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Oraii A, Healey JS, Benz AP, Pandey AK, Wong JA, Fonguh S, Wang J, Conen D, Gerstein HC, Connolly SJ, McIntyre WF. Association of Eligibility for a Sodium-Glucose Cotransporter 2 Inhibitor and Cardiovascular Events in Patients With Atrial Fibrillation. Can J Cardiol 2022; 38:1434-1441. [PMID: 35562018 DOI: 10.1016/j.cjca.2022.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce heart failure (HF) in a broad range of populations, but they have not been studied specifically in patients with atrial fibrillation (AF). We aimed to examine the association between SGLT2i eligibility and cardiovascular events in patients with AF to evaluate the potential utility of SGLT2is for AF management. METHODS We pooled data from 2 randomized controlled trials (RCTs) of patients with AF (RE-LY and ACTIVE-W). Among patients assigned to anticoagulation arms, those meeting the enrollment criteria from at least 1 of the phase 3 SGLT2i RCTs were classified as "SGLT2i eligible" and the remainder as "SGLT2i ineligible." The primary outcome was the composite of HF hospitalization or cardiovascular death. RESULTS A total of 21,484 patients with AF (mean age: 71.2 ± 8.8, 36.1% women, median CHA2DS2-VASc Score = 3) were included. The proportion of patients with AF eligible for SGLT2i was 41.2%. SGLT2i-eligible patients had higher rates of cardiovascular death or hospitalization for HF (5.8 vs 3.2 per 100 person-years, Plog-rank < 0.001), cardiovascular death (3.9 vs 1.5 per 100 person-years, Plog-rank < 0.001), and hospitalization for HF (2.5 vs 1.9 per 100 person-years, Plog-rank < 0.001). The age- and sex-adjusted model showed that SGLT2i-eligible patients were at a higher risk of cardiovascular death and hospitalization for HF (hazard ratio [HR], 1.97; 95% confidence interval [CI], 1.79-2.17; P < 0.001), cardiovascular death (HR, 2.75; 95% CI, 2.41-3.13; P < 0.001), and hospitalization for HF (HR, 1.41; 95% CI, 1.23-1.62; P < 0.001) than ineligible patients. CONCLUSIONS Most patients with AF do not currently have indications for SGLT2is but still have substantial risk of cardiovascular events. Future randomized trials should evaluate the efficacy of SGLT2is in patients with AF.
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Affiliation(s)
- Alireza Oraii
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Arjun K Pandey
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jorge A Wong
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sylvanus Fonguh
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jia Wang
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - David Conen
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Hertzel C Gerstein
- Population Health Research Institute, Hamilton, Ontario, Canada; Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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Chen W, Khurshid S, Singer DE, Atlas SJ, Ashburner JM, Ellinor PT, McManus DD, Lubitz SA, Chhatwal J. Cost-effectiveness of Screening for Atrial Fibrillation Using Wearable Devices. JAMA HEALTH FORUM 2022; 3:e222419. [PMID: 36003419 PMCID: PMC9356321 DOI: 10.1001/jamahealthforum.2022.2419] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/10/2022] [Indexed: 11/18/2022] Open
Abstract
Question Is population-based atrial fibrillation (AF) screening using wearable devices cost-effective? Findings In this economic evaluation of 30 million simulated individuals with an age, sex, and comorbidity profile matching the US population aged 65 years or older, AF screening using wearable devices was cost-effective, with the overall preferred strategy identified as wearable photoplethysmography, followed conditionally by wearable electrocardiography with patch monitor confirmation (incremental cost-effectiveness ratio, $57 894 per quality-adjusted life-year). The cost-effectiveness of screening was consistent across multiple scenarios, including strata of sex, screening at earlier ages, and with variation in the association of anticoagulation with risk of stroke associated with screening-detected AF. Meaning This study suggests that contemporary AF screening using wearable devices may be cost-effective. Importance Undiagnosed atrial fibrillation (AF) is an important cause of stroke. Screening for AF using wrist-worn wearable devices may prevent strokes, but their cost-effectiveness is unknown. Objective To evaluate the cost-effectiveness of contemporary AF screening strategies, particularly wrist-worn wearable devices. Design, Setting, and Participants This economic evaluation used a microsimulation decision-analytic model and was conducted from September 8, 2020, to May 23, 2022, comprising 30 million simulated individuals with an age, sex, and comorbidity profile matching the US population aged 65 years or older. Interventions Eight AF screening strategies, with 6 using wrist-worn wearable devices (watch or band photoplethysmography, with or without watch or band electrocardiography) and 2 using traditional modalities (ie, pulse palpation and 12-lead electrocardiogram) vs no screening. Main Outcomes and Measures The primary outcome was the incremental cost-effectiveness ratio, defined as US dollars per quality-adjusted life-year (QALY). Secondary measures included rates of stroke and major bleeding. Results In the base case analysis of this model, the mean (SD) age was 72.5 (7.5) years, and 50% of the individuals were women. All 6 screening strategies using wrist-worn wearable devices were estimated to be more effective than no screening (range of QALYs gained vs no screening, 226-957 per 100 000 individuals) and were associated with greater relative benefit than screening using traditional modalities (range of QALYs gained vs no screening, −116 to 93 per 100 000 individuals). Compared with no screening, screening using wrist-worn wearable devices was associated with a reduction in stroke incidence by 20 to 23 per 100 000 person-years but an increase in major bleeding by 20 to 44 per 100 000 person-years. The overall preferred strategy was wearable photoplethysmography, followed conditionally by wearable electrocardiography with patch monitor confirmation, which had an incremental cost-effectiveness ratio of $57 894 per QALY, meeting the acceptability threshold of $100 000 per QALY. The cost-effectiveness of screening was consistent across multiple scenarios, including strata of sex, screening at earlier ages (eg, ≥50 years), and with variation in the association of anticoagulation with risk of stroke in the setting of screening-detected AF. Conclusions and Relevance This economic evaluation of AF screening using a microsimulation decision-analytic model suggests that screening using wearable devices is cost-effective compared with either no screening or AF screening using traditional methods.
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Affiliation(s)
- Wanyi Chen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Shaan Khurshid
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Steven J. Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey M. Ashburner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Patrick T. Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston
| | - David D. McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester
| | - Steven A. Lubitz
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston
| | - Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
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De Caterina R, Agewall S, Andreotti F, Angiolillo DJ, Bhatt DL, Byrne RA, Collet JP, Eikelboom J, Fanaroff AC, Gibson CM, Goette A, Hindricks G, Lip GYH, Potpara T, Thiele H, Lopes RD, Galli M. Great Debate: Triple antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting should be limited to 1 week. Eur Heart J 2022; 43:3512-3527. [PMID: 35925556 DOI: 10.1093/eurheartj/ehac294] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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A Watch-Type Electrocardiography Is a Reliable Tool for Detecting Paroxysmal Cardiac Arrhythmias. J Clin Med 2022; 11:jcm11123333. [PMID: 35743404 PMCID: PMC9224975 DOI: 10.3390/jcm11123333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/03/2022] [Accepted: 06/08/2022] [Indexed: 02/05/2023] Open
Abstract
Background: A substantial proportion of cardiac arrhythmias are paroxysmal in nature, and 12-lead electrocardiography (ECG) and Holter monitoring often fail to detect paroxysmal arrhythmias. We designed and evaluated a watch-type, electrocardiograph-recording, wearable device (w-ECG) to overcome the limitations of 12-lead ECG and Holter monitoring. Methods: We prospectively enrolled 96 patients with symptoms assumed to be related to cardiac arrhythmias. Electrocardiography recording was performed with both the w-ECG and Holter monitoring. Detection of any arrhythmia was the primary outcome endpoint and was compared between the w-ECG and Holter monitoring. Results: Any arrhythmia was detected in 51 (53.1%) and 27 (28.1%) patients by the w-ECG and Holter monitoring, respectively (odds ratio (OR) = 2.9, p < 0.001). The w-ECG was superior to Holter monitoring for the detection of clinically significant arrhythmias (excluding atrial premature contraction, ventricular premature contraction, and non-sustained atrial tachyarrhythmia) (OR = 2.34, p = 0.018). In 27 (28.1%) patients, cardiac arrhythmias were detected only by the w-ECG, with atrial fibrillation being the most frequent case (13 patients). Based on ECGs recorded by using the w-ECG, 17 patients (17.7%) received therapeutic interventions, including radiofrequency catheter ablation. Conclusions: The w-ECG is capable of recording ECGs of good quality, with a discernable P wave and distinguishable QRS morphology. The ability of the w-ECG to detect cardiac arrhythmias was significantly better than that of Holter monitoring, and a significant proportion of patients received therapeutic intervention based on ECGs recorded by the w-ECG.
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Mahmood H, Shahid F, Egred M, Farag M. Management of antithrombotic therapy in patients at high bleeding risk after percutaneous coronary intervention for acute coronary syndromes: a case report. Eur Heart J Case Rep 2022; 6:ytac224. [PMID: 35909506 PMCID: PMC9336549 DOI: 10.1093/ehjcr/ytac224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/12/2021] [Accepted: 05/28/2022] [Indexed: 12/04/2022]
Abstract
Background Choosing antithrombotic therapy for patients at high bleeding risk, particularly those requiring long-term anticoagulant therapy, who have acute coronary syndromes (ACS) and/or undergoing percutaneous coronary intervention (PCI) is becoming increasingly complex. Case summary A 78-year-old women was hospitalized with chest pain and a diagnosis of non-ST-elevation ACS was made. It was decided that the patient should undergo coronary angiogram with a view for angioplasty. Subsequently, she underwent successful PCI to the left anterior descending artery. Shortly after PCI, she was noted to be in atrial fibrillation. Furthermore, she had per rectal bleeding and acute kidney injury, which were managed conservatively. Aspirin and ticagrelor were stopped and she was discharged on dual antithrombotic therapy with clopidogrel and apixaban. Discussion Available evidence, driven mainly from expert consensus documents, advocates a case-by-case comprehensive evaluation that integrates patient- and procedure-related factors to assess patients for thrombotic and bleeding tendencies to identify those who may gain most net clinical benefit of antithrombotic combination therapy. In general, if thrombotic drivers prevail, an augmented antithrombotic regime with a view for a longer duration should be planned, and if bleeding drivers prevail, a de-escalated regime with a view for a shorter duration should be sought.
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Affiliation(s)
- Hamid Mahmood
- Cardiology Department, Northwest General Hospital and Research Centre , Peshawar , Pakistan
| | - Farhan Shahid
- Cardiothoracic Department, Freeman Hospital , Newcastle-Upon-Tyne , UK
| | - Mohaned Egred
- Cardiothoracic Department, Freeman Hospital , Newcastle-Upon-Tyne , UK
| | - Mohamed Farag
- Hammersmith Hospital, Imperial College Healthcare NHS Trust , London , UK
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De Luca L, Rubboli A, Lettino M, Tubaro M, Leonardi S, Casella G, Valente S, Rossini R, Sciahbasi A, Natale E, Trambaiolo P, Navazio A, Cipriani M, Corda M, De Nardo A, Francese GM, Napoletano C, Tizzani E, Nardi F, Roncon L, Caldarola P, Riccio C, Gabrielli D, Oliva F, Massimo Gulizia M, Colivicchi F. ANMCO position paper on antithrombotic treatment of patients with atrial fibrillation undergoing intracoronary stenting and/or acute coronary syndromes. Eur Heart J Suppl 2022; 24:C254-C271. [PMID: 35663586 PMCID: PMC9155223 DOI: 10.1093/eurheartj/suac020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) with or without acute coronary syndromes (ACS) represent a subgroup with a challenging pharmacological management. Indeed, if on the one hand, antithrombotic therapy should reduce the risk related to recurrent ischaemic events and/or stent thrombosis; on the other hand, care must be taken to avoid major bleeding events. In recent years, several trials, which overall included more than 12 000 patients, have been conducted demonstrating the safety of different therapeutic combinations of oral antiplatelet and anticoagulant agents. In the present ANMCO position paper, we propose a decision-making algorithm on antithrombotic strategies based on scientific evidence and expert consensus to be adopted in the periprocedural phase, at the time of hospital discharge, and in the long-term follow-up of patients with AF undergoing PCI with/without ACS.
