51
|
Update to Evidence-Based Secondary Prevention Strategies After Acute Coronary Syndrome. CJC Open 2020; 2:402-415. [PMID: 32995726 PMCID: PMC7499366 DOI: 10.1016/j.cjco.2020.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/03/2020] [Indexed: 02/07/2023] Open
Abstract
A recent acute coronary syndrome provides an opportunity to optimise secondary prevention strategies to reduce the risk of future cardiovascular events. This review provides an updated synopsis of current evidence-based approaches. New clinical trial data on the use of antiplatelet and anticoagulants allow choices of the selection and duration of treatment. Lipid lowering after an acute coronary syndrome is now enhanced, with proprotein convertase subtilisin-kexin type 9 inhibitors providing added benefit on top of statin and ezetimibe treatment in high-risk patients. In addition, a recent trial of icosapent ethyl, a highly purified ethyl ester of eicosapentaenoic acid, addresses residual risk in patients with elevated triglycerides already treated with statins. The use of both sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide-1 receptor agonists in patients with type 2 diabetes reduces cardiovascular events independently of glucose lowering.
Collapse
|
52
|
Extended antithrombotic therapy in secondary prevention: “There is no such thing as a free lunch”. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2020.11.022] [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
|
53
|
Costa M. Extended antithrombotic therapy in secondary prevention: "There is no such thing as a free lunch". Rev Port Cardiol 2020; 39:503-504. [PMID: 32847712 DOI: 10.1016/j.repc.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Marco Costa
- Cardiovascular Intervention Unit, Cardiology Department, Centro Hospitalar e Universitário de Coimbra, Portugal.
| |
Collapse
|
54
|
Calderone D, Capodanno D, Angiolillo DJ. An updated drug profile of ticagrelor with considerations on the treatment of patients with coronary artery disease and diabetes mellitus. Expert Rev Cardiovasc Ther 2020; 18:449-464. [PMID: 32662726 DOI: 10.1080/14779072.2020.1792293] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Ticagrelor is an antiplatelet agent acting through direct and reversible competitive inhibition of the platelet P2Y12 receptor. While the clinical merits of ticagrelor in patients who experienced an acute coronary syndrome are widely accepted, its role in stable coronary artery disease is less established. Recently, large-scale trials of ticagrelor have been published in this setting, including a trial in patients with diabetes mellitus (DM). AREAS COVERED This review aims to inform about recent findings on ticagrelor, by appraising the current body of evidence on its use in different clinical scenarios, particularly in DM, ranging from pharmacology to clinical outcomes and future directions. EXPERT OPINION The results of the THEMIS trial, conducted in DM patients with stable coronary artery disease and no prior stroke or myocardial infarction, showed that although ticagrelor in addition to aspirin reduced the risk of ischemic events, this was associated with a parallel increase in bleeding complications. However, patients with history of percutaneous coronary intervention seemed to benefit more from adjunctive ticagrelor therapy. Careful bleeding and ischemic risk stratification remains crucial to define the best antithrombotic strategy for the individual patient.
Collapse
Affiliation(s)
- Dario Calderone
- Division of Cardiology, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine , Jacksonville, FL, USA
| |
Collapse
|
55
|
Low-Dose Ticagrelor in Patients With High Ischemic Risk and Previous Myocardial Infarction: A Multicenter Prospective Real-World Observational Study. J Cardiovasc Pharmacol 2020; 76:173-180. [DOI: 10.1097/fjc.0000000000000856] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
56
|
Siasos G, Skotsimara G, Oikonomou E, Sagris M, Vasiliki-Chara M, Bletsa E, Stampouloglou P, Theofilis P, Charalampous G, Tousoulis D. Antithrombotic Treatment in Diabetes Mellitus: A Review of the Literature about Antiplatelet and Anticoagulation Strategies Used for Diabetic Patients in Primary and Secondary Prevention. Curr Pharm Des 2020; 26:2780-2788. [PMID: 32303164 DOI: 10.2174/1381612826666200417145605] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/10/2020] [Indexed: 02/06/2023]
Abstract
Background:
Diabetes mellitus (DM) is on the rise globally. Its prevalence has nearly doubled
during the last two decades and it is estimated to affect 8.8% of the global population.
Cardiovascular disease (CVD) is the leading cause of death in diabetic population and despite
modern anti-inflammatory and cardioprotective therapeutic strategies diabetic patients have at
least a twice fold risk of cardiovascular events. Prothrombotic state in DM is associated with
multiple determinants such as platelet alterations, oxidative stress, endothelial changes,
circulating mediators. Thus, proper antithrombotic strategies to reduce the risk of CVD in this
population is critical.
Methods:
This article reviews the current antiplatelet and anticoagulant
agents in the aspect of primary and secondary prevention of CVD in the diabetic population.
Results:
The use of aspirin may be considered only at high-risk patients in the absence of
contraindications. Cangrelor was not inferior to clopidogrel in preventing the composite outcome
of CV death, myocardial infraction and revascularization without increasing major bleeding.
Triple therapy in the subpopulation with DM significantly reduced the composite primary
outcome of CV death, myocardial infraction or repeat target lesion revascularization. That was
not the case for stent thrombosis, which was similar in both groups. Importantly, triple therapy
did not result in increased bleeding complications, which were similar in both groups. However,
cilostazol is linked to various adverse effects (e.g., headache, palpitations, and gastrointestinal
disturbances) that drive many patients to withdrawal.
Conclusion:
In conclusion, DM is a
rapidly growing disease that increases the risk of CVD, AF, and CV mortality. Proper
antithrombotic strategies to reduce CVD risk in DM is a necessity. Also, new antithrombotic
treatments and combination therapies may play a critical role to overcome antiplatelet resistance
in DM patients and reduce morbidity and mortality attributed to CVD.
Collapse
Affiliation(s)
- Gerasimos Siasos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, 114 Vas. Sofias avenue, 11527, Athens, Greece
| | - Georgia Skotsimara
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, 114 Vas. Sofias avenue, 11527, Athens, Greece
| | - Evangelos Oikonomou
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, 114 Vas. Sofias avenue, 11527, Athens, Greece
| | - Marios Sagris
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, 114 Vas. Sofias avenue, 11527, Athens, Greece
| | - Mystakidi Vasiliki-Chara
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, 114 Vas. Sofias avenue, 11527, Athens, Greece
| | - Evanthia Bletsa
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, 114 Vas. Sofias avenue, 11527, Athens, Greece
| | - Panagiota Stampouloglou
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, 114 Vas. Sofias avenue, 11527, Athens, Greece
| | - Panagiotis Theofilis
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, 114 Vas. Sofias avenue, 11527, Athens, Greece
| | - Georgios Charalampous
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, 114 Vas. Sofias avenue, 11527, Athens, Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, 114 Vas. Sofias avenue, 11527, Athens, Greece
| |
Collapse
|
57
|
Wittbrodt E, Bhalla N, Andersson Sundell K, Gao Q, Dong L, Cavender MA, Hunt P, Wong ND, Mellström C. Assessment of the high risk and unmet need in patients with CAD and type 2 diabetes (ATHENA): US healthcare resource utilization, cost and burden of illness in the Diabetes Collaborative Registry. Endocrinol Diabetes Metab 2020; 3:e00133. [PMID: 32704557 PMCID: PMC7375123 DOI: 10.1002/edm2.133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 03/13/2020] [Accepted: 03/14/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND THEMIS (NCT01991795) showed that in patients with type 2 diabetes (T2D) and stable coronary artery disease (CAD) but with no prior myocardial infarction (MI) or stroke, ticagrelor plus acetylsalicylic acid (ASA) decreased the incidence of ischaemic cardiovascular events compared with placebo plus ASA. To complement these findings, we assessed disease burden and healthcare resource utilization (HRU) in US patients with CAD and T2D, but without a prior MI or stroke. METHODS This observational study used 2013-2014 data from the Diabetes Collaborative Registry linked to Medicare administrative claims. Two cohorts of patients with T2D were studied: patients at high cardiovascular risk (THEMIS-like cohort; N = 56 040) and patients at high cardiovascular risk or taking P2Y12 inhibitors (CAD-T2D cohort; N = 69 790). Outcomes included the composite of all-cause death, MI and stroke; the individual events from the composite endpoint; HRU; and costs. RESULTS Median age was 73.0 years, and median follow-up was 1.3 years in both cohorts. Event rates of the composite outcome were 16.34 (95% confidence interval: 16.31-16.37) and 17.64 (17.61-17.67) per 100 person-years for the THEMIS-like and CAD-T2D cohorts, respectively. The incidence rate of bleeding events was 0.13 events per 100 person-years in both cohorts. Healthcare costs per patient-year were USD 8741 and USD 9150 in the THEMIS-like and CAD-T2D cohorts, respectively. CONCLUSIONS Patients in the THEMIS-like cohort and the broader CAD-T2D population had similarly substantial cardiovascular event rates and healthcare costs, indicating that patients with CAD and T2D similar to the THEMIS population are at an increased cardiovascular risk.
Collapse
Affiliation(s)
| | | | | | - Qi Gao
- Baim Institute for Clinical ResearchBostonMAUSA
| | - Liyan Dong
- Baim Institute for Clinical ResearchBostonMAUSA
| | | | | | | | | |
Collapse
|
58
|
Dedov II, Shestakova MV, Mayorov AY, Shamkhalova MS, Sukhareva OY, Galstyan GR, Tokmakova AY, Nikonova TV, Surkova EV, Kononenko IV, Egorova DN, Ibragimova LI, Shestakova EA, Klefortova II, Sklyanik IA, Yarek-Martynova IY, Severina AS, Martynov SA, Vikulova OK, Kalashnikov VY, Bondarenko IZ, Gomova IS, Starostina EG, Ametov AS, Antsiferov MB, Bardymova TP, Bondar IA, Valeeva FV, Demidova TY, Mkrtumyan AM, Petunina NA, Ruyatkina LA, Suplotova LA, Ushakova OV, Khalimov YS. Diabetes mellitus type 2 in adults. DIABETES MELLITUS 2020. [DOI: 10.14341/dm12507] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Tatiana P. Bardymova
- Irkutsk State Medical Academy of Postgraduate Education – Branch Campus of the Russian Medical Academy of Continuing Professional Education
| | | | | | | | - Ashot M. Mkrtumyan
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov
| | - Nina A. Petunina
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | | | | | | | | |
Collapse
|
59
|
Ticagrelor Versus Clopidogrel in Patients with Late or Very Late Stent Thrombosis. Cardiovasc Drugs Ther 2020; 34:677-684. [DOI: 10.1007/s10557-020-07021-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2020] [Indexed: 11/26/2022]
|
60
|
De Luca G, Verdoia M, Savonitto S, Piatti L, Grosseto D, Morici N, Bossi I, Sganzerla P, Tortorella G, Cacucci M, Murena E, Toso A, Bongioanni S, Ravera A, Corrada E, Mariani M, Di Ascenzo L, Petronio AS, Cavallini C, Vitrella G, Antonicelli R, Rogacka R, De Servi S. Impact of diabetes on clinical outcome among elderly patients with acute coronary syndrome treated with percutaneous coronary intervention: insights from the ELDERLY ACS 2 trial. J Cardiovasc Med (Hagerstown) 2020; 21:453-459. [PMID: 32355067 DOI: 10.2459/jcm.0000000000000978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite recent improvements in percutaneous coronary revascularization and antithrombotic therapies for the treatment of acute coronary syndromes, the outcome is still unsatisfactory in high-risk patients, such as the elderly and patients with diabetes. The aim of the current study was to investigate the prognostic impact of diabetes on clinical outcome among patients included in the Elderly-ACS 2 trial, a randomized, open-label, blinded endpoint study carried out at 32 centers in Italy. METHODS Our population is represented by 1443 patients included in the Elderly-ACS 2 trial. Diabetes was defined as known history of diabetes at admission. The primary endpoint of this analysis was cardiovascular mortality, while secondary endpoints were all-cause death, recurrent myocardial infarction, Bleeding Academic Research Consortium type 2 or 3 bleeding, and rehospitalization for cardiovascular event or stent thrombosis within 12 months after index admission. RESULTS Diabetes was present in 419 (29%) out of 1443 patients. Diabetic status was significantly associated with major cardiovascular risk factors and history of previous coronary disease, presentation with non-ST segment elevation myocardial infarction (P = 0.01) more extensive coronary disease (P = 0.02), more advanced Killip class at presentation (P = 0.003), use at admission of statins (P = 0.004) and diuretics at discharge (P < 0.001). Median follow-up was 367 days (interquartile range: 337-378 days). Diabetic status was associated with an absolute increase in the rate of cardiovascular mortality as compared with patients without diabetes [5.5 vs. 3.3%, hazard ratio (HR) 1.7 (0.99-2.8), P = 0.054], particularly among those treated with clopidogrel [HR (95% confidence interval (CI)) = 1.89 (0.93-3.87), P = 0.08]. However, this difference disappeared after correction for baseline differences [Adjusted HR (95% CI) 1.1(0.4-2.9), P = 0.86]. Similar findings were observed for other secondary endpoints, except for bleeding complications, significantly more frequent in diabetic patients [HR (95% CI) 2.02 (1.14-3.6), P = 0.02; adjusted HR (95% CI) = 2.1 (1.01-4.3), P = 0.05]. No significant interaction was observed between type of dual antiplatelet therapy, diabetic status and outcome. CONCLUSION Among elderly patients with acute coronary syndromes, diabetic status was associated with higher rates of comorbidities, more severe cardiovascular risk profile and major bleeding complications fully accounting for the absolute increase in mortality. In fact, diabetes mellitus did not emerge as an independent predictor of survival in advanced age.
