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Lo Russo GV, Balla AK, Alarouri HS, Liu CH, Adi MZ, Killu AM, Alkhouli M. Impact of early bleeding on long-term mortality after left atrial appendage occlusion. Heart Rhythm 2024:S1547-5271(24)02911-4. [PMID: 39032523 DOI: 10.1016/j.hrthm.2024.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 06/28/2024] [Accepted: 07/13/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Short-term antithrombotic therapy is recommended after left atrial appendage occlusion (LAAO) to reduce the risk of device-related thrombosis. However, patients referred for LAAO have excess bleeding risk. Yet, short-term bleeding events post-LAAO are not well characterized. OBJECTIVES We aimed to evaluate the incidence of early bleeding post-LAAO and its association with long-term mortality risk. We also sought to identify predictors of early bleeding. METHODS Patients who underwent LAAO at Mayo Clinic between 2018 and 2023 were included. Early bleeding was defined as bleeding that occurred within 3 months of discharge. A multivariable Cox proportional hazards model was used to assess the association between early bleeding and death and to estimate the hazard ratio. Multivariable regression analysis was used to identify predictors of early bleeding. RESULTS Of the 592 patients included, 389 (66%) were male, and the mean age was 75.6 years. Eighty-three patients (14.0%) experienced early bleeding, with the majority having minimal (63.4%) or minor (17.3%) bleeding. At a median follow-up of 14.4 months (interquartile range 4.2-27.9 months), early bleeding after LAAO was associated with an increased risk of all-cause mortality (adjusted hazard ratio 2.07; 95% confidence interval 1.15-3.75; P = .02). A history of intracranial bleeding, nonparoxysmal atrial fibrillation, CHA2DS2-VASc score, and early device-related thrombosis were independent predictors of early bleeding. Antithrombotic therapy at discharge was not associated with early nonprocedural bleeding. CONCLUSION One in 7 patients experience a nonprocedural bleeding event within 90 days of LAAO. Early bleeding after LAAO is associated with a higher all-cause mortality risk during mid-term follow-up. Further studies are needed to optimize the management of patients undergoing LAAO.
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Affiliation(s)
- Gerardo V Lo Russo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Abdalla Kara Balla
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hasan S Alarouri
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Chia-Hao Liu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Cardiology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Mahmoud Zhour Adi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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Matsuoka Y, Sotomi Y, Hikoso S, Nakatani D, Okada K, Dohi T, Kida H, Oeun B, Sunaga A, Sato T, Kitamura T, Sakata Y, Sato H, Hori M, Komuro I, Sakata Y. The Prognostic Impact of In-Hospital Major Bleeding and Recurrence of Myocardial Infarction during Acute Phase after Percutaneous Coronary Intervention for Acute Myocardial Infarction. J Atheroscler Thromb 2024; 31:158-170. [PMID: 37599086 PMCID: PMC10857835 DOI: 10.5551/jat.64274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/02/2023] [Indexed: 08/22/2023] Open
Abstract
AIM Both recurrent myocardial infarction (ReMI) and bleeding events after acute myocardial infarction (AMI) were reportedly associated with increased mortality. To date, the prognostic impact of these events on subsequent outcomes in East Asians is still unclear. In this study, we aimed to investigate the impact of bleeding or thrombotic events during acute phase on subsequent mortality and time-dependent change of the impact in patients with AMI undergoing percutaneous coronary intervention (PCI). METHOD We conducted a prospective, multicenter, observational study of patients with AMI (n=12,093). The patients who did not undergo emergent PCI were excluded. In addition, the patients registered before 2003 were excluded because the data of bleeding severity was not obtained. Eligible patients were divided into two groups based on the occurrence of major bleeding within 7 days of PCI, and the same approach was performed for ReMI within 7 days of PCI. The endpoint of this study was all-cause death. We assessed the impact of major bleeding and ReMI, which occurred within 7 days of index PCI, on the subsequent clinical outcomes up to 5 years. RESULTS A total of 6,769 patients were found to be eligible. All-cause death occurred in 898 (13.3%) patients during a median follow-up period of 1,726 [511-1,840] days. After adjustment for multiple confounders, major bleeding in 7 days from index PCI was independently associated with higher 30-day and 30-day to 1-year mortality (odds ratio [OR]: 2.06 [1.45-2.92] p<0.001, OR: 2.03 [1.28-3.15] p=0.002), whereas ReMI was not (OR: 1.93 [0.92-3.80] p=0.07, OR: 0.81 [0.24-2.03] p=0.68). Major bleeding and ReMI did not affect mortality between 1 and 5 years (hazard ratio [HR]: 1.32 [0.77-2.26] p=0.31, HR: 0.48 [0.12-1.94] p=0.30). CONCLUSION Major bleeding in 7 days from admission was independently associated with higher 30-day and 1-year mortality but not during 1-5 years. ReMI did not affect mortality in all phases. We should be more concerned about bleeding event during acute phase after PCI.
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Affiliation(s)
- Yuki Matsuoka
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Daisaku Nakatani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Transformative System for Medical Information, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tomoharu Dohi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hirota Kida
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Bolrathanak Oeun
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Akihiro Sunaga
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Taiki Sato
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yasuhiko Sakata
- Department of Clinical Medicine and Development and Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Sato
- Graduate School of Human Welfare Studies Health Care Center and Clinic, Kwansei Gakuin University, Hyogo, Japan
| | | | - Issei Komuro
- Department of Cardiovascular Medicine, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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3
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Monteleone P, Kadian-Dodov D, Parikh SA. Response to "Not All Grams per Deciliter of Hemoglobin Are Equal". JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101252. [PMID: 39132222 PMCID: PMC11308543 DOI: 10.1016/j.jscai.2023.101252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 08/13/2024]
Affiliation(s)
- Peter Monteleone
- The University of Texas at Austin Dell School of Medicine, Ascension Texas Cardiovascular, Austin, Texas
| | | | - Sahil A. Parikh
- Center for Interventional Cardiovascular Care and Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
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4
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Kornowski R, Konigstein M, Jonas M, Assali A, Vaknin‐Assa H, Segev A, Danenberg H, Halabi M, Roguin A, Kerner A, Lev E, Karamasis GV, Johnson TW, Anderson R, Blaxill J, Jadhav S, Hoole S, Witberg G, Issever MO, Ben‐Yehuda O, Baumbach A. Percutaneous Coronary Interventions Using a Ridaforolimus-Eluting Stent in Patients at High Bleeding Risk. J Am Heart Assoc 2024; 13:e029051. [PMID: 38214256 PMCID: PMC10926822 DOI: 10.1161/jaha.122.029051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 11/01/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Patients treated with percutaneous coronary intervention are often considered to be at a high bleeding risk (HBR). Drug-eluting stents have been shown to be superior to bare-metal stents in patients with HBR, even when patients were given abbreviated periods of dual antiplatelet therapy (DAPT). Short DAPT has not been evaluated with the EluNIR ridaforolimus-eluting stent. The aim of this study was to evaluate the safety and efficacy of a shortened period of DAPT following implantation of the ridaforolimus-eluting stent in patients with HBR. METHODS AND RESULTS This was a prospective, multicenter, binational, single-arm, open-label trial. Patients were defined as HBR according to the LEADERS-FREE (Prospective Randomized Comparison of the BioFreedom Biolimus A9 Drug-Coated Stent versus the Gazelle Bare-Metal Stent in Patients at High Bleeding Risk) trial criteria. After percutaneous coronary intervention, DAPT was given for 1 month to patients presenting with stable angina. In patients presenting with an acute coronary syndrome, DAPT was given for 1 to 3 months, at the investigator's discretion. The primary end point was a composite of cardiac death, myocardial infarction, or stent thrombosis up to 1 year (Academic Research Consortium definite and probable). Three hundred fifteen patients undergoing percutaneous coronary intervention were enrolled, and 56.4% presented with acute coronary syndrome; 33.7% were receiving oral anticoagulation. At 1 year, the primary end point occurred in 15 patients (4.9%), meeting the prespecified performance goal of 14.1% (P<0.0001). Stent thrombosis (Academic Research Consortium definite and probable) occurred in 2 patients (0.6%). Bleeding Academic Research Consortium type 3 and 5 bleeding occurred in 6 patients (1.9%). CONCLUSIONS We observed favorable results in patients with HBR who underwent percutaneous coronary intervention with a ridaforolimus-eluting stent and received shortened DAPT, including a low rate of ischemic events and low rate of stent thrombosis. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03877848.
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Affiliation(s)
- Ran Kornowski
- Rabin MCTel‐AvivIsrael
- Faculty of Medicine, Tel‐Aviv UniversityTel AvivIsrael
| | - Maayan Konigstein
- Tel Aviv Sourasky MCTel‐AvivIsrael
- Faculty of Medicine, Tel‐Aviv UniversityTel AvivIsrael
| | - Michael Jonas
- Faculty of MedicineHebrew University of Jerusalem, Kaplan MCRehovotIsrael
| | - Abid Assali
- Meir MCKfar SabaIsrael
- Faculty of Medicine, Tel‐Aviv UniversityTel AvivIsrael
| | - Hana Vaknin‐Assa
- Rabin MCTel‐AvivIsrael
- Faculty of Medicine, Tel‐Aviv UniversityTel AvivIsrael
| | - Amit Segev
- Sheba Medical CenterRamat GanIsrael
- Faculty of Medicine, Tel‐Aviv UniversityTel AvivIsrael
| | | | | | | | | | - Eli Lev
- Assuta Ashdod MCAshdodIsrael
| | | | | | | | | | - Sachin Jadhav
- Nottingham University HospitalsNottinghamUnited Kingdom
| | | | - Guy Witberg
- Rabin MCTel‐AvivIsrael
- Faculty of Medicine, Tel‐Aviv UniversityTel AvivIsrael
| | | | | | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research InstituteQueen Mary University of London and Barts Heart CentreLondonUnited Kingdom
- Yale University School of MedicineNew HavenCTUSA
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Thomas A, Gitto M, Shah S, Saito Y, Tirziu D, Chieffo A, Stefanini GG, Lansky AJ. Antiplatelet Strategies Following PCI: A Review of Trials Informing Current and Future Therapies. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100607. [PMID: 39130709 PMCID: PMC11307978 DOI: 10.1016/j.jscai.2023.100607] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 08/13/2024]
Abstract
Dual antiplatelet therapy (DAPT) has been paramount in preventing thrombosis following percutaneous coronary intervention for nearly 3 decades. However, over the years, DAPT has seen significant changes in the agents utilized and duration of therapy as trials have raced to keep up with advancements made in stent technology and our understanding of bleeding and ischemic risk. Recently, there have been a number of trials demonstrating significant reductions in bleeding events with shorter DAPT durations, which are not yet reflected in practice guidelines. Further, there has been a shift toward more individualized antiplatelet regimens to meet patient-specific risk profiles. This review provides a comprehensive summary of the major trials that have informed current DAPT strategies, puts into context recent trials driving a shift toward more tailored antiplatelet regimens, and highlights gaps in knowledge that remain and the ongoing trials designed to address them.
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Affiliation(s)
- Alexander Thomas
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Mauro Gitto
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
- Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy
| | - Samit Shah
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Yuichi Saito
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Daniela Tirziu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Giulio G. Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
- Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy
| | - Alexandra J. Lansky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
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Costa F, Montalto C, Branca M, Hong SJ, Watanabe H, Franzone A, Vranckx P, Hahn JY, Gwon HC, Feres F, Jang Y, De Luca G, Kedhi E, Cao D, Steg PG, Bhatt DL, Stone GW, Micari A, Windecker S, Kimura T, Hong MK, Mehran R, Valgimigli M. Dual antiplatelet therapy duration after percutaneous coronary intervention in high bleeding risk: a meta-analysis of randomized trials. Eur Heart J 2023; 44:954-968. [PMID: 36477292 DOI: 10.1093/eurheartj/ehac706] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 10/13/2022] [Accepted: 11/15/2022] [Indexed: 12/12/2022] Open
Abstract
AIMS The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in patients at high bleeding risk (HBR) is still debated. The current study, using the totality of existing evidence, evaluated the impact of an abbreviated DAPT regimen in HBR patients. METHODS AND RESULTS A systematic review and meta-analysis was performed to search randomized clinical trials comparing abbreviated [i.e. very-short (1 month) or short (3 months)] with standard (≥6 months) DAPT in HBR patients without indication for oral anticoagulation. A total of 11 trials, including 9006 HBR patients, were included. Abbreviated DAPT reduced major or clinically relevant non-major bleeding [risk ratio (RR): 0.76, 95% confidence interval (CI): 0.61-0.94; I2 = 28%], major bleeding (RR: 0.80, 95% CI: 0.64-0.99, I2 = 0%), and cardiovascular mortality (RR: 0.79, 95% CI: 0.65-0.95, I2 = 0%) compared with standard DAPT. No difference in all-cause mortality, major adverse cardiovascular events, myocardial infarction, or stent thrombosis was observed. Results were consistent, irrespective of HBR definition and clinical presentation. CONCLUSION In HBR patients undergoing PCI, a 1- or 3-month abbreviated DAPT regimen was associated with lower bleeding and cardiovascular mortality, without increasing ischaemic events, compared with a ≥6-month DAPT regimen. STUDY REGISTRATION PROSPERO registration number CRD42021284004.
