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Power D, Schäfer U, Guedeney P, Claessen BE, Sartori S, Sorrentino S, Lefèvre T, Kupatt C, Tchetche D, Dumonteil N, Webb JG, Colombo A, Windecker S, Ten Berg JM, Hildick-Smith D, Boekstegers P, Linke A, Tron C, Van Belle E, Asgar AW, Jeger R, Sardella G, Hink U, Husser O, Grube E, Lechthaler I, Wijngaard P, Anthopoulos P, Deliargyris EN, Bernstein D, Hengstenberg C, Mehran R, Dangas GD. Impact of percutaneous closure device type on vascular and bleeding complications after TAVR: A post hoc analysis from the BRAVO-3 randomized trial. Catheter Cardiovasc Interv 2019; 93:1374-1381. [PMID: 31116908 DOI: 10.1002/ccd.28295] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/04/2019] [Accepted: 04/06/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND/OBJECTIVE Prostar XL (PS) and ProGlide (PG) are common vascular closure devices (VCD) used in TAVR via transfemoral vascular approach. The impact of these VCD on vascular and bleeding complications remains unclear. METHODS The BRAVO-3 trial randomized 802 patients undergoing transfemoral TAVR. We stratified patients according to type of VCD used and examined the 30-day incidence of major or minor vascular complications, major bleeding (BARC ≥3b), AKI and major adverse cardiac and cerebrovascular events (MACCE; death, myocardial infarction or stroke). RESULTS A total of 746 (93%) patients were treated with either PS (n = 352, 47%) or PG (n = 394, 53%) VCD, without significant differences in successful deployment rate (PS 322 [91.2%] vs. PG 373 [94.2%] respectively, p = .20). PG was associated with a significantly lower incidence of major or minor vascular complications, compared to PS (adjusted OR: 0.54; 95% CI: 0.37-0.80; p < .01). Rates of acute kidney injury were also lower with the PG device. There was no significant difference between bleeding, MACCE, and death. CONCLUSIONS Compared to PS, the PG VCD was associated with a lower rate of major or minor vascular complications and lower rates of AKI after transfemoral TAVR.
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Khan AA, Dangas GD. Overlapping bio-absorbable scaffolds: Aim for D2D technique? Catheter Cardiovasc Interv 2019; 91:1210-1211. [PMID: 29894590 DOI: 10.1002/ccd.27662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 04/19/2018] [Indexed: 11/08/2022]
Abstract
The results of overlapping metallic stents have been concerning but this practice is often unavoidable in the setting of long or tortuous lesions, diameter discrepancy of proximal and distal vessel, and for residual dissections. Theoretically, bio-absorbable scaffolds may carry an advantage over metallic stents due to the progressive resorption of the scaffold theoretically rendering the overlap a non-issue; this has not been clinically evident. Since stent/scaffold overlap cannot be entirely avoided, improved stent delivery/deployment and scaffold design modification may reduce complications in this complex patient subset.
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Faggioni M, Baber U, Sartori S, Chandrasekhar J, Cohen DJ, Henry TD, Claessen BE, Dangas GD, Gibson CM, Krucoff MW, Vogel B, Moliterno DJ, Sorrentino S, Colombo A, Chieffo A, Kini A, Farhan S, Ariti C, Witzenbichler B, Weisz G, Steg PG, Pocock S, Mehran R. Influence of Baseline Anemia on Dual Antiplatelet Therapy Cessation and Risk of Adverse Events After Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2019; 12:e007133. [DOI: 10.1161/circinterventions.118.007133] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Theodoropoulos K, Malyshev Y, Suleman UJ, Kamran H, Starakis I, Hahalis G, Dangas GD, Spiropoulos K, Salciccioli L. IS OBSTRUCTIVE SLEEP APNEA ASSOCIATED WITH SUB-CLINICAL CAROTID ATHEROSCLEROSIS IN THE ABSENCE OF TRADITIONAL RISK FACTORS? A META-ANALYSIS OF 2053 PATIENTS. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)30668-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Attizzani GF, Patel SM, Dangas GD, Szeto WY, Sorajja P, Reardon MJ, Popma JJ, Kodali S, Chenoweth S, Costa MA. Comparison of Local Versus General Anesthesia Following Transfemoral Transcatheter Self-Expanding Aortic Valve Implantation (from the Transcatheter Valve Therapeutics Registry). Am J Cardiol 2019; 123:419-425. [PMID: 30527797 DOI: 10.1016/j.amjcard.2018.10.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/24/2018] [Accepted: 10/25/2018] [Indexed: 10/27/2022]
Abstract
