151
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Vries MJA, van der Meijden PEJ, Henskens YMC, ten Cate-Hoek AJ, ten Cate H. Assessment of bleeding risk in patients with coronary artery disease on dual antiplatelet therapy. Thromb Haemost 2015. [DOI: 10.1160/th-15-04-0355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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152
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Sabbag A, Guetta V, Fefer P, Matetzky S, Gottlieb S, Meisel S, Iakobishvili Z, Blatt A, Goldenberg I, Segev A. Temporal Trends and Outcomes Associated with Major Bleeding in Acute Coronary Syndromes: A Decade-Long Perspective from the Acute Coronary Syndrome Israeli Surveys 2000-2010. Cardiology 2015; 132:163-71. [DOI: 10.1159/000430838] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 04/21/2015] [Indexed: 11/19/2022]
Abstract
Objectives: The implementation of an early invasive approach and the increased use of potent anti-thrombotic drugs have resulted in higher rates of major bleeding events (MBE) in patients with acute coronary syndrome (ACS). There are limited data on the temporal trends for the rates of MBE over the last decade and associated outcomes. Methods: Rates, characteristics, risk factors and clinical outcomes associated with MBE were assessed among 11,538 patients enrolled in the biennial Acute Coronary Syndrome Israeli Surveys (ACSIS) 2000-2010. Results: A total of 143 patients (1.2%) experienced MBE during the index hospitalization for ACS. There was a significant increase in the risk of MBE in the late (2006-2010) versus the early (2000-2004) surveys (0.9 and 1.6% respectively, adjusted OR 1.86, p < 0.001). In the multivariate analysis, factors independently associated with a significant increase in the risk of MBE included undergoing primary percutaneous coronary intervention (OR 2.21, p < 0.005), experiencing renal failure (OR 4.19, p < 0.001) and systolic blood pressure level at admission (OR 1.12, per 10- mm Hg decrement, p = 0.011). Patients who experienced MBE had a >3.5-fold increased risk for 1-year mortality (adjusted HR = 3.52, p < 0.001). Interestingly, the mortality risk associated with MBE was evident only among those who experienced non-access-site bleeding (HR = 1.9; p = 0.001). Conclusions: In the past decade, there has been a significant increase in the rate of MBE. However, we found that only major bleeding that was not related to the vascular access site affected subsequent mortality.
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153
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Summaria F, Giannico MB, Talarico GP, Patrizi R. Antiplatelet Therapy in Hemodialysis Patients Undergoing Percutaneous Coronary Interventions. Nephrourol Mon 2015; 7:e28099. [PMID: 26528445 PMCID: PMC4623612 DOI: 10.5812/numonthly.28099] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 03/17/2015] [Indexed: 01/17/2023] Open
Abstract
Context: Coronary artery disease is highly prevalent among patients with end stage renal disease/hemodialysis (ESRD/HD) and coronary percutaneous interventions (PCI) has been increased by nearly 50% over the past decade. After PCI with stent placement, guidelines recommend dual antiplatelet therapy (DAPT), but no specifically tailored pharmacotherapy approach is outlined for this frail population, mostly excluded from large randomized clinical trials (RCTs). Evidence Acquisition: We reviewed current evidences on the use of antiplatelet therapy in patients with ESRD/HD undergoing PCI, focusing on the efficacy and safety of specific agents and their indications for detailed clinical settings. Results: Clinical setting in HD patients is the principal determinant of the type, onset, combination and duration of the DAPT. However, irrespective clinical setting, in addition to aspirin, clopidogrel is currently the most used antiplatelet agent even if no information derived from RCTs are available in ESRD. Due to the large experience acquired in routine clinical practice, the awareness of safety is higher for clopidogrel than newer antiplatelet agents. Because of lack of data, the use of prasugrel and ticagrelor is actually not recommended. However, in case of high ischemic and acceptable bleeding risk, they may be selectively used in ESRD/HD. Conclusions: This investigation might contribute to delineate the best treatment options for this high risk population.
