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Capodanno D, Bhatt DL, Eikelboom JW, Fox KAA, Geisler T, Michael Gibson C, Gonzalez-Juanatey JR, James S, Lopes RD, Mehran R, Montalescot G, Patel M, Steg PG, Storey RF, Vranckx P, Weitz JI, Welsh R, Zeymer U, Angiolillo DJ. Dual-pathway inhibition for secondary and tertiary antithrombotic prevention in cardiovascular disease. Nat Rev Cardiol 2020; 17:242-257. [PMID: 31953535 DOI: 10.1038/s41569-019-0314-y] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2019] [Indexed: 12/24/2022]
Abstract
Advances in antiplatelet therapies for patients with cardiovascular disease have improved patient outcomes over time, but the challenge of balancing the risks of ischaemia and bleeding remains substantial. Moreover, many patients with cardiovascular disease have a residual risk of ischaemic events despite receiving antiplatelet therapy. Therefore, novel strategies are needed to prevent clinical events through mechanisms beyond platelet inhibition and with an acceptable associated risk of bleeding. The advent of non-vitamin K antagonist oral anticoagulants, which attenuate fibrin formation by selective inhibition of factor Xa or thrombin, has renewed the interest in dual-pathway inhibition strategies that combine an antiplatelet agent with an anticoagulant drug. In this Review, we highlight the emerging pharmacological rationale and clinical development of dual-pathway inhibition strategies for the prevention of atherothrombotic events in patients with different manifestations of cardiovascular disease, such as coronary artery disease, cerebrovascular disease and peripheral artery disease.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. 'G. Rodolico', Azienda Ospedaliero-Universitaria 'Policlinico-Vittorio Emanuele', University of Catania, Catania, Italy
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton General Hospital and McMaster University, Hamilton, ON, Canada
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital of Tübingen, Tübingen, Germany
| | - C Michael Gibson
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, MA, USA
| | | | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Renato D Lopes
- Division of Cardiology, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, Institut de Cardiologie, Pitié Salpêtrière Hôpital (AP-HP), Paris, France
| | - Manesh Patel
- Division of Cardiology, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - P Gabriel Steg
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris University, FACT (French Alliance for Cardiovascular Trials), INSERM U1148, Paris, France
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences at the University of Hasselt, Hasselt, Belgium
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Robert Welsh
- Cardiac Sciences Department, Mazankowski Alberta Heart Institute and University of Alberta, Edmonton, AL, Canada
| | - Uwe Zeymer
- Klinikum Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA.
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52
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Álvarez Álvarez B, Abou Jokh Casas C, Cordero A, Gómez ÁM, Álvarez ABC, Bermejo RA, Acuña JMG, Gude Sampedro F, Juanatey JRG. Coronariografía precoz y mortalidad a largo plazo en infarto agudo de miocardio de alto riesgo. Registro CARDIOCHUS-HUSJ. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.02.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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53
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Sundaram V, Bloom C, Zakeri R, Halcox J, Cohen A, Bowrin K, Briere JB, Banerjee A, Simon DI, Cleland JGF, Rajagopalan S, Quint JK. Temporal trends in the incidence, treatment patterns, and outcomes of coronary artery disease and peripheral artery disease in the UK, 2006–2015. Eur Heart J 2019; 41:1636-1649. [DOI: 10.1093/eurheartj/ehz880] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 09/26/2019] [Accepted: 12/02/2019] [Indexed: 12/24/2022] Open
Abstract
Abstract
Aims
Most reports estimating national incidence rates of coronary (CAD) and peripheral arterial disease (PAD) have focused on stable outpatients or acute or elective hospital admissions, but not on the overall burden of disease. In this study, we report the changing trends in the population-level incidence of CAD and PAD, respectively from 2006 to 2015, statin utilization for secondary prevention and survival outcomes using multiple nationally representative data sources from the UK (primary care encounters, hospital admissions, and procedure-level data).
Methods and results
A nationally representative study of linked primary and secondary care electronic health records of 4.6 million individuals from the UK. We calculated crude and standardized annual incidence rates separately for CAD and PAD. Statin use for secondary prevention, trends in annual major vascular event rates, and mortality between 2006 and 2015, were estimated for CAD and PAD, respectively. We identified 160 376 and 70 753 patients with incident CAD and PAD, respectively. The age- and sex-standardized incidence of CAD was similar in 2006 (443 per 100 000 person-years) and 2015 [436 per 100 000 person-years; adjusted incidence rate ratio (IRR) 0.98, 95% confidence interval (CI) 0.96–1.00]. In contrast, there was a 15% decline in the standardized incidence of PAD (236 per 100 000 person-years in 2006 to 202 per 100 000 person-years in 2015; adjusted IRR 0.85, 95% CI 0.82–0.88). The proportion of incident CAD and PAD patients prescribed long-term statins, was only 66% and 55%, respectively and was less common amongst women, patients aged >70 years, with heart failure, chronic lung disease, or depression. Cardiovascular mortality declined by 43% for incident CAD (adjusted IRR 0.57, 95% CI 0.50–0.64) between 2006 and 2015 but did not decline for incident PAD (adjusted IRR 0.84, 95% CI 0.70–1.00).
