIVE The anti-inflammatory drug colchicine has recently shown benefits in the prevention of major adverse cardiovascular events (MACE) in patients with the acute coronary syndrome (ACS) and chronic coronary syndromes (CCS). This meta-analysis focuses on understanding Colchicine's effects on the high-sensitivity C-reactive protein (hs-CRP) to provide mechanistic insight to explain its clinical event reduction. METHODS A computerized search of MEDLINE was conducted to retrieve journal articles with studies performed on humans from 1 January 2005 to 1 January 2022, using keywords: 'Colchicine AND Coronary', 'Colchicine AND CRP', and 'Colchicine AND Coronary Artery Disease'. Studies were included if they measured hs-CRP changes from baseline, and colchicine or placebo were given to patients with ACS or CCS. RESULTS Thirteen studies with a biomarker subgroup population of 1636 patients were included in the hs-CRP meta-analysis. Of those 13 studies, 8 studies with a total population of 6016 reported clinical events defined as myocardial infarction (MI), stroke, cardiovascular death, periprocedural MI, repeat angina after PCI and repeat revascularization. Multivariate analysis revealed a weak negative correlation of -0.1056 ( P = 0.805) between change in CRP and clinical events. Overall, colchicine treatment resulted in a greater reduction in hs-CRP levels compared with placebo (Mean Difference: -1.59; 95% Confidence Interval, -2.40 to -0.79, P = 0.0001) and clinical events (Odds Ratio: 0.78; 95% Confidence Interval 0.64 to 0.95, P = 0.01). CONCLUSION Colchicine therapy is associated with a reduction in hs-CRP and clinical events in patients with ACS and CCS. This finding supports colchicine's anti-inflammatory efficacy via CRP reduction to explain its clinical benefit.
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Affiliation(s)
- Mustafa Alam
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY
| | | | - Mamas A. Mamas
- Keele Cardiac Research Group, Keele University, Stoke-on-Trent, UK
| | - Olga V. Savinova
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY
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Li J, Wang Q, Wu C, Qu X, Zhang L, He X, Ma S, Qiu M, Wang X. Safety and Efficacy of Ticagrelor versus Clopidogrel in East Asian Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention Treated with Dual Antiplatelet Therapy: A Meta-Analysis of Randomized Controlled Trials. Cardiology 2023; 148:363-373. [PMID: 37094558 PMCID: PMC10614237 DOI: 10.1159/000530602] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/03/2023] [Indexed: 04/26/2023]
Abstract
INTRODUCTION The treatment strategy for dual antiplatelet therapy (DAPT) with ticagrelor has been controversial in East Asian patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Our meta-analysis aimed to demonstrate whether intensified antithrombotic regimens with ticagrelor plus aspirin have more beneficial effects and fewer adverse events compared to those of clopidogrel plus aspirin in East Asian patients with ACS undergoing PCI. METHODS We searched PubMed, Embase, Web of Science, ScienceDirect, Clinical Trials, Cochrane Library, and Chinese Clinical Trial Registry for randomized controlled trials (RCTs) comparing the efficacy of DAPT with ticagrelor or clopidogrel plus aspirin for secondary prevention of ACS in East Asian patients undergoing PCI. Risk ratios (RRs) and 95% confidence intervals (CIs) were used as the metrics of choice for assessing treatment effects. The primary endpoint was bleeding events, and the secondary endpoints were major adverse cardiovascular and cerebrovascular events (MACCEs, including cardiovascular death, nonfatal myocardial infarction [MI], and stroke), all-cause death, and definite/probable/possible stent thrombosis. The I2 index was used to assess heterogeneity. RESULTS Six RCTs involving a total of 2,725 patients met the inclusion criteria. The incidence of all bleeding events with ticagrelor was higher than that with clopidogrel (RR, 1.65; 95% CI, 1.31-2.07), but the incidence of MACCE was not significantly different between the two groups (RR, 1.08; 95% CI, 0.54-2.16). All-cause death (RR, 1.10; 95% CI, 0.67-1.79), cardiovascular death (RR, 1.42; 95% CI, 0.68-2.98), nonfatal MI (RR, 0.92; 95% CI, 0.48-1.78), stroke (RR, 1.00; 95% CI, 0.40-2.50), and stent thrombosis (RR, 0.76; 95% CI, 0.19-2.98) were not statistically different between the two groups. CONCLUSION Ticagrelor increased the risk of bleeding and did not increase treatment efficacy compared to that of clopidogrel in the East Asian population who have ACS treated with PCI.
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Affiliation(s)
- Jingyuan Li
- College of Life Science and Biopharmaceutical, Shenyang Pharmaceutical University, Shenyang, China
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Qian Wang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Chunliu Wu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiaoyu Qu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Lei Zhang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiaofeng He
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Sicong Ma
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Miaohan Qiu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiaozeng Wang
- College of Life Science and Biopharmaceutical, Shenyang Pharmaceutical University, Shenyang, China
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
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166
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Koch T, Lahu S, Coughlan JJ, Cassese S, Voll F, Ndrepepa G, Menichelli M, Valina C, Hemetsberger R, Witzenbichler B, Bernlochner I, Joner M, Xhepa E, Mayer K, Kessler T, Laugwitz KL, Richardt G, Schunkert H, Angiolillo DJ, Sibbing D, Kastrati A, Kufner S. Association between Platelet Count and Treatment Effect of Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes. Thromb Haemost 2023; 123:464-477. [PMID: 36442805 PMCID: PMC10060058 DOI: 10.1055/a-1988-5047] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/27/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The relative efficacy and safety of ticagrelor and prasugrel based dual antiplatelet therapy strategies according to the platelet count (PC) in patients with acute coronary syndromes (ACS) have not been defined. METHODS This is a posthoc analysis of the ISAR-REACT 5 trial, in which patients presenting with ACS were randomized to treatment with ticagrelor versus prasugrel. Patients were divided into quartiles according to PC. The primary endpoint was incidence of death, myocardial infarction, or stroke, and the safety endpoint was incidence of BARC (Bleeding Academic Research Consortium) type 3 to 5 bleeding at 12 months. RESULTS A total of 3,943 patients with known PC (997 patients in quartile 1 (Q1), 1,003 in quartile 2 (Q2) [205 ± 10.3 × 109/L], 961 patients in quartile 3 (Q3) [241 ± 11.7 × 109/L], and 982 patients in quartile 4 (Q4) [317 ± 68.6 × 109/L]). There was no significant interaction between treatment arm (ticagrelor vs. prasugrel) and PC group with respect to primary endpoint (Q1: 8.8 vs. 6.3%, hazard ratio [HR] =1.41, 95% confidence interval [CI]: 0.89-2.23; p = 0.148; Q2: 9.9 vs. 5.8%, HR = 1.68, 95% CI: 1.06-2.66; p = 0.027; Q3: 7.8 vs. 5.5%, HR = 1.43, 95% CI: 0.87-2.37; p = 0.159; Q4: 10.1 vs. 10.1%, HR = 1.05, 95% CI: 0.71-1.57; p = 0.799; p for interaction [p int] = 0.482) and with respect to bleeding endpoint (Q1: 5.8 vs. 4.2%, HR = 1.41, 95% CI: 0.76-2.63; p = 0.279; Q2: 6.4 vs. 3.7%, HR = 1.62, 95% CI: 0.85-2.06; p = 0.140; Q3: 4.4 vs. 3.0%, HR = 1.53, 95% CI: 0.73-3.18; p = 0.258; Q4: 5.6 vs. 8.5%, HR = 0.67, 95% CI: 0.40-1.14; p = 0.138, p int = 0.102). CONCLUSIONS In this analysis, incidences of ischemic and bleeding events at 12 months are comparable across quartiles of platelet count.
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Affiliation(s)
- Tobias Koch
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Shqipdona Lahu
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - J. J. Coughlan
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Salvatore Cassese
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Felix Voll
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Gjin Ndrepepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | | | - Christian Valina
- Department of Cardiology and Angiology II, University Heart Center Freiburg - Bad Krozingen, Standort Bad Krozingen, Germany
| | - Rayyan Hemetsberger
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | | | - Isabell Bernlochner
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael Joner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Erion Xhepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Katharina Mayer
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Thorsten Kessler
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Karl-Ludwig Laugwitz
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Gert Richardt
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Heribert Schunkert
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Iffeldorf and Ludwig-Maximilians-Universität München, Munich, Germany
| | - Adnan Kastrati
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Sebastian Kufner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
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De Caterina R. [Debate on antiplatelet monotherapy: Why not leaving out good old aspirin for clopidogrel or ticagrelor in monotherapy in chronic coronary syndromes after a percutaneous coronary intervention]. G Ital Cardiol (Rome) 2023; 24:16S-18S. [PMID: 37158026 DOI: 10.1714/4035.40100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Affiliation(s)
- Raffaele De Caterina
- Cattedra di Cardiologia, Università degli Studi, Pisa - Fondazione Villaserena per la Ricerca, Città Sant'Angelo (PE)
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Sabouret P, Spadafora L, Fischman D, Ullah W, Zeitouni M, Gulati M, De Rosa S, Savage MP, Costabel JP, Banach M, Biondi-Zoccai G, Galli M. De-escalation of antiplatelet therapy in patients with coronary artery disease: Time to change our strategy? Eur J Intern Med 2023; 110:1-9. [PMID: 36575107 DOI: 10.1016/j.ejim.2022.12.008] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/26/2022]
Abstract
Dual antiplatelet therapy (DAPT) is the gold standard after acute coronary syndromes (ACS) or chronic coronary syndromes (CCS) undergoing percutaneous coronary intervention (PCI). Because local and systemic ischemic complications can occur particularly in the early phase (i.e. 1-3 months) after ACS or PCI, the synergistic platelet inhibition of aspirin and a P2Y12 inhibitor is of the utmost importance in this early phase. Moreover, the use of the more potent P2Y12 inhibitors prasugrel and ticagrelor have shown to further reduce the incidence of ischemic events compared to clopidogrel after an ACS. On the other hand, prolonged and potent antiplatelet therapy are inevitably associated with increased bleeding, which unlike thrombotic risk, tends to be stable over time and may outweigh the benefit of reducing ischemic events in these patients. The duration and composition of antiplatelet therapy remains a topic of debate in cardiology due to competing ischemic and bleeding risks, with guidelines and recommendations considerably evolving in the past years. An emerging strategy, called "de-escalation", consisting in the administration of a less intense antithrombotic therapy after a short course of standard DAPT, has shown to reduce bleeding without any trade-off in ischemic events. De-escalation may be achieved with different antithrombotic strategies and can be either unguided or guided by platelet function or genetic testing. The aim of this review is to summarize the evidence and provide practical recommendations on the use of different de-escalation strategies in patients with ACS and CCS.