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Affiliation(s)
- Francesco Costa
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, A.O.U. Policlinic 'G. Martino', Messina 98100, Italy
| | - Claudio Montalto
- De Gasperis Cardio Center, Interventional Cardiology Unit, Niguarda Hospital, Milan, Italy
| | | | - Sung-Jin Hong
- Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
| | | | - Anna Franzone
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences, University of Hasselt, Hasselt, Belgium
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Fausto Feres
- Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Yangsoo Jang
- Department of Cardiology, CHA Bundang Medical Center, Seongnam, Korea
| | | | - Elvin Kedhi
- Clinique Hopitaliere Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Davide Cao
- Cardio Center, Humanitas Research Hospital IRCCS, Milan, Italy
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, A.O.U. Policlinic 'G. Martino', Messina 98100, Italy
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan
| | - Myeong-Ki Hong
- Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Marco Valgimigli
- Cardiocentro Ticino Institute and Università della Svizzera Italiana (USI), Lugano, Switzerland
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Outcomes of Patients Treated with Blood Transfusion in a Contemporary Tertiary Care Medical Center Intensive Cardiac Care Unit. J Clin Med 2023; 12:jcm12041304. [PMID: 36835840 PMCID: PMC9965353 DOI: 10.3390/jcm12041304] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/21/2023] [Accepted: 02/03/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Acutely ill patients treated with blood transfusion (BT) have unfavorable prognoses. Nevertheless, data regarding outcomes in patients treated with BT admitted into a contemporary tertiary care medical center intensive cardiac care unit (ICCU) are limited. The current study aimed to assess the mortality rate and outcomes of patients treated with BT in a modern ICCU. METHODS Prospective single center study where we evaluated mortality, in the short and long term, of patients treated with BT between the period of January 2020 and December 2021 in an ICCU. OUTCOMES A total of 2132 consecutive patients were admitted to the ICCU during the study period and were followed-up for up to 2 years. In total, 108 (5%) patients were treated with BT (BT-group) during their admission, with 305 packed cell units. The mean age was 73.8 ± 14 years in the BT-group vs. 66.6 ± 16 years in the non-BT (NBT) group, p < 0.0001. Females were more likely to receive BT as compared with males (48.1% vs. 29.5%, respectively, p < 0.0001). The crude mortality rate was 29.6% in the BT-group and 9.2% in the NBT-group, p < 0.0001. Multivariate Cox analysis found that even one unit of BT was independently associated with more than two-fold the mortality rate [HR = 2.19 95% CI (1.47-3.62)] as compared with the NBT-group, p < 0.0001]. Receiver operating characteristic (ROC) curve was plotted for multivariable analysis and showed area under curve (AUC) of 0.8 [95% CI (0.760-0.852)]. CONCLUSIONS BT continues to be a potent and independent predictor for both short- and long-term mortality even in a contemporary ICCU, despite the advanced technology, equipment and delivery of care. Further considerations for refining the strategy of BT administration in ICCU patients and guidelines for different subsets of high-risk patients may be warranted.
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Su X, Li J, Du L, Wei Y, Li H, Sang H. Acute myocardial infarction post-gastrointestinal bleeding: A clinical dilemma with poor prognosis. Saudi J Gastroenterol 2023; 29:47-52. [PMID: 36153929 PMCID: PMC10117005 DOI: 10.4103/sjg.sjg_301_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) complicating acute myocardial infarction (AMI) is a severe clinical condition with treatment contradiction and poor prognosis. This study aimed to evaluate the rate of in-hospital mortality in patients with GIB who subsequently suffered from AMI and to explore the potential risk factors for this condition. METHODS In this retrospective study, a total of 77 patients diagnosed with GIB, who subsequently suffered from AMI, were enrolled from January 2013 to March 2022. Demographic, laboratory, and clinical data were collected. The in-hospital mortality was the outcome of interest. Logistic regression analysis was used to investigate the potential risk factors of in-hospital mortality. RESULTS Among the 77 patients included in this study, 62 (80.52%) were males. The mean age of patients was 65.88 ± 12.15 years, and 48 patients (62.34%) were non-ST-segment elevation myocardial infarction (NSTEMI). There were 16 (20.78%) cases of in-hospital deaths. The subjects who died showed higher levels of white blood cell count (13.05 ± 5.76 vs. 9.31 ± 4.07 × 109/L, P = 0.003) and troponin I (TnI) (9.23 ± 9.17 vs. 4.12 ± 5.03 μg/L, P = 0.003). Besides, there were higher proportions of cardiogenic shock (81.25% vs. 26.23%, P < 0.001) and mechanical ventilator usage (75.0% vs. 11.48%, P < 0.001) among the patients who died. The multivariate logistic regression analysis showed that white blood cell count (odds ratio [OR] 1.19, 95% confidence interval [CI] 1.02-1.39, P = 0.030), cardiogenic shock (OR 12.18, 95% CI 3.06-48.39, P = 0.017), and mechanical ventilator usage (OR 7.21, 95% CI 1.28-40.51, P = 0.025) were independently associated with in-hospital mortality. CONCLUSIONS The in-hospital mortality of patients with GIB who subsequently develop AMI is high. White blood cell count, cardiogenic shock, and mechanical ventilator usage are independent predictors of in-hospital mortality.
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Affiliation(s)
- Xin Su
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junlei Li
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lijuan Du
- Department of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuzhen Wei
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haiyu Li
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haiqiang Sang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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9
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Vascular Closure Devices versus Manual Compression in Cardiac Interventional Procedures: Systematic Review and Meta-Analysis. Cardiovasc Ther 2022; 2022:8569188. [PMID: 36134143 PMCID: PMC9482152 DOI: 10.1155/2022/8569188] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/20/2022] [Accepted: 08/22/2022] [Indexed: 11/18/2022] Open
Abstract
Backgrounds Manual compression (MC) and vascular closure device (VCD) are two methods of vascular access site hemostasis after cardiac interventional procedures. However, there is still controversial over the use of them and a lack of comprehensive and systematic meta-analysis on this issue. Methods Original articles comparing VCD and MC in cardiac interventional procedures were searched in PubMed, EMbase, Cochrane Library, and Web of Science through April 2022. Efficacy, safety, patient satisfaction, and other parameters were assessed between two groups. Heterogeneity among studies was evaluated by I2 index and the Cochran Q test, respectively. Publication bias was assessed using the funnel plot and Egger's test. Results A total of 32 studies were included after screening with inclusion and exclusion criteria (33481 patients). This meta-analysis found that VCD resulted in shorter time to hemostasis, ambulation, and discharge (p < 0.00001). In terms of vascular complication risks, VCD group might be associated with a lower risk of major complications (p = 0.0001), but the analysis limited to randomized controlled trials did not support this result (p = 0.68). There was no significant difference in total complication rates (p = 0.08) and bleeding-related complication rates (p = 0.05) between the two groups. Patient satisfaction was higher in VCD group (p = 0.002). Meta-regression analysis revealed no specific covariate as an influencing factor for above results (p > 0.05). Conclusions Compared with MC, the use of VCDs significantly shortens the time of hemostasis and allows earlier ambulation and discharge, meanwhile without increase in vascular complications. In addition, use of VCDs achieves higher patient satisfaction and leads cost savings for patients and institutions.
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Sarajlic P, Simonsson M, Jernberg T, Bäck M, Hofmann R. Incidence, associated outcomes, and predictors of upper gastrointestinal bleeding following acute myocardial infarction: a SWEDEHEART-based nationwide cohort study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:483-491. [PMID: 34423350 PMCID: PMC9366628 DOI: 10.1093/ehjcvp/pvab059] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/15/2021] [Accepted: 08/02/2021] [Indexed: 01/10/2023]
Abstract
AIMS Of all spontaneous bleeding complications in patients with acute myocardial infarction (MI), upper gastrointestinal bleeding (UGIB) is common and of specific interest since it could be prevented by several prophylactic measures. We aimed to determine the incidence, associated outcomes, and predictors of UGIB following acute MI. METHODS AND RESULTS All patients with acute MI enrolled in the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) registry from January 2007 to June 2016 and discharged alive on any antithrombotic therapy (n = 149 477) were followed regarding UGIB for 1 year. Associated outcomes were determined by Cox proportional hazards regression with UGIB as a time-dependent covariate, adjusting for baseline characteristics, invasive treatment, and medical treatment at discharge. Predictors of UGIB were determined by logistic regression and machine learning models.At 1 year, UGIB had occurred in 2230 patients (cumulative incidence 1.5%) and was significantly associated with an increased risk of all-cause death [hazard ratio (HR) 2.86, 95% confidence interval (CI) 2.58-3.16] and stroke (HR 1.80, 95% CI 1.32-2.45) but not with recurrent MI (HR 1.17, 95% CI 0.97-1.42). The most important predictors of UGIB were haemoglobin, age, systolic blood pressure, blood glucose, smoking status, previous upper gastrointestinal bleeding, and antithrombotic and gastroprotective treatment. CONCLUSION After acute MI, readmission because of UGIB is common and significantly associated with poor prognosis. By using machine learning in addition to traditional logistic regression, new predictors of UGIB, such as blood glucose and smoking status, were identified.
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Affiliation(s)
- Philip Sarajlic
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Moa Simonsson
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm, Sweden
- Theme Heart and Vessels, Division of Valvular and Coronary Disease, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Magnus Bäck
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
- Theme Heart and Vessels, Division of Valvular and Coronary Disease, Karolinska University Hospital, Stockholm, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institute, Sodersjukhuset, Stockholm, Sweden
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11
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Su X, Wei Y, Pang S, Zhang Z, Zhang Y, Zheng P, Li H, Sang H, Dong J. Clinical Characteristics and Risk Factors of In-Hospital Mortality in Patients With Acute Myocardial Infarction With Subsequent Gastrointestinal Bleeding: A Single-Center Experience. Front Cardiovasc Med 2022; 9:942467. [PMID: 35911533 PMCID: PMC9326005 DOI: 10.3389/fcvm.2022.942467] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/06/2022] [Indexed: 12/16/2022] Open
Abstract
Objective Gastrointestinal bleeding (GIB) post acute myocardial infarction (AMI) is a severe clinical condition with a poor prognosis. The purpose of the study was to evaluate the rate of in-hospital mortality in patients with GIB post-AMI and to identify the potential risk factors of this situation. Methods In this single-center retrospective study, a total of 154 patients diagnosed with AMI who subsequently suffered GIB were enrolled from October 2013 to December 2021. Demographic, laboratory, and clinical data were collected. The in-hospital mortality was the outcome of interest. Logistic regression analysis was used to investigate the potential risk factors of in-hospital mortality. Results Among the 154 subjects included in the final analysis, the mean age was 65.58 ± 11.20 years, and 104 (67.53%) were males. GIB occurred in 11 patients after thrombolytic therapy, 50 patients after percutaneous coronary intervention (PCI), and 93 patients during drug conservative treatment. A total of 41 patients died in the hospital. The in-hospital mortality rate of the thrombolysis group, PCI group, and drug conservative treatment group was 27.27% (3/11), 28.00% (14/50), and 25.81% (24/93), respectively. There was no difference in the in-hospital mortality among the three groups. The multivariate logistic regression analysis showed that the peak levels of TnI (OR 1.07, 95% CI 1.02–1.12, P = 0.011), condition of cardiogenic shock after admission (OR 14.52, 95% CI 3.36–62.62, P < 0.001), and the use of the mechanical ventilator (OR 8.14, 95% CI 2.03–32.59, P = 0.003) were significantly associated with in-hospital mortality. Conclusion Regardless of the treatment strategy for AMI, once GIB occurred, the prognosis was poor. High in-hospital mortality in patients with GIB post-AMI was independently associated with the peak levels of TnI, condition of cardiogenic shock, and the use of a mechanical ventilator.
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Affiliation(s)
- Xin Su
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuzhen Wei
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shuo Pang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zeqing Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yunxiao Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peipei Zheng
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haiyu Li
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haiqiang Sang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jianzeng Dong
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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12
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Zhao X, Liu C, Zhou P, Sheng Z, Li J, Zhou J, Chen R, Wang Y, Chen Y, Song L, Zhao H, Yan H. Development and Validation of a Prediction Rule for Major Adverse Cardiac and Cerebrovascular Events in High-Risk Myocardial Infarction Patients After Primary Percutaneous Coronary Intervention. Clin Interv Aging 2022; 17:1099-1111. [PMID: 35880211 PMCID: PMC9307870 DOI: 10.2147/cia.s358761] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 06/06/2022] [Indexed: 11/23/2022] Open
Abstract
Background and Aims We aimed to develop a clinical prediction tool to improve the prognosis of major adverse cardiac and cerebrovascular events (MACCE) among high-risk myocardial infarction (MI) patients undergoing primary percutaneous coronary intervention (PCI). Methods The present study was a prospective and observational study. A total of 4151 consecutive MI patients who underwent primary PCI at Fuwai Hospital in Beijing, China (January 2010 and June 2017) were enrolled. Forty-eight patients without follow-up data were excluded from the study. The pre-specified criteria (Supplementary Information 1) were chosen to enroll MI patients at high risk for MACCE complications after PCI. Results The full model included seven variables, with a risk score of 160 points. Derivation and validation cohort models predicting MACCE had C-statistics of 0.695 and 0.673. The area under the curve (AUC) of the survival receiver operating characteristic curve (ROC) for predicting MACCE was 0.991 and 0.883 in the derivation and validation cohorts, respectively. Conclusion The predicted model was internally validated and calibrated in large cohorts of patients with high-risk MI receiving primary PCI to predict MACCE and showed modest accuracy in the derivation and validation cohorts.