Collapse
Affiliation(s)
- Giuseppe De Luca
- Azienda Ospedaliera-Universitaria 'Maggiore della Carità', Eastern Piedmont University, Novara
| | - Monica Verdoia
- Azienda Ospedaliera-Universitaria 'Maggiore della Carità', Eastern Piedmont University, Novara
| | | | | | | | | | - Irene Bossi
- ASST Grande Ospedale Metropolitano Niguarda, Milano
| | | | | | | | | | | | | | | | - Elena Corrada
- Humanitas Clinical and Research Center, Rozzano, Italy
| | | | | | | | | | | | | | - Renata Rogacka
- Statistics and Biomathematics Unit, Department of Molecular and Transactional Medicine, University of Brescia, Brescia
| | | |
Collapse
|
61
|
Guía ESC 2019 sobre diabetes, prediabetes y enfermedad cardiovascular, en colaboración con la European Association for the Study of Diabetes (EASD). Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.11.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
62
|
Ticagrelor With or Without Aspirin in High-Risk Patients With Diabetes Mellitus Undergoing Percutaneous Coronary Intervention. J Am Coll Cardiol 2020; 75:2403-2413. [DOI: 10.1016/j.jacc.2020.03.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 02/28/2020] [Accepted: 03/09/2020] [Indexed: 11/21/2022]
|
63
|
Liang LR, Ma Q, Feng L, Qiu Q, Zheng W, Xie WX. Long-term effect of clopidogrel in patients with and without diabetes: A systematic review and meta-analysis of randomized controlled trials. World J Diabetes 2020; 11:137-149. [PMID: 32313612 PMCID: PMC7156296 DOI: 10.4239/wjd.v11.i4.137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/19/2020] [Accepted: 02/18/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous studies have shown that patients with diabetes mellitus (DM) respond poorly to clopidogrel treatment.
AIM To systematically evaluate the efficacy of clopidogrel for the treatment of acute coronary syndromes or ischemic stroke in patients with or without DM.
METHODS PubMed, the Cochrane Central Register of Controlled Trials, and EMBASE were searched from 1980 on 27 June 2019 to identify relevant randomized controlled trials that compared the effect of a combination of clopidogrel and aspirin with aspirin alone. A random-effects meta-analysis was used to estimate the hazard ratio (HR) and its 95% confidence interval (CI). Sensitivity analysis was performed using a fixed-effect model. The I2 statistic was used to evaluate the heterogeneity of the study data.
RESULTS Six randomized controlled trials, comprising 43352 participants (13491 with and 29861 without DM) who had received antiplatelet therapy for ≥ 3 mo, were included in the meta-analysis. Compared with aspirin alone, a combination of clopidogrel and aspirin significantly reduced the risk of any cardiovascular event in patients without DM (HR = 0.78, 95%CI: 0.71–0.86, P < 0.001; I2 = 23%, P = 0.26). Clopidogrel plus aspirin also significantly reduced cardiovascular risk in patients with DM, although the effect was smaller (HR = 0.89, 95%CI: 0.81–0.99, P = 0.030; I2 = 0%, P = 0.74). Nevertheless, there was no significant difference in the efficacy of clopidogrel at reducing the risk of cardiovascular events in patients with DM vs those without (P for interaction = 0.062).
CONCLUSION Thus, the present study shows that the addition of clopidogrel to aspirin significantly lowers cardiovascular risk in patients with or without DM who have experienced ischemic cardiovascular disease. The beneficial effect of the addition of clopidogrel to aspirin for patients with DM was lower than that in patients without DM, although the modifying effect of DM did not reach significance.
Collapse
Affiliation(s)
- Li-Rong Liang
- Department of Clinical Epidemiology & Tobacco Dependence Treatment Research, Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Qian Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Lin Feng
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing 100034, China
| | - Qi Qiu
- Institute of Clinical Pharmacology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Wen Zheng
- Emergency Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Wu-Xiang Xie
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing 100034, China
| |
Collapse
|
64
|
Arnold SV, Bhatt DL, Barsness GW, Beatty AL, Deedwania PC, Inzucchi SE, Kosiborod M, Leiter LA, Lipska KJ, Newman JD, Welty FK. Clinical Management of Stable Coronary Artery Disease in Patients With Type 2 Diabetes Mellitus: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e779-e806. [PMID: 32279539 DOI: 10.1161/cir.0000000000000766] [Citation(s) in RCA: 132] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Although cardiologists have long treated patients with coronary artery disease (CAD) and concomitant type 2 diabetes mellitus (T2DM), T2DM has traditionally been considered just a comorbidity that affected the development and progression of the disease. Over the past decade, a number of factors have shifted that have forced the cardiology community to reconsider the role of T2DM in CAD. First, in addition to being associated with increased cardiovascular risk, T2DM has the potential to affect a number of treatment choices for CAD. In this document, we discuss the role that T2DM has in the selection of testing for CAD, in medical management (both secondary prevention strategies and treatment of stable angina), and in the selection of revascularization strategy. Second, although glycemic control has been recommended as a part of comprehensive risk factor management in patients with CAD, there is mounting evidence that the mechanism by which glucose is managed can have a substantial impact on cardiovascular outcomes. In this document, we discuss the role of glycemic management (both in intensity of control and choice of medications) in cardiovascular outcomes. It is becoming clear that the cardiologist needs both to consider T2DM in cardiovascular treatment decisions and potentially to help guide the selection of glucose-lowering medications. Our statement provides a comprehensive summary of effective, patient-centered management of CAD in patients with T2DM, with emphasis on the emerging evidence. Given the increasing prevalence of T2DM and the accumulating evidence of the need to consider T2DM in treatment decisions, this knowledge will become ever more important to optimize our patients' cardiovascular outcomes.
Collapse
|
65
|
Gimeno Orna JA, Ortez Toro JJ, Peteiro Miranda CM. Evaluation and management of residual cardiovascular risk in patients with diabetes. ENDOCRINOL DIAB NUTR 2020; 67:279-288. [PMID: 31351814 DOI: 10.1016/j.endinu.2019.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/01/2019] [Accepted: 05/21/2019] [Indexed: 12/22/2022]
Abstract
Presence of diabetes (types 1 and 2) increases the risk of atherosclerotic cardiovascular disease. Despite adequate metabolic control and treatment of vascular risk factors until the goals recommended by the clinical practice guidelines are achieved, residual cardiovascular risk may be very high in some patients with diabetes. Stratifying the vascular risk for each patient as precisely as possible is therefore necessary. Consolidated strategies to improve patient prognosis include aggressive reduction of LDL cholesterol, blood pressure control, achievement of the best HbA1c control possible without inducing hypoglycemia, use of hypoglycemic drugs shown to have cardiovascular benefits, and use of platelet aggregation inhibitors in patients with greater initial risk. Emerging strategies for patients with very high or extreme risk would include use of drugs intended to decrease triglyceride-rich lipoproteins and inflammation.
Collapse
Affiliation(s)
- José Antonio Gimeno Orna
- Instituto de Investigación Sanitaria de Aragón, Zaragoza, España; Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España.
| | - José Jorge Ortez Toro
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | | |
Collapse
|
66
|
Bhatt DL, Eikelboom JW, Connolly SJ, Steg PG, Anand SS, Verma S, Branch KRH, Probstfield J, Bosch J, Shestakovska O, Szarek M, Maggioni AP, Widimský P, Avezum A, Diaz R, Lewis BS, Berkowitz SD, Fox KAA, Ryden L, Yusuf S. Role of Combination Antiplatelet and Anticoagulation Therapy in Diabetes Mellitus and Cardiovascular Disease: Insights From the COMPASS Trial. Circulation 2020; 141:1841-1854. [PMID: 32223318 PMCID: PMC7314494 DOI: 10.1161/circulationaha.120.046448] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Patients with established coronary artery disease or peripheral artery disease often have diabetes mellitus. These patients are at high risk of future vascular events. Methods: In a prespecified analysis of the COMPASS trial (Cardiovascular Outcomes for People Using Anticoagulation Strategies), we compared the effects of rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg daily) versus placebo plus aspirin in patients with diabetes mellitus versus without diabetes mellitus in preventing major vascular events. The primary efficacy end point was the composite of cardiovascular death, myocardial infarction, or stroke. Secondary end points included all-cause mortality and all major vascular events (cardiovascular death, myocardial infarction, stroke, or major adverse limb events, including amputation). The primary safety end point was a modification of the International Society on Thrombosis and Haemostasis criteria for major bleeding. Results: There were 10 341 patients with diabetes mellitus and 17 054 without diabetes mellitus in the overall trial. A consistent and similar relative risk reduction was seen for benefit of rivaroxaban plus aspirin (n=9152) versus placebo plus aspirin (n=9126) in patients both with (n=6922) and without (n=11 356) diabetes mellitus for the primary efficacy end point (hazard ratio, 0.74, P=0.002; and hazard ratio, 0.77, P=0.005, respectively, Pinteraction=0.77) and all-cause mortality (hazard ratio, 0.81, P=0.05; and hazard ratio, 0.84, P=0.09, respectively; Pinteraction=0.82). However, although the absolute risk reductions appeared numerically larger in patients with versus without diabetes mellitus, both subgroups derived similar benefit (2.3% versus 1.4% for the primary efficacy end point at 3 years, Gail-Simon qualitative Pinteraction<0.0001; 1.9% versus 0.6% for all-cause mortality, Pinteraction=0.02; 2.7% versus 1.7% for major vascular events, Pinteraction<0.0001). Because the bleeding hazards were similar among patients with and without diabetes mellitus, the prespecified net benefit for rivaroxaban appeared particularly favorable in the patients with diabetes mellitus (2.7% versus 1.0%; Gail-Simon qualitative Pinteraction=0.001). Conclusions: In stable atherosclerosis, the combination of aspirin plus rivaroxaban 2.5 mg twice daily provided a similar relative degree of benefit on coronary, cerebrovascular, and peripheral end points in patients with and without diabetes mellitus. Given their higher baseline risk, the absolute benefits appeared larger in those with diabetes mellitus, including a 3-fold greater reduction in all-cause mortality. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01776424.
Collapse
Affiliation(s)
- Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School Boston, MA (D.L.B.)
| | - John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (J.W.E., S.J.C., S.S.A., J.B., O.S., S.Y.)
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (J.W.E., S.J.C., S.S.A., J.B., O.S., S.Y.)
| | - P Gabriel Steg
- Université de Paris and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (P.G.S.)
| | - Sonia S Anand
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (J.W.E., S.J.C., S.S.A., J.B., O.S., S.Y.)
