51
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Ismail N, Jordan KP, Rao S, Kinnaird T, Potts J, Kadam UT, Mamas MA. Incidence and prognostic impact of post discharge bleeding post acute coronary syndrome within an outpatient setting: a systematic review. BMJ Open 2019; 9:e023337. [PMID: 30787079 PMCID: PMC6398751 DOI: 10.1136/bmjopen-2018-023337] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 11/19/2018] [Accepted: 01/23/2019] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE The primary objective was to determine the incidence of bleeding events post acute coronary syndrome (ACS) following hospital discharge. The secondary objective was to determine the prognostic impact of bleeding on mortality, major adverse cardiovascular events (MACE), myocardial re-infarction and rehospitalisation in the postdischarge setting. DESIGN A narrative systematic review. DATA SOURCE Medline, Embase, Amed and Central (Cochrane) were searched up to August 2018. STUDY SELECTION For the primary objective, randomised controlled trials (RCT) and observational studies reporting on the incidence of bleeding post hospital discharge were included. For the secondary objective, RCTs and observational studies that compared patients with bleeding versus those without bleeding post hospital discharge vis-à-vis mortality, MACE, myocardial re-infarction and rehospitalisation were included. RESULTS 53 studies (36 observational studies and 17 RCTs) with a combined cohort of 714 458 participants for the primary objectives and 187 317 for the secondary objectives were included. Follow-up ranged from 1 month to just over 4 years. The incidence of bleeding within 12 months post hospital discharge ranged from 0.20% to 37.5% in observational studies and between 0.96% and 39.4% in RCTs. The majority of bleeds occurred in the initial 3 months after hospital discharge with bruising the most commonly reported event. Major bleeding increased the risk of mortality by nearly threefold in two studies. One study showed an increased risk of MACE (HR 3.00,95% CI 2.75 to 3.27; p<0.0001) with bleeding and another study showed a non-significant association with rehospitalisation (HR 1.20,95% CI 0.95 to 1.52; p=0.13). CONCLUSION Bleeding complications following ACS management are common and continue to occur in the long term after hospital discharge. These bleeding complications may increase the risk of mortality and MACE, but greater evidence is needed to assess their long-term effects. PROSPERO REGISTRATION NUMBER CRD42017062378.
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Affiliation(s)
- Nafiu Ismail
- Research Institute for Primary Care and Health Sciences, Keele University, Newcastle, UK
| | - Kelvin P Jordan
- Research Institute for Primary Care and Health Sciences, Keele University, Newcastle, UK
| | - Sunil Rao
- The Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Jessica Potts
- Research Institute for Primary Care and Health Sciences, Keele University, Newcastle, UK
| | - Umesh T Kadam
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Mamas A Mamas
- Research Institute for Primary Care and Health Sciences, Keele University, Newcastle, UK
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Guedeney P, Sorrentino S, Claessen B, Mehran R. The link between anemia and adverse outcomes in patients with acute coronary syndrome. Expert Rev Cardiovasc Ther 2019; 17:151-159. [DOI: 10.1080/14779072.2019.1575729] [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] [Indexed: 02/06/2023]
Affiliation(s)
- Paul Guedeney
- The Zena and Michael A. Weiner Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, USA
- Institut de Cardiologie, Sorbonne Université, ACTION Study group, INSERM UMRS 1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Sabato Sorrentino
- The Zena and Michael A. Weiner Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, USA
- Division of cardiology, Department of Medical and Surgical Science, Magna Graecia University, Catanzaro, Italy
| | - Bimmer Claessen
- The Zena and Michael A. Weiner Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, USA
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53
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Acara AC, Bolatkale M. Endothelial Nitric Oxide Level as a Predictor of Coronary Complexity in Patients With Unstable Angina Pectoris. Am J Med Sci 2019; 357:453-460. [PMID: 31000423 DOI: 10.1016/j.amjms.2019.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 01/27/2019] [Accepted: 02/08/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND The Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score is an anatomic scoring system based on coronary angiography that quantifies lesion severity and complexity and predicts morbidity and mortality to guide decision making between coronary artery bypass graft surgery and percutaneous coronary intervention in patients with acute coronary syndrome. The present study aimed to compare nitric oxide levels with the SYNTAX score in terms of predicting coronary complexity and the treatment decision for unstable angina pectoris in the emergency department. METHODS The study included 120 patients with unstable angina pectoris and 120 control group subjects. Nitric oxide levels were compared with the SYNTAX score and the treatment decision. The UAP group was divided into 2 subgroups, first based on SYNTAX score of ≤18, >18-27 or >27 and then on the treatment decision of coronary angiography, percutaneous coronary intervention, or coronary artery bypass graft surgery. RESULTS The mean nitric oxide levels in the unstable angina pectoris group were lower than in the control group (P < 0.001). Nitric oxide levels were negatively correlated with the SYNTAX score and the treatment decision (r = -0.227, P = 0.013; r = -0.498, P < 0.001, respectively). The nitric oxide levels were decreased with SYNTAX score >27 compared with >18-27 and ≤18 (P = 0.04-0.003, respectively). Nitric oxide levels were decreased in coronary artery bypass graft surgery subgroup compared with the coronary angiography and percutaneous coronary intervention groups (P < 0.001-0.018 and P < 0.001, respectively). CONCLUSIONS Nitric oxide may be considered as a novel biomarker in the prediction of coronary complexity in patients with unstable angina pectoris.
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Affiliation(s)
- Ahmet Cagdas Acara
- Department of Emergency Medicine, Bozyaka Research and Training Hospital, Izmir, Turkey
| | - Mustafa Bolatkale
- Department of Emergency Medicine, Medipol University Hospital, Istanbul, Turkey.
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54
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Ahn SG, Lee JW, Youn YJ, Lee SH, Cho JH, Kang WC, Park JP, Shin WY, Lim SH, Choi YJ, Kim K, Lim DS, Chun W, Kim JH, Yoon J. In-hospital outcome differences between transradial and transfemoral coronary approaches: Data from the Korean percutaneous coronary intervention registry. Catheter Cardiovasc Interv 2019; 94:378-384. [PMID: 30604498 DOI: 10.1002/ccd.28032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 12/02/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES We aimed to investigate specific subgroups in which the benefit of transradial coronary interventions (TRIs) would be enhanced. BACKGROUND The advantage of TRIs over transfemoral coronary interventions (TFIs) might differ according to a given clinical condition, urgency of the procedure, and operator volume pattern. METHODS Using a cohort from the 2014 Korean Percutaneous Coronary Intervention Registry, in-hospital outcomes of the TRI group (n = 22,993) were matched to those of the TFI group (n = 15,581). After propensity score matching, the composite endpoints between the groups and subgroups for all-cause death, nonfatal myocardial infarctions (MIs), or transfusions were analyzed. RESULTS The composite endpoints occurred less frequently in the TRI group than the TFI group [2.1% vs. 5.5%, OR 0.63, 95% CI 0.55-0.72]. The TRI group had a lower rate of death (OR 0.44, 95% CI 0.33-0.60) and nonfatal MI (OR 0.66, 95% CI 0.54-0.81) than the TFI group. The TRI group required fewer transfusions than the TFI group (OR 0.72, 95% CI 0.59-0.88). TRI benefits were consistent across subgroups except patients with chronic kidney disease and those treated in low tertile PCI volume centers. The favorable outcome of TRI was greater in the elderly (≥75 years), patients with ST-elevation MI, those who underwent emergent PCI, and those treated in high tertile PCI volume hospitals (P for the interaction <0.001 for all). CONCLUSIONS Compared to TFI, TRI had favorable composite in-hospital outcomes. TRI benefits were pronounced in high-risk clinical settings and in high PCI volume centers.
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Affiliation(s)
- Sung Gyun Ahn
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Jun-Won Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Young Jin Youn
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Seung-Hwan Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Jang Hyun Cho
- Department of Cardiology, St. Carollo Hospital, Republic of Korea
| | - Woong Chol Kang
- Department of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Jong-Pil Park
- Division of Cardiology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Republic of Korea
| | - Won-Yong Shin
- Department of Cardiology, Soon Chun Hyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Seong-Hoon Lim
- Division of Cardiovascular disease, College of Medicine, Dankook University Hospital, Cheonan, Republic of Korea
| | - Yu Jeong Choi
- Eulji University School of Medicine, Division of Cardiology, Eulji Medical Center, Daejeon, Republic of Korea
| | - Kyungsoo Kim
- Department of Cardiology, Hanyang University Hospital, Seoul, Republic of Korea
| | - Do-Sun Lim
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Woojung Chun
- Department of Cardiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Ju Han Kim
- Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Republic of Korea
| | - Junghan Yoon
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Republic of Korea
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Zhang Q, Wang C, Shi S, Chen H, Zhou Y. Relationship of left ventricular thrombus formation and adverse outcomes in acute anterior myocardial infarction in patients treated with primary percutaneous coronary intervention. Clin Cardiol 2019; 42:69-75. [PMID: 30367476 PMCID: PMC6436520 DOI: 10.1002/clc.23106] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/17/2018] [Accepted: 10/23/2018] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The incidence of left ventricular thrombus (LVT) is 4% to 15% in patients with anterior acute ST-segment elevation myocardial infarction (ant-AMI) in the era of primary percutaneous coronary intervention (PPCI). And patients with LVT have higher in-hospital mortality. HYPOTHESIS There is a relationship between LVT formation and 1-year major adverse cardio-cerebrovascular events (MACCE) in patients with ant-AMI treated by PPCI. METHODS Our study population included 1488 consecutive patients with ant-AMI. The primary endpoint was the incidence of MACCE within 1 year after AMI. The secondary endpoint was the thrombosis disappearance. RESULTS A total of 106 (7.1%) patients were diagnosed with LVT and 1382 (92.9%) patients without LVT. Patients with LVT had a higher incidence of MACCE than in patients without LVT (21.7%vs10.3%; P < 0.001). Univariate analysis showed LVT was associated with an increase in MACCE risk (odds ratio [OR] = 2.40; 95% confidence interval [CI] [1.37-4.21]; P < 0.001). When examining MACCE components individually, LVT was only associated with the incidence of congestive heart failure (OR = 2.41; 95% CI [1.29-4.58]; P = 0.001). After adjustment for principal confounders, LVT remained an independent risk factor for MACCE (HR = 2.28; 95% CI [1.12-6.38]; P = 0.020). Other independent predictors include 24-hour LVEF, creatine kinase peak value, and age. Further analysis found patients with LVT in international normalized ratio (INR) ≥ 2 group had lower MACCE risk and higher thrombus disappearance than in INR < 2 group (13.5%vs29.6%; P = 0.044; 90.4%vs74.1%; P = 0.029). CONCLUSION For patients with ant-AMI treated by PPCI, LVT is an independent predictor of 1-year MACCE events. Treatment with vitamin K antagonist in the therapeutic range (INR ≥ 2) has the potential to reduce MACCE risk and promote disappearance of thrombus.