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Affiliation(s)
- Xiaoxiao Zhao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Chen Liu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Peng Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Zhaoxue Sheng
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Jiannan Li
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Jinying Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Runzhen Chen
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Ying Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Yi Chen
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Li Song
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Hanjun Zhao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Hongbing Yan
- Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen, People's Republic of China
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13
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Cao D, Camaj A, Mehran R. Balance of Ischemia and Bleeding in Selecting Intensity and Duration of Antithrombotic Regimens. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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14
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de Veer AJWM, Bennaghmouch N, Bor WL, Herrman JPR, Vrolix M, Meuwissen M, Vandendriessche T, Adriaenssens T, de Bruyne B, Magro M, Dewilde WJM, Ten Berg JM. The WOEST 2 registry : A prospective registry on antithrombotic therapy in atrial fibrillation patients undergoing percutaneous coronary intervention. Neth Heart J 2022; 30:302-311. [PMID: 35230636 PMCID: PMC9123099 DOI: 10.1007/s12471-022-01664-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Patients on oral anticoagulants (OACs) undergoing percutaneous coronary intervention (PCI) also require aspirin and a P2Y12 inhibitor (triple therapy). However, triple therapy increases bleeding. The use of non-vitamin K antagonist oral anticoagulants (NOACs) and stronger P2Y12 inhibitors has increased. The aim of our study was to gain insight into antithrombotic management over time. METHODS A prospective cohort study of patients on OACs for atrial fibrillation or a mechanical heart valve undergoing PCI was performed. Thrombotic outcomes were myocardial infarction, stroke, target-vessel revascularisation and all-cause mortality. Bleeding outcome was any bleeding. We report the 30-day outcome. RESULTS The mean age of the 758 patients was 73.5 ± 8.2 years. The CHA2DS2-VASc score was ≥ 3 in 82% and the HAS-BLED score ≥ 3 in 44%. At discharge, 47% were on vitamin K antagonists (VKAs), 52% on NOACs, 43% on triple therapy and 54% on dual therapy. Treatment with a NOAC plus clopidogrel increased from 14% in 2014 to 67% in 2019. The rate of thrombotic (4.5% vs 2.0%, p = 0.06) and bleeding (17% vs. 14%, p = 0.42) events was not significantly different in patients on VKAs versus NOACs. Also, the rate of thrombotic (2.9% vs 3.4%, p = 0.83) and bleeding (18% vs 14%, p = 0.26) events did not differ significantly between patients on triple versus dual therapy. CONCLUSIONS Patients on combined oral anticoagulation and antiplatelet therapy undergoing PCI are elderly and have both a high bleeding and ischaemic risk. Over time, a NOAC plus clopidogrel became the preferred treatment. The rate of thrombotic and bleeding events was not significantly different between patients on triple or dual therapy or between those on VKAs versus NOACs.
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Affiliation(s)
- A J W M de Veer
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - N Bennaghmouch
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - W L Bor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J P R Herrman
- Department of Cardiology, OLVG, Amsterdam, The Netherlands
| | - M Vrolix
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - M Meuwissen
- Department of Cardiology, Amphia Hospital, Breda, The Netherlands
| | - T Vandendriessche
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - T Adriaenssens
- Department of Cardiovascular Medicine, University Hospital Leuven, Leuven, Belgium
| | - B de Bruyne
- Cardiovascular Research Centre Aalst, OLV Clinic, Aalst, Belgium
| | - M Magro
- Department of Cardiology, Elizabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - W J M Dewilde
- Department of Cardiology, Imelda Hospital, Bonheiden, Belgium
| | - J M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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15
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Sotomi Y, Kozuma K, Kashiwabara K, Higuchi Y, Ando K, Morino Y, Ako J, Tanabe K, Muramatsu T, Nakazawa G, Hikoso S, Sakata Y. Randomised controlled trial to investigate optimal antithrombotic therapy in patients with non-valvular atrial fibrillation undergoing percutaneous coronary intervention: a study protocol of the OPTIMA-AF trial. BMJ Open 2021; 11:e048354. [PMID: 34907043 PMCID: PMC8671924 DOI: 10.1136/bmjopen-2020-048354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 10/11/2021] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The optimal antithrombotic strategy for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is uncertain. For patients with non-AF, many trials are now evaluating short 1-month dual antiplatelet therapy. In patients with AF undergoing PCI, in contrast, short dual therapy (P2Y12 inhibitor +direct oral anticoagulant (DOAC)) has not yet been evaluated. METHODS AND ANALYSIS The OPTIMA-AF trial (OPTIMAl antiplatelet therapy in combination with direct oral anticoagulants in patients with non-valvular Atrial Fibrillation undergoing percutaneous coronary intervention with everolimus-eluting stent) is an investigator-initiated, open-label, nationwide, multicentre, prospective, randomised controlled trial. The primary objective is to compare the efficacy and safety of short dual therapy (1-month DOAC +P2Y12 inhibitor followed by DOAC monotherapy) against long dual therapy (12-month DOAC +P2Y12 inhibitor followed by DOAC monotherapy) in the treatment of AF subjects undergoing PCI. The primary efficacy endpoint is a composite of death or thromboembolic events (myocardial infarction, definite stent thrombosis, stroke or systemic embolism) at 365 days; and the primary safety endpoint is bleeding (International Society on Thrombosis and Haemostasis major or clinically relevant non-major bleeding) at 365 days. This trial is intended to show the non-inferiority of short dual therapy versus long dual therapy in terms of the primary efficacy endpoint and show superiority in terms of the primary safety endpoint. A total of 1090 subjects will be randomised in a 1:1 ratio at approximately 60 sites. ETHICS AND DISSEMINATION This study received approval from the Certified Review Board of Osaka University (a certified research ethics committee by the Japanese Clinical Research Act). The findings will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER Japan Registry of Clinical Trials: jRCTs051190053; Pre-results.
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Affiliation(s)
- Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ken Kozuma
- Department of Medicine, Division of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Kosuke Kashiwabara
- Department of Biostatistics, School of Public Health, University of Tokyo, Tokyo, Japan
| | | | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Yoshihiro Morino
- Department of Internal Medicine, Division of Cardiology, Iwate Medical University, Iwate, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kengo Tanabe
- Department of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Takashi Muramatsu
- Department of Cardiology, Fujita Health University School of Medicine, Aichi, Japan
| | - Gaku Nakazawa
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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16
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Sawayama Y, Yamaji K, Kohsaka S, Yamamoto T, Higo Y, Numasawa Y, Inohara T, Ishii H, Amano T, Ikari Y, Nakagawa Y. Variation in in-hospital mortality and its association with percutaneous coronary intervention-related bleeding complications: A report from nationwide registry in Japan. PLoS One 2021; 16:e0261371. [PMID: 34898658 PMCID: PMC8668123 DOI: 10.1371/journal.pone.0261371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 11/29/2021] [Indexed: 11/22/2022] Open
Abstract
Large-scale registries have demonstrated that in-hospital mortality after percutaneous coronary intervention (PCI) varies widely across institutions. However, whether this variation is related to major procedural complications (e.g., bleeding) is unclear. In this study, institutional variation in in-hospital mortality and its association with PCI-related bleeding complications were investigated. We analyzed 388,866 procedures at 718 hospitals performed from 2017 to 2018, using data from a nationwide PCI registry in Japan. Hospitals were stratified into quintiles according to risk-adjusted in-hospital mortality (very low, low, medium, high, and very high). Incidence of bleeding complications, defined as procedure-related bleeding events that required a blood transfusion, and in-hospital mortality in patients who developed bleeding complications were calculated for each quintile. Overall, 4,048 (1.04%) in-hospital deaths and 1,535 (0.39%) bleeding complications occurred. Among patients with bleeding complications, 270 (17.6%) died during hospitalization. In-hospital mortality ranged from 0.22% to 2.46% in very low to very high mortality hospitals. The rate of bleeding complications varied modestly from 0.27% to 0.57% (odds ratio, 1.95; 95% confidence interval, 1.58–2.39). However, mortality after bleeding complications markedly increased by quintile and was 6-fold higher in very high mortality hospitals than very low mortality hospitals (29.0% vs. 4.8%; odds ratio, 12.2; 95% confidence interval, 6.90–21.7). In conclusion, institutional variation in in-hospital mortality after PCI was associated with procedure-related bleeding complications, and this variation was largely driven by differences in mortality after bleeding complications rather than difference in their incidence. These findings underscore the importance of efforts toward reducing not only bleeding complications but also, even more importantly, subsequent mortality once they have occurred.
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Affiliation(s)
- Yuichi Sawayama
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Kyohei Yamaji
- Division of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Yamamoto
- Department of Cardiovascular Medicine, Kohka Public Hospital, Kohka, Japan
| | - Yosuke Higo
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Taku Inohara
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Aichi, Japan
| | - Yuji Ikari
- Department of Cardiology, Tokai University School of Medicine, Isehara, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
- * E-mail:
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Salisbury AC, Safley DM, Kennedy KF, Bhardwaj B, Aronow HD, Jones WS, Feldman DN, Secemsky E, Tsai TT, Attaran RR, Spertus JA. Development and validation of a predictive model for bleeding after peripheral vascular intervention: A report from the National Cardiovascular Data Registry Peripheral Vascular Interventions Registry. Catheter Cardiovasc Interv 2021; 98:1363-1372. [PMID: 34569709 DOI: 10.1002/ccd.29961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/08/2021] [Accepted: 09/18/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To develop a model to predict risk of in-hospital bleeding following endovascular peripheral vascular intervention. BACKGROUND Peri-procedural bleeding is a common, potentially preventable complication of catheter-based peripheral vascular procedures and is associated with increased mortality. We used the National Cardiovascular Data Registry (NCDR) Peripheral Vascular Interventions (PVI) Registry to develop a novel risk-prediction model to identify patients who may derive the greatest benefit from application of strategies to prevent bleeding. METHODS We examined all patients undergoing lower extremity PVI at 76 NCDR PVI hospitals from 2014 to 2017. Patients with acute limb ischemia (n = 1600) were excluded. Major bleeding was defined as overt bleeding with a hemoglobin (Hb) drop of ≥ 3 g/dl, any Hb decline of ≥ 4 g/dl, or a blood transfusion in patients with pre-procedure Hb ≥ 8 g/dl. Hierarchical multivariable logistic regression was used to develop a risk model to predict major bleeding. Model validation was performed using 1000 bootstrapped replicates of the population after sampling with replacement. RESULTS Among 25,382 eligible patients, 1017 (4.0%) developed major bleeding. Predictors of bleeding included age, female sex, critical limb ischemia, non-femoral access, prior heart failure, and pre-procedure hemoglobin. The model demonstrated good discrimination (optimism corrected c-statistic = 0.67), calibration (corrected slope = 0.98, intercept of -0.04) and range of predicted risk (1%-18%). CONCLUSIONS Post-procedural PVI bleeding risk can be predicted based upon pre- and peri-procedural patient characteristics. Further studies are needed to determine whether this model can be utilized to improve procedural safety through developing and targeting bleeding avoidance strategies.
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Affiliation(s)
- Adam C Salisbury
- University of Missouri-Kansas City, Kansas City, Missouri, USA
- Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
| | - David M Safley
- University of Missouri-Kansas City, Kansas City, Missouri, USA
- Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
| | - Kevin F Kennedy
- Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
| | | | - Herbert D Aronow
- Lifespan Cardiovascular Institute, Brown University, Providence, Rhode, USA
| | - William Schuyler Jones
- Division of Cardiology, Duke Heart Center, Duke University Health System, Durham, North Carolina, USA
| | - Dmitriy N Feldman
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
| | - Eric Secemsky
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Thomas T Tsai
- University of Colorado Institute for Health Research and Kaiser Permanente, Denver, Colorado, USA
| | | | - John A Spertus
- University of Missouri-Kansas City, Kansas City, Missouri, USA
- Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
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18
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Wein B, Zaczkiewicz M, Graf M, Zimmermann O, Gori T, Nef HM, Kastner J, Mehilli J, Richardt G, Wöhrle J, Achenbach S, Riemer T, Hamm C, Torzewski J. No difference in 30-day outcome and quality of life in transradial versus transfemoral access - Results from the German Austrian ABSORB registry (GABI-R). CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40:144-149. [PMID: 34844868 DOI: 10.1016/j.carrev.2021.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Radial (RA) instead of femoral access (FA) for coronary interventions has become a European Society of Cardiology Class-IA guideline recommendation. But when the decision on the access site is left to the discretion of the operator, differences in adverse event rates mitigate. METHODS We compared the 30-day outcome for RA and FA in all patients recruited for the observational German Austrian ABSORB Registry (GABI-R) in regard to all-cause mortality, stroke, myocardial infarction (MI), TIMI major bleedings (TMB) and quality of life (QoL). All patients were treated with a bioresorbable vascular scaffold. Access site was left to the discretion of the operator. RESULTS In total, 3137 patients included by 92 centers received percutaneous coronary interventions (PCI) for acute MI in 51.5% and non-acute settings in 48.5%. RA was performed in 47.8% and had a higher median radiation exposure (3896 vs. 3082 cGycm2, p < 0.001). There was no difference in the amount of contrast used. There was also no difference in all-cause mortality (0.53% vs. 0.49%, p = 0.86), the combination of death, MI and stroke (1.87% vs. 1.83%, p = 0.94), but a trend towards more TMB (0.47% vs. 1.04%, p = 0.07) with FA. These outcomes were consistent across the subgroups of patients with ST-elevation MI, non-ST-elevation-ACS and stable coronary artery disease. Finally, QoL did not differ between RA and FA. CONCLUSIONS In this contemporary GABI-R cohort, in which access site was left to the discretion of the operator, both access routes were safe and equal concerning QoL (ClinicalTrials.gov; NCT02066623).