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Affiliation(s)
- Pierre Sabouret
- Heart Institute, ACTION Study Group-CHU Pitié-Salpétrière, 47-83 Boulevard de l'Hôpital, Paris, France; Collège National des Cardiologues Français (CNCF), Paris, France.
| | - Luigi Spadafora
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - David Fischman
- Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Waqas Ullah
- Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Michel Zeitouni
- Heart Institute, ACTION Study Group-CHU Pitié-Salpétrière, 47-83 Boulevard de l'Hôpital, Paris, France
| | - Martha Gulati
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, USA
| | | | | | - Juan Pablo Costabel
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz and Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy; Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
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ten Haaf ME, van Geuns RJM, van der Linden MM, Smits PC, de Vries AG, Doevendans PA, Appelman Y, Boersma E. Sex-Related Bleeding Risk in Acute Coronary Syndrome Patients Receiving Dual Antiplatelet Therapy with Aspirin and a P2Y12 Inhibitor. Med Princ Pract 2023; 32:200-208. [PMID: 36948164 PMCID: PMC10601701 DOI: 10.1159/000529863] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 02/06/2023] [Indexed: 03/24/2023] Open
Abstract
OBJECTIVE The aim of this work was to study sex differences in major bleeding risk in relation to dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). METHODS AND RESULTS The Rijnmond Collective Cardiology Research registry was designed to evaluate the application and outcomes of DAPT after ACS/PCI in the Rijnmond region in the Netherlands. Overall, 1,172 women (median age 67.5 years) and 3,087 men (median age 62.2 years) with ACS/PCI were enrolled between August 2011 and June 2013. Based on a tailored regional DAPT guideline aiming at bleeding risk minimization, 52.6% women and 66.9% men received prasugrel as first-choice P2Y12 inhibitor, in addition to aspirin. Women more frequently had contraindications for the use of prasugrel (and therefore received clopidogrel) than men (47.9 vs. 26.9%, p < 0.001). Femoral access was more common in women than in men (47.6 vs. 38.1%, p < 0.001). Women had higher incidence of major bleeding at 1 year than men (2.6 vs. 1.6%, p = 0.018). After adjustment for established bleeding risk factors, female sex was associated with over two-fold higher risk of major bleeding (adjusted hazard ratio 2.33; 95% confidence interval 1.26-4.32). This difference was apparent at discharge and appeared to be caused by access site bleedings (0.9 vs. 0.1%, p < 0.001). No sex differences were found in non-access site-related major bleeding up to 1 year. CONCLUSION Women with ACS/PCI receiving DAPT had higher major bleeding risk caused by an excess in access site bleeds, mainly in relation to the femoral approach.
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Affiliation(s)
- Monique E. ten Haaf
- Department of Cardiology, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- The Netherlands Heart Institute, Utrecht, The Netherlands
| | | | | | - Pieter C. Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Arie G. de Vries
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Pieter A. Doevendans
- The Netherlands Heart Institute, Utrecht, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
- Cardiovascular Research School Erasmus University Rotterdam (COEUR), Rotterdam, The Netherlands
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170
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Koshy AN, Giustino G, Sartori S, Hooda A, Feng Y, Snyder C, Dasgupta S, Kumar KR, Krishnamoorthy-Melarcode P, Sweeny J, Khera S, Serrao GW, Sharma R, Dangas G, Kini AS, Mehran R, Sharma SK. Ticagrelor or prasugrel versus clopidogrel in patients undergoing percutaneous coronary intervention for chronic coronary syndromes. EUROINTERVENTION 2023; 18:1244-1253. [PMID: 36660810 PMCID: PMC10018287 DOI: 10.4244/eij-d-22-00654] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/09/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Potent P2Y12 inhibitors such as ticagrelor and prasugrel are superior to clopidogrel in acute coronary syndrome (ACS) patients treated with percutaneous coronary intervention (PCI). Whether this benefit extends to a patient population with chronic coronary syndromes (CCS) is unclear. AIMS We sought to compare the safety and efficacy of prasugrel and ticagrelor versus clopidogrel in patients undergoing PCI for CCS. METHODS Consecutive patients undergoing PCI for CCS at a tertiary centre between 2014 and 2019 who were discharged on prasugrel or ticagrelor were compared with those on clopidogrel. The primary endpoint was the composite of death and myocardial infarction (MI), with secondary outcomes including rates of bleeding, stroke, and target vessel revascularisation at 1 year. RESULTS Overall, 11,508 patients were included in the study (ticagrelor/prasugrel n=2,860 [24.9%], clopidogrel n=8,648 [75.1%]) with an increasing frequency of potent P2Y12 inhibitor use over the study period (ptrend<0.001). Clopidogrel was used more frequently in patients with multimorbid risk factors, whereas anatomical or procedural complexity was associated with ticagrelor/prasugrel use (left main PCI, bifurcation PCI, number of lesions, rotational atherectomy). No difference in the incidence of death or MI was noted across the groups (ticagrelor/prasugrel vs clopidogrel: 2.7% vs 3.1%, adjusted hazard ratio [adjHR] 0.86, 95% confidence interval [CI]: 0.62-1.17; p=0.33) or secondary outcomes including bleeding (adjHR 0.75, 95% CI: 0.46-1.21; p=0.23) on propensity score stratification analysis. Additionally, no difference in the primary outcome was observed across subgroups, including those undergoing complex PCI. CONCLUSIONS Ticagrelor and prasugrel are increasingly used in patients with CCS undergoing PCI with similar 1-year efficacy and safety when compared to clopidogrel. Whether use of these agents can be beneficial in patients undergoing PCI for CCS with a high thrombotic and low bleeding risk warrants further study.
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Affiliation(s)
- Anoop N Koshy
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Cardiology, Austin Health, The University of Melbourne, Melbourne, Australia
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amit Hooda
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Clayton Snyder
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shabitri Dasgupta
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kartik R Kumar
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Joseph Sweeny
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sahil Khera
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregory W Serrao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raman Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Annapoorna S Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Tsai PC, Chuang WJ, Ko AMS, Chen JS, Chiu CH, Chen CH, Yeh YH. Neutral effects of SGLT2 inhibitors in acute coronary syndromes, peripheral arterial occlusive disease, or ischemic stroke: a meta-analysis of randomized controlled trials. Cardiovasc Diabetol 2023; 22:57. [PMID: 36915157 PMCID: PMC10012509 DOI: 10.1186/s12933-023-01789-5] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/03/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND Patients with type 2 diabetes are at increased risk for cardiovascular diseases. Sodium-glucose transport 2 inhibitors (SGLT2i) have been shown to enhance cardiovascular health since their debut as a second-line therapy for diabetes. Acute coronary syndrome (ACS), peripheral arterial occlusive disease (PAOD), and ischemic stroke (IS) are types of atherosclerotic cardiovascular disease (ASCVD), although the benefits of treating these disorders have not been shown consistently. METHODS We searched four databases (PubMed, Embase, the Cochrane library, and clinicaltrial.gov) for randomized clinical trials (RCTs) until November of 2022. Comparisons were made between SGLT2i-treated and control individuals with type 2 diabetes. Primary outcomes were ACS, PAOD, and IS; secondary outcomes included cardiovascular mortality and all-cause mortality. Risk ratio (RR) and 95% confidence intervals (CI) were determined using a fixed effects model. Cochrane's risk-of-bias (RoB2) instrument was used to assess the validity of each study that met the inclusion criteria. RESULTS We enrolled 79,504 patients with type 2 diabetes from 43 RCTs. There was no difference in the risk of ACS (RR = 0.97, 95% CI 0.89-1.05), PAOD (RR = 0.98, 95% CI 0.78-1.24), or IS (RR = 0.95, 95% CI 0.79-1.14) among patients who took an SGLT2i compared to those who took a placebo or oral hypoglycemic drugs. Subgroup analysis revealed that none of the SGLT2i treatments (canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin) significantly altered outcomes when analyzed separately. Consistent with prior findings, SGLT2i reduced the risk of cardiovascular mortality (RR = 0.85, 95% CI 0.77-0.93) and all-cause mortality (RR = 0.88, 95% CI 0.82-0.94). CONCLUSION Our results appear to contradict the mainstream concepts regarding the cardiovascular effects of SGLT2i since we found no significant therapeutic benefits in SGLT2i to reduce the incidence of ACS, PAOD, or IS when compared to placebo or oral hypoglycemic drugs.
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Affiliation(s)
- Pei-Chien Tsai
- Department and Graduate Institute of Biomedical Sciences, Chang Gung University, No. 259, Wenhua 1st Rd, Guishan Dist., Taoyuan City, 33302, Taiwan
- Master's Program in Clinical Trials and Assessment, Department of Biomedical Sciences, Chang Gung University, No. 259, Wenhua 1st Rd, Guishan Dist., Taoyuan City, 33302, Taiwan
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, No. 5, Fuxing st., Guishan Dist., Taoyuan City, 333, Taiwan
- Healthy Aging Research Center, Chang Gung University, No. 259, Wenhua 1st Rd, Guishan Dist., Taoyuan City, 33302, Taiwan
| | - Wei-Jung Chuang
- Master's Program in Clinical Trials and Assessment, Department of Biomedical Sciences, Chang Gung University, No. 259, Wenhua 1st Rd, Guishan Dist., Taoyuan City, 33302, Taiwan
| | - Albert Min-Shan Ko
- Department and Graduate Institute of Biomedical Sciences, Chang Gung University, No. 259, Wenhua 1st Rd, Guishan Dist., Taoyuan City, 33302, Taiwan
- Master's Program in Clinical Trials and Assessment, Department of Biomedical Sciences, Chang Gung University, No. 259, Wenhua 1st Rd, Guishan Dist., Taoyuan City, 33302, Taiwan
- Healthy Aging Research Center, Chang Gung University, No. 259, Wenhua 1st Rd, Guishan Dist., Taoyuan City, 33302, Taiwan
- Cardiovascular Department, Chang Gung Memorial Hospital, No. 5, Fuxing st., Guishan Dist., Taoyuan City, 333, Taiwan
| | - Jui-Shuan Chen
- Master's Program in Clinical Trials and Assessment, Department of Biomedical Sciences, Chang Gung University, No. 259, Wenhua 1st Rd, Guishan Dist., Taoyuan City, 33302, Taiwan
| | - Cheng-Hsun Chiu
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, No. 5, Fuxing st., Guishan Dist., Taoyuan City, 333, Taiwan
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, No. 5, Fuxing st., Guishan Dist., Taoyuan City, 333, Taiwan
| | - Chun-Han Chen
- Master's Program in Clinical Trials and Assessment, Department of Biomedical Sciences, Chang Gung University, No. 259, Wenhua 1st Rd, Guishan Dist., Taoyuan City, 33302, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, No. 5, Fuxing st., Guishan Dist., Taoyuan City, 333, Taiwan.
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd, Guishan Dist., Taoyuan City, 33302, Taiwan.
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172
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Gumiężna K, Baruś P, Sygitowicz G, Wiśniewska A, Ochijewicz D, Pasierb K, Klimczak-Tomaniak D, Kuca-Warnawin E, Kochman J, Grabowski M, Opolski G, Tomaniak M, Filipiak KJ. Immature platelet fraction in cardiovascular diagnostics and antiplatelet therapy monitoring. Cardiol J 2023; 30:817-824. [PMID: 36908161 PMCID: PMC10635728 DOI: 10.5603/cj.a2023.0019] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 09/11/2022] [Accepted: 12/09/2022] [Indexed: 03/14/2023] Open
Abstract
Immature platelet fraction (IPF), circulating platelets still containing RNA, can be easily calculated by automated flow cytometry, this makes them an accessible biomarker. Higher IPF concentrations were reported in patients with thrombocytopenia, patients who were smokers, and also those who were diabetics. Several studies have reported their diagnostic and prognostic importance in patients presenting with acute coronary syndromes, especially ST-segment elevation myocardial infarction, where increased IPF level is an independent predictor of cardiovascular death. In addition, higher IPF were reported in patients with inadequate response to either clopidogrel or prasugrel, suggesting their potential role in antiplatelet therapy monitoring. Their prognostic significance was also observed in both coronary artery disease and postcardiac surgery status, where their higher levels correlated with the risk of major adverse cardiac events. The current review aims to present the current evidence on diagnostic, prognostic and potentially therapeutic roles of IPF in cardiovascular medicine.