Transfemoral transcatheter aortic valve replacement (TF-TAVR) is mostly performed under general anesthesia (GA) in most US centers. We examined in-hospital and 30-day outcomes in patients who underwent TF-TAVR with a self-expanding bioprosthesis using local anesthesia (LA) or GA. Patients from the Transcatheter Valve Therapeutics Registry who underwent TF-TAVR from January 2014 to June 2016 with LA or GA were evaluated. Propensity matching was performed and procedural and clinical outcomes compared up to 30 days. A total of 11,006 patients were included (GA: 8,239 [74.9%] and LA: 2,767 [25.1%]). After propensity matching (n = 1,988 matched sets), device success was similar (94.5% vs 94.6%, p = 0.905). No differences in in-hospital stroke (2.7% vs 2.3%, p = 0.413) or paravalvular regurgitation grade (p = 0.113) were noted. Fewer LA patients were converted to open heart surgery (0.2% vs 0.6%, p = 0.076) or experienced an in-hospital major vascular complication (0.7% vs 1.4%, p = 0.026). Intensive care unit time (40.1 ± 58.4 vs 50.9 ± 72.1 hours, p < 0.001) and postprocedure length of stay (4.1 ± 3.6 vs 5.0 ± 4.5 days, p < 0.001) were significantly shorter with LA. In-hospital and 30-day all-cause mortality were lower in the LA cohort compared to the GA cohort ([1.1% vs 2.7%, p < 0.001] and [2.1% vs 3.9%, p = 0.001]). In conclusion, in the largest series of self-expanding bioprostheses for TF-TAVR, these propensity-matched cohorts demonstrate that LA is an acceptable alternative to GA with comparable success, lower safety outcomes, complications rates, and in-hospital and 30-day all-cause mortality.
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Claessen BE, Dangas GD. Leave nothing behind: Promising results for coronary drug-coated balloons in clinical practice. Catheter Cardiovasc Interv 2019; 93:189-190. [PMID: 30719858 DOI: 10.1002/ccd.28085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 12/31/2018] [Indexed: 11/05/2022]
Abstract
1,025 patients with de novo coronary artery disease (66.9%) or in-stent restenosis (ISR) (33.1%) underwent treatment with paclitaxel drug-coated balloons in a multinational single-arm registry. Bail-out stenting rate was only 4.8%. One-year target lesion revascularization was 2.3% for de novo lesions, 2.9% for bare metal stent ISR, and 5.8% for drug-eluting stent ISR. Short-term results with coronary drug-coated balloons are promising. Nonetheless, long-term data, preferably from randomized trials are necessary to confirm their safety and efficacy.
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Giustino G, Dangas GD. Bioresorbable Vascular Scaffolds in Women. JACC Cardiovasc Interv 2019; 10:1891-1893. [PMID: 28935082 DOI: 10.1016/j.jcin.2017.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 08/17/2017] [Indexed: 01/11/2023]
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Dangas GD, Mehran R. Bleeding After Aortic Valve Replacement Matters: Important Mortality Risk. JACC Cardiovasc Interv 2019; 10:1447-1448. [PMID: 28728658 DOI: 10.1016/j.jcin.2017.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 06/06/2017] [Indexed: 10/19/2022]
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Baber U, Dangas GD. Left Main PCI With DES Versus CABG: Cautionary Note or Cause for Concern? J Am Coll Cardiol 2018; 72:2823-2825. [PMID: 30522645 DOI: 10.1016/j.jacc.2018.09.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 09/30/2018] [Indexed: 11/28/2022]
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Kalkman DN, Aquino M, Claessen BE, Baber U, Guedeney P, Sorrentino S, Vogel B, de Winter RJ, Sweeny J, Kovacic JC, Shah S, Vijay P, Barman N, Kini A, Sharma S, Dangas GD, Mehran R. Residual inflammatory risk and the impact on clinical outcomes in patients after percutaneous coronary interventions. Eur Heart J 2018; 39:4101-4108. [PMID: 30358832 DOI: 10.1093/eurheartj/ehy633] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 09/22/2018] [Indexed: 11/14/2022] Open
Abstract