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Affiliation(s)
- Qian Zhang
- Department of Emergency, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Chun‐Mei Wang
- Department of Emergency, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Shu‐Tian Shi
- Department of Emergency, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Hong Chen
- Department of Emergency, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Yu‐Jie Zhou
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University, Beijing Institute of Heart Lung and Blood Vessel DiseaseBeijingChina
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56
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Incidence and predictors of bleeding in ACS patients treated with PCI and prasugrel or ticagrelor: An analysis from the RENAMI registry. Int J Cardiol 2018; 273:29-33. [DOI: 10.1016/j.ijcard.2018.09.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 08/14/2018] [Accepted: 09/04/2018] [Indexed: 01/28/2023]
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57
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Chen S, Redfors B, Liu Y, Ben-Yehuda O, Morice MC, Leon MB, Kandzari DE, Mehran R, Lembo NJ, Banning AP, Merkely B, Kappetein AP, Sabik JF, Serruys PW, Stone GW. Radial versus femoral artery access in patients undergoing PCI for left main coronary artery disease: analysis from the EXCEL trial. EUROINTERVENTION 2018; 14:1104-1111. [DOI: 10.4244/eij-d-18-00711] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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58
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Affiliation(s)
- Michel R Le May
- From the Division of Cardiology, University of Ottawa Heart Institute, Ontario, Canada.
| | - George A Wells
- From the Division of Cardiology, University of Ottawa Heart Institute, Ontario, Canada
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59
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Feng X, Zhang X, Dai J, Bin J. Efficacy and safety of a 260-cm Amplatz Super Stiff guidewire during transradial percutaneous coronary intervention. Medicine (Baltimore) 2018; 97:e12568. [PMID: 30334943 PMCID: PMC6211875 DOI: 10.1097/md.0000000000012568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Although transradial percutaneous coronary intervention (TR-PCI) is widely used in clinical practice, guidewire-related complications are an important cause of transradial approach failure. We investigated the prognostic value of the 260-cm Amplatz Super Stiff guidewire for reducing the complication rate during TR-PCI. METHODS Five hundred patients with positive Allen's test results were divided into 3 groups according to the type of angiography guidewire: group A, 150-cm Emerald guidewire standard J-tip (n = 160); group B, 150-cm Radifocus guidewire M (n = 176); and group C, exchangeable 260-cm Amplatz Super Stiff guidewire after placement of a 150-cm Radifocus guidewire M (n = 164). RESULTS Group C had the highest success rate (P = .008) and the lowest incidence of operative complications such as radial artery spasms and hematomas (P = .030 and P = .036, respectively). In addition, the groups differed significantly in terms of fluoroscopy and catheter placement times (P = .02. and P < .001, respectively); group C had the shortest times for these occurrences. CONCLUSIONS The exchangeable 260-cm Amplatz Super Stiff guidewire markedly decreased the incidence of guidewire-related complications, reduced fluoroscopy times, and increased the procedural success rate. Therefore, this tool can be considered a safe, effective, and feasible exchangeable guidewire for TR-PCI.
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Affiliation(s)
- Xuguang Feng
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong
- Affiliated Hospital of Inner Mongolia Medical University, Huhhot
| | - Xiaoyun Zhang
- Affiliated Hospital of Inner Mongolia Medical University, Huhhot
| | - Jun Dai
- Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jianping Bin
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong
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Bogabathina H, Singireddy S, Shi R, Morris L, Abdulbaki A, Zabher H, Katikaneni P, Modi K. Does micropuncture technique really help reduce vascular complications? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:762-765. [DOI: 10.1016/j.carrev.2018.03.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 03/22/2018] [Accepted: 03/22/2018] [Indexed: 11/17/2022]
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Esmonde S, Sharma D, Peace A. Antiplatelet agents in uncertain clinical scenarios-a bleeding nightmare. Cardiovasc Diagn Ther 2018; 8:647-662. [PMID: 30498688 PMCID: PMC6232352 DOI: 10.21037/cdt.2018.06.09] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 06/28/2018] [Indexed: 12/14/2022]
Abstract
Despite over 40 years since the first percutaneous coronary intervention (PCI) was performed, the optimal dual antiplatelet therapy (DAPT) regime poses a significant challenge for clinicians, especially in certain scenarios. DAPT is the standard of care in PCI following an acute coronary syndrome (ACS) or for elective patients with obstructive coronary artery disease (CAD). There remains significant uncertainty regarding DAPT in patients at high risk of bleeding, such as the elderly and patients requiring anticoagulation. More and more clinicians are faced with a dilemma of weighing risks and benefits from the increasing list of potent, new antiplatelet agents and direct oral anticoagulants (DOACs) in a growing, aging population. Historically, most studies failed to recognize bleeding risk, instead focusing on ischemic risk. In recent years however, bleeding has been recognized as a very significant driver of morbidity and mortality in patients undergoing PCI. There is a paucity of data in this cohort leading to divergent and sometimes conflicting recommendations, largely based on expert consensus of opinion. In the current review, we critically evaluate the available evidence in these uncertain scenarios.
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Affiliation(s)
- Sean Esmonde
- Department of Cardiology, Altnagelvin Area Hospital, Western Health and Social Care Trust, Derry/Londonderry, Northern Ireland, UK
| | - Divyesh Sharma
- Department of Cardiology, Altnagelvin Area Hospital, Western Health and Social Care Trust, Derry/Londonderry, Northern Ireland, UK
| | - Aaron Peace
- Department of Cardiology, Altnagelvin Area Hospital, Western Health and Social Care Trust, Derry/Londonderry, Northern Ireland, UK
- Northern Ireland Centre for Stratified Medicine, Ulster University, C-TRIC, Derry/Londonderry, Northern Ireland, UK
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Kim Y, Ahn Y, Kim I, Lee DH, Kim MC, Sim DS, Hong YJ, Kim JH, Jeong MH. Feasibility of Coronary Angiography and Percutaneous Coronary Intervention via Left Snuffbox Approach. Korean Circ J 2018; 48:1120-1130. [PMID: 30088362 PMCID: PMC6221867 DOI: 10.4070/kcj.2018.0181] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/05/2018] [Accepted: 07/17/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Feasibility of coronary angiography (CAG) and percutaneous coronary intervention (PCI) via left snuffbox approach is still concerned. We aimed to investigate efficacy and safety of the left snuffbox approach for CAG and PCI. METHODS Left snuffbox approach was tried in 150 patients who planned to perform CAG or PCI for suspected myocardial ischemia between 1 November 2017 and 31 March 2018. RESULTS Success rate of radial artery (RA) cannulation via snuffbox approach was 88.0% (n=132). Among 132 individuals, 58 (43.9%) acute coronary syndrome (ACS) patients were included. The diameter of snuffbox RA was significantly smaller than conventional RA (2.57 mm vs. 2.72 mm, p<0.001) from quantitative computed angiography of 101 patients. However, CAG via snuffbox approach by 6 French sheath was successfully performed in all 132 patients. In addition, there was significant correlation between the snuffbox and conventional RA diameter (r=0.856, p<0.001). In 42 PCI cases, including 25 patients with acute myocardial infarction (AMI), the success rate of PCI via snuffbox approach was 97.6% (n=41). Intravascular imaging-guided PCI was performed in 8 (19.5%) patients and multi-vessel PCI in 4 (9.8%) cases. Regarding vascular complication, forearm swelling with bruising, not requiring surgery or transfusion, occurred in 2 (4.9%) PCI cases. CONCLUSIONS Left snuffbox approach is suitable for CAG and PCI compared with the conventional radial approach.
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Affiliation(s)
- Yongcheol Kim
- Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea.
| | - Inna Kim
- Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Doo Hwan Lee
- Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Min Chul Kim
- Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Doo Sun Sim
- Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Young Joon Hong
- Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Ju Han Kim
- Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Myung Ho Jeong
- Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Gwangju, Korea
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Xu Y, Jin C, Qiao S, Wu Y, Yan H, Dou K, Xu B, Yang J, Yang Y. A Comparison of Transradial and Transfemoral Percutaneous Coronary Intervention in Chinese Women Based on a Propensity Score Analysis. Korean Circ J 2018; 48:719-727. [PMID: 30073810 PMCID: PMC6072662 DOI: 10.4070/kcj.2018.0040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/22/2018] [Accepted: 04/04/2018] [Indexed: 01/27/2023] Open
Abstract
Background and Objectives Over the past decades, transradial approach for percutaneous coronary intervention (PCI) has been increasingly adopted in clinical practice. Women represent a large population who will possibly benefit from PCI, but they are often under-represented in clinical studies. Therefore, the role of TRI in women remains to be further defined. This study sought to compare safety and efficacy for transradial intervention (TRI) and transfemoral intervention (TFI) in women undergoing PCI in China. Methods The study population consisted of 5,067 women undergoing PCI at Fuwai Hospital, Beijing, China between 2006 and 2011 (TRI: n=4,105, TFI: n=962). Incidence rates of clinical outcomes during hospitalization and at 1-year follow-up were compared between TRI and TFI. In order to minimize potential biases, a 1:1 propensity score matching (PSM) was performed. A total of 899 pairs were matched. Results Baseline and procedural characteristics were well-balanced between TRI and TFI groups after controlling for confounders using PSM. TRI was associated with reduced major post-PCI bleeding (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.54–0.76; p<0.001) and access site complications (OR, 0.67; 95% CI, 0.61–0.74; p<0.001) after PSM. There was no statistical differences in the incidence rates of major adverse cardiac events (a composite of cardiac death, myocardial infarction, and target vessel revascularization) both during hospitalization and at 1-year follow-up (p>0.05). Conclusions In this propensity score-based analysis of TRI versus TFI in Chinese women, TRI showed advantages of safety and feasibility over TFI. A wider adoption of TRI in women has the potential to improve outcomes in treatment of coronary artery diseases.
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Affiliation(s)
- Yi Xu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chen Jin
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shubin Qiao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongjian Wu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongbing Yan
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kefei Dou
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingang Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuejin Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Yoshida R, Morishima I, Takagi K, Morita Y, Tsuboi H, Murohara T. Comparison Between Long-Term Clinical Outcomes of Vitamin K Antagonist and Direct Oral Anticoagulants in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Circ J 2018; 82:2016-2024. [DOI: 10.1253/circj.cj-17-1171] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Ruka Yoshida
- Department of Cardiology, Ogaki Municipal Hospital
| | | | | | | | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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65
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Mincu RI, Rassaf T, Totzeck M. Red blood cell transfusion in patients with ST-elevation myocardial infarction-a meta-analysis of more than 21,000 patients. Neth Heart J 2018; 26:454-460. [PMID: 30039381 PMCID: PMC6115305 DOI: 10.1007/s12471-018-1137-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Red blood cell transfusion remains controversial in patients with acute coronary syndromes and particularly in patients with ST-elevation myocardial infarction (STEMI). METHODS We systematically searched PubMed, Cochrane, EMBASE, and Web of Science for studies published until January 2017 describing the outcomes in patients with STEMI who received red blood cell transfusion, compared with patients who did not. RESULTS A total of 21,770 patients with STEMI from 5 cohort studies were included in the meta-analysis, 984 (4.5%) received red blood cell transfusion and 20,786 (95.4%) did not. Red blood cell transfusion was associated with a higher risk of in-hospital and long-term mortality, emergency repeated percutaneous coronary intervention (PCI), reinfarction rate, stroke rate, and heart failure. The group with red blood cell transfusion had a slightly higher incidence of diabetes mellitus and hypertension, but a lower incidence of smoking. The two groups had the same incidence of prior myocardial infarction, prior coronary artery bypass graft surgery and malignancy. Prior heart failure, prior stroke and prior PCI were more frequent in the group that had received red blood cell transfusion. The mean nadir haemoglobin was 8.5 ± 0.1 g/dl in the group with red blood cell transfusion and 12.5 ± 0.4 g/dl in the control group, p < 0.001. CONCLUSIONS Red blood cell transfusion increases the morbidity and mortality in patients with STEMI. This difference could not be explained by the higher morbidity in the red blood cell transfusion group alone. Further randomised controlled trials are required to provide a reliable haemoglobin threshold for these patients.