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Affiliation(s)
- Leonardo De Luca
- Cardiology, Department of Cardio-Thoraco-Vascular, Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense, 87, 00152 Roma, Italy
| | - Andrea Rubboli
- Cardiology, Cardiovascular Department, Ospedale S. Maria delle Croci, Ravenna, Italy
| | - Maddalena Lettino
- Department of Cardiology, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Marco Tubaro
- CCU, Intensive and Interventional Cardiology Department, P.O. San Filippo Neri, Roma, Italy
| | - Sergio Leonardi
- University of Pavia and IRCCS S. Matteo Foundation General Hospital, Pavia, Italy
| | - Gianni Casella
- Cardiology Department, Ospedale Maggiore, Azienda USL di Bologna, Bologna, Italy
| | - Serafina Valente
- Cardio-Thoracic Department, A.O.U. Senese, Ospedale Santa Maria alle Scotte, Siena, Italy
| | - Roberta Rossini
- Emergency Department and Critical Areas, Azienda Ospedaliera Santa Croce e Carle, Cuneo, Italy
| | | | - Enrico Natale
- Cardiology, Department of Cardio-Thoraco-Vascular, Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense, 87, 00152 Roma, Italy
| | - Paolo Trambaiolo
- Cardiology Department, Ospedale Sandro Pertini, ASL RM2, Roma, Italy
| | - Alessandro Navazio
- Hospital Cardiology Department, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, Italy
| | - Manlio Cipriani
- Cardiology 2-Heart Failure and Transplants, Dipartimento Cardiotoracovascolare "A. De Gasperis", ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Marco Corda
- Cardiology Department, Azienda Ospedaliera G. Brotzu, Cagliari, Italy
| | - Alfredo De Nardo
- Cardiology-ICU Department, Ospedale Civile "G. Jazzolino", Vibo Valentia, Italy
| | - Giuseppina Maura Francese
- Cardiology Department, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania, Italy
| | - Cosimo Napoletano
- Cardiology-ICU Department-Cath Lab, Presidio Ospedaliero "G. Mazzini", Teramo, Italy
| | | | - Federico Nardi
- Cardiology Department, Ospedale Santo Spirito, Casale Monferrato (AL), Italy
| | - Loris Roncon
- Cardiology Department, Ospedale Santa Maria della Misericordia, Rovigo, Italy
| | | | - Carmine Riccio
- Follow-up of the Post-Acute Patient, Cardio-Vascular Department, AORN Sant'Anna and San Sebastiano, Caserta, Italy
| | - Domenico Gabrielli
- Cardiology, Department of Cardio-Thoraco-Vascular, Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense, 87, 00152 Roma, Italy
| | - Fabrizio Oliva
- Cardiology 2-Heart Failure and Transplants, Dipartimento Cardiotoracovascolare "A. De Gasperis", ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, Presidio Ospedaliero San Filippo Neri, ASL Roma 1, Roma, Italy
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Cho MS, Kang DY, Oh YS, Lee CH, Choi EK, Lee JH, Kwon CH, Park GM, Park HW, Park KH, Park KM, Hwang J, Yoo KD, Cho YR, Kim YR, Hwang KW, Jin ES, Kim PJ, Kim KH, Park DW, Nam GB. Edoxaban-based long-term antithrombotic therapy in patients with atrial fibrillation and stable coronary disease: Rationale and design of the randomized EPIC-CAD trial. Am Heart J 2022; 247:123-131. [PMID: 35149036 DOI: 10.1016/j.ahj.2022.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/26/2022] [Accepted: 01/29/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Anticoagulants are the standard therapy for patients with atrial fibrillation (AF) and antiplatelet therapy for those with coronary artery disease (CAD). However, compelling clinical evidence is still lacking regarding the long-term maintenance strategy with the combination of anticoagulant and antiplatelet drugs in patients with AF and stable CAD. DESIGN The EPIC-CAD trial is an investigator-initiated, multicenter, open-label randomized trial comparing the safety and efficacy of 2 antithrombotic strategies in patients with high-risk AF (CHA2DS2-VASc score ≥ 2 points) and stable CAD (≥6 months after revascularization for stable angina or ≥12 months for acute coronary syndrome; or medical therapy alone). Patients (approximately N = 1,038) will be randomly assigned at a 1:1 ratio to (1) monotherapy with edoxaban (a non-vitamin K antagonist oral anticoagulant) or (2) combination therapy with edoxaban plus a single antiplatelet agent. The primary endpoint is the net composite outcome of death from any cause, stroke, systemic embolism, myocardial infarction, unplanned revascularization, and major or clinically relevant nonmajor bleeding at 1 year after randomization. RESULTS As of December 2021, approximately 901 patients had been randomly enrolled over 2 years at 18 major cardiac centers across South Korea. The completed enrollment is expected at the mid-term of 2022, and the primary results will be available by 2023. CONCLUSIONS EPIC-CAD is a large-scale, multicenter, pragmatic design trial, which will provide valuable clinical insight into edoxaban-based long-term antithrombotic therapy in patients with high-risk AF and stable CAD.
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Mareev YV, Polyakov DS, Vinogradova NG, Fomin IV, Mareev VY, Belenkov YN, Ageev FT, Artemjeva EG, Badin YV, Bakulina EV, Galyavich AS, Ionova TS, Kamalov GM, Kechedzhieva SG, Koziolova NA, Malenkova VY, Malchikova SV, Smirnova EA, Tarlovskaya EI, Shcherbinina EV, Yakushin SS. Epidemiology of atrial fibrillation in a representative sample of the European part of the Russian Federation. Analysis of EPOCH-CHF study. KARDIOLOGIIA 2022; 62:12-19. [PMID: 35569159 DOI: 10.18087/cardio.2022.4.n1997] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/04/2022] [Indexed: 06/15/2023]
Abstract
Aim To study true prevalence of atrial fibrillation (AF) in a representative sample from the European part of the Russian Federation; to describe characteristics of patients with AF; and to provide the frequency of anticoagulant treatment.Material and methods Cross-sectional data of the EPOCH epidemiological study (2017) were used. Data were collected in 8 constituent entities of the Russian Federation; the sample size was 11 453 people. The sample included all respondents who had given their consent for participation and were older than 10 years. Statistical tests were performed in the R system for statistical data analysis.Results The prevalence of AF in the representative sample from the European part of the Russian Federation was 2.04 %. The AF prevalence increased with age and reached a maximum value of 9.6% in the age group of 80 to 89 years. The AF prevalence among females was 1.5 times higher than among men. With age standardization, the AF prevalence was 18.95 and 21.33 per 1,000 people for men and women, respectively. The AF prevalence increased in the presence of concurrent cardiovascular diseases (CVDs) or diabetes mellitus as well as with an increased number of comorbidities in the same person and reached 70.3 and 60.0 % in patients with 4 and 5 comorbidities, respectively. Patients with AF had a greater number of comorbidities and higher CHA2DS2VASc scores (5.0 vs. 2.0, p<0.001) compared to patients with CVDs without AF. Only 22.6 % of patients with CVD and AF took anticoagulants. Only 23.9% of patients with absolute indications for the anticoagulant treatment received anticoagulants.Conclusion The AF prevalence in the European part of the Russian Federation was 2.04 %; it increased with age and in patients with concurrent CVDs or diabetes mellitus. Most of AF patients (93.2 %) required a mandatory treatment with oral anticoagulants.
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Affiliation(s)
- Yu V Mareev
- National Medical Research Center for Therapy and Preventive Medicine; Medical Research and Educational Center, Lomonosov Moscow State University
| | | | - N G Vinogradova
- Privolzhsky Research Medical University; Municipal Clinical Hospital #38 of the Nizhny Novgorod Region
| | - I V Fomin
- Privolzhsky Research Medical University
| | - V Yu Mareev
- Medical Research and Educational Center, Lomonosov Moscow State University; School of Fundamental Medicine, Lomonosov Moscow State University
| | | | - F T Ageev
- Scientific Medical Research Center of Cardiology
| | | | | | | | | | | | | | | | | | | | | | - E A Smirnova
- Academician Pavlov Ryazan State Medical University
| | | | | | - S S Yakushin
- Academician Pavlov Ryazan State Medical University
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Badescu MC, Badulescu OV, Butnariu LI, Floria M, Ciocoiu M, Costache II, Popescu D, Bratoiu I, Buliga-Finis ON, Rezus C. Current Therapeutic Approach to Atrial Fibrillation in Patients with Congenital Hemophilia. J Pers Med 2022; 12:519. [PMID: 35455634 PMCID: PMC9029474 DOI: 10.3390/jpm12040519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 11/21/2022] Open
Abstract
Cardiovascular disease in hemophiliacs has an increasing prevalence due to the aging of this population. Hemophiliacs are perceived as having a high bleeding risk due to the coagulation factor VIII/IX deficiency, but it is currently acknowledged that they also have an important ischemic risk. The treatment of atrial fibrillation (AF) is particularly challenging since it usually requires anticoagulant treatment. The CHA2DS2-VASc score is used to estimate the risk of stroke and peripheral embolism, and along with the severity of hemophilia, guide the therapeutic strategy. Our work provides the most complete, structured, and updated analysis of the current therapeutic approach of AF in hemophiliacs, emphasizing that there is a growing interest in therapeutic strategies that allow for short-term anticoagulant therapy. Catheter ablation and left atrial appendage occlusion have proven to be efficient and safe procedures in hemophiliacs, if appropriate replacement therapy can be provided.
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Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Oana Viola Badulescu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (O.V.B.); (M.C.)
- Hematology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Lacramioara Ionela Butnariu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mariana Floria
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- Internal Medicine Clinic, “Dr. Iacob Czihac” Emergency Military Clinical Hospital Iasi, 700483 Iasi, Romania
| | - Manuela Ciocoiu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (O.V.B.); (M.C.)
| | - Irina-Iuliana Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Diana Popescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
| | - Ioana Bratoiu
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Oana Nicoleta Buliga-Finis
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
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Liang B, Zhu YC, Gu N. Comparative Safety and Efficacy of Eight Antithrombotic Regimens for Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Front Cardiovasc Med 2022; 9:832164. [PMID: 35387437 PMCID: PMC8978794 DOI: 10.3389/fcvm.2022.832164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/21/2022] [Indexed: 11/20/2022] Open
Abstract
Background Antithrombotic therapy for patients with atrial fibrillation undergoing percutaneous coronary intervention is facing major treatment problems in clinical practice. Methods We firstly conducted a Bayesian network meta-analysis to study the safety and efficacy of different antithrombotic regimens. Only randomized controlled trials from PubMed, Web of Science, Cochrane Central Register of Controlled Trials, Embase, and China National Knowledge Infrastructure were included in our study. The Bayesian random-effects model was used in this study. The primary safety and efficacy outcomes were major bleeding according to the criteria of Thrombolysis In Myocardial Infarction (TIMI) and trial-defined major adverse cardiovascular events, respectively. The secondary safety outcomes were combined TIMI major and minor bleeding, trial-defined primary bleeding events, and intracranial hemorrhage. The secondary efficacy outcomes were all-cause or cardiovascular mortality, myocardial infarction, stroke, stent thrombosis, and hospitalization. Results Total of 11,532 patients from the five randomized controlled trials were analyzed, of whom 8,426 were male. Compared with vitamin K antagonist (VKA) plus P2Y12 inhibitor, the odds ratios (95% credible intervals) for TIMI major bleeding were 1.70 (0.77–3.80) for VKA plus dual antiplatelet therapy (DAPT), 1.20 (0.30–4.60) for rivaroxaban plus P2Y12 inhibitor, 1.00 (0.25–3.90) for rivaroxaban plus DAPT, 0.76 (0.21–2.80) for dabigatran plus P2Y12 inhibitor, 0.71 (0.25–2.10) for apixaban plus P2Y12 inhibitor, 1.40 (0.52–3.80) for apixaban plus DAPT, and 1.00 (0.27–4.00) for edoxaban plus P2Y12 inhibitor. For trial-defined major adverse cardiovascular events, compared with VKA plus P2Y12 inhibitor, the odds ratios (95% credible intervals) were 1.10 (0.61–2.00) for VKA plus DAPT, 1.20 (0.45–3.70) for rivaroxaban plus P2Y12 inhibitor, 1.10 (0.38–3.20) for rivaroxaban plus DAPT, 1.10 (0.43–3.10) for dabigatran plus P2Y12 inhibitor, 1.00 (0.47–2.20) for apixaban plus P2Y12 inhibitor, 0.99 (0.46–2.20) for apixaban plus DAPT, and 1.20 (0.43–3.40) for edoxaban plus P2Y12 inhibitor. Apixaban plus P2Y12 inhibitor was the highest-ranking of safety outcomes and VKA plus P2Y12 inhibitor was the highest-ranking of efficacy outcomes other than trial-defined major adverse cardiovascular events. Conclusion Apixaban plus P2Y12 inhibitor seems to be linked with fewer bleeding complications while retaining antithrombotic efficacy. Moreover, for most efficacy indicators, the ranking of VKA plus P2Y12 inhibitor is still very high. Systematic Review Registration [www.crd.york.ac.uk/prospero/], identifier [CRD42020149894].
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Affiliation(s)
- Bo Liang
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Yong-Chun Zhu
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Ning Gu
- Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
- *Correspondence: Ning Gu,
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Antiplatelet therapy after percutaneous coronary intervention: current status and future perspectives. Cardiovasc Interv Ther 2022; 37:255-263. [PMID: 35237927 DOI: 10.1007/s12928-022-00847-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 12/12/2022]
Abstract
Antiplatelet therapy after percutaneous coronary intervention (PCI) has been changing in parallel with the development of drug-eluting stents (DES) and antiplatelet agents. The recommendation of dual antiplatelet therapy duration is getting shorter due to the decreased risk of stent thrombosis in new-generation DES, the use of a P2Y12 inhibitor as a monotherapy, and the increasing prevalence of high bleeding risk patients. Antithrombotic therapy after PCI has also changed due to the introduction of direct oral anticoagulants. Aspirin-free P2Y12 inhibitor monotherapy is now being evaluated in several prospective studies as a novel strategy of antiplatelet therapy after PCI. This review shows a current status and provides future perspectives for the antiplatelet therapy after PCI.