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Affiliation(s)
- Karolina Gumiężna
- First Department of Cardiology, Medical University of Warsaw, Poland
| | - Piotr Baruś
- First Department of Cardiology, Medical University of Warsaw, Poland
| | - Grażyna Sygitowicz
- Department of Clinical Chemistry and Laboratory Diagnostics, Medical University of Warsaw, Poland
| | | | - Dorota Ochijewicz
- First Department of Cardiology, Medical University of Warsaw, Poland
| | - Karolina Pasierb
- First Department of Cardiology, Medical University of Warsaw, Poland
| | - Dominika Klimczak-Tomaniak
- Department of Cardiology, Hypertension and Internal Medicine, Medical University of Warsaw, Poland
- Department of Immunology, Transplantation and Internal Medicine, Medical University of Warsaw, Poland
| | - Ewa Kuca-Warnawin
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Janusz Kochman
- First Department of Cardiology, Medical University of Warsaw, Poland
| | - Marcin Grabowski
- First Department of Cardiology, Medical University of Warsaw, Poland
| | - Grzegorz Opolski
- First Department of Cardiology, Medical University of Warsaw, Poland
| | - Mariusz Tomaniak
- First Department of Cardiology, Medical University of Warsaw, Poland.
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173
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Mahmood MM, Nawaz MJ. Prescription of statins after acute coronary syndrome; a single-centre observational study. J PAK MED ASSOC 2023; 73:646-649. [PMID: 36932772 DOI: 10.47391/jpma.4328] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
There is limited information about the current use of high-intensity statins (HIS) after acute coronary syndrome (ACS) in Pakistani patients. We studied the prescription of HIS in patients admitted with ACS to Ittefaq Hospital, Lahore, Pakistan, from February 2019 to December 2019. Among the 411 patients, 221 (53.8%) patients underwent Percutaneous Coronary Intervention (PCI), 62 (15.1%) were referred for Coronary Artery Bypass Graft (CABG), and 128 (31.1%) were treated medically. Overall 408 (99.3%) patients were prescribed statins and 198 (48.2%) received HIS, with 45 (10.9%) patients receiving maximally allowed dose (Atorvastatin 80mg or Rosuvastatin 40mg). Patients treated with PCI were more likely to be prescribed HIS (73.3% vs 26.7%, p <0.001), while older patients (>75 years of age), those treated medically, and patients with severely reduced LV systolic function were significantly less likely to receive HIS (p <0.001). Our study, therefore, identifies a gap in implementation of guidelines for HIS use, particularly among the medically treated ACS patients.
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174
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Jimeno Sánchez J, Chabbar Boudet MC, Morlanes Gracia P, Laita Monreal S, López Perales CR, Cuko G, Albarrán Martín C, Garza Benito F. [Anti-smoking intervention in the acute phase of acute coronary syndrome: Is there additional benefit in patients included in a cardiac rehabilitation program?]. J Healthc Qual Res 2023; 38:105-111. [PMID: 35933320 DOI: 10.1016/j.jhqr.2022.06.005] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/30/2022] [Accepted: 06/27/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Smoking is a challenge in secondary prevention after acute coronary syndrome (ACS). The objective was to assess whether the early anti-smoking intervention (ASI), in the acute hospitalization phase, improves the abstinence rate obtained during a cardiac rehabilitation program (CRP). METHODS Multicenter clinical trial in which smoker patients admitted for ACS were randomized 1:1 to receive or not ASI from the first day of admission. Upon discharge, both groups were referred to the CRP, performing abstinence controls using co-oximetry. Patients lost were considered smokers. RESULTS 72 patients were included, 58 men (80.5%), mean age 53 ± 8.1 years. They were admitted for ST elevation myocardial infarction 42 (58%), non-ST elevation myocardial infarction 29 (40%) and unstable angina 1 (1.3%). They smoked an average of 22 ± 11.3 cigarettes/day (pack-year index 37 ± 20). They completed the Richmond test (8.8 ± 1.3) and Fagestrom (5.69 ± 2.1). 36 patients (50%) were randomized to ASI, with no differences in the baseline characteristics of both groups. The dropout rate at the time of inclusion in CRP was higher in the ASI group (69 vs. 44%; p 0.034; OR 2.84), without statistical significance at discharge from the CRP (58 vs. 50%; p 0.478; OR 1.4) or at 12 months (58 vs. 44%; p 0.24; OR 1.75). CONCLUSIONS The ASI during admission significantly improves the smoking cessation rate at the time of inclusion in the CRP. Part of these beneficial effects are reduced in the follow-up losing statistical significance with respect to the control group.
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Affiliation(s)
| | - M C Chabbar Boudet
- Hospital Universitario Miguel Servet, Zaragoza, España; Hospital Nuestra Señora de Gracia, Zaragoza, España
| | | | | | | | - G Cuko
- Hospital Nuestra Señora de Gracia, Zaragoza, España
| | - C Albarrán Martín
- Hospital Nuestra Señora de Gracia, Zaragoza, España; Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - F Garza Benito
- Hospital Nuestra Señora de Gracia, Zaragoza, España; Hospital Royo Villanova, Zaragoza, España
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175
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Greco A, Finocchiaro S, Angiolillo DJ, Capodanno D. Advances in the available pharmacotherapy for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Expert Opin Pharmacother 2023; 24:453-471. [PMID: 36693142 DOI: 10.1080/14656566.2023.2171788] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 01/19/2023] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Non-ST-segment elevation acute coronary syndromes (NSTE-ACS), including non-ST-segment-elevation myocardial infarction (NSTEMI) and unstable angina, represent a leading cause of mortality worldwide, with important socio-economic consequences. NSTEMI accounts for the majority of acute coronary syndromes and usually develops on the background of a nonocclusive thrombus. We searched for relevant literature in the field in PubMed and clinicaltrials.gov as of July 2022. AREAS COVERED A number of pharmacotherapies are currently available for treatment and secondary prevention, mainly including antithrombotic, lipid-lowering and anti-inflammatory drugs. Pretreatment with aspirin, anticoagulant and statin therapy is of key importance in the preprocedural phase, while pretreating with an oral P2Y12 inhibitor is not routinely indicated in patients undergoing early invasive management. For patients undergoing percutaneous coronary revascularization, pharmacotherapy essentially consists of antithrombotic drugs, which should be carefully selected. Finally, antithrombotic, lipid-lowering and anti-inflammatory drugs are important components of long-term secondary prevention after a NSTE-ACS. EXPERT OPINION This article reviews the evidence supporting recommendation on pharmacotherapy in patients presenting with a NSTE-ACS. Several randomized clinical trials are still ongoing and are expected to further inform scientific knowledge and clinical practice, with the final aim to improve the treatment of NSTE-ACS patients.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
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176
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Levens AD, den Haan MC, Jukema JW, Heringa M, van den Hout WB, Moes DJAR, Swen JJ. Feasibility of Community Pharmacist-Initiated and Point-of-Care CYP2C19 Genotype-Guided De-Escalation of Oral P2Y12 Inhibitors. Genes (Basel) 2023; 14:genes14030578. [PMID: 36980851 PMCID: PMC10048116 DOI: 10.3390/genes14030578] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 03/02/2023] Open
Abstract
Tailoring antiplatelet therapy based on CYP2C19 pharmacogenetic (PGx) testing can improve cardiovascular outcomes and potentially reduce healthcare costs in patients on a P2Y12-inhibitor regime with prasugrel or ticagrelor. However, ubiquitous adoption—particularly in an outpatient setting—remains limited. We conducted a proof-of-concept study to evaluate the feasibility of CYP2C19-guided de-escalation of prasugrel/ticagrelor to clopidogrel through point-of-care (POC) PGx testing in the community pharmacy. Multiple feasibility outcomes were assessed. Overall, 144 patients underwent CYP2C19 PGx testing in 27 community pharmacies. Successful test results were obtained in 142 patients (98.6%). De-escalation to clopidogrel occurred in 19 patients (20%) out of 95 (67%) eligible for therapy de-escalation, which was mainly due to PGx testing not being included in cardiology guidelines. Out of the 119 patients (84%) and 14 pharmacists (100%) surveyed, 109 patients (92%) found the community pharmacy a suitable location for PGx testing, and the majority of pharmacists (86%) thought it has added value. Net costs due to PGx testing were estimated at €43 per patient, which could be reduced by earlier testing and could turn into savings if de-escalation would double to 40%. Although the observed de-escalation rate was low, POC CYP2C19-guided de-escalation to clopidogrel appears feasible in a community pharmacy setting.
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Affiliation(s)
- Amar D. Levens
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Melina C. den Haan
- Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - J. Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands
| | - Mette Heringa
- SIR Institute for Pharmacy Practice and Policy, 2331 JE Leiden, The Netherlands
| | - Wilbert B. van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Dirk Jan A. R. Moes
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Jesse J. Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Correspondence:
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177
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Bagyawantha NMY, Coombes ID, Gawarammana I, Fahim M. Impact of a clinical pharmacist on optimising the quality use of medicines according to the acute coronary syndrome (ACS) secondary prevention guidelines and medication adherence following discharge in patients with ACS in Sri Lanka: a prospective non-randomised controlled trial study protocol. BMJ Open 2023; 13:e059413. [PMID: 36759028 PMCID: PMC9923319 DOI: 10.1136/bmjopen-2021-059413] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
OBJECTIVES Ensuring quality use of medicines (QUM) through clinical pharmacy services can improve therapeutic outcomes of patients diagnosed with acute coronary syndrome (ACS). The major objective of this study is to demonstrate the added value of a clinical pharmacist to the medical and nursing team providing care to patients with ACS on the continuation of quality use of the patients' medicine after discharge. STUDY DESIGN This protocol outlines a prospective, non-blinded, non-randomised, controlled interventional study. STUDY SETTING The study will be conducted at the professorial medical wards of a tertiary care teaching hospital in Sri Lanka. PARTICIPANTS Sample size will be 746 patients in both control and intervention arms. Patients diagnosed with ACS who are 18 years old or above and expected to visit the hospital for their routine clinic follow-ups after discharge will be recruited and randomised 1:1 to either the intervention group or the control group. Patients who are diagnosed and suffering from psychological disorders will be excluded from this study. INTERVENTIONS The planned interventions that will be delivered at discharge include review and optimisation of medications, assessing patient adherence and providing discharge medication counselling. Data will be collected at recruitment, 1 month, 3 months and 6 months' time intervals in both groups. Improvement of patients' medication adherence, reduction of hospital readmissions, reduction of drug-related problems, the attitude of doctors and nurses towards clinical pharmacy services and the cost-effectiveness of the clinical pharmacy services will be the major outcomes of this study. ETHICS AND DISSEMINATION Ethical approval for this study has been obtained from the ethics review committee, Faculty of Medicine, University of Peradeniya (2019/EC/26) and the trial is registered at the Sri Lanka Clinical Trials Registry. The results of this study will be disseminated via conference proceedings, journal publications and thesis presentations. TRIAL REGISTRATION NUMBER SLCTR/2019/039.