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Affiliation(s)
- R I Mincu
- Medical Faculty, West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, Essen, Germany.,University and Emergency Hospital, Cardiac Research Unit, 'Carol Davila' University of Medicine and Pharmacy, Bucharest, Romania
| | - T Rassaf
- Medical Faculty, West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, Essen, Germany
| | - M Totzeck
- Medical Faculty, West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, Essen, Germany.
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Alexopoulos D, Vlachakis P, Lekakis J. Triple Antithrombotic Therapy in Atrial Fibrillation Patients Undergoing PCI: a Fading Role. Cardiovasc Drugs Ther 2018. [PMID: 28643219 DOI: 10.1007/s10557-017-6730-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Triple antithrombotic therapy (TAT), consisting of aspirin, a P2Y12 receptor antagonist and oral anticoagulant (OAC) medication has been considered as an 'unavoidable' strategy for a 1-12 months for atrial fibrillation (AF) patients post acute coronary syndrome or percutaneous coronary angioplasty with stenting. However, TAT has rather poorly been adopted in real life practice, mainly because of an accompanying increased bleeding potential and lack of definitive results of randomized clinical trials. Several registries, meta-analyses and small randomized trials have so far provided the base of guidelines recommendations. Furthermore, in the recently published Open-Label, Randomized, Controlled, Multicenter Study Exploring Two Treatment Strategies of Rivaroxaban and a Dose-Adjusted Oral Vitamin K Antagonist Treatment Strategy in Subjects with Atrial Fibrillation who Undergo Percutaneous Coronary Intervention (PIONEER AF-PCI) trial involving 2124 patients, the primary safety endpoint of clinically significant bleeding was significantly reduced in the rivaroxaban low dose (15 mg daily) plus single P2Y12 receptor antagonist arm compared to TAT, with no difference in the secondary efficacy endpoint. Despite several limitations of the PIONEER AF-PCI trial, it appears that among patients who omit aspirin, there may be equivalent ischemic protection with dual therapy and no disadvantage for additional risk of thrombotic events.
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Affiliation(s)
- Dimitrios Alexopoulos
- 2nd Department of Cardiology, Attikon University Hospital, National and Capodistrian University of Athens Medical School, Rimini 1, Chaidari, 12462, Athens, Greece.
| | - Panagiotis Vlachakis
- 2nd Department of Cardiology, Attikon University Hospital, National and Capodistrian University of Athens Medical School, Rimini 1, Chaidari, 12462, Athens, Greece
| | - John Lekakis
- 2nd Department of Cardiology, Attikon University Hospital, National and Capodistrian University of Athens Medical School, Rimini 1, Chaidari, 12462, Athens, Greece
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Divanji P, Shunk K. Modern Antiplatelet Therapy: When Is Clopidogrel the Right Choice? CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2018. [DOI: 10.15212/cvia.2017.0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Optimum Antithrombotic Therapy in Patients Requiring Long-Term Anticoagulation and Undergoing Percutaneous Coronary Intervention. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5690640. [PMID: 29770334 PMCID: PMC5889881 DOI: 10.1155/2018/5690640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/14/2017] [Indexed: 02/07/2023]
Abstract
Management of patients on long-term anticoagulation requiring percutaneous coronary intervention is challenging. Triple therapy with oral anticoagulant and dual antiplatelet therapy is the standard of care. However, there is no strong evidence to support this strategy. There is emerging data regarding the safety and efficacy of dual therapy with oral anticoagulant and single antiplatelet therapy in these patients. In this comprehensive review we highlight available evidence regarding various antithrombotic regimens' efficacy and safety in patient with coronary artery disease undergoing percutaneous coronary intervention with long-term anticoagulation therapy requirements.
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69
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Impact of percutaneous invasive coronary procedures using a radial approach on endothelial function of radial artery. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2018; 14:95-98. [PMID: 29743910 PMCID: PMC5939551 DOI: 10.5114/aic.2018.74361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 12/07/2017] [Indexed: 01/09/2023] Open
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Bogabathina H, Shi R, Singireddy S, Morris L, Abdulbaki A, Zabher H, Katikaneni P, Modi K. Reduction of vascular complication rates from femoral artery access in contemporary women undergoing cardiac catheterization. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:27-30. [PMID: 29724517 DOI: 10.1016/j.carrev.2018.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 03/27/2018] [Accepted: 03/27/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Femoral arterial access (FAA) during diagnostic coronary angiography (CAG) and percutaneous coronary interventions (PCI) are associated with several vascular complications (VC). VC rate in our experience a decade ago was 3.02% and higher in women (4.7% in women, and 1.67% in men, p < 0.0006), with an OR of 2.81 (95% CI: 1.51-5.22). METHODS Patients who underwent CAG and PCI utilizing FAA (n = 2617) were separated into Period 1 (2005 to 2008; 1970 patients; Male 1045; Female 925) and Period 2 (2016-2017; 647 patients; Male 357; Female 290). FA access was preceded by anatomic FA localization during Period 1 vs. additional fluoroscopic marking of femoral head during Period 2. Ultrasound guidance was not utilized during either period. VCs were defined as hematoma>3 cm, major bleeding requiring blood transfusion or hemoglobin drop >2 g, retroperitoneal bleed, pseudoaneurysm, AV fistula, arterial thrombosis, distal embolism, dissection, and transient limb ischemia. RESULTS Rate of VCs did not differ from Periods 1 to 2 (2.44% vs. 2.32%, p = 1.0). An elevated rate of VCs experienced by women in Period 1 (Female 3.68% vs. Male 1.34%, p < 0.05) is no longer noted in Period 2(Female 2.07% vs. Male 2.52%, p = 0.79). Vascular closure device (VCD) use was protective in both Periods 1 and 2. CONCLUSIONS The use of fluoroscopic marking of femoral head prior to access, smaller sheath size, and being a high femoral volume center may have contributed to the reduced incidence of VCs in women. VCD utilization is continuing to reduce VC rates in both men and women.
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Affiliation(s)
- Hari Bogabathina
- Department of Medicine, Section of Cardiology, Louisiana State University Health Sciences Center - Shreveport, Shreveport, LA, United States.
| | - Runhua Shi
- Department of Medicine, Section of Cardiology, Louisiana State University Health Sciences Center - Shreveport, Shreveport, LA, United States
| | - Sampath Singireddy
- Department of Medicine, Section of Cardiology, Louisiana State University Health Sciences Center - Shreveport, Shreveport, LA, United States
| | - Liam Morris
- Department of Medicine, Section of Cardiology, Louisiana State University Health Sciences Center - Shreveport, Shreveport, LA, United States
| | - Abdulrahman Abdulbaki
- Department of Medicine, Section of Cardiology, Louisiana State University Health Sciences Center - Shreveport, Shreveport, LA, United States
| | - Henock Zabher
- Department of Medicine, Section of Cardiology, Louisiana State University Health Sciences Center - Shreveport, Shreveport, LA, United States
| | - Pavan Katikaneni
- Department of Medicine, Section of Cardiology, Louisiana State University Health Sciences Center - Shreveport, Shreveport, LA, United States
| | - Kalgi Modi
- Department of Medicine, Section of Cardiology, Louisiana State University Health Sciences Center - Shreveport, Shreveport, LA, United States
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71
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Pek PP, Zheng H, Ho AFW, Wah W, Tan HC, Foo LL, Ong MEH. Comparison of epidemiology, treatments and outcomes of ST segment elevation myocardial infarction between young and elderly patients. Emerg Med J 2018; 35:289-296. [PMID: 29545356 DOI: 10.1136/emermed-2017-206754] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 02/14/2018] [Accepted: 02/26/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND With an ageing population, there is a need to understand the relative risk/benefit of interventions for elderly ST segment elevation myocardial infarction (STEMI) patients. The primary aim of this study was to compare epidemiology, treatments and outcomes between young and elderly STEMI patients. Our secondary aim was to determine the cut-off age when the benefits of primary percutaneous coronary intervention (PCI) were less pronounced. METHODS Data were collected by the Singapore Myocardial Infarction Registry. Patients were categorised into young (age <65 years) and elderly STEMI (age ≥65 years) patients. RESULTS We analysed 14 006 STEMI cases collected between January 2007 and December 2014; 33.9% were elderly STEMI patients. Elderly STEMI patients had longer median door to balloon (73 vs 64 min, P<0.001) time and were less likely to receive PCI (proportion difference=-23.6%, 95% CI -25.3 to -22.0). In the absence of PCI, elderly STEMI patients had a higher mortality within 30 days (elderly: HR 1.65, 95% CI 1.36 to 1.99, P<0.001; young: HR 1.10, 95% CI 0.79 to 1.54, P=0.573) and 1 year (elderly: HR 1.83, 95% CI 1.57 to 2.14, P<0.001; young: HR 1.41, 95% CI 1.09 to 1.83, P=0.009) of admission. The 1 year survival benefit of PCI started to decline after the age of 65 years. CONCLUSION Elderly STEMI patients were less likely to receive PCI and had longer door to balloon times. Survival benefit of PCI decreased after the age of 65 years, with the decline most evident from age 85 years onwards. The risks of PCI need to be weighed carefully against its benefits, especially in very elderly patients.
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Affiliation(s)
- Pin Pin Pek
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Huili Zheng
- National Registry of Diseases Office, Health Promotion Board, Singapore
| | - Andrew Fu Wah Ho
- Emergency Medicine Residency Program, SingHealth Services, Singapore
| | - Win Wah
- Unit for Prehospital Emergency Care, Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Huay Cheem Tan
- Department of Cardiology, National University Heart Centre, Singapore
| | - Ling Li Foo
- National Registry of Diseases Office, Health Promotion Board, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore.,Health Services and Systems Research, Duke-NUS Medical School, Singapore
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Schoenfeld MS, Kassas I, Shah B. Transradial Artery Access in Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:11. [PMID: 29478085 DOI: 10.1007/s11936-018-0607-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Early revascularization is the gold standard for management of patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS). The use of transradial artery access (TRA) in percutaneous coronary intervention (PCI) has increased in recent years and has emerged as a safe and effective approach to PCI in high-risk patients, with advantages in reduced major bleeding events, other peri-procedural complications, and all-cause mortality when compared with transfemoral artery access (TFA). Multiple randomized clinical trials have demonstrated these advantages of TRA vs. TFA PCI in STEMI patients. Although there remains a lack of dedicated randomized trials in CS, observational data suggest benefits on the same endpoints as in STEMI with TRA vs. TFA PCI in CS. This review summarizes the existing literature on the use of TRA compared to TFA for STEMI and CS patients; the reduction of major bleeding events, other peri-procedural complications, and mortality associated with TRA in STEMI and CS; and technical considerations and challenges in the care of these high-risk patient populations.
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Affiliation(s)
- Matthew S Schoenfeld
- New York University School of Medicine, 530 First Avenue, HCC-14, New York, NY, 10016, USA
| | - Ibrahim Kassas
- New York University School of Medicine, 530 First Avenue, HCC-14, New York, NY, 10016, USA
| | - Binita Shah
- VA New York Harbor Healthcare System, Manhattan Campus, New York University School of Medicine, 423 E 23rd Street, Room 12023-W, New York, NY, 10010, USA.