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Wang W, Huang Q, Pan D, Zheng W, Zheng S. The optimal duration of triple antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome or undergoing percutaneous coronary intervention: A network meta-analysis of randomized clinical trials. Int J Cardiol 2022; 357:33-38. [DOI: 10.1016/j.ijcard.2022.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/15/2022] [Accepted: 03/23/2022] [Indexed: 11/17/2022]
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Towashiraporn K, Krittayaphong R. Current Perspectives on Antithrombotic Therapy for the Treatment of Acute Coronary Syndrome. Int J Gen Med 2022; 15:2397-2414. [PMID: 35264877 PMCID: PMC8901254 DOI: 10.2147/ijgm.s289295] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/03/2022] [Indexed: 12/20/2022] Open
Abstract
Acute coronary syndrome (ACS) is one of the leading causes of death worldwide. Percutaneous coronary intervention (PCI) is the treatment of choice for ACS as this procedure reduces the morbidity and mortality rates of patients in clinical trials and daily practice. However, patients with a history of prior ACS who undergo PCI are still at high risk for recurrent major adverse cardiac events (MACE). Because the antithrombotic drugs reduce the rate of MACE and minimize stent-related complications such as target vessel failure or stent thrombosis, the utilization of these agents is the cornerstone treatment for secondary prevention of ACS patients after PCI. Unfortunately, using the antithrombotic agents may be associated with bleeding complications, including major or fatal bleeding. Therefore, premature discontinuation of antithrombotic regimens regarding the hemorrhagic events is sometimes inevitable and possibly leads to fatal complications such as stent thrombosis. To minimize the bleeding issues, shorten antithrombotic regimens have been proposed, which theoretically offers improved safety. Nevertheless, inappropriate withdrawal of antithrombotic drugs may increase the rate of ischemic events. On the other hand, an unnecessary prolonged antithrombotic regimen may cause avoidable bleeding. Balancing the risk of bleeding against the benefits of using antithrombotic drugs is therefore challenging especially for the patients who contain both bleeding and ischemic risks such as ACS patients who are concomitant using the anticoagulants. Currently, the treatment paradigms are shifting from the “one size fits all approach” toward the “tailored approach”. This means that the antithrombotic regimens can be adjustable individually. As a result, various clinical risk scoring systems have been established to help physicians with their decision-making. However, besides the development of these dedicated scoring tools, clinical judgment for balancing the safety versus the efficacy before deciding on the antithrombotic plan is still imperative.
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Affiliation(s)
- Korakoth Towashiraporn
- Her Majesty Cardiac Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rungroj Krittayaphong
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Correspondence: Rungroj Krittayaphong, Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand, Tel +66 2-419-6104, Fax +66 2-412-7412, Email
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Roy AT, Schwamm LH, Singhal AB. Use of Prolonged Cardiac Rhythm Monitoring to Identify Atrial Fibrillation After Cryptogenic Stroke. Curr Cardiol Rep 2022; 24:337-346. [PMID: 35171442 DOI: 10.1007/s11886-022-01652-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Prolonged cardiac monitoring (PCM) improves detection of atrial fibrillation (AF) after cryptogenic stroke. We summarize current research supporting the use of PCM as part of the cryptogenic stroke evaluation, while highlighting areas that require more investigation. RECENT FINDINGS Despite increased AF detection with longer durations of PCM, more definitive research is needed to demonstrate how PCM improves clinical outcomes. The optimal type, timing, and length of cardiac monitoring after cryptogenic stoke remains unknown. Clinical calculators will be important to risk stratify which cryptogenic stroke patients are most likely to benefit from PCM. Currently, AF detection after cryptogenic stroke should prompt consideration of anticoagulation, but it is unclear if all durations and timing of AF after stroke should be treated the same. PCM remains an important part of the cryptogenic stroke work up, and detection of AF allows for anticoagulation initiation. Additional research is needed to further refine our application of PCM to cryptogenic stroke.
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Affiliation(s)
- Alexis T Roy
- Stroke Service, Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Lee H Schwamm
- Stroke Service, Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Aneesh B Singhal
- Stroke Service, Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
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Xu Z, Chen N, Sun H, Jiang T, Deng Q, Zhou J, Zhang Y. Dual Antiplatelet Therapy in Patients With Minor Stroke Receiving Intravenous Thrombolysis. Front Neurol 2022; 13:819896. [PMID: 35185771 PMCID: PMC8854355 DOI: 10.3389/fneur.2022.819896] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/07/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionConcern over the potential severe bleeding risk of dual antiplatelet therapy for patients with minor stroke after intravenous thrombolysis (IVT) leads to different antiplatelet strategies in the secondary prevention of stroke. Our aim was to investigate the effect of dual antiplatelet therapy on patients with minor ischemic stroke receiving IVT.MethodsFrom November 2016 to April 2021, a total of 855 consecutive patients who received IVT were observed. We collected and analyzed demographic characteristics, medical history, clinical information, and important time metrics of patients with minor ischemic stroke. Comparative and multivariate logistic regression analyses were used to explore the clinical significance of single or dual antiplatelet therapy after IVT. Propensity score matching analyses (1:1 matching including baseline characteristics of patients) were also performed.ResultsA total of 245 patients were enrolled in the study (118 patients in the single antiplatelet therapy group and 127 patients in the dual antiplatelet group). No significant difference was found in baseline characteristics except stroke etiology (p < 0.001) for patients with minor stroke. The dual antiplatelet group showed a higher proportion of 90-day modified Rankin Scale (mRS) (0–1) than the single antiplatelet group (p = 0.030). Furthermore, patients receiving dual antiplatelet therapy had excellent outcomes (90-day mRS 0–1) after adjustment (odds ratio [OR] 2.76, 95% CI 1.27–6.01, p = 0.010). Other secondary outcomes (recurrent stroke within 90 days, symptomatic intracerebral hemorrhage, and early neurological deterioration) were not significantly different between the two groups. These findings were generally consistent in propensity score analyses.ConclusionsDual antiplatelet therapy may be a potential therapeutic approach in patients with minor stroke receiving IVT. Further randomized controlled trials are required to confirm this finding.
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Affiliation(s)
- Zhaohan Xu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Nihong Chen
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Neurology, Nanjing Yuhua Hospital, Yuhua Branch of Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Huiling Sun
- General Clinical Research Centre, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Teng Jiang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Qiwen Deng
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Qiwen Deng
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Junshan Zhou
| | - Yingdong Zhang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- *Correspondence: Yingdong Zhang ;
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Is There a Role for Triple Therapy After ACS? Curr Cardiol Rep 2022; 24:191-200. [PMID: 35112242 DOI: 10.1007/s11886-022-01634-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The optimal antithrombotic strategy in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) remains the subject of controversy. In this article, we review the current evidence for the use of triple therapy in acute coronary syndrome (ACS) patients. RECENT FINDINGS The recently published trials of AF patients undergoing PCI have shown that combination of non-vitamin K oral anticoagulants (NOACs) with an antiplatelet agent is either superior or non-inferior to vitamin K antagonist (VKA) plus dual antiplatelet therapy (DAPT) in reducing bleeding complications with no difference in regard to thromboembolic events. Currently, the use of dual therapy (preferably with a NOAC and clopidogrel) is recommended over triple therapy in these patients. The optimal duration should be guided by the assessment of an individual's risk of thrombosis and bleeding events.
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Antithrombotic Strategies in Patients with Atrial Fibrillation and Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention. J Clin Med 2022; 11:jcm11030512. [PMID: 35159964 PMCID: PMC8836736 DOI: 10.3390/jcm11030512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 02/04/2023] Open
Abstract
Patients with atrial fibrillation (AF) are at increased risk for coronary artery disease (CAD). After percutaneous coronary intervention (PCI), the antithrombotic therapy consists of a combination of anticoagulant and antiplatelet agents to reduce the ischemic and thromboembolic risk, at the cost of increased bleeding events. In the past few years, several randomized clinical trials involving over 12,000 patients have been conducted to compare the safety of vitamin K antagonist (VKA) and direct-acting oral anticoagulants (DOACs) in association with a single- or double-antiplatelet agent, in the so-called dual- (DAT) or triple-antithrombotic therapy (TAT). These studies and several meta-analyses showed a consistent benefit for reducing bleeding events of DAT over TAT and of DOAC over VKA, without concerns about ischemic endpoints, except for a trend for increased stent thrombosis risk. The present paper examines current international guidelines’ recommendations and reviews clinical trials, meta-analyses, and observational studies conducted on AF patients treated with DAT or TAT after PCI for acute coronary syndromes.
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Secondary Prevention of Cardioembolic Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00064-8] [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]
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70
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Gutierrez C, Hatamy E. Cardiac Arrhythmias. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Fanaroff AC, Li S, Marquis-Gravel G, Giri J, Lopes RD, Piccini JP, Wang TY. Atrial Fibrillation and Coronary Artery Disease: A Long-Term Perspective on the Need for Combined Antithrombotic Therapy. Circ Cardiovasc Interv 2021; 14:e011232. [PMID: 34932388 DOI: 10.1161/circinterventions.121.011232] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Older adults with atrial fibrillation (AF) are often treated with the shortest possible duration of antiplatelet/anticoagulant therapy after myocardial infarction (MI) or percutaneous coronary intervention (PCI) due to concern for bleeding. However, the risk of recurrent MI or PCI prompting antiplatelet therapy extension is unknown in this population. METHODS Using the National Cardiovascular Data Registry linked to Medicare claims, we described the cumulative incidence of recurrent MI or PCI over a median of 7-year follow-up for patients ≥65 years old with AF discharged alive after acute MI between 2008 and 2017. We used pharmacy fill data to describe the proportion of patients filling prescriptions for both oral anticoagulants and P2Y12 inhibitors for ≥50% of the indicated duration after MI or PCI. RESULTS Of 187 622 older patients discharged alive after MI, 50 539 (26.9%) had AF. Over a median of 7-year follow-up in patients with AF, the cumulative incidence was 14.5% for recurrent MI, 12.1% for PCI, 7.9% for stroke, and 9.5% for bleeding hospitalization. Among 7998 patients with AF and recurrent MI or PCI, 1668 (20.9%) had >1 MI or PCI during follow-up. Assuming each MI or PCI should be followed by 6 months of P2Y12 inhibitor therapy, patients with AF who had a recurrent MI/PCI had a median estimated indication for antiplatelet/anticoagulant treatment of 287 days (194, 358), but filled both P2Y12 inhibitor and oral anticoagulant for a median of 0 days (0, 21). In this cohort, 12.2% of patients filled prescriptions for both a P2Y12 inhibitor and oral anticoagulant for ≥50% of the indicated duration. CONCLUSIONS Older adults with AF and MI have high incidences of downstream recurrent MI or PCI requiring extended antiplatelet/anticoagulant therapy durations, yet many appear to be under-treated. These results highlight the need for better thrombosis prevention strategies in this group of patients.
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Affiliation(s)
- Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute of Health Economics, Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia (A.C.F., J.G.)
| | - Shuang Li
- Duke Clinical Research Institute (S.L., G.M.-G., R.D.L., J.P.P., T.Y.W.), Duke University, Durham, NC
| | - Guillaume Marquis-Gravel
- Duke Clinical Research Institute (S.L., G.M.-G., R.D.L., J.P.P., T.Y.W.), Duke University, Durham, NC
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute of Health Economics, Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia (A.C.F., J.G.)
| | - Renato D Lopes
- Duke Clinical Research Institute (S.L., G.M.-G., R.D.L., J.P.P., T.Y.W.), Duke University, Durham, NC.,Department of Medicine (R.D.L., J.P.P., T.Y.W.), Duke University, Durham, NC
| | - Jonathan P Piccini
- Duke Clinical Research Institute (S.L., G.M.-G., R.D.L., J.P.P., T.Y.W.), Duke University, Durham, NC.,Department of Medicine (R.D.L., J.P.P., T.Y.W.), Duke University, Durham, NC
| | - Tracy Y Wang
- Duke Clinical Research Institute (S.L., G.M.-G., R.D.L., J.P.P., T.Y.W.), Duke University, Durham, NC.,Department of Medicine (R.D.L., J.P.P., T.Y.W.), Duke University, Durham, NC
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Sotomi Y, Kozuma K, Kashiwabara K, Higuchi Y, Ando K, Morino Y, Ako J, Tanabe K, Muramatsu T, Nakazawa G, Hikoso S, Sakata Y. Randomised controlled trial to investigate optimal antithrombotic therapy in patients with non-valvular atrial fibrillation undergoing percutaneous coronary intervention: a study protocol of the OPTIMA-AF trial. BMJ Open 2021; 11:e048354. [PMID: 34907043 PMCID: PMC8671924 DOI: 10.1136/bmjopen-2020-048354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The optimal antithrombotic strategy for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is uncertain. For patients with non-AF, many trials are now evaluating short 1-month dual antiplatelet therapy. In patients with AF undergoing PCI, in contrast, short dual therapy (P2Y12 inhibitor +direct oral anticoagulant (DOAC)) has not yet been evaluated. METHODS AND ANALYSIS The OPTIMA-AF trial (OPTIMAl antiplatelet therapy in combination with direct oral anticoagulants in patients with non-valvular Atrial Fibrillation undergoing percutaneous coronary intervention with everolimus-eluting stent) is an investigator-initiated, open-label, nationwide, multicentre, prospective, randomised controlled trial. The primary objective is to compare the efficacy and safety of short dual therapy (1-month DOAC +P2Y12 inhibitor followed by DOAC monotherapy) against long dual therapy (12-month DOAC +P2Y12 inhibitor followed by DOAC monotherapy) in the treatment of AF subjects undergoing PCI. The primary efficacy endpoint is a composite of death or thromboembolic events (myocardial infarction, definite stent thrombosis, stroke or systemic embolism) at 365 days; and the primary safety endpoint is bleeding (International Society on Thrombosis and Haemostasis major or clinically relevant non-major bleeding) at 365 days. This trial is intended to show the non-inferiority of short dual therapy versus long dual therapy in terms of the primary efficacy endpoint and show superiority in terms of the primary safety endpoint. A total of 1090 subjects will be randomised in a 1:1 ratio at approximately 60 sites. ETHICS AND DISSEMINATION This study received approval from the Certified Review Board of Osaka University (a certified research ethics committee by the Japanese Clinical Research Act). The findings will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER Japan Registry of Clinical Trials: jRCTs051190053; Pre-results.