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Affiliation(s)
- Bastian Wein
- Medical Department I, University Hospital Augsburg, Augsburg, Germany
| | | | - Matthias Graf
- Cardiovascular Center Oberallgaeu-Kempten, Kempten, Germany
| | | | - Tommaso Gori
- Department of Cardiology I, University Medical Center, Johannes Gutenberg University Mainz and DZHK Site Rhein Main, Germany
| | - Holger M Nef
- University of Giessen, Medizinische Klinik I, Department of Cardiology, Giessen, Germany
| | - Johannes Kastner
- Department of Cardiology, University of Vienna - Medical School, Vienna, Austria
| | - Julinda Mehilli
- Department of Cardiology, Pneumonology and Intensive Care Medicine - LAKUMED Hospital Landshut-Achdorf, Germany
| | - Gert Richardt
- Herzzentrum, Segeberger Kliniken GmbH, Bad Segeberg, Germany
| | - Jochen Wöhrle
- Department of Cardiology, Angiology, Pneumonology and Intensive Care, Medical Campus Bodensee, Friedrichshafen, Germany
| | - Stephan Achenbach
- Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Medizinische Klinik 2, Erlangen, Germany
| | - Thomas Riemer
- IHF GmbH - Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Christian Hamm
- University of Giessen, Medizinische Klinik I, Department of Cardiology, Giessen, Germany; Kerckhoff Heart and Thorax Centre, Department of Cardiology, Bad Nauheim, Germany
| | - Jan Torzewski
- Cardiovascular Center Oberallgaeu-Kempten, Kempten, Germany.
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Outcomes after ticagrelor versus clopidogrel treatment in end-stage renal disease patients with acute myocardial infarction: a nationwide cohort study. Sci Rep 2021; 11:20826. [PMID: 34675293 PMCID: PMC8531372 DOI: 10.1038/s41598-021-00360-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/08/2021] [Indexed: 11/15/2022] Open
Abstract
Clinical outcomes are unknown after ticagrelor treatment in patients with end-stage renal disease (ESRD) who are diagnosed with acute myocardial infarction (AMI). ESRD patients who were on hemodialysis and received dual antiplatelet therapy (DAPT) for AMI between July 2013 and December 2016 were identified in Taiwan's National Health Insurance Research Database. Using stabilized inverse probability of treatment weighting, patients receiving aspirin plus ticagrelor (n = 530) were compared with those receiving aspirin plus clopidogrel (n = 2462) for the primary efficacy endpoint, a composite of all-cause death, nonfatal myocardial infarction, or nonfatal stroke, and bleeding, defined according to the Bleeding Academic Research Consortium. Study outcomes were compared between the two groups using Cox proportional hazards model or competing risk model for the hazard ratio or subdistribution hazard ratio (SHR). During 9 months of follow-up, ticagrelor was comparable to clopidogrel with respect to the risks of primary efficacy endpoint [11.69 vs. 9.28/100 patient-months; SHR, 1.16; 95% confidence interval (CI) 0.97–1.4] and bleeding (5.55 vs. 4.36/100 patient-months; SHR 1.14; 95% CI 0.88–1.47). In conclusion, among hemodialysis patients receiving DAPT for AMI, ticagrelor was comparable to clopidogrel with regard to the composite efficacy endpoint and bleeding.
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20
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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21
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Lin CJ, Lee WC, Lee CH, Chung WJ, Hsueh SK, Chen CJ, Yang CH, Fang HY, Cheng CI, Wu CJ. Feasibility and Safety of Chronic Total Occlusion Percutaneous Coronary Intervention via Distal Transradial Access. Front Cardiovasc Med 2021; 8:673858. [PMID: 34041286 PMCID: PMC8141614 DOI: 10.3389/fcvm.2021.673858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/13/2021] [Indexed: 11/13/2022] Open
Abstract
Aims: The current study aims to verify the feasibility and safety of chronic total occlusion (CTO)-percutaneous coronary intervention (PCI) via the distal transradial access (dTRA). Methods: Between April 2017 and December 2019, 298 patients who underwent CTO PCI via dTRA were enrolled in this study. The baseline demographic and procedural characteristics were listed and compared between groups. The incidences of access-site vascular complications and procedural complications and mortality were recorded. Results: The mean J-CTO (Japanese chronic total occlusion) score was 2.6 ± 0.9 points. The mean access time was 4.6 ± 2.9 min, and the mean procedure time was 115.9 ± 55.6 min. Left radial snuffbox access was performed successfully in 286 patients (96.5%), and right radial snuffbox access was performed successfully in 133 patients (97.7%). Bilateral radial snuffbox access was performed in 107 patients (35.9%). 400 dTRA (95.5%) received glidesheath for CTO intervention. Two patients (0.7%) developed severe access-site vascular complications. None of the patients experienced severe radial artery spasm and only 2 patients (0.5%) developed radial artery occlusion during the follow-up period. The overall procedural success rate was 93.5%. The procedural success rate was 96.5% in patients with antegrade approach and 87.7% in patients with retrograde approach. Conclusions: It is both safe and feasible to use dTRA plus Glidesheath for complex CTO intervention. The incidences of procedure-related complications and severe access-site vascular complications, and distal radial artery occlusion were low.
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Affiliation(s)
- Cheng-Jui Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wei-Chieh Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chieh-Ho Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wen-Jung Chung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shu-Kai Hsueh
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Jen Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheng-Hsu Yang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheng-I Cheng
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chiung-Jen Wu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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22
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Sawano M, Spertus JA, Masoudi FA, Rumsfeld JS, Numasawa Y, Inohara T, Kennedy K, Ueda I, Miyata H, Fukuda K, Kohsaka S. Bleeding avoidance strategies and percutaneous coronary intervention outcomes: A 10-year observation from a Japanese Multicenter Registry. Am Heart J 2021; 235:113-124. [PMID: 33472053 DOI: 10.1016/j.ahj.2021.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/14/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Bleeding avoidance strategies (BASs) are increasingly adopted for patients undergoing percutaneous coronary intervention (PCI) due to bleeding complications. However, their association with bleeding events outside of Western countries remains unclear. In collaboration with the National Cardiovascular Data Registry (NCDR) CathPCI registry, we aimed to assess the time trend and impact of BAS utilization among Japanese patients. METHODS Our study included 19,656 consecutive PCI patients registered over 10 years. These patients were divided into 4-time frame groups (T1: 2008-2011, T2: 2012-2013, T3: 2014-2015, and T4: 2016-2018). BAS was defined as the use of transradial approach or vascular closure device (VCD) use after transfemoral approach (TFA). Model performance of the NCDR CathPCI bleeding model was evaluated. The degree of bleeding reduction associated with BAS adoption was estimated via multilevel mixed-effects multivariable logistic regression analysis. RESULTS The NCDR CathPCI bleeding risk score demonstrated good discrimination in the Japanese population (C-statistics 0.79-0.81). The BAS adoption rate increased from 43% (T1) to 91% (T4), whereas the crude CathPCI-defined bleeding rate decreased from 10% (T1) to 7% (T4). Adjusted odds ratios for bleeding events were 0.25 (95% confidence interval, 0.14-0.45, P< .001) for those undergoing TFA with VCD in T4 and 0.26 (95% confidence interval 0.20-0.35, P< .001) for transradial approach in T4 compared to patients that received TFA without VCD in T1. CONCLUSIONS BAS use over the studied time frames was associated with lower risk of bleeding complications among Japanese. Nonetheless, observed bleeding rates remained higher compared to the US population.
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23
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Sattar Y, Majmundar M, Ullah W, Mamtani S, Kumar A, Robinson S, Zghouzi M, Mir T, Dhamrah U, Al-Khadra Y, Pacha HM, Darmoch F, Soud M, Hakim Z, Bagur R, Kaul P, Ijioma N, Panchal A, Shroff AR, Alraies MC. Outcomes of Transradial Versus Transfemoral Access of Percutaneous Coronary Intervention in STEMI: Systematic Review and Updated Meta-analysis. Expert Rev Cardiovasc Ther 2021; 19:433-444. [PMID: 33896335 DOI: 10.1080/14779072.2021.1915768] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Transradial (TR) percutaneous coronary intervention (PCI) is a preferable PCI route. The complication difference between TR and TF approaches is controversial. METHODS PubMed, Embase, and the Cochrane databases were queried for PCI outcomes of TR TF in STEMI for major cardiac and cerebrovascular events (MACCE), major bleeding, and mortality. The odds ratio (OR) was calculated using the random-effect model. RESULTS We included 56 studies comprising of 68,733 patients (TR, n = 26,179; TF, n = 42,537). TR-PCI was associated with statistically significant lower odds of MACCE (OR = 0.66, 95% CI: 0.49-0.88, p-value = 0.005), major bleeding (OR = 0.47, 95% CI 0.32-0.68, p-value<0.001), mortality (OR = 0.59, 95% CI 0.43-0.80, p-value<0.001) at in hospital follow-up. TR-PCI was associated with statistically significant lower MACCE (OR = 0.59, 95% CI 0.43-0.80, p-value<0.001), major bleeding (OR = 0.58, 95% CI 0.49-0.68, p-value<0.001), and mortality (OR = 0.61, 95% CI 0.44-0.86, p-value = 0.005) at 30-day follow-up. The same difference was seen at 1-year. CONCLUSION TR-PCI was associated with lower odds of MACCE, major bleeding, and mortality during short- and long-term follow-up.
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Affiliation(s)
- Yasar Sattar
- Internal Medicine , Icahn School of Medicine at Mount Sinai Elmhurst Hospital, NY, New York, USA
| | - Monil Majmundar
- New York Medical College, Metropolitan Hospital Center, New York, NY, USA
| | - Waqas Ullah
- Internal Medicine, Abington Jefferson Health, Abington, PA, USA
| | - Sahil Mamtani
- Internal Medicine, Atlantic Care Regional Medical Center, Atlantic City, NJ, USA
| | - Ashish Kumar
- Internal Medicine, St John's Medical College Hospital, Bangalore, India
| | - Sam Robinson
- Internal Medicine , Icahn School of Medicine at Mount Sinai Elmhurst Hospital, NY, New York, USA
| | - Mohamed Zghouzi
- Department of Cardiology, Detroit Medical Center, Detroit, MI, USA
| | - Tanveer Mir
- Department of Cardiology, Detroit Medical Center, Detroit, MI, USA
| | - Umaima Dhamrah
- Internal Medicine , Icahn School of Medicine at Mount Sinai Elmhurst Hospital, NY, New York, USA
| | - Yasser Al-Khadra
- Department of Cardiology, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Homam Moussa Pacha
- McGovern Medical School, University of Texas Health Science Center, Memorial Hermann Heart & Vascular Institute, Houston, TX, USA
| | - Fahed Darmoch
- Internal Medicine, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Mohamad Soud
- Department of Cardiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Zaher Hakim
- Department of Cardiology, Detroit Medical Center, Detroit, MI, USA
| | - Rodrigo Bagur
- London Health Science Centre, Western University, London, Canada
| | - Prashant Kaul
- Department of Cardiology, Piedmont Heart Institute, Atlanta, GA, USA
| | | | - Ankur Panchal
- Department of Cardiology, University of Pittsburgh Medical Center, PA, USA
| | - Adhir R Shroff
- Department of Cardiology, University of Illinois at Chicago/Jesse Brown VA Medical Center, Chicago, IL, USA
| | - M Chadi Alraies
- Department of Cardiology, Detroit Medical Center, Detroit, MI, USA
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24
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2773] [Impact Index Per Article: 924.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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25
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Hishikari K, Hikita H, Abe F, Ito N, Kanno Y, Iiya M, Murai T, Takahashi A, Yonetsu T, Sasano T. Risk factors and prognostic impact of post-discharge bleeding after endovascular therapy for peripheral artery disease. Vasc Med 2021; 26:281-287. [PMID: 33645340 DOI: 10.1177/1358863x21992863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This study evaluated the incidence, predictors, and impact of bleeding requiring hospitalization following successful endovascular therapy (EVT) for peripheral artery disease. Platelet inhibition after EVT reduces the risk of major adverse limb events but increases the risk of bleeding. The incidence of post-discharge bleeding after EVT, its independent predictors, and its prognostic importance in clinical practice have not been fully addressed. We evaluated 779 consecutive patients who underwent EVT. We found that 77 patients (9.9%) were hospitalized for major bleeding during follow-up after EVT (median 39 months, range 22-66 months), with almost half (48.1%) of the bleeding categorized as gastrointestinal bleeding. Significant predictors of post-discharge bleeding were hemodialysis (hazard ratio (HR), 3.12; 95% CI: 1.93 to 5.05; p < 0.001) and dual antiplatelet therapy (DAPT) use (HR, 1.87; 95% CI: 1.03 to 3.41; p = 0.041). During follow-up, the all-cause mortality-free survival rate was significantly worse in patients who had experienced major bleeding than in those who had not (log-rank test χ2 = 54.6; p < 0.001). Cox proportional hazards analysis showed that major bleeding (HR, 2.78; 95% CI: 1.90 to 4.06; p < 0.001) was an independent predictor of all-cause death after EVT. Hospitalization for post-discharge bleeding after EVT is associated with a substantially increased risk of death, even after successful EVT. We concluded that patients' predicted bleeding risk should be considered when selecting patients likely to benefit from EVT, and that the risk should be considered especially thoroughly in hemodialysis patients.