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Affiliation(s)
- Nanayakkara Muhandiramalaya Yasakalum Bagyawantha
- Department of Pharmacy, Faculty of Allied Health Sciences, University of Peradeniya, Peradeniya, Central, Sri Lanka
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Ian D Coombes
- School of Pharmacy, The University of Queensland, Saint Lucia, Queensland, Australia
- Collaboration of Australians and Sri Lankans for Pharmacy Practice, Education and Research (CASPPER), Brisbane, Queensland, Australia
| | - Indika Gawarammana
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Central, Sri Lanka
| | - Mohamed Fahim
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- School of Pharmacy, University of Sydney, Sydney, New South Wales, Australia
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178
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O'Malley K, Hwang YJ, Trost J, Feldman L. Things We Do for No Reason™: Routine pretreatment with a P2Y12 receptor inhibitor before invasive coronary angiography for patients with a non-ST elevation acute coronary syndrome. J Hosp Med 2023; 18:177-180. [PMID: 35920593 DOI: 10.1002/jhm.12931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 05/06/2022] [Revised: 07/13/2022] [Accepted: 07/20/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Kevin O'Malley
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yoseob Joseph Hwang
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeffrey Trost
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Leonard Feldman
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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179
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Berwanger O. Rivaroxaban for Patients With Acute Coronary Syndromes-Where Do We Stand? JAMA Netw Open 2023; 6:e2255724. [PMID: 36763365 DOI: 10.1001/jamanetworkopen.2022.55724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 02/11/2023] Open
Affiliation(s)
- Otavio Berwanger
- George Institute for Global Health UK, Imperial College London, London, United Kingdom
- Hospital Israelita Albert Einstein, São Paulo, Brazil
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180
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Kumar A, Lutsey PL, St Peter WL, Schommer JC, Van't Hof JR, Rajpurohit A, Farley JF. Comparative Effectiveness of Ticagrelor, Prasugrel, and Clopidogrel for Secondary Prophylaxis in Acute Coronary Syndrome: A Propensity Score-Matched Cohort Study. Clin Pharmacol Ther 2023; 113:401-411. [PMID: 36399019 PMCID: PMC9877194 DOI: 10.1002/cpt.2797] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022]
Abstract
Comparative effectiveness evaluation of newer P2Y12 inhibitors (prasugrel and ticagrelor) compared with clopidogrel after acute coronary syndrome (ACS) is limited in real-world US populations. The objective of this study was to evaluate cardiovascular events based on ticagrelor, prasugrel, and clopidogrel use in a real-world patient setting. This retrospective cohort study used the IBM MarketScan database (January 1, 2013, to December 31, 2018) to create three propensity score-matched pairs: ticagrelor vs. clopidogrel (N = 21,719), prasugrel vs. clopidogrel (N = 11,513), and prasugrel vs. ticagrelor (N = 11,065). The primary outcome was a composite of myocardial ischemia, unstable angina, stroke, and heart failure hospitalization. These groups were compared in a time-to-event analysis for the primary outcome at 30, 90, and 180 days following P2Y12 inhibitors initiation after percutaneous coronary intervention. Compared with clopidogrel, ticagrelor use suggested a 10% reduction in the primary outcome at 90 days (hazard ratio (HR): 0.90, 95% confidence interval (CI): 0.82-0.99). There were no differences for all other matched pairs or follow-up combinations. In the subgroup analysis of females, the results suggested a risk reduction of 27% for prasugrel at 30 days (HR: 0.73, 95% CI: 0.53-1.00) and 17% for ticagrelor at 90 days (HR: 0.83, 95% CI: 0.70-0.98) when compared with clopidogrel. Among patients treated with bare-metal stents, the results suggested that prasugrel vs. ticagrelor was associated with a 55% and 33% reduced risk for the primary outcome at 30 days and 180 days, respectively. With limited evidence in the United States comparing these drugs, this study helps inform clinicians when choosing P2Y12 inhibitors after ACS.
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Affiliation(s)
- Arun Kumar
- Department of Pharmacy Practice & Administrative SciencesJames L. Winkle College of Pharmacy, University of CincinnatiCincinnatiOhioUSA
| | - Pamela L. Lutsey
- Division of Epidemiology and Community HealthSchool of Public Health, University of MinnesotaMinneapolisMinnesotaUSA
| | - Wendy L. St Peter
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
| | - Jon C. Schommer
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
| | - Jeremy R. Van't Hof
- Cardiovascular Division and Lillehei Heart InstituteUniversity of Minnesota Medical SchoolMinneapolisMinnesotaUSA
| | - Abhijeet Rajpurohit
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
| | - Joel F. Farley
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
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181
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Thomas CD, Williams AK, Lee CR, Cavallari LH. Pharmacogenetics of P2Y 12 receptor inhibitors. Pharmacotherapy 2023; 43:158-175. [PMID: 36588476 PMCID: PMC9931684 DOI: 10.1002/phar.2758] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 01/03/2023]
Abstract
Oral P2Y12 inhibitors are commonly prescribed for cardiovascular disease and include clopidogrel, prasugrel, and ticagrelor. Each of these drugs has its strengths and weaknesses. Prasugrel and ticagrelor are more potent inhibitors of platelet aggregation and were shown to be superior to clopidogrel in preventing major adverse cardiovascular events after an acute coronary syndrome and percutaneous coronary intervention (PCI) in the absence of genotyping. However, both are associated with an increased risk for non-coronary artery bypass-related bleeding. Clopidogrel is a prodrug requiring bioactivation, primarily via the CYP2C19 enzyme. Approximately 30% of individuals have a CYP2C19 no function allele and decreased or no CYP2C19 enzyme activity. Clopidogrel-treated carriers of a CYP2C19 no function allele have decreased exposure to the clopidogrel active metabolite and lesser inhibition of platelet aggregation, which likely contributed to reduced clopidogrel efficacy in clinical trials. The pharmacogenetic data for clopidogrel are most robust in the setting of PCI, but evidence is accumulating for other indications. Guidance is available from expert consensus groups and regulatory agencies to assist with integrating genetic information into P2Y12 inhibitor prescribing decisions, and CYP2C19 genotype-guided antiplatelet therapy after PCI is one of the most common examples of clinical pharmacogenetic implementation. Herein, we review the evidence for pharmacogenetic associations with clopidogrel response and outcomes with genotype-guided P2Y12 inhibitor selection and describe guidance to assist with pharmacogenetic implementation. We also describe processes for applying genotype data for P2Y12 inhibitor therapy selection and remaining gaps in the field. Ultimately, consideration of both clinical and genetic factors may guide selection of P2Y12 inhibitor therapy that optimally balances the atherothrombotic and bleeding risks.
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Affiliation(s)
- Cameron D Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Alexis K Williams
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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182
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Zhou S, Xiao Y, Zhou C, Zheng Z, Jiang W, Shen Q, Zhu C, Pan H, Liu C, Zeng G, Ge L, Zhang Y, Ouyang Z, Fu G, Pan G, Chen F, Huang L, Liu Q. Effect of Rivaroxaban vs Enoxaparin on Major Cardiac Adverse Events and Bleeding Risk in the Acute Phase of Acute Coronary Syndrome: The H-REPLACE Randomized Equivalence and Noninferiority Trial. JAMA Netw Open 2023; 6:e2255709. [PMID: 36763358 PMCID: PMC9918885 DOI: 10.1001/jamanetworkopen.2022.55709] [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] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
IMPORTANCE Parenteral enoxaparin is a preferred anticoagulant used in the acute phase for patients with acute coronary syndrome (ACS). The safety and efficacy of short-term low-dose rivaroxaban in this clinical setting remain unknown. OBJECTIVE To compare the safety and efficacy of rivaroxaban vs enoxaparin in the acute phase of ACS. DESIGN, SETTING, AND PARTICIPANTS This multicenter, prospective, open-label, active-controlled, equivalence and noninferiority trial was conducted from January 2017 through May 2021 with a 6-month follow-up at 21 hospitals in China. Participants included patients with ACS missing the primary reperfusion window or before selective revascularization. Data were analyzed from November 2021 to November 2022. INTERVENTIONS Participants were randomized 1:1:1 to oral rivaroxaban 2.5 mg or 5 mg or 1 mg/kg subcutaneous enoxaparin twice daily in addition to dual antiplatelet therapy (DAPT; aspirin 100 mg and clopidogrel 75 mg once daily) for a mean of 3.7 days. MAIN OUTCOMES AND MEASURES The primary safety end point was bleeding events, as defined by the International Society on Thrombosis and Haemostasis, and the primary efficacy end point was major adverse cardiovascular events (MACEs), including cardiac death, myocardial infarction, rerevascularization, or stroke during the 6-month follow-up. RESULTS Of 2055 enrolled patients, 2046 (99.6%) completed the trial (mean [SD] age 65.8 [8.2] years, 1443 [70.5%] male) and were randomized to enoxaparin (680 patients), rivaroxaban 2.5 mg (683 patients), or rivaroxaban 5 mg (683 patients). Bleeding rates were 46 patients (6.8%) in the enoxaparin group, 32 patients (4.7%) in the rivaroxaban 2.5 mg group, and 36 patients (5.3%)in the rivaroxaban 5 mg group (rivaroxaban 2.5 mg vs enoxaparin: noninferiority hazard ratio [HR], 0.68; 95% CI, 0.43 to 1.07; P = .005; rivaroxaban 5 mg vs enoxaparin: noninferiority HR, 0.88; 95% CI, 0.70 to 1.09; P = .001). The incidence of MACEs was similar among groups, and noninferiority was reached in the rivaroxaban 5 mg group (HR, 0.60; 95% CI, 0.31 to 1.16, P = .02) but not in the rivaroxaban 2.5 mg group (HR, 0.68; 95% CI, 0.36 to 1.30; P = .05) compared with the enoxaparin group. CONCLUSIONS AND RELEVANCE In this equivalence and noninferiority trial, oral rivaroxaban 5 mg showed noninferiority to subcutaneous enoxaparin (1 mg/kg) for patients with ACS treated with DAPT during the acute phase. Results of this feasibility study provide useful information for designing future randomized clinical trials with sufficient sample sizes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03363035.
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Affiliation(s)
- Shenghua Zhou
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, People’s Republic of China
| | - Yichao Xiao
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, People’s Republic of China
| | - Chonglun Zhou
- Department of Cardiology, Xiangxiang People’s Hospital, Xiangxiang, People’s Republic of China
| | - Zhaofen Zheng
- Department of Cardiology, Hunan Provincial People’s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, People’s Republic of China
| | - Weihong Jiang
- Department of Cardiology, Third Xiangya Hospital of Central South University, Changsha, People’s Republic of China
| | - Qiang Shen
- Department of Cardiology, First People’s Hospital of Huaihua, Huaihua, People’s Republic of China
| | - Can Zhu
- Department of Cardiology, First Affiliated Hospital of Jishou University, Jishou, People’s Republic of China
| | - Hongwei Pan
- Department of Cardiology, Hunan Provincial People’s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, People’s Republic of China
| | - Changhui Liu
- Department of Cardiology, First Affiliated Hospital of University of South China, Hengyang, People’s Republic of China
| | - Gaofeng Zeng
- Department of Cardiology, Second Affiliated Hospital of University of South China, Hengyang, People’s Republic of China
| | - Liangqing Ge
- Department of Cardiology, First People’s Hospital of Changde City, Changde, People’s Republic of China
| | - Yumin Zhang
- Department of Cardiology, Third Hospital of Changsha, Changsha, People’s Republic of China
| | - Zewei Ouyang
- Department of Cardiology, Central Hospital of Shaoyang, Shaoyang, People’s Republic of China
| | - Guang Fu
- Department of Cardiology, First Hospital of Changsha, Changsha, People’s Republic of China
| | - Gang Pan
- Department of Cardiology, First People’s Hospital of Yueyang, Yueyang, People’s Republic of China
| | - Feng Chen
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, People’s Republic of China
| | - Lihong Huang
- Department of Biostatistics, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Qiming Liu
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, People’s Republic of China
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183
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Cimmino G, Loffredo FS, De Rosa G, Cirillo P. Colchicine in Athero-Thrombosis: Molecular Mechanisms and Clinical Evidence. Int J Mol Sci 2023; 24:ijms24032483. [PMID: 36768804 PMCID: PMC9917272 DOI: 10.3390/ijms24032483] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
Several lines of evidence have clearly indicated that inflammation plays a pivotal role in the development of atherosclerosis and of its thrombotic complications such as acute coronary syndromes or ischemic stroke. Thus, it has been postulated that the use of anti-inflammatory agents might be extremely useful to improve cardiovascular outcome. Recently, increasing attention has been reserved to one of the oldest plant-derived drugs still in use in clinical practice, colchicine that has been used as drug to treat inflammatory diseases such gout or Mediterranean fever. To date, current guidelines of the European Society of Cardiology have included colchicine as first line choice for treatment of acute and recurrent pericarditis. Moreover, several studies have investigated its role in the clinical scenarios of cardiovascular disease including chronic and acute coronary syndromes with promising results. In this review, starting from a description of the mechanism(s) involved behind its anti-inflammatory effects, we give an overview on its potential effects in atherothrombosis and finally present an updated overview of clinical evidence on the role of this drug in cardiovascular disease.