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Affiliation(s)
- Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ken Kozuma
- Department of Medicine, Division of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Kosuke Kashiwabara
- Department of Biostatistics, School of Public Health, University of Tokyo, Tokyo, Japan
| | | | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Yoshihiro Morino
- Department of Internal Medicine, Division of Cardiology, Iwate Medical University, Iwate, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kengo Tanabe
- Department of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Takashi Muramatsu
- Department of Cardiology, Fujita Health University School of Medicine, Aichi, Japan
| | - Gaku Nakazawa
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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Lee OH, Kim Y, Cho DK, Kim JS, Kim BK, Choi D, Hong MK, Jeong MH, Jang Y. Temporal Trends of Antithrombotic Therapy in Patients With Acute Myocardial Infarction and Atrial Fibrillation: Insight From the KAMIR-NIH Registry. Front Cardiovasc Med 2021; 8:762090. [PMID: 34901221 PMCID: PMC8655723 DOI: 10.3389/fcvm.2021.762090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/05/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Triple therapy is the combination of dual antiplatelet therapy plus oral anticoagulant after stent implantation. Current guidelines recommend triple therapy for acute coronary syndrome with atrial fibrillation (AF). This study aimed to identify temporal trends of antithrombotic therapy in patients with acute myocardial infarction (AMI) and AF. Methods: Among 13,104 consecutive patients from the Korea Acute Myocardial Infarction Registry-National Institute of Health (KAMIR-NIH) registry, we identified 453 patients with AF after stent implantation for AMI; these patients were then divided into those who did and did not use oral anticoagulant (OAC) [OAC group (n = 71) vs. non-OAC group (n = 382), respectively]. Results: The results showed that the prevalence of AF in AMI patients was 5.4% (712/13,104). Among 453 patients, only 15.7% (71/453) were treated with OAC while dual or single antiplatelet therapy was provided for 84.7% (382/453) of patients. In patients with high stroke risk (CHA2DS2-VASc score ≥ 2), OACs were used only in 17% (69/406). Multivariate analysis revealed that female sex [odds ratio (OR) 2.11; 95% CI: 1.17–3.79], diabetes mellitus (DM) (OR 2.37; 95% CI: 1.35–4.17), prior cerebrovascular accident (CVA) (OR 4.19; 95% CI: 2–8.75), and congestive heart failure (CHF) (OR 1.89; 95% CI: 1.09–3.3) as the significant determinants of OAC use. Conclusion: The study concluded that OAC was underused. Approximately, 15%, of AMI patients with AF undergoing PCI with stent and female gender, DM, prior CVA history, and a history of CHF or the presence of moderate to severe left ventricle systolic impairment were significant determinants of OAC use.
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Affiliation(s)
- Oh-Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, South Korea
| | - Yongcheol Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, South Korea
| | - Deok-Kyu Cho
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, South Korea
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Donghoon Choi
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, South Korea
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Myung Ho Jeong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Yangsoo Jang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
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Bir S, Kelley RE. Antithrombotic Therapy in the Prevention of Stroke. Biomedicines 2021; 9:1906. [PMID: 34944719 PMCID: PMC8698439 DOI: 10.3390/biomedicines9121906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/09/2021] [Accepted: 12/11/2021] [Indexed: 11/24/2022] Open
Abstract
OVERVIEW Ischemic stroke is a leading cause of death and disability throughout the world. Antithrombotic therapy, which includes both antiplatelet and anticoagulant agents, is a primary medication of choice for the secondary prevention of stroke. However, the choices vary with the need to incorporate evolving, newer information into the clinical scenario. There is also the need to factor in co-morbid medical conditions as well as the cost ramifications for a particular patient as well as compliance with the regimen. Pertinent Updates: In the acute setting, dual antiplatelet therapy from three weeks to up to three months has become recognized as a reasonable approach for patients with either minor stroke or transient ischemic attack or those with symptoms associated with higher-grade intracranial stenosis. This approach is favored for non-cardioembolic stroke as a cardiogenic mechanism tends to be best managed with attention to the cardiac condition as well as anticoagulant therapy. Risk stratification for recurrent stroke is important in weighing potential risk versus benefits. For example, prolonged dual antiplatelet therapy, with a combination such as aspirin and clopidogrel or aspirin and ticagrelor, tends to have negation of the potential clinical benefit of stroke prevention, over time, by the enhanced bleeding risk. Anticoagulant choices are now impacted by newer agents, initially identified as novel oral anticoagulants (NOACs), which also became associated with "non-vitamin K" agents as they are no longer considered novel. Alternatively, they are now often identified as direct oral anticoagulants (DOACs). They tend to be viewed as superior or non-inferior to warfarin with the caveat that warfarin is still viewed as the agent of choice for stroke prevention in patients with mechanical heart valves. CONCLUSION Based upon cumulative information from multiple clinical trials of secondary prevention of stroke, there is an increasing array of approaches in an effort to provide optimal management. Antithrombotic therapy, including in combination with anticoagulant therapy, continues to evolve with the general caveat that "one size does not fit all". In view of this, we desire to provide an evidence-based approach for the prevention of stroke with antithrombotic agents.
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Affiliation(s)
| | - Roger E. Kelley
- Department of Neurology, Ochsner/LSU Health Sciences Center, Shreveport, LA 71130, USA;
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Lee CC, Chang CH, Hung Y, Lin CS, Yang SP, Cheng SM, Yu FH, Lin WS, Lin WY. Changes of antithrombotic prescription in atrial fibrillation patients with acute coronary syndrome or percutaneous coronary intervention and the subsequent impact on long-term outcomes: a longitudinal cohort study. Thromb J 2021; 19:100. [PMID: 34906162 PMCID: PMC8670061 DOI: 10.1186/s12959-021-00353-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 11/28/2021] [Indexed: 01/08/2023] Open
Abstract
Objectives The choice of optimal antithrombotic therapy in atrial fibrillation (AF) patients with acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) remains controversial. The aim of this longitudinal cohort study is to investigate the prescribing pattern of antithrombotic regimen in different cohorts and its subsequent impact. Setting and design Longitudinal data from the Tri-Service General Hospital-Coronary Heart Disease (TSGH-CHD) registry, between January 2016 and August 2018 was screened. Participants and method Patients with prior history of nonvalvular AF, who had ACS presentation or underwent PCI were selected, and these patients were divided into cohort 1 and cohort 2, according to the index date of antithrombotic prescription before and after the PIONEER AF-PCI study. Primary and secondary outcomes The primary safety endpoints were composites of major bleeding and/or clinically relevant non-major bleeding. The secondary efficacy endpoints included the occurrence of all-cause mortality, stroke/systemic embolization, nonfatal myocardial infarction (MI), and >30-days coronary revascularization. Results A total of 121 patients were included into analysis (cohort 1=35; cohort 2=86). Comparing with cohort 1, the prescription rate of triple antithrombotic therapy (TAT) increased from 17.1 to 38.4%, especially the regimen with dual antiplatelet therapy (DAPT) plus low-dose non-vitamin-K dependent oral anticoagulation (NOAC). However, the prescription rate of dual antithrombotic therapy (DAT) decreased (14.3–10.5%), as well as the prescription rate of DAPT (68.6–51.2%). These changes of antithrombotic prescription across different cohorts were not associated with risk of adverse safety (HR= 0.87; 95% CI, 0.42-1.80, p=0.710) and efficacy outcomes (HR=0.96; 95% CI, 0.40-2.32, p=0.930). Conclusions Entering the NOAC era, the prescription of TAT increased alongside the decrease in DAT. As the prescription rate of DAPT without anticoagulation remained high, future efforts are mandatory to improve the implementation of guidelines and clinical practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-021-00353-z.
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Affiliation(s)
- Chiao-Chin Lee
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chiao-Hsiang Chang
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yuan Hung
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin-Sheng Lin
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Ping Yang
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shu-Meng Cheng
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Fan-Han Yu
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Shiang Lin
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wen-Yu Lin
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan. .,Division of Cardiology, Department of Internal Medicine Tri-Service General Hospital, National Defense Medical Center, No. 325, Cheng-Gong Road, Section 2, Neihu 114, Taipei, Taiwan.
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Fanaroff AC, Lopes RD. The role of triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention. Prog Cardiovasc Dis 2021; 69:11-17. [PMID: 34883097 DOI: 10.1016/j.pcad.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
Dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel forms the backbone of secondary prevention in patients with acute coronary syndromes (ACS) or who undergo percutaneous coronary intervention (PCI), but in patients with atrial fibrillation (AF), oral anticoagulation (OAC) is superior to antiplatelet therapy for the prevention of stroke and systemic embolism. Patients with AF who undergo PCI or have an ACS event therefore have an indication for both OAC and DAPT, so-called triple antithrombotic therapy. However, observational analyses have shown that the annual rate of major bleeding on triple therapy exceeds 10%. For this reason, five major randomized clinical trials have compared double antithrombotic therapy with OAC and a P2Y12 inhibitor versus triple therapy in patients with AF who underwent PCI or had an ACS event. Each of the trials showed that double antithrombotic therapy reduced the rate of major and clinically relevant non-major bleeding compared with triple therapy and was non-inferior for prevention of ischemic events, including cardiovascular death, myocardial infarction, or stroke. In the one trial that directly compared warfarin with a non-vitamin K antagonist oral anticoagulant (NOAC), apixaban reduced the rate of major or clinically relevant non-major bleeding compared with warfarin and was non-inferior with respect to prevention of ischemic events. As a result of these trials, consensus guidelines recommend that patients with AF who undergo PCI or have an ACS event should be treated with triple antithrombotic therapy (OAC + P2Y12 inhibitor + aspirin) for 7 days or less, followed by double antithrombotic therapy (OAC + P2Y12 inhibitor) for 6 to 12 months.
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Affiliation(s)
- Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute, and Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Renato D Lopes
- Division of Cardiovascular Medicine and Duke Clinical Research Institute, Durham, NC, United States of America.
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Lemesle G, Bauters C, Bonello L, Fauchier L, Cayla G, Marijon E, Guenoun M, Schurtz G, Ninni S, Richardson M, Albert F, Cohen S, Lamblin N, Danchin N. Management of antithrombotics in situations with a gap in evidence: A national French survey focusing on patients with coronary artery disease and atrial fibrillation. Int J Cardiol 2021; 348:15-21. [PMID: 34864080 DOI: 10.1016/j.ijcard.2021.11.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/21/2021] [Accepted: 11/29/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND If several randomized studies allowed to better apprehend what should be the best antithrombotic strategy in patients with concomitant coronary artery disease (CAD) and atrial fibrillation (AF), there are still several clinical situations with a gap of evidence. METHODS We conducted a national French survey in September-October 2020 among cardiologists in order to assess what are daily practices regarding the antithrombotic management in several specific clinical settings where no or little scientific evidence is available. The questionnaires were built by a committee of 6 cardiologists routinely involved in the field of CAD and/or AF. RESULTS Among the 6388 French cardiologists, 483 (7.6%) cardiologists participated to the survey. The rate of participation was rather homogeneous across the country. The mean age of participants was 48 +/- 12.7. There were 134 women (27.7%) and 349 men. Altogether, 181 (37.5%) cardiologists worked in private, 153 (31.7%) in non-universitary public and 83 (17.2%) in universitary public centers. The remaining had shared activity. Among the participants, 150 were interventional (coronary) cardiologists (31.1%). Others were general cardiologists (n = 229), specialists in the field of rhythmology (n = 43), heart failure (n = 17) or imaging (n = 44). The survey consisted of 10 questions pertaining to 2 virtual clinical scenarios. CONCLUSIONS The present survey is an illustration of how therapeutic decisions may vary in such situations with little or no scientific evidence. Such surveys may help experts to build consensus (answers with little variability) and to target the need for future trials and more research (answers with a lot of variability).