Aims It remains unknown what percentage of patients treated with percutaneous coronary artery intervention (PCI) have high residual inflammatory risk (RIR). Moreover, the impact of RIR on clinical outcomes has not been established. The objective of this study is to determine the prevalence of patients with persistent high levels of inflammation after PCI and to evaluate clinical outcomes according to inflammatory response. Methods and results This is a retrospective cohort study assessing patients undergoing PCI between 2009 and 2016 with serial inflammatory status assessment from a large, prospective, and single-centre PCI registry. Assessment of inflammation status with at least two high sensitive C-reactive protein (hsCRP) measurements at baseline and follow-up with >4 weeks apart. High RIR was defined as an hsCRP≥ 2 mg/L. Patients were divided into four groups: persistent high RIR, increased RIR (first low-, then high hsCRP), attenuated RIR (first high-, then low hsCRP), or persistent low RIR. The primary endpoint was all-cause mortality at 1 year follow-up. Occurrence of myocardial infarction (MI) was assessed as secondary outcome. Seven thousand and twenty-six patients were identified with serial hsCRP measurements (30.8% of all PCI patients). Of these patients 2654 (38%) had persistent high RIR, 719 patients (10%) had increased RIR, 1088 patients (15%) had attenuated RIR, and persistent low RIR was seen in 2565 patients (37%). All-cause mortality at 1 year was 2.6% in patients with persistent high RIR, compared with 1.0% in increased RIR, 0.3% in attenuated RIR, and 0.7% in persistent low RIR patients, P < 0.01. MI at 1 year was observed in 7.5% of persistent high RIR, compared with 6.4% in increased RIR, 4.6% in attenuated RIR, and 4.3% in persistent low RIR, P < 0.01. In an adjusted model, including accounting for diabetes mellitus, acute coronary syndrome, and baseline low-density lipoprotein, results were sustained. Conclusion Persistent high RIR is observed frequently in patients undergoing PCI. In these patients, significantly higher all-cause mortality and MI rates are observed at 1 year follow-up. Residual inflammatory risk in patients undergoing PCI should be identified and treatment options should be further explored.
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Farkouh ME, Domanski M, Dangas GD, Godoy LC, Mack MJ, Siami FS, Hamza TH, Shah B, Stefanini GG, Sidhu MS, Tanguay JF, Ramanathan K, Sharma SK, French J, Hueb W, Cohen DJ, Fuster V. Long-Term Survival Following Multivessel Revascularization in Patients With Diabetes: The FREEDOM Follow-On Study. J Am Coll Cardiol 2018; 73:629-638. [PMID: 30428398 DOI: 10.1016/j.jacc.2018.11.001] [Citation(s) in RCA: 157] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 11/01/2018] [Accepted: 11/01/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND The FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease) trial demonstrated that for patients with diabetes mellitus (DM) and multivessel coronary disease (MVD), coronary artery bypass grafting (CABG) is superior to percutaneous coronary intervention with drug-eluting stents (PCI-DES) in reducing the rate of major adverse cardiovascular and cerebrovascular events after a median follow-up of 3.8 years. It is not known, however, whether CABG confers a survival benefit after an extended follow-up period. OBJECTIVES The purpose of this study was to evaluate the long-term survival of DM patients with MVD undergoing coronary revascularization in the FREEDOM trial. METHODS The FREEDOM trial randomized 1,900 patients with DM and MVD to undergo either PCI with sirolimus-eluting or paclitaxel-eluting stents or CABG on a background of optimal medical therapy. After completion of the trial, enrolling centers and patients were invited to participate in the FREEDOM Follow-On study. Survival was evaluated using Kaplan-Meier analysis, and Cox proportional hazards models were used for subgroup and multivariate analyses. RESULTS A total of 25 centers (of 140 original centers) agreed to participate in the FREEDOM Follow-On study and contributed a total of 943 patients (49.6% of the original cohort) with a median follow-up of 7.5 years (range 0 to 13.2 years). Of the 1,900 patients, there were 314 deaths during the entire follow-up period (204 deaths in the original trial and 110 deaths in the FREEDOM Follow-On). The all-cause mortality rate was significantly higher in the PCI-DES group than in the CABG group (24.3% [159 deaths] vs. 18.3% [112 deaths]; hazard ratio: 1.36; 95% confidence interval: 1.07 to 1.74; p = 0.01). Of the 943 patients with extended follow-up, the all-cause mortality rate was 23.7% (99 deaths) in the PCI-DES group and 18.7% (72 deaths) in the CABG group (hazard ratio: 1.32; 95% confidence interval: 0.97 to 1.78; p = 0.076). CONCLUSIONS In patients with DM and MVD, coronary revascularization with CABG leads to lower all-cause mortality than with PCI-DES in long-term follow-up. (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes [FREEDOM]; NCT00086450).