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Ontario, Canada (S.V.)
| | | | | | - Jackie Bosch
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (J.W.E., S.J.C., S.S.A., J.B., O.S., S.Y.).,School of Rehabilitation Science, Mc-Master University, Hamilton, Ontario, Canada (J.B.)
| | - Olga Shestakovska
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (J.W.E., S.J.C., S.S.A., J.B., O.S., S.Y.)
| | - Michael Szarek
- State University of New York, Downstate School of Public Health, Brooklyn (M.S.)
| | | | - Petr Widimský
- Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Alvaro Avezum
- Hospital Alemão Oswaldo Cruz, São Paulo, Brazil (A.A.)
| | - Rafael Diaz
- Estudios Clínicos Latino América, Rosario, Argentina (R.D.).,Instituto Cardiovascular de Rosario, Argentina (R.D.)
| | - Basil S Lewis
- Lady Davis Carmel Medical Centre and the Technion-Israel Institute of Technology, Haifa (B.S.L.)
| | | | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.)
| | - Lars Ryden
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (L.R.)
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (J.W.E., S.J.C., S.S.A., J.B., O.S., S.Y.)
| | | |
Collapse
|
67
|
Koziolova NA, Karavaev PG, Veklich AS. [Choosing Antithrombotic Therapy in Patients with Coronary Heart Disease and Type 2 Diabetes Mellitus: How to Reduce the Risk of Death]. KARDIOLOGIIA 2020; 60:109-119. [PMID: 32394865 DOI: 10.18087/cardio.2020.4.n1042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/18/2020] [Indexed: 06/11/2023]
Abstract
This review presents prevalence of type 2 diabetes mellitus (DM) in patients with ischemic heart disease (IHD), risk factors in common, and a considerable worsening of prognosis in their combination. The authors addressed pathophysiological mechanisms of platelet dysfunction and negative changes in the coagulation system in IHD patients with type 2 DM, which predetermine activation of the prothrombotic pathway of hemostasis formation. Difficulties in optimal selection of antithrombotic therapy were demonstrated for both patients with type 2 DM without a history of cardiovascular diseases and IHD patients with type 2 DM. The authors paid attention to the fact that results of randomized clinical studies (RCS) that included patients with type 2 DM and acute coronary syndrome or after coronary revascularization cannot be extrapolated to the entire population of patients with stable IHD. At present, the preferable choice of antithrombotic therapy for patients with type 2 DM and stable IHD is a combination of rivaroxaban 2.5 mg twice a day and acetylsalicylic acid 100 mg/day. This combination provides a maximal clinical benefit compared to other strategies presented in RCS.
Collapse
Affiliation(s)
- N A Koziolova
- State funded educational institution of the highest education "E.A. Wagner Perm State Medical University" Public Health Ministry of Russian Federation, Perm, Russia
| | - P G Karavaev
- State funded educational institution of the highest education "E.A. Wagner Perm State Medical University" Public Health Ministry of Russian Federation, Perm, Russia
| | - A S Veklich
- State funded educational institution of the highest education "E.A. Wagner Perm State Medical University" Public Health Ministry of Russian Federation, Perm, Russia
| |
Collapse
|
68
|
Chandrasekhar J, Dangas G, Baber U, Sartori S, Qadeer A, Aquino M, Vogel B, Faggioni M, Vijay P, Claessen BE, Goel R, Moreno P, Krishnan P, Kovacic JC, Kini A, Mehran R, Sharma S. Impact of insulin treated and non‐insulin‐treated diabetes compared to patients without diabetes on 1‐year outcomes following contemporary PCI. Catheter Cardiovasc Interv 2020; 96:298-308. [DOI: 10.1002/ccd.28841] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 02/11/2020] [Accepted: 02/25/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Jaya Chandrasekhar
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - George Dangas
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - Usman Baber
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - Samantha Sartori
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - Abdul Qadeer
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - Melissa Aquino
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - Birgit Vogel
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - Michela Faggioni
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - Pooja Vijay
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - Bimmer E. Claessen
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - Ridhima Goel
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - Pedro Moreno
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - Prakash Krishnan
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - Jason C. Kovacic
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - Annapoorna Kini
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - Roxana Mehran
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| | - Samin Sharma
- Department of Cardiology, Icahn School of Medicine at Mount Sinai New York New York USA
| |
Collapse
|
69
|
Ruiz-Nodar JM, Esteve-Pastor MA, Rivera-Caravaca JM, Sandín M, Lozano T, Vicente-Ibarra N, Orenes-Piñero E, Macías MJ, Pernías V, Carrillo L, Candela E, Veliz A, Tello-Montoliu A, Martínez Martínez JG, Marín F. One-year efficacy and safety of prasugrel and ticagrelor in patients with acute coronary syndromes: Results from a prospective and multicentre ACHILLES registry. Br J Clin Pharmacol 2020; 86:1052-1061. [PMID: 31912949 DOI: 10.1111/bcp.14213] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/08/2019] [Accepted: 11/04/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Prasugrel and ticagrelor have demonstrated higher efficacy than clopidogrel in their main clinical trials for patients with acute coronary syndrome (ACS). However, the long-term prognosis and different clinical characteristics related to the type of antiplatelet prescription in current clinical practice ACS patients have not been analysed in depth. The objective of this study was to analyse the clinical profile of ACS and the efficacy and safety of novel oral P2Y12 inhibitors in current clinical practice patients discharged afterACS. METHODS We collected data from the ACHILLES registry, and an observational, prospective and multicentre registry of patients discharged after ACS. We analysed baseline characteristics, clinical profile and therapy during ACS admission and compared with the different treatments at discharge. After 1 year of follow-up, ischaemic and major bleeding events were analysed. Multivariate Cox regression analysis and Kaplan Meier curves were also plotted. RESULTS Of 1717 consecutive patients, 1294 (75.4%) were discharged with a P2Y12 inhibitor without oral anticoagulation. Novel oral P2Y12 inhibitors were indicated in 47%. Patients treated with clopidogrel were elderly (69.1 ± 13.4 vs 60.4 ± 11.5 years; P < .001) and had a higher prevalence of cardiovascular risk factors. GRACE and CRUSADE scores were higher in the clopidogrel than in novel oral P2Y12 inhibitors group (P < .001). After 1 year of follow-up, 64(5.0%/year) patients had a new myocardial infarction, 127(10.0%/year) had a major adverse cardiovascular event (MACE) and 78(6.1%/year) died. Patients treated with clopidogrel had a significantly higher annual rate of cardiovascular mortality, MACE and all-cause mortality (allP < .001) without differences in major bleeding (P = .587) compared with novel oral P2Y12 inhibitors. After multivariate adjustment for the main clinical variables related to adverse prognosis in ACS patients, the discharge with novel oral P2Y12 inhibitors therapy was independently associated with lower risk of all-cause mortality (HR0.49, 95% CI [0.24-0.98], P = .044) and lower risk of MACE (HR0.64, 95% CI [0.41-0.98], P = .044). CONCLUSIONS In this prospective, observational and current clinical practice ACS registry, the use of novel oral P2Y12 inhibitors was associated with a reduction in adverse events compared with clopidogrel in patients with ACS. Novel oral P2Y12 inhibitors prescription at discharge was independently associated with lower all-cause mortality and MACE without differences in bleeding events. However, clopidogrel remained the most common P2Y12 inhibitor employed for ACS, especially in older and high-risk patients.
Collapse
Affiliation(s)
- Juan Miguel Ruiz-Nodar
- Department of Cardiology. Hospital General Universitario de Alicante. Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante,, Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria, CIBER-CV, Murcia, Spain
| | - Jose Miguel Rivera-Caravaca
- Department of Cardiology. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria, CIBER-CV, Murcia, Spain
| | - Miriam Sandín
- Department of Cardiology. Hospital General Universitario de Alicante. Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante,, Spain
| | - Teresa Lozano
- Department of Cardiology. Hospital General Universitario de Alicante. Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante,, Spain
| | - Nuria Vicente-Ibarra
- Department of Cardiology, Hospital General Universitario de Elche, Alicante, Spain
| | - Esteban Orenes-Piñero
- Department of Cardiology. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria, CIBER-CV, Murcia, Spain
| | - Manuel Jesús Macías
- Department of Cardiology. Hospital General Universitario de Alicante. Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante,, Spain
| | - Vicente Pernías
- Department of Cardiology, Hospital General Universitario de Elche, Alicante, Spain
| | - Luna Carrillo
- Department of Cardiology. Hospital General Universitario de Alicante. Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante,, Spain
| | - Elena Candela
- Department of Cardiology. Hospital General Universitario de Alicante. Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante,, Spain
| | - Andrea Veliz
- Department of Cardiology. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria, CIBER-CV, Murcia, Spain
| | - Antonio Tello-Montoliu
- Department of Cardiology. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria, CIBER-CV, Murcia, Spain
| | - Juan Gabriel Martínez Martínez
- Department of Cardiology. Hospital General Universitario de Alicante. Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante,, Spain
| | - Francisco Marín
- Department of Cardiology. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria, CIBER-CV, Murcia, Spain
| |
Collapse
|
70
|
Abstract
Aspirin and P2Y12 inhibitors remain commonly prescribed antiplatelet drugs in the treatment of atherothrombotic conditions. Despite established benefits of dual antiplatelet therapy (DAPT) in the setting of acute coronary syndromes, there remains residual ischemic risk in this group and the problem of bleeding complications is an ongoing issue. DAPT with aspirin and ticagrelor has now been studied in other patient groups such as those with concurrent diabetes and stable coronary artery disease, and those undergoing elective percutaneous coronary intervention (PCI). Recent trials of ticagrelor monotherapy have suggested this may have benefits over standard-of-care in some settings, such as PCI, but not in others such as peripheral arterial disease or stroke. A novel subcutaneously administered P2Y12 inhibitor, selatogrel, has shown powerful, rapid and consistent effect in a phase 2 study. Aspirin dosing remains an area of investigation, particularly in the setting of DAPT. A novel regimen of very-low-dose twice-daily aspirin has hypothetical advantages in pharmacodynamic and pharmacokinetic effects, maintaining antiplatelet effect whilst reducing potentially harmful peak-trough variation.
Collapse
Affiliation(s)
- William A E Parker
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield , Sheffield, UK.,South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield, UK
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield , Sheffield, UK.,South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield, UK
| |
Collapse
|
71
|
Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, Prescott E, Storey RF, Deaton C, Cuisset T, Agewall S, Dickstein K, Edvardsen T, Escaned J, Gersh BJ, Svitil P, Gilard M, Hasdai D, Hatala R, Mahfoud F, Masip J, Muneretto C, Valgimigli M, Achenbach S, Bax JJ. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41:407-477. [PMID: 31504439 DOI: 10.1093/eurheartj/ehz425] [Citation(s) in RCA: 3671] [Impact Index Per Article: 917.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
72
|
Abstract
Antiplatelet therapies are an essential tool to reduce the risk of developing clinically apparent atherothrombotic disease and are a mainstay in the therapy of patients who have established cardiovascular, cerebrovascular, and peripheral artery disease. Strategies to intensify antiplatelet regimens are limited by concomitant increases in clinically significant bleeding. The development of novel antiplatelet therapies targeting additional receptor and signaling pathways, with a focus on maintaining antiplatelet efficacy while preserving hemostasis, holds tremendous potential to improve outcomes among patients with atherothrombotic diseases.
