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Thomas I, EncisoSilva J, Schlueter M, Greenberg B. Anticoagulation Therapy and NOACs in Heart Failure. Handb Exp Pharmacol 2016; 243:515-535. [PMID: 28233177 DOI: 10.1007/164_2016_126] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Current evidence indicates that heart failure (HF) confers a hyper-coagulable state that is associated with adverse events including stroke, systemic embolism, and mortality. This may be due to the elevated levels of pro-thrombotic and pro-inflammatory cytokines that are seen in patients with acute and chronic HF. Left ventricular wall motion abnormalities in patients with systolic dysfunction predispose to local thrombosis due to blood stasis as does atrial fibrillation (AF) which leads to blood stasis in regions of the atria. The high risk of thromboemboli in HF patients with AF has resulted in the use anticoagulation therapy to prevent the occurrence of catastrophic events. There is evidence, however, that the pro-inflammatory, pro-thrombotic state that exists in HF puts patients who are in sinus rhythm at risk. The novel oral anticoagulants (NOACs) have been shown in RCT to have at least equivalent efficacy in reducing stroke as warfarin while exposing patients to a lower risk of bleeding. The fact that the NOACs don't require routine monitoring to assure that patients remain within the therapeutic range and have relatively simple dosing requirements and a safer risk profile makes them attractive substitutes to warfarin in HF patients with atrial fibrillation and other conditions (e.g. deep venous thrombosis). Post hoc analyses from a subset of HF patients from the RCTs in AF patients have demonstrated similar findings as were reported in the entire populations that were included in the trials. As a result, NOACS are commonly used now in HF patients with AF. For HF patients with reduced ejection fraction in sinus rhythm, the use of warfarin in randomized clinical trials (RCT) to reduce stroke has been disappointing and associated with increase bleeding risk when compared to aspirin. The advantages of the NOACs over warfarin, however, raise the question of whether they might improve outcomes in HF patients who are in sinus rhythm. The currently ongoing COMMANDER-HF trial has been designed to address this issue. In this chapter we review evidence of existence of a prothombotic state in HF, the pharmacodynamics and clinical trials of the NOACs and the outcomes from NOAC substudies in the HF subgroup. We also discuss the rationale for using anticoagulation in HF independent of arrhythmia burden.
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Affiliation(s)
- Isac Thomas
- Cardiology Division, Department of Medicine, University of California, San Diego, 9444 Medical Center Drive, La Jolla, CA, 92034-7411, USA
| | - Jorge EncisoSilva
- Cardiology Division, Department of Medicine, University of California, San Diego, 9444 Medical Center Drive, La Jolla, CA, 92034-7411, USA
| | - Michelle Schlueter
- Cardiology Division, Department of Medicine, University of California, San Diego, 9444 Medical Center Drive, La Jolla, CA, 92034-7411, USA
| | - Barry Greenberg
- Cardiology Division, Department of Medicine, University of California, San Diego, 9444 Medical Center Drive, La Jolla, CA, 92034-7411, USA.
