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A terapêutica antitrombótica: atual e em desenvolvimento. ANGIOLOGIA E CIRURGIA VASCULAR 2016. [DOI: 10.1016/j.ancv.2016.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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102
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Dual antiplatelet therapy is associated with prolonged survival after lower extremity revascularization. J Vasc Surg 2016; 64:1633-1644.e1. [PMID: 27575814 DOI: 10.1016/j.jvs.2016.05.098] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 05/23/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) after coronary stenting prolongs survival by preventing both in-stent thrombosis and other cardiovascular atherothrombotic events. Patients with peripheral artery disease (PAD) typically have a heavy burden of unrevascularized coronary artery disease and also stand to benefit from increased atherothrombotic protection with DAPT. The potential benefit of DAPT compared with aspirin alone in patients with PAD is not well described. METHODS We identified all patients undergoing an initial elective lower extremity revascularization (bypass or endovascular) from 2003 to 2016 in the Vascular Quality Initiative registry discharged on aspirin or aspirin plus a thienopyridine antiplatelet agent (DAPT). We first estimated models predicting the likelihood of receiving DAPT and then used inverse probability weighting to account for baseline differences in the likelihood of receiving DAPT and compared late survival. For sensitivity analysis, we also performed Cox proportion hazard modeling on the unweighted cohorts and generated adjusted survival curves. RESULTS We identified 57,041 patients undergoing lower extremity revascularization (28% bypass). Of 15,985 bypasses (69% for critical limb ischemia [CLI]), 38% were discharged on DAPT. Of 41,056 endovascular interventions (39% for CLI), 69% were discharged on DAPT. Analyses using inverse probability weighting demonstrated a small survival benefit to DAPT at 1 year for bypass (93% vs 92% [P = .001]) and endovascular interventions (93% vs 92% [P = .005]) that was sustained through 5 years of follow-up (bypass, 80% vs 78% [P = .004]; endovascular, 76% vs 73% [P = .002]). When stratified by severity of PAD, DAPT had a survival benefit for patients with CLI undergoing bypass (5 years, 70% vs 66% [P = .04]) and endovascular intervention (5 years, 71% vs 67% [P = .01]) but not for patients with claudication (bypass, 89% vs 88% [P = .36]; endovascular, 87% vs 85% [P = .46]). The protective effect of DAPT was similar when using Cox proportional hazard models after bypass (hazard ratio, 0.81 [95% confidence interval, 0.72-0.90]) and endovascular intervention (hazard ratio, 0.89 [95% confidence interval, 0.83-0.95]). CONCLUSIONS DAPT at time of discharge was associated with prolonged survival for patients with CLI undergoing lower extremity revascularization but not for those with claudication. Further research is needed to quantify the risks associated with DAPT and to identify subgroups at increased risk of thrombotic and bleeding complications to guide medical management of patients with PAD.
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Capodanno D, Alberts M, Angiolillo DJ. Antithrombotic therapy for secondary prevention of atherothrombotic events in cerebrovascular disease. NATURE REVIEWS. CARDIOLOGY 2016. [PMID: 27489191 DOI: 10.1038/nrcardio.2016.111.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Atherothrombosis is the common underlying process for numerous progressive manifestations of cardiovascular disease, including coronary artery disease (CAD) and cerebrovascular disease (CVD). Antiplatelet therapy is the cornerstone of pharmacological management in patients with atherothrombosis. Over the past 20 years, major advances in antiplatelet pharmacotherapy have been made, particularly for the treatment of patients with CAD. The treatment of patients with concomitant CAD and CVD is complex, owing to their increased risk of both ischaemia and bleeding. When CVD arises from large artery atherosclerosis, antithrombotic therapies are essential to prevent stroke or transient ischaemic attack (TIA). However, the use of antithrombotic medications in patients with CVD can put them at high risk of intracranial haemorrhage. As such, the risk-benefit profile of various combinations of antiplatelet agents in patients with both CAD and CVD is uncertain. This Review provides a state-of-the-art account of the available evidence on antithrombotic therapies for the secondary prevention of atherothrombotic events in patients with concomitant CAD and CVD, particularly those with a history of noncardioembolic stroke or TIA.
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Affiliation(s)
- Davide Capodanno
- Ferrarotto Hospital, University of Catania, Via Salvatore Citelli 6, 95124 Catania CT, Italy
| | - Mark Alberts
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75390, USA
| | - Dominick J Angiolillo
- University of Florida College of Medicine-Jacksonville, 653 West 8th Street, Jacksonville, Florida 32209, USA
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Antithrombotic therapy for secondary prevention of atherothrombotic events in cerebrovascular disease. Nat Rev Cardiol 2016; 13:609-22. [PMID: 27489191 DOI: 10.1038/nrcardio.2016.111] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Atherothrombosis is the common underlying process for numerous progressive manifestations of cardiovascular disease, including coronary artery disease (CAD) and cerebrovascular disease (CVD). Antiplatelet therapy is the cornerstone of pharmacological management in patients with atherothrombosis. Over the past 20 years, major advances in antiplatelet pharmacotherapy have been made, particularly for the treatment of patients with CAD. The treatment of patients with concomitant CAD and CVD is complex, owing to their increased risk of both ischaemia and bleeding. When CVD arises from large artery atherosclerosis, antithrombotic therapies are essential to prevent stroke or transient ischaemic attack (TIA). However, the use of antithrombotic medications in patients with CVD can put them at high risk of intracranial haemorrhage. As such, the risk-benefit profile of various combinations of antiplatelet agents in patients with both CAD and CVD is uncertain. This Review provides a state-of-the-art account of the available evidence on antithrombotic therapies for the secondary prevention of atherothrombotic events in patients with concomitant CAD and CVD, particularly those with a history of noncardioembolic stroke or TIA.
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Getachew H, Bhagavathula AS, Abebe TB, Belachew SA. Inappropriate prescribing of antithrombotic therapy in Ethiopian elderly population using updated 2015 STOPP/START criteria: a cross-sectional study. Clin Interv Aging 2016; 11:819-27. [PMID: 27382265 PMCID: PMC4920226 DOI: 10.2147/cia.s107394] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Inappropriate use of antiplatelets and anticoagulants among elderly patients increases the risk of adverse outcomes. The aim of this study was to assess the prevalence of inappropriate prescribing of antithrombotic therapy in hospitalized elderly patients. Methods A retrospective cross-sectional, single-center study was conducted at the Gondar University Hospital. A total of 156 hospitalized elderly patients fulfilling the inclusion/exclusion criteria were included in the study. The Screening Tool for Older Person’s Prescription/Screening Tool to Alert doctors to Right Treatment criteria version 2 were applied to patients’ data to identify the total number of inappropriate prescribing (IPs) including potentially inappropriate medications and potential prescribing omissions. Results A total of 70 IPs were identified in 156 patients who met the inclusion criteria. Of these, 36 (51.4%) were identified as potentially inappropriate medications by the Screening Tool for Older Person’s Prescription criteria. The prevalence of IP per patient indicated that 58 of the 156 (37.2%) patients were exposed to at least one IP. Of these, 32 (55.2%) had at least one potentially inappropriate medication and 33 (56.9%) had at least one potential prescribing omission. Patients hospitalized due to venous thromboembolism (adjusted odds ratio [AOR] =29.87, 95% confidence interval [CI], 1.26–708.6), stroke (AOR =7.74, 95% CI, 1.27–47.29), or acute coronary syndrome (AOR =13.48, 95% CI, 1.4–129.1) were less likely to be exposed to an IP. An increase in Charlson comorbidity index score was associated with increased IP exposure (AOR =0.60, 95% CI, 0.39–0.945). IPs were about six times more likely to absent in patients prescribed with antiplatelet only therapy (AOR =6.23, 95% CI, 1.90–20.37) than those receiving any other groups of antithrombotics. Conclusion IPs are less common in elderly patients primarily admitted due to venous thromboembolism, stroke, and acute coronary syndrome, and those elderly patients prescribed with only antiplatelet. Patients with higher Charlson comorbidity index were, however, associated with increased IPs exposure. Our study may guide further research to reduce high-risk prescription of antithrombotics in the elderly.
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Affiliation(s)
- Henok Getachew
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Akshaya Srikanth Bhagavathula
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tamrat Befekadu Abebe
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Sewunet Admasu Belachew
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Lack of Evidence for Dual Antiplatelet Therapy after Endovascular Arterial Procedures: A Meta-analysis. Eur J Vasc Endovasc Surg 2016; 52:253-62. [PMID: 27241270 DOI: 10.1016/j.ejvs.2016.04.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 04/25/2016] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT) has mainly replaced mono antiplatelet therapy (MAPT) and is recommended after arterial endovascular revascularization. The aim of this meta-analysis was to summarize the available evidence for DAPT after endovascular revascularization throughout the arterial system. METHODS A systematic search was performed in Medline, Embase, and the Cochrane Register. Two reviewers independently performed data extraction and quality assessment using the Cochrane Collaboration risk of bias assessment tool. Included in the search were randomized controlled trials (RCTs) comparing DAPT with MAPT after endovascular procedures for the treatment of coronary, carotid, or peripheral artery disease, reporting at least one clinical outcome. Articles were excluded if patients received anticoagulation in addition to antiplatelet therapy in the post-procedural phase. The primary outcome was restenosis or stent thrombosis, and secondary outcomes were major adverse cardiac events (MACE), target lesion revascularization, cerebrovascular accident or transient ischemic attack, bleeding, and death. Meta-analyses of binary outcomes were performed using the random effects model and described as risk ratios (RRs) and 95% confidence intervals (95% CIs). Chi-square tests were used to test for heterogeneity. RESULTS Nine articles were included in this study, involving lower limb peripheral arteries (1), carotid arteries (2), and coronary arteries (6). The pooled results of coronary trials showed a RR for restenosis with DAPT of 0.60 (95% CI 0.28-1.31) and for myocardial infarction 0.49 (95% CI 0.12-2.03). In the carotid artery trials the RR for restenosis was 0.22 (95% CI 0.04-1.20) and for peripheral arteries 1.02 (95% CI 0.56-1.82). A meta-analysis of bleeding risk of all the included trials showed a RR of 1.06 (95% CI 0.32-3.52) with DAPT. CONCLUSION The available evidence comparing DAPT with MAPT after endovascular arterial revascularization is limited and the majority of trials were conducted in the cardiology field. No significant evidence for superiority of DAPT compared with MAPT was found, but there was also no evidence of an increased bleeding risk with DAPT over MAPT.