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Van Mieghem NM, Unverdorben M, Valgimigli M, Mehran R, Boersma E, Baber U, Hengstenberg C, Shi M, Chen C, Saito S, Veltkamp R, Vranckx P, Dangas GD. Edoxaban Versus standard of care and their effects on clinical outcomes in patients having undergone Transcatheter Aortic Valve Implantation in Atrial Fibrillation-Rationale and design of the ENVISAGE-TAVI AF trial. Am Heart J 2018; 205:63-69. [PMID: 30172099 DOI: 10.1016/j.ahj.2018.07.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 07/08/2018] [Indexed: 11/26/2022]
Abstract
Transcatheter aortic valve implantation, also called transcatheter aortic valve replacement (TAVR), is the treatment of choice for patients with severe aortic stenosis and intermediate to high operative risk. A significant portion of TAVR patients have atrial fibrillation (AF) requiring chronic oral anticoagulation. In moderate- to high-risk AF patients, the direct factor Xa inhibitor edoxaban is noninferior to vitamin K antagonists (VKAs) for prevention of stroke or systemic embolism with less bleeding and cardiovascular deaths. ENVISAGE-TAVI AF (NCT02943785) is a multinational, multicenter, prospective, randomized, open-label, blinded end point evaluation study comparing edoxaban to VKA-based therapy in approximately 1,400 patients with an indication for chronic oral anticoagulation after successful transfemoral TAVR. The coprimary end points are to assess the differential effects of the 2 treatments (a) on net adverse clinical events (the composite of all-cause death, myocardial infarction, ischemic stroke, systemic thromboembolism, valve thrombosis, and major bleeding events) and (b) on major bleeding. Twelve hours to 5 days after successful TAVR, patients will be randomized to 60 mg daily oral edoxaban or any VKA (international normalized ratio: 2.0-3.0 or 1.6-2.6 [numbers inclusive] in Japan if age ≥ 70 years). Antiplatelet therapy may be administered per physician's discretion. Randomization will be stratified by edoxaban dose reduction (per local label). Treatment duration will be up to 36 months. The study is powered (80%) to detect noninferiority (margin for the hazard ratio: 1.38) for the composite primary end points, followed by superiority testing.
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Kalkman DN, Chandrasekhar J, Aquino M, Woudstra P, Beijk MA, Sartori S, Baber U, Tijssen J, Koch KT, Dangas GD, Colombo A, De Winter RJ, Mehran R. P1661Evaluation of transradial versus transfemoral procedures in all-comers patients treated with the dual-therapy stent. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Chandrasekhar J, Kalkman DN, Aquino M, Baber U, Sartori S, Woudstra P, Beijk MA, Tijssen J, Koch KT, Dangas GD, Colombo A, De Winter RJ, Mehran R. P1664Clinical outcomes by potency of P2Y12 inhibitor following COMBO DTS PCI: From the COMBO collaboration. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kalkman DN, Chandrasekhar J, Aquino M, Woudstra P, Beijk MA, Sartori S, Baber U, Tijssen J, Koch KT, Dangas GD, Colombo A, De Winter RJ, Mehran R. P4554Impact of the presence of chronic kidney disease on 1-year target lesion failure in patients treated with a dual-therapy stent. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p4554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Chandrasekhar J, Aquino M, Sartori S, Baber U, Kalkman DN, Dangas GD, De Winter RJ, Mehran R, Colombo A. P1663COMBO stent PCI for elderly patients: one year clinical outcomes and DAPT cessation patterns from the global MASCOT registry. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Claessen BE, Dangas GD. The quest for the optimal treatment for in-stent restenosis. Catheter Cardiovasc Interv 2018; 92:300-301. [PMID: 30230205 DOI: 10.1002/ccd.27777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 06/15/2018] [Indexed: 11/07/2022]
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Chandrasekhar J, Aquino M, Sartori S, Baber U, Sorrentino S, Kalkman DN, Dangas GD, De Winter RJ, Mehran R, Colombo A. P2646COMBO PCI outcomes in patients categorized by baseline PARIS bleeding risk score: from the global MASCOT registry. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Kerkmeijer LS, Claessen BE, Baber U, Sartori S, Chandrasekhar J, Stefanini GG, Stone GW, Steg PG, Chieffo A, Weisz G, Windecker S, Mikhail GW, Kastrati A, Morice MC, Dangas GD, de Winter RJ, Mehran R. Incidence, determinants and clinical impact of definite stent thrombosis on mortality in women: From the WIN-DES collaborative patient-level pooled analysis. Int J Cardiol 2018; 263:24-28. [DOI: 10.1016/j.ijcard.2018.04.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/06/2018] [Accepted: 04/10/2018] [Indexed: 11/30/2022]