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Israeli Z, Lavi S, Bertand OF, Mamas MA, Bagur R. Radial versus femoral approach for same-day inter-facility transfer for percutaneous coronary intervention. J Interv Cardiol 2018; 31:230-235. [PMID: 29315802 DOI: 10.1111/joic.12486] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 11/30/2017] [Accepted: 12/01/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The use of radial approach for coronary angiography, followed by same-day inter-facility transfer for percutaneous coronary intervention (PCI) has not yet been evaluated. OBJECTIVES We sought to assess the safety and feasibility of using the transradial as compared to the transfemoral approach in patients undergoing diagnostic angiogram with same-day transfer to a PCI facility. METHODS Patients that underwent diagnostic coronary angiography between January 2011 and June 2017 in a referring facility, and were transferred for same-day PCI were included. Patients' demographics, as well as procedural data and in-hospital outcome, were collected. RESULTS Three hundred fifty-two participants were included. Of these, 36 (10.2%) patients received transradial access. Patients in the transradial group were older (68 ± 10 vs 62 ± 12 years, P = 0.007), and received a significantly higher total dose of heparin including both, diagnostic and PCI procedures (5935 ± 1865 vs 10029 ± 2771 units, P < 0.001). None of the transradial patients experienced bleeding or access-related complications. In the transfemoral group, 9 (3%) vascular-access complications were recorded. Contrast volume was lower for transradial patients (177 ± 47 vs 216 ± 75 mL, P < 0.001). A higher proportion of outpatients were discharged from the PCI-center the same day after transradial procedures (53% vs 1.3%, P < 0.001). CONCLUSIONS Transradial access for inter-facility transfer for PCI after diagnostic angiogram appears safe and feasible, without increasing the risk for ischemic hand complications. Transradial access was associated with fewer bleeding and vascular access-site complications, and with a higher likelihood for a same-day discharge home in outpatients.
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Affiliation(s)
- Zeev Israeli
- Interventional Cardiology Laboratories, London Health Sciences Centre, London, Ontario, Canada
| | - Shahar Lavi
- Interventional Cardiology Laboratories, London Health Sciences Centre, London, Ontario, Canada
| | - Olivier F Bertand
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
| | - Rodrigo Bagur
- Interventional Cardiology Laboratories, London Health Sciences Centre, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.,Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
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Abstract
Antiplatelet drugs, such as aspirin, P2Y12 antagonists, and glycoprotein (GP) IIb/IIIa inhibitors, have proved to be successful in reducing the morbidity and mortality associated with arterial thrombosis. These agents are, therefore, the cornerstone of therapy for patients with acute coronary syndromes. However, these drugs all carry an inherent risk of bleeding, which is associated with adverse cardiovascular outcomes and mortality. Thus, the potential benefits of more potent, conventional antiplatelet drugs are likely be offset by the increased risk of bleeding. Data from experiments in vivo have highlighted potentially important differences between haemostasis and thrombosis, raising the prospect of developing new antiplatelet drugs that are not associated with bleeding. Indeed, in preclinical studies, several novel antiplatelet therapies that seem to inhibit thrombosis while maintaining haemostasis have been identified. These agents include inhibitors of phosphatidylinositol 3-kinase-β (PI3Kβ), protein disulfide-isomerase, activated GPIIb/IIIa, GPIIb/IIIa outside-in signalling, protease-activated receptors, and platelet GPVI-mediated adhesion pathways. In this Review, we discuss how a therapeutic ceiling has been reached with existing antiplatelet drugs, whereby increased potency is offset by elevated bleeding risk. The latest advances in our understanding of thrombus formation have informed the development of new antiplatelet drugs that are potentially safer than currently available therapies.
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Comparison of prasugrel versus clopidogrel in Korean patients with acute myocardial infarction undergoing successful revascularization. J Cardiol 2018; 71:36-43. [DOI: 10.1016/j.jjcc.2017.05.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/01/2017] [Accepted: 05/22/2017] [Indexed: 11/21/2022]
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Tamburino C, Capodanno D, Miccichè E, D’Urso L, Calvi V, Angiolillo D, Tamburino C, Capranzano P. Platelet function profiles in the elderly: Results of a pharmacodynamic study in patients on clopidogrel therapy and effects of switching to prasugrel 5 mg in patients with high platelet reactivity. Thromb Haemost 2017; 106:1149-57. [DOI: 10.1160/th11-05-0346] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 09/23/2011] [Indexed: 11/05/2022]
Abstract
SummaryStudies specifically designed to assess clopidogrel response in the elderly as well as treatment alternatives to improve platelet inhibition in this highrisk population are lacking. This study aimed to define phar-macodynamic (PD) profiles, including high platelet reactivity (HPR) rates, among elderly patients on maintenance clopidogrel therapy and to assess the PD effects of prasugrel 5 mg/day in elderly with HPR. This was a prospective observational PD study enrolling consecutive ≥75-year-old patients on maintenance clopidogrel therapy (75 mg/day) who were tested for clopidogrel response by the VerifyNow P2Y12 assay and light transmittance aggregometry (LTA). HPR rates were estimated using multiple definitions. HPR patients identified by the VerifyNow P2Y12 assay [P2Y12 reaction unit (PRU) ≥230] were switched to prasugrel 5 mg/day, and platelet function testing was performed after 15 days of treatment. PD testing was completed in 100 patients. The HPR prevalence varied between 25% and 32%, depending on the definition used. A PRU ≥230 was observed in 25 patients; of these, 20 switched to prasugrel 5 mg/day. This resulted in significant reduction in PRU mean values (279.8 ± 45.1 vs. 171.7 ± 65.2, p=0.0002) with an absolute between-treatment difference of 108.1 (95% confidence intervals 75.2–140.9). Accordingly, switching to prasugrel 5 mg/day overcame HPR in most (80%) patients. Consistently, all LTA measures were significantly lower after prasugrel compared with clopidogrel. In conclusion, a considerable proportion of elderly patients exhibit HPR while on standard clopidogrel therapy. Switching to 5 mg/day prasugrel in elderly patients with HPR is associated with enhanced platelet inhibition and overcomes HPR in the majority of these patients.
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Reeh M, Ghadban T, Dedow J, Vettorazzi E, Uzunoglu FG, Nentwich M, Kluge S, Izbicki JR, Vashist YK. Allogenic Blood Transfusion is Associated with Poor Perioperative and Long-Term Outcome in Esophageal Cancer. World J Surg 2017; 41:208-215. [PMID: 27730355 DOI: 10.1007/s00268-016-3730-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Esophageal resection for cancer (EC) is still associated with considerable mortality and morbidity rates. Allogenic blood transfusion (aBT) is associated with poor short-term and long-term outcome in surgical oncology. We aimed to evaluate the effect of aBT in a homogeneous population of EC patients undergoing esophagectomy without perioperative treatment. METHODS We analyzed 565 esophagectomies performed due to EC. Allogenic blood transfusion was correlated to clinicopathological parameters, perioperative mortality and morbidity as well as the long-term outcome. Results are presented as adjusted odds ratio (OR) or hazard ratio (HR) with 95 % confidence interval (95 % CI). RESULTS Patients receiving aBT (aBT(+)) had no higher tumor stages or higher rates of lymph node metastasis (P = 0.65 and 0.17, respectively) compared to patients without aBT (aBT(-)). Allogenic blood transfusion was strongly associated with perioperative morbidity (OR 1.9, 95 % CI 1.1-3.5, P = 0.02) and mortality (OR 2.9, 95 % CI 1.0-8.6, P = 0.04). Tumor recurrence rate was significantly higher in aBT(+) patients (P = 0.001). The disease-free and overall survival were significantly longer in aBT(-) compared to aBT(+) patients (P = 0.016 and <0.001, respectively). Patients receiving aBT had almost doubled risk for tumor recurrence (HR 1.8, 95 % CI 1.2-2.5, P = 0.001) and death (HR 2.2, 95 % CI 1.5-3.2, P < 0.001). CONCLUSION Allogenic blood transfusion has a significant impact on the natural course of EC after complete resection. The poor short-term and long-term outcome warrants further evaluation of the underlying molecular mechanisms induced by allogenic blood transfusion in cancer patients.
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Affiliation(s)
- Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Tarik Ghadban
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Josephine Dedow
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Faik G Uzunoglu
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Michael Nentwich
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Yogesh K Vashist
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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Farooq V, Goedhart D, Ludman P, de Belder MA, Harcombe A, El-Omar M. Relationship Between Femoral Vascular Closure Devices and Short-Term Mortality From 271 845 Percutaneous Coronary Intervention Procedures Performed in the United Kingdom Between 2006 and 2011: A Propensity Score-Corrected Analysis From the British Cardiovascular Intervention Society. Circ Cardiovasc Interv 2017; 9:CIRCINTERVENTIONS.116.003560. [PMID: 27225421 DOI: 10.1161/circinterventions.116.003560] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 04/17/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The impact of vascular closure devices (VCDs) via the femoral arterial access site on short-term mortality in patients undergoing percutaneous coronary intervention is currently unknown. METHODS AND RESULTS The association between femoral arterial vascular access site management (manual pressure [including external clamp] versus VCD) and 30-day mortality was examined in a national real-world registry of 271 845 patients undergoing percutaneous coronary intervention for elective, non-ST-segment-elevation myocardial infarction and ST-segment-elevation myocardial infarction indications in the United Kingdom between 2006 and 2011. Crude and propensity score-corrected analyses were performed using Cox regression, with additional analyses undertaken in clinically relevant subgroups; 40.1% (n=109 001) of subjects were treated with manual pressure and 59.9% (n=162 844) with VCD. Subjects treated with VCD had fewer comorbidities and were less likely to present with ST-segment-elevation myocardial infarction and cardiogenic shock (P<0.001). Crude 30-day mortality was lower in the group treated with VCD compared with manual pressure (hazard ratio [HR], 0.58; 95% confidence interval [CI], 0.54-0.61; 1.4% versus 2.4%, log rank P<0.0001), findings that were substantially reduced but persisted after propensity score correction (HR, 0.91; 95% CI, 0.86-0.97; 1.8% versus 2.0% versus P<0.001). A more pronounced association of VCD with a reduction in 30-day mortality was evident in females (HR, 0.85; 95% CI, 0.77-0.94; Pinteraction=0.037), presentation with acute coronary syndrome (HR, 0.88; 95% CI, 0.83-0.94; Pinteraction=0.0027), or recent lysis (HR, 0.63; 95% CI, 0.40-1.01; Pinteraction=0.0001). CONCLUSIONS When compared with manual pressure, VCD was associated with a minor short-term (30-day) prognostic benefit after propensity score correction in the global population and clinically relevant subgroups. The potential for residual confounding factors impacting on short-term mortality cannot be excluded, despite the study having measured and balanced all recorded confounder factors.