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Patel NR, Patel DV, Murumkar PR, Yadav MR. Contemporary developments in the discovery of selective factor Xa inhibitors: A review. Eur J Med Chem 2016; 121:671-698. [PMID: 27322757 DOI: 10.1016/j.ejmech.2016.05.039] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/25/2016] [Accepted: 05/19/2016] [Indexed: 11/25/2022]
Abstract
Thrombosis is a leading cause of death in cardiovascular diseases such as myocardial infarction (MI), unstable angina and acute coronary syndrome (ACS) in the industrialized world. Venous thromboembolism is observed in about 1 million people every year in United States causing significant morbidity and mortality. Conventional antithrombotic therapy has been reported to have several disadvantages and limitations like inconvenience in oral administration, bleeding risks (heparin analogs), narrow therapeutic window and undesirable interactions with food and drugs (vitamin K antagonist-warfarin). The unmet medical demand for orally active safe anticoagulants has generated widespread interest among the medicinal chemists engaged in this field. To modulate blood coagulation, various enzymes involved in the coagulation process have received great attention as potential targets by various research groups for the development of oral anticoagulants. Among these enzymes, factor Xa (FXa) has remained the centre of attention in the last decade. Intensive research efforts have been made by various research groups for the development of small, safe and orally bioavailable FXa inhibitors. This review is an attempt to compile the research work of various researchers in the direction of development of FXa inhibitors reported since 2010 onward.
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Affiliation(s)
- Nirav R Patel
- Faculty of Pharmacy, Kalabhavan Campus, The Maharaja Sayajirao University of Baroda, Vadodara 390001, Gujarat, India
| | - Dushyant V Patel
- Faculty of Pharmacy, Kalabhavan Campus, The Maharaja Sayajirao University of Baroda, Vadodara 390001, Gujarat, India
| | - Prashant R Murumkar
- Faculty of Pharmacy, Kalabhavan Campus, The Maharaja Sayajirao University of Baroda, Vadodara 390001, Gujarat, India
| | - Mange Ram Yadav
- Faculty of Pharmacy, Kalabhavan Campus, The Maharaja Sayajirao University of Baroda, Vadodara 390001, Gujarat, India.
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Role of Vitamin K Antagonists in the Prevention of Thrombotic Bypass Occlusion After Infrainguinal Venous Bypass. Eur J Vasc Endovasc Surg 2016; 52:124-31. [PMID: 27142190 DOI: 10.1016/j.ejvs.2016.03.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 03/23/2016] [Indexed: 11/22/2022]
Abstract
CLINICAL VIGNETTE Despite being the most common antithrombotic strategy in trials comparing venous with prosthetic grafts, the use of vitamin K antagonists (VKAs) to improve the outcome of venous bypass remains the subject of debate. In this systematic review, evidence supporting the use of VKAs for improving venous patency following infrainguinal venous bypass is provided. CLINICAL QUESTION A 67 year old man with lifestyle limiting claudication underwent a successful infrainguinal venous bypass. Can VKAs help preserve patency after venous bypass surgery? METHODS A systematic review of electronic databases, including MEDLINE and Embase, was conducted. Only randomized controlled studies comparing VKAs with aspirin (ASA) were included. The main outcome was bypass patency. RESULTS Four studies using different intensities of anticoagulation ± ASA were identified. All but one showed a benefit of VKAs over ASA with respect to primary patency. However, this benefit was also accompanied by an increased risk of bleeding. The Dutch Bypass Oral Anticoagulants, or ASA, study was the largest included and showed that VKAs (without concomitant ASA) were superior to ASA alone for the prevention of graft occlusion (hazard ratio 0.69, 95% confidence interval 0.54-0.88). CONCLUSION Current evidence suggests that VKAs are superior to ASA for the prevention of infrainguinal autologous venous graft thrombosis.
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Berger JS, Katona BG, Jones WS, Patel MR, Norgren L, Baumgartner I, Blomster J, Mahaffey KW, Held P, Millegård M, Heizer G, Reist C, Fowkes FG, Hiatt WR. Design and rationale for the Effects of Ticagrelor and Clopidogrel in Patients with Peripheral Artery Disease (EUCLID) trial. Am Heart J 2016; 175:86-93. [PMID: 27179727 DOI: 10.1016/j.ahj.2016.01.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 01/24/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Despite overwhelming data demonstrating the efficacy of antiplatelet therapy in heart disease and stroke, data in peripheral artery disease (PAD) are less compelling. Aspirin has modest evidence supporting a reduction in cardiovascular events in patients with PAD, whereas clopidogrel monotherapy may be more effective in PAD. Ticagrelor, a potent, reversibly binding P2Y12 receptor antagonist, is beneficial in patients with acute coronary syndrome and prior myocardial infarction. The EUCLID trial is designed to address the need for effective antiplatelet therapy in PAD to decrease the risk of cardiovascular events. STUDY DESIGN EUCLID is a randomized, double-blind, parallel-group, multinational clinical trial designed to evaluate the efficacy and safety of ticagrelor compared with clopidogrel for the prevention of major adverse cardiovascular events in subjects with symptomatic PAD. Subjects with established PAD will be randomized in a 1:1 fashion to ticagrelor 90 mg twice daily or clopidogrel 75 mg daily. The primary end point is a composite of cardiovascular death, myocardial infarction, or ischemic stroke. Other end points address limb events including acute leg ischemia, need for revascularization, disease progression by ankle-brachial index, and quality of life. The primary safety objective is Thrombolysis in Myocardial Infarction-defined major bleeding. Recruitment began in December 2012 and was completed in March 2014; 13,887 patients were randomized. The trial will continue until at least 1,364 adjudicated primary end points occur. CONCLUSIONS The EUCLID study is investigating whether treatment with ticagrelor versus clopidogrel, given as antiplatelet monotherapy, will reduce the incidence of cardiovascular and limb-specific events in patients with symptomatic PAD.
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Patti G, Pengo V, Marcucci R, Cirillo P, Renda G, Santilli F, Calabrò P, De Caterina AR, Cavallari I, Ricottini E, Parato VM, Zoppellaro G, Di Gioia G, Sedati P, Cicchitti V, Davì G, Golia E, Pariggiano I, Simeone P, Abbate R, Prisco D, Zimarino M, Sofi F, Andreotti F, De Caterina R. The left atrial appendage: from embryology to prevention of thromboembolism. Eur Heart J 2016; 38:877-887. [DOI: 10.1093/eurheartj/ehw159] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 03/26/2016] [Indexed: 12/13/2022] Open
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Garry J, Duke A, Labropoulos N. Systematic review of the complications following isolated calf deep vein thrombosis. Br J Surg 2016; 103:789-96. [DOI: 10.1002/bjs.10152] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/03/2015] [Accepted: 02/10/2016] [Indexed: 01/23/2023]
Abstract
Abstract
Background
A large number of studies have examined the potential complications of calf deep vein thrombosis (DVT). There is no consensus on when or how to treat patients to prevent these complications. This systematic review assessed the rate of proximal propagation, pulmonary embolism, major bleeding and recurrence in patients with isolated calf DVT.
Methods
Database searches of MEDLINE, the Cochrane Library, Scopus, CINAHL and Web of Science were undertaken along with extensive cross-referencing. Two independent reviewers screened the papers using stringent inclusion and exclusion criteria. Included studies were graded on six methodological standards. Data on propagation, pulmonary embolism, recurrence and major bleeding were abstracted.
Results
A total of 4261 papers were found; 15 met the inclusion criteria, including five randomized clinical trials and ten prospective cohort studies. The propagation rate to the popliteal vein or above was around 9 per cent and the rate of pulmonary embolism was close to 1·5 per cent. No studies found anticoagulant therapy to reduce the rate of adverse outcomes.
Conclusion
The literature on calf DVT is heterogeneous, limiting conclusions from data analysis. Adverse outcomes are infrequent and studies do not suggest that they are reduced by anticoagulation.
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Affiliation(s)
- J Garry
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - A Duke
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - N Labropoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York, USA
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112
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Barriocanal AM, López A, Monreal M, Montané E. Quality assessment of peripheral artery disease clinical guidelines. J Vasc Surg 2016; 63:1091-8. [DOI: 10.1016/j.jvs.2015.12.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 12/19/2015] [Indexed: 10/22/2022]
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Abstract
Platelets play a very important role in physiological haemostasis and thrombus formation. Platelet aggregation is the key pathophysiological factor in the development of arterial ischaemic events, including coronary artery disease, cerebrovascular accidents and peripheral arterial disease. As such, antiplatelet therapy plays a very important role in preventing recurrent events in the individuals who are affected by one of these conditions. Until recently, the repertoire of antiplatelet therapy was limited to aspirin and clopidogrel. However, this landscape has changed dramatically with the advent of newer and more potent agents, prasugrel and ticagrelor and also the glycoprotein IIb/IIIa antagonists. This armamentarium is likely to expand further with the advent of protease-activated receptor-1 antagonists and the intravenous cangrelor. This review summarises the different agents available and some practical considerations for their use from a general physician's perspective.