Collapse
Affiliation(s)
- Arjun Majithia
- From the Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA
| | - Deepak L Bhatt
- From the Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA
| |
Collapse
|
73
|
Patti G, Cavallari I, Andreotti F, Calabrò P, Cirillo P, Denas G, Galli M, Golia E, Maddaloni E, Marcucci R, Parato VM, Pengo V, Prisco D, Ricottini E, Renda G, Santilli F, Simeone P, De Caterina R. Prevention of atherothrombotic events in patients with diabetes mellitus: from antithrombotic therapies to new-generation glucose-lowering drugs. Nat Rev Cardiol 2020; 16:113-130. [PMID: 30250166 PMCID: PMC7136162 DOI: 10.1038/s41569-018-0080-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Diabetes mellitus is an important risk factor for a first cardiovascular event and for worse outcomes after a cardiovascular event has occurred. This situation might be caused, at least in part, by the prothrombotic status observed in patients with diabetes. Therefore, contemporary antithrombotic strategies, including more potent agents or drug combinations, might provide greater clinical benefit in patients with diabetes than in those without diabetes. In this Consensus Statement, our Working Group explores the mechanisms of platelet and coagulation activity, the current debate on antiplatelet therapy in primary cardiovascular disease prevention, and the benefit of various antithrombotic approaches in secondary prevention of cardiovascular disease in patients with diabetes. While acknowledging that current data are often derived from underpowered, observational studies or subgroup analyses of larger trials, we propose antithrombotic strategies for patients with diabetes in various cardiovascular settings (primary prevention, stable coronary artery disease, acute coronary syndromes, ischaemic stroke and transient ischaemic attack, peripheral artery disease, atrial fibrillation, and venous thromboembolism). Finally, we summarize the improvements in cardiovascular outcomes observed with the latest glucose-lowering drugs, and on the basis of the available evidence, we expand and integrate current guideline recommendations on antithrombotic strategies in patients with diabetes for both primary and secondary prevention of cardiovascular disease. Patients with diabetes mellitus have a prothrombotic status that increases the risk of cardiovascular events and worsens prognosis after these events. In this Consensus Statement, the Working Group on Thrombosis of the Italian Society of Cardiology proposes antithrombotic strategies for patients with diabetes in various cardiovascular settings.
Collapse
Affiliation(s)
- Giuseppe Patti
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Ilaria Cavallari
- Unit of Cardiovascular Science, Campus Bio-Medico University, Rome, Italy
| | - Felicita Andreotti
- Cardiovascular and Thoracic Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Paolo Calabrò
- Department of Cardio-thoracic and Respiratory Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Gentian Denas
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Mattia Galli
- Cardiovascular and Thoracic Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Enrica Golia
- Department of Cardio-thoracic and Respiratory Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Ernesto Maddaloni
- Department of Medicine, Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Vito Maurizio Parato
- Cardiology Unit, Madonna del Soccorso Hospital, San Benedetto del Tronto, Italy.,Politecnica Delle Marche University, San Benedetto del Tronto, Italy
| | - Vittorio Pengo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Giulia Renda
- Institute of Cardiology, G. d'Annunzio University, Chieti, Italy
| | - Francesca Santilli
- Department of Medicine and Aging, G. d'Annunzio University, Chieti, Italy
| | - Paola Simeone
- Department of Medicine and Aging, G. d'Annunzio University, Chieti, Italy
| | - Raffaele De Caterina
- Institute of Cardiology, G. d'Annunzio University, Chieti, Italy. .,Fondazione G. Monasterio, Pisa, Italy.
| | | |
Collapse
|
74
|
Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Collapse
|
75
|
Diabetes Mellitus and Acute Myocardial Infarction: Impact on Short and Long-Term Mortality. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1307:153-169. [PMID: 32020518 DOI: 10.1007/5584_2020_481] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Diabetes mellitus (DM) is an important risk factor for acute myocardial infarction (AMI) and a frequent co-morbidity in patients hospitalized with AMI, being present in about 30% of cases. Although current treatment of AMI has considerably improved survival in both patients with and without DM, the presence of DM still doubles the case fatality rate during both the acute phase of AMI and at long-term follow-up. This higher mortality risk of DM patients strongly indicates a particular need for better treatment options in these patients and suggests that intensive medical treatment, prolonged surveillance, and stringent control of other risk factors should be carefully pursued and maintained for as long as possible in them.In this review, we will focus on the close association between DM and in-hospital and long-term mortality in AMI patients. We will also aim at providing current evidence on the mechanisms underlying this association and on emerging therapeutic strategies, which may reduce the traditional mortality gap that still differentiates AMI patients with DM from those without.
Collapse
|
76
|
Welsh RC, Peterson ED, De Caterina R, Bode C, Gersh B, Eikelboom JW. Applying contemporary antithrombotic therapy in the secondary prevention of chronic atherosclerotic cardiovascular disease. Am Heart J 2019; 218:100-109. [PMID: 31715433 DOI: 10.1016/j.ahj.2019.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 09/12/2019] [Indexed: 11/30/2022]
Abstract
For 4 decades, antithrombotic therapy with aspirin has been a cornerstone of secondary prevention for patients with chronic atherosclerotic cardiovascular disease (ASCVD). Unfortunately, despite the use of evidence-based therapies, patients with ASCVD continue to have recurrent major adverse cardiovascular events including death, myocardial infarction, and stroke-at a rate of approximately 2%-4% per year. To combat this continuing risk, several recent trials have evaluated the efficacy and safety of more intensive antithrombotic strategies through prolonged dual antiplatelet therapy (DAPT), combining a P2Y12 receptor antagonists and low-dose aspirin, or alternatively applying a dual pathway inhibition approach, combining low-dose non-vitamin K antagonist anticoagulant and low-dose aspirin. Both combination strategies have been shown to reduce recurrent ischemic events but at the cost of increased bleeding events. The clinical application of these antithrombotic strategies requires clinicians to assess and balance the risk of recurrent ischemic and bleeding events in an individual patient. Furthermore, clinicians may also need to adapt their antithrombotic strategies to achieve best patient outcomes, as ASCVD is a progressive disease and the risks of cardiovascular ischemic and bleeding events may shift over time. This state-of-the-art article reviews evidence from the trials and provides a practical approach to the application of DAPT and dual pathway antithrombotic therapy in the long-term management of patients with chronic ASCVD.
Collapse
Affiliation(s)
- Robert C Welsh
- Mazankowski Alberta Heart Institute and University of Alberta, Edmonton, Alberta, Canada.
| | - Eric D Peterson
- Duke Outcomes Research Center, Duke University School of Medicine, Durham, NC, United States
| | - Raffaele De Caterina
- Institute of Cardiology and Centre of Excellence on Ageing, G d'Annunzio University, Chieti and G Monasterio Foundation, Pisa, Italy
| | - Christoph Bode
- Department of Cardiology and Angiology, Heart Center, University of Freiburg, Freiburg, Germany
| | - Bernard Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN, United States
| | - John W Eikelboom
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| |
Collapse
|
77
|
Dillinger JG, Henry P. La DAPT chez le patient diabétique coronarien. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2019. [DOI: 10.1016/s1878-6480(19)30959-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
78
|
Steg PG, Bhatt DL, Simon T, Fox K, Mehta SR, Harrington RA, Held C, Andersson M, Himmelmann A, Ridderstråle W, Leonsson-Zachrisson M, Liu Y, Opolski G, Zateyshchikov D, Ge J, Nicolau JC, Corbalán R, Cornel JH, Widimský P, Leiter LA. Ticagrelor in Patients with Stable Coronary Disease and Diabetes. N Engl J Med 2019; 381:1309-1320. [PMID: 31475798 DOI: 10.1056/nejmoa1908077] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with stable coronary artery disease and diabetes mellitus who have not had a myocardial infarction or stroke are at high risk for cardiovascular events. Whether adding ticagrelor to aspirin improves outcomes in this population is unclear. METHODS In this randomized, double-blind trial, we assigned patients who were 50 years of age or older and who had stable coronary artery disease and type 2 diabetes mellitus to receive either ticagrelor plus aspirin or placebo plus aspirin. Patients with previous myocardial infarction or stroke were excluded. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, or stroke. The primary safety outcome was major bleeding as defined by the Thrombolysis in Myocardial Infarction (TIMI) criteria. RESULTS A total of 19,220 patients underwent randomization. The median follow-up was 39.9 months. Permanent treatment discontinuation was more frequent with ticagrelor than placebo (34.5% vs. 25.4%). The incidence of ischemic cardiovascular events (the primary efficacy outcome) was lower in the ticagrelor group than in the placebo group (7.7% vs. 8.5%; hazard ratio, 0.90; 95% confidence interval [CI], 0.81 to 0.99; P = 0.04), whereas the incidence of TIMI major bleeding was higher (2.2% vs. 1.0%; hazard ratio, 2.32; 95% CI, 1.82 to 2.94; P<0.001), as was the incidence of intracranial hemorrhage (0.7% vs. 0.5%; hazard ratio, 1.71; 95% CI, 1.18 to 2.48; P = 0.005). There was no significant difference in the incidence of fatal bleeding (0.2% vs. 0.1%; hazard ratio, 1.90; 95% CI, 0.87 to 4.15; P = 0.11). The incidence of an exploratory composite outcome of irreversible harm (death from any cause, myocardial infarction, stroke, fatal bleeding, or intracranial hemorrhage) was similar in the ticagrelor group and the placebo group (10.1% vs. 10.8%; hazard ratio, 0.93; 95% CI, 0.86 to 1.02). CONCLUSIONS In patients with stable coronary artery disease and diabetes without a history of myocardial infarction or stroke, those who received ticagrelor plus aspirin had a lower incidence of ischemic cardiovascular events but a higher incidence of major bleeding than those who received placebo plus aspirin. (Funded by AstraZeneca; THEMIS ClinicalTrials.gov number, NCT01991795.).
Collapse
Affiliation(s)
- P Gabriel Steg
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Deepak L Bhatt
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Tabassome Simon
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Kim Fox
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Shamir R Mehta
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Robert A Harrington
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Claes Held
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Marielle Andersson
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Anders Himmelmann
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Wilhelm Ridderstråle
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Maria Leonsson-Zachrisson
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Yuyin Liu
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Grzegorz Opolski
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Dmitry Zateyshchikov
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Junbo Ge
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - José C Nicolau
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Ramón Corbalán
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Jan H Cornel
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Petr Widimský
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| | - Lawrence A Leiter
- From the French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Université de Paris, INSERM Unité 1148 (P.G.S.), Assistance Publique-Hôpitaux de Paris (P.G.S., T.S.), Hôpital Saint Antoine, Department of Clinical Pharmacology, Unité de Recherche Clinique (T.S.), and Sorbonne Université (T.S.) - all in Paris; the National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London (P.G.S., K.F.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Baim Institute for Clinical Research (Y.L.) - both in Boston; the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON (S.R.M.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (L.A.L.) - both in Canada; Stanford University, Stanford, CA (R.A.H.); the Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala (C.H.), and AstraZeneca BioPharmaceuticals Research and Development, Mölndal (M.A., A.H., W.R., M.L.-Z.) - both in Sweden; the Department of Cardiology, Medical University of Warsaw, Warsaw, Poland (G.O.); City Clinical Hospital No. 51, State Health Care Agency, Moscow (D.Z.); Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China (J.G.); Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (J.C.N.); Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile (R.C.); Northwest Clinics, Department of Cardiology, Alkmaar, Dutch Network for Cardiovascular Research, Utrecht, and Department of Cardiology, Radboud University Medical Center, Nijmegen - all in the Netherlands (J.H.C.); and Cardiocenter Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic (P.W.)