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Zannad F, Greenberg B, Cleland JGF, Gheorghiade M, van Veldhuisen DJ, Mehra MR, Anker SD, Byra WM, Fu M, Mills RM. Rationale and design of a randomized, double-blind, event-driven, multicentre study comparing the efficacy and safety of oral rivaroxaban with placebo for reducing the risk of death, myocardial infarction or stroke in subjects with heart failure and significant coronary artery disease following an exacerbation of heart failure: the COMMANDER HF trial. Eur J Heart Fail 2015; 17:735-42. [PMID: 25919061 PMCID: PMC5029775 DOI: 10.1002/ejhf.266] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 03/04/2015] [Accepted: 03/11/2015] [Indexed: 01/06/2023] Open
Abstract
AIMS Thrombin is a critical element of crosstalk between pathways contributing to worsening of established heart failure (HF). The aim of this study is to explore the efficacy and safety of rivaroxaban 2.5 mg bid compared with placebo (with standard care) after an exacerbation of HF in patients with reduced ejection fraction (HF-rEF) and documented coronary artery disease. METHODS This is an international prospective, multicentre, randomized, double-blind, placebo-controlled, event-driven study of approximately 5000 patients for a targeted 984 events. Patients must have a recent symptomatic exacerbation of HF, increased plasma concentrations of natriuretic peptides (B-type natriuretic peptide ≥200 pg/mL or N-terminal pro-B-type natriuretic peptide ≥800 pg/mL), with left ventricular ejection fraction ≤40% and coronary artery disease. Patients requiring anticoagulation for atrial fibrillation or other conditions will be excluded. After an index event (overnight hospitalization, emergency department or observation unit admission, or unscheduled outpatient parenteral treatment for worsening HF), patients will be randomized 1:1 to rivaroxaban or placebo (with standard of care). The primary efficacy outcome event is a composite of all-cause mortality, myocardial infarction or stroke. The principal safety outcome events are the composite of fatal bleeding or bleeding into a critical space with potential permanent disability, bleeding events requiring hospitalization and major bleeding events according to International Society on Thrombosis and Haemostasis bleeding criteria. CONCLUSION COMMANDER HF is the first prospective study of a target-specific oral antithrombotic agent in HF. It will provide important information regarding rivaroxaban use following an HF event in an HF-rEF patient population with coronary artery disease.
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Affiliation(s)
- Faiez Zannad
- Inserm Centre d'Investigation Clinique CIC 1433, UMR 1116, CHU de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Université de Lorraine, Nancy, France
| | - Barry Greenberg
- Department of Medicine, Cardiology Division, University of California, San Diego, La Jolla, CA, USA
| | - John G F Cleland
- National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, England
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Mandeep R Mehra
- Brigham and Women's Hospital Heart and Vascular Center, and Harvard Medical School, Boston, MA, USA
| | - Stefan D Anker
- Division of Innovative Clinical Trials, Department of Cardiology, University Medical Centre Göttingen (UMG), Göttingen, Germany
| | - William M Byra
- Janssen Research & Development, LLC, 920 US 202, Raritan, NJ, USA
| | - Min Fu
- Janssen Research & Development, LLC, 920 US 202, Raritan, NJ, USA
| | - Roger M Mills
- Janssen Research & Development, LLC, 920 US 202, Raritan, NJ, USA
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Pinto DS, Kohli P, Fan W, Kirtane AJ, Kociol RD, Meduri C, Deliargyris EN, Prats J, Reynolds MR, Stone GW, Michael Gibson C. Bivalirudin is associated with improved clinical and economic outcomes in heart failure patients undergoing percutaneous coronary intervention: Results from an observational database. Catheter Cardiovasc Interv 2015; 87:363-73. [PMID: 26011467 DOI: 10.1002/ccd.26023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 04/18/2015] [Indexed: 11/05/2022]
Abstract
BACKGROUND Outcomes with bivalirudin compare favorably with heparin ± GPIIb/IIIa receptor inhibition (heparin ± GPI) during percutaneous coronary intervention (PCI). Patients with congestive heart failure (CHF) have increased risk for complications. The objective was to investigate clinical and economic outcomes for bivalirudin ± GPI vs. heparin ± GPI among PCI patients with CHF. METHODS Using the Premier Hospital Database, PCI patients with CHF were stratified by anticoagulant: bivalirudin, bivalirudin ± GPI, heparin and heparin ± GPI. The probability of receiving bivalirudin ± GPI was estimated using individual and hospital variables. Using propensity scores, each bivalirudin ± GPI patient was matched to a heparin ± GPI patient. The primary outcome was in-hospital death. Bleeding rates, transfusion, length of stay and in-hospital cost were ascertained. RESULTS Overall, 116,313 patients at 315 hospitals received bivalirudin (n = 45,559) bivalirudin + GPI (n = 8,115), heparin (n = 27,972) or heparin + GPI (n = 34,667). Patients had STEMI (21.2%), NSTEMI (29.1%), unstable angina (16.6%), stable angina (5.7%) or other ischemic heart disease (24.2%). Of these, 79.1% of bivalirudin patients matched, resulting in 84,948 analyzed patients. Compared with heparin ± GPI patients, bivalirudin ± GPI patients had fewer deaths (3.3% vs. 3.9%; p < 0.0001), less clinically apparent bleeding (10.2% vs. 11.4%; p < 0.0001), clinically apparent bleeding with transfusion (2.7% vs. 3.2%, p <0.0001), and transfusion (8.5% vs. 9.8%, p < 0.0001). Patients receiving bivalirudin had shorter length of stay (6.3 vs. 6.8 days; p < 0.0001) and lower in-hospital cost (mean $26,706 vs. $27,166 [median $19,414 vs. $19,798]; p < 0.0001). In conclusion, this is the largest retrospective analysis of PCI patients with CHF and demonstrates bivalirudin ± GPI compared with heparin ± GPI is associated with lower inpatient rates of death, bleeding, and cost.