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Affiliation(s)
- Jecko Thachil
- Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
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114
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Liu J, Wang D, Tan G, Yuan R, Xu M, Xiong Y, Liu M. Predicting the Outcomes of Acute Ischemic Stroke with Rheumatic Heart Disease: The Values of CHADS2, CHA2DS2-VASc, and HAS-BLED Scores. J Stroke Cerebrovasc Dis 2016; 25:722-6. [PMID: 26774873 DOI: 10.1016/j.jstrokecerebrovasdis.2015.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 08/27/2015] [Accepted: 09/06/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVE The CHADS2 and CHA2DS2-VASc score were used to evaluate the atrial fibrillation-related risk of stroke, and HAS-BLED score was used to estimate the oral anticoagulation-bleeding risk. We investigated the relationships between these 3 scores and the outcomes of acute ischemic stroke (AIS) patients with rheumatic heart disease (RHD) at 3 months after stroke. METHODS We retrospectively included patients admitted within 1 month after stroke from October 2011 to February 2014 who was also diagnosed with RHD. The patients' demographics; National Institutes of Health Stroke Scale score on admission; risk factors; prior anticoagulation; and CHADS2, CHA2DS2-VASc, and HAS-BLED scores on admission were collected, and symptomatic intracranial hemorrhage (sICH) during hospitalization was observed as well. The patients were followed up at 3 months after stroke to assess the clinical outcomes. RESULTS Of 1425 patients with AIS, 172 patients were diagnosed with RHD. Eleven patients (6.4%) were lost to follow-up at 3 months. One hundred sixty-one patients (48 males, mean age 57.5 years) were finally analyzed in the study. The HAS-BLED score was associated with the occurrence of sICH in both univariate (P = .001; odds ratio [OR] 2.223, 95% confidence interval [CI] 1.40-3.54) and multivariate analysis (P = .031; OR 2.366, 95% CI 1.08-5.17). The CHADS2 and CHA2DS2-VASc scores were both related to the sICH (CHADS2: P = .032; OR 1.522, 95% CI 1.04-2.23; CHA2DS2-VASc: P = .011; OR 1.498, 95% CI 1.10-2.04, respectively), and to the poor outcomes at 3 months (CHADS2: P = .013; OR .688, 95% CI .51-.92; CHA2DS2-VASc: P = .014; OR .754, 95% CI .60-.94, respectively) in the univariate analysis. CONCLUSION The HAS-BLED score was independently associated with the occurrence of sICH in AIS patients with RHD.
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Affiliation(s)
- Junfeng Liu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Deren Wang
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ge Tan
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ruozhen Yuan
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Mangmang Xu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yao Xiong
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Liu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.
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Rogers KC, Oliphant CS, Finks SW. Clinical efficacy and safety of cilostazol: a critical review of the literature. Drugs 2016; 75:377-95. [PMID: 25758742 DOI: 10.1007/s40265-015-0364-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Cilostazol is a unique antiplatelet agent that has been commercially available for over two decades. As a phosphodiesterase III inhibitor, it reversibly inhibits platelet aggregation yet also possesses vasodilatory and antiproliferative properties. It has been widely studied in a variety of disease states, including peripheral arterial disease, cerebrovascular disease, and coronary artery disease with percutaneous coronary intervention. Overall, cilostazol appears to be a promising agent in the management of these disease states with a bleeding profile comparable to placebo; even when combined with other antiplatelet agents, cilostazol does not appear to increase the rate of bleeding. Despite the possible benefit of cilostazol, its use is limited by tolerability as some patients often report drug discontinuation due to headache, diarrhea, dizziness, or increased heart rate. To date, it has been predominantly studied in the Asian population, making it difficult to extrapolate these results to a more diverse patient population. This paper discusses the evolving role of cilostazol in the treatment of vascular diseases.
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Affiliation(s)
- Kelly C Rogers
- Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, 881 Madison Ave, Rm 457, Memphis, TN, 38163, USA,
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Nansseu JRN, Noubiap JJN. Aspirin for primary prevention of cardiovascular disease. Thromb J 2015; 13:38. [PMID: 26640414 PMCID: PMC4669607 DOI: 10.1186/s12959-015-0068-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 08/29/2015] [Indexed: 01/27/2023] Open
Abstract
Although aspirin has a well-established role in preventing adverse events in patients with known cardiovascular disease (CVD), its benefit in patients without a history of CVD remains under scrutiny. Current data have provided insight into the risks of aspirin use, particularly bleeding, compared with its benefits in primary CVD prevention. Although aspirin is inexpensive and widely available, especially in developing countries, there is lack of evidence that the benefits outweigh the adverse events with continuous aspirin use in primary CVD prevention. Therefore, the decision to initiate aspirin therapy should be an individual clinical judgment that weighs the absolute benefit in reducing the risk of a first cardiovascular event against the absolute risk of major bleeding, and tailored to the patient's CVD risk. This risk must be calculated, based on accurate and cost-benefit locally developed risk assessment tools, the most discriminating threshold be identified. Additionally, patients preferences should be taken into account when making the decision to initiate aspirin therapy in primary prevention of CVD or not. Physicians should continuously be trained to calculate their patients CVD risk, and concomitant strategies be emphasized.
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Affiliation(s)
- Jobert Richie N Nansseu
- Department of Public Health, Faculty of Medicine and Biomedical Sciences of the University of Yaoundé I, PO Box 1364, Yaoundé, Cameroon ; Sickle Cell Disease Unit, Mother and Child Centre of the Chantal Biya Foundation, Yaoundé, Cameroon
| | - Jean Jacques N Noubiap
- Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa ; Medical Diagnostic Centre, Yaoundé, Cameroon
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Abstract
Dual antiplatelet therapy with aspirin, a platelet cyclooxygenase-1 inhibitor and P2Y12 receptor blockers, remains the major drug strategy to prevent ischemic event occurrence in patients with acute coronary syndromes and in patients undergoing coronary stenting, but there some limitations that can be overcome by targeting novel targets. Unlike direct thrombin inhibitors that bind directly to thrombin, targeting the platelet thrombin receptor, protease activated receptor (PAR)-1, may offer a better choice for the attenuation of atherosclerosis progression, thrombus-mediated ischemic events and restenosis without interfering with primary hemostasis. Vorapaxar - a synthetic analogue of himbacine, is a high affinity and highly selective PAR-1 antagonist that can effectively inhibit thrombin-induced platelet aggregation. In the TRACER trial, the addition of vorapaxar to standard therapy in patients with non-stent thrombosis-elevation- acute coronary syndromes did not significantly reduce the primary composite end point occurrence of cardiovascular (CV) death, myocardial infarction (MI), stroke, hospitalization for ischemia, or urgent revascularization, but significantly increased the GUSTO moderate and severe bleeding (p < 0.001) and intracranial hemorrhage (ICH). In the TRA 2°P-TIMI 50 trial, in patients with a history of MI and peripheral arterial disease (PAD) (67% of the total population), the end point of CV death, MI, or stroke was significantly (20%) reduced with vorapaxar whereas GUSTO moderate or severe bleeding was increased (1.5-fold), but not ICH or fatal bleeding and the net clinical outcome favoring the vorapaxar therapy. Based on these favorable results, the FDA approved vorapaxar for the reduction of thrombotic cardiovascular events in patients with prior MI or with PAD for long term therapy. A careful patient selection is needed to balance efficacy versus safety. At this time, patients with high risk for recurrent ischemic event occurrence such as patients with diabetes mellitus and previous MI can be safely treated with vorapaxar for long-term therapy.
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Affiliation(s)
- Udaya S Tantry
- a "Inova Center for Thrombosis Research and Drug Development" Inova Heart and Vascular Institute , Fairfax , VA , USA
| | - Fang Liu
- a "Inova Center for Thrombosis Research and Drug Development" Inova Heart and Vascular Institute , Fairfax , VA , USA.,b Department of Neurology , Beijing Hospital , Beijing 100730 , China
| | - Gailing Chen
- a "Inova Center for Thrombosis Research and Drug Development" Inova Heart and Vascular Institute , Fairfax , VA , USA.,c Department of Cardiology , China-Japan Friendship Hospital , Beijing 100029 , China
| | - Paul A Gurbel
- a "Inova Center for Thrombosis Research and Drug Development" Inova Heart and Vascular Institute , Fairfax , VA , USA
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118
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Vela Vásquez R, Peláez Romero R. Aspirin and spinal haematoma after neuraxial anaesthesia: Myth or reality? Br J Anaesth 2015; 115:688-98. [DOI: 10.1093/bja/aev348] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Polo Friz H, Molteni M, Cimminiello C. The dogma of aspirin: a critical review of evidence on the best monotherapy after dual antiplatelet therapy. Thromb J 2015; 13:28. [PMID: 26347594 PMCID: PMC4561422 DOI: 10.1186/s12959-015-0059-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 06/04/2015] [Indexed: 02/02/2023] Open
Abstract
Dual antiplatelet therapy based on the combination of an adenosine diphosphate (ADP)-receptor antagonist plus aspirin has demonstrated to be more effective in reducing the rate of major ischemic vascular events compared to aspirin monotherapy in some clinical settings. The current controversy on the duration of dual antiplatelet therapy should not conceal another major issue: the choice of the more appropriate antiplatelet monotherapy after the dual treatment phase. The aim of this article is to critically analyze the available evidence in this topic. Data from studies like CAPRIE, MATCH, PROFESS, CHANCE, DAPT and others, raise questions as why antiplatelet monotherapy after the dual phase should only be based on aspirin, in spite of a lack of evidence surprisingly not highlighted by key opinion leaders and experts. We conclude that, whether ADP-receptor antagonist rather than aspirin may be proposed as monotherapy seems not only have no answer but also not place in the current specialists’ analysis, as if a dogmatic approach were prevalent. Perhaps the time for an open debate on these topics is ripe.