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Affiliation(s)
- Giovanni Cimmino
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
- Correspondence: ; Tel.: +39-081-7064239
| | - Francesco S. Loffredo
- Department of Advanced Biomedical Sciences, Section of Cardiology, University of Naples “Federico II”, 80131 Naples, Italy
| | - Gennaro De Rosa
- Department of Advanced Biomedical Sciences, Section of Cardiology, University of Naples “Federico II”, 80131 Naples, Italy
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, Section of Cardiology, University of Naples “Federico II”, 80131 Naples, Italy
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184
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Dimitroglou Y, Aggeli C, Theofilis P, Tsioufis P, Oikonomou E, Tsioufis K, Tousoulis D. Lipoprotein(a) as a Predictive Biomarker and Therapeutic Target for Acute Coronary Syndromes. Curr Pharm Des 2023; 29:1835-1843. [PMID: 37264657 DOI: 10.2174/1381612829666230601155001] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/05/2023] [Accepted: 05/03/2023] [Indexed: 06/03/2023]
Abstract
Coronary artery disease (CAD) is the leading cause of morbidity and mortality in Western societies, despite the significant advances that have improved primary and secondary prevention. Hence, several novel biomarkers have been identified as potential diagnostic and therapeutic targets which could improve outcomes even when traditional risk factors are well-controlled. Lipoprotein (a) [Lp(a)] has pro-atherogenic, pro-thrombotic, and pro-inflammatory properties, and its levels are relatively constant and genetically predetermined. Several epidemiological studies have associated high Lp(a) with increased risk for acute coronary syndromes (ACS) even when other CAD risk factors are included in the multivariate analysis. However, until recently, specific therapeutic options targeting Lp(a) were not associated, and thus, Lp(a) is currently used as a risk and treatment modifying biomarker with guidelines suggesting the intensified treatment of low-density lipoprotein in intermediate- to-high-risk patients with increased Lp(a) levels. Lately, specific treatment options targeting Lp(a) have become available and include antisense oligonucleotides and small-interfering RNA, which induce a robust reduction of Lp(a). Results of ongoing phase-3 trials will answer whether Lp(a) will become a biomarker specifically treated to reduce the burden of cardiovascular mortality. The scope of this review article is to present the current evidence regarding the use of Lp(a) as a biomarker, predictive of increased CAD risk, and to discuss the future perspectives on pharmaceutical reduction of Lp(a) as a therapeutic target in high-risk patients.
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Affiliation(s)
- Yannis Dimitroglou
- 1st Cardiology Clinic, 'Hippokration' General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantina Aggeli
- 1st Cardiology Clinic, 'Hippokration' General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Theofilis
- 1st Cardiology Clinic, 'Hippokration' General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Tsioufis
- 1st Cardiology Clinic, 'Hippokration' General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Oikonomou
- 1st Cardiology Clinic, 'Hippokration' General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Tsioufis
- 1st Cardiology Clinic, 'Hippokration' General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Clinic, 'Hippokration' General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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185
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Costabel JP, Duronto E, Guetta J, Ceresetto J, Guardiani F, Fescina JP, Procopio G, Casey M, Higa C, Villareal R, Bonorino J, Lamelas P. [Use of parenteral anticoagulants in patients with coronary syndrome]. Medicina (B Aires) 2023; 83:948-965. [PMID: 38117714] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
Anticoagulant treatment, together with antiplatelet therapy, plays an important role in the treatment of acute coronary syndromes. Its use is associated with a reduction in new ischemic events, stent thrombosis, and lower mortality. However, in clinical practice there is great heterogeneity in its use, leading to suboptimal results in treatment. This paper conducts a narrative review on the use of parenteral anticoagulants in patients with acute coronary syndromes, depending on the clinical scenario, as well as the revascularization strategy used and the bleeding risk. The different anticoagulant schemes available in acute coronary syndromes with and without segment ST elevation are addressed, based on the updated evidence. Finally, evidence-based strategies for risk stratification for bleeding and therapeutic management are developed.
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Affiliation(s)
- Juan P Costabel
- Servicio de Cardiología, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina. E-mail:
| | - Ernesto Duronto
- Servicio de Cardiología, Fundación Favaloro, Buenos Aires, Argentina
| | - Javier Guetta
- Servicio de Cardiología, Centro de Educación Medica e Investigaciones Clínicas Norberto Quirno (CEMIC), Buenos Aires, Argentina
| | - José Ceresetto
- Servicio de Cardiología, Hospital Británico, Buenos Aires, Argentina
| | | | - Juan P Fescina
- Servicio de Cardiología, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Gastón Procopio
- Servicio de Cardiología, Fundación Favaloro, Buenos Aires, Argentina
| | - Marcelo Casey
- Servicio de Cardiología, FLENI, Buenos Aires, Argentina
| | - Claudio Higa
- Servicio de Cardiología, Hospital Alemán, Buenos Aires, Argentina
| | | | - José Bonorino
- Servicio de Cardiología, Hospital Austral, Buenos Aires, Argentina
| | - Pablo Lamelas
- Servicio de Cardiología, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
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186
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Sagris M, Theofilis P, Papanikolaou A, Antonopoulos AS, Tsioufis C, Tousoulis D. Direct Oral Anticoagulants use in Patients with Stable Coronary Artery Disease, Acute Coronary Syndrome or Undergoing Percutaneous Coronary Intervention. Curr Pharm Des 2023; 29:2787-2794. [PMID: 38038010 DOI: 10.2174/0113816128259508231118141831] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/27/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023]
Abstract
The investigation for the optimal anticoagulation strategy for patients with stable coronary artery disease, acute coronary syndromes, and undergoing percutaneous coronary intervention constitutes a great challenge for physicians and is a field of extensive research. Although aspirin is commonly recommended as a protective measure for all patients with coronary artery disease and dual antiplatelet therapy for those undergoing procedures, such as percutaneous coronary intervention or coronary artery bypass graft surgery, the risk of recurrent cardiovascular events remains significant. In this context, the shortcomings associated with the use of vitamin K antagonists have led to the assessment of direct oral anticoagulants as promising alternatives. This review will explore and provide a comprehensive analysis of the existing data regarding the use of direct oral anticoagulants in patients with stable coronary artery disease or acute coronary syndrome, as well as their effectiveness in those undergoing percutaneous coronary intervention or coronary artery bypass graft surgery.
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Affiliation(s)
- Marios Sagris
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Panagiotis Theofilis
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Angelos Papanikolaou
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Alexios S Antonopoulos
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Constantinos Tsioufis
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
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187
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Şabanoğlu C, Sinan ÜY, Akboğa MK, Çoner A, Gök G, Kocabaş U, Bekar L, Gazi E, Cengiz M, Kılıç S, İnanç İH, Çakmak HA, Zoghi M. Long-Term Prognosis of Patients with Heart Failure: Follow-Up Results of Journey HF-TR Study Population. Anatol J Cardiol 2023; 27:26-33. [PMID: 36680444 PMCID: PMC9893707 DOI: 10.14744/anatoljcardiol.2022.2171] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/21/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Despite advances in therapeutic management of patients with heart failure, there is still an increasing morbidity and mortality all over the world. In this study, we aimed to present the 3-year follow-up outcomes of patients included in the Journey HF-TR study in 2016 that has evaluated the clinical characteristics and management of patients with acute heart failure admitted to the hospital and present a national registry data. METHODS The study was designed retrospectively between November 2016 and December 2019. Patient data included in the previously published Journey HF-TR study were used. Among 1606 patients, 1484 patients were included due to dropout of 122 patients due to inhospital death and due to exclusion of 173 due to incomplete data. The study included 1311 patients. Age, gender, concomitant chronic conditions, precipitating factors, New York Heart Association, and left ventricular ejection fraction factors were adjusted in the Cox regression analysis. RESULTS During the 3-year follow-up period, the ratio of hospitalization and mortality was 70.5% and 52.1%, respectively. Common causes of mortality were acute decompensation of heart failure and acute coronary syndrome. Angiotensin receptor blockers, betablockers, statin, and sacubitril/valsartan were found to reduce mortality. Hospitalization due to acute decompensated heart failure, acute coronary syndrome, lung diseases, oncological diseases, and cerebrovascular diseases was associated with the increased risk of mortality. Implantation of cardiac devices also reduced the mortality. CONCLUSIONS Despite advances in therapeutic management of patients with heart failure, our study demonstrated that the long-term mortality still is high. Much more efforts are needed to improve the inhospital and long-term survival of patients with chronic heart failure.