| |
Collapse
|
79
|
Affiliation(s)
- Eric R Bates
- From the Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| |
Collapse
|
80
|
Verma S, Poulter NR, Bhatt DL, Bain SC, Buse JB, Leiter LA, Nauck MA, Pratley RE, Zinman B, Ørsted DD, Monk Fries T, Rasmussen S, Marso SP. Effects of Liraglutide on Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus With or Without History of Myocardial Infarction or Stroke. Circulation 2019; 138:2884-2894. [PMID: 30566004 DOI: 10.1161/circulationaha.118.034516] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The glucagon-like peptide-1 analog liraglutide reduced cardiovascular events and mortality in patients with type 2 diabetes mellitus in the LEADER trial (Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes). In a post hoc analysis, we evaluated the efficacy of liraglutide in those with and without a history of myocardial infarction (MI) and/or stroke. METHODS LEADER was a randomized trial of liraglutide (1.8 mg or maximum tolerated dose) versus placebo in 9340 patients with type 2 diabetes mellitus and high cardiovascular risk, with a median follow-up of 3.8 years. The primary outcome was a composite of cardiovascular death, nonfatal MI, or nonfatal stroke (major adverse cardiovascular events). Risk groups in this post hoc analysis were defined by history of MI/stroke, established atherosclerotic cardiovascular disease without MI/stroke, or cardiovascular risk factors alone. RESULTS Of the 9340 patients, 3692 (39.5%) had a history of MI/stroke, 3083 (33.0%) had established atherosclerotic cardiovascular disease without MI/stroke, and 2565 (27.5%) had risk factors alone. Major adverse cardiovascular events occurred in 18.8% of patients with a history of MI/stroke (incidence rate, 5.0 per 100 patient-years), 11.6% of patients with established atherosclerotic cardiovascular disease without MI/stroke (incidence rate, 3.0 per 100 patient-years), and 9.8% of patients with cardiovascular risk factors alone (incidence rate, 2.6 per 100 patient-years). Liraglutide reduced major adverse cardiovascular events in patients with a history of MI/stroke (322 of 1865 [17.3%] versus 372 of 1827 patients [20.4%]; hazard ratio, 0.85; 95% CI, 0.73-0.99) and in those with established atherosclerotic cardiovascular disease without MI/stroke (158 of 1538 [10.3%] versus 199 of 1545 patients [12.9%]; hazard ratio, 0.76; 95% CI, 0.62-0.94) compared with placebo. In patients with risk factors alone, the hazard ratio for liraglutide versus placebo was 1.08 (95% CI, 0.84-1.38, Pinteraction=0.11). Similar results were seen for secondary outcomes across risk groups. CONCLUSIONS In this post hoc analysis of patients with type 2 diabetes mellitus and high cardiovascular risk, liraglutide reduced cardiovascular outcomes both in patients with a history of MI/stroke and in those with established atherosclerotic cardiovascular disease without MI/stroke. The cardiovascular effect appeared neutral in patients with cardiovascular risk factors alone. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01179048.
Collapse
Affiliation(s)
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
| | - Stephen C Bain
- Institute of Life Science, Swansea University, United Kingdom (S.C.B.)
| | - John B Buse
- University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
| | | | - Michael A Nauck
- Diabetes Center Bochum-Hattingen, St Josef-Hospital, Ruhr-University Bochum, Germany (M.A.N.)
| | - Richard E Pratley
- Florida Hospital Translational Research Institute for Metabolism and Diabetes, Orlando (R.E.P.)
| | - Bernard Zinman
- Lunenfeld Tanebaum Research Institute, Mount Sinai Hospital, University of Toronto, Canada (B.Z.)
| | - David D Ørsted
- Novo Nordisk A/S, Søborg, Denmark (D.D.Ø., T.M.F., S.R.)
| | - Tea Monk Fries
- Novo Nordisk A/S, Søborg, Denmark (D.D.Ø., T.M.F., S.R.)
| | | | - Steven P Marso
- Hospital Corporation of America (HCA) Midwest Health Heart & Vascular Institute, Kansas City, MO (S.P.M.)
| |
Collapse
|
81
|
Howard CE, Nambi V, Jneid H, Khalid U. Extended Duration of Dual-Antiplatelet Therapy After Percutaneous Coronary Intervention: How Long Is Too Long? J Am Heart Assoc 2019; 8:e012639. [PMID: 31576769 PMCID: PMC6818039 DOI: 10.1161/jaha.119.012639] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Charles E Howard
- Section of Cardiology Department of Medicine Baylor College of Medicine Houston TX
| | - Vijay Nambi
- Section of Cardiology Medical Care Line Michael E. DeBakey VA Medical Center Houston TX.,Section of Cardiology Department of Medicine Baylor College of Medicine Houston TX
| | - Hani Jneid
- Section of Cardiology Medical Care Line Michael E. DeBakey VA Medical Center Houston TX.,Section of Cardiology Department of Medicine Baylor College of Medicine Houston TX
| | - Umair Khalid
- Section of Cardiology Medical Care Line Michael E. DeBakey VA Medical Center Houston TX.,Section of Cardiology Department of Medicine Baylor College of Medicine Houston TX
| |
Collapse
|
82
|
Bhatt DL, Steg PG, Mehta SR, Leiter LA, Simon T, Fox K, Held C, Andersson M, Himmelmann A, Ridderstråle W, Chen J, Song Y, Diaz R, Goto S, James SK, Ray KK, Parkhomenko AN, Kosiborod MN, McGuire DK, Harrington RA. Ticagrelor in patients with diabetes and stable coronary artery disease with a history of previous percutaneous coronary intervention (THEMIS-PCI): a phase 3, placebo-controlled, randomised trial. Lancet 2019; 394:1169-1180. [PMID: 31484629 DOI: 10.1016/s0140-6736(19)31887-2] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/19/2019] [Accepted: 07/24/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients with stable coronary artery disease and diabetes with previous percutaneous coronary intervention (PCI), particularly those with previous stenting, are at high risk of ischaemic events. These patients are generally treated with aspirin. In this trial, we aimed to investigate if these patients would benefit from treatment with aspirin plus ticagrelor. METHODS The Effect of Ticagrelor on Health Outcomes in diabEtes Mellitus patients Intervention Study (THEMIS) was a phase 3 randomised, double-blinded, placebo-controlled trial, done in 1315 sites in 42 countries. Patients were eligible if 50 years or older, with type 2 diabetes, receiving anti-hyperglycaemic drugs for at least 6 months, with stable coronary artery disease, and one of three other mutually non-exclusive criteria: a history of previous PCI or of coronary artery bypass grafting, or documentation of angiographic stenosis of 50% or more in at least one coronary artery. Eligible patients were randomly assigned (1:1) to either ticagrelor or placebo, by use of an interactive voice-response or web-response system. The THEMIS-PCI trial comprised a prespecified subgroup of patients with previous PCI. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, or stroke (measured in the intention-to-treat population). FINDINGS Between Feb 17, 2014, and May 24, 2016, 11 154 patients (58% of the overall THEMIS trial) with a history of previous PCI were enrolled in the THEMIS-PCI trial. Median follow-up was 3·3 years (IQR 2·8-3·8). In the previous PCI group, fewer patients receiving ticagrelor had a primary efficacy outcome event than in the placebo group (404 [7·3%] of 5558 vs 480 [8·6%] of 5596; HR 0·85 [95% CI 0·74-0·97], p=0·013). The same effect was not observed in patients without PCI (p=0·76, pinteraction=0·16). The proportion of patients with cardiovascular death was similar in both treatment groups (174 [3·1%] with ticagrelor vs 183 (3·3%) with placebo; HR 0·96 [95% CI 0·78-1·18], p=0·68), as well as all-cause death (282 [5·1%] vs 323 [5·8%]; 0·88 [0·75-1·03], p=0·11). TIMI major bleeding occurred in 111 (2·0%) of 5536 patients receiving ticagrelor and 62 (1·1%) of 5564 patients receiving placebo (HR 2·03 [95% CI 1·48-2·76], p<0·0001), and fatal bleeding in 6 (0·1%) of 5536 patients with ticagrelor and 6 (0·1%) of 5564 with placebo (1·13 [0·36-3·50], p=0·83). Intracranial haemorrhage occurred in 33 (0·6%) and 31 (0·6%) patients (1·21 [0·74-1·97], p=0·45). Ticagrelor improved net clinical benefit: 519/5558 (9·3%) versus 617/5596 (11·0%), HR=0·85, 95% CI 0·75-0·95, p=0·005, in contrast to patients without PCI where it did not, pinteraction=0·012. Benefit was present irrespective of time from most recent PCI. INTERPRETATION In patients with diabetes, stable coronary artery disease, and previous PCI, ticagrelor added to aspirin reduced cardiovascular death, myocardial infarction, and stroke, although with increased major bleeding. In that large, easily identified population, ticagrelor provided a favourable net clinical benefit (more than in patients without history of PCI). This effect shows that long-term therapy with ticagrelor in addition to aspirin should be considered in patients with diabetes and a history of PCI who have tolerated antiplatelet therapy, have high ischaemic risk, and low bleeding risk. FUNDING AstraZeneca.
Collapse
Affiliation(s)
- Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School Boston, MA, USA.
| | - Philippe Gabriel Steg
- French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, AP-HP, Hôpital Bichat, Université de Paris, Institut National de la Santé et de la Recherche Médicale U-1148, Paris, France; National Heart and Lung Institute, Royal Brompton Hospital, Imperial College London, London, UK
| | - Shamir R Mehta
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; McMaster University, Hamilton, ON, Canada
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Tabassome Simon
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, Sorbonne-Université, Paris, France
| | - Kim Fox
- National Heart and Lung Institute, Royal Brompton Hospital, Imperial College London, London, UK
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Marielle Andersson
- AstraZeneca BioPharmaceuticals Research & Development, Late-stage Development, Cardiovascular, Renal and Metabolic, Mölndal, Sweden
| | - Anders Himmelmann
- AstraZeneca BioPharmaceuticals Research & Development, Late-stage Development, Cardiovascular, Renal and Metabolic, Mölndal, Sweden
| | - Wilhelm Ridderstråle
- AstraZeneca BioPharmaceuticals Research & Development, Late-stage Development, Cardiovascular, Renal and Metabolic, Mölndal, Sweden
| | - Jersey Chen
- AstraZeneca BioPharmaceuticals Research & Development, Late-stage Development, Cardiovascular, Renal and Metabolic, Gaithersburg, MD, USA
| | - Yang Song
- Baim Institute for Clinical Research, Boston, MA, USA
| | - Rafael Diaz
- Department of Medicine, Estudios Clínicos Latino América, Rosario, Argentina
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Isehara, Japan
| | - Stefan K James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Kausik K Ray
- Department of Primary Care and Public Health, Imperial Centre for Cardiovascular Disease Prevention, Imperial College London, London, UK
| | | | - Mikhail N Kosiborod
- Saint Luke's Mid-America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Darren K McGuire
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | |
Collapse
|
83
|
Pharmacodynamic Effects of Vorapaxar in Patients With and Without Diabetes Mellitus: Results of the OPTIMUS-5 Study. JACC Basic Transl Sci 2019; 4:763-775. [PMID: 31998847 PMCID: PMC6978557 DOI: 10.1016/j.jacbts.2019.07.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 07/31/2019] [Accepted: 07/31/2019] [Indexed: 12/18/2022]
Abstract
Vorapaxar reduces thrombotic cardiovascular events in patients with atherosclerotic disease, with enhanced effects in those with DM. Adjunctive vorapaxar therapy reduces platelet-mediated thrombogenicity without affecting clot kinetics in both patients with and those without DM having prior MI/PAD on dual antiplatelet therapy with aspirin and clopidogrel. The pharmacodynamic effects of vorapaxar occur via selective blockade of the PAR-1 on the platelet membrane without apparent interplay with other platelet signaling pathways. Aspirin withdrawal, which leaves patients on a background of clopidogrel and vorapaxar, increases markers specific to COX-1–mediated blockade, leading to an increase in platelet-mediated global thrombogenicity, particularly among patients with DM.