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Affiliation(s)
- Keiichi Hishikari
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan.,Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Hikita
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Fumichika Abe
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Naruhiko Ito
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Yoshinori Kanno
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Munehiro Iiya
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Tadashi Murai
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | | | - Taishi Yonetsu
- Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuo Sasano
- Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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26
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Cao D, Dangas G, Mehran R. Long-Term Ticagrelor in Stable Patients With Prior Myocardial Infarction: Bleeding Avoidance First and Foremost. J Am Heart Assoc 2021; 10:e019889. [PMID: 33559475 PMCID: PMC7955350 DOI: 10.1161/jaha.120.019889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Davide Cao
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
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27
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Tung YC, See LC, Chang SH, Liu JR, Kuo CT, Chang CJ. Impact of bleeding during dual antiplatelet therapy in patients with coronary artery disease. Sci Rep 2020; 10:21345. [PMID: 33288822 PMCID: PMC7721794 DOI: 10.1038/s41598-020-78400-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 11/10/2020] [Indexed: 11/09/2022] Open
Abstract
This nationwide retrospective cohort study used the National Health Insurance Research Database of Taiwan to compare the impact of bleeding on clinical outcomes in patients with acute myocardial infarction (AMI) versus chronic coronary syndrome (CCS). Between July 2007 and December 2010, patients with AMI (n = 15,391) and CCS (n = 19,724) who received dual antiplatelet therapy after coronary stenting were identified from the database. AMI was associated with increased risks of MI (AMI vs. CCS: 0.38 vs. 0.16 per 100 patient-months; p < 0.01), all-cause death (0.49 vs. 0.32 per 100 patient-months; p < 0.01), and BARC type 3 bleeding (0.22 vs. 0.13 per 100 patient-months; p < 0.01) at 1 year compared with CCS, while the risk of BARC type 2 bleeding was marginally higher in the CCS patients than in the AMI patients (1.32 vs. 1.4 per 100 person-months; p = 0.06). Bleeding was an independent predictor of MI, stroke, and all-cause death in this East Asian population, regardless of the initial presentation. Among the patients with bleeding, AMI was associated with a higher risk of ischemic events at 1 year after bleeding compared with CCS (MI: 0.34 vs. 0.25 per 100 patient-months; p = 0.06; ischemic stroke: 0.22 vs. 0.13 per 100 patient-months; p = 0.02). The 1-year mortality after bleeding was comparable between the two groups after propensity score weighting. In conclusion, bleeding conferred an increased risk of adverse outcomes in East Asian patients with AMI and CCS.
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Affiliation(s)
- Ying-Chang Tung
- Cardiovascular Department, Linkou Chang Gung Memorial Hospital, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 33305, Taiwan, ROC.,College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan, ROC.,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Shu-Hao Chang
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Chi-Tai Kuo
- Cardiovascular Department, Linkou Chang Gung Memorial Hospital, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 33305, Taiwan, ROC.,College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Chi-Jen Chang
- Cardiovascular Department, Linkou Chang Gung Memorial Hospital, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 33305, Taiwan, ROC. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC.
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28
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Costa F, Cohen MG. Transfusion and Mortality After Transcatheter Aortic Valve Replacement: Association or Causation? Circ Cardiovasc Interv 2020; 13:e010225. [PMID: 33272032 DOI: 10.1161/circinterventions.120.010225] [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] [Indexed: 11/16/2022]
Affiliation(s)
- Francesco Costa
- Department of Clinical and Experimental Medicine, Policlinic "G Martino", University of Messina, Italy (F.C.)
| | - Mauricio G Cohen
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospitals and Clinics, FL (M.G.C.)
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29
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Apostolidou E, Kolte D, Kennedy KF, Beale CE, Abbott JD, Ehsan A, Gurm HS, Carson JL, Mamdani S, Aronow HD. Institutional Red Blood Cell Transfusion Rates Are Correlated Following Endovascular and Surgical Cardiovascular Procedures: Evidence That Local Culture Influences Transfusion Decisions. J Am Heart Assoc 2020; 9:e016232. [PMID: 33140685 PMCID: PMC7763716 DOI: 10.1161/jaha.119.016232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background The relationship between local hospital culture and transfusion rates following endovascular and surgical cardiovascular procedures has not been well studied. Methods and Results Patients undergoing coronary revascularization, aortic valve replacement, lower extremity peripheral vascular intervention, or carotid artery revascularization from up to 852 US hospitals in the Nationwide Readmissions Database were identified. Crude and risk‐standardized red blood cell transfusion rates were determined for each procedure. Pearson correlation coefficients were calculated between respective procedural transfusion rates. Median odds ratios were estimated to reflect between‐hospital variability in red blood cell transfusion rates following the same procedure for a given patient. There was wide variation in red blood cell transfusion rates across different procedures, from 2% following carotid endarterectomy to 29% following surgical aortic valve replacement. For surgical and endovascular modalities, transfusion rates at the same hospital were highly correlated for aortic valve replacement (r=0.67; P<0.001), moderately correlated for coronary revascularization (r=0.56; P<0.001) and peripheral vascular intervention (r=0.51; P<0.001), and weakly correlated for carotid artery revascularization (r=0.19, P<0.001). Median odds ratios were all >2, highest for coronary artery bypass graft surgery and surgical aortic valve replacement, indicating substantial site variation in transfusion rates. Conclusions After adjustment for patient‐related factors, wide variation in red blood cell transfusion rates remained across surgical and endovascular procedures employed for the same cardiovascular condition. Transfusion rates following these procedures are highly correlated at individual hospitals and vary widely across hospitals. In aggregate, these findings suggest that local institutional culture significantly influences the decision to transfuse following invasive cardiovascular procedures and highlight the need for randomized data to inform such decisions.
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Affiliation(s)
- Eirini Apostolidou
- Division of Cardiology Alpert Medical School of Brown University Providence RI
| | - Dhaval Kolte
- Division of Cardiology Massachusetts General Hospital and Harvard Medical School Boston MA
| | - Kevin F Kennedy
- Statistical Consultant to the Cardiovascular Institute Kansas City MO
| | | | - J Dawn Abbott
- Division of Cardiology Alpert Medical School of Brown University Providence RI
| | - Afshin Ehsan
- Division of Cardiothoracic Surgery Alpert Medical School of Brown University Providence RI
| | | | - Jeffrey L Carson
- Division of Internal Medicine Robert Wood Johnson University Hospital New Brunswick NJ
| | - Shafiq Mamdani
- Division of Cardiology Alpert Medical School of Brown University Providence RI
| | - Herbert D Aronow
- Division of Cardiology Alpert Medical School of Brown University Providence RI
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30
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Khang MK, Kuriakose AE, Nguyen T, Co CMD, Zhou J, Truong TTD, Nguyen KT, Tang L. Enhanced Endothelial Cell Delivery for Repairing Injured Endothelium via Pretargeting Approach and Bioorthogonal Chemistry. ACS Biomater Sci Eng 2020; 6:6831-6841. [PMID: 33320611 DOI: 10.1021/acsbiomaterials.0c00957] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Arterial wall injury often leads to endothelium cell activation, endothelial detachment, and atherosclerosis plaque formation. While abundant research efforts have been placed on treating the end stages of the disease, no cure has been developed to repair injured and denude endothelium often occurred at an early stage of atherosclerosis. Here, a pretargeting cell delivery strategy using combined injured endothelial targeting nanoparticles and bioorthogonal click chemistry approach was developed to deliver endothelial cells to replenish the injured endothelium via a two-step process. First, nanoparticles bearing glycoprotein 1b α (Gp1bα) proteins and tetrazine (Tz) were fabricated to provide a homogeneous nanoparticle coating on an injured arterial wall via the interactions between Gp1bα and von Willebrand factor (vWF), a ligand that is present on denuded endothelium. Second, transplanted endothelium cells bearing transcyclooctene (TCO) would be quickly immobilized on the surfaces of nanoparticles via TCO:Tz reactions. In vitro binding studies under both static and flow conditions confirmed that our novel Tz-labeled Gp1bα-conjugated poly(lactic-co-glycolic acid) (PLGA) nanoparticles can successfully pretargeted toward the injured site and support rapid adhesion of endothelial cells from the circulation. Ex vivo results also confirm that such an approach is highly efficient in mediating the local delivery of endothelial cells at the sites of arterial injury. The results support that this pretargeting cell delivery approach may be used for repairing injured endothelium in situ at its early stage.
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Affiliation(s)
- Min Kyung Khang
- Department of Bioengineering, University of Texas at Arlington, P.O. Box 19138, Arlington, Texas 76010, United States.,Department of Chemistry and Biochemistry, University of Texas at Arlington, Arlington, Texas 76010, United States
| | - Aneetta Elizabeth Kuriakose
- Department of Bioengineering, University of Texas at Arlington, P.O. Box 19138, Arlington, Texas 76010, United States
| | - Tam Nguyen
- Department of Bioengineering, University of Texas at Arlington, P.O. Box 19138, Arlington, Texas 76010, United States
| | - Cynthia My-Dung Co
- Department of Bioengineering, University of Texas at Arlington, P.O. Box 19138, Arlington, Texas 76010, United States
| | - Jun Zhou
- Department of Bioengineering, University of Texas at Arlington, P.O. Box 19138, Arlington, Texas 76010, United States
| | - Thuy Thi Dang Truong
- Department of Bioengineering, University of Texas at Arlington, P.O. Box 19138, Arlington, Texas 76010, United States
| | - Kytai Truong Nguyen
- Department of Bioengineering, University of Texas at Arlington, P.O. Box 19138, Arlington, Texas 76010, United States
| | - Liping Tang
- Department of Bioengineering, University of Texas at Arlington, P.O. Box 19138, Arlington, Texas 76010, United States
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31
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Marques FPL, Valle FH, Araujo GND, Pinheiro Machado G, Amantea R, Fuchs FC, Bergoli LC, Goncalves SC, Wainstein M, Wainstein R. Safety and feasibility of upper limb vascular access for cardiac catheterization in anticoagulated and non-anticoagulated patients. J Vasc Access 2020; 22:935-941. [PMID: 33164636 DOI: 10.1177/1129729820971528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The upper limb approach utilizing transradial access for combined left and right heart catheterization (CLRHC) and ultrasound-guided antecubital venous access for isolated right heart catheterization (IRHC) are strategies that may reduce risks, especially in anticoagulated patients. combined left and right heart catheterization. OBJECTIVES To assess safety and feasibility of upper limb approach for IRHC or CLRHC in anticoagulated versus non-anticoagulated patients. METHODS Ninety-three patients who underwent IRHC or CLRHC with ultrasound-guided antecubital venous access and transradial arterial access were prospectively enrolled. The primary outcome was a composite of procedure failure and incidence of immediate vascular complications. RESULTS Of the 93 patients, 44 (47%) were on anticoagulation and 49 (53%) were not. Mean age was 54 ± 17 and 53 ± 15 years, respectively. Atrial fibrillation (39% vs 15%) and chronic kidney disease (21% vs 6%) were more common in anticoagulated patients. The main indication for anticoagulation was deep vein thrombosis/pulmonary thromboembolism in 22 patients (50%). The primary outcome occurred in 4 (8%) patients in the non-anticoagulated group as compared with 0 in the anticoagulated group (p = 0.12). Procedure failure occurred in two patients (4%) and immediate vascular complications in two patients (4%) in the non-anticoagulated group (p = 0.3 for all). There was no difference between groups regarding duration of the procedure, radiation dose, fluoroscopy time, post-procedure recovery room time and median time to venous or arterial hemostasis. CONCLUSIONS The upper limb approach for heart catheterization had similar rates of procedure failure and immediate vascular complications in anticoagulated patients when compared to non-anticoagulated patients.
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Affiliation(s)
- Felipe Pereira Lima Marques
- Universidade Federal do Rio Grande do Sul, Postgraduate Program in Health Science: Cardiology and Cardiovascular Sciences, Porto Alegre, Brazil
| | - Felipe Homem Valle
- Universidade Federal do Rio Grande do Sul, Postgraduate Program in Health Science: Cardiology and Cardiovascular Sciences, Porto Alegre, Brazil
| | - Gustavo Neves de Araujo
- Universidade Federal do Rio Grande do Sul, Postgraduate Program in Health Science: Cardiology and Cardiovascular Sciences, Porto Alegre, Brazil
| | - Guilherme Pinheiro Machado
- Universidade Federal do Rio Grande do Sul, Postgraduate Program in Health Science: Cardiology and Cardiovascular Sciences, Porto Alegre, Brazil
| | - Rodrigo Amantea
- Universidade Federal do Rio Grande do Sul, School of Medicine, Porto Alegre, Brazil
| | - Felipe C Fuchs
- Universidade Federal do Rio Grande do Sul, Postgraduate Program in Health Science: Cardiology and Cardiovascular Sciences, Porto Alegre, Brazil.,Hospital de Clínicas de Porto Alegre, Division of Cardiology, Porto Alegre, Brazil
| | - Luiz Carlos Bergoli
- Universidade Federal do Rio Grande do Sul, Postgraduate Program in Health Science: Cardiology and Cardiovascular Sciences, Porto Alegre, Brazil.,Hospital de Clínicas de Porto Alegre, Division of Cardiology, Porto Alegre, Brazil
| | - Sandro Cadaval Goncalves
- Universidade Federal do Rio Grande do Sul, Postgraduate Program in Health Science: Cardiology and Cardiovascular Sciences, Porto Alegre, Brazil.,Hospital de Clínicas de Porto Alegre, Division of Cardiology, Porto Alegre, Brazil
| | - Marco Wainstein
- Universidade Federal do Rio Grande do Sul, Postgraduate Program in Health Science: Cardiology and Cardiovascular Sciences, Porto Alegre, Brazil.,Hospital de Clínicas de Porto Alegre, Division of Cardiology, Porto Alegre, Brazil
| | - Rodrigo Wainstein
- Universidade Federal do Rio Grande do Sul, Postgraduate Program in Health Science: Cardiology and Cardiovascular Sciences, Porto Alegre, Brazil.,Hospital de Clínicas de Porto Alegre, Division of Cardiology, Porto Alegre, Brazil
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Sharma S, Patel N, Jeevanantham V, Gupta K, Earnest MB. Safety and efficacy study of the wound care 360° SiteSeal® vascular closure device in percutaneous cardiac catheterization procedures. Vascular 2020; 29:228-236. [PMID: 32718220 DOI: 10.1177/1708538120934573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Vascular access site complications after percutaneous transfemoral cardiovascular procedures remain a common cause of morbidity and mortality. We evaluated the SiteSeal® VCD for achieving hemostasis following diagnostic cardiac catheterization. METHODS We conducted a prospective case control single center study to assess the safety and efficacy of SiteSeal® VCD compared to standard manual compression following diagnostic cardiac catheterization. Forty patients were enrolled in study to receive either SiteSeal® device or manual compression (20 in each group). RESULTS Patients in the SiteSeal® group achieved hemostasis in a significantly shorter time (4 ± 2.4 vs. 19 ± 2.4 min, P < 0.001), had shorter time from hemostasis to ambulation (95 ± 44 vs. 388 ± 63 min, P < 0.001) and significantly earlier device deployment to discharge time compared to the manual compression group (4.7 ± 1.1 vs. 8.9 ± 4.8 h, P = 0.001). There was one non-major bleeding event in the SiteSeal® group which occurred >24 h after discharge from the hospital and was managed conservatively. In the remaining device patients, there was no clinical or Doppler ultrasound evidence of major or minor vascular complication with good overall patient comfort at discharge, 7 days and 30 days follow-up. CONCLUSIONS In this first clinical experience, the SiteSeal® VCD achieved safe and efficient hemostasis, allowed for earlier ambulation and faster discharge compared to manual compression.