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Affiliation(s)
- Duane S Pinto
- Cardiology Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Payal Kohli
- Cardiology Division, University of California, San Francisco
| | - Weihong Fan
- The Medicines Company, Parsippany, New Jersey
| | - Ajay J Kirtane
- Columbia University Medical Center/New York Presbyterian Hospital and Cardiovascular Research Foundation, New York, New York
| | - Robert D Kociol
- Cardiology Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Christopher Meduri
- Cardiology Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | | | - Jayne Prats
- The Medicines Company, Parsippany, New Jersey
| | - Matthew R Reynolds
- Lahey Clinic, Burlington, MA and Harvard Clinical Research Institute, Boston, Massachusetts
| | - Gregg W Stone
- Columbia University Medical Center/New York Presbyterian Hospital and Cardiovascular Research Foundation, New York, New York
| | - C Michael Gibson
- Cardiology Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Burkot J, Kopec G, Pera J, Slowik A, Dziedzic T. Decompensated Heart Failure Is a Strong Independent Predictor of Functional Outcome After Ischemic Stroke. J Card Fail 2015; 21:642-6. [PMID: 25800549 DOI: 10.1016/j.cardfail.2015.03.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 02/02/2015] [Accepted: 03/13/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND Up to 24% of stroke patients have chronic heart failure. The aim of this study was to determine the frequency and prognostic significance of decompensated heart failure (DHF) in acute stroke patients. METHODS AND RESULTS Five hundred sixty-six patients (median age 73 y, 48% men) admitted to the stroke unit within 24 hours after stroke were prospectively included. Diagnosis of DHF was made by a cardiologist during hospitalization. Function outcome was assessed 1 month after stroke onset with the use of a modified Rankin Scale. Unfavorable outcome was defined as scores 3-6. DHF was diagnosed in 17% of patients. Fifty-seven percent of patients with DHF had preserved ejection fraction. Patients with DHF were older and more often female and more frequently suffered from hypertension, diabetes mellitus, atrial fibrillation, and myocardial infarction. They also had more severe neurologic deficit and more often had hyperglycemia, leukocytosis, fever, pneumonia, and renal failure. After multivariate analysis, adjusting for age, stroke severity, atrial fibrillation, myocardial infarction, hyperglycemia, pneumonia, fever, leukocytosis, proteinuria, and reduced ejection fraction, DHF remained an independent predictor of worse outcome (odds ratio 2.34, 95% CI 1.12-4.89; P = .02). CONCLUSIONS DHF is a strong independent predictor of poor functional prognosis after ischemic stroke.
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Affiliation(s)
- Jacek Burkot
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Grzegorz Kopec
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Joanna Pera
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Tomasz Dziedzic
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland.