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Affiliation(s)
- Gilles Lemesle
- Heart and Lung Institute, University hospital of Lille, F-59000 Lille, France; Univ. Lille, F-59000, France; Institut Pasteur of Lille, Inserm U1011, F-59000 Lille, France; FACT (French Alliance for Cardiovascular Trials), F-75000 Paris, France.
| | - Christophe Bauters
- Heart and Lung Institute, University hospital of Lille, F-59000 Lille, France; Institut Pasteur of Lille, Inserm U1167, F-59000 Lille, France; Univ. Lille, F-59000, France
| | - Laurent Bonello
- Aix-Marseille Univ, Intensive care unit, Department of Cardiology, Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France; Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Marseille, France; Centre for CardioVascular and Nutrition research (C2VN), INSERM 1263, INRA 1260, Marseille, France
| | - Laurent Fauchier
- Department of Cardiology, CHU de Trousseau, University François-Rabelais, 37170 Chambray-lès-, Tours, France
| | - Guillaume Cayla
- Department of Cardiology, University Hospital of Nîmes, 30000 Nîmes, France
| | - Eloi Marijon
- Department of Cardiology, Hôpital Européen Georges Pompidou, AP-HP, University of Paris, Paris, France
| | - Maxime Guenoun
- Department of Cardiology, Hôpital Européen de Marseille, 13003 Marseille, France
| | - Guillaume Schurtz
- Heart and Lung Institute, University hospital of Lille, F-59000 Lille, France
| | - Sandro Ninni
- Heart and Lung Institute, University hospital of Lille, F-59000 Lille, France; Univ. Lille, F-59000, France; Institut Pasteur of Lille, Inserm U1011, F-59000 Lille, France; FACT (French Alliance for Cardiovascular Trials), F-75000 Paris, France
| | - Marjorie Richardson
- Heart and Lung Institute, University hospital of Lille, F-59000 Lille, France
| | - Franck Albert
- Department of Cardiology, Hospital of Chartres, 28000 Chartres, France
| | - Serge Cohen
- Department of Cardiology, Hôpital St Antoine, APHP, Paris, France
| | - Nicolas Lamblin
- Heart and Lung Institute, University hospital of Lille, F-59000 Lille, France; Institut Pasteur of Lille, Inserm U1167, F-59000 Lille, France; Univ. Lille, F-59000, France
| | - Nicolas Danchin
- Department of Cardiology, Hôpital Européen Georges Pompidou, AP-HP, University of Paris, FACT (French Alliance for Cardiovascular Trials), Paris, France
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Amano M, Miyake M, Kitai T, Obayashi Y, Takegami M, Nishimura K, Furukawa Y, Izumi C. Additional Effects of Antiplatelet Therapy on Anticoagulant Agents in Patients With Bioprosthetic Valves and Atrial Fibrillation. Circ J 2021; 86:415-424. [PMID: 34853280 DOI: 10.1253/circj.cj-21-0716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The additional effects of single-antiplatelet therapy (SAPT) on anticoagulant therapy are still unclear in patients with atrial fibrillation (AF) after bioprosthetic valve replacement.Methods and Results:We conducted a subanalysis of a multicenter, retrospective, observational registry of patients with bioprosthetic valves and AF in Japan. Patients administered anticoagulants alone comprised the ACA group (n=107), and patients given concomitant SAPT and anticoagulant therapy comprised the On SAPT group (n=82). The primary efficacy endpoint was the incidence of stroke/systemic embolism, and the primary safety endpoint was the incidence of major bleeding. The observation period was 46.3±24.6 months. The primary efficacy endpoint occurred in 12 patients, and the cumulative incidence of primary efficacy events was significantly higher in the ACA group compared with the On SAPT group (P=0.039). The primary safety endpoint occurred in 22 patients, and the cumulative incidence of primary safety events was similar between groups (P=0.66). No differences between the groups were observed for cardiac events. CONCLUSIONS Additional SAPT on anticoagulant therapy in patients with bioprosthetic valves and AF was associated with a reduction in stroke/systemic embolic events, although the cumulative incidence of bleeding was similar, regardless of additional SAPT. These findings suggest that additional SAPT on anticoagulant therapy may be safe and effective in real-world clinical settings.
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Affiliation(s)
- Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Takeshi Kitai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.,Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Yuki Obayashi
- Department of Cardiology, Tenri Hospital.,Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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Shao QY, Wang ZJ, Ma XT, Lin XZ, Pan L, Zhou YJ. Stroke of antiplatelet and anticoagulant therapy in patients with coronary artery disease: a meta-analysis of randomized controlled trials. BMC Cardiovasc Disord 2021; 21:574. [PMID: 34852763 PMCID: PMC8638430 DOI: 10.1186/s12872-021-02384-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We performed a meta-analysis sought to investigate the risk of stroke with antiplatelet and anticoagulant therapies among patients with coronary artery disease (CAD). METHODS We searched PubMed, EMBASE, and Cochrane Library for randomized controlled trials from January 1995 to March 2020. Studies were retrieved if they reported data of stroke for patients with CAD and were randomized to receive intensive versus conservative antithrombotic therapies, including antiplatelet and oral anticoagulant (OAC). Analyses were pooled by random-effects modeling. A total of 42 studies with 301,547subjects were enrolled in this analysis. RESULTS Intensive antithrombotic therapy significantly reduced risk of all stroke (RR 0.86, 95% CI 0.80-0.94) and ischemic stroke (RR 0.80, 95% CI 0.71-0.91), but increased risk of hemorrhagic stroke (RR 1.36, 95% CI 1.00-1.86) and intracranial hemorrhage (RR 1.46, 95% CI 1.17-1.81). Subgroup analyses indicated that OAC yields more benefit to all stroke than antiplatelet therapy (OAC: RR 0.73, 95% CI 0.58-0.92; Antiplatelet: RR 0.90, 95% CI 0.83-0.97; Between-group heterogeneity P value = 0.030). The benefit of antiplatelet therapy on all stroke and ischemic stroke were mainly driven by the studies comparing longer versus shorter duration of dual antiplatelet therapy (All stroke: RR 0.86, 95% CI 0.78-0.95; ischemic stroke: RR 0.84, 95% CI 0.75-0.94). CONCLUSIONS Among CAD patients who have already received antiplatelet therapy, either strengthening antiplatelet or anticoagulant treatments significantly reduced all stroke, mainly due to the reduction of ischemic stroke, although it increased the risk of hemorrhagic stroke and intracranial hemorrhage. OAC yields more benefit to all stroke than antiplatelet therapy.
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Affiliation(s)
- Qiao Yu Shao
- Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing, China
| | - Zhi Jian Wang
- Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing, China. .,Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Avenue #2, Chaoyang District, Beijing, 100029, China.
| | - Xiao Teng Ma
- Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing, China
| | - Xu Ze Lin
- Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing, China
| | - Liu Pan
- Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing, China
| | - Yu Jie Zhou
- Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing, China
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Dawwas GK, Barnes GD, Dietrich E, Cuker A, Leonard CE, Genuardi MV, Lewis JD. Cardiovascular and major bleeding outcomes with antiplatelet and direct oral anticoagulants in patients with acute coronary syndrome and atrial fibrillation: A population-based analysis. Am Heart J 2021; 242:71-81. [PMID: 34450051 DOI: 10.1016/j.ahj.2021.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are replacing warfarin for stroke prevention in patients with atrial fibrillation (AF). OBJECTIVE To assess the effectiveness and safety of concomitant treatment with antiplatelet-DOAC compared to antiplatelet-warfarin in patients with acute coronary syndrome (ACS) and AF. DESIGN Retrospective propensity score-matched cohort study using United States-based commercial healthcare database from January 2016 to June 2019. PARTICIPANTS New-users of antiplatelet-DOAC and antiplatelet-warfarin who initiated the combined therapy within 30 days following incident ACS diagnosis. MEASUREMENTS Primary study outcomes were recurrent cardiovascular diseases (CVD) (ie, a composite of stroke and myocardial infarction) and major bleeding events identified via discharge diagnoses. We controlled for potential confounders via propensity score matching (PSM). We generated marginal hazard ratios (HRs) via Cox proportional hazards regression using a robust variance estimator while adjusting for calendar time. RESULTS After PSM, a total of 2,472 persons were included (1,236 users of antiplatelet-DOAC and 1,236 users of antiplatelet-warfarin). The use of antiplatelet-DOAC (vs. antiplatelet-warfarin) was associated with a reduced rate of recurrent CVD (adjusted HR 0.72, 95% confidence interval [CI], 0.56-0.92) and major bleeding events (adjusted HR, 0.49, 95% CI 0.33-0.72). LIMITATIONS Residual confounding. CONCLUSIONS In real-world data of AF patients with concurrent ACS, the use of antiplatelet-DOAC following ACS diagnosis was associated with a lower rate of recurrent CVD and major bleeding events compared with antiplatelet-warfarin. These findings highlight a potential promising role for DOACs in patients with ACS and AF requiring combined antiplatelet therapy.
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Chao T, Joung B, Takahashi Y, Lim TW, Choi E, Chan Y, Guo Y, Sriratanasathavorn C, Oh S, Okumura K, Lip GYH. 2021 Focused update of the 2017 consensus guidelines of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation. J Arrhythm 2021; 37:1389-1426. [PMID: 34887945 PMCID: PMC8637102 DOI: 10.1002/joa3.12652] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/22/2021] [Indexed: 12/19/2022] Open
Abstract
The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The Practice Guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of AF Better Care (ABC) pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian patients with AF with single 1 stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the "coronavirus disease 2019" (COVID-19) pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.
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Affiliation(s)
- Tze‐Fan Chao
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- Institute of Clinical Medicine, and Cardiovascular Research CenterNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Boyoung Joung
- Division of CardiologyDepartment of Internal MedicineYonsei University College of MedicineSeoulRepublic of Korea
| | - Yoshihide Takahashi
- The Department of Advanced Arrhythmia ResearchTokyo Medical and Dental UniversityTokyoJapan
| | - Toon Wei Lim
- National University Heart CentreNational University HospitalSingaporeSingapore
| | - Eue‐Keun Choi
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
| | - Yi‐Hsin Chan
- Microscopy Core LaboratoryChang Gung Memorial HospitalLinkouTaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
- Microscopy Core LaboratoryChang Gung Memorial HospitalLinkouTaoyuanTaiwan
| | - Yutao Guo
- Pulmonary Vessel and Thrombotic DiseaseChinese PLA General HospitalBeijingChina
| | | | - Seil Oh
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
| | - Ken Okumura
- Division of CardiologySaiseikai Kumamoto HospitalKumamotoJapan
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool & Liverpool Heart and Chest HospitalLiverpoolUK
- Aalborg Thrombosis Research UnitDepartment of Clinical MedicineAalborg UniversityAalborgDenmark
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Valle FH, Goodman SG, Tan M, Ha A, Mansour S, Welsh RC, Yan AT, Bainey KR, Rinfret S, Potter BJ, Khan R, Simkus G, Natarajan MK, Schwalm J, Daneault B, Eisenberg MJ, Abunassar J, Har B, Gregoire J, Tanguay JF, Overgaard CB, Dery JP, De Larochelliere R, Paradis JM, Madan M, Elbarouni B, So DY, Quraishi AUR, Bagai A. Antithrombotic Therapy After Percutaneous Coronary Intervention in Patients With Atrial Fibrillation: Findings From the CONNECT AF+PCI Study. CJC Open 2021; 3:1419-1427. [PMID: 34993453 PMCID: PMC8712598 DOI: 10.1016/j.cjco.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 07/02/2021] [Indexed: 11/29/2022] Open
Abstract
Background In patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI), selecting an antithrombotic regimen requires balancing risks of ischemic cardiac events, stroke, and bleeding. Methods We studied 467 patients with AF undergoing PCI in the time period from December 2015 to July 2018 identified via a chart audit by 47 Canadian cardiologists in the CONNECT AF+PCI (the Coordinated National Network to Engage Interventional Cardiologists in the Antithrombotic Treatment of Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention) study, to determine patterns of initial antithrombotic therapy selection. Results The median (25th, 75th percentile) CHADS2 score was 2 (1, 3), and PCI was performed in the setting of acute coronary syndrome in 62.1%. Triple antithrombotic therapy (TAT) was the initial treatment in 62.7%, dual-pathway therapy in 25.7%, and dual antiplatelet therapy in 11.6%, with a temporal increase in use of dual-pathway therapy during the course of the study; median intended TAT duration was 1 (1, 3) month. Compared with patients selected for TAT, patients selected for dual-pathway therapy were less likely to have prior myocardial infarction (35.8% vs 25.8%, P = 0.045) and prior PCI (33.8% vs 23.3%, P = 0.03), and they received shorter total length of stents (38 [23, 56] vs 30 [20, 46] mm, P = 0.03). Patients selected for dual-pathway therapy had a higher prevalence of prior stroke/transient ischemic attack (13.0% vs 23.3%, P = 0.01). There was no difference in prevalence of anemia (21.5% vs 25.8%, P = 0.30). Use of dual-pathway therapy was similar among patients with acute coronary syndrome and those with stable disease (24.1% vs 28.2%, P = 0.32). Conclusions Approximately one-quarter of AF patients undergoing PCI are treated with dual-pathway therapy in Canadian practice, with its use increasing during the studied period. Patients selected for dual-pathway therapy have less-complex coronary disease history and intervention.
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Affiliation(s)
- Felipe H. Valle
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shaun G. Goodman
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Mary Tan
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Andrew Ha
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Samer Mansour
- Centre hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Robert C. Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew T. Yan
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Stephane Rinfret
- Centre universitaire de santé McGill, McGill University, Montreal, Quebec, Canada
| | - Brian J. Potter
- Centre hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Razi Khan
- Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Gerald Simkus
- Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Madhu K. Natarajan
- Hamilton Health Sciences, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - J.D. Schwalm
- Hamilton Health Sciences, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Benoit Daneault
- Centre hospitalier universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mark J. Eisenberg
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Joseph Abunassar
- Kingston Health Sciences Centre, Queen’s University, Kingston, Ontario, Canada
| | - Bryan Har
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Jean Gregoire
- Institut de Cardiologie de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Jean-Francois Tanguay
- Institut de Cardiologie de Montréal, University of Montreal, Montreal, Quebec, Canada
| | | | - Jean-Pierre Dery
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec City, Quebec, Canada
| | - Robert De Larochelliere
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec City, Quebec, Canada
| | - Jean-Michel Paradis
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec City, Quebec, Canada
| | - Mina Madan
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Basem Elbarouni
- St.Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Derek Y.F. So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ata-Ur-Rehman Quraishi
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Akshay Bagai
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Corresponding author: Dr Akshay Bagai, Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, 30 Bond St, Toronto, Ontario M5B1W8, Canada. Tel.: +1-416-864-5783.