Vorapaxar reduces thrombotic cardiovascular events at the expense of increased bleeding. However, the differential pharmacodynamic (PD) effects of vorapaxar according to diabetes mellitus (DM) status are unknown. Moreover, although withdrawal of aspirin has emerged as a bleeding reduction strategy, the PD effects of stopping aspirin in patients treated with vorapaxar also are unknown. In this prospective PD investigation, vorapaxar was associated with reduced platelet-mediated thrombogenicity without affecting clot kinetics irrespective of DM status. However, platelet-mediated thrombogenicity increased after aspirin withdrawal, particularly among patients with DM. (Optimizing anti-Platelet Therapy In diabetes MellitUS-5 Study [OPTIMUS-5]; NCT02548650)
Collapse
Key Words
- ADP, adenosine diphosphate
- CAT, collagen-related peptide + adenosine diphosphate + thrombin receptor activating peptide
- CI, confidence interval
- COX, cyclooxygenase
- DAPT, dual antiplatelet therapy
- DM, diabetes mellitus
- LTA, light transmittance aggregometry
- MI, myocardial infarction
- MPA, maximum platelet aggregation
- PAD, peripheral arterial disease
- PAR, protease-activated receptor
- PD, pharmacodynamic
- TRAP, thrombin receptor activating peptide
- TXB2, thromboxane B2
- VASP, vasodilator-stimulated phosphoprotein
- dual antiplatelet therapy
- o.d., once daily
- pharmacodynamics
- platelets
- thrombin
- vorapaxar
Collapse
|
84
|
Fox KAA, Metra M, Morais J, Atar D. The myth of ‘stable’ coronary artery disease. Nat Rev Cardiol 2019; 17:9-21. [DOI: 10.1038/s41569-019-0233-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2019] [Indexed: 12/17/2022]
|
85
|
Bansilal S, Bonaca MP, Cornel JH, Storey RF, Bhatt DL, Steg PG, Im K, Murphy SA, Angiolillo DJ, Kiss RG, Parkhomenko AN, Lopez-Sendon J, Isaza D, Goudev A, Kontny F, Held P, Jensen EC, Braunwald E, Sabatine MS, Oude Ophuis AJ. Ticagrelor for Secondary Prevention of Atherothrombotic Events in Patients With Multivessel Coronary Disease. J Am Coll Cardiol 2019; 71:489-496. [PMID: 29406853 DOI: 10.1016/j.jacc.2017.11.050] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 11/05/2017] [Accepted: 11/25/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients with prior myocardial infarction (MI) and multivessel coronary disease (MVD) are at high risk for recurrent coronary events. OBJECTIVES The authors investigated the efficacy and safety of ticagrelor versus placebo in patients with MVD in the PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis In Myocardial Infarction 54) trial. METHODS Patients with a history of MI 1 to 3 years before inclusion in the PEGASUS-TIMI 54 trial were stratified in a pre-specified analysis based on the presence of MVD. The effect of ticagrelor (60 mg and 90 mg) on the composite of cardiovascular death, MI, or stroke (major adverse cardiovascular events [MACE]), as well as the composite of coronary death, MI, or stent thrombosis (coronary events), and on TIMI major bleeding, intracranial hemorrhage (ICH), and fatal bleeding were evaluated over a median of 33 months. RESULTS A total of 12,558 patients (59.4%) had MVD. In the placebo arm, compared with patients without MVD, those with MVD were at higher risk for MACE (9.37% vs. 8.57%, adjusted hazard ratio [HRadj]: 1.24; p = 0.026) and for coronary events (7.67% vs. 5.34%, HRadj: 1.49; p = 0.0005). In patients with MVD, ticagrelor reduced the risk of MACE (7.94% vs. 9.37%, HR: 0.82; p = 0.004) and coronary events (6.02% vs. 7.67%, HR: 0.76; p < 0.0001), including a 36% reduction in coronary death (HR: 0.64; 95% confidence interval: 0.48 to 0.85; p = 0.002). In this subgroup, ticagrelor increased the risk of TIMI major bleeding (2.52% vs. 1.08%, HR: 2.67; p < 0.0001), but not ICH or fatal bleeds. CONCLUSIONS Patients with prior MI and MVD are at increased risk of MACE and coronary events, and experience substantial relative and absolute risk reductions in both outcomes with long-term ticagrelor treatment relative to those without MVD. Ticagrelor increases the risk of TIMI major bleeding, but not ICH or fatal bleeding. For patients with prior MI and MVD, ticagrelor is an effective option for long-term antiplatelet therapy. (Prevention of Cardiovascular Events [e.g., Death From Heart or Vascular Disease, Heart Attack, or Stroke] in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin [PEGASUS]; NCT01225562).
Collapse
Affiliation(s)
- Sameer Bansilal
- Zena and Michael Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marc P Bonaca
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jan H Cornel
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar and Dutch Network for Cardiovascular Research (WCN), the Netherlands
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Deepak L Bhatt
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ph Gabriel Steg
- DHU (Département Hospitalo-Universitaire)-FIRE (Fibrosis, Inflammation, REmodelling), Hôpital Bichat, AP-HP (Assistance Publique-Hôpitaux de Paris), Université Paris-Diderot, Sorbonne-Paris Cité, and FACT (French Alliance for Cardiovascular clinical Trials), an F-CRIN network, INSERM U-1148, Paris, France; National Heart and Lung Institute, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, Imperial College, London, United Kingdom
| | - Kyungah Im
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Robert G Kiss
- Department of Cardiology, Military Hospital, Budapest, Hungary
| | | | | | - Daniel Isaza
- Fundacion Cardioinfantil, Instituto de Cardiología, Bogotá, Cundinamarca, Colombia
| | - Assen Goudev
- Medical University Sofia, Queen Ioanna Hospital, Sofia, Bulgaria
| | - Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway; Drammen Heart Center, Drammen, Norway
| | - Peter Held
- AstraZeneca Research and Development, Mölndal, Sweden
| | - Eva C Jensen
- AstraZeneca Research and Development, Mölndal, Sweden
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - A J Oude Ophuis
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar and Dutch Network for Cardiovascular Research (WCN), the Netherlands; Department of Cardiology, CWZ Hospital, Nijmegen, the Netherland
| |
Collapse
|
86
|
Antithrombotics: From Aspirin to DOACs in Coronary Artery Disease and Atrial Fibrillation (Part 3/5). J Am Coll Cardiol 2019; 74:699-711. [PMID: 31277840 DOI: 10.1016/j.jacc.2019.02.080] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/22/2019] [Accepted: 02/04/2019] [Indexed: 01/09/2023]
Abstract
For secondary prevention of coronary artery disease (CAD), oral antiplatelet therapy is essential. In case of coronary intervention, temporary dual antiplatelet therapy is mandatory as well. Recently, low-dose oral anticoagulation has entered the CAD arena. Atrial fibrillation (AF) is often seen in CAD and vice versa. In most patients stroke prevention in AF consists of oral anticoagulation. In many cases of CAD in patients with AF, anticoagulation has to be combined with antiplatelet agents (so called, dual pathway antithrombotic therapy). Excess bleeding in these conditions is a rapidly rising problem. This review addresses the antithrombotic options in CAD alone, in AF alone, and in their combination, when either an invasive or a noninvasive approach has been chosen.
Collapse
|
87
|
Affiliation(s)
- Muhammad Shahzeb Khan
- Department of Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, IL
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| |
Collapse
|
88
|
Sharma AN, Deyell JS, Sharma SN, Barseghian A. Role of and Recent Evidence for Antiplatelet Therapy in Prevention of Cardiovascular Disease in Diabetes. Curr Cardiol Rep 2019; 21:78. [PMID: 31254105 DOI: 10.1007/s11886-019-1168-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW When treating patients with diabetes mellitus (DM), the benefits of antiplatelet therapy in preventing cardiovascular disease must be weighed against an increased risk of bleeding. Recent trials have sought to determine both the optimal anti-platelet regimen for patients with DM, and who specifically requires medication among the DM population. This paper will review recent trials and evidence recommending the use of antiplatelet therapy in the prevention of cardiovascular disease in patients with diabetes. RECENT FINDINGS Seven notable trials assessed the effectiveness of antiplatelet therapy in the DM population. The ASCEND trial concluded 100 mg aspirin/day reduced rates of serious vascular events (OR 0.88, p < 0.01) but also increased rates of major bleeding events (OR 1.29, p < 0.01). The DAPT study revealed a longer dual antiplatelet regimen (30 months vs. 18 months) after coronary stent placement was more effective in reducing rates of stent thrombosis (0.5% vs. 1.1%, p = 0.06) and rates of myocardial infarction (3.5% vs. 4.8%, p = 0.06). DECLARE DIABETES showed that adding cilostazol to dual antiplatelet therapy after a coronary stent procedure reduced rates of in-stent and in-segment late loss and increased rates of revascularization (p < 0.04). In PEGASUS-TIMI, daily ticagrelor demonstrated reduced rates of major adverse cardiovascular and cerebrovascular events (OR 0.84, p < 0.04). The DAVID trial compared daily picotamide with daily aspirin therapy, finding reduced mortality rates in the picotamide group (OR 0.55, p < 0.05). Lastly, ACUITY found bivalirudin monotherapy resulted in lower rates of major bleeding events when compared to a glycoprotein IIb/IIa inhibitor and heparin or bivalirudin combination regimen (p < 0.01). Dual antiplatelet therapy guidelines still typically revolve around aspirin, but an increasing number of studies have demonstrated other drugs that may have a role in preventing atherosclerotic cardiovascular disease while decreasing the risk of major bleeding. Overall, it is wise to weigh the cardiovascular risk of a DM patient before prescribing antiplatelet medication. More research is necessary to determine a universal drug or combination of drugs that is safe and effective for DM patients.
Collapse
Affiliation(s)
- Ajay Nair Sharma
- School of Medicine, University of California Irvine, Irvine, CA, USA.,Division of Cardiology, UC Irvine, 333 City Blvd West. Ste 400, Orange, CA, 92868, USA
| | - Jacob S Deyell
- School of Medicine, University of California Irvine, Irvine, CA, USA.,Division of Cardiology, UC Irvine, 333 City Blvd West. Ste 400, Orange, CA, 92868, USA
| | | | - Ailin Barseghian
- Division of Cardiology, UC Irvine, 333 City Blvd West. Ste 400, Orange, CA, 92868, USA.
| |
Collapse
|
89
|
Furtado RH, Bonaca MP, Raz I, Zelniker TA, Mosenzon O, Cahn A, Kuder J, Murphy SA, Bhatt DL, Leiter LA, McGuire DK, Wilding JP, Ruff CT, Nicolau JC, Gause-Nilsson IA, Fredriksson M, Langkilde AM, Sabatine MS, Wiviott SD. Dapagliflozin and Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus and Previous Myocardial Infarction. Circulation 2019; 139:2516-2527. [DOI: 10.1161/circulationaha.119.039996] [Citation(s) in RCA: 171] [Impact Index Per Article: 34.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Remo H.M. Furtado
- Thrombolysis in Myocardial Infarction (TIMI) Study Group–Brigham and Women’s Hospital, Boston, MA (R.H.M.F., T.A.Z., J.K., S.A.M., D.L.B., C.T.R., M.S.S., S.D.W.)
- Instituto do Coracao (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de Sao Paulo, Brazil (R.H.M.F., J.C.N.)
| | - Marc P. Bonaca
- CPC Clinical Research and Vascular Research Unity, University of Colorado, Denver (M.P.B.)
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel (I.R., O.M., A.C.)
| | - Thomas A. Zelniker
- Thrombolysis in Myocardial Infarction (TIMI) Study Group–Brigham and Women’s Hospital, Boston, MA (R.H.M.F., T.A.Z., J.K., S.A.M., D.L.B., C.T.R., M.S.S., S.D.W.)
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel (I.R., O.M., A.C.)