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Affiliation(s)
- Suresh Sharma
- Department of Cardiovascular medicine, 21638University of Kansas Medical Center and Hospital, Kansas City, USA
| | - Nilay Patel
- Department of Cardiovascular medicine, 21638University of Kansas Medical Center and Hospital, Kansas City, USA
| | - Vinodh Jeevanantham
- Department of Cardiovascular medicine, 21638University of Kansas Medical Center and Hospital, Kansas City, USA
| | - Kamal Gupta
- Department of Cardiovascular medicine, 21638University of Kansas Medical Center and Hospital, Kansas City, USA
| | - Matthew B Earnest
- Department of Cardiovascular medicine, 21638University of Kansas Medical Center and Hospital, Kansas City, USA
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Bhardwaj B, Spertus JA, Kennedy KF, Jones WS, Safley D, Tsai TT, Aronow HD, Vora AN, Pokharel Y, Kumar A, Attaran RR, Feldman DN, Armstrong E, Prasad A, Gray B, Salisbury AC. Bleeding Complications in Lower-Extremity Peripheral Vascular Interventions: Insights From the NCDR PVI Registry. JACC Cardiovasc Interv 2020; 12:1140-1149. [PMID: 31221303 DOI: 10.1016/j.jcin.2019.03.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study sought to assess periprocedural bleeding complications in lower-extremity peripheral vascular interventions (PVIs). BACKGROUND Few studies have examined the incidence, predictors, or outcomes of periprocedural bleeding after lower-extremity PVI. METHODS The study examined patients undergoing PVI at 76 hospitals in the National Cardiovascular Data Registry PVI registry from 2014 to 2016. Post-PVI major bleeding was defined as any overt bleeding with a hemoglobin (Hb) drop of ≥3 g/dl, any Hb decline of ≥4 g/dl, or blood transfusion in patients with pre-procedure Hb >8 g/dl within 72 h of their procedure. Hierarchical multivariable logistic regression was used to identify factors independently associated with post-PVI bleeding. The study also examined adjusted in-hospital mortality among patients with or without major bleeding complications. RESULTS Among 18,289 PVI procedures, major bleeding occurred in 744 (4.10%). Patient characteristics independently associated with bleeding included age, female sex, heart failure, pre-procedural hemoglobin <12 g/dl, nonelective PVI, and critical limb ischemia on presentation. Procedural characteristics associated with bleeding included nonfemoral vascular access, use of thrombolytic therapy, PVI of the aortoiliac segment, and multilesion interventions, whereas use of closure devices was associated with less bleeding. All-cause in-hospital mortality was higher in patients who experienced bleeding than in those who did not (6.60% vs. 0.30%; p < 0.001; adjusted hazard ratio: 10.9; 95% confidence interval: 6.9 to 17.0). CONCLUSIONS Major bleeding occurred in 4.10% of lower-extremity PVI procedures and was associated with several patient and procedural characteristics, as well as in-hospital mortality. These insights can be incorporated into strategies to reduce periprocedural bleeding after PVI.
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Affiliation(s)
- Bhaskar Bhardwaj
- Division of Cardiovascular Diseases, University of Missouri, Columbia, Missouri; Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - John A Spertus
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri; Division of Cardiovascular Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri
| | - Kevin F Kennedy
- Division of Cardiovascular Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri
| | - W Schuyler Jones
- Division of Cardiology, Duke University Health System, Duke Heart Center, Durham, North Carolina
| | - David Safley
- Division of Cardiovascular Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri
| | - Thomas T Tsai
- Division of Cardiovascular Medicine, University of Colorado and Institute for Health Research, Kaiser Permanente, Denver, Colorado
| | - Herbert D Aronow
- Division of Cardiovascular Medicine, Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - Amit N Vora
- Division of Cardiology, Duke University Health System, Duke Heart Center, Durham, North Carolina
| | - Yashashwi Pokharel
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri; Division of Cardiovascular Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri
| | - Arun Kumar
- Division of Cardiovascular Diseases, University of Missouri, Columbia, Missouri
| | - Robert R Attaran
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Dmitriy N Feldman
- Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Ehrin Armstrong
- Division of Cardiovascular Medicine, University of Colorado, Denver, Colorado and Denver Veterans Affairs Medical Center, Denver, Colorado
| | - Anand Prasad
- Division of Cardiology, Department of Medicine, UT Health San Antonio, San Antonio, Texas
| | - Bruce Gray
- Department of Surgery at Greenville Health System, Greenville, South Carolina
| | - Adam C Salisbury
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri; Division of Cardiovascular Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri.
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Murali S, Vogrin S, Noaman S, Dinh DT, Brennan AL, Lefkovits J, Reid CM, Cox N, Chan W. Bleeding Severity in Percutaneous Coronary Intervention (PCI) and Its Impact on Short-Term Clinical Outcomes. J Clin Med 2020; 9:jcm9051426. [PMID: 32403442 PMCID: PMC7291133 DOI: 10.3390/jcm9051426] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 11/27/2022] Open
Abstract
Bleeding severity in patients undergoing percutaneous coronary intervention (PCI), defined by the Bleeding Academic Research Consortium (BARC), portends adverse prognosis. We analysed data from 37,866 Australian patients undergoing PCI enrolled in the Victorian Cardiac Outcomes Registry (VCOR), and investigated the association between increasing BARC severity and in-hospital and 30-day major adverse cardiac and cerebrovascular events (MACCE) (a composite of mortality, myocardial infarction, stent thrombosis, target vessel revascularisation, or stroke). Independent predictors associated with major bleeding (BARC groups 3&5), and MACCE were also assessed. There was a stepwise increase in in-hospital and 30-day MACCE with greater severity of bleeding. Independent predictors of bleeding included female sex (Odds Ratio (OR) 1.34), age (OR 1.02), fibrinolytic therapy (OR 1.77), femoral access (OR 1.51), and ticagrelor (OR 1.42), all significant at the p < 0.001 level. Following adjustment of clinically important variables, BARC 3&5 bleeds (OR 4.37) were still predictive of cumulative in-hospital and 30-day MACCE. In conclusion, major bleeding is an uncommon but potentially fatal PCI complication and was independently associated with greater MACCE rates. Efforts to mitigate the occurrence of bleeding, including radial access and judicious use of potent antiplatelet therapies, may ameliorate the risk of short-term adverse clinical outcomes.
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Affiliation(s)
- Shashank Murali
- Department of Medicine, University of Melbourne, Melbourne 3010, Victoria, Australia; (S.M.); (S.N.)
| | - Sara Vogrin
- Department of Medicine-Western Health, Melbourne Medical School, University of Melbourne, Melbourne 3010, Victoria, Australia;
| | - Samer Noaman
- Department of Medicine, University of Melbourne, Melbourne 3010, Victoria, Australia; (S.M.); (S.N.)
- Department of Cardiology, Western Health, St Albans 3021, Victoria, Australia;
- Department of Cardiology, Alfred Health, Melbourne 3004, Victoria, Australia
| | - Diem T. Dinh
- School of Public Health & Preventive Medicine, Monash University, Melbourne 3004, Victoria, Australia; (D.T.D.); (A.L.B.); (J.L.); (C.M.R.)
| | - Angela L. Brennan
- School of Public Health & Preventive Medicine, Monash University, Melbourne 3004, Victoria, Australia; (D.T.D.); (A.L.B.); (J.L.); (C.M.R.)
| | - Jeffrey Lefkovits
- School of Public Health & Preventive Medicine, Monash University, Melbourne 3004, Victoria, Australia; (D.T.D.); (A.L.B.); (J.L.); (C.M.R.)
| | - Christopher M. Reid
- School of Public Health & Preventive Medicine, Monash University, Melbourne 3004, Victoria, Australia; (D.T.D.); (A.L.B.); (J.L.); (C.M.R.)
- School of Public Health, Curtin University, Perth 6102, Western Australia, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, St Albans 3021, Victoria, Australia;
| | - William Chan
- Department of Medicine, University of Melbourne, Melbourne 3010, Victoria, Australia; (S.M.); (S.N.)
- Department of Cardiology, Western Health, St Albans 3021, Victoria, Australia;
- Department of Cardiology, Alfred Health, Melbourne 3004, Victoria, Australia
- Correspondence: ; Tel.: +61-(03)-8345-1333
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Freund A, Jobs A, Lurz P, Feistritzer HJ, de Waha-Thiele S, Meyer-Saraei R, Montalescot G, Huber K, Noc M, Windecker S, Zeymer U, Ouarrak T, Schneider S, Thiele H, Desch S. Frequency and Impact of Bleeding on Outcome in Patients With Cardiogenic Shock. JACC Cardiovasc Interv 2020; 13:1182-1193. [DOI: 10.1016/j.jcin.2020.02.042] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/04/2020] [Accepted: 02/27/2020] [Indexed: 01/17/2023]
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Chung MK, Refaat M, Shen WK, Kutyifa V, Cha YM, Di Biase L, Baranchuk A, Lampert R, Natale A, Fisher J, Lakkireddy DR. Atrial Fibrillation. J Am Coll Cardiol 2020; 75:1689-1713. [DOI: 10.1016/j.jacc.2020.02.025] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 02/07/2020] [Accepted: 02/13/2020] [Indexed: 12/16/2022]
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Hamandi M, Saad M, Hasan R, Megaly M, Abbott JD, Dib C, Szerlip M, Potluri S, Lotfi A, Kiemeneij F, Al-Azizi KM. Distal Versus Conventional Transradial Artery Access for Coronary Angiography and Intervention: A Meta-Analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1209-1213. [PMID: 32321695 DOI: 10.1016/j.carrev.2020.03.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Distal transradial artery access (dTRA) through the anatomical snuffbox is a novel approach for performing coronary angiography and interventions. However, the safety and efficacy of dTRA as compared to conventional TRA (cTRA) remains unknown. We aim to evaluate the outcomes of dTRA versus cTRA for coronary angiography and intervention. METHODS Electronic search of the National Library of Medicine PubMed and Cochrane Library databases was performed until April 2019 for studies comparing the clinical outcomes of dTRA approach versus conventional TRA (cTRA) approach in coronary angiography and interventions. Random-effects DerSimonian-Laird risk ratios (RR) were calculated. The main outcome was failure of access site utilization. Other outcomes included access site hematoma, radial artery spasm, dissection, and occlusion. RESULTS Five studies (4 observational and 1 randomized controlled) with a total of 6746 patients (dTRA n = 3209 and cTRA n = 3537) were available for analysis. The failure rate was similar in dTRA and cTRA groups (5.26% versus 3.75%; RR = 1.36; 95%CI 0.41-4.48; p = 0.62). Similarly, no difference was observed between dTRA and cTRA in regards to access site hematoma (1.20% versus 1.24%, RR = 1.01; 95%CI 0.49-2.07; p = 0.99), radial artery spasm (1.42 versus 3.84%, RR = 0.91; 95%CI 0.32-2.62; p = 0.86), or radial artery dissection (0.11 versus 0.20%, RR = 0.63; 95%CI 0.18-2.16; p = 0.46). The rate of radial artery occlusion was lower with dTRA (2.30 versus 4.86%, RR = 0.51; 95%CI 0.32-0.81; p = 0.004) as compared to cTRA. CONCLUSION Distal TRA appears to be a safe and effective alternative to conventional TRA. The outcomes of this novel technique warrant further randomized studies.
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Affiliation(s)
- Mohanad Hamandi
- Department of Interventional Cardiology, Baylor Scott & White-The Heart Hospital, Plano, TX, USA
| | - Marwan Saad
- Division of Cardiovascular Medicine, The Warren Alpert School of Medicine at Brown University, Providence, RI, USA
| | - Rimsha Hasan
- Department of Medicine, Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michael Megaly
- Department of Cardiovascular Medicine, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - J Dawn Abbott
- Division of Cardiovascular Medicine, The Warren Alpert School of Medicine at Brown University, Providence, RI, USA
| | - Chad Dib
- Department of Interventional Cardiology, Baylor Scott & White-The Heart Hospital, Plano, TX, USA
| | - Molly Szerlip
- Department of Interventional Cardiology, Baylor Scott & White-The Heart Hospital, Plano, TX, USA
| | - Srinivasa Potluri
- Department of Interventional Cardiology, Baylor Scott & White-The Heart Hospital, Plano, TX, USA
| | - Amir Lotfi
- Interventional Cardiology, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA, USA
| | - Ferdinand Kiemeneij
- Interventional Cardiology, Cardiologie Kliniek Flevoland, Lelystad, Netherlands
| | - Karim M Al-Azizi
- Department of Interventional Cardiology, Baylor Scott & White-The Heart Hospital, Plano, TX, USA.