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Affiliation(s)
- Vasim Farooq
- From the Department of Cardiology, Manchester Heart Centre, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom (V.F., D.G., M.E.-O.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Department of Cardiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom (A.H.)
| | - Dick Goedhart
- From the Department of Cardiology, Manchester Heart Centre, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom (V.F., D.G., M.E.-O.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Department of Cardiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom (A.H.)
| | - Peter Ludman
- From the Department of Cardiology, Manchester Heart Centre, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom (V.F., D.G., M.E.-O.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Department of Cardiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom (A.H.)
| | - Mark A de Belder
- From the Department of Cardiology, Manchester Heart Centre, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom (V.F., D.G., M.E.-O.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Department of Cardiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom (A.H.)
| | - Alun Harcombe
- From the Department of Cardiology, Manchester Heart Centre, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom (V.F., D.G., M.E.-O.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Department of Cardiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom (A.H.)
| | - Magdi El-Omar
- From the Department of Cardiology, Manchester Heart Centre, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom (V.F., D.G., M.E.-O.); Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Department of Cardiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom (A.H.).
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79
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Cambronero F, Caro-Martínez C, Hurtado-Martínez JA, Marín F, Pastor-Pérez FJ, Mateo-Martínez A, Sánchez-Martínez M, Pinar-Bermúdez E, Valdés M, Manzano-Fernández S. Mild kidney disease as a risk factor for major bleeding in patients with atrial fibrillation undergoing percutaneous coronary stenting. Thromb Haemost 2017; 107:51-8. [DOI: 10.1160/th11-08-0524] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 09/30/2011] [Indexed: 01/03/2023]
Abstract
SummaryBleeding risk is increased in patients with atrial fibrillation (AF) and moderate to severe kidney disease (KD); however, the implication of mild KD on bleeding remains unclear. The aim of this study was to determine whether the presence of mild KD increases risk for major bleeding (MB) in patients with AF undergoing percutaneous coronary intervention with stent implantation (PCI-S). Two hundred eighty-five patients were included. Patients were classified into three kidney function groups: moderate to severe KD (n=91; <60 ml/min/1.73 m2), mild KD (n=139; 60–89 ml/min/1.73 m2) and non-KD (n=55; ≥90 ml/min/1.73 m2). Estimated glomerular filtration rate was calculated using the simplified Modification of Diet in Renal Disease equation. Patients were followed for one year, and the occurrence of MB was obtained in all. A total of 28 patients (9.8%) presented MB. MB complications examined as a function of KD groups revealed that there was a graded increase in MB with worsening renal function (non KD=1.8%, mild KD=7.9%, moderate to severe KD=17.6%; p <0.001). Multivariable Cox regression analysis showed that mild KD was associated with nearly a 2.5-fold (2.43 95% confidence interval 1.11–5.34, p=0.039) increase in the risk of MB as compared with non-KD patients. Other independent predictors of MB were moderate-severe KD, anaemia and triple antithrombotic therapy after PCI-S (C-index=0.76). In this population, mild KD confers a significantly increase in the risk for MB complications. Future studies should assess the potential role of incorporating mild KD into the bleeding risk scales to improve the stratification of these patients.
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80
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Cornara S, Somaschini A, De Servi S, Crimi G, Ferlini M, Baldo A, Camporotondo R, Gnecchi M, Ferrario Ormezzano M, Oltrona Visconti L, De Ferrari GM. Prognostic Impact of in-Hospital-Bleeding in Patients With ST-Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention. Am J Cardiol 2017; 120:1734-1741. [PMID: 28865893 DOI: 10.1016/j.amjcard.2017.07.076] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/14/2017] [Accepted: 07/20/2017] [Indexed: 12/01/2022]
Abstract
Several studies established a link between bleeding and mortality in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI); however, it is unclear whether bleeding has a direct role in worsening the prognosis or if it is simply a marker of patient frailty. We investigated whether bleeding is an independent predictor of mortality in patients with STEMI treated with pPCI. The relationship between the presence of heart failure on presentation (Killip classification), bleeding occurrence, and outcome was also assessed. Bleeding was defined as the combination of Thrombolysis in Myocardial Infarction major and minor bleeding. Short- and long-term mortalities were estimated using the Kaplan-Meyer analysis. Multivariable analysis was performed by the Cox regression model. As an alternative method to address the potential confounding factors, we performed a propensity-matched analysis adjusted for all variables included in the CRUSADE score. In the 1,911 consecutive patients with STEMI considered, bleeding (observed in 11.4% of patients) was an independent predictor of 30-day (hazard ratio 2.61, 95% confidence interval 1.30 to 5.25, p = 0.007) and 1-year mortality (hazard ratio 1.98, 95% confidence interval 1.13 to 3.47, p = 0.017) but not in a landmark analysis starting from 30 days to 1 year. Bleeding was significantly associated with higher 30-day and 1-year mortality in patients with Killip class ≥II, but not in patients with Killip class I. In conclusion, in-hospital bleeding is independently associated with increased mortality in the early period after STEMI, also after adjusting for variables associated with the risk of bleeding. Bleeding was associated with increased mortality in patients with signs of heart failure at admission, whereas it had no effects in patients with Killip class I.
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Affiliation(s)
- Stefano Cornara
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, Unit of Cardiology, University of Pavia, Pavia, Italy
| | - Alberto Somaschini
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, Unit of Cardiology, University of Pavia, Pavia, Italy
| | | | - Gabriele Crimi
- Division of Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marco Ferlini
- Division of Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Baldo
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, Unit of Cardiology, University of Pavia, Pavia, Italy
| | - Rita Camporotondo
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Massimiliano Gnecchi
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, Unit of Cardiology, University of Pavia, Pavia, Italy
| | | | | | - Gaetano M De Ferrari
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, Unit of Cardiology, University of Pavia, Pavia, Italy.
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81
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Galyfos G, Sigala F, Filis K. Transradial versus Transfemoral access in patients undergoing peripheral artery angioplasty/stenting: A meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 19:457-465. [PMID: 29126947 DOI: 10.1016/j.carrev.2017.09.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 09/24/2017] [Accepted: 09/27/2017] [Indexed: 10/18/2022]
Abstract
Transradial (TR) access has been extensively compared to transfemoral (TF) access in patients undergoing percutaneous coronary interventions, with TR method showing a clear benefit over the latter. However, comparative data concerning peripheral artery endovascular interventions has been limited in the literature. Therefore, a systematic review was conducted in order to compare main outcomes between TR and TF access in patients undergoing peripheral artery angioplasty and/or stenting. Main outcomes included technical success, major/minor bleeding risk, access site complications, hospital stay, death, myocardial infarction, neurological events and other procedural parameters. TR and TF access methods seem to be associated with similar early outcomes in patients undergoing non-coronary endovascular angioplasty and/or stenting although paucity of data necessitates the conduction of better designed studies.
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Affiliation(s)
- George Galyfos
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece.
| | - Fragiska Sigala
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - Konstantinos Filis
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
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82
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Agarwal N, Jain A, Mahmoud AN, Bishnoi R, Golwala H, Karimi A, Mojadidi MK, Garg J, Gupta T, Patel NK, Wayangankar S, Anderson RD. Safety and Efficacy of Dual Versus Triple Antithrombotic Therapy in Patients Undergoing Percutaneous Coronary Intervention. Am J Med 2017; 130:1280-1289. [PMID: 28460853 DOI: 10.1016/j.amjmed.2017.03.057] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 03/28/2017] [Accepted: 03/28/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Choosing an antithrombotic regimen after coronary intervention in patients with concomitant indication for anticoagulation is a challenge commonly encountered by clinicians. METHODS We performed a meta-analysis of observational studies and randomized, controlled trials comparing outcomes of triple therapy (dual antiplatelet therapy and anticoagulant) with dual therapy (single antiplatelet therapy and anticoagulant) in patients taking long-term anticoagulants after percutaneous coronary intervention. Major bleeding was the primary outcome. Random effects overall risk ratios (RRs) were calculated using the DerSimonian and Laird model. RESULTS Nine observational studies and 2 randomized controlled trials with a total of 7276 patients met our selection criteria. At a mean follow-up of 10.8 months major bleeding was higher in the triple therapy cohort compared with dual therapy (6.6% vs 3.8%; RR 1.54; 95% confidence interval [CI], 1.2-1.98; P <.01). No difference was observed between the 2 groups for all-cause mortality (RR 0.98; 95% CI, 0.68-1.43; P = .93), major adverse cardiac events (RR 1.03; 95% CI, 0.8-1.32; P = .83), thromboembolic events (RR 1.02; 95% CI, 0.49-2.10; P = .96), myocardial infarction (RR 0.85; 95% CI, 0.67-1.09; P = .21), stent thrombosis (RR 0.77; 95% CI, 0.46-1.3; P = .33), and target vessel revascularization (RR 0.87; 95% CI, 0.66-1.15; P = .33). CONCLUSION In patients receiving anticoagulant therapy, a strategy of single antiplatelet therapy confers a benefit of less major bleeding with no difference in all-cause mortality, cardiovascular mortality, major adverse cardiac events, myocardial infarction, stent thrombosis, or thromboembolic event rate compared with dual antiplatelet therapy.
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Affiliation(s)
- Nayan Agarwal
- Department of Medicine, University of Florida, Gainesville
| | - Ankur Jain
- Department of Medicine, University of Florida, Gainesville
| | | | - Rohit Bishnoi
- Department of Medicine, University of Florida, Gainesville
| | - Harsh Golwala
- Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Ashkan Karimi
- Department of Medicine, University of Florida, Gainesville
| | | | - Jalaj Garg
- Department of Medicine, Lehigh Valley Hospital, Allentown, Pa
| | - Tanush Gupta
- Department of Medicine, Montefiore Medical Centre, Albert Einstein College of Medicine, Bronx, NY
| | - Nimesh Kirit Patel
- Department of Medicine, Virginia Commonwealth University Health System, Richmond
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83
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Association of polymorphisms of platelet receptors GPIa (807C>T), GPVI (13254T>C), and P2Y12 (34C>T and H1/H2 haplotype) with increased risk of periprocedural bleeding in patients undergoing coronary angiography/percutaneous coronary intervention. Adv Cardiol 2017; 13:202-209. [PMID: 29056992 PMCID: PMC5644038 DOI: 10.5114/aic.2017.70187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 04/19/2017] [Indexed: 01/02/2023]
Abstract
Introduction Periprocedural bleeding related to coronary angiography (CAG) or percutaneous coronary intervention (PCI) is associated with worse prognosis. Determining genetic variations associated with increased bleeding risk may help to identify high-risk patients. Aim To analyse the association between single nucleotide polymorphisms (SNPs) of crucial haemostatic platelet receptors (GPIa, GPVI, P2Y12) and the risk of periprocedural bleeding complications related to CAG/PCI. Material and methods The population consisted of 73 patients with ischaemic heart disease who developed bleeding complications within 30 days after CAG/PCI and 331 patients without bleeding. The frequency of SNPs of GPIa 807C/T, GPVI 13254T/C, P2Y12 32C/T, and P2Y12 H1/H2 haplotype was analysed using polymerase chain reaction (PCR) hybridization methods. Results The prevalence of variant alleles GPIa 807T, GPVI 13254C, P2Y12 34T, and P2Y12 H2 haplotype in the total study population was 56.7%, 20.3%, 56.2%, and 24.3%, respectively. The presence of variant alleles was not related to increased risk of periprocedural bleeding: GPIa 807C/T (OR = 1.29, 95% CI: 0.75–2.24, p = 0.334), GPVI 12354T/C (OR = 0.82, 95% CI: 0.40–1.64, p = 0.551), P2Y12 34C/T (OR = 0.71, 95% CI: 0.42–1.22, p = 0.189), P2Y12 H1/H2 haplotype (OR = 0.69, 95% CI: 0.35–1.36, p = 0.258). The frequency of the homozygous form of P2Y12 H2 haplotype was higher in the group of patients who developed bleeding (OR = 2.79, 95% CI: 0.51–13.77, p = 0.161). Conclusions No significant association of the SNPs of GPIa 807C/T, GPVI 13254T/C, P2Y12 32C/T, and P2Y12 H1/H2 haplotype with increased risk of periprocedural bleeding was found in patients with ischaemic heart disease undergoing CAG/PCI.