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Giustino G, Redfors B, Kirtane AJ, Mehran R, Dangas GD, Witzenbichler B, Neumann FJ, Weisz G, Généreux P, Maehara A, McAndrew T, Farhan S, Rinaldi MJ, Metzger DC, Henry TD, Cox DA, Duffy PL, Mazzaferri EL, Brodie BR, Stuckey TD, Gurbel P, Ben-Yehuda O, Stone GW. Platelet Reactivity and Risk of Ischemic Stroke After Coronary Drug-Eluting Stent Implantation: From the ADAPT-DES Study. JACC Cardiovasc Interv 2018; 11:1277-1286. [PMID: 29908967 DOI: 10.1016/j.jcin.2018.01.263] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 10/14/2022]
Abstract
OBJECTIVES The authors sought to investigate the association between P2Y12 reaction units (PRU) and the risk of ischemic stroke (IS) after successful coronary drug-eluting stents (DES) implantation. BACKGROUND The association between platelet reactivity on clopidogrel and the risk for ischemic cerebrovascular events remains unclear. METHODS Incidence, predictors, and prognostic impact of IS were evaluated among patients enrolled in the multicenter, prospective ADAPT-DES (Assessment of Dual AntiPlatelet Therapy With Drug Eluting Stents) study. By protocol, patients were maintained on aspirin for 2 years and clopidogrel for at least 1 year. Baseline platelet reactivity on clopidogrel and aspirin were assessed by means of VerifyNow point-of-care assay after successful DES implantation. RESULTS Among 8,582 patients enrolled, 68 (0.8%) had an IS during 2-year follow-up. Across the spectrum of PRU, rates of IS were progressively greater as patients transitioned from the lowest quintile of PRU (more P2Y12 receptor inhibition; 2-year rate of 0.51%) to the highest quintile of PRU (less P2Y12 receptor inhibition; 2-year rate of 1.34%; adjusted p = 0.04). PRU >208 was independently associated with higher risk of IS at 2 years (adjusted hazard ratio 1.81; 95% confidence interval 1.08 to 3.04; p = 0.03). The association between higher PRU and risk for IS was also consistent in patients with versus without high CHA2DS2-VASc score (pinteraction = 0.30) and in those on or off oral anticoagulation at discharge (pinteraction = 0.99). Occurrence of IS was strongly associated with increased risk of all-cause mortality at 2 years (adjusted HR: 4.16; 95% CI: 1.95 to 8.87; p < 0.0001). CONCLUSIONS Higher PRU was associated with increased risk of IS after coronary DES implantation. Ensuring adequate platelet P2Y12 receptor inhibition may reduce the risk of IS in this patient population. (Assessment of Dual AntiPlatelet Therapy With Drug Eluting Stents [ADAPT-DES]; NCT00638794).
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Giustino G, Redfors B, Mehran R, Kirtane AJ, Baber U, Généreux P, Witzenbichler B, Neumann FJ, Weisz G, Maehara A, Rinaldi MJ, Metzger DC, Henry TD, Cox DA, Duffy PL, Mazzaferri EL, Brodie BR, Stuckey TD, Dangas GD, Brener SJ, Ozgu Ozan M, Stone GW. Sex differences in the effect of diabetes mellitus on platelet reactivity and coronary thrombosis: From the Assessment of Dual Antiplatelet Therapy with Drug-Eluting Stents (ADAPT-DES) study. Int J Cardiol 2018; 246:20-25. [PMID: 28867009 DOI: 10.1016/j.ijcard.2017.05.091] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 04/22/2017] [Accepted: 05/23/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Whether the consequences of diabetes mellitus (DM) are worse for women than for men treated with drug-eluting stents (DES) and antiplatelet therapy remain unclear. METHODS Patients from the Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents study were stratified according to sex and DM status. We investigated the sex-specific effect of DM on high on-clopidogrel platelet reactivity (HPR), defined as a P2Y12 reaction units ≥208, and the adjusted association of DM on the 2-year risk for coronary thrombotic events (CTE), defined as spontaneous myocardial infarction or definite or probable stent thrombosis. RESULTS Out of 8582 patients included in the study, 829 were women with DM (9.6%) and 1954 were men with DM (16.2%). The prevalence of insulin-treated DM (ITDM) was greater in women (p<0.0001). By multivariable logistic regression, DM was associated with a greater likelihood of HPR that was uniform between sexes (pint=0.88). Following adjustment for baseline variables and HPR, in women a stepwise increase in risk for CTEs was observed in the transition from no DM to non-ITDM (NITDM) (adjusted hazard ratio [adjHR]: 1.31; 95% CI: 0.78-2.18) to ITDM (adjHR: 2.69; 95% CI: 1.23-3.45). This increase in risk associated with subtypes of DM was of smaller magnitude in men (for NITDM, adjHR: 1.04; 95% CI: 0.77-1.39; for ITDM, adjHR: 1.46; 95% CI: 1.05-2.03; pint=0.016). CONCLUSIONS In a population treated with DES and antiplatelet therapy, the risk for CTE associated with DM seems to be greater in women and was independent of HPR.