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Affiliation(s)
- Hernan Polo Friz
- Department of Medicine, Vimercate Hospital Azienda Ospedaliera di Desio e Vimercate, Vimercate, Italy
| | - Mauro Molteni
- Department of Medicine, Vimercate Hospital Azienda Ospedaliera di Desio e Vimercate, Vimercate, Italy
| | - Claudio Cimminiello
- Department of Medicine, Vimercate Hospital Azienda Ospedaliera di Desio e Vimercate, Vimercate, Italy
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120
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The role of antiplatelet therapy in patients with peripheral artery disease and lower extremity peripheral artery revascularization. Curr Opin Cardiol 2015; 30:525-35. [DOI: 10.1097/hco.0000000000000208] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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121
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Saroukhani A, Ravari H, Pezeshki Rad M. Effects of Intravenous and Catheter Directed Thrombolytic Therapy with Recombinant Tissue Plasminogen Activator (Alteplase) in Non-Traumatic Acute Limb Ischemia; A Randomized Double-Blind Clinical Trial. Bull Emerg Trauma 2015; 3:86-92. [PMID: 27162909 PMCID: PMC4771247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 02/08/2015] [Accepted: 02/20/2015] [Indexed: 06/05/2023] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of intravenous and catheter directed thrombolysis by recombinant tissue plasminogen activator (Alteplase) in the patients with non-traumatic acute limb ischemia (ALI). METHODS This was a randomized clinical trial being performed between 2009 and 2011 in Mashhad University of Medical Sciences. We included those patients who were<75 years, with symptoms of less than 14 days duration, ALI of grade IIa and IIb (according to Rutherford classification) and absence of distal run off. Baseline assessment of peripheral circulation performed in all the patients. Patients were randomly assigned to undergo intravenous (n=18) or catheter directed thrombolysis (n=20) with Alteplase. The primary endpoint of the study was improvement of clinical status measured by Rutherford classification, ankle brachial index (ABI), visual analogue scale (VAS) score measured at 1, 3 and 6 months. The secondary endpoint of the study was complete or near complete recanalization of the occluded artery. RESULTS A total number of 38 patients with mean age of 54.13±13.5 years were included in the study. There were 23 (60.5%) men and 15 (39.5%) women among the patients. Overall 3 (7.9%) patients had upper and 35 (92.1%) lower extremity ischemia. There was no significant difference between two study groups. None of the patients experienced major therapeutic side effects. Both ABI and VAS score improved in patients who have received first dose of t-PA within 24-hourof ALI. There was no significant difference between two study groups regarding the 6-month clinical grade (p=0.088), VAS score (p=0.316) and ABI (p=0.360). The angiographic improvement was significantly higher in CDT group (p<0.001). CONCLUSION Intravenous and catheter directed thrombolysis with t-PA is a safe and effective method in treatment of acute arteriolar ischemia of extremities. However there both intravenous thrombolysis and CDT are comparable regarding the clinical outcome.
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Affiliation(s)
- Abbas Saroukhani
- Vascular and Endovascular Surgery Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hassan Ravari
- Vascular and Endovascular Surgery Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Masoud Pezeshki Rad
- Vascular and Endovascular Surgery Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Vaidya A, Joore MA, ten Cate-Hoek AJ, ten Cate H, Severens JL. Cost-effectiveness of risk assessment and tailored treatment for peripheral arterial disease patients. Biomark Med 2015; 8:989-99. [PMID: 25343671 DOI: 10.2217/bmm.14.45] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM The objective of this study was to explore the cost-effectiveness of D-dimer biomarker and the societal value (headroom) of a hypothetical perfect biomarker for risk assessment and subsequent treatment stratification of prophylactic treatment for peripheral arterial disease (PAD). PATIENTS & METHODS Decision analytic modeling. RESULTS Use of the D-dimer biomarker to prescribe oral anticoagulants in the high-risk subset of patients is a cost-effective healthcare intervention. The headroom (societal willingness to pay multiplied by incremental quality-adjusted life years) available for the hypothetical perfect biomarker amounted to €83,877. CONCLUSION D-dimer-based PAD risk assessment and treatment tailoring is cost effective. Identification of high-risk PAD patients and prescription of oral anticoagulants could potentially save substantial costs and improve chances of survival for high-risk PAD patients. However, further research of risk stratifying biomarkers test accuracy is needed to support and strengthen the results of this modeling study.
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Affiliation(s)
- Anil Vaidya
- Department of Clinical Epidemiology & Medical Technology Assessment (KEMTA), Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
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Vemulapalli S, Patel MR, Jones WS. Limb Ischemia: Cardiovascular Diagnosis and Management from Head to Toe. Curr Cardiol Rep 2015; 17:611. [DOI: 10.1007/s11886-015-0611-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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124
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Sarode K, Mohammad A, Das S, Vinas A, Banerjee A, Tsai S, Armstrong EJ, Shammas NW, Klein A, Brilakis ES, Banerjee S. Comparison of dual-antiplatelet therapy durations after endovascular revascularization of infrainguinal arteries. Ann Vasc Surg 2015; 29:1235-44. [PMID: 26026491 DOI: 10.1016/j.avsg.2015.03.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 11/04/2014] [Accepted: 03/19/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND The optimal dual-antiplatelet therapy (DAPT) duration after endovascular revascularization of infrainguinal arteries is uncertain. METHODS This study examines DAPT prescription trends and 12-month major adverse limb events (MALEs; a composite of repeat endovascular or surgical revascularization, acute vessel thrombosis, or amputation of the target limb), major adverse cardiovascular events (MACEs; all-cause mortality, nonfatal myocardial infarction [MI], stroke, or coronary revascularization), fatal bleeding events, and those requiring interruption or discontinuation of DAPT (hemorrhagic complications) for patients enrolled into the Excellence in Peripheral Artery Disease (XLPAD) registry. RESULTS Data on 368 patients prescribed antiplatelet therapy were analyzed; 8.2% were prescribed antiplatelet monotherapy, 48.6% DAPT for ≤3 months, and 43.2% for >3 months. Patients in the >3 DAPT prescribed group were older, had preexisting coronary artery disease (CAD), and prior MI (all P < 0.001). Overall MALE in the ≤3 and >3-month DAPT prescribed groups were 22.3% and 23.9%, respectively (P = 0.541). Survival analysis showed significantly higher rates of MACE in patients prescribed >3-month DAPT (17.6% vs. 9.5%; P = 0.019). An "as-treated" analysis excluded 10 patients who were prescribed DAPT for >3 months and revealed similar rates of MALE (24.9% vs. 20.8%; P = 0.386) and MACE (12.2% vs. 14.8%; P = 0.443) in patients receiving ≤3 and >3 DAPT. Hemorrhagic complications were similar across all prescribed and "as-treated" DAPT groups. CONCLUSIONS After infrainguinal endovascular procedures, patients with underlying CAD were prescribed longer (>3 months) duration of DAPT and experienced more cardiovascular events compared with those prescribed ≤3 months of DAPT. Adverse limb events were similar in both groups.
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Affiliation(s)
- Karan Sarode
- Veteran Affairs North Texas Health Care System, Dallas, TX; University of Texas Southwestern Medical Center, Dallas, TX
| | - Atif Mohammad
- Veteran Affairs North Texas Health Care System, Dallas, TX; University of Texas Southwestern Medical Center, Dallas, TX
| | - Swagata Das
- Veteran Affairs North Texas Health Care System, Dallas, TX
| | - Ariel Vinas
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Shirling Tsai
- Veteran Affairs North Texas Health Care System, Dallas, TX; University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Andrew Klein
- St. Louis University Medical Center, St. Louis, MO
| | - Emmanouil S Brilakis
- Veteran Affairs North Texas Health Care System, Dallas, TX; University of Texas Southwestern Medical Center, Dallas, TX
| | - Subhash Banerjee
- Veteran Affairs North Texas Health Care System, Dallas, TX; University of Texas Southwestern Medical Center, Dallas, TX.
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Weinberg I, Gu X, Giri J, Kim SE, Bacharach MJ, Gray BH, Katzen BT, Matsumoto AH, Chi YW, Rogers KR, Froehlich J, Olin JW, Gornik HL, Jaff MR. Anti-platelet and anti-hypertension medication use in patients with fibromuscular dysplasia: Results from the United States Registry for Fibromuscular Dysplasia. Vasc Med 2015; 20:447-53. [PMID: 25964292 DOI: 10.1177/1358863x15584982] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Fibromuscular dysplasia (FMD), a non-inflammatory arterial disease, may lead to renovascular hypertension (HTN) and cerebrovascular disease. Little is known about medication use in FMD. Clinical features and medication use were reviewed in a national FMD registry (12 US sites). Medication usage was assessed in raw and adjusted analyses. Covariates included demographic characteristics, co-morbid conditions and vascular bed involvement. A total of 874 subjects (93.6% female) were included in the analysis. Mean age was 55.6±13.1 years, 74.5% had HTN, 25.4% had a history of transient ischemic attack or stroke, and 7.5% had a history of coronary artery disease (CAD). Renal and cerebrovascular arteries were affected in 70.4% and 74.7%, respectively. Anti-platelet agents were administered to 72.9% of patients. In multivariate analyses, factors associated with a greater likelihood of anti-platelet agent use were older age (OR=1.02 per year, p=0.005), CAD (OR=3.76, p=0.015), cerebrovascular artery FMD involvement in isolation (OR=2.31, p<0.0001) or a history of previous intervention for FMD (OR=1.52, p=0.036). A greater number of anti-HTN medications was evident in isolated renal versus isolated cerebrovascular FMD patients. Factors associated with a greater number of anti-HTN medications were older age (OR=1.03 per year, p<0.0001), history of HTN (OR=24.04, p<0.0001), history of CAD (OR=2.71, p=0.0008) and a history of a previous therapeutic procedure (OR=1.72, p=0.001). In conclusion, in FMD, medication use varies based on vascular bed involvement. Isolated renal FMD patients receive more anti-HTN agents and there is greater anti-platelet agent use among patients with cerebrovascular FMD. Further studies correlating medication use in FMD with clinically meaningful patient outcomes are necessary.