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Sorrentino S, Nguyen P, Salerno N, Polimeni A, Sabatino J, Makris A, Hennessy A, Giustino G, Spaccarotella C, Mongiardo A, De Rosa S, Juergens C, Indolfi C. Standard Versus Ultrasound-Guided Cannulation of the Femoral Artery in Patients Undergoing Invasive Procedures: A Meta-Analysis of Randomized Controlled Trials. J Clin Med 2020; 9:jcm9030677. [PMID: 32138283 PMCID: PMC7141204 DOI: 10.3390/jcm9030677] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/10/2020] [Accepted: 02/26/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND It is unclear whether or not ultrasound-guided cannulation (UGC) of the femoral artery is superior to the standard approach (SA) in reducing vascular complications and improving access success. OBJECTIVE We sought to compare procedural and clinical outcomes of femoral UGC versus SA in patients undergoing percutaneous cardiovascular intervention (PCvI). METHODS We searched EMBASE, MEDLINE, Scopus and web sources for randomized trials comparing UGC versus SA. We estimated risk ratio (RR) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) for categorical and continuous variables, respectively. Primary efficacy endpoint was the success rate at the first attempt, while secondary efficacy endpoints were access time and number of attempts. Primary safety endpoints were the rates of vascular complications, while secondary endpoints were major bleeding, as well as access site hematoma, venepuncture, pseudoaneurysms and retroperitoneal hematoma. This meta-analysis has been registered on Centre for Open Science (OSF) (osf.io/fy82e). RESULTS Seven trials were included, randomizing 3180 patients to UGC (n = 1564) or SA (n = 1616). Efficacy between UGC and SA was the main metric assessed in most of the trials, in which one third of the enrolled patients underwent interventional procedures. The success rate of the first attempt was significantly higher with UGC compared to SA, (82.0% vs. 58.7%; RR: 1.36; 95% CI: 1.17 to 1.57; p < 0.0001; I2 = 88%). Time to access and number of attempts were significantly reduced with UGC compared to SA (SMD: -0.19; 95% CI: -0.28 to -0.10; p < 0.0001; I2 = 22%) and (SMD: -0.40; 95% CI: -0.58 to -0.21; p < 0.0001; I2 = 82%), respectively. Compared with SA, use of UGC was associated with a significant reduction in vascular complications (1.3% vs. 3.0%; RR: 0.48; CI 95%: 0.25 to 0.91; p = 0.02; I2 = 0%) and access-site hematoma (1.2% vs. 3.3%; RR: 0.41; CI 95%: 0.20 to 0.83; p = 0.01; I2 = 27%), but there were non-significant differences in major bleeding (0.7% vs. 1.4%; RR: 0.57; CI 95%: 0.24 to 1.32; p = 0.19; I2 = 0%). Rates of venepuncture were lower with UGC (3.6% vs. 12.1%; RR: 0.32; CI 95%: 0.20 to 0.52; p < 0.00001; I2 = 55%). CONCLUSION This study, which included all available data to date, demonstrated that, compared to a standard approach, ultrasound-guided cannulation of the femoral artery is associated with lower access-related complications and higher efficacy rates. These results could be of great clinical relevance especially in the femoral cannulation of high risk patients.
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Affiliation(s)
- Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, 88100 Catanzaro, Italy; (S.S.); (A.P.); (J.S.); (C.S.); (A.M.); (S.D.R.)
| | - Phong Nguyen
- Campbelltown Hospital, Campbelltown, NSW 2560, Australia; (P.N.); (A.H.)
- Liverpool Hospital, Liverpool, NSW 2170, Australia; (A.M.); (C.J.)
- Western Sydney University, Campbelltown, NSW 2560, Australia
- University of New South Wales, Liverpool, NSW 1871, Australia
| | - Nadia Salerno
- Division of Cardiology, Ferrari Hospital, 87012 Castrovillari, Italia;
| | - Alberto Polimeni
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, 88100 Catanzaro, Italy; (S.S.); (A.P.); (J.S.); (C.S.); (A.M.); (S.D.R.)
| | - Jolanda Sabatino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, 88100 Catanzaro, Italy; (S.S.); (A.P.); (J.S.); (C.S.); (A.M.); (S.D.R.)
| | - Angela Makris
- Liverpool Hospital, Liverpool, NSW 2170, Australia; (A.M.); (C.J.)
- Western Sydney University, Campbelltown, NSW 2560, Australia
- University of New South Wales, Liverpool, NSW 1871, Australia
| | - Annemarie Hennessy
- Campbelltown Hospital, Campbelltown, NSW 2560, Australia; (P.N.); (A.H.)
- Liverpool Hospital, Liverpool, NSW 2170, Australia; (A.M.); (C.J.)
- Western Sydney University, Campbelltown, NSW 2560, Australia
| | - Gennaro Giustino
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| | - Carmen Spaccarotella
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, 88100 Catanzaro, Italy; (S.S.); (A.P.); (J.S.); (C.S.); (A.M.); (S.D.R.)
| | - Annalisa Mongiardo
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, 88100 Catanzaro, Italy; (S.S.); (A.P.); (J.S.); (C.S.); (A.M.); (S.D.R.)
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, 88100 Catanzaro, Italy; (S.S.); (A.P.); (J.S.); (C.S.); (A.M.); (S.D.R.)
| | - Craig Juergens
- Liverpool Hospital, Liverpool, NSW 2170, Australia; (A.M.); (C.J.)
- University of New South Wales, Liverpool, NSW 1871, Australia
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, 88100 Catanzaro, Italy; (S.S.); (A.P.); (J.S.); (C.S.); (A.M.); (S.D.R.)
- URT-CNR, Department of Medicine, Research Center for Cardiovascular Diseases, Viale Europa S/N, 88100 Catanzaro, Italy
- Correspondence: ; Tel.: +39-0961-364-7067; Fax: +39-0961-364-7351
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Discharge Hemoglobin Association with Long-Term Outcomes of ST-Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention. Cardiovasc Ther 2020; 2020:8647837. [PMID: 32190122 PMCID: PMC7068153 DOI: 10.1155/2020/8647837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/11/2019] [Accepted: 01/03/2020] [Indexed: 11/17/2022] Open
Abstract
Background Anemia following acute myocardial infarction (AMI) is associated with poor outcomes. While previous studies in patients with AMI have focused on anemia at admission, we hypothesized that hemoglobin (Hb) decline during hospitalization and lower discharge Hb would be associated with greater long-term mortality in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). Methods We analyzed records of 983 STEMI patients who were treated with primary PCI. The primary end point was all-cause mortality at 1 year and 2 years. The relationship between discharge Hb levels, decline in Hb levels, bleeding event classification, and all-cause mortality was determined. Results Overall, 16.4% of patients had bleeding events, which were classified by the Thrombolysis in Myocardial Infarction (TIMI) score as 7% minimal, 8.6% minor, and 0.9% major. No significant gastrointestinal bleed and cerebral hemorrhage occurred in hospitals among these patients. The incidence rate of the 2-year all-cause mortality increased with severity of the bleeding event score (8.78% for no bleeding vs. 11.59% for minimal bleeding vs. 20.24% for minor bleeding vs. 55.56% for major bleeding, P < 0.001). Discharge Hb was significantly associated with 2-year mortality in an unadjusted model (hazard ratio (HR) per 1 g/L decrease in discharge Hb = 1.020, 95% confidence interval (CI): 1.006–1.034, P < 0.001). Discharge Hb was significantly associated with 2-year mortality in an unadjusted model (hazard ratio (HR) per 1 g/L decrease in discharge Hb = 1.020, 95% confidence interval (CI): 1.006–1.034, P < 0.001). Discharge Hb was significantly associated with 2-year mortality in an unadjusted model (hazard ratio (HR) per 1 g/L decrease in discharge Hb = 1.020, 95% confidence interval (CI): 1.006–1.034, Conclusions In this population of patients hospitalized for STEMI, all-cause mortality increased with lower discharge Hb, and discharge Hb was a significant predictor of mortality risk.
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Prouse A, Gunzburger E, Yang F, Morrison J, Valle JA, Armstrong EJ, Waldo SW. Contemporary Use and Outcomes of Arterial Closure Devices After Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. J Am Heart Assoc 2020; 9:e015223. [PMID: 32063086 PMCID: PMC7070201 DOI: 10.1161/jaha.119.015223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Arterial closure devices reduce the length of bedrest after invasive cardiac procedures via the femoral approach, but there are conflicting data on their association with major bleeding and vascular complications. We thus sought to evaluate the contemporary use of femoral arterial closure devices and their association with major bleeding among patients undergoing percutaneous coronary intervention. Methods and Results We identified patients undergoing percutaneous intervention via the femoral approach within the Veterans Affairs Healthcare System from December 2004 through September 2018. The association between arterial closure device use and major bleeding was evaluated using both propensity matching and instrumental variable analyses, incorporating contrast‐induced nephropathy as a falsification end point. We identified 132 373 percutaneous coronary interventions performed by 681 operators, with closure device use increasing 1.2% each year (linear trend P<0.001). In a propensity‐matched cohort, closure devices were associated with a 1.1% reduction in periprocedural bleeding (95% CI, −1.5% to −0.6%). Closure devices were also associated with a numerical decrease in contrast‐inducted nephropathy that did not reach statistical significance (−0.6%; 95% CI, −1.3% to 0.1%). In an instrumental variable analysis of closure device use, there was no difference in the bleeding rate between those who received a closure device and those who did not (0.2%; 95% CI, −0.9% to 1.2%). Conclusions Arterial closure devices are associated with a reduction in major bleeding within a propensity‐matched cohort. This association dissipates in an instrumental variable analysis, highlighting some of the methodologic limitations of comparative effectiveness research in observational analyses.
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Affiliation(s)
- Andrew Prouse
- Division of Cardiology Department of Medicine Denver Health Medical Center Denver CO.,Division of Cardiology Department of Medicine University of Colorado School of Medicine Aurora CO
| | - Elise Gunzburger
- Center of Innovation Rocky Mountain Regional VA Medical Center Aurora CO
| | - Fan Yang
- Center of Innovation Rocky Mountain Regional VA Medical Center Aurora CO
| | - Justin Morrison
- Division of Cardiology Department of Medicine University of Colorado School of Medicine Aurora CO
| | - Javier A Valle
- Division of Cardiology Department of Medicine University of Colorado School of Medicine Aurora CO.,Center of Innovation Rocky Mountain Regional VA Medical Center Aurora CO.,Division of Cardiology Department of Medicine Rocky Mountain Regional VA Medical Center Aurora CO
| | - Ehrin J Armstrong
- Division of Cardiology Department of Medicine University of Colorado School of Medicine Aurora CO.,Division of Cardiology Department of Medicine Rocky Mountain Regional VA Medical Center Aurora CO
| | - Stephen W Waldo
- Division of Cardiology Department of Medicine University of Colorado School of Medicine Aurora CO.,Center of Innovation Rocky Mountain Regional VA Medical Center Aurora CO.,Division of Cardiology Department of Medicine Rocky Mountain Regional VA Medical Center Aurora CO
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Abraham NS. Antiplatelets, anticoagulants, and colonoscopic polypectomy. Gastrointest Endosc 2020; 91:257-265. [PMID: 31585125 PMCID: PMC7386094 DOI: 10.1016/j.gie.2019.09.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/17/2019] [Indexed: 02/07/2023]
Abstract
The management of antiplatelet and anticoagulant (ie, antithrombotic) agents is challenging in the periendoscopic setting. In this state-of-the-art update, we review current best practice recommendations focusing on the risk of immediate and delayed postpolypectomy bleeding in the context of drug discontinuation (ie, temporary interruption) and drug continuation. The data regarding polypectomy technique (cold snare vs conventional thermal-based) and prophylactic placement of hemostatic clips are evaluated to assess whether these endoscopic techniques are beneficial in reducing postpolypectomy bleeding. Finally, clinical takeaways are provided to facilitate safer polypectomy among patients on antiplatelet and anticoagulant agents.
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Affiliation(s)
- Neena S Abraham
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA; Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
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Agarwal N, Mahmoud AN, Mojadidi MK, Golwala H, Elgendy IY. Dual versus triple antithrombotic therapy in patients undergoing percutaneous coronary intervention-meta-analysis and meta-regression. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:1134-1139. [PMID: 30862490 DOI: 10.1016/j.carrev.2019.02.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 01/06/2019] [Accepted: 02/19/2019] [Indexed: 11/27/2022]
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Abstract
Peripheral vascular intervention (PVI) improves quality of life and reduces major adverse limb events in patients with peripheral arterial disease. PVI is commonly performed via the femoral artery, and the most common adverse periprocedural event is a vascular access complication. Transradial access for PVI has the potential to reduce vascular access complications and improve patient outcomes. Further study is needed to elucidate the risks of stroke, acute kidney injury, and radiation exposure in the setting of transradial PVI. As transradial access for PVI progresses, it will be important to build the evidence base along with procedural experience.
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Affiliation(s)
| | - Sunil V Rao
- Division of Cardiology, Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC 27701, USA
| | - Rajesh V Swaminathan
- Division of Cardiology, Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC 27701, USA
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Ismail N, Jordan KP, Kadam UT, Edwards JJ, Kinnaird T, Mamas MA. Bleeding After Hospital Discharge Following Acute Coronary Syndrome: Incidence, Types, Timing, and Predictors. J Am Heart Assoc 2019; 8:e013679. [PMID: 31657257 PMCID: PMC6898798 DOI: 10.1161/jaha.119.013679] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background The incidence and predictors of bleeding after acute coronary syndrome are unclear within the real‐world setting. Our objective was to determine the incidence, types, timing, and predictors of bleeding complications following hospital discharge after acute coronary syndrome. Methods and Results We used the Clinical Practice Research Datalink, with linkage to Hospital Episode Statistics, to determine the incidence, timing, and types of bleeding events within 12 months after hospital discharge for acute coronary syndrome. We assessed independent associations between postdischarge bleeding and baseline patient characteristics using a competing risk regression model, accounting for death as a competing event. Among 27 660 patients surviving to hospital discharge, 3620 (13%) experienced bleeding complications at a median time of 123 days (interquartile range, 45–223 days) after discharge. The incidence of bleeding was 162/1000 person‐years (95% CI, 157–167/1000 person‐years) within the first 12 months after hospital discharge. Bruising (949 bleeds [26%]) was the most common type of first bleeding event, followed by gastrointestinal bleed (705 bleeds [20%]), whereas intracranial bleed was relatively rare (81 bleeds [2%]). Significant predictors of postdischarge bleeding included history of bleeding complication, oral anticoagulant prescription, history of peripheral vascular disease, chronic obstructive pulmonary disease, and advanced age (>80 years). Predictors for postdischarge bleeding varied, depending on the anatomic site of the bleeding event. Conclusions Bleeding complications after hospital discharge for acute coronary syndrome are common. Patients who experience these bleeding events have distinct baseline characteristics, which vary by anatomic site of the bleed. These characteristics can inform risk‐benefit considerations in deciding on favorable combination and duration of secondary antithrombotic therapy.