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Khan AA, Dangas GD. The quest for a "diabetic" stent. Catheter Cardiovasc Interv 2018; 91:892-893. [PMID: 29634860 DOI: 10.1002/ccd.27612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 03/02/2018] [Indexed: 11/09/2022]
Abstract
Patients with diabetes mellitus and extensive coronary artery disease generally had worse outcomes with early generation drug eluting stents (DES) as compared to coronary artery bypass grafting. Initial results with Amphilimus eluting coronary stent in patients with diabetes have been promising in small studies The data from Sardella et al. should be used, in conjunction with previous clinical studies with this DES type, as hypothesis generating for a large multicenter randomized trial to aid in our quest to find the "new diabetic stent."
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Palaiodimos L, Kokkinidis DG, Faillace RT, Foley TR, Dangas GD, Price MJ, Mastoris I. Percutaneous closure of patent foramen ovale vs. medical treatment for patients with history of cryptogenic stroke: A systematic review and meta-analysis of randomized controlled trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:852-858. [PMID: 29576519 DOI: 10.1016/j.carrev.2018.02.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 02/04/2018] [Accepted: 02/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with history of cryptogenic stroke are more likely to have a patent foramen ovale (PFO) and should be managed with antithrombotic agents, while the alternative option is percutaneous closure of PFOs. Our aim was to perform a meta-analysis of randomized controlled trials (RCTs) comparing percutaneous closure vs. medical treatment for patients with PFO and prior cryptogenic stroke. METHODS Medline, Scopus and Cochrane databases were reviewed. A random-effect model meta-analysis was used and I-square was utilized to assess the heterogeneity. New ischemic stroke was defined as the primary endpoint. A sensitivity analysis was performed for Amplatzer device. Subgroup analyses were performed for different patient and PFO characteristics for the composite endpoints as defined by the included RCTs. RESULTS In total of 3440 patients were included in this meta-analysis. Closure devices were superior to medical therapy for prevention of recurrent ischemic strokes (HR = 0.29; CI: 0.02-0.56), but were associated with increased risk of new onset of atrial fibrillation (AF) and atrial flutter (RR = 4.67; CI: 2.22-9.81). However, in the sensitivity analysis for Amplatzer device, there was no difference between the two groups in new onset of atrial arrhythmias. Closure devices were superior across all different subgroups when compared to medical treatment with the exception of patients with a small shunt. CONCLUSION This meta-analysis shows that closure devices for patients with PFO and history of cryptogenic stroke can significantly decrease the risk of a new ischemic stroke. The use of Amplatzer device was not associated with increased risk of newly diagnosed atrial arrhythmias.
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Abstract
Several chronic total occlusions (CTOs) may be undilatable despite successful wire passage; several techniques can be used for lesion preparation, such as high-pressure balloon inflations, rotational atherectomy laser, cutting balloon, and scoring balloons. Presence of moderate to severe calcification and lesion length over 40 mm in association with comorbidities, such as diabetes mellitus and reduced ejection fraction, may contribute to making a CTO lesion undilatable. Still, appropriate therapy selection for a patient with CTO should be individualized and procedure safety attended to.
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Song L, Guan C, Yan H, Qiao S, Wu Y, Yuan J, Dou K, Yang Y, Dangas GD, Xu B. Validation of contemporary risk scores in predicting coronary thrombotic events and major bleeding in patients with acute coronary syndrome after drug-eluting stent implantations. Catheter Cardiovasc Interv 2018; 91:573-581. [PMID: 29322612 DOI: 10.1002/ccd.27468] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 11/29/2017] [Indexed: 11/08/2022]
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