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84
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Mentias A, Raza MQ, Barakat AF, Youssef D, Raymond R, Menon V, Simpfendorfer C, Franco I, Ellis S, Tuzcu EM, Kapadia SR. Effect of Shorter Door-to-Balloon Times Over 20 Years on Outcomes of Patients With Anterior ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Am J Cardiol 2017; 120:1254-1259. [PMID: 28838603 DOI: 10.1016/j.amjcard.2017.07.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/05/2017] [Accepted: 07/12/2017] [Indexed: 10/19/2022]
Abstract
Cardiovascular disease remains the most common cause of mortality. We studied the change in outcomes for anterior ST-elevation myocardial infarction (STEMI) between 1995 and 2014. Over the past 20 years, 1,658 patients presenting to our center with anterior STEMI underwent primary percutaneous coronary intervention within 12 hours of presentation. We divided these into 4 quartiles, 1995 to 1999 (n = 312), 2000 to 2004 (n = 408), 2005 to 2009 (n = 428), and 2010 to 2014 (n = 510). Across the 4 quartiles, mean age decreased (64.4, 62, 60.3, and 60 years, p <0.01). In all groups, there was a significant rise in prevalence of smoking, hypertension, and obesity. The median length of hospital stay decreased (6, 4.4, 4.2, and 3.6 days, p <0.01), as did the median door-to-balloon time (DBT) (217, 194, 135, and 38 minutes, p <0.01). Thirty-day and 1-year mortality improved over time (14.4%, 11.8%, 8.4%, and 7.8%; and 20.5%, 16.4%, 15.9%, and 13.9%) (p = 0.01 both). Also, 3-year mortality improved (25.3%, 21.6%, 21.3%, and 16.5%, p = 0.02). After adjusting for age, gender, co-morbidities, ejection fraction, clinical shock, and mitral regurgitation, shorter DBT was associated with lower long-term mortality (compared with DBT <60 minutes; 60 to 90 minutes hazard ratio [HR] 1.67, 95% confidence interval [CI] 0.93 to 3.00, p = 0.084; 90 to 120 minutes, HR 1.74, 95% CI 1.02 to 2.95, p = 0.04; >120 minutes, HR 1.91, 95% CI 1.23 to 2.96, p = 0.004). In conclusion, over the past 2 decades, long-term outcomes improved in patients presenting with anterior STEMI associated with shortening of DBT.
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85
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Boccalandro F, Dhindsa M, Subramaniyam P, Mok M. Feasibility of coronary fractional flow reserve with dual anti-platelet therapy in low risk coronary lesions without systemic anticoagulation-results of the SMART-FFR study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 19:343-347. [PMID: 28927636 DOI: 10.1016/j.carrev.2017.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 08/13/2017] [Accepted: 08/15/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Fractional flow reserve (FFR) is used to assess the functional significance of coronary artery stenoses. The optimal anti-thrombotic regimen for FFR has not been studied. PURPOSE The goal of this study was to determine whether FFR could be safely performed in Type A coronary lesions, using only upstream dual anti-platelet therapy (DAT) with aspirin and clopidogrel, compared with DAT plus anticoagulation in low risk coronary lesions. METHODS/MATERIALS Two hundred patients undergoing FFR for Type A intermediate coronary lesions were blindly randomized into two groups of 100 patients each. Group 1: Upstream DAT, without intra-procedural anti-coagulation and Group 2: Upstream DAT plus intra-procedural bivalirudin. The primary end-points were any coronary thrombotic complications during the index hospital stay, and a composite end-point of any major adverse cardiovascular events (MACE) at 30-days. Secondary end-points included post-procedure troponin levels and TIMI major and minor bleeding scores. RESULTS There were no thrombotic complications reported. At 30-days, two MACE occurred in Group 1, and three in Group 2 (p=0.83). No difference was seen in the post-procedure troponin levels (p=0.72), or TIMI bleeding scores study between groups (p=093). CONCLUSIONS This initial study evaluating a simplified anti-thrombotic regimen for FFR, suggests that FFR can be performed in low risk coronary lesions using DAT without the need for intra-procedural anticoagulation, with similar results as DAT plus anticoagulation with bivalirudin. Further research in this area is needed to determine the optimal and most cost-effective anti-thrombotic regimen for FFR calculation.
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Affiliation(s)
- Fernando Boccalandro
- ProCare - Odessa Heart Institute, Odessa, TX, United States; Permian Research Foundation, Odessa, TX, United States; Department of Internal Medicine, Texas Tech University Health Science Center, Odessa, TX, United States.
| | - Mandeep Dhindsa
- Department of Internal Medicine, Texas Tech University Health Science Center, Odessa, TX, United States
| | - Prem Subramaniyam
- Michigan State University, Department of Internal Medicine, Lansing, MI, United States
| | - Mary Mok
- University of Texas San Antonio, Department of Internal Medicine, San Antonio, TX, United States
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86
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Sardar MR, Goldsweig AM, Abbott JD, Sharaf BL, Gordon PC, Ehsan A, Aronow HD. Vascular complications associated with transcatheter aortic valve replacement. Vasc Med 2017; 22:234-244. [PMID: 28494713 DOI: 10.1177/1358863x17697832] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) is now an accepted pathway for aortic valve replacement for patients who are at prohibitive, severe and intermediate risk for traditional aortic valve surgery. However, with this rising uptrend and adaptation of this new technology, vascular complications and their management remain an Achilles heel for percutaneous aortic valve replacement. The vascular complications are an independent predictor of mortality for patients undergoing TAVR. Early recognition of these complications and appropriate management is paramount. In this article, we review the most commonly encountered vascular complications associated with currently approved TAVR devices and their optimal percutaneous management techniques.
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Affiliation(s)
- M Rizwan Sardar
- 1 Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, RI, USA.,2 Aultman Hospital, Northeast Ohio Medical University (NEOMED), Rootstown, OH, USA
| | - Andrew M Goldsweig
- 1 Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - J Dawn Abbott
- 1 Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Barry L Sharaf
- 1 Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Paul C Gordon
- 1 Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Afshin Ehsan
- 1 Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Herbert D Aronow
- 1 Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, RI, USA
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87
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Cho MS, Park DW. Stent thrombosis and optimal duration of dual antiplatelet therapy after coronary stenting in contemporary practice. Korean J Intern Med 2017; 32:769-779. [PMID: 28823143 PMCID: PMC5583458 DOI: 10.3904/kjim.2016.391] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 08/03/2017] [Indexed: 02/07/2023] Open
Abstract
The introduction of drug-eluting stents (DES) in the practice of percutaneous coronary intervention (PCI) has substantially reduced angiographic and clinical restenosis but is associated with an increasing propensity for very late stent thrombosis (ST). Among several clinical, lesion, or procedure-related predictors of ST, early discontinuation of dual antiplatelet therapy (DAPT) is the most important factor for DES-associated late thrombosis; therefore, the optimal duration of DAPT is a major issue to be critically considered in the current DES era. Given that the benefit and risk of longer duration DAPT should be simultaneously considered, the optimal DAPT period following DES implantation has been controversial. Several small-to-medium sized randomized clinical trials and observational registries have indicated that short-term DAPT (< 6 months) is not inferior to 12-month DAPT with fewer bleeding events, whereas prolonged duration of DAPT (> 12 months) failed to prove its superiority. However, compelling evidence from a landmark DAPT trial has clearly demonstrated the efficacy of prolonged DAPT up to 30 months in terms of preventing ST and major cardiovascular adverse events at the expense of major bleeding. In addition, coupled with various risk algorithms, a more individualized approach to balance the efficacy and safety of optimal DAPT duration has been emphasized. In this review article, we systematically summarize the cumulative evidence from key clinical studies and try to help the physician make decisions on the optimal duration of DAPT in contemporary PCI practice.
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Affiliation(s)
| | - Duk-Woo Park
- Correspondence to Duk-Woo Park, M.D. Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3995 Fax: +82-2-475-6898 E-mail:
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88
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Brinkert M, Southern DA, James MT, Knudtson ML, Anderson TJ, Charbonneau F. Incidence and Prognostic Implications of Late Bleeding After Myocardial Infarction or Unstable Angina According to Treatment Strategy. Can J Cardiol 2017; 33:998-1005. [DOI: 10.1016/j.cjca.2017.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 04/27/2017] [Accepted: 05/02/2017] [Indexed: 11/29/2022] Open
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89
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Shavadia JS, Youngson E, Bainey KR, Bakal J, Welsh RC. Outcomes and Prognostic Impact of Prophylactic Oral Anticoagulation in Anterior ST-Segment Elevation Myocardial Infarction Patients With Left Ventricular Dysfunction. J Am Heart Assoc 2017; 6:JAHA.117.006054. [PMID: 28673899 PMCID: PMC5586310 DOI: 10.1161/jaha.117.006054] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The contemporary role of prophylactic anticoagulation following extensive anterior wall ST‐segment myocardial infarction (STEMI) is unclear. Methods and Results We evaluated anterior STEMI patients with left ventricle dysfunction (left ventricular ejection fraction ≤40%) (“high risk”), categorized by prophylactic warfarin use, within a regional STEMI. Patients with pre‐existing atrial fibrillation were excluded. The primary outcome was an adjusted (for Global Registry of Acute Coronary Events risk score) 1‐year composite of recurrent ischemia, stroke/transient ischemic attack/systemic embolism, or all‐cause death. Of the 2032 STEMI admissions, 436 (21.5%) were high risk. After excluding 19 (4.4%) patients with definite left ventricle thrombus and 21 (4.8%) in‐hospital deaths (2 had left ventricle thrombus), prophylactic warfarin was utilized in 236/398 (59.3%) high‐risk survivors. Prescriptions were comparable across sex, but recipients were on average younger (58.5 years versus 64.0 years, P<0.001) and lower risk (Global Registry of Acute Coronary Events risk: 163 versus 181, P<0.001). No association on the adjusted ischemic composite (23.3% versus 25.3%, odds ratio 0.96, 95% CI 0.60–1.55) or thromboembolic events (2.1% versus 1.2%, odds ratio 1.99, 95% CI 0.38–10.51) was observed, but reduced 1‐year all‐cause mortality was noted (2.5% versus 8.6%, odds ratio 0.30, 95% CI 0.11–0.81); numerically higher major bleeding was observed at 1 year (2.5% versus 1.2%, odds ratio 2.17, 95% CI 0.43–10.96). Conclusions A high utilization of prophylactic warfarin occurs in anterior STEMI patients with left ventricle dysfunction, yet appears to provide no additional benefit on the ischemic composite. The association with lower all‐cause mortality, but higher bleeding, calls for an improved understanding of its role in high‐risk STEMI.