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Affiliation(s)
- Ido Weinberg
- The Fireman Vascular Center, Massachusetts General Hospital, Boston, MA, USA
| | - Xiaokui Gu
- Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Jay Giri
- Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Soo E Kim
- Cleveland Clinic Heart and Vascular Institute and the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | | | - Bruce H Gray
- University of South Carolina School of Medicine/Greenville, Greenville, SC, USA
| | | | - Alan H Matsumoto
- Department of Radiology, Division of Vascular Interventional Radiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Yung-Wei Chi
- Division of Cardiovascular Medicine, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Kevin R Rogers
- Cardiology Division, University of Colorado, Denver, CO, USA
| | - James Froehlich
- Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey W Olin
- Zena and Michael A. Wiener Cardiovascular Institute and Marie-José and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai School of Medicine, New York, NY, USA
| | - Heather L Gornik
- Cleveland Clinic Heart and Vascular Institute and the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Michael R Jaff
- The Fireman Vascular Center, Massachusetts General Hospital, Boston, MA, USA
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Skibba AA, West MR, Evans JR, Hopkins SP, Maltais S, Rush DS. Aspergillus thromboembolism from a mycotic ascending aortic pseudoaneurysm. J Vasc Surg Cases 2015; 1:94-96. [PMID: 31724580 PMCID: PMC6849891 DOI: 10.1016/j.jvsc.2015.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 03/01/2015] [Indexed: 11/29/2022] Open
Abstract
This case report describes an immune-competent patient with acute upper extremity ischemia caused by thromboembolism from an Aspergillus-infected ascending aortic pseudoaneurysm. Efforts to identify the source of an acute arterial thromboembolic occlusion should be made, and a high index of suspicion for mycotic infection should be maintained in patients with an atypical presentation, such as fevers of unknown origin. Additional measures, such as pathologic examination of thromboembolic debris, blood cultures, and positron emission tomography, should be performed to identify the etiology in these unexplained situations.
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Affiliation(s)
- Afshin A Skibba
- Division of Vascular Surgery, East Tennessee State University, Johnson City, Tenn
| | - Michael R West
- Division of Vascular Surgery, East Tennessee State University, Johnson City, Tenn
| | - James R Evans
- Division of Vascular Surgery, East Tennessee State University, Johnson City, Tenn
| | - Steven P Hopkins
- Division of Vascular Surgery, East Tennessee State University, Johnson City, Tenn
| | - Simon Maltais
- Department of Cardiac Surgery, Vanderbilt Heart and Vascular Institute, Nashville, Tenn
| | - Daniel S Rush
- Division of Vascular Surgery, East Tennessee State University, Johnson City, Tenn
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127
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Parsi K, Hannaford P. Intra-arterial injection of sclerosants: Report of three cases treated with systemic steroids. Phlebology 2015; 31:241-50. [DOI: 10.1177/0268355515578988] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Intra-arterial injection of sclerosants is a significant but uncommon complication of sclerotherapy that may result in extensive tissue necrosis and in rare cases digit or limb amputation. We have managed three cases in the past 10 years. One patient was referred for immediate treatment following intra-arterial injection of liquid polidocanol. The other two had undergone foam sclerotherapy with polidocanol and sodium tetradecyl sulphate, respectively. All patients were treated with a combination of oral steroids (prednisone 0.5–1 mg/kg) and systemic anticoagulants (enoxaparin 1.5 mg/kg daily subcutaneous injection). One case progressed to skin ulceration where prednisone was started five days after the adverse event and prematurely stopped after four weeks. The other cases did not progress to necrosis or other long-term sequelae. In these patients, prednisone was commenced immediately and slowly reduced over the following 12 weeks. The inflammation that follows ischemia plays a significant role in tissue necrosis and the immediate management of this adverse event may benefit from anti-inflammatory measures and in particular systemic steroid therapy unless contraindicated.
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Affiliation(s)
- Kurosh Parsi
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent’s Centre for Applied Medical Research (AMR), St. Vincent’s Hospital, Sydney, Australia
- Department of Dermatology, St. Vincent’s Hospital, Sydney, Australia
- University of New South Wales, Sydney, Australia
| | - Patricia Hannaford
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent’s Centre for Applied Medical Research (AMR), St. Vincent’s Hospital, Sydney, Australia
- University of New South Wales, Sydney, Australia
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Tangelder MJD, Nwachuku CE, Jaff M, Baumgartner I, Duggal A, Adams G, Ansel G, Grosso M, Mercuri M, Shi M, Minar E, Moll FL. A Review of Antithrombotic Therapy and the Rationale and Design of the Randomized Edoxaban in Patients With Peripheral Artery Disease (ePAD) Trial Adding Edoxaban or Clopidogrel to Aspirin After Femoropopliteal Endovascular Intervention. J Endovasc Ther 2015; 22:261-8. [DOI: 10.1177/1526602815574687] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Compared with the coronary setting, knowledge about antithrombotic therapies after endovascular treatment (EVT) is inadequate in patients with peripheral artery disease (PAD). Based on a review of trials and guidelines, which is summarized in this article, there is scant evidence that antithrombotic drugs improve outcome after peripheral EVT. To address this knowledge gap, the randomized, open-label, multinational edoxaban in patients with Peripheral Artery Disease (ePAD) study ( ClinicalTrials.gov identifier NCT01802775) was designed to explore the safety and efficacy of a combined regimen of antiplatelet therapy with clopidogrel and anticoagulation with edoxaban, a selective and direct factor Xa inhibitor, both combined with aspirin. As of July 2014, 203 patients (144 men; mean age 67 years) from 7 countries have been enrolled. These patients have been allocated to once-daily edoxaban [60 mg for 3 months (or 30 mg in the presence of factors associated with increased exposure)] or clopidogrel (75 mg/d for 3 months). All patients received aspirin (100 mg/d) for the 6-month duration of the study. The primary safety endpoint is major or clinically relevant nonmajor bleeding; the primary efficacy endpoint is restenosis or reocclusion at the treated segment(s) measured at 1, 3, and 6 months using duplex ultrasound scanning. All outcomes will be assessed and adjudicated centrally in a masked fashion. The ePAD study is the first of its kind to investigate a combined regimen of antiplatelet therapy and anticoagulation through factor Xa inhibition with edoxaban.
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Affiliation(s)
| | | | - Michael Jaff
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Iris Baumgartner
- Swiss Cardiovascular Center, University Hospital Bern, Switzerland
| | - Anil Duggal
- Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | - George Adams
- Rex Healthcare, University of North Carolina Health Systems, Raleigh, NC, USA
| | - Gary Ansel
- Riverside Methodist Hospital, Columbus, OH, USA
| | | | | | - Minggao Shi
- Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | - Erich Minar
- Vienna General Hospital, Medical University of Vienna, Austria
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Race as a predictor of delay from diagnosis to endarterectomy in clinically significant carotid stenosis. J Vasc Surg 2015; 62:49-56. [PMID: 25776188 DOI: 10.1016/j.jvs.2015.01.057] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 01/27/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Prompt carotid endarterectomy (CEA) in clinically significant carotid stenosis is important in the prevention of neurologic sequelae. The greatest benefit from surgery is obtained by prompt revascularization on diagnosis. It has been demonstrated that black patients both receive CEA less frequently than white patients do and experience worse postoperative outcomes. We sought to test our hypothesis that black race is an independent risk factor for a prolonged time from sonographic diagnosis of carotid stenosis warranting surgery to the day of operation (TDO). METHODS From 1998 to 2013 at a single institution, 166 CEA patients were retrospectively reviewed using Synthetic Derivative, a de-identified electronic medical record. Factors potentially affecting TDO, including demographics, preoperative cardiac stress testing, degree of stenosis, smoking status, and comorbidities, were noted. Multivariate analysis was performed on variables that trended with prolonged TDO on univariate analysis (P < .10) to determine independent (P < .05) predictors of TDO. Subgroup analyses were further performed on the symptomatic and asymptomatic stenosis cohorts. RESULTS There were 32 black patients and 134 white patients studied; the mean TDO was 78 ± 17 days vs 33 ± 3 days, respectively (P < .001). In addition to the need for preoperative cardiac stress testing, black race was the only variable that demonstrated a trend with (P < .10) or was an independent risk factor for (P < .05) prolonged TDO among all patients (B = 42 days; P < .001) and within the symptomatic (B = 35 days; P = .08) and asymptomatic (B = 35 days; P = .003) cohorts. On Kaplan-Meier analysis, black patients in each stratum of symptomatology (all, symptomatic, and asymptomatic patients) experienced prolonged TDO (log-rank, P < .03 for all three groups). CONCLUSIONS Black race is a risk factor for a temporal delay in CEA for carotid stenosis. Awareness of this disparity may help surgeons avoid undesirable delays in operation for their black patients.