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel (I.R., O.M., A.C.)
| | - Julia Kuder
- Thrombolysis in Myocardial Infarction (TIMI) Study Group–Brigham and Women’s Hospital, Boston, MA (R.H.M.F., T.A.Z., J.K., S.A.M., D.L.B., C.T.R., M.S.S., S.D.W.)
| | - Sabina A. Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group–Brigham and Women’s Hospital, Boston, MA (R.H.M.F., T.A.Z., J.K., S.A.M., D.L.B., C.T.R., M.S.S., S.D.W.)
| | - Deepak L. Bhatt
- Thrombolysis in Myocardial Infarction (TIMI) Study Group–Brigham and Women’s Hospital, Boston, MA (R.H.M.F., T.A.Z., J.K., S.A.M., D.L.B., C.T.R., M.S.S., S.D.W.)
| | - Lawrence A. Leiter
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Ontario, Canada (L.A.L.)
| | - Darren K. McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - John P.H. Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, UK (J.P.H.W.)
| | - Christian T. Ruff
- Thrombolysis in Myocardial Infarction (TIMI) Study Group–Brigham and Women’s Hospital, Boston, MA (R.H.M.F., T.A.Z., J.K., S.A.M., D.L.B., C.T.R., M.S.S., S.D.W.)
| | - Jose C. Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de Sao Paulo, Brazil (R.H.M.F., J.C.N.)
| | | | | | | | - Marc S. Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group–Brigham and Women’s Hospital, Boston, MA (R.H.M.F., T.A.Z., J.K., S.A.M., D.L.B., C.T.R., M.S.S., S.D.W.)
| | - Stephen D. Wiviott
- Thrombolysis in Myocardial Infarction (TIMI) Study Group–Brigham and Women’s Hospital, Boston, MA (R.H.M.F., T.A.Z., J.K., S.A.M., D.L.B., C.T.R., M.S.S., S.D.W.)
| |
Collapse
|
90
|
Bhatt DL, Fox K, Harrington RA, Leiter LA, Mehta SR, Simon T, Andersson M, Himmelmann A, Ridderstråle W, Held C, Steg PG. Rationale, design and baseline characteristics of the effect of ticagrelor on health outcomes in diabetes mellitus patients Intervention study. Clin Cardiol 2019; 42:498-505. [PMID: 30788847 PMCID: PMC6522985 DOI: 10.1002/clc.23164] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 02/18/2019] [Accepted: 02/19/2019] [Indexed: 12/13/2022] Open
Abstract
In the setting of prior myocardial infarction, the oral antiplatelet ticagrelor added to aspirin reduced the risk of recurrent ischemic events, especially, in those with diabetes mellitus. Patients with stable coronary disease and diabetes are also at elevated risk and might benefit from dual antiplatelet therapy. The Effect of Ticagrelor on Health Outcomes in diabEtes Mellitus patients Intervention Study (THEMIS, NCT01991795) is a Phase 3b randomized, double‐blinded, placebo‐controlled trial of ticagrelor vs placebo, on top of low dose aspirin. Patients ≥50 years with type 2 diabetes receiving anti‐diabetic medications for at least 6 months with stable coronary artery disease as determined by a history of previous percutaneous coronary intervention, bypass grafting, or angiographic stenosis of ≥50% of at least one coronary artery were enrolled. Patients with known prior myocardial infarction (MI) or stroke were excluded. The primary efficacy endpoint is a composite of cardiovascular death, myocardial infarction, or stroke. The primary safety endpoint is Thrombolysis in Myocardial Infarction major bleeding. A total of 19 220 patients worldwide have been randomized and at least 1385 adjudicated primary efficacy endpoint events are expected to be available for analysis, with an expected average follow‐up of 40 months (maximum 58 months). Most of the exposure is on a 60 mg twice daily dose, as the dose was lowered from 90 mg twice daily partway into the study. The results may revise the boundaries of efficacy for dual antiplatelet therapy and whether it has a role outside acute coronary syndromes, prior myocardial infarction, or percutaneous coronary intervention.
Collapse
Affiliation(s)
- Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School Boston, Boston, Massachusetts
| | - Kim Fox
- National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London, UK
| | - Robert A Harrington
- Stanford Center for Clinical Research (SCCR), Department of Medicine, Stanford University, Stanford, California
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shamir R Mehta
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Tabassome Simon
- AP-HP, Hôpital Saint Antoine, Department of Clinical Pharmacology-URCEST, Sorbonne-Université Paris, Paris, France
| | - Marielle Andersson
- AstraZeneca Gothenburg, Department of Cardiovascular, Renal and Metabolism, Mölndal, Sweden
| | - Anders Himmelmann
- AstraZeneca Gothenburg, Department of Cardiovascular, Renal and Metabolism, Mölndal, Sweden
| | - Wilhelm Ridderstråle
- AstraZeneca Gothenburg, Department of Cardiovascular, Renal and Metabolism, Mölndal, Sweden
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Philippe Gabriel Steg
- FACT (French Alliance for Cardiovascular Trials), an F-CRIN Network, Département Hospitalo-Universitaire FIRE, AP-HP, Hôpital Bichat, Université Paris-Diderot, Paris, France.,Département Hospitalo-Universitaire FIRE, AP-HP, Hôpital Bichat,Université Paris-Diderot, INSERM U-1148, Paris, France.,National Heart & Lung Institute NHLI, Imperial College, Royal Brompton Hospital, London, UK
| | | |
Collapse
|
91
|
Guerbaai RA, Mahata I, Maréchaux S, Le Jemtel TH, Ennezat PV. Is ticagrelor worth its high cost and side-effects? Acta Cardiol 2019; 74:93-98. [PMID: 29730968 DOI: 10.1080/00015385.2018.1469371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Ticagrelor is a reversible P2Y12 receptor antagonist that is more potent than clopidogrel. When used in combination with aspirin, it reduces cardiovascular events in patients with acute coronary syndrome. However, unbiased review of 5 randomised controlled trials indicates that although statistically significant, the clinical superiority of ticagrelor over clopidogrel is modest. Thus, identification of patients who benefit the most from ticagrelor is a priority. Besides bleeding issues, ticagrelor can frequently cause bouts of dyspnoea, which requires ticagrelor replacement by another P2Y12 receptor antagonist, with a loading dose.
Collapse
Affiliation(s)
| | - Indrajeet Mahata
- Tulane School of Medicine, Tulane Heart and Vascular Institute, New Orleans, LA, USA
| | - Sylvestre Maréchaux
- GCS-Groupement des Hôpitaux de l’Institut Catholique de Lille, Hôpital Saint Philibert, Faculty of Medicine and Maieutics, Catholic University of Lille, Lille, France
| | - Thierry H. Le Jemtel
- Tulane School of Medicine, Tulane Heart and Vascular Institute, New Orleans, LA, USA
| | - Pierre-Vladimir Ennezat
- Department of Cardiology, Centre Hospitalier Regional Universitaire Grenoble-Alpes, La Tronche, France
| |
Collapse
|
92
|
Hommels TM, Hermanides RS, Rasoul S, Berta B, IJsselmuiden AJJ, Jessurun GAJ, Benit E, Pereira B, De Luca G, Kedhi E. Everolimus-eluting bioresorbable scaffolds for treatment of coronary artery disease in patients with diabetes mellitus: the midterm follow-up of the prospective ABSORB DM Benelux study. Cardiovasc Diabetol 2019; 18:25. [PMID: 30851731 PMCID: PMC6408833 DOI: 10.1186/s12933-019-0827-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 02/18/2019] [Indexed: 02/07/2023] Open
Abstract
Background Percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM) remains challenging even with modern drug-eluting stents (DES) due to high rates of repeat revascularization. Everolimus-eluting bioresorbable scaffolds (EE-BRS) might allow for repeat intervention prolonging the time interval of percutaneous treatment options. Methods The ABSORB DM Benelux Study is a dedicated prospective, international study to evaluate the midterm safety and efficacy of EE-BRS in DM patients. All DM patients that received ≥ 1 EE-BRS for any indication were enrolled and prospectively followed. Study endpoints were major adverse cardiac events (MACE): a composite of all-cause death, any myocardial infarction (MI) and ischemic-driven target vessel revascularization (TVR); target lesion failure (TLF): a composite of cardiac death (CD), target vessel MI, and ischemic-driven target lesion revascularization (TLR), as well as definite or probable scaffold thrombosis (ScT). Results Between April 2015 till March 2017, 150 DM patients and 188 lesions were treated and followed up to 3 years. Device implantation success was 100%. MACE occurred in 15.2% (event rate of 8.8 per 100 PY). TLF was reported in 11.7% (7.0 events per 100 PY). CD, target vessel MI, ischemic-driven TLR occurred in 3.4%, 3.6% and 5.5% respectively, while ScT was observed in 1.4%. There were no occurrences of late or very late ScT. Conclusion EE-BRS treatment in DM patients shows comparable midterm safety and efficacy outcomes when historically compared with modern DES. New-generation EE-BRS might offer an attractive alternative to metallic DES in treatment of fast progressing atherosclerosis population as in DM patients. Trial registration NTR5447. Registered 05 October 2015, retrospectively registered
Collapse
Affiliation(s)
- T M Hommels
- Isala Klinieken, Isala Hartcentrum, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - R S Hermanides
- Isala Klinieken, Isala Hartcentrum, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - S Rasoul
- Zuyderland Medisch Centrum, Heerlen, The Netherlands
| | - B Berta
- Isala Klinieken, Isala Hartcentrum, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | | | | | - E Benit
- Virga Jesse Ziekenhuis, Hasselt, Belgium
| | - B Pereira
- Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg
| | - G De Luca
- Isala Klinieken, Isala Hartcentrum, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - E Kedhi
- Isala Klinieken, Isala Hartcentrum, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands. .,, Dokter van Heesweg 2, Postbus 10400, 8000 GK, Zwolle, The Netherlands.
| |
Collapse
|
93
|
Kumar A, Patel DR, Wolski KE, Lincoff AM, Kashyap SR, Ruotolo G, McErlean E, Weerakkody G, Riesmeyer JS, Nicholls SJ, Nissen SE, Menon V. Baseline fasting plasma insulin levels predict risk for major adverse cardiovascular events among patients with diabetes and high-risk vascular disease: Insights from the ACCELERATE trial. Diab Vasc Dis Res 2019; 16:171-177. [PMID: 31014095 DOI: 10.1177/1479164119827604] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Despite optimal treatment, type II diabetes mellitus remains associated with an increased risk for future cardiovascular events. We sought to determine the association between baseline fasting plasma insulin levels and major adverse cardiovascular outcomes in patients with type II diabetes mellitus and high-risk vascular disease enrolled in the ACCELERATE (Assessment of Clinical Effects of Cholesteryl Ester Transfer Protein Inhibition with Evacetrapib in Patients at a High Risk for Vascular Outcomes) trial. METHODS We included all patients with type II diabetes mellitus who had a central laboratory measured fasting plasma insulin level drawn at baseline as part of the study protocol. Hazard ratios were generated for the risk of major adverse cardiovascular outcomes (composite of cardiovascular death, non-fatal myocardial infarction, stroke, hospitalization for unstable angina and coronary revascularization) with increasing quartile of baseline fasting plasma insulin level. We then performed a multivariable regression adjusting for significant baseline characteristics. RESULTS Among 12,092 patients in ACCELERATE, 2042 patients with type II diabetes mellitus had a baseline fasting plasma insulin level drawn. Median follow-up was 28 months. The study population had a mean age of 66.6 years, 79.2% male and 96.2% had established coronary artery disease. During follow-up, major adverse cardiovascular outcomes occurred in 238 patients (11.6%); of these events, 177 were coronary revascularization (8.7%). We observed a statistically significant relationship between rates of revascularization and rising quartile of baseline fasting plasma insulin level which was not noted for the other individual components of major adverse cardiovascular outcomes. Patients with type II diabetes mellitus who underwent revascularization were noted to have significantly higher baseline fasting plasma insulin levels (27.7 vs 21.4 mU/L, p-value = 0.009) although baseline haemoglobin A1c (6.63% vs 6.55%), body mass index (31.5 vs 31.1 kg/m2) and medical therapy were otherwise similar to the group not undergoing revascularization. Following multivariable regression adjusting for significant characteristics including exposure to evacetrapib, the log of baseline fasting plasma insulin level was found to be an independent predictor for major adverse cardiovascular outcomes (hazard ratio = 1.36, 95% confidence interval = 1.09-1.69, p-value = 0.007); this was driven by need for future revascularization (hazard ratio = 1.56, 95% confidence interval = 1.21-2.00, p-value = 0.001). CONCLUSION In a contemporary population of patients with type II diabetes mellitus and high-risk vascular disease on optimum medical therapy, baseline hyperinsulinaemia was an independent predictor for major adverse cardiovascular outcomes and need of future coronary revascularization. These results suggest a pathophysiological link between hyperinsulinaemia and progression of atherosclerotic vascular disease among diabetics.