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Pope MK, Atar D, Svilaas A, Hole T, Nielsen JD, Hintze U, Crisby M, Raatikainen P, Airaksinen KEJ, Virdone S, Pieper K, Kayani G, Le Heuzey JY, Steffel J, Stepinska J, Bassand JP, Camm AJ. Risk profile, antithrombotic treatment and clinical outcomes of patients in Nordic countries with atrial fibrillation - results from the GARFIELD-AF registry. Ann Med 2021; 53:485-494. [PMID: 33818226 PMCID: PMC8023647 DOI: 10.1080/07853890.2021.1893897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/16/2021] [Indexed: 10/27/2022] Open
Abstract
AIMS The objective was to evaluate the clinical characteristics, management and two-year outcomes of patients with newly diagnosed non-valvular atrial fibrillation at risk for stroke in Nordic countries. METHODS We examined the baseline characteristics, antithrombotic treatment, and two-year clinical outcomes of patients from four Nordic countries. RESULTS A total of 52,080 patients were enrolled in the GARFIELD-AF. Out of 29,908 European patients, 2,396 were recruited from Nordic countries. The use of oral anticoagulants, alone or in combination with antiplatelet (AP), was higher in Nordic patients in all CHA2DS2-VASc categories: 0-1 (72.8% vs 60.3%), 2-3 (78.7% vs 72.9%) and ≥4 (79.2% vs 74.1%). In Nordic patients, NOAC ± AP was more frequently prescribed (32.0% vs 27.7%) and AP monotherapy was less often prescribed (10.4% vs 18.2%) when compared with Non-Nordic European patients. The rates (per 100 patient years) of all-cause mortality and non-haemorrhagic stroke/systemic embolism (SE) were similar in Nordic and Non-Nordic European patients [3.63 (3.11-4.23) vs 4.08 (3.91-4.26), p value = .147] and [0.98 (0.73-1.32) vs 1.02 (0.93-1.11), p value = .819], while major bleeding was significantly higher [1.66 (1.32-2.09) vs 1.01 (0.93-1.10), p value < .001]. CONCLUSION Nordic patients had significantly higher major bleeding than Non-Nordic-European patients. In contrast, rates of all-cause mortality and non-haemorrhagic stroke/SE were comparable. CLINICAL TRIAL REGISTRATION Unique identifier: NCT01090362. URL: http://www.clinicaltrials.gov. KEY MESSAGE Nordic countries had significantly higher major bleeding than Non-Nordic-European countries. Rates of mortality and non-haemorrhagic stroke/SE were similar .
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Affiliation(s)
- Marita Knudsen Pope
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Hamar Hospital, Innlandet Hospital Trust, Hamar, Norway
| | - Dan Atar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Arne Svilaas
- Nymoen Medical Centre, Kongsberg, Norway
- Lipid Clinic, Oslo University Hospital, Oslo, Norway
| | - Torstein Hole
- Clinic of Medicine and Rehabilitation, More and Romsdal Hospital Trust, Alesund, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU – Norwegian University of Science and Technology, Trondheim, Norway
| | - Jørn Dalsgaard Nielsen
- Department of Cardiology, Copenhagen University Hospital, Copenhagen University, Copenhagen, Denmark
| | - Ulrik Hintze
- Department of Cardiology, Hospital of South West Jutland, Esbjerg, University of Southern Denmark, Denmark
| | - Milita Crisby
- Department of Neurobiology, Care Science and Society, Karolinska University Hospital, Stockholm, Sweden
| | - Pekka Raatikainen
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, Tampere, Finland
| | | | | | | | | | | | - Jan Steffel
- Division of Electrophysiology and Pacing, Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
| | - Janina Stepinska
- Institute of Cardiology, Intensive Cardiac Therapy Clinic, Warsaw, Poland
| | - Jean-Pierre Bassand
- Thrombosis Research Institute, London, UK
- University of Besançon, Besancon, France
| | - A. John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St. George’s University of London, London, UK
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Kim SS, Lee KH, Yoon NS, Park HW, Cho JG. What is Standard Dose of Rivaroxaban in Elderly Asian Patients with Atrial Fibrillation: 20ms versus. 15mg? Clin Appl Thromb Hemost 2021; 27:10760296211061148. [PMID: 34786989 PMCID: PMC8606923 DOI: 10.1177/10760296211061148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Although there is no age criterion for rivaroxaban dose reduction, elderly patients with atrial fibrillation (AF) are often prescribed an off-label reduced dose. We aimed to evaluate whether age is a necessary criterion for rivaroxaban dose reduction in Korean patients with AF. Among 2208 patients who prescribed warfarin or rivaroxaban, 552 patients over 75 years without renal dysfunction (creatinine clearance >50 mL/min) were compared based on propensity score matching. The rivaroxaban group was further divided into a 20 mg (R20; on-label) and a 15 mg (R15; off-label). Primary net clinical benefit (NCB) was defined as the composite of stroke, systemic embolism, major bleeding, and all-cause mortality. Secondary NCB was defined as the composite of stroke, systemic embolism, and major bleeding. Patients were followed for 1 year, or until the first outcome occurrence. Both rivaroxaban groups had comparable efficacy compared with warfarin. However, both R20 (0.9% vs 7.4%, p = .014) and R15 (2.3% vs 7.4%, p = .018) had a significant reduction in major bleeding. There were no differences in efficacy or safety outcomes between R20 and R15. R20 had significantly reduced primary (hazard ratio [HR] 0.33, 95% confidence interval [CI]: 0.12–0.93) and secondary (HR 0.31, 95% CI: 0.10–0.93) NCBs compared with warfarin. However, primary and secondary NCBs were not reduced in R15. In real-world practice with elderly patients with AF, off-label rivaroxaban dose reduction to 15 mg conferred no benefits. Therefore, guideline-adherent rivaroxaban 20 mg is favorable in elderly Korean patients with AF.
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Affiliation(s)
| | - Ki Hong Lee
- 65416The Heart Center of Chonnam National University Hospital, Gwangju, Korea.,34931Chonnam National University Medical School, Gwangju, Korea
| | - Nam Sik Yoon
- 65416The Heart Center of Chonnam National University Hospital, Gwangju, Korea.,34931Chonnam National University Medical School, Gwangju, Korea
| | - Hyung Wook Park
- 65416The Heart Center of Chonnam National University Hospital, Gwangju, Korea.,34931Chonnam National University Medical School, Gwangju, Korea
| | - Jeong Gwan Cho
- 65416The Heart Center of Chonnam National University Hospital, Gwangju, Korea.,34931Chonnam National University Medical School, Gwangju, Korea
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85
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2021 Focused Update Consensus Guidelines of the Asia Pacific Heart Rhythm Society on Stroke Prevention in Atrial Fibrillation: Executive Summary. Thromb Haemost 2021; 122:20-47. [PMID: 34773920 PMCID: PMC8763451 DOI: 10.1055/s-0041-1739411] [Citation(s) in RCA: 199] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in the Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The practice guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of the AF Better Care pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian AF patients with single one stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the “coronavirus disease 2019” pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.
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86
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Polidori MC, Alves M, Bahat G, Boureau AS, Ozkok S, Pfister R, Pilotto A, Veronese N, Bo M. Atrial fibrillation: a geriatric perspective on the 2020 ESC guidelines. Eur Geriatr Med 2021; 13:5-18. [PMID: 34727362 PMCID: PMC8562074 DOI: 10.1007/s41999-021-00537-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/03/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The Task Force for the diagnosis and management of atrial fibrillation (AF) of the European Society of Cardiology (ESC) published in 2020 the updated Guidelines for the Diagnosis and Management of Atrial Fibrillation with the contribution of the European Heart Rhythm Association (EHRA) of the ESC and the European Association for Cardiothoracic Surgery (EACTS). METHODS AND RESULTS In this narrative viewpoint, we approach AF from the perspective of aging medicine and try to provide the readers with information usually neglected in clinical routine, mainly due to the fact that while the large majority of AF patients in real life are older, frail and cognitively impaired, these are mostly excluded from clinical trials, and physicians' attitudes often prevail over standardized algorithms. CONCLUSIONS On the basis of existing evidence, (1) opportunistic AF screening by pulse palpation or ECG rhythm strip is cost-effective, and (2) whereas advanced chronological age by itself is not a contraindication to AF treatment, a Comprehensive Geriatric Assessment (CGA) including frailty, cognitive impairment, falls and bleeding risk may assist in clinical decision making to provide the best individualized treatment.
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Affiliation(s)
- M Cristina Polidori
- Ageing Clinical Research, Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany. .,Cologne Excellence Cluster On Cellular Stress-Responses in Aging-Associated Diseases (CECAD), University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
| | - Mariana Alves
- Serviço de Medicina III, Hospital Pulido Valente, CHULN, Lisbon, Portugal.,Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Gulistan Bahat
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
| | - Anne Sophie Boureau
- Department of Geriatrics, CHU Nantes and Université de Nantes, CNRS, INSERM, l'Institut du Thorax, 44000, Nantes, France
| | - Serdar Ozkok
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
| | - Roman Pfister
- Department of Cardiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Alberto Pilotto
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, Galliera Hospital, Genoa, Italy.,Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Nicola Veronese
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette, Corso Bramante 88, 10126, Turin, Italy
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Lv WH, Dong JZ, Du X, Hu R, He L, Long DY, Sang CH, Jia CQ, Feng L, Li X, Ning M, Chen X, Cui YK, Tang RB, Ma CS. Antithrombotic strategy and its relationship with outcomes in patients with atrial fibrillation and chronic coronary syndrome. J Thromb Thrombolysis 2021; 53:868-877. [PMID: 34677727 DOI: 10.1007/s11239-021-02588-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2021] [Indexed: 10/20/2022]
Abstract
This study aimed to explore antithrombotic strategy and its relationship with outcomes in patients with atrial fibrillation (AF) at high risk for stroke and chronic coronary syndrome (CCS) in real-world clinical practice. Patients with AF at high risk for stroke complicated with CCS from China Atrial Fibrillation Registry (CAFR) were enrolled. The patients were divided into non-antithrombotic (Non-AT) group, oral anticoagulants (OAC) group, antiplatelet therapy (APT) group (aspirin or clopidogrel), and dual antiplatelet therapy (DAPT) group (aspirin + clopidogrel) according to their antithrombotic strategies at baseline. The patients with OAC + single antiplatelet drug (14 cases) and OAC + dual antiplatelet therapy (7 cases) were excluded for the small sample size. The primary effectiveness outcome was the composite outcome of coronary events, thromboembolism, and all-cause mortality. The primary safety outcome was major bleeding events. From 2011 to 2018, 25,512 patients were included in the CARF study, 769 patients with AF at high risk for stroke and CCS were enrolled in this study. After a follow-up of 47.4 ± 25.3 months, the incidences of primary effectiveness outcome were 44.6%, 25.7%, 43.6%, and 29.1% in the four groups, respectively (P < 0.001). The incidences of primary effectiveness and all-cause mortality were both significantly lower in the OAC group than in the Non-AT group, (25.7% vs. 44.6%, HR 0.53, 95% CI 0.39-0.73, P < 0.001) and (14.6% vs. 38.5%, HR 0.36, 95%CI 0.25-0.52, P < 0.001). In multivariate analysis, age (HR 1.03, 95%CI 1.01-1.05, P = 0.015), heart failure (HR 1.67, 95%CI 1.20-2.33, P = 0.002) and OAC (HR 0.66, 95%CI 0.47-0.91, P = 0.012) were independent factors for the composite outcome. There was no significant difference in major bleeding events between the four groups. OAC monotherapy significantly reduced the primary effectiveness composite outcome and all-cause mortality in the patients with AF at high risk for stroke complicated with CCS. However, there was no significant difference in major bleeding among the different antithrombotic strategies.Trial Registration www.chictr.org.cn (No. ChiCTR-OCH-13003729).