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Affiliation(s)
- Jay S Shavadia
- University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.,Duke Clinical Research Institute, Edmonton, Alberta, Canada
| | - Erik Youngson
- University of Alberta, Edmonton, Alberta, Canada.,Alberta Health Services, Edmonton, Alberta, Canada
| | - Kevin R Bainey
- University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Jeffrey Bakal
- University of Alberta, Edmonton, Alberta, Canada.,Alberta Health Services, Edmonton, Alberta, Canada
| | - Robert C Welsh
- University of Alberta, Edmonton, Alberta, Canada .,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
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90
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Wang H, Li Y, Cong H, Ding S, Liu B, Li L, Chen Y, Jia S, Jing Q, Zhao X, Liu H, Liang Z, Li J, Bao D, Han Y. Efficiency and safety of bivalirudin in patients undergoing emergency percutaneous coronary intervention via radial access: A subgroup analysis from the bivalirudin in acute myocardial infarction versus heparin and GPI plus heparin trial. Catheter Cardiovasc Interv 2017; 89:1157-1165. [PMID: 27677411 DOI: 10.1002/ccd.26804] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 09/05/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To explore the efficiency and safety of bivalirudin in patients undergoing emergency percutaneous coronary intervention via radial access. BACKGROUND Bivalirudin reduces bleeding risks over heparin in patients undergoing PCI. However, bleeding advantages of bivalirudin in patients undergoing transradial intervention is uncertain. METHODS In the BRIGHT trial, 1,723 patients underwent emergency PCI via radial access, with 576 patients in the bivalirudin arm, 576 in the heparin arm and 571 in the heparin plus tirofiban arm. The primary outcome was 30-day net adverse clinical event (NACE), defined as a composite of major cardiac and cerebral events or any bleeding. RESULTS 30-day NACE occurred in 5.7% with bivalirudin, 7.8% with heparin alone (vs. bivalirudin, P = 0.159), and 10.3% with heparin plus tifofiban (vs. bivalirudin, P = 0.004). The 30-day bleeding rate was 0.9% for bivalirudin, 2.3% for heparin (vs. bivalirudin, P = 0.057), and 5.8% for heparin plus tirofiban (vs. bivalirudin, P < 0.001). Major cardiac and cerebral events (4.9 vs. 5.7 vs. 4.6%, P = 0.899), stent thrombosis (0.5 vs. 0.5 vs. 0.7%, P = 0.899) and acquired thrombocytopenia (0.2 vs. 0.5 vs. 0.9%, P = 0.257) at 30 days were similar among three arms. The interaction test for PCI access and randomized treatment showed no significance on all bleeding (P > 0.05). CONCLUSIONS The bleeding benefit of bivalirudin was independent of artery access. Bivalirudin lead to statistical reduction on bleeding risks in comparison to heparin plus tirofiban, and only small numerical difference in comparison to heparin, with comparable risks of ischemic events and stent thrombosis in patients with acute myocardial infarction (AMI) undergoing emergency transradial PCI. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Heyang Wang
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016, China
| | - Yi Li
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016, China
| | - Hongliang Cong
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, 300051, China
| | - Shifang Ding
- Department of Cardiology, Wuhan General Hospital of Guangzhou Military, Wuhan, China
| | - Bin Liu
- Department of Orthopedics, The Second Hospital, Jilin University, Changchun, China
| | - Lu Li
- First Department of Cardiology, Shenzhou Hospital, Shenyang Medical College, Shenyang, 110002, China
| | - Yundai Chen
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Shaobin Jia
- Department of Cardiology, Affiliated Hospital of Ningxia Medical College, Yinchuan, China
| | - Quanmin Jing
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016, China
| | - Xin Zhao
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016, China
| | - Haiwei Liu
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016, China
| | - Zhenyang Liang
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016, China
| | - Jing Li
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016, China
| | - Dan Bao
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016, China
| | - Yaling Han
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016, China
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Avdikos G, Karatasakis A, Tsoumeleas A, Lazaris E, Ziakas A, Koutouzis M. Radial artery occlusion after transradial coronary catheterization. Cardiovasc Diagn Ther 2017; 7:305-316. [PMID: 28567356 DOI: 10.21037/cdt.2017.03.14] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The transradial approach (TRA) for coronary angiography and interventions is increasingly utilized around the world. Radial artery occlusion (RAO) is the most common significant complication after transradial catheterization, with incidence varying between 1% and 10%. Although RAO is rarely accompanied by hand ischemia, it is an important complication because it prohibits future transradial access and radial artery utilization as a conduit for coronary artery bypass grafting or arteriovenous fistula formation. In this review, we discuss factors predicting the occurrence of RAO, aspects of accurate and prompt recognition, methods that contribute to its prevention and possible treatment options.
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Affiliation(s)
- Grigorios Avdikos
- Second Department of Cardiology, Hellenic Red Cross Hospital of Athens, Athens, Greece
| | - Aris Karatasakis
- University of Texas, Southwestern Medical Center, Dallas, Texas, USA
| | - Andreas Tsoumeleas
- Second Department of Cardiology, Hellenic Red Cross Hospital of Athens, Athens, Greece
| | - Efstathios Lazaris
- Second Department of Cardiology, Hellenic Red Cross Hospital of Athens, Athens, Greece
| | - Antonios Ziakas
- First Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Koutouzis
- Second Department of Cardiology, Hellenic Red Cross Hospital of Athens, Athens, Greece
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92
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Park JY, Rha SW, Choi BG, Oh DJ, Choi CU, Youn YJ, Yoon J. Comparison of Clinical Outcomes between the Right and Left Radial Artery Approaches from the Korean Transradial Coronary Intervention Registry. Yonsei Med J 2017; 58:521-526. [PMID: 28332356 PMCID: PMC5368136 DOI: 10.3349/ymj.2017.58.3.521] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/24/2017] [Accepted: 01/25/2017] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Transradial intervention (TRI) shows anatomical and technical differences between the right radial approach (RRA) and left radial approach (LRA). The aim of this study was to evaluate the efficacy and safety using LRA, compared with RRA. MATERIALS AND METHODS A total of 1653 consecutive patients who underwent TRI from November 2004 to October 2010 were enrolled in the Korean multicenter TRI registry. The patients were divided into two groups: the RRA group (n=792 patients) and the LRA group (n=861 patients). To adjust for any potential confounders, propensity score matched (PSM) analysis was performed (C-statistic: 0.726). After PSM, a total of 1100 patients were enrolled for analysis. RESULTS After PSM, the RRA group exhibited a larger contrast volume (259.3±119.6 mL vs. 227.0±90.7 mL, p<0.001), a longer fluoroscopic time (22.5±28.0 minutes vs. 17.1±12.6 minutes) and higher access site change (12.3% vs. 1.0%, p<0.001) than the LRA group. Meanwhile, the LRA group showed a shorter procedure time (49.2±30.4 minutes vs. 55.4±28.7 minutes, p=0.003) than the RRA group. After PSM, in-hospital complications and 12-month cumulative clinical outcomes were similar between the two groups. CONCLUSION Of the two TRI methods, LRA was associated with better procedural efficacy, including shorter procedural time, smaller contrast volume, and less access site change than RRA. However, both methods showed similar 12-month cumulative clinical outcomes. Therefore, LRA was deemed superior to RRA in terms of procedural feasibility without a significant difference in clinical outcomes.
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Affiliation(s)
- Ji Young Park
- Division of Cardiology, Departement of Internal Medicine, Cardiovascular Center, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Seung Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea.
| | - Byong Geol Choi
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Dong Ju Oh
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Cheol Ung Choi
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Young Jin Youn
- Division of Cardiology, Departement of Internal Medicine, Cardiovascular Center, Yonsei University Wonju Hospital, Wonju, Korea
| | - Junghan Yoon
- Division of Cardiology, Departement of Internal Medicine, Cardiovascular Center, Yonsei University Wonju Hospital, Wonju, Korea
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93
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Ducrocq G, Schulte PJ, Budaj A, Cornel JH, Held C, Himmelmann A, Husted S, Storey RF, Cannon CP, Becker RC, James SK, Katus HA, Lopes RD, Sorbets E, Wallentin L, Steg PG. Balancing the risk of spontaneous ischemic and major bleeding events in acute coronary syndromes. Am Heart J 2017; 186:91-99. [PMID: 28454837 DOI: 10.1016/j.ahj.2017.01.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 01/20/2017] [Indexed: 01/23/2023]
Abstract
Evaluation of antithrombotic treatments for acute coronary syndromes (ACS) requires balancing ischemic and bleeding risks to assess net benefit. We sought to compare the relative effects of ischemic and bleeding events on mortality. METHODS In the PLATelet inhibition and patient Outcomes (PLATO) trial, we compared spontaneous ischemic events (myocardial infarction or stroke) with spontaneous major bleeding events (PLATO major, Thrombolysis In Myocardial Infarction [TIMI] major, Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries [GUSTO] severe) with respect to risk of mortality using time-dependent Cox proportional hazards models. The comparison was performed using ratio of hazard ratios for mortality increase after ischemic vs bleeding events. RESULTS A total of 822 patients (4.4%) had ≥1 spontaneous ischemic event; 485 patients (2.6%), ≥1 spontaneous PLATO major bleed, 282 (1.5%), ≥1 spontaneous TIMI major bleed; and 207 (1.1%), ≥1 spontaneous severe GUSTO bleed. In patients who had both events, bleeding occurred first in most patients. Regardless of classification, major bleeding events were associated with increased short- and long-term mortality that were not significantly different from the increase associated with spontaneous ischemic events: ratio of hazard ratios (95% CIs) for short- and long-term mortality after spontaneous ischemic vs bleeding events: 1.46 (0.98-2.19) and 0.92 (0.52-1.62) (PLATO major); 1.26 (0.80-1.96) and 1.19 (0.58-2.24) (TIMI major), 0.72 (0.47-1.10) and 0.83 (0.38-1.79) (GUSTO severe) (all P>0.05) CONCLUSIONS: In patients with ACS on dual antiplatelet therapy, spontaneous major bleeding events seem "prognostically equivalent" to spontaneous ischemic complications. This result allows quantitative comparisons between both actual and predicted bleeding and ischemic risks. Our findings help to better define net clinical benefit of antithrombotic treatments and more accurately estimate mortality after ischemic and bleeding events in patients with ACS.