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Cohen A, Imfeld S, Markham J, Granziera S. The use of aspirin for primary and secondary prevention in venous thromboembolism and other cardiovascular disorders. Thromb Res 2015; 135:217-25. [DOI: 10.1016/j.thromres.2014.11.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 10/30/2014] [Accepted: 11/01/2014] [Indexed: 01/23/2023]
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Peeters Weem S, Leunissen T, Teraa M, Vonken E, de Borst G, Moll F. Personalized Antiplatelet Therapy Following Endovascular Revascularization in Peripheral Artery Occlusive Disease: A Novel Concept. EJVES Short Rep 2015. [DOI: 10.1016/j.ejvssr.2015.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Pascoe H, Robertson D. Catheter-directed thrombolysis for acute limb ischaemia: An audit. Australas Med J 2014; 7:471-5. [PMID: 25646123 DOI: 10.4066/amj.2014.2065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acute limb ischaemia (ALI) is commonly managed with surgical intervention but catheter-directed thrombolysis (CDT) is a proven treatment alternative. CDT as a treatment for ALI is not common and is dependent on local practice. All patients receiving urokinase infusions at our institution currently require a bed in the high-dependency unit (HDU). Administering the infusion requires significant nursing time and this can be accommodated in HDU where the nurse-to-patient ratio is higher than it is on general wards. AIMS To report the outcomes of the initial admission of patients who received CDT to manage ALI, and to give a cost estimate of their care. METHOD A retrospective audit was undertaken of all patients who received CDT with urokinase for the management of ALI over a four-year period. Success of thrombolysis was defined as a patient's survival with no need for any surgical intervention prior to discharge. Outcome measures included the requirement for further vascular procedures in the same admission, the complication rate, and the median urokinase dose and duration. Cost estimates were based on hospital pharmacy and administration data. RESULTS Seventy-three patients (median age 66 years, range 27-93 years) were included in the audit. The median urokinase dose was 2.3 million units (range 0.9-5.0 million units) with a median duration of treatment of 26 hours (range 3-96 hours). Fifty-seven patients did not require any further intervention prior to discharge, 14 had further intervention, and two died (one from a brainstem haemorrhage and one who deteriorated despite thrombolysis). The total cost per CDT case at our institution is currently approximately AUD $4,500 and AUD $6,700 for a patient being treated in HDU for one and two days, respectively. If patients were treated on a general ward, the cost would be approximately AUD $2,600 and AUD $3,000, respectively. CONCLUSION Rates of clinically acceptable clot lysis were high for patients treated with urokinase for ALI. Complication rates were comparable with published studies. Infusions can be required for prolonged periods of time and given the low complication rate, managing patients on a general ward rather than in the HDU is a feasible alternative and would reduce costs substantially.
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Affiliation(s)
| | - Donald Robertson
- Barwon Health, University Hospital Geelong, Geelong, VIC, Australia
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Atturu G, Homer-Vanniasinkam S, Russell DA. Pharmacology in peripheral arterial disease: what the interventional radiologist needs to know. Semin Intervent Radiol 2014; 31:330-7. [PMID: 25435658 DOI: 10.1055/s-0034-1393969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Peripheral arterial disease (PAD) is a progressive disease with significant morbidity and mortality. Risk factor control, using diet and lifestyle modification, exercise, and pharmacological methods, improves symptoms and reduces associated cardiovascular events in these patients. Antiplatelet agents and anticoagulants may be used to reduce the incidence of acute events related to thrombosis. The armamentarium available for symptom relief and disease modification is discussed. Novel treatments such as therapeutic angiogenesis are in their evolutionary phase with promising preclinical data.
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Affiliation(s)
- Gnaneswar Atturu
- Leeds Vascular Institute, Leeds General Infirmary, Leeds, United Kingdom
| | | | - David A Russell
- Leeds Vascular Institute, Leeds General Infirmary, Leeds, United Kingdom
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134
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Chong AY, So DY. Ticagrelor for the treatment of peripheral arterial disease. Expert Opin Investig Drugs 2014; 23:1737-43. [PMID: 25376000 DOI: 10.1517/13543784.2014.974803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Peripheral arterial disease (PAD) is a manifestation, and marker of severity, of a generalized atherosclerotic process. Antiplatelet therapy is recommended to prevent cardiovascular events but much of the evidence to support this is drawn from studies on older drugs. AREAS COVERED In this review, the authors discuss the available evidence for the basis of current recommendations and review the data from Phase I to III trials on ticagrelor as a potential future treatment. This paper also reviews the properties of ticagrelor, its adverse effects, and how it differs from current recommended antiplatelet agents. As it is also more potent, a personalized approach to antiplatelet therapy may prove useful. It further highlights the additional effects of ticagrelor mediated by adenosine and their potential benefits, which may provide an explanation to its superior outcomes in trials comparing it with clopidogrel. EXPERT OPINION Although there is a current lack of evidence to support the use of ticagrelor in patients with PAD, its unique pleomorphic properties make it attractive for future investigations and development of similar drugs.
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Affiliation(s)
- Aun-Yeong Chong
- University of Ottawa Heart Institute, Division of Cardiology, Department of Medicine , 40 Ruskin Street, Ottawa K1Y 4W7, Ontario , Canada +1 613 761 5387 ; +1 613 761 4338 ;
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Di Minno G, Spadarella G, Cafaro G, Petitto M, Lupoli R, Di Minno A, de Gaetano G, Tremoli E. Systematic reviews and meta-analyses for more profitable strategies in peripheral artery disease. Ann Med 2014; 46:475-89. [PMID: 25045928 PMCID: PMC4245179 DOI: 10.3109/07853890.2014.932618] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
In the peripheral arteries, a thrombus superimposed on atherosclerosis contributes to the progression of peripheral artery disease (PAD), producing intermittent claudication (IC), ischemic necrosis, and, potentially, loss of the limb. PAD with IC is often undiagnosed and, in turn, undertreated. The low percentage of diagnosis (∼30%) in this setting of PAD is of particular concern because of the potential worsening of PAD (amputation) and the high risk of adverse vascular outcomes (vascular death, coronary artery disease, stroke). A Medline literature search of the highest-quality systematic reviews and meta-analyses of randomized controlled trials documents that, due to risk of bias, imprecision, and indirectness, the overall quality of the evidence concerning diagnostic tools and antithrombotic interventions in PAD is generally low. Areas of research emerge from the information collected. Appropriate treatments for PAD patients will only derive from ad-hoc studies. Innovative imaging techniques are needed to identify PAD subjects at the highest vascular risk. Whether IC unresponsive to physical exercise and smoking cessation identifies those with a heritable predisposition to more severe vascular events deserves to be addressed. Devising ways to improve prevention of vascular events in patients with PAD implies a co-ordinated approach in vascular medicine.
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Affiliation(s)
- Giovanni Di Minno
- Department of Clinical Mediine and Surgery, Università degli Studi di Napoli , Naples , Italy
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136
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Antithrombotic therapy after infrainguinal bypass. J Vasc Surg 2014; 60:1367-1375. [PMID: 25441694 DOI: 10.1016/j.jvs.2014.07.105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 07/30/2014] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Bypass surgery is regularly performed for the treatment of critical limb ischemia, but the risk of occlusion remains significant. Antiplatelet therapy in patients with arterial disease is useful for secondary cardiovascular and bypass occlusion prevention. However, despite the common use of an antiplatelet agent, especially aspirin, which became the standard of care, the risk of graft occlusion persists. The best antithrombotic treatment for bypass patency therefore remains a matter of debate. METHODS We conducted a systematic literature search to identify studies and consensus reporting the use of antithrombotic treatment to prevent bypass occlusion. We excluded case reports and clinical trials with a placebo arm. RESULTS Aspirin remains the mainstay of treatment to improve infrainguinal bypass patency; however, the effect differs according to the bypass material used. The greatest beneficial effect of antiplatelet agents was observed with prosthetic bypasses. In such cases, the addition of clopidogrel to aspirin, for at least 1 year, in patients who benefited from a below-knee bypass graft significantly improved bypass patency (occlusion 32% vs 47% for aspirin alone; P = .02) and the amputation rate (9.4% vs 19.2% for aspirin alone; P = .03), without increasing the incidence of major hemorrhage. In contrast, antiplatelet regimens were less efficacious for autologous vein bypasses. The addition of a vitamin K antagonist (VKA) is not routinely proposed because of the increased incidence of associated major hemorrhage. The use of VKA alone, instead of aspirin, should probably be discussed in selected patients, and a combination of VKA and antiplatelet agents should be discussed in patients with venous infrainguinal bypasses considered to be at a high risk for occlusion. CONCLUSIONS Although aspirin remains the first-line treatment to prevent infrainguinal bypass occlusion, future studies are needed to define stronger recommendations.
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137
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Antiplatelet therapy before, during, and after extremity revascularization. J Vasc Surg 2014; 60:1085-91. [DOI: 10.1016/j.jvs.2014.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 07/09/2014] [Indexed: 11/22/2022]
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de Troia A, Biasi L, Iazzolino L, Azzarone M, Tecchio T, Rossi C, Salcuni P. Endovascular Stent Grafting of a Posterior Tibial Artery Pseudoaneurysm Secondary to Penetrating Trauma: Case Report and Review of the Literature. Ann Vasc Surg 2014; 28:1789.e13-7. [DOI: 10.1016/j.avsg.2014.02.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 02/04/2014] [Accepted: 02/04/2014] [Indexed: 11/25/2022]
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Abstract
Acute limb ischemia is a vascular event presenting with sudden decrease in limb perfusion (of <14 days' duration) that threatens limb viability. Acute thrombosis of the native artery or graft makes up the bulk of etiopathogenesis. Prompt revascularization is the cornerstone of management of acute limb ischemia in limbs that have not undergone irreversible tissue and nerve damage. Amputation is performed in patients with irreversible tissue and nerve damage.