Conclusion and relevance
In the UK, the standardized incidence of CAD appears stable but mortality rates are falling, whereas the standardized incidence of PAD is falling but mortality rates are not.
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Affiliation(s)
- Varun Sundaram
- Department of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA
- Department of Population Health, National Heart and Lung Institute, Imperial College London, Emmanuel Kaye Building, Manresa Road, London SW3 6LR, UK
| | - Chloe Bloom
- Department of Population Health, National Heart and Lung Institute, Imperial College London, Emmanuel Kaye Building, Manresa Road, London SW3 6LR, UK
| | - Rosita Zakeri
- Department of Population Health, National Heart and Lung Institute, Imperial College London, Emmanuel Kaye Building, Manresa Road, London SW3 6LR, UK
- Department of Cardiovascular Medicine, Royal Brompton and Harefield Hospitals NHS Foundation Trust, London SW3 6NJ, UK
| | - Julian Halcox
- Department of Cardiovascular Medicine, Swansea University Medical School, Swansea, West Glamorgan, SA2 8PP UK
| | - Alexander Cohen
- Department of Hematological Medicine, Guys and St Thomas NHS Foundation Trust, King's College London, Westminster Bridge Road, Denmark Hill, London SE5 9RS, UK
| | | | | | - Amitava Banerjee
- Institute of Health Informatics, University College London, 222 Euston Road, Regent's Park, London NW1 2DA, UK
| | - Daniel I Simon
- Department of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - John G F Cleland
- Department of Population Health, National Heart and Lung Institute, Imperial College London, Emmanuel Kaye Building, Manresa Road, London SW3 6LR, UK
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, University Ave, Glasgow G12 8QQ, UK
| | - Sanjay Rajagopalan
- Department of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Jennifer K Quint
- Department of Population Health, National Heart and Lung Institute, Imperial College London, Emmanuel Kaye Building, Manresa Road, London SW3 6LR, UK
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK
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54
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Kite TA, Gersh BJ, Gershlick AH. Spotlight on N-STEMI ACS: getting the right patients the right treatment, and at the right time. EUROINTERVENTION 2019; 15:e1041-e1045. [PMID: 31857276 DOI: 10.4244/eijv15i12a196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Thomas A Kite
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Centre, University Hospitals of Leicester Glenfield Hospital, Leicester, United Kingdom
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55
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Hermann M, Witassek F, Erne P, Eberli F, Muller O, Roffi M, Maggiorini M, Radovanovic D, Rickli H. Impact of cardiac rehabilitation participation on patient-reported lifestyle changes one year after myocardial infarction. Eur J Prev Cardiol 2019; 27:2318-2321. [PMID: 31841024 DOI: 10.1177/2047487319895429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Matthias Hermann
- University Heart Center, Department of Cardiology, University Hospital Zurich, Switzerland.,Cardiology, Zürcher RehaZentrum Wald, Switzerland
| | - Fabienne Witassek
- AMIS Plus Data Center, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Paul Erne
- AMIS Plus Data Center, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Franz Eberli
- Department of Cardiology, Triemli Hospital Zurich, Switzerland
| | - Olivier Muller
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Switzerland
| | - Marco Roffi
- Department of Cardiology, University Hospital Geneva, Switzerland
| | - Marco Maggiorini
- Institute for Intensive Care Medicine, University Hospital Zurich, Switzerland
| | - Dragana Radovanovic
- AMIS Plus Data Center, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Hans Rickli
- Department of Cardiology, Kantonsspital St. Gallen, Switzerland
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56
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Ahrens I, Averkov O, Zúñiga EC, Fong AYY, Alhabib KF, Halvorsen S, Abdul Kader MABSK, Sanz‐Ruiz R, Welsh R, Yan H, Aylward P. Invasive and antiplatelet treatment of patients with non-ST-segment elevation myocardial infarction: Understanding and addressing the global risk-treatment paradox. Clin Cardiol 2019; 42:1028-1040. [PMID: 31317575 PMCID: PMC6788484 DOI: 10.1002/clc.23232] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/27/2019] [Accepted: 07/06/2019] [Indexed: 12/14/2022] Open
Abstract
Clinical guidelines for the treatment of patients with non-ST-segment elevation myocardial infarction (NSTEMI) recommend an invasive strategy with cardiac catheterization, revascularization when clinically appropriate, and initiation of dual antiplatelet therapy regardless of whether the patient receives revascularization. However, although patients with NSTEMI have a higher long-term mortality risk than patients with ST-segment elevation myocardial infarction (STEMI), they are often treated less aggressively; with those who have the highest ischemic risk often receiving the least aggressive treatment (the "treatment-risk paradox"). Here, using evidence gathered from across the world, we examine some reasons behind the suboptimal treatment of patients with NSTEMI, and recommend approaches to address this issue in order to improve the standard of healthcare for this group of patients. The challenges for the treatment of patients with NSTEMI can be categorized into four "P" factors that contribute to poor clinical outcomes: patient characteristics being heterogeneous; physicians underestimating the high ischemic risk compared with bleeding risk; procedure availability; and policy within the healthcare system. To address these challenges, potential approaches include: developing guidelines and protocols that incorporate rigorous definitions of NSTEMI; risk assessment and integrated quality assessment measures; providing education to physicians on the management of long-term cardiovascular risk in patients with NSTEMI; and making stents and antiplatelet therapies more accessible to patients.