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Affiliation(s)
- Wen-He Lv
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Jian-Zeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Rong Hu
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Liu He
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Chaoyang District, Beijing, 100029, People's Republic of China
| | - De-Yong Long
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Cai-Hua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Chang-Qi Jia
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Li Feng
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Xu Li
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Man Ning
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Xuan Chen
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Yi-Kai Cui
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Ri-Bo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Chaoyang District, Beijing, 100029, People's Republic of China.
| | - Chang-Sheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Chaoyang District, Beijing, 100029, People's Republic of China
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Maksimova MY, Fonyakin AV, Geraskina LA. Prevention of ischemic stroke in atrial fibrillation from the point of view of a neurologist. Standards and real clinical practice. TERAPEVT ARKH 2021; 93:1240-1245. [DOI: 10.26442/00403660.2021.10.201105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 11/05/2021] [Indexed: 11/22/2022]
Abstract
The article outlines aspects of the current state of the problem of the priority choice of an oral anticoagulant for indefinite prevention of stroke and systemic thromboembolism in patients with atrial fibrillation. The advantages of direct oral angicoagulants over warfarin are presented, as well as a comparative analysis of the individual characteristics of the main direct oral angicoagulants from the point of view of personification of preventive therapy in accordance with modern treatment standards. The efficacy and safety of oral anticoagulant therapy has been reviewed in terms of the net clinical benefit. Particular attention is paid to the age-related aspects of choosing an anticoagulant for indefinite prophylaxis; an assessment of anticoagulants is presented in accordance with the FORTA concept, which regulates the use of drugs in elderly patients. In conclusion, recommendations are formulated for the choice of an anticoagulant in patients with atrial fibrillation in the most common clinical situations. As a general rule, the choice of a particular drug should be individualized based on risk factors, tolerability, net clinical benefit, patient preference, potential adverse interactions, and other clinical characteristics.
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89
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Reddin C, Judge C, Loughlin E, Murphy R, Costello M, Alvarez A, Ferguson J, Smyth A, Canavan M, O’Donnell MJ. Association of Oral Anticoagulation With Stroke in Atrial Fibrillation or Heart Failure: A Comparative Meta-Analysis. Stroke 2021; 52:3151-3162. [PMID: 34281383 PMCID: PMC8478106 DOI: 10.1161/strokeaha.120.033910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 03/04/2021] [Accepted: 03/31/2021] [Indexed: 01/11/2023]
Abstract
Background and Purpose Atrial fibrillation and heart failure with reduced ejection fraction (HFrEF) are common sources of cardioembolism. While oral anticoagulation is strongly recommended for atrial fibrillation, there are marked variations in guideline recommendations for HFrEF due to uncertainty about net clinical benefit. This systematic review and meta-analysis evaluates the comparative association of oral anticoagulation with stroke and other cardiovascular risk in populations with atrial fibrillation or HFrEF in sinus rhythm and identify factors mediating different estimates of net clinical benefit. Methods PubMed and Embase were searched from database inception to November 20, 2019 for randomized clinical trials comparing oral anticoagulation to control. A random-effects meta-analysis was used to estimate a pooled treatment-effect overall and within atrial fibrillation and HFrEF trials. Differences in treatment effect were assessed by estimating I2 among all trials and testing the between-trial-population P-interaction. The primary outcome measure was all stroke. Secondary outcome measures were ischemic stroke, hemorrhagic stroke, mortality, myocardial infarction, and major hemorrhage. Results Twenty-one trials were eligible for inclusion, 15 (n=19 332) in atrial fibrillation (mean follow-up: 23.1 months), and 6 (n=9866) in HFrEF (mean follow-up: 23.9 months). There were differences in primary outcomes between trial populations, with all-cause mortality included for 95.2% of HFrEF trial population versus 0.38% for atrial fibrillation. Mortality was higher in controls groups of HFrEF populations (19.0% versus 9.6%) but rates of stroke lower (3.1% versus 7.0%) compared with atrial fibrillation. The association of oral anticoagulation with all stroke was consistent for atrial fibrillation (odds ratio, 0.51 [95% CI, 0.42–0.63]) and HFrEF (odds ratio, 0.61 [95% CI, 0.47–0.79]; I2=12.4%; P interaction=0.31). There were no statistically significant differences in the association of oral anticoagulation with cardiovascular events, mortality or bleeding between populations. Conclusions The relative association of oral anticoagulation with stroke risk, and other cardiovascular outcomes, is similar for patients with atrial fibrillation and HFrEF. Differences in the primary outcomes employed by trials in HFrEF, compared with atrial fibrillation, may have contributed to differing conclusions of the relative efficacy of oral anticoagulation.
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Affiliation(s)
- Catriona Reddin
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
| | - Conor Judge
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Translational Medical Device Laboratory (C.J.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
- Wellcome Trust – HRB, Irish Clinical Academic Training (C.J.)
| | - Elaine Loughlin
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
| | - Robert Murphy
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
| | - Maria Costello
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
| | - Alberto Alvarez
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
| | - John Ferguson
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
| | - Andrew Smyth
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
| | - Michelle Canavan
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
| | - Martin J. O’Donnell
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
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Khurshid S, Chen W, Singer DE, Atlas SJ, Ashburner JM, Choi JG, Hur C, Ellinor PT, McManus DD, Chhatwal J, Lubitz SA. Comparative Clinical Effectiveness of Population-Based Atrial Fibrillation Screening Using Contemporary Modalities: A Decision-Analytic Model. J Am Heart Assoc 2021; 10:e020330. [PMID: 34476979 PMCID: PMC8649502 DOI: 10.1161/jaha.120.020330] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/21/2021] [Indexed: 12/17/2022]
Abstract
Background Atrial fibrillation (AF) screening is endorsed by certain guidelines for individuals aged ≥65 years. Yet many AF screening strategies exist, including the use of wrist-worn wearable devices, and their comparative effectiveness is not well-understood. Methods and Results We developed a decision-analytic model simulating 50 million individuals with an age, sex, and comorbidity profile matching the United States population aged ≥65 years (ie, with a guideline-based AF screening indication). We modeled no screening, in addition to 45 distinct AF screening strategies (comprising different modalities and screening intervals), each initiated at a clinical encounter. The primary effectiveness measure was quality-adjusted life-years, with incident stroke and major bleeding as secondary measures. We defined continuous or nearly continuous modalities as those capable of monitoring beyond a single time-point (eg, patch monitor), and discrete modalities as those capable of only instantaneous AF detection (eg, 12-lead ECG). In total, 10 AF screening strategies were effective compared with no screening (300-1500 quality-adjusted life-years gained/100 000 individuals screened). Nine (90%) effective strategies involved use of a continuous or nearly continuous modality such as patch monitor or wrist-worn wearable device, whereas 1 (10%) relied on discrete modalities alone. Effective strategies reduced stroke incidence (number needed to screen to prevent a stroke: 3087-4445) but increased major bleeding (number needed to screen to cause a major bleed: 1815-4049) and intracranial hemorrhage (number needed to screen to cause intracranial hemorrhage: 7693-16 950). The test specificity was a highly influential model parameter on screening effectiveness. Conclusions When modeled from a clinician-directed perspective, the comparative effectiveness of population-based AF screening varies substantially upon the specific strategy used. Future screening interventions and guidelines should consider the relative effectiveness of specific AF screening strategies.
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Affiliation(s)
- Shaan Khurshid
- Cardiovascular Research Center and Cardiac Arrhythmia ServiceDivision of CardiologyMassachusetts General HospitalBostonMA
| | - Wanyi Chen
- Institute for Technology AssessmentMassachusetts General HospitalBostonMA
| | - Daniel E. Singer
- Division of General Internal MedicineMassachusetts General HospitalMA
- Department of MedicineHarvard Medical SchoolBostonMA
| | - Steven J. Atlas
- Division of General Internal MedicineMassachusetts General HospitalMA
- Department of MedicineHarvard Medical SchoolBostonMA
| | - Jeffrey M. Ashburner
- Division of General Internal MedicineMassachusetts General HospitalMA
- Department of MedicineHarvard Medical SchoolBostonMA
| | - Jin G. Choi
- University of Chicago Pritzker School of MedicineChicagoIL
| | - Chin Hur
- Department of MedicineColumbia UniversityNew YorkNY
- Department of EpidemiologyMailman School of Public HealthColumbia UniversityNew YorkNY
| | - Patrick T. Ellinor
- Cardiovascular Research Center and Cardiac Arrhythmia ServiceDivision of CardiologyMassachusetts General HospitalBostonMA
| | - David D. McManus
- Department of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Jagpreet Chhatwal
- Institute for Technology AssessmentMassachusetts General HospitalBostonMA
| | - Steven A. Lubitz
- Cardiovascular Research Center and Cardiac Arrhythmia ServiceDivision of CardiologyMassachusetts General HospitalBostonMA
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91
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Beaulieu MC, Boivin-Proulx LA, Matteau A, Mansour S, Gobeil JF, Potter BJ. Evolution of Antithrombotic Management of Atrial Fibrillation After Percutaneous Coronary Intervention Over 10 Years and Guidelines Uptake. CJC Open 2021; 3:1025-1032. [PMID: 34505042 PMCID: PMC8413257 DOI: 10.1016/j.cjco.2021.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/05/2021] [Indexed: 02/07/2023] Open
Abstract
Background The management of atrial fibrillation and/or flutter (AF) patients requiring percutaneous coronary intervention (PCI) has evolved significantly. The Canadian Cardiovascular Society AF guidelines, last updated in 2020, seek to aid physicians in balancing both bleeding and thrombotic risks. Methods A tertiary academic centre registry of patients with AF who had PCI was examined for the antithrombotic therapy at discharge in 4 time periods (cohort 2010–2011; cohort 2014–2015; cohort 2017; cohort 2019). Discharge prescription patterns were compared among the cohorts, using the χ2 test. In addition, antithrombotic management in cohorts 2017 and 2019 were compared to guideline-expected therapy, using the χ2 test. Results A total of 576 AF patients undergoing PCI were included. Clinical and procedural characteristics were similar among cohorts, except for an increase in drug-eluting stent use in the most recent cohort (94% vs 99%; P = 0.04). The rate of oral anticoagulation increased over time (75% vs 89%; P < 0.01), driven primarily by an increase in direct oral anticoagulants prescription (63% vs 84%; P < 0.01). In contrast to previous cohorts, there was no significant difference between the observed and the guideline-expected anticoagulation rate in cohort 2019 (89% vs 94%; P = 0.23). Conclusions A combination of expert guidance and educational initiatives in the past decade contributed to dramatic changes in the management of patients with AF undergoing PCI.
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Affiliation(s)
| | | | | | | | | | - Brian J. Potter
- Corresponding author: Dr Brian J. Potter, Health Innovation and Evaluation Hub, Research Centre of CHUM, Cardiology & Interventional Cardiology, CHUM, Pavillon S, S03-334, 850, Rue St-Denis, Montréal, Quebec H2 × 0A9, Canada. Tel.: +1-514-890-8000 ext.15473; fax: +1-514-412-7212.
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92
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Han S, Han S, Jang SW, Lee MY, On YK, Bang OY, Lee JM, Park YJ, Shin JS, Kang S, Suh HS, Kim YH. Treatment Pattern of Antithrombotic Therapy over Time after Percutaneous Coronary Intervention in Patients with Atrial Fibrillation in Real-World Practice in Korea. Healthcare (Basel) 2021; 9:healthcare9091185. [PMID: 34574959 PMCID: PMC8472294 DOI: 10.3390/healthcare9091185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/03/2021] [Accepted: 09/06/2021] [Indexed: 11/20/2022] Open
Abstract
We examined antithrombotic treatment patterns with clinical characteristics and therapy changes over time in patients with atrial fibrillation (AF) after percutaneous coronary intervention (PCI). Using the Health Insurance Review and Assessment service claims database (01JAN2007-30NOV2016) in Korea, we included adult patients with AF and PCI: (1) who underwent PCI with stenting between 01JAN2008 and 30NOV2016; (2) with ≥1 claim for AF (ICD code: I48) (3) with antithrombotics 1 day prior to or at the date of PCI; and (4) with CHADS2-VASc of ≥2. In this study, 7749 patients with AF who underwent PCI, triple therapy, dual therapy, dual antiplatelet therapy (DAPT), and single antiplatelet therapy were prescribed to 24.6%, 3.4%, 60.8%, and 11.0%, respectively. In the triple therapy group, 23.1% persisted with triple therapy for 12 months, whereas the remaining patients switched to a different therapy. In the entire cohort and several subgroups, the median treatment duration of triple therapy was 55–87 days. DAPT use for 12 months was the most common treatment pattern (62.6%) in the DAPT group (median treatment duration, 324–345 days). A significant discrepancy exists between the current guidelines and real-world practice regarding antithrombotic treatment with PCI for patients with AF. Appropriate use of anticoagulants should be emphasized.
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Affiliation(s)
- Seongwook Han
- Division of Cardiology, Department of Internal Medicine, Dongsan Hospital, Keimyung University School of Medicine, Daegu 42601, Korea;
| | - Sola Han
- Pharmaceutical Economics, Big Data Analysis & Policy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea;
| | - Sung-Won Jang
- Division of Cardiology, Department of Internal Medicine, Catholic University of Korea, Seoul 06591, Korea;
| | - Myung-Yong Lee
- Division of Cardiology, Department of Internal Medicine, Dankook University, Cheonan 31116, Korea;
| | - Young-Keun On
- Department of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06355, Korea;
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06355, Korea;
| | - Ji-Min Lee
- Pfizer Korea Ltd., Seoul 04631, Korea; (J.-M.L.); (Y.-J.P.); (J.-S.S.); (S.K.)
| | - Yoo-Jung Park
- Pfizer Korea Ltd., Seoul 04631, Korea; (J.-M.L.); (Y.-J.P.); (J.-S.S.); (S.K.)
| | - Ji-Soo Shin
- Pfizer Korea Ltd., Seoul 04631, Korea; (J.-M.L.); (Y.-J.P.); (J.-S.S.); (S.K.)
| | - Seongsik Kang
- Pfizer Korea Ltd., Seoul 04631, Korea; (J.-M.L.); (Y.-J.P.); (J.-S.S.); (S.K.)
| | - Hae Sun Suh
- Pharmaceutical Economics, Big Data Analysis & Policy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea;
- Correspondence: (H.S.S.); (Y.-H.K.); Tel.: +82-2-9619492 (H.S.S.); +82-2-9206394 (Y.-H.K.)
| | - Young-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University, Seoul 02841, Korea
- Correspondence: (H.S.S.); (Y.-H.K.); Tel.: +82-2-9619492 (H.S.S.); +82-2-9206394 (Y.-H.K.)