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Affiliation(s)
- Francesco Summaria
- Department of Cardiology-Policlinico Casilino, Catheter Laboratory, Rome, Italy
- Corresponding author: Francesco Summaria, Department of Cardiology-Policlinico Casilino, Catheter Laboratory, Rome, Italy. Tel: +39-0623188448, E-mail:
| | - Maria B. Giannico
- Department of Cardiology-Policlinico Casilino, Catheter Laboratory, Rome, Italy
| | | | - Roberto Patrizi
- Department of Cardiology-Policlinico Casilino, Catheter Laboratory, Rome, Italy
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154
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Andreotti F, Rocca B, Husted S, Ajjan RA, ten Berg J, Cattaneo M, Collet JP, De Caterina R, Fox KAA, Halvorsen S, Huber K, Hylek EM, Lip GYH, Montalescot G, Morais J, Patrono C, Verheugt FWA, Wallentin L, Weiss TW, Storey RF. Antithrombotic therapy in the elderly: expert position paper of the European Society of Cardiology Working Group on Thrombosis. Eur Heart J 2015; 36:3238-49. [PMID: 26163482 DOI: 10.1093/eurheartj/ehv304] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2014] [Accepted: 06/12/2015] [Indexed: 12/19/2022] Open
Affiliation(s)
- Felicita Andreotti
- Department of Cardiovascular Science, Catholic University Medical School, Largo F Vito 1, Rome 00168, Italy
| | - Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Steen Husted
- Medical Department, Region Hospital West, Herning/Holstebro, Denmark
| | - Ramzi A Ajjan
- Division of Cardiovascular and Diabetes Research, The LIGHT Laboratories, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
| | - Jurrien ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Marco Cattaneo
- Medicina 3, Ospedale San Paolo - Dipartimento di SCienze della Salute, UNiversità degli Studi di Milano, Milan, Italy
| | - Jean-Philippe Collet
- Institut de Cardiologie, INSERM UMRS 1166, Allies in Cardiovascular Trials Initiatives and Organized Networks Group, Pitié-Salpêtrière Hospital (Assistance Publique-Hôpitaux de Paris), Université Pierre et Marie Curie, Paris, France
| | - Raffaele De Caterina
- Department of Cardiology, 'G. d'Annunzio' University - Ospedale SS. Annunziata, Chieti, Italy
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Sigrun Halvorsen
- Department of Cardiology B, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3rd Department of Internal Medicine, Cardiology and Emergency Medicine, Wilhelminen Hospital, Montleartstrasse 37, Vienna A-1160, Austria
| | - Elaine M Hylek
- Department of Medicine, Boston University School of Medicine-Boston Medical Center, Boston, MA, USA
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK
| | - Gilles Montalescot
- Institut de Cardiologie, INSERM UMRS 1166, Pitié-Salpêtrière Hospital (Assistance Publique-Hôpitaux de Paris), Université Pierre et Marie Curie, Paris, France
| | - Joao Morais
- Department of Cardiology, Hospital de Santo André, Leiria, Portugal
| | - Carlo Patrono
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | | | - Lars Wallentin
- Uppsala Clinical Research Center and Department of Medical Sciences (Cardiology), Uppsala University, Uppsala, Sweden
| | - Thomas W Weiss
- 3rd Department of Internal Medicine, Cardiology and Emergency Medicine, Wilhelminen Hospital, Montleartstrasse 37, Vienna A-1160, Austria
| | - Robert F Storey
- Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
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155
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Khoo CW, Holroyd EW, Butler R, Nolan J, Mamas MA. Transradial percutaneous coronary intervention in high-risk patients. Interv Cardiol 2015. [DOI: 10.2217/ica.15.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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156
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Khan R, Lopes RD, Neely ML, Stevens SR, Harrington RA, Diaz R, Cools F, Jansky P, Montalescot G, Atar D, Lopez-Sendon J, Flather M, Liaw D, Wallentin L, Alexander JH, Goodman SG. Characterising and predicting bleeding in high-risk patients with an acute coronary syndrome. Heart 2015; 101:1475-84. [DOI: 10.1136/heartjnl-2014-307346] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 05/27/2015] [Indexed: 12/22/2022] Open
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157
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Kazi DS, Leong TK, Chang TI, Solomon MD, Hlatky MA, Go AS. Association of spontaneous bleeding and myocardial infarction with long-term mortality after percutaneous coronary intervention. J Am Coll Cardiol 2015; 65:1411-20. [PMID: 25857906 DOI: 10.1016/j.jacc.2015.01.047] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 01/04/2015] [Accepted: 01/22/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND Platelet inhibition after percutaneous coronary intervention (PCI) reduces the risk of myocardial infarction (MI) but increases the risk of bleeding. MIs and bleeds during the index hospitalization for PCI are known to negatively affect long-term outcomes. The impact of spontaneous bleeding occurring after discharge on long-term mortality is unknown. OBJECTIVES This study sought to examine, in a real-world cohort, the association between spontaneous major bleeding or MI after PCI and long-term mortality. METHODS We conducted a retrospective cohort study of patients ≥30 years of age who underwent a PCI between 1996 and 2008 in an integrated healthcare delivery system. We used extended Cox regression to examine the associations of spontaneous bleeding and MI with all-cause mortality, after adjustment for time-updated demographics, comorbidities, periprocedural events, and longitudinal medication exposure. RESULTS Among 32,906 patients who had a PCI and survived the index hospitalization, 530 had bleeds and 991 had MIs between 7 and 365 days post-discharge. There were 4,048 deaths over a mean follow-up of 4.42 years. The crude annual death rate after a spontaneous bleed (9.5%) or MI (7.6%) was higher than among patients who experienced neither event (2.6%). Bleeding was associated with an increased rate of death (adjusted hazard ratio [HR]: 1.61, 95% confidence interval [CI]: 1.30 to 2.00), similar to that after an MI (HR: 1.91; 95% CI: 1.62 to 2.25). The association of bleeding with death remained significant after additional adjustment for the longitudinal use of antiplatelet agents. CONCLUSIONS Spontaneous bleeding after a PCI was independently associated with higher long-term mortality, and conveyed a risk comparable to that of an MI during follow-up. This tradeoff between efficacy and safety bolsters the argument for personalizing antiplatelet therapy after PCI on the basis of the patient's long-term risk of both thrombotic and bleeding events.