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Affiliation(s)
- Gregory Ducrocq
- FACT (French Alliance for Cardiovascular Trials), Paris, France; Assistance Publique-Hôpitaux de Paris, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Paris, France; Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France; INSERM-Unité 1148, Paris, France.
| | - Phillip J Schulte
- Duke Clinical Research Institute, Duke University, Medical Center, Durham, NC; Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Andrzej Budaj
- Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland
| | - Jan H Cornel
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Claes Held
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Steen Husted
- Medical Department, Hospital Unit West, Herning/Holstebro, Denmark
| | - Robert F Storey
- Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
| | - Christopher P Cannon
- Cardiovascular Division, Brigham and Women's Hospital, and Baim Institute for Clinical Research Boston, MA
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Stefan K James
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Hugo A Katus
- Medizinishe Klinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Medical Center, Durham, NC
| | - Emmanuel Sorbets
- FACT (French Alliance for Cardiovascular Trials), Paris, France; Assistance Publique-Hôpitaux de Paris, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Paris, France; INSERM-Unité 1148, Paris, France; Hôpital Avicenne (Assistance Publique-Hôpitaux de Paris), and Université Paris 13, Bobigny, France
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Philippe Gabriel Steg
- FACT (French Alliance for Cardiovascular Trials), Paris, France; Assistance Publique-Hôpitaux de Paris, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Paris, France; Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France; INSERM-Unité 1148, Paris, France; NHLI Imperial College, ICMS, Royal Brompton Hospital, London, UK
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94
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Transradial approach for coronary angiography and intervention in the elderly: A meta-analysis of 777,841 patients. Int J Cardiol 2017; 228:45-51. [DOI: 10.1016/j.ijcard.2016.11.207] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 11/06/2016] [Indexed: 01/11/2023]
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95
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Song JW, Soh S, Shim JK. Dual antiplatelet therapy and non-cardiac surgery: evolving issues and anesthetic implications. Korean J Anesthesiol 2017; 70:13-21. [PMID: 28184261 PMCID: PMC5296381 DOI: 10.4097/kjae.2017.70.1.13] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 12/29/2016] [Accepted: 12/29/2016] [Indexed: 11/10/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) consisting of aspirin plus a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) is imperative for the treatment of acute coronary syndrome, particularly during the re-endothelialization period after percutaneous coronary intervention (PCI). When patients undergo surgery during this period, the consequences of stent thrombosis are far more serious than those of bleeding complications, except in cases of intracranial surgery. The recommendations for perioperative DAPT have changed with emerging evidence regarding the improved efficacy of non-first-generation drug (everolimus, zotarolimus)-eluting stents (DES). The mandatory interval of 1 year for elective surgery after DES implantation was shortened to 6 months (3 months if surgery cannot be further delayed). After this period, it is generally recommended that the P2Y12 inhibitor be stopped for the amount of time necessary for platelet function recovery (clopidogrel 5-7 days, prasugrel 7-10 days, ticagrelor 3-5 days), and that aspirin be continued during the perioperative period. In emergent or urgent surgeries that cannot be delayed beyond the recommended period after PCI, proceeding to surgery with continued DAPT should be considered. For intracranial procedures or other selected surgeries in which increased bleeding risk may also be fatal, cessation of DAPT (possibly with continuation or minimized interruption [3-4 days] of aspirin) with bridge therapy using short-acting, reversible intravenous antiplatelet agents such as cangrelor (P2Y12 inhibitor) or glycoprotein IIb/IIIa inhibitors (tirofiban, eptifibatide) may be contemplated. Such a critical decision should be individually tailored based on consensus among the anesthesiologist, cardiologist, surgeon, and patient to minimize both ischemic and bleeding risks.
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Affiliation(s)
- Jong Wook Song
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sarah Soh
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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96
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De Silva K, Myat A, Cotton J, James S, Gershlick A, Stone GW. Bleeding associated with the management of acute coronary syndromes. Heart 2017; 103:546-562. [PMID: 28087588 DOI: 10.1136/heartjnl-2015-307602] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Kalpa De Silva
- Department of Cardiology, King's College Hospital, London, UK
| | - Aung Myat
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.,Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
| | - James Cotton
- Department of Cardiology, Heart and Lung Centre, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Anthony Gershlick
- Department of Cardiology, University of Leicester, Leicester, UK.,NIHR Leicester Cardiovascular Biomedical Research Centre, Leicester, UK
| | - Gregg W Stone
- Department of Cardiology, Columbia University Medical Center, New York Presbyterian Hospital, New York City, New York, USA
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97
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Jin C, Xu Y, Qiao S, Tang X, Wu Y, Yan H, Dou K, Xu B, Yang J, Xian Y, Yang Y. Comparison of Transradial and Transfemoral Approaches in Women Undergoing Percutaneous Coronary Intervention in China: A Retrospective Observational Study. Angiology 2017; 68:799-806. [PMID: 28056519 DOI: 10.1177/0003319716685670] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite increasing adoption of the transradial approach for percutaneous coronary intervention (PCI) in clinical practice, the role of transradial intervention (TRI) in women remains a significant debate. We identified 1392 women from a consecutive cohort of patients undergoing PCI in China in 2010 and compared the efficacy and hospital costs between TRI and transfemoral intervention. An inverse probability weighting (IPW) method was used to control for potential bias. After IPW adjustment, patients receiving TRI were less likely to experience post-PCI bleeding (adjusted odds ratio [OR]: 0.46, 95% confidence interval [CI]: 0.30-0.71) and major adverse cardiac events (adjusted OR 0.35, 95% CI 0.19-0.63) and more likely to have shorter length of stay in hospital (1.2 days difference, 95% CI: 0.6-1.7). Moreover, TRI was associated with a cost saving of ¥ (Yuan Renminbi) 7474 (approximately US$1150, 95% CI: ¥2993-¥11 624). More than 70% of this saving was driven by lower PCI-related costs. In conclusion, the use of TRI in women was associated with more favorable outcomes and lower hospital costs.
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Affiliation(s)
- Chen Jin
- 1 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Xu
- 1 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shubin Qiao
- 1 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinran Tang
- 1 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongjian Wu
- 1 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongbing Yan
- 1 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kefei Dou
- 1 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- 1 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingang Yang
- 1 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Xian
- 2 Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Yuejin Yang
- 1 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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98
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Supra-plasma expanders: the future of treating blood loss and anemia without red cell transfusions? JOURNAL OF INFUSION NURSING 2016; 38:217-22. [PMID: 25871869 DOI: 10.1097/nan.0000000000000103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Oxygen delivery capacity during profoundly anemic conditions depends on blood's oxygen-carrying capacity and cardiac output. Oxygen-carrying blood substitutes and blood transfusion augment oxygen-carrying capacity, but both have given rise to safety concerns, and their efficacy remains unresolved. Anemia decreases oxygen-carrying capacity and blood viscosity. Present studies show that correcting the decrease of blood viscosity by increasing plasma viscosity with newly developed plasma expanders significantly improves tissue perfusion. These new plasma expanders promote tissue perfusion, increasing oxygen delivery capacity without increasing blood oxygen-carrying capacity, thus treating the effects of anemia while avoiding the transfusion of blood.
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99
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Wang J, Yu W, Jin Q, Li Y, Liu N, Hou X, Yu Y. Risk Factors for Post-TAVI Bleeding According to the VARC-2 Bleeding Definition and Effect of the Bleeding on Short-Term Mortality: A Meta-analysis. Can J Cardiol 2016; 33:525-534. [PMID: 28256429 DOI: 10.1016/j.cjca.2016.12.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 12/05/2016] [Accepted: 12/05/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In this study we investigated the effect of post-transcatheter aortic valve implantation (TAVI) bleeding (per Valve Academic Research Consortium-2 [VARC-2] bleeding criteria) on 30-day postoperative mortality and examined the correlation between pre- or intraoperative variables and bleeding. METHODS Multiple electronic literature databases were searched using predefined criteria, with bleeding defined per Valve Academic Research Consortium-2 criteria. A total of 10 eligible articles with 3602 patients were included in the meta-analysis. RESULTS The meta-analysis revealed that post-TAVI bleeding was associated with a 323% increase in 30-day postoperative mortality (odds risk [OR]; 4.23, 95% confidence interval [CI], 2.80-6.40; P < 0.0001) without significant study heterogeneity or publication bias. In subgroup analysis we found that patients with major bleeding/life-threatening bleeding showed a 410% increase in mortality compared with patients without bleeding (OR, 5.10; 95% CI, 3.17-8.19; P < 0.0001). Transapical access was associated with an 83% increase in the incidence of bleeding compared with transfemoral access (OR, 1.83; 95% CI, 1.43-2.33; P < 0.0001). Multiple logistic regression analysis revealed that atrial fibrillation (AF) was independently correlated with TAVI-associated bleeding (OR, 2.63; 95% CI, 1.33-5.21; P = 0.005). Meta-regression showed that potential modifiers like the Society of Thoracic Surgeons (STS) score, mortality, the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE), aortic valve area, mean pressure gradient, left ventricular ejection fraction, preoperative hemoglobin and platelet levels, and study design had no significant effects on the results of the meta-analysis. CONCLUSIONS Post-TAVI bleeding, in particular, major bleeding/life-threatening bleeding, increased 30-day postoperative mortality. Transapical access was a significant bleeding risk factor. Preexisting AF independently correlated with TAVI-associated bleeding, likely because of AF-related anticoagulation. Recognition of the importance and determinants of post-TAVI bleeding should lead to strategies to improve outcomes.
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Affiliation(s)
- Jiayang Wang
- Department of Cardiac Surgery, Beijing An Zhen Hospital Capital Medical University, Beijing, China; Center for Cardiac Intensive Care, Beijing An Zhen Hospital Capital Medical University, Beijing, China
| | - Wenyuan Yu
- Department of Cardiac Surgery, Beijing An Zhen Hospital Capital Medical University, Beijing, China
| | - Qi Jin
- Center for Cardiac Intensive Care, Beijing An Zhen Hospital Capital Medical University, Beijing, China
| | - Yaqiong Li
- Center for Cardiac Intensive Care, Beijing An Zhen Hospital Capital Medical University, Beijing, China
| | - Nan Liu
- Center for Cardiac Intensive Care, Beijing An Zhen Hospital Capital Medical University, Beijing, China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing An Zhen Hospital Capital Medical University, Beijing, China
| | - Yang Yu
- Department of Cardiac Surgery, Beijing An Zhen Hospital Capital Medical University, Beijing, China.
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100
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Chiang KH, Kao YT, Leu HB, Huang PH, Huang SS, Cheng TM, Pan JP. Higher post-acute myocardial infarction plasma haptoglobin level is associated with poor long-term overall survival. Int J Cardiol 2016; 229:102-107. [PMID: 27913007 DOI: 10.1016/j.ijcard.2016.11.220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/07/2016] [Indexed: 10/20/2022]
Abstract
AIM To evaluate the association of post-acute myocardial infarction (AMI) plasma haptoglobin (Hp) levels with long-term overall survival in AMI patients. METHODS AND RESULTS Patients who were diagnosed of AMI were recruited and their Hp phenotypes and plasma levels were determined. According to previously reported cutoff point for Hp level (288.4ng/ml), patients were classified as higher Hp group (>288.4ng/ml) and lower Hp group (≤288.4ng/ml). The primary outcome was overall survival. This study recruited and followed a total of 117 patients for a median of 11.0 (3.2-17.6) years. Higher Hp group had 46 patients (39.3%) and lower Hp group had 71 patients (60.7%). Twelve patients had Hp 1-1 (10.3%), 50 with Hp 2-1 (42.7%), and 55 with Hp 2-2 (47.0%). The lower Hp group had significantly better overall survival (174.1 [51.6-212.5] vs. 106.5 [22.2-209.1], P=0.037). There was no significant difference in overall survival between the three phenotype groups (P=0.477). Multivariate regression analysis revealed that increased age (adjusted HR=1.06, 95% CI: 1.03-1.10, P<0.001) and higher Hp level (adjusted HR=1.65, 95%=1.02-2.67, P=0.040) were significantly associated with poor overall survival. CONCLUSION Higher post-AMI plasma Hp level was independently associated with poor overall survival in AMI patients. No significant difference in overall survival was noted between three Hp phenotype groups. Acute phase Hp level might reflect the severity of oxidative stress during inflammation process.
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Affiliation(s)
- Kuang-Hsing Chiang
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Yung-Ta Kao
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hsin-Bang Leu
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Healthcare and Service Center, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Po-Hsun Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shao-Sung Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Healthcare and Service Center, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tsai-Mu Cheng
- Institute for Translational Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.
| | - Ju-Pin Pan
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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