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93
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Long‐term antithrombotic therapy for patients with atrial fibrillation and stable coronary artery disease. Cochrane Database Syst Rev 2021; 2021:CD014819. [PMCID: PMC8543784 DOI: 10.1002/14651858.cd014819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2024]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the efficacy and safety of different long‐term antithrombotic regimens for people with AF and stable CAD.
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94
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Panov AV. Antithrombotic Management for Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-07-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Comprehensive protection of a patient with atrial fibrillation (AF) should not only reduce the risk of stroke and systemic embolism, but also reduce the risk coronary events and ensure high adherence to treatment. In accordance with consensus document issued by the European Heart Rhythm Association, European Society of Cardiology, European Association of Percutaneous Cardiovascular Interventions, as well as with other recent Russian Society of Cardiology Guidelines, the management of antithrombotic therapy of patients with AF undergoing percutaneous coronary intervention (PCI) requires that multiple and interconnected issues. The review article addresses questions about duration of initial triple antithrombotic therapy (TAT), selection of P2Y12 inhibitor, choice of oral anticoagulant to be combined with antiplatelet therapy, intensity of oral anticoagulation throughout combination therapy, and choice of oral anticoagulant for indefinite therapy. In general, it is recommended to refuse the routine use of TAT for most patients. Accordingly, for patients who need both anticoagulant and antiplatelet therapy, it is strongly recommended that the default strategy after recent PCI is a double antithrombotic therapy consisting of an anticoagulant and one antiplatelet, preferably from the group of P2Y12 inhibitors. When conducting combined antithrombotic therapy, preference should be given to clopidogrel compared to other, more powerful P2Y12 inhibitors and direct oral anticoagulant (DOAC) instead of vitamin K antagonists. The primary choice of DOAC in patients with AF who have undergone PCI should be carried out taking into account such factors as individual risk of stroke and bleeding, adherence to treatment, concomitant diseases, pharmacological characteristics and evidence base of a specific DOAC, taking other medications, etc. The pharmacokinetic features of rivaroxaban, which create the possibility of its single administration, the evidence base for reducing coronary risks in various variants of the course of coronary heart disease, determines the special positions of the drug for the comprehensive protection of patients with AF after PCI.
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95
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Baturina OА, Andreev DA, Sychev DIA, Mesitskaya DF, Andranovich SV, Babakova NA, Suvorov AY. Results of Register in Patients with Acute Coronary Syndrome and Atrial Fibrillation Receiving Rivaroxaban. ACTA ACUST UNITED AC 2021; 61:52-58. [PMID: 34311688 DOI: 10.18087/cardio.2021.6.n1630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/01/2021] [Indexed: 11/18/2022]
Abstract
Aim To evaluate outcomes in patients with acute coronary syndrome and atrial fibrillation who receive rivaroxaban and the patients' compliance with the antithrombotic therapy.Material and methods The study was performed from October 2017 through December 2019 and included 129 patients. Events between the discharge from the hospital and 12 months of follow-up were recorded. The primary endpoint was development of major, minor or requiring medical attention bleeding according to the TIMI scale. The secondary endpoint was a combination of recurrent myocardial infarction, nonfatal acute ischemic cerebrovascular disease, nonfatal systemic embolism, stent thrombosis, and cardiovascular mortality.Results 32 (24.8%) patients early terminated the antiplatelet treatment and 22 (17.1%) patients terminated the rivaroxaban treatment. 26 (20.2 %) patients had hemorrhagic complications. The highest incidence of hemorrhage was observed within the first 2 months after the discharge. None of the bleedings was fatal. Composite endpoint events were observed in 24 (18.6 %) patients, including 14 (10.9 %) who died from cardiovascular causes.Conclusion The compliance with the antiplatelet therapy was insufficient. The incidence of hemorrhagic complications was relatively high; minor and requiring medical attention hemorrhages mostly contributed to the structure of these complications. The observed incidence of recurrent ischemic events associated with a high mortality presents a more serious problem compared to hemorrhagic complications of the combination antiplatelet therapy and warrants a more aggressive tactics of the antiplatelet treatment in high-risk patients.
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Affiliation(s)
- O А Baturina
- I.M. Sechenov First Moscow State Medical University (Sechenov University),Moscow
| | - D A Andreev
- I.M. Sechenov First Moscow State Medical University (Sechenov University),Moscow
| | - D I A Sychev
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow
| | - D F Mesitskaya
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow
| | - S V Andranovich
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow
| | - N A Babakova
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow
| | - A Yu Suvorov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow
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96
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1091] [Impact Index Per Article: 363.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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97
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Bálint A, Kupó P, Tornyos D, El Alaoui El Abdallaoui O, Jánosi A, Komócsi A. Oral anticoagulation and outcomes in patients with acute myocardial infarction: Insights from the Hungarian Myocardial Infarction Registry. Int J Clin Pract 2021; 75:e14179. [PMID: 33759332 DOI: 10.1111/ijcp.14179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/02/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Anticoagulation reduces the risk of stroke and embolization and is recommended in most patients with atrial fibrillation. Patients after coronary intervention and acute coronary syndromes require antiplatelet treatment. Although oral anticoagulation (OAC) therapy may interfere with the outcome of patients after coronary intervention, its exact impact remains unclear. Importantly, risk-benefit relations may be considerably different after myocardial infarction. MATERIAL AND METHODS Data of patients registered from the Hungarian Myocardial Infarction Registry, a mandatory nationwide program for hospitals treating patients with myocardial infarction, were processed. Patients registered between 01.2014. and 12.2017 were included. All-cause mortality, the composite of cardiac events (MACE), and transfusion were compared between patients receiving OAC treatment and a propensity score (PS) matched control group. Subgroup analyses of different anticoagulation and antiplatelet strategies were performed with propensity weighted Cox proportional hazards' models to estimate risk during the first year after the index event. RESULTS From 30 681 patients 1875 cases received OAC treatment and had apparently worse prognosis. After PS-matching, however, we found no difference regarding mortality (hazard ratio [HR]: 0.91 95% CI 0.77-1.09, P = .303), MACE (HR: 0.92 95% CI 0.78-1.09, P = .335) or transfusion (HR: 1.21, 95% CI 0.97-1.49, P = .086). In PS-adjusted analyses for the OAC group, patients who received aspirin were associated with lower mortality (HR: 0.77, 95% CI: 0.60-0.997, P = .048) and MACE (HR:0.73, 95% CI 0.58-0.92, P = .008) compared to those without aspirin. CONCLUSIONS In patients with acute myocardial infarction, the prognosis of OAC-treated patients was comparable to the PS matched control; however, the omission of aspirin therapy was associated with unfavorable outcomes.
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Affiliation(s)
- Alexandra Bálint
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Kupó
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Dániel Tornyos
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | | | - András Jánosi
- Hungarian Myocardial Infarction Registry, György Gottsegen Hungarian Institute of Cardiology, Budapest, Hungary
| | - András Komócsi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
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98
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99
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Benz AP, Johansson I, Dewilde WJM, Lopes RD, Mehran R, Sartori S, Sarafoff N, Yasuda S, McIntyre WF, Healey JS, Shoamanesh A, Eikelboom JW, Connolly SJ. Antiplatelet Therapy in Patients with Atrial Fibrillation: A Systematic Review and Metaanalysis of Randomized Trials. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 8:648-659. [PMID: 34142118 DOI: 10.1093/ehjcvp/pvab044] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/26/2021] [Accepted: 06/14/2021] [Indexed: 11/13/2022]
Abstract
AIMS To systematically assess the effects of antiplatelets on clinical outcomes in patients with atrial fibrillation (AF), treated and not treated with oral anticoagulation. METHODS AND RESULTS We searched MEDLINE, Embase and CENTRAL from inception until September 2020. From 5,446 citations, we selected randomized trials allocating patients with AF to antiplatelet therapy vs. control. We applied random-effects models for meta-analysis and assessed potential effect modification with background anticoagulation use. Eighteen trials including 21,518 participants met our prespecified eligibility criteria. In 10 studies without background anticoagulation, antiplatelets reduced all-cause stroke (486/6,165 [events/patients] vs. 621/6,061; risk ratio [RR] 0.77, 95% confidence interval [CI] 0.69-0.86, I2=0%). In 8 studies with background anticoagulation, there was a signal for an increase in all-cause stroke with antiplatelets (97/4,608 vs. 72/4,684; RR 1.33, 95% CI 0.98-1.79, I2=0%), p-value for interaction < 0.001. A similar pattern emerged for ischaemic stroke. Irrespective of background anticoagulation use, antiplatelets increased major bleeding (509/10,402 vs. 328/10,496; RR 1.54, 95% CI 1.35-1.77, I2=0%) and intracranial Haemorrhage (107/10,221 vs. 65/10,232; RR 1.64, 95% CI 1.20-2.24, I2=0%), and reduced myocardial infarction (201/9,679 vs. 260/9,751; RR 0.79, 95% CI 0.65-0.94, I2=0%), all p-values for interaction ≥ 0.36. Antiplatelets did not affect mortality (1,221/10,299 vs. 1,211/10,287; RR 1.02, 95% CI 0.89-1.17, I2=29%), p-value for interaction = 0.23. CONCLUSIONS In patients with AF not receiving oral anticoagulation, antiplatelet therapy modestly reduced stroke. There was a corresponding signal for harm when used on top of anticoagulation. Irrespective of background anticoagulation use, antiplatelet therapy significantly increased bleeding, moderately reduced myocardial infarction and did not affect mortality.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, Canada.,Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
| | - Isabelle Johansson
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Nikolaus Sarafoff
- Deutsches Herzzentrum München, Klinik für Herz-und Kreislauferkrankungen, Technische Universität Munich, Germany
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - William F McIntyre
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Ashkan Shoamanesh
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Canada
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100
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Al-Makhamreh HK, Al-Sabbagh MQ, Shaban AE, Obiedat AF, Hammoudeh AJ. Prevalence, Epidemiological Characteristics, and Pharmacotherapy of Coronary Artery Disease among Patients with Atrial Fibrillation: Data from Jo-Fib Study. ACTA ACUST UNITED AC 2021; 57:medicina57060605. [PMID: 34208175 PMCID: PMC8230731 DOI: 10.3390/medicina57060605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 05/31/2021] [Accepted: 06/08/2021] [Indexed: 12/15/2022]
Abstract
Background and Objectives: Patients with AF are at increased risk for Coronary Artery Disease (CAD) owing to their shared etiologies and risk factors. This study aimed to assess the prevalence, cardiovascular risk factors, and used medications of CAD in AF patients. Materials and Methods: This retrospective, case-control study utilized data from the Jordanian Atrial Fibrillation (Jo-Fib) registry. Investigators collected clinical features, history of co-existing comorbidities, CHA2DS2-VASc, and HAS BLED scores for all AF patients aged >18 visiting 19 hospitals and 30 outpatient cardiology clinics. A multivariable binary logistic regression was used to asses for factors associated with higher odds of having CAD. Results: Out of 2000 patients with AF, 227 (11.35%) had CAD. Compared to the rest of the sample, those with CAD had significantly higher prevalence of hypertension (82.38%; p < 0.01), hypercholesterolemia (66.52%, p < 0.01), diabetes (56.83%, p < 0.01), and smoking (18.06%, p = 0.04). Patients with AF and CAD had higher use of anticoagulants/antiplatelet agents combination (p < 0.01) compared to the rest of the sample. Females had lower CAD risk than males (OR = 0.35, 95% CI: 0.24-0.50). AF Patients with dyslipidemia (OR = 2.5, 95% CI: 1.8-3.4), smoking (OR = 1.7, 95% CI: 1.1-2.6), higher CHA2DS2-VASc score (OR = 1.5, 95% CI: 1.4-1.7), and asymptomatic AF (OR = 1.9, 95% CI: 1.3-2.6) had higher risk for CAD. Conclusions: Owing to the increased prevalence of CAD in patients with AF, better control of cardiac risk factors is recommended for this special group. Future studies should investigate such interesting relationships to stratify CAD risk in AF patients. We believe that this study adds valuable information regarding the prevalence, epidemiological characteristics, and pharmacotherapy of CAD in patients with AF.
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Affiliation(s)
- Hanna K. Al-Makhamreh
- Division of Cardiology, Department of Internal Medicine, Jordan University Hospital, University of Jordan School of Medicine, Amman 11942, Jordan;
| | - Mohammed Q. Al-Sabbagh
- University of Jordan School of Medicine, Amman 11942, Jordan; (A.E.S.); (A.F.O.)
- Department of neurology, University of Kansas Medical Center, Kansas City, KS 66160, USA
- Correspondence: or ; Tel.: +962-(79)-8944820
| | - Ala’ E. Shaban
- University of Jordan School of Medicine, Amman 11942, Jordan; (A.E.S.); (A.F.O.)
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