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Affiliation(s)
- Bhaskar Purushottam
- Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave Levy L. Place, New York, NY 10029, USA
| | - Karthik Gujja
- Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave Levy L. Place, New York, NY 10029, USA
| | - Adrian Zalewski
- Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave Levy L. Place, New York, NY 10029, USA
| | - Prakash Krishnan
- Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave Levy L. Place, New York, NY 10029, USA.
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Kohli P, Whelton SP, Hsu S, Yancy CW, Stone NJ, Chrispin J, Gilotra NA, Houston B, Ashen MD, Martin SS, Joshi PH, McEvoy JW, Gluckman TJ, Michos ED, Blaha MJ, Blumenthal RS. Clinician's guide to the updated ABCs of cardiovascular disease prevention. J Am Heart Assoc 2014; 3:e001098. [PMID: 25246448 PMCID: PMC4323829 DOI: 10.1161/jaha.114.001098] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
To facilitate the guideline-based implementation of treatment recommendations in the ambulatory setting and to encourage participation in the multiple preventive health efforts that exist, we have organized several recent guideline updates into a simple ABCDEF approach. We would remind clinicians that evidence-based medicine is meant to inform recommendations but that synthesis of patient-specific data and use of appropriate clinical judgment in each individual situation is ultimately preferred.
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Affiliation(s)
- Payal Kohli
- Division of Cardiology, University of California San Francisco (UCSF), San Francisco, CA (P.K.)
| | - Seamus P. Whelton
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Steven Hsu
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Clyde W. Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (C.W.Y., N.J.S.)
| | - Neil J. Stone
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (C.W.Y., N.J.S.)
| | - Jonathan Chrispin
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Nisha A. Gilotra
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Brian Houston
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - M. Dominique Ashen
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Seth S. Martin
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Parag H. Joshi
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - John W. McEvoy
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Ty J. Gluckman
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Erin D. Michos
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Michael J. Blaha
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
| | - Roger S. Blumenthal
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (S.P.W., S.H., J.C., N.A.G., B.H., D.A., S.S.M., P.H.J., J.W.M.E., T.J.G., E.D.M., M.J.B., R.S.B.)
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141
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Azarbal A, Clavijo L, Gaglia MA. Antiplatelet Therapy for Peripheral Arterial Disease and Critical Limb Ischemia. J Cardiovasc Pharmacol Ther 2014; 20:144-56. [DOI: 10.1177/1074248414545126] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antiplatelet therapy is invariably prescribed for patients with peripheral arterial disease and critical limb ischemia, and numerous major society guidelines espouse their use, but high-quality data in this high-risk and challenging patient population are often lacking. This article summarizes the major guidelines for antiplatelet therapy, reviews the major studies of antiplatelet therapy in peripheral arterial disease (including data for aspirin, clopidogrel, dipyridamole, cilostazol, and prostanoids), and offers perspective on the potential benefits of ticagrelor, vorapaxar, and rivaroxaban. The review concludes with a discussion of the relative lack of efficacy that antiplatelet therapy has shown in regard to peripheral vascular outcomes.
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Affiliation(s)
- Amir Azarbal
- Department of Internal Medicine, University of Alabama-Huntsville, Huntsville, AL, USA
| | - Leonardo Clavijo
- Division of Cardiovascular Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Michael A. Gaglia
- Division of Cardiovascular Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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Perez P, Esteban C, Sauquillo JC, Yeste M, Manzano L, Mujal A, Jiménez Caballero PE, Aguilar E, Sánchez Muñoz-Torrero JF, Monreal M. Cilostazol and outcome in outpatients with peripheral artery disease. Thromb Res 2014; 134:331-5. [PMID: 24951338 DOI: 10.1016/j.thromres.2014.05.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 05/22/2014] [Accepted: 05/30/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cilostazol increases the walking distance in patients with intermittent claudication, but there is scarce evidence of any effect on the risk for subsequent ischemic events, bleeding or death. PATIENTS AND METHODS We used data from the FRENA Registry to compare the clinical outcome in stable outpatients with intermittent claudication, according to the use of cilostazol. RESULTS As of January 2013, 1,317 patients with intermittent claudication were recruited in FRENA, of whom 191 (14.5%) received cilostazol. Over a mean follow-up of 18months, 39 patients developed myocardial infarction, 23 ischemic stroke, 20 underwent limb amputation, 15 had major bleeding and 70 died. There were no significant differences in the rate of subsequent ischemic events, major bleeding or death between patients receiving or not receiving cilostazol. On multivariate analysis, the use of cilostazol had no influence on the risk for subsequent myocardial infarction (hazard ratio [HR]: 0.97; 95% CI: 0.33-20.8), ischemic stroke (HR: 1.46; 95% CI: 0.48-4.43), limb amputation (HR: 0.34; 95% CI: 0.04-20.6), major bleeding (HR: 1.52; 95% CI: 0.33-7.09) or death (HR: 0.90; 95% CI: 0.40-20.0). CONCLUSIONS In stable outpatients with intermittent claudication, the use of cilostazol was not associated with increased rates of subsequent ischemic events, major bleeding or death.
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Affiliation(s)
- Paulina Perez
- Department of Vascular Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Facultad de Medicina, Universitat Autónoma de Barcelona, Spain
| | - Carlos Esteban
- Department of Vascular Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | | | - Monserrat Yeste
- Department of Angiology and Vascular Surgery, Hospital de Terrassa, Terrassa, Barcelona, Spain
| | - Luis Manzano
- Department of Internal Medicine, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Abel Mujal
- Department of Internal Medicine, Hospital Universitari Parc Taulí Sabadell, Sabadell, Spain
| | | | - Eduardo Aguilar
- Department of Internal Medicine, Hospital de Alcañiz, Alcañiz, Teruel, Spain
| | | | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain.
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143
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Cerezo-Manchado JJ, Roldan V, Rosafalco M, Anton AI, Arroyo AB, Garcia-Barbera N, Martínez AB, Padilla J, Corral J, Vicente V, Gonzalez-Conejero R. Effect of VKORC1, CYP2C9 and CYP4F2 genetic variants in early outcomes during acenocoumarol treatment. Pharmacogenomics 2014; 15:987-96. [DOI: 10.2217/pgs.13.232] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Aim: To analyze VKORC1, CYP2C9 and CYP4F2 polymorphisms in relation to the main outcomes in the first stages of acenocoumarol therapy. Patients & methods: Nine hundred and forty one patients who had started therapy and in whom time to stable dosage, time to over-anticoagulation and adverse events occurred during 3 first months were retrospectively analyzed. Results: VKORC1 AA patients needed fewer days to reach stable dosage (p = 0.017). International normalized ratio [INR] at 72 h, and VKORC1 and CYP2C9 genotypes conditioned INR values >2.5 (p < 0.001, p = 0.002 and p < 0.001, respectively), whereas CYP4F2 T carriers had a low risk of the same outcome (p = 0.009). In regards to combined genotypes, CYP4F2 had a significant effect on over-anticoagulation at the beginning of therapy except for the VKORC1 AA and CYP2C9*3 combination. Conclusion: In addition to VKORC1 and CYP2C9, CYP4F2 gene has a slight but significant role in reaching INR >2.5 during the first weeks of acenocoumarol therapy. Original submitted 22 July 2013; Revision submitted 14 November 2013
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Affiliation(s)
- Juan Jose Cerezo-Manchado
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Vanessa Roldan
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | | | - Ana Isabel Anton
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Ana Belen Arroyo
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Nuria Garcia-Barbera
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Ana Belen Martínez
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Jose Padilla
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Javier Corral
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Vicente Vicente
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Rocio Gonzalez-Conejero
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
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Katsanos K, Tepe G, Tsetis D, Fanelli F. Standards of Practice for Superficial Femoral and Popliteal Artery Angioplasty and Stenting. Cardiovasc Intervent Radiol 2014; 37:592-603. [DOI: 10.1007/s00270-014-0876-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 09/04/2013] [Indexed: 11/30/2022]
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145
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Aiello A, Anichini R, Brocco E, Caravaggi C, Chiavetta A, Cioni R, Da Ros R, De Feo ME, Ferraresi R, Florio F, Gargiulo M, Galzerano G, Gandini R, Giurato L, Graziani L, Mancini L, Manzi M, Modugno P, Setacci C, Uccioli L. Treatment of peripheral arterial disease in diabetes: a consensus of the Italian Societies of Diabetes (SID, AMD), Radiology (SIRM) and Vascular Endovascular Surgery (SICVE). Nutr Metab Cardiovasc Dis 2014; 24:355-369. [PMID: 24486336 DOI: 10.1016/j.numecd.2013.12.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 10/31/2013] [Accepted: 12/01/2013] [Indexed: 02/07/2023]
Abstract
Diabetic foot (DF) is a chronic and highly disabling complication of diabetes. The prevalence of peripheral arterial disease (PAD) is high in diabetic patients and, associated or not with peripheral neuropathy (PN), can be found in 50% of cases of DF. It is worth pointing out that the number of major amputations in diabetic patients is still very high. Many PAD diabetic patients are not revascularised due to lack of technical expertise or, even worse, negative beliefs because of poor experience. This despite the progress obtained in the techniques of distal revascularisation that nowadays allow to reopen distal arteries of the leg and foot. Italy has one of the lowest prevalence rates of major amputations in Europe, and has a long tradition in the field of limb salvage by means of an aggressive approach in debridement, antibiotic therapy and distal revascularisation. Therefore, we believe it is appropriate to produce a consensus document concerning the treatment of PAD and limb salvage in diabetic patients, based on the Italian experience in this field, to share with the scientific community.