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Affiliation(s)
- Nafiu Ismail
- Centre for Prognosis Research Research Institute for Primary Care and Health Sciences Keele University Staffordshire United Kingdom.,Keele Cardiovascular Research Group Keele University Staffordshire United Kingdom
| | - Kelvin P Jordan
- Centre for Prognosis Research Research Institute for Primary Care and Health Sciences Keele University Staffordshire United Kingdom
| | - Umesh T Kadam
- Department of Health Sciences University of Leicester Leicester United Kingdom
| | - John J Edwards
- Centre for Prognosis Research Research Institute for Primary Care and Health Sciences Keele University Staffordshire United Kingdom
| | - Tim Kinnaird
- Department of Cardiology University Hospital of Wales Cardiff Wales United Kingdom
| | - Mamas A Mamas
- Centre for Prognosis Research Research Institute for Primary Care and Health Sciences Keele University Staffordshire United Kingdom.,Keele Cardiovascular Research Group Keele University Staffordshire United Kingdom
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45
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Nguyen P, Makris A, Hennessy A, Jayanti S, Wang A, Park K, Chen V, Nguyen T, Lo S, Xuan W, Leung M, Juergens C. Standard versus ultrasound-guided radial and femoral access in coronary angiography and intervention (SURF): a randomised controlled trial. EUROINTERVENTION 2019; 15:e522-e530. [PMID: 31113763 DOI: 10.4244/eij-d-19-00336] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS This study aimed to compare outcomes in unselected patients undergoing cardiac catheterisation via transradial versus transfemoral access and standard versus ultrasound-guided arterial access. METHODS AND RESULTS This was a prospective, randomised (radial vs. femoral and standard vs. ultrasound), 2x2 factorial trial of 1,388 patients undergoing coronary angiography and percutaneous coronary intervention. The primary outcome was a composite of ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) major bleeding, MACE (death, stroke, myocardial infarction or urgent target lesion revascularisation) and vascular complications at 30 days. Transradial access reduced the primary outcome (RR 0.37, 95% CI: 0.17-0.81; p=0.013), mostly driven by ACUITY major bleeding (RR 0.343, 95% CI: 0.123-0.959; p=0.041) when compared with the transfemoral approach. There was no difference in the primary outcome between standard and ultrasound guidance (p=0.76). Ultrasound guidance, however, reduced mean access time (93 sec vs. 111 sec; p=0.009), attempts (1.47 vs. 1.9; p<0.0001), difficult accesses (4.5% vs. 9.2%; p=0.0007), venepuncture (4.1% vs. 9.2%; p<0.0001) and improved first-pass success (73% vs. 59.7%; p<0.0001). CONCLUSIONS Transradial access significantly reduced the composite outcome compared to transfemoral access. Ultrasound guidance did not reduce the primary outcome compared to the standard technique, but significantly improved the efficiency and overall success rate of arterial access.
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Affiliation(s)
- Phong Nguyen
- Campbelltown Hospital, Campbelltown, NSW, Australia
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Kwok CS, Kontopantelis E, Kinnaird T, Potts J, Rashid M, Shoaib A, Nolan J, Bagur R, de Belder MA, Ludman P, Mamas MA. Retroperitoneal Hemorrhage After Percutaneous Coronary Intervention: Incidence, Determinants, and Outcomes as Recorded by the British Cardiovascular Intervention Society. Circ Cardiovasc Interv 2019; 11:e005866. [PMID: 29445000 DOI: 10.1161/circinterventions.117.005866] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 12/14/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Retroperitoneal hemorrhage (RH) is a rare bleeding complication of percutaneous coronary intervention, which can result as a consequence of femoral access or can occur spontaneously. This study aims to evaluate temporal changes in RH, its predictors, and clinical outcomes in a national cohort of patients undergoing percutaneous coronary intervention in the United Kingdom. METHODS AND RESULTS We analyzed RH events in patients who underwent percutaneous coronary intervention between 2007 and 2014. Multiple logistic regression models were used to identify factors associated with RH and to quantify the association between RH and 30-day mortality and major adverse cardiovascular events. A total of 511 106 participants were included, and 291 in hospital RH events were recorded (0.06%). Overall, rates of RH declined from 0.09% to 0.03% between 2007 and 2014. The strongest independent predictors of RH events were femoral access (odds ratio [OR], 19.66; 95% confidence interval [CI], 11.22-34.43), glycoprotein IIb/IIIa inhibitor (OR, 2.63; 95% CI, 1.99-3.47), and warfarin use (OR, 2.53; 95% CI, 1.07-5.99). RH was associated with a significant increase in 30-day mortality (OR, 3.59; 95% CI, 2.19-5.90) and in-hospital major adverse cardiovascular events (OR, 5.76; 95% CI, 3.71-8.95). A legacy effect was not observed; patients with RH who survived 30 days did not have higher 1-year mortality compared with those without this complication (hazard ratio, 0.97; 95% CI, 0.49-1.91). CONCLUSIONS Our results suggest that RH is a rare event that is declining in the United Kingdom, related to transition to transradial access site utilization, but remains a clinically important event associated with increased 30-day mortality but no long-term legacy effect.
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Affiliation(s)
- Chun Shing Kwok
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Evangelos Kontopantelis
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Tim Kinnaird
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Jessica Potts
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Muhammad Rashid
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Ahmad Shoaib
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - James Nolan
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Rodrigo Bagur
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Mark A de Belder
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Peter Ludman
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Mamas A Mamas
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.).
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Xu Y, Jin C, Qiao S, Wu Y, Yan H, Dou K, Xu B, Yang Y. A Propensity Score Matching Analysis of Transradial Versus Transfemoral Approaches in Octogenarians Undergoing Percutaneous Coronary Intervention. ACTA CARDIOLOGICA SINICA 2019; 35:301-307. [PMID: 31249460 DOI: 10.6515/acs.201905_35(3).20181025b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Despite the widespread adoption of the transradial approach for elderly patients undergoing percutaneous coronary intervention (PCI) in clinical practice, data on octogenarians in China are still relatively limited. This study sought to compare both the safety and efficacy of transradial intervention (TRI) and transfemoral intervention (TFI) in octogenarians in China. Methods We identified 254 octogenarians who underwent PCIs in Fuwai Hospital, Beijing, China between January 1, 2006 and April 30, 2011. TRI was used in 184 patients and TFI was used in 70 patients. Incidence rates of in- hospital and 1-year clinical outcomes were compared between the two groups. Ono-to-one propensity score matching (PSM) was performed to control for potential bias. A total of 48 pairs were matched. Results Baseline and procedural characteristics were balanced between the TRI and TFI groups. Patients undergoing TRI had significantly fewer access site complications (10.3% vs. 20.0%, p = 0.040), although this difference did not remain significant in propensity score-matched patients (10.4% vs. 22.9%, p = 0.100). After PSM, the patients undergoing TRI were less likely to have major post-PCI bleeding (0 vs. 12.5%, odds ratio 0.47, 95% confidence interval 0.37-0.58, p = 0.026). There were no statistical differences in the incidence rates of major adverse cardiac events (a composite of cardiac death, myocardial infarction, and target vessel revascularization) and their components both during hospitalization and at 1-year. Conclusions Compared with TFI, TRI was safer and more feasible for octogenarians undergoing PCI.
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Affiliation(s)
- Yi Xu
- Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chen Jin
- Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shubin Qiao
- Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongjian Wu
- Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongbing Yan
- Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kefei Dou
- Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuejin Yang
- Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Siddiqui WJ, Khan MY, Rawala MS, Jethwani K, Khan MH, Alvarez C, Kashif R, Hasni SF, Aggarwal S, Kohut A, Eisen H. Anti-thrombotic therapy strategies with long-term anticoagulation after percutaneous coronary intervention - a systematic review and meta-analysis. J Community Hosp Intern Med Perspect 2019; 9:203-210. [PMID: 31258858 PMCID: PMC6586086 DOI: 10.1080/20009666.2019.1611330] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/18/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Long-term oral anticoagulants (OAC) increases bleeding risk after the percutaneous coronary intervention (PCI) with dual antiplatelet therapy (DAPT) with Aspirin and P2Y12 inhibitors. We hypothesize that dual anti-thrombotic therapy (DATT) reduces bleeding without increased cardiovascular events. Objectives: DATT does not increase adverse cardiovascular events compared to triple anti-thrombotic therapy (TATT). Method: We searched MEDLINE, PUBMED, Google Scholar, Cochrane and EMBASE from inception to 6 April 2019 for randomized control trials (RCTs) comparing DATT to TATT after PCI. Results: We identified 641 citations (411 after excluding duplicates). Four RCTs with 5,317 patients (3,039 on DATT vs 2,278 on TATT) were included. DATT arm showed significantly reduced [total bleeding, 731 vs. 784, odds ratio [OR] = 0.51, Confidence Interval [CI] = 0.39–0.67, p < 0.00001, I2 = 71% (I2 = 0% without WOEST study)], [TIIMI major bleeding 60 vs. 80, OR = 0.56, CI = 0.4–0.79, p = 0.0009, I2 = 0%], and [TIIMI minor bleeding, 70 vs 126, OR = 0.43, CI = 0.32–0.59, p < 0.00001, I2 = 0%]. There was no difference in subsequent strokes, myocardial infarction, stent thrombosis, and mortality. A trend towards decreased non-cardiac deaths with DATT was observed, 14 vs 26, OR = 0.55, CI = 0.27–1.10, p = 0.09, I2 = 6%. Conclusions: DATT is associated with significantly reduced bleeding and a trend towards reduced non-cardiac death with no difference in adverse cardiovascular outcomes.
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Affiliation(s)
- Waqas Javed Siddiqui
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Muhammad Yasir Khan
- Department of Medicine, Capital Health Regional Medical Center, Trenton, NJ, USA
| | | | - Kadambari Jethwani
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | | | - Chikezie Alvarez
- Department of Medicine, Seton Hall University, St. Francis Medical Center, Trenton, NJ, USA
| | - Ramsha Kashif
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Syed Farhan Hasni
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Sandeep Aggarwal
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Andrew Kohut
- Pennsylvania Hospital, University of Pennsylvania, PhiladelpShia, PA, USA
| | - Howard Eisen
- Penn State Hershey Heart and Vascular Institute, Hershey, PA, USA
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Apostolidou E, Aronow HD, Beale CE, Kolte D, Kennedy KF, Sellke FW, Gordon PC, Sharaf B, Ehsan A. Association Between Red Blood Cell Transfusion and Clinical Outcomes Among Patients Undergoing Transcatheter Aortic Valve Replacement. Ann Thorac Surg 2019; 107:1791-1798. [DOI: 10.1016/j.athoracsur.2018.11.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 10/06/2018] [Accepted: 11/05/2018] [Indexed: 11/27/2022]
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50
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Sotomi Y, Hirata A, Amiya R, Kobayashi T, Hirayama A, Sakata Y, Higuchi Y. Bleeding Risk of Add-On Anti-Platelet Agents to Direct Oral Anticoagulants in Patients With Nonvalvular Atrial Fibrillation (From 2216 Patients in the DIRECT Registry). Am J Cardiol 2019; 123:1293-1300. [PMID: 30717887 DOI: 10.1016/j.amjcard.2019.01.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/14/2019] [Accepted: 01/15/2019] [Indexed: 10/27/2022]
Abstract
Clinical outcomes of the real-world Asian nonvalvular atrial fibrillation (NVAF) patients treated with DOAC and the incremental bleeding risk of add-on antiplatelet therapy to direct oral anticoagulants (DOACs) are still to be investigated. We conducted a single-center prospective observational registry of NVAF patients treated with DOACs: the DIRECT registry (UMIN000033283). All patients with NVAF (N = 2216) who were users of dabigatran (N = 648), rivaroxaban (N = 538), apixaban (N = 599), or edoxaban (N = 431) from June 2011 to November 2017 were enrolled (71.6 ± 10.8 years, 36.4% female, follow-up duration: 407.2 ± 388.3 days). No add-on antiplatelet agent was prescribed to 1,739 patients, while single and dual antiplatelet therapy (SAPT and DAPT) in combination with DOAC were prescribed to 411 and 66 patients, respectively. The primary safety endpoint was any bleeding which was defined as a composite of major bleeding according to the International Society on Thrombosis and Hemostasis criteria and clinically relevant non-major bleeding. Patients treated with add-on antiplatelet agents irrespective of SAPT or DAPT had a higher any-bleeding risk than those without (hazard ratio: 1.42; 95% confidence interval 1.16-1.74, p = 0.001). Multivariate adjusted hazard of add-on antiplatelet therapy was not statistically significant (hazard ratio: 1.20; 95% confidence interval 0.94-1.53, p = 0.147). In conclusion, NVAF patients treated with antiplatelet agents and DOAC had a significantly higher bleeding risk than those using DOAC only. However, after adjustment of patients' background, add-on antiplatelet therapy to DOAC itself did not influence to a bleeding risk.
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