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Affiliation(s)
- Cengiz Şabanoğlu
- Department of Cardiology, Kırıkkale Yüksek İhtisas Hospital, Kırıkkale, Turkey
| | - Ümit Yaşar Sinan
- Department of Cardiology, İstanbul University-Cerrahpaşa Institute of Cardiology, İstanbul, Turkey
| | - Mehmet Kadri Akboğa
- Department of Cardiology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ali Çoner
- Department of Cardiology, Başkent University Hospital, Antalya, Turkey
| | - Gülay Gök
- Department of Cardiology, Faculty of Medicine, İstanbul Medipol University, İstanbul, Turkey
| | - Umut Kocabaş
- Department of Cardiology, Başkent University Hospital, İzmir, Turkey
| | - Lütfü Bekar
- Department of Cardiology, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Emine Gazi
- Department of Cardiology, Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Mahir Cengiz
- Department of Cardiology, Faculty of Medicine, İstanbul Aydın University, İstanbul, Turkey
| | - Salih Kılıç
- Department of Cardiology, Adana City Training and Research Hospital, Adana, Turkey
| | - İbrahim Halil İnanç
- Department of Cardiology, Faculty of Medicine, Haliç University, İstanbul, Turkey
| | - Hüseyin Altuğ Çakmak
- Department of Cardiology, Adana City Training and Research Hospital, Adana, Turkey
| | - Mehdi Zoghi
- Department of Cardiology, Ege University Hospital, İzmir, Turkey
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188
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Li Y, Zhao R, Yu P, Xu Y, Zhang Q, Han Y. The Increased Ischemic Risk During the Early Period After Clopidogrel Noncompliance in Patients with Acute Coronary Syndrome: A Meta-Analysis. Clin Appl Thromb Hemost 2023; 29:10760296231196477. [PMID: 37644847 PMCID: PMC10469223 DOI: 10.1177/10760296231196477] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/03/2023] [Indexed: 08/31/2023] Open
Abstract
Although dual antiplatelet therapy for secondary prevention in acute coronary syndrome (ACS) is highly recommended by current guidelines, P2Y12 inhibitor non-adherence often occurs and devastates prognosis. To evaluate whether the ischemic risk during the early period of clopidogrel noncompliance was increased among ACS patients, a comprehensive search of PubMed, Embase, and Web of Science was conducted to identify studies reporting early ischemic risk after clopidogrel noncompliance in ACS patients. The primary endpoint was a composite of death or myocardial infarction (MI). Effect sizes were synthesized in patients with or without revascularization. A total of 7 observational studies focusing on clopidogrel noncompliance were included in this meta-analysis, whereas no studies involving ticagrelor or prasugrel were retrieved. A significantly increased risk of death or MI 0 to 90 days after clopidogrel noncompliance was found compared with that during 90 to 180 or 90 to 360 days regardless of revascularization (incidence rate ratio [IRR]: 2.01, 95% confidence interval (CI): 1.62-2.49, P < .001, I2 = 9%) or not (IRR: 1.61, 95% CI: 1.05-2.48, P < .001, I2 = 74%). Patients undergoing percutaneous coronary intervention had a higher risk of death or MI 0 to 90 days after clopidogrel noncompliance compared with 90-180 or 90-360 days irrespective of drug-eluting stent or bare metal stent implantation (P < .05 for both). The early ischemic risk after clopidogrel noncompliance is significantly higher than the late risk in ACS patients. Antiplatelet noncompliance remains a serious concern.
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Affiliation(s)
- Yushan Li
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiovascular Diseases, General Hospital of Northern Theater Command, Shenyang, China
| | - Ruting Zhao
- Department of Internal Medicine, Chinese PLA No. 31694 Army Health Company, Benxi, China
| | - Peng Yu
- Department of Internal Medicine, Chinese PLA No. 65529 Army Health Company, Liaoyang, China
| | - Yan Xu
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiovascular Diseases, General Hospital of Northern Theater Command, Shenyang, China
| | - Quanyu Zhang
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiovascular Diseases, General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiovascular Diseases, General Hospital of Northern Theater Command, Shenyang, China
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189
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Azzahhafi J, Broek WWAVD, Chan Pin Yin DRPP, Harmsze AM, van Schaik RHN, Ten Berg JM. The Clinical Implementation of CYP2C19 Genotyping in Patients with an Acute Coronary Syndrome: Insights From the FORCE-ACS Registry. J Cardiovasc Pharmacol Ther 2023; 28:10742484231210704. [PMID: 37899583 DOI: 10.1177/10742484231210704] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
BACKGROUND Guidelines recommend prasugrel or ticagrelor for acute coronary syndrome (ACS) patients. However, these P2Y12 inhibitors increase bleeding risk compared to clopidogrel. Although genotype-guided P2Y12-inhibitor selection has been shown to reduce bleeding risk, data on its clinical implementation is lacking. METHODS The study included ACS patients receiving genotype-guided antiplatelet therapy, utilising either a point-of-care (POC) device or laboratory-based testing. We aimed to collect qualitative and quantitative data on genotyping, eligibility for de-escalation, physician adherence to genotype results, time to de-escalation and cost reduction. RESULTS Of the 1,530 patients included in the ACS registry from 2021 to 2023, 738 ACS patients treated with ticagrelor received a CYP2C19 genotype test. The median turnover time of genotyping was 6.3 hours (interquartile range [IQR], 3.2-16.7), with 82.3% of the genotyping results known within 24 hours after admission. POC genotyping exhibited significantly shorter turnaround times compared to laboratory-based testing (with respective medians of 5.7 vs 47.8 hours; P < .001). Of the genotyped patients, 81.7% were eligible for de-escalation which was carried out within 24 hours in 70.9% and within 48 h in 93.0%. The time to de-escalation was significantly shorter using POC (25.4 hours) compared to laboratory-based testing (58.9 hours; P < .001). Implementing this strategy led to a reduction of €211,150.50 in medication costs. CONCLUSIONS CYP2C19 genotype-guided-de-escalation in an all-comers ACS population is feasible. POC genotyping leads to shorter turnaround times and quicker de-escalation. Time to de-escalation from ticagrelor to clopidogrel in noncarriers was short, with high physician adherence to genotype results.
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Affiliation(s)
- Jaouad Azzahhafi
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | - Ankie M Harmsze
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Cardiology, University Medical Center Maastricht, Maastricht, the Netherlands
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190
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Pyka Ł, Hudzik B, Bartuś S, Buszman P, Gierlotka M, Wojakowski W, Hiczkiewicz J, Kleinrok A, Skrzypek M, Kuliczkowski W, Gąsior M. Anticoagulation for Atrial Fibrillation in Acute Coronary Syndrome Survivors Reduces Major Cardiovascular Events and Mortality. J Cardiovasc Pharmacol Ther 2023; 28:10742484231212106. [PMID: 38158229 DOI: 10.1177/10742484231212106] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
The prevalence of atrial fibrillation (AF) in acute coronary syndrome (ACS) patients is increasing. Data on outcomes of anticoagulation in ACS patients with AF are lacking. The aim of our study was to investigate the prevalence of stroke, myocardial infarction, bleeding complications, and all-cause mortality in this population. PL-ACS and AMI-PL registries gather an all-comer population of ACS patients in Poland, exceeding half a million records. We have selected ACS survivors with concomitant AF on admission, divided them into subgroups with regard to the administered anticoagulation, and followed up with them for a 12-month period (n = 13,973). Subsequently, groups were propensity score matched for age, sex, ejection fraction, diabetes, heart failure, renal impairment, and type of ACS. The study population was divided with regard to the administration of anticoagulation. Anticoagulation was prescribed in 2,466 patients (17.6%). The (D)OAC+ patients were younger; however, comorbidities were more prevalent in this group. The 12-month follow-up showed that the (D)OAC+ patients had significantly lower rates of all-cause mortality, myocardial infarction, and ischemic stroke, with no significant increase in bleeding events. After matching, the study groups consisted of 2,194 patients each and showed no differences in baseline characteristics. The outcomes of the 12-month observation were similar to the findings before matching. This all-comer national registry analysis shows that the use of guideline-recommended therapy and anticoagulation in ACS survivors with AF is associated with a lower rate of all-cause mortality, recurrent myocardial infarction, and ischemic stroke.
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Affiliation(s)
- Łukasz Pyka
- Third Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia in Katowice, Zabrze, Poland
| | - Bartosz Hudzik
- Third Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia in Katowice, Zabrze, Poland
- Department of Cardiovascular Disease Prevention, Faculty of Public Health in Bytom, Medical University of Silesia in Katowice, Katowice, Poland
| | - Stanisław Bartuś
- Second Department of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Paweł Buszman
- Department of Epidemiology, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, Katowice, Poland
| | - Marek Gierlotka
- Department of Cardiology, University of Opole, Opole, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Third Division of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Jarosław Hiczkiewicz
- Clinical Department of Cardiology, Nowa Sól Multidisciplinary Hospital, Nowa Sól, Poland
| | - Andrzej Kleinrok
- Department of Cardiology, The Pope John Paul II Province Hospital of Zamość, Zamość, Poland
| | - Michał Skrzypek
- Department of Biostatistics, Faculty of Public Health in Bytom, Medical University of Silesia, Bytom, Poland
| | | | - Mariusz Gąsior
- Third Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia in Katowice, Zabrze, Poland
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191
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Bai R, Yang Q, Xi R, Che Q, Zhao Y, Guo M, Dong G, Gao Z, Fu C, Wang P, Gu F, Du J, Zhang D, Duan W, Li L, Shi D. The effectiveness and safety of Chinese Patent Medicines based on syndrome differentiation in patients following percutaneous coronary intervention due to acute coronary syndrome (CPM trial): A nationwide Cohort Study. Phytomedicine 2023; 109:154554. [PMID: 36610159 DOI: 10.1016/j.phymed.2022.154554] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/24/2022] [Accepted: 11/15/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND The incidence of cardiovascular events remains not unusual in patients following percutaneous coronary intervention (PCI) due to acute coronary syndrome (ACS). Chinese patent medicine (CPM) therapy based on syndrome differentiation in addition to conventional medicine (CM) had been expected to further reduce the risk of cardiovascular events. PURPOSE To assess the effectiveness and safety of CPM based on syndrome differentiation in patients following PCI due to ACS. STUDY DESIGN Nationwide prospective cohort study. METHODS CPM study was conducted in 40 centers in mainland China. Patients following PCI due to ACS entered to syndrome differentiation-based CPM (SDCPM) or CM group according to whether they received CPM or not. The CPM comprised Guanxin Danshen dripping pills, Qishen Yiqi dripping pills, or Danlou tablets, and was used correspondingly with the syndrome differentiation of traditional Chinese medicine. The follow-up time was 36 months. The primary endpoint was composed of cardiac death, non-fatal myocardial infarction and urgent revascularization. The secondary endpoint included rehospitalization due to ACS, heart failure, stroke, other thrombotic events. Seattle Angina Questionnaire (SAQ) was used to evaluate quality of life. RESULTS Between February 2012 and December 2018, ascertainment of the primary endpoint was completed in 2,724 patients of follow-up. 1,380 patients were in SDCPM group. At a median follow-up of 541 (interquartile range 513 - 564) days, the primary endpoint occurred in 126 (8.61%) patients in SDCPM group and 167 (11.62%) patients in CM group (adjusted hazard ratio [HR] = 0.70; [95% confidence interval [CI] 0.55 - 0.89]; p = 0.003). The secondary endpoint occurred in 144 (9.84%) patients in SDCPM group and 197 (13.71%) patients in CM group (adjusted HR = 0.66; [95% CI 0.53 - 0.82]; p < 0.001). The SAQ score in SDCPM group was higher than CM group (366.78 ± 70.19 vs 356.43 ± 73.80, p < 0.001). There were no significant differences of adverse events between two groups. CONCLUSION In patients following PCI due to ACS, SDCPM in addition to CM treatment reduced the primary and secondary endpoints, as well as improved the quality of life without adverse events.
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Affiliation(s)
- Ruina Bai
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China; National Clinical Research Center for Chinese Medicine Cardiology, Beijing 100091, China
| | - Qiaoning Yang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China; NMPA Key Laboratory for Clinical Research and Evaluation of Traditional Chinese Medicine, Beijing 100091, China
| | - Ruixi Xi
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China; National Clinical Research Center for Chinese Medicine Cardiology, Beijing 100091, China
| | - Qianzi Che
- Institute of Basic Research In Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Yang Zhao
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China; NMPA Key Laboratory for Clinical Research and Evaluation of Traditional Chinese Medicine, Beijing 100091, China
| | - Ming Guo
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China; National Clinical Research Center for Chinese Medicine Cardiology, Beijing 100091, China
| | - Guoju Dong
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China; National Clinical Research Center for Chinese Medicine Cardiology, Beijing 100091, China
| | - Zhuye Gao
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China; National Clinical Research Center for Chinese Medicine Cardiology, Beijing 100091, China
| | - Changgeng Fu
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China; National Clinical Research Center for Chinese Medicine Cardiology, Beijing 100091, China
| | - Peili Wang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China; National Clinical Research Center for Chinese Medicine Cardiology, Beijing 100091, China
| | - Feng Gu
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China; National Clinical Research Center for Chinese Medicine Cardiology, Beijing 100091, China
| | - Jianpeng Du
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China; National Clinical Research Center for Chinese Medicine Cardiology, Beijing 100091, China
| | - Dawu Zhang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China; National Clinical Research Center for Chinese Medicine Cardiology, Beijing 100091, China
| | - Wenhui Duan
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China; National Clinical Research Center for Chinese Medicine Cardiology, Beijing 100091, China
| | - Lizhi Li
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China; National Clinical Research Center for Chinese Medicine Cardiology, Beijing 100091, China.
| | - Dazhuo Shi
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China; National Clinical Research Center for Chinese Medicine Cardiology, Beijing 100091, China.