Collapse
Affiliation(s)
- Anirudh Kumar
- 1 Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Divyang R Patel
- 1 Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kathy E Wolski
- 1 Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A Michael Lincoff
- 1 Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sangeeta R Kashyap
- 2 Endocrinology and Metabolism Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Ellen McErlean
- 1 Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | | | - Stephen J Nicholls
- 4 South Australian Health and Medical Research Institute, The University of Adelaide, Adelaide, SA, Australia
| | - Steven E Nissen
- 1 Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Venu Menon
- 1 Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
94
|
Li DT, Li SB, Zheng JY, Tang HH, Qiu YG, Xue N, Cao Y. Analysis of Ticagrelor's Cardio-protective Effects on Patients with ST-segment Elevation Acute Coronary Syndrome Accompanied with Diabetes. Open Med (Wars) 2019; 14:234-240. [PMID: 30847400 PMCID: PMC6401390 DOI: 10.1515/med-2019-0017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 10/17/2018] [Indexed: 01/27/2023] Open
Abstract
Background To analyze the cardio-protective effects of ticagrelor in patients with acute coronary syndrome with S-T segment elevation. Methods The sample was 200 patients who had been diagnosed with acute coronary syndrome accompanied by diabetes Mellitus type II. Only patients having ST segment elevation before the treatment were included. Then, the subjects were further randomly divided into an observation group and a control group. The control group of 100 patients received clopidogrel; the observation group of 100 patients of ticagrelor. The serous creatine kinase CK-MB, functional cardiac indexes of left ventricular end diastolic diameter (LVDD), cardiac troponin I, ventricular ejection fraction, and relevant major adverse cardiovascular events (MACE) were compared between the two groups. Results One month after a percutaneous coronary intervention (PCI) the observation group showed better results against angina, stent thrombosis, and all-cause mortality compared with those of the control subjects. Six months after treatment, both groups suffered adverse reactions. The number of patients who suffered adverse reactions in respiratory tract in the observation group was higher than in the control group. The inhibition of platelet aggregation IPA of ticagrelor was found to be significantly higher than clopidogrel, having a significant p value. Conclusion Ticagrelor can effectively protect myocardial function for patients with ST-segment elevation acute coronary syndrome accompanied by diabetes and can reduce the incidence of adverse reactions..
Collapse
Affiliation(s)
- Dong-Tao Li
- Department of Cardiology, Navy General Hospital, Haidian District, 100048 Beijing, China
| | - Shun-Bao Li
- Department of Cardiology, Baoding First Central Hospital, Baoding, Hebei, 071000 China
| | - Jian-Yong Zheng
- Department of Cardiology, Navy General Hospital, Haidian District, 100048 Beijing, China
| | - Hai-Hong Tang
- Department of Cardiology, Navy General Hospital, Haidian District, 100048 Beijing, China
| | - Yi-Gang Qiu
- Department of Cardiology, Navy General Hospital, Haidian District, 100048 Beijing, China
| | - Ning Xue
- Department of Cardiology, Navy General Hospital, Haidian District, 100048 Beijing, China
| | - Yi Cao
- Department of Cardiology, Navy General Hospital, No. 6 Fucheng Road, Haidian District, Beijing, People's Republic of China
| |
Collapse
|
95
|
Parker WAE, Orme RC, Hanson J, Stokes HM, Bridge CM, Shaw PA, Sumaya W, Thorneycroft K, Petrucci G, Porro B, Judge HM, Ajjan RA, Rocca B, Storey RF. Very-low-dose twice-daily aspirin maintains platelet inhibition and improves haemostasis during dual-antiplatelet therapy for acute coronary syndrome. Platelets 2019; 30:148-157. [PMID: 30759035 PMCID: PMC6425913 DOI: 10.1080/09537104.2019.1572880] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Higher aspirin doses may be inferior in ticagrelor-treated acute coronary syndrome (ACS) patients and reducing bleeding risk whilst maintaining antithrombotic benefits could improve outcomes. We characterized the pharmacodynamics of a novel dual-antiplatelet-therapy regimen consisting of very-low-dose twice-daily (BD) aspirin with standard-dose ticagrelor. A total of 20 ticagrelor-treated ACS patients entered a randomized crossover to take aspirin 20 mg BD (12-hourly) during one 14-day period and 75 mg once-daily (OD) in the other. After 14 days of treatment, serum thromboxane (TX)B2 and light-transmittance aggregometry were assessed pre- and 2 h post-morning-dose, bleeding time was measured post-dose, and TXA2 and prostacyclin stable metabolites were measured in urine collected 2 h post-morning-dose. Data are expressed as mean ± SD. After 14 days treatment, serum TXB2 levels were significantly greater 2 h post-dosing with aspirin 20 mg BD vs. 75 mg OD (3.0 ± 3.6 ng/mL vs. 0.8 ± 1.9 ng/mL; p = 0.018) whereas pre-dosing levels were not significantly different (3.5 ± 4.1 ng/mL vs. 2.5 ± 3.1 ng/mL, p = 0.23). 1-mmol/L arachidonic acid-induced platelet aggregation was similarly inhibited by both regimens pre-dose (8.5 ± 14.3% vs. 5.1 ± 3.6%, p = 0.24) and post-dose (8.7 ± 14.2% vs. 6.6 ± 5.3%; p = 0.41). Post-dose bleeding time was shorter with 20 mg BD (680 ± 306 s vs. 834 ± 386 s, p = 0.02). Urinary prostacyclin and TX metabolite excretion were not significantly different. In conclusion, compared to aspirin 75 mg OD, aspirin 20 mg BD provided consistent inhibition of platelet TXA2 release and aggregation, and improved post-dose hemostasis, in ticagrelor-treated ACS patients. Further studies are warranted to assess whether this regimen improves the balance of clinical efficacy and safety.
Collapse
Affiliation(s)
- William A E Parker
- a Department of Infection, Immunity and Cardiovascular Disease , University of Sheffield , Sheffield , United Kingdom.,b Department of Cardiology , Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield , UK
| | - Rachel C Orme
- a Department of Infection, Immunity and Cardiovascular Disease , University of Sheffield , Sheffield , United Kingdom.,b Department of Cardiology , Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield , UK
| | - Jessica Hanson
- a Department of Infection, Immunity and Cardiovascular Disease , University of Sheffield , Sheffield , United Kingdom
| | - Hannah M Stokes
- a Department of Infection, Immunity and Cardiovascular Disease , University of Sheffield , Sheffield , United Kingdom
| | - Claire M Bridge
- a Department of Infection, Immunity and Cardiovascular Disease , University of Sheffield , Sheffield , United Kingdom
| | - Patricia A Shaw
- a Department of Infection, Immunity and Cardiovascular Disease , University of Sheffield , Sheffield , United Kingdom
| | - Wael Sumaya
- a Department of Infection, Immunity and Cardiovascular Disease , University of Sheffield , Sheffield , United Kingdom.,b Department of Cardiology , Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield , UK
| | - Kirstie Thorneycroft
- a Department of Infection, Immunity and Cardiovascular Disease , University of Sheffield , Sheffield , United Kingdom
| | - Giovanna Petrucci
- c Institute of Pharmacology , Catholic University School of Medicine , Rome , Italy
| | - Benedetta Porro
- d Centro Cardiologico Monzino , Istituto di Ricovero e Cura a Carattere Scientifico Cardiologico Monzino , Milan , Italy
| | - Heather M Judge
- a Department of Infection, Immunity and Cardiovascular Disease , University of Sheffield , Sheffield , United Kingdom
| | - Ramzi A Ajjan
- e Leeds Institute of Cardiovascular and Metabolic Medicine , University of Leeds , Leeds , UK
| | - Bianca Rocca
- c Institute of Pharmacology , Catholic University School of Medicine , Rome , Italy
| | - Robert F Storey
- a Department of Infection, Immunity and Cardiovascular Disease , University of Sheffield , Sheffield , United Kingdom.,b Department of Cardiology , Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield , UK
| |
Collapse
|
96
|
|
97
|
|
98
|
Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Collapse
|
99
|
Bonaca MP, Gutierrez JA, Cannon C, Giugliano R, Blazing M, Park JG, White J, Tershakovec A, Braunwald E. Polyvascular disease, type 2 diabetes, and long-term vascular risk: a secondary analysis of the IMPROVE-IT trial. Lancet Diabetes Endocrinol 2018; 6:934-943. [PMID: 30396865 DOI: 10.1016/s2213-8587(18)30290-0] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/14/2018] [Accepted: 09/17/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Polyvascular disease and type 2 diabetes are each associated with increased cardiovascular risk, but whether these risks are additive is unknown. In this exploratory analysis of a randomised trial, we explored the long-term cardiovascular risk associated with polyvascular disease, type 2 diabetes, and their combination in patients with acute coronary syndrome, and assessed the effect of ezetimibe given on top of statin therapy in patients with these concomitant conditions. METHODS IMPROVE-IT was a multicentre, double-blind, randomised, placebo-controlled trial assessing the effect of ezetimibe added to statin therapy after acute coronary syndrome. Recruitment was from Oct 26, 2005, to July 8, 2010, and the trial was done at 1158 sites in 39 countries. 18 144 patients aged 50 years and older who had been stabilised after an acute coronary syndrome were randomly assigned to 40 mg per day simvastatin plus either 10 mg per day ezetimibe or matched placebo, for a median duration of 6 years. In this post-hoc exploratory analysis, we assessed the prespecified endpoints of the trial, including the primary composite endpoint (cardiovascular death, a major coronary event [non-fatal myocardial infarction, documented unstable angina requiring hospital admission, or coronary revascularisation occurring at least 30 days after randomisation], or stroke [ischaemic or haemorrhagic]) by concomitant polyvascular disease at baseline (peripheral artery disease or previous stroke or transient ischaemic attack) and stratified by concomitant type 2 diabetes. Efficacy analyses were done according to intention to treat and event rates. IMPROVE-IT is registered with ClinicalTrials.gov, number NCT00202878. FINDINGS 1005 patients (6%) had peripheral artery disease and 1071 (6%) had stroke or transient ischaemic attack at baseline. Of these, 388 (39%) and 409 (38%) also had concomitant type 2 diabetes, respectively. At 7 years, patients with either polyvascular disease or type 2 diabetes had similar rates of the primary endpoint (39·8% and 39·9%, respectively), which were higher than patients without polyvascular disease or diabetes (29·6%). Polyvascular disease with concomitant type 2 diabetes was associated with further heightened risk (60·0% 7-year Kaplan-Meier rate, adjusted hazard ratio versus those with polyvascular disease 1·60, 95% CI 1·38-1·85; p<0·0001). Ezetimibe reduced cardiovascular risk consistently across groups with greater numerical absolute risk reductions in the highest-risk subgroups. INTERPRETATION In patients with coronary artery disease, concomitant polyvascular disease or type 2 diabetes are associated with increased long-term cardiovascular risk. The combination of polyvascular disease and diabetes is additive, resulting in very high risk. The benefit of ezetimibe is consistent in patients with and without polyvascular disease and type 2 diabetes; however, by nature of their higher risk patients with one, or especially both, of these diseases might derive the greatest absolute benefits. FUNDING Merck.
Collapse
Affiliation(s)
- Marc P Bonaca
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - J Antonio Gutierrez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Christopher Cannon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Robert Giugliano
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Michael Blazing
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Jeong-Gun Park
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jennifer White
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | - Eugene Braunwald
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
100
|
Abstract
Patients surviving an acute coronary syndrome (ACS) remain at increased risk of ischemic events long term. This paper reviews current evidence and guidelines for oral antiplatelet therapy for secondary prevention following ACS, with respect to decreased risk of ischemic events versus bleeding risk according to individual patient characteristics and risk factors. Specifically, data are reviewed from clinical studies of clopidogrel, prasugrel, ticagrelor and vorapaxar, as well as the results of systematic reviews and meta-analyses looking at the benefits and risks of oral antiplatelet therapy, and the relative merits of shorter versus longer duration of dual antiplatelet therapy, in different patient groups.
Collapse
Affiliation(s)
- Jeffrey S Berger
- Division of Cardiology, New York University Langone Medical Center, New York, NY, USA.
- Marc and Ruti Bell Program in Vascular Biology, New York University School of Medicine, 530 First Avenue, Skirball 9R, New York, NY, 10016, USA.
| |
Collapse
|