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Affiliation(s)
- Ingo Ahrens
- Augustinerinnen Hospital, Academic Teaching HospitalUniversity of CologneCologneGermany
| | - Oleg Averkov
- Pirogov Russian National Research Medical UniversityMoscowRussia
| | | | - Alan Y. Y. Fong
- Department of CardiologySarawak Heart CentreKota SamarahanMalaysia
| | - Khalid F. Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac CentreCollege of Medicine, King Saud UniversityRiyadhSaudi Arabia
| | | | | | | | - Robert Welsh
- Mazankowski Alberta Heart Institute and University of AlbertaEdmontonAlbertaCanada
| | | | - Philip Aylward
- South Australian Health and Medical Research InstituteFlinders University and Medical CentreAdelaideAustralia
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57
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Nadarajah R, Gale CP. Profiling the cohort profile. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2019; 5:185-186. [PMID: 31127809 DOI: 10.1093/ehjqcco/qcz028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
| | - Chris P Gale
- Leeds Institute for Data Analytics, University of Leeds, Level 11, Worsely building, Clarendon Way, Leeds, UK
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58
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Álvarez Álvarez B, Abou Jokh Casas C, Cordero A, Martínez Gómez Á, Cid Álvarez AB, Agra Bermejo R, García Acuña JM, Gude Sampedro F, González Juanatey JR. Early revascularization and long-term mortality in high-risk patients with non-ST-elevation myocardial infarction. The CARDIOCHUS-HUSJ registry. ACTA ACUST UNITED AC 2019; 73:35-42. [PMID: 31122784 DOI: 10.1016/j.rec.2019.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 02/27/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION AND OBJECTIVES This study sought to analyze the association of early coronary angiography with all-cause mortality and cardiovascular mortality in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) using a large contemporary cohort of patients with NSTEACS from 2 Spanish tertiary hospitals. METHODS This retrospective observational study included 5673 consecutive NSTEACS patients from 2 Spanish hospitals between 2005 and 2016. We performed propensity score matching to obtain a well-balanced subset of patients with the same probability of undergoing an early strategy, resulting in 3780 patients. Survival analyses were performed by Cox regression models once proportional risk test were verified. RESULTS Among the study participants, only 2087 patients (40.9%) underwent early invasive coronary angiography. The median follow-up was 59.0 months [interquartile range, 25.0-80.0 months]. All-cause mortality was 19.0%, cardiovascular mortality was 12.8%, and 51.1% patients experienced at least 1 major cardiovascular adverse event in the follow-up. After propensity score matching, the early strategy was associated with significantly lower mortality (hazard ratio: 0.79; 95% confidence interval 0.62-0.98) in high-risk NSTEACS patients. The darly strategy showed a nonsignificant inverse tendency in patients with GRACE score <140. CONCLUSIONS In high-risk (GRACE score≥ 140) NSTEACS patients in a contemporary real-world registry, early coronary angiography (first 24hours after hospital admission) may be associated with reduced all-cause mortality and cardiovascular mortality at long-term follow-up.
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Affiliation(s)
- Belén Álvarez Álvarez
- Departamento de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV).
| | - Charigan Abou Jokh Casas
- Departamento de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV).
| | - Alberto Cordero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV); Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - Álvaro Martínez Gómez
- Departamento de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)
| | - Ana Belén Cid Álvarez
- Departamento de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)
| | - Rosa Agra Bermejo
- Departamento de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)
| | - José María García Acuña
- Departamento de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)
| | - Francisco Gude Sampedro
- Departamento de Epidemiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, Spain
| | - José Ramón González Juanatey
- Departamento de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)
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59
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Lüscher TF. Acute coronary sydromes: the impressive impact of guideline-based management in NSTEMI. Eur Heart J 2018; 39:3753-3756. [PMID: 30403802 DOI: 10.1093/eurheartj/ehy642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Thomas F Lüscher
- Imperial College and Director of Research, Education & Development, Royal Brompton and Harefield Hospitals, London, UK.,Center for Molecular Cardiology, University of Zurich, Switzerland.,EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, Zurich, Switzerland
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60
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Affiliation(s)
- Marco Roffi
- Division of Cardiology, University Hospital, Rue Gabrielle Perret-Gentil 4, Geneva 14, Switzerland
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
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