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192
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Siasos G, Tsigkou V, Bletsa E, Stampouloglou PK, Oikonomou E, Kalogeras K, Katsarou O, Pesiridis T, Vavuranakis M, Tousoulis D. Antithrombotic Treatment in Coronary Artery Disease. Curr Pharm Des 2023; 29:2764-2779. [PMID: 37644793 DOI: 10.2174/1381612829666230830105750] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/16/2023] [Accepted: 07/20/2023] [Indexed: 08/31/2023]
Abstract
Coronary artery disease exhibits growing mortality and morbidity worldwide despite the advances in pharmacotherapy and coronary intervention. Coronary artery disease is classified in the acute coronary syndromes and chronic coronary syndromes according to the most recent guidelines of the European Society of Cardiology. Antithrombotic treatment is the cornerstone of therapy in coronary artery disease due to the involvement of atherothrombosis in the pathophysiology of the disease. Administration of antiplatelet agents, anticoagulants and fibrinolytics reduce ischemic risk, which is amplified early post-acute coronary syndromes or post percutaneous coronary intervention; though, antithrombotic treatment increases the risk for bleeding. The balance between ischemic and bleeding risk is difficult to achieve and is affected by patient characteristics, procedural parameters, concomitant medications and pharmacologic characteristics of the antithrombotic agents. Several pharmacological strategies have been evaluated in patients with coronary artery disease, such as the effectiveness and safety of antithrombotic agents, optimal dual antiplatelet treatment schemes and duration, aspirin de-escalation strategies of dual antiplatelet regimens, dual inhibition pathway strategies as well as triple antithrombotic therapy. Future studies are needed in order to investigate the gaps in our knowledge, including special populations.
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Affiliation(s)
- Gerasimos Siasos
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
- Cardiovascular Division, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Vasiliki Tsigkou
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Evanthia Bletsa
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Panagiota K Stampouloglou
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Evangelos Oikonomou
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Konstantinos Kalogeras
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Ourania Katsarou
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Theodoros Pesiridis
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Manolis Vavuranakis
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Dimitris Tousoulis
- Department of Cardiology, School of Medicine, 'Hippokration' General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Zieminski JJ, Mara KC, Wamsley KS, Stulak JM, Nei SD. A Single-Center Bleeding Comparison of Warfarin Plus Aspirin or Clopidogrel Following Coronary Artery Bypass Grafting and Surgical Valve Replacement. Clin Appl Thromb Hemost 2023; 29:10760296231156175. [PMID: 36974469 PMCID: PMC10052485 DOI: 10.1177/10760296231156175] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/11/2023] [Accepted: 01/24/2023] [Indexed: 03/29/2023] Open
Abstract
The optimal antithrombotic therapy following combined coronary artery bypass graft (CABG) and surgical valve replacement (SVR) surgery remains unclear. The aim of this single-center, retrospective cohort study was to assess the safety and effectiveness of a vitamin K antagonist (VKA) plus either aspirin or clopidogrel in patients following combined CABG and SVR. The primary endpoint was the occurrence of bleeding within six months. The secondary endpoint was the occurrence of CV death, stroke, acute coronary syndrome (ACS), or valve dysfunction. Outcomes were identified by pre-specified ICD codes. A total of 629 patients were included in the analysis, with 583 patients receiving aspirin and 46 patients receiving clopidogrel. Bleeding occurred in 1.7% of patients receiving aspirin and in 0% of patients receiving clopidogrel (p = 0.99). CV death, stroke, ACS, or valve dysfunction occurred in 3.1% of patients receiving aspirin and 4.3% of patients receiving clopidogrel (p = 0.65). In this study, there were no differences in the safety or effectiveness of a VKA plus either aspirin or clopidogrel following combined CABG and SVR.
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Affiliation(s)
| | - Kristin C. Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | - John M. Stulak
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Scott D. Nei
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
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194
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Anchidin OI, Rosianu SH, Nemes A, Aldica M, Blendea D, Molnar A, Moldovan H, Pop D. The Effectiveness of Antiplatelet Therapy and the Factors Influencing It in Patients with Acute Coronary Syndrome before and during the COVID-19 Pandemic. Medicina (B Aires) 2022; 59:medicina59010084. [PMID: 36676708 PMCID: PMC9861818 DOI: 10.3390/medicina59010084] [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] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/20/2022] [Accepted: 12/26/2022] [Indexed: 01/03/2023] Open
Abstract
Background and Objectives: Dual antiplatelet therapy (DAPT) is essential in the treatment of patients with acute coronary syndrome (ACS). The objective of this study was to evaluate the effectiveness of antiplatelet medication in our practice and to investigate the factors that influence it. Materials and Methods: A prospective cohort observational study was conducted, in which 193 patients with ACS were enrolled. The patients were stented in the catheterization laboratory between May 2019 and October 2020, before and during the COVID-19 pandemic, and were receiving DAPT. Their platelet functions were tested using a Multiplate Analyzer. In addition to this, clinical data, demographics, laboratory tests, and cardiovascular risk factors were also analyzed. Results: 43.46% of the patients treated with aspirin were found to be resistant to it. This phenomenon was more common in men (48.17% vs. 31.48%, p = 0.036), and it was associated with being under the age of 50 (OR: 2.08; 95% CI: 1.11-3.90) and weighing over 70 kg (OR: 3.00; 95% CI: 1.21-7.40). Most of the patients treated with clopidogrel were in the optimal treatment window, while about half of the patients treated with ticagrelor had an exaggerated pharmacological response. Among the laboratory parameters, leukocytosis and platelet count were found to be determinants of platelet reactivity for both the aspirin and ticagrelor treatments. Conclusions: Many patients treated with antiplatelet agents are outside of the treatment window. The results obtained showed that low doses of gastro-resistant aspirin tablets are ineffective, and their efficacy can be influenced by various clinical and laboratory factors. Patients receiving ticagrelor have significantly reduced platelet reactivity, influenced only by certain laboratory indicators. The pandemic significantly influenced the results of the platelet aggregation tests only in patients treated with clopidogrel.
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Affiliation(s)
- Ovidiu-Ionut Anchidin
- Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania
- “Niculae Stancioiu” Heart Institute, 400001 Cluj-Napoca, Romania
- Correspondence: (O.-I.A.); (A.M.); Tel.: +40-729164361 (O.-I.A.)
| | - Stefan Horia Rosianu
- Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania
- “Niculae Stancioiu” Heart Institute, 400001 Cluj-Napoca, Romania
| | - Ancuta Nemes
- “Niculae Stancioiu” Heart Institute, 400001 Cluj-Napoca, Romania
| | - Mihai Aldica
- “Niculae Stancioiu” Heart Institute, 400001 Cluj-Napoca, Romania
| | - Dan Blendea
- Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania
- “Niculae Stancioiu” Heart Institute, 400001 Cluj-Napoca, Romania
| | - Adrian Molnar
- Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania
- “Niculae Stancioiu” Heart Institute, 400001 Cluj-Napoca, Romania
- Correspondence: (O.-I.A.); (A.M.); Tel.: +40-729164361 (O.-I.A.)
| | - Horatiu Moldovan
- Department of Cardiovascular Surgery, Bucharest Clinical Emergency Hospital, 014461 Bucharest, Romania
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Dana Pop
- Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania
- Department of Cardiology, Clinical Rehabilitation Hospital, 400437 Cluj-Napoca, Romania
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195
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Liu J, Zhao D, Hao YC, Yang N, Sun ZQ, Liu J. [Low-density lipoprotein cholesterol levels and lipid-lowering treatment status among young and middle-aged ultra-high-risk patients with acute coronary syndrome in China]. Zhonghua Xin Xue Guan Bing Za Zhi 2022; 50:1161-1168. [PMID: 36517436 DOI: 10.3760/cma.j.cn112148-20220920-00731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Objective: To assess low-density lipoprotein cholesterol (LDL-C) levels and use of lipid-lowering treatment among young and middle-aged ultra-high-risk patients with acute coronary syndrome (ACS) in China. Methods: The study was based on the"Improving Care for Cardiovascular Disease in China (CCC)-ACS"project, a collaborative registry by and Chinese Society of Cardiology (CSC) and the American Heart Association. Hospitalized-patients with ACS were consecutively enrolled from 159 tertiary and 82 secondary hospitals across China, related clinical information was collected. This study included young and middle-aged hospitalized patients (18-59 years) with ACS from November 2014 to December 2019 registered in CCC-ACS project. Ultra-high-risk was defined according to Chinese expert consensus on lipid management of ultra-high-risk atherosclerotic cardiovascular disease (ASCVD) patients of CSC. The mean LDL-C levels at admission, pre-hospital lipid-lowering therapy and proportion of patients with LDL-C target achieved were analyzed. Results: A total of 42 230 patients younger than 60 years with ACS were included in this study. The mean age was (50.4±6.9) years, and 86.8% (36 676/42 230) of the ACS patients were male. Among them, 86.9% (36 687/42 230) met the criteria of ultra-high-risk. The mean level of LDL-C at admission was (2.8±1.0)mmol/L, only 5.3 % (1 948/36 687) patients achieved the targeted goal of LDL-C<1.4 mmol/L. Among the ultra-high-risk ASCVD patients, 17.5% (6 430/36 687) received lipid-lowering drugs before hospitalization, 96.4% (6 198/6 430) of whom received statins monotherapy. Among patients receiving pre-hospital statins, only 9.9% (626/6 323) patients reached an LDL-C<1.4 mmol/L at admission. Conclusions: The majority of young and middle-aged hospitalized patients with ACS are ultra-high-risk patients for ASCVD in China. Pre-hospital lipid-lowering drugs use is lower in these ultra-high-risk ASCVD patients and most patients do not reach the new LDL-C target level at admission.