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Imbalzano E, Ceravolo R, Di Stefano R, Vatrano M, Saitta A. Treatment failure of low molecular weight heparin bridging therapy in atrial fibrillation after acute coronary syndrome. Int J Cardiol 2014; 171:289-91. [DOI: 10.1016/j.ijcard.2013.11.079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 11/23/2013] [Indexed: 12/19/2022]
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Gurbel PA, Tantry US. Antiplatelet and Anticoagulant Agents in Heart Failure. JACC-HEART FAILURE 2014; 2:1-14. [DOI: 10.1016/j.jchf.2013.07.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 07/25/2013] [Accepted: 07/25/2013] [Indexed: 01/11/2023]
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Abstract
This article refers to 'Impact of aspirin and statins on longterm survival in patients with acute myocardial infarction complicated by heart failure: an analysis in 1746 patients' by C. Lewinter et al., published in this issue on page 95-102.
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Treatment failure of low molecular weight heparin in post-surgery orthopedic case. Int J Cardiol 2013; 169:e36-7. [DOI: 10.1016/j.ijcard.2013.08.109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 08/29/2013] [Indexed: 11/20/2022]
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Kurt Ö, Cakar M, Balta S, Sarlak H, Akhan M, Demirbas S, Demirkol S. Vegetable and fruit intake protects from chronic heart failure. Int J Cardiol 2013; 168:2985. [PMID: 23680594 DOI: 10.1016/j.ijcard.2013.04.098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Accepted: 04/04/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Ömer Kurt
- Gulhane Medical Academy, Department of Internal Medicine, Ankara, Turkey.
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Tulino D, Imbalzano E, Casale M, D'Angelo M, Coglitore S, Di Bella G, Dattilo G. Treatment failure of low molecular weight heparin in diabetic patient. Int J Cardiol 2013; 168:e63-4. [DOI: 10.1016/j.ijcard.2013.07.064] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 07/03/2013] [Indexed: 11/27/2022]
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Dattilo G, Lamari A, Di Bella G, Scarano M, De Luca E, Mutone D, Busacca P, Coglitore S. Treatment failure of low molecular weight heparin bridging therapy. Int J Cardiol 2013; 167:e106-7. [DOI: 10.1016/j.ijcard.2013.03.183] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 03/31/2013] [Indexed: 12/19/2022]
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de Meirelles LR, Matsuura C, Resende ADC, Salgado AA, Pereira NR, Coscarelli PG, Mendes-Ribeiro AC, Brunini TMC. Chronic exercise leads to antiaggregant, antioxidant and anti-inflammatory effects in heart failure patients. Eur J Prev Cardiol 2013; 21:1225-32. [PMID: 23695648 DOI: 10.1177/2047487313491662] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Heart failure (HF) patients are at an increased risk of thrombotic events. Here, we investigated the effects of exercise training on platelet function and factors involved in its modulation in HF. DESIGN AND METHODS Thirty HF patients were randomized to 6 months of supervised exercise training or to a control group that remained sedentary. Exercise training consisted of 30 min of moderate-intensity treadmill exercise, followed by resistance and stretching exercises, performed three times a week. Blood was collected before and after the intervention for platelet and plasma obtainment. RESULTS Peak VO2 increased after exercise training (18.0 ± 2.2 vs. 23.8 ± 0.5 mlO2/kg/min; p < 0.05). Exercise training reduced platelet aggregation induced by both collagen and ADP (approximately -6%; p < 0.05), as well as platelet nitric oxide synthase activity (0.318 ± 0.030 vs. 0.250 ± 0.016 pmol/10(8) cells; p < 0.05). No difference in the above-mentioned variables were observed in the control group. No significant difference was observed in intraplatelet cyclic guanosine monophosphate levels among groups. There was a significant increase in the activity of the antioxidant enzymes superoxide dismutase and catalase in plasma and platelets, resulting in a decrease in both lipid and protein oxidative damage. Systemic levels of the inflammatory markers C-reactive protein, fibrinogen, and tumour necrosis factor α were also reduced in HF after training. CONCLUSIONS Our results suggest that regular exercise training is a valuable adjunct to optimal medical management of HF, reducing platelet aggregation via antioxidant and anti-inflammatory effects, and, therefore, reducing the risk of future thrombotic events.
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Affiliation(s)
| | | | | | | | | | | | - Antônio C Mendes-Ribeiro
- State University of Rio de Janeiro, Rio de Janeiro, Brazil Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
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