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Affiliation(s)
- A Aiello
- P.O. Campobasso - ASReM, Campobasso, Italy
| | - R Anichini
- Servizi di Diabetologia, USL 3, Pistoia, Italy
| | - E Brocco
- Policlinico Abano Terme, Presidio Ospedaliero ULSS 16, Veneto, Italy
| | - C Caravaggi
- Istituto Clinico "Città Studi", Milan, Italy
| | | | - R Cioni
- Dipartimento Radiologia Diagnostica, interventistica e medicina nucleare, Azienda Ospedaliera Universitaria Pisana, Pisa, italy
| | - R Da Ros
- Centro Diabetologico Monfalcone (GO) - Ass2, Gorizia, Italy
| | - M E De Feo
- U.O.S. Diabetologia A.O.R.N. "A. Cardarelli", Naples, Italy
| | - R Ferraresi
- Emodinamica Interventistica Cardiovascolare, Istituto Clinico Città Studi, Milan, Italy
| | - F Florio
- IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - M Gargiulo
- Chirurgia Vascolare, Azienda Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - G Galzerano
- Department of Surgery Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy
| | - R Gandini
- Dipartimento Diagnostica per immagini, Imaging molecolare, radioterapia e radiologia interventistica, Policlinico Universitario Tor Vergata, Rome, Italy
| | - L Giurato
- Diabetic Foot Unit, Dept of Internal Medicine, Policlinico Universitario Tor Vergata, Rome, Italy
| | - L Graziani
- Unità Operativa di Cardiologia Invasiva, Istituto Clinico "Città di Brescia", Brescia, Italy
| | - L Mancini
- Istituto Dermatologico Immacolata IRCCS, Rome, Italy
| | - M Manzi
- Radiologia Interventistica, Policlinico Abano Terme, Presidio Ospedaliero ULSS 16, Veneto, Italy
| | - P Modugno
- Dipartimento Malattie Cardiovascolari Fondazione Giovanni Paolo II, Università Cattolica Sacro Cuore, Campobasso, Italy
| | - C Setacci
- Department of Surgery Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy
| | - L Uccioli
- Diabetic Foot Unit, Dept of Internal Medicine, Policlinico Universitario Tor Vergata, Rome, Italy.
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146
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Bellmunt S, Roqué M, Osorio D, Pardo H, Escudero JR, Bonfill X. Healthcare quality indicators of peripheral artery disease based on systematic reviews. Eur J Vasc Endovasc Surg 2014; 48:60-9. [PMID: 24650396 DOI: 10.1016/j.ejvs.2014.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 02/01/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Peripheral artery disease (PAD) is a major health problem whose clinical management includes multiple options regarding risk factor control, diagnosis, and medical and surgical treatment. The aim was to generate indicators based on systematic reviews to evaluate the quality of healthcare provided in PAD. METHODS Electronic searches were run for systematic reviews in The Cochrane Library (Issue 6, 2011), MEDLINE, EMBASE, and other databases (up to June 2011). Conclusive systematic reviews of high methodological quality were selected to formulate clinical recommendations. Indicators were derived from clinical recommendations with moderate to very high strength of evidence as assessed by the GRADE system. RESULTS From 1,804 reviews initially identified, 29 conclusive and high-quality systematic reviews were selected and nine clinical recommendations were formulated with a moderate to very high strength of recommendation. Six indicators were finally generated: four on pharmacological interventions, antiplatelet agents, naftidrofuryl, cilostazol, and statins; and two lifestyle interventions, exercise and tobacco cessation. No indicators were derived for diagnostic tests or surgical techniques. Most indicators targeted patients with intermittent claudication. CONCLUSIONS These quality indicators will help clinicians to assess the appropriateness of healthcare provided in PAD. The development of evidence-based indicators in PAD is limited by the lack of methodological quality of the research in this disease, the inconclusiveness of the evidence on diagnostic and surgical techniques, and the dynamic nature of the vascular diseases field.
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Affiliation(s)
- S Bellmunt
- Vascular and Endovascular Surgery Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
| | - M Roqué
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Spain; Iberoamerican Cochrane Centre, Barcelona, Spain
| | - D Osorio
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Clinical Epidemiology and Public Health Service, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - H Pardo
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Iberoamerican Cochrane Centre, Barcelona, Spain
| | - J-R Escudero
- Vascular and Endovascular Surgery Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - X Bonfill
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Spain; Iberoamerican Cochrane Centre, Barcelona, Spain; Clinical Epidemiology and Public Health Service, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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147
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Bellmunt S, Alonso-Coello P. Cilostazol. Chest 2014. [DOI: 10.1378/chest.13-1791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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148
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Whayne TF. A review of the role of anticoagulation in the treatment of peripheral arterial disease. Int J Angiol 2013; 21:187-94. [PMID: 24293975 DOI: 10.1055/s-0032-1330232] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Peripheral arterial disease (PAD) is a major medical/surgical problem associated with high risk for coronary heart disease (CHD). Anticoagulation plays a significant role in the management of the PAD patient. However, evidence-based medicine supports only select anticoagulants, mainly antiplatelet agents. The available anticoagulant classes, their individual medications, and the mechanisms of action are described. Dextran 40, platelet glycoprotein (GP) IIb/IIIa receptor antagonists, direct thrombin (factor IIa, FIIa) inhibitors, and factor Xa (FXa) inhibitors do not, at this juncture, appear to have a significant role to play in the PAD patient. Aspirin has been used in PAD patients for a few decades, as has warfarin, but the role of warfarin is very limited. An attempt has been made to place each medication and its function in context all the way to the present with oral direct thrombin (FIIa) and FXa inhibitors described. These inhibitors may ultimately play an, as yet, undefined role in PAD. Specific use of anticoagulants in PAD patients is described and aspirin still stands out as a fundamental therapy. The thienopyridines, especially clopidogrel, have their established place and there is some evidence for benefit from the use of clopidogrel in dual therapy with aspirin. Dipyridamole, especially with aspirin as dual therapy, and cilostazol also have their evidence-based niches. The main role played by warfarin is for the patient with a vein graft in the arterial circulation. Heparin retains significant procedural importance. For now, Class I, Level of Evidence A center around aspirin for the PAD patient with clopidogrel, an alternative agent.
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Affiliation(s)
- Thomas F Whayne
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky
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149
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Mazzone A, Di Salvo M, Mazzuca S, Valerio A, Gussoni G, Bonizzoni E, Campanini M, Vescovo G, Nozzoli C. Effects of iloprost on pain-free walking distance and clinical outcome in patients with severe stage IIb peripheral arterial disease: the FADOI 2bPILOT Study. Eur J Clin Invest 2013; 43:1163-70. [PMID: 24102344 DOI: 10.1111/eci.12159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 08/15/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with peripheral arterial disease (PAD) at stage IIb, pain-free walking distance (PFWD) less than 100 m and unsuitable for revascularization have both impaired quality of life and severe clinical outcome. Aim of the study was to evaluate the efficacy of the prostacyclin analogue iloprost, added to standard therapy, in these patients. MATERIAL AND METHODS Patients were randomized to receive standard medical therapy (Group A) or standard therapy plus iloprost (Group B), for 1 year. Iloprost was administered for 10 days every 3 months. Treadmill test was performed every 3 months, in Group B before starting the 10-day iloprost cycle. RESULTS Fifty patients in Group A and 51 in Group B were enrolled. Mean baseline and 12-month PFWD values were 75.4 ± 21.3 and 128.9 ± 62.9 for iloprost group and 70.3 ± 21.6 and 99.6 ± 62.6 m for controls. Patients treated with iloprost had significantly higher PFWD at 9 and 12 months. This finding was confirmed after carrying forward the last valid observation (124.7 ± 63.4 vs. 88.4 ± 63.1 m, P < 0.01). Major cardiovascular events occurred in 32.0% and 3.9% of patients in Group A and Group B, respectively (P < 0.001). Five patients in Group A died vs. none in Group B (P = 0.02). No serious unexpected adverse reactions occurred in patients receiving iloprost. CONCLUSIONS Iloprost, added to standard therapy, significantly increases exercise capacity in patients with PAD at severe stage IIb. The percentage of patients who died or experienced major cardiovascular events was significantly lower in patients receiving iloprost. Future studies should focus on the effects of this therapy on clinical outcome.
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Affiliation(s)
- Antonino Mazzone
- Internal Medicine, Hospital Civile, Legnano - President FADOI Foundation, Rome, Italy
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150
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Grebe MT, Sternitzky R. [Management of peripheral vascular disease based on current guidelines. Peripheral artery occlusive disease of the iliac and femoral arteries and carotid artery stenosis]. Herz 2013; 38:848-54. [PMID: 24165989 DOI: 10.1007/s00059-013-3985-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The article summarizes the recommendations of current European and American guidelines concerning the diagnosis and treatment of peripheral arterial occlusive disease and carotid artery stenosis. In comparison to older recommendations, current guidelines concerning endovascular treatment and concomitant medical therapy have been changed in recent years. With the exception of very complex and long lesions, endovascular methods are seen as the therapy of choice for revascularization of the iliac and femoral arteries. For cardiovascular risk reduction, patients with symptomatic peripheral arterial disease and stenosis of the carotid arteries should receive antiplatelet as well as statin therapy and should not be treated different from patients with coronary artery disease.
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Affiliation(s)
- M T Grebe
- Gemeinschaftspraxis im Erlenringcenter, Herz- und Gefäßzentrum Marburg, Erlenring 19, 35037, Marburg, Deutschland,
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