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196
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Patel SM, Qamar A, Giugliano RP, Jarolim P, Marston NA, Park JG, Blazing MA, Cannon CP, Braunwald E, Morrow DA. Association of Serial High-Sensitivity Cardiac Troponin T With Subsequent Cardiovascular Events in Patients Stabilized After Acute Coronary Syndrome: A Secondary Analysis From IMPROVE-IT. JAMA Cardiol 2022; 7:1199-1206. [PMID: 36260325 PMCID: PMC9582963 DOI: 10.1001/jamacardio.2022.3627] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/30/2022] [Indexed: 01/13/2023]
Abstract
Importance Studies have demonstrated an association between single measures of high-sensitivity troponin (hsTn) and future cardiovascular events in patients with chronic coronary syndromes. However, limited data exist regarding the association between changes in serial values of hsTn and subsequent cardiovascular events in this patient population. Objective To evaluate the association between changes in high-sensitivity troponin T (hsTnT) and subsequent cardiovascular events in patients stabilized after acute coronary syndrome (ACS). Design, Setting, and Participants This is a secondary analysis from the Improved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT), a randomized clinical trial of ezetimibe vs placebo on a background of simvastatin in 18 144 patients hospitalized for an ACS across 1147 sites in 39 countries. The current biomarker substudy includes the 6035 participants consenting to the biomarker substudy with available hsTnT at months 1 and 4. Data were collected from October 26, 2005, through July 8, 2010, with the database locked October 21, 2014. Data were analyzed from February 28, 2021, through August 14, 2022. Main Outcomes and Measures The outcomes of interest were cardiovascular death, myocardial infarction (MI), stroke, or hospitalization for heart failure (HHF). Associations of absolute and relative changes in hsTnT between month 1 and month 4 as a function of the starting month 1 hsTnT and the composite outcome were examined using landmark analyses. Results Of 6035 patients in this analysis (median [IQR] age, 64 [57-71]), 1486 (24.6%) were female; 361 (6.0%) were Asian; 121 were (2.0%) Black; 252 (4.2%) were Spanish descent; 4959 were (82.2%) White; and 342 (5.7%) reported another race (consolidated owing to small numbers), declined to respond, or were not asked to report race owing to regulatory prohibitions. Most patients (4114 [68.2%]) had stable hsTnT values (change <3 ng/L), with 1158 (19.2%) and 763 (12.6%) having changes of 3 to less than 7 ng/L and 7 ng/L or more, respectively. After adjustment for clinical risk factors and stratification by the starting month 1 hsTnT level, an absolute increase in hsTnT of 7 ng/L or more was associated with a more than 3-fold greater risk of the composite outcome (adjusted hazard ratio [aHR], 3.33; 95% CI, 1.99-5.57; P < .001), whereas decreases of 7 ng/L or more were associated with similar to lower risk (aHR, 0.51; 95% CI, 0.26-1.03; P = .06) compared with stable values. There was a stepwise association moving from larger absolute decreases (aHR, 0.51; 95% CI, 0.26-1.03) to larger absolute increases (aHR, 3.33; 95% CI, 1.99-5.57) in hsTnT with future risk of the composite outcome (P trend <.001). A similar association was observed when analyzed on the basis of relative percent and continuous change. Conclusions and Relevance Among stable patients post-ACS, changes in hsTnT were associated with a gradient of risk of subsequent cardiovascular events across the range of starting hsTnT values. Serial assessment of hsTnT may refine risk stratification with the potential to guide therapy decisions in this patient population. Trial Registration ClinicalTrials.gov Identifier: NCT00202878.
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Affiliation(s)
- Siddharth M. Patel
- Thrombolysis in Myocardial Infarction Clinical Trials (TIMI) Study Group, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Arman Qamar
- Section of Interventional Cardiology & Vascular Medicine, NorthShore University Health System, University of Chicago Pritzker School of Medicine, Evanston, Illinois
| | - Robert P. Giugliano
- Thrombolysis in Myocardial Infarction Clinical Trials (TIMI) Study Group, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Petr Jarolim
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicholas A. Marston
- Thrombolysis in Myocardial Infarction Clinical Trials (TIMI) Study Group, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jeong-Gun Park
- Thrombolysis in Myocardial Infarction Clinical Trials (TIMI) Study Group, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michael A. Blazing
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Christopher P. Cannon
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Eugene Braunwald
- Thrombolysis in Myocardial Infarction Clinical Trials (TIMI) Study Group, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - David A. Morrow
- Thrombolysis in Myocardial Infarction Clinical Trials (TIMI) Study Group, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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197
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Hu MJ, Wang XN, Tan JS, Yang YJ. Association of beta-blocker therapy at discharge with clinical outcomes in patients without heart failure or left ventricular systolic dysfunction after acute coronary syndrome: An updated systematic review and meta-analysis. Arch Cardiovasc Dis 2022; 115:637-646. [PMID: 36376209 DOI: 10.1016/j.acvd.2022.09.004] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 09/14/2022] [Accepted: 09/19/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Beta-blockers are the standard treatment for acute coronary syndrome (ACS) based on evidence from the prethrombolytic era. We sought to examine the effect of beta-blocker treatment on patients without heart failure or left ventricular systolic dysfunction after ACS in the contemporary percutaneous coronary intervention (PCI) era. METHODS We systematically searched PubMed, Web of Science, Cochrane Library, ClinicalTrials.gov and Google Scholar for studies comparing beta-blockers versus no beta-blockers in ACS patients in the contemporary PCI era. The primary outcome was all-cause death. Pooling unadjusted and multivariable adjusted results were calculated under random-effects models. RESULTS Data from 15 studies (n=205,672), including 1 randomized trial, were analysed. Compared with no beta-blockers, beta-blocker therapy at discharge may reduce the risk of all-cause death (odds ratio [OR] 0.66, 95% confidence interval [CI]: 0.50-0.86; I2=81.9%). Subgroup analysis according to single or multicentre studies indicated similar results. Prospective studies suggested that all-cause death was less common in the beta-blocker group. After multivariable adjustment, a lower risk of all-cause death was still observed with beta-blockers (OR: 0.74, 95% CI: 0.59-0.94; I2=40.1%). No differences existed in major adverse cardiovascular events (MACE), cardiac death, myocardial infarction, heart failure, revascularization or stroke, before and after multivariable adjustment. CONCLUSIONS In patients without heart failure or left ventricular systolic dysfunction after ACS in the contemporary PCI era, beta-blocker therapy may still be beneficial due to a potential reduced risk of all-cause death.
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Affiliation(s)
- Meng-Jin Hu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Xiao-Ning Wang
- School of Medicine, Shandong University, Jinan 250000, China
| | - Jiang-Shan Tan
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Yue-Jin Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China.
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198
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Jin Y, Ma J, Wang Z, Zou Y, Wang G, Wu Y, Wang Y, Liu H, Yin T, Ye P. Performance of the ABCD-GENE Score for Predicting Clinical Outcomes in Clopidogrel-Treated Patients with ACS. J Cardiovasc Transl Res 2022; 15:1385-1392. [PMID: 35437618 DOI: 10.1007/s12265-022-10255-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 04/04/2022] [Indexed: 12/16/2022]
Abstract
The ABCD-GENE score was constructed to identify patients with high platelet reactivity (HPR) after 30 days of clopidogrel treatment. In our study, 1297 eligible patients with acute coronary syndrome (ACS) were included, and 44 (3.4%) major adverse cardiovascular events (MACEs) occurred during the 12-month clopidogrel treatment. The score with a cutoff of ≥ 10 was independently associated with the risk of 5-day HPR (adjusted HR: 1.73, 95% CI: 1.09-2.74, P = 0.020) and MACEs (adjusted HR: 2.25, 95% CI: 1.19-4.25, P = 0.013). The risk of MACEs increased when the multivariable model with the score (≥ 10) plus 5-day HPR was used (adjusted HR: 4.37, 95% CI: 1.90-10.10, P = 0.001). The c-statistic for MACEs was 0.60 when using the score threshold of ≥ 10 and 0.63 when using the model with the score plus 5-day HPR. As a simple tool, the ABCD-GENE score could identify clopidogrel-treated Chinese patients with ACS who are at increased risk of MACEs. The addition of 5-day HPR could slightly improve the diagnostic ability of the score.
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Affiliation(s)
- Ying Jin
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
- Department of Geriatrics, Air Force Medical Center of Chinese PLA, Beijing, 100141, China
| | - Jing Ma
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of Chinese PLA General Hospital, Beijing, 100142, China
| | - Ziqian Wang
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - Yuting Zou
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - Guanyun Wang
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - Yangxun Wu
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - Yuyan Wang
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - Haiping Liu
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - Tong Yin
- Medical School of Chinese PLA, Beijing, 100853, China.
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China.
| | - Ping Ye
- Medical School of Chinese PLA, Beijing, 100853, China.
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China.
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Wöhrle J, Seeger J. Prasugrel and Ticagrelor Treatment Among Patients With ACS: Is There a Need for a New Randomized Trial? JACC Cardiovasc Interv 2022; 15:2281-2283. [PMID: 36423971 DOI: 10.1016/j.jcin.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 10/11/2022] [Indexed: 11/22/2022]
Affiliation(s)
- Jochen Wöhrle
- Department of Cardiology and Intensive Care, Medical Campus Lake Constance, Friedrichshafen, Germany.
| | - Julia Seeger
- Department of Cardiology and Intensive Care, Medical Campus Lake Constance, Friedrichshafen, Germany
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Ratti G, Monda C, Ratti F, Golino M, Fulgione L, Fulgione C, Mallardo M, Tammaro P. Long-term dual antiplatelet therapy and nuisance bleeding: impact on quality of life. Monaldi Arch Chest Dis 2022; 93. [PMID: 36412132 DOI: 10.4081/monaldi.2022.2437] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022] Open
Abstract
Long term dual antiplatelet therapy (LTDAPT), with ticagrelor 60 mg and low-dose aspirin, is indicated after acute coronary syndrome (ACS) for the secondary prevention of atherothrombotic events in high-risk patients with a history of ACS of at least 1 year. LTDAPT had a good tolerability and safety profile, but the risk of TIMI major bleeding was increased. However, even non-significant bleeding may be important because it has an effect on the quality of life and therefore may lead to treatment discontinuation. We, therefore, evaluated patients' experiences with LTDAPT and the impact of nuisance bleeding on quality of life and treatment adherence. We retrospectively reviewed 225 patients in follow-up after ACS with at least one high-risk condition, treated with ticagrelor 60 mg twice daily (after 90 mg twice daily for 12 months). The outpatient follow-up program after hospitalization provides a visit on day 30 after discharge, then after 3 months, continuing with six-monthly checks. We assessed the presence and intensity of bleeding, as well as health-related quality of life (HRQoL), at each visit. The TIMI score was used to determine the severity of the bleeding. Any overt bleeding event that did not meet the major and minor criteria was labeled "minimal" and could be framed as "nuisance bleeding." The HRQoL was assessed by the EuroQol-5 and Dimension (EQ-5D) visual analog scale (VAS) score. Minimal bleedings were present in 49 patients (21%), but only in one case (by decision of the patient) there was a cause for discontinuation of therapy. However, 39 (79%) subjects had asked for opinions on stopping the therapy during the telephone consultation. Factors influencing LTDAPT knowledge included access to medication counselling, engaging with information communicated during medication counselling, and access to timely, relevant and expert information and advice after discharge from the hospital. All adverse events, judged to be "not serious" in trials, may have an effect on the quality of life and therefore may lead to treatment discontinuation. The authors underline the importance of careful outpatient follow-up and ongoing counselling, to check out compliance and possible adverse effect of LTDAPT.
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Affiliation(s)
- Gennaro Ratti
- Cardiology/ICU Department, S. Giovanni Bosco Hospital, Naples.
| | - Cinzia Monda
- Cardiology/ICU Department, S. Giovanni Bosco Hospital, Naples.
| | - Federica Ratti
- Pharmacy Department, "Federico II" University of Naples.
| | - Marco Golino
- Cardiology/ICU Department, S. Giovanni Bosco Hospital, Naples.
| | - Ludovica Fulgione
- Advanced Biomedical Science Department, "Federico II" University of Naples.
| | | | | | - Paolo Tammaro
- Cardiology/ICU Department, S. Giovanni Bosco Hospital, Naples.
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