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Affiliation(s)
- Dhruv S Kazi
- Division of Cardiology, San Francisco General Hospital, San Francisco, California; Department of Medicine (Cardiology), University of California San Francisco, San Francisco, California; Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California.
| | - Thomas K Leong
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Tara I Chang
- Department of Medicine, Stanford University, Stanford, California
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Medicine, Stanford University, Stanford, California
| | - Mark A Hlatky
- Department of Medicine, Stanford University, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California
| | - Alan S Go
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California; Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Health Research and Policy, Stanford University, Stanford, California
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158
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RAJANI NIKILK, BROWN ADAMJ, MCCORMICK LIAMM, PARWAIZ HAMMAD, KAUSHAL ANMOL, HOOLE STEPHENP, WEST NICKEJ. Institutional Switch from Transfemoral to Transradial Vascular Access for Percutaneous Coronary Intervention was Associated with a Reduction in Bleeding Events: A Singlecenter Experience of >10,000 Consecutive Cases. J Interv Cardiol 2015; 28:296-304. [DOI: 10.1111/joic.12205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- NIKIL K. RAJANI
- Department of Interventional Cardiology; Papworth Hospital NHS Foundation Trust; Cambridge United Kingdom
| | - ADAM J. BROWN
- Department of Interventional Cardiology; Papworth Hospital NHS Foundation Trust; Cambridge United Kingdom
| | - LIAM M. MCCORMICK
- Department of Interventional Cardiology; Papworth Hospital NHS Foundation Trust; Cambridge United Kingdom
| | - HAMMAD PARWAIZ
- Department of Interventional Cardiology; Papworth Hospital NHS Foundation Trust; Cambridge United Kingdom
| | - ANMOL KAUSHAL
- Department of Interventional Cardiology; Papworth Hospital NHS Foundation Trust; Cambridge United Kingdom
| | - STEPHEN P. HOOLE
- Department of Interventional Cardiology; Papworth Hospital NHS Foundation Trust; Cambridge United Kingdom
| | - NICK E. J. WEST
- Department of Interventional Cardiology; Papworth Hospital NHS Foundation Trust; Cambridge United Kingdom
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159
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Correia LCL, Ferreira F, Kalil F, Silva A, Pereira L, Carvalhal M, Cerqueira M, Lopes F, Sá ND, Noya-Rabelo M. Comparison of ACUITY and CRUSADE Scores in Predicting Major Bleeding during Acute Coronary Syndrome. Arq Bras Cardiol 2015; 105:20-7. [PMID: 26039664 PMCID: PMC4523284 DOI: 10.5935/abc.20150058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/19/2015] [Indexed: 12/22/2022] Open
Abstract
Background The ACUITY and CRUSADE scores are validated models for prediction of major
bleeding events in acute coronary syndrome (ACS). However, the comparative
performances of these scores are not known. Objective To compare the accuracy of ACUITY and CRUSADE in predicting major bleeding events
during ACS. Methods This study included 519 patients consecutively admitted for unstable angina,
non-ST-elevation or ST-elevation myocardial infarction. The scores were calculated
based on admission data. We considered major bleeding events during
hospitalization and not related to cardiac surgery, according to the Bleeding
Academic Research Consortium (BARC) criteria (type 3 or 5: hemodynamic
instability, need for transfusion, drop in hemoglobin ≥ 3 g, and intracranial,
intraocular or fatal bleeding). Results Major bleeding was observed in 31 patients (23 caused by femoral puncture, 5
digestive, 3 in other sites), an incidence of 6%. While both scores were
associated with bleeding, ACUITY demonstrated better C-statistics (0.73, 95% CI =
0.63 - 0.82) as compared with CRUSADE (0.62, 95% CI = 0.53 - 0.71; p = 0.04). The
best performance of ACUITY was also reflected by a net reclassification
improvement of + 0.19 (p = 0.02) over CRUSADE’s definition of low or high risk.
Exploratory analysis suggested that the presence of the variables ‘age’ and ‘type
of ACS’ in ACUITY was the main reason for its superiority. Conclusion The ACUITY Score is a better predictor of major bleeding when compared with the
CRUSADE Score in patients hospitalized for ACS.
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Affiliation(s)
| | - Felipe Ferreira
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, BR
| | - Felipe Kalil
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, BR
| | - André Silva
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, BR
| | - Luisa Pereira
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, BR
| | | | | | - Fernanda Lopes
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, BR
| | - Nicole de Sá
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, BR
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160
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Honda Y, Muramatsu T, Ito Y, Sakai T, Hirano K, Yamawaki M, Araki M, Kobayashi N, Takimura H, Sakamoto Y, Mouri S, Tsutumi M, Takama T, Takafuji H, Tokuda T, Makino K. Impact of ultra-long second-generation drug-eluting stent implantation. Catheter Cardiovasc Interv 2015; 87:E44-53. [DOI: 10.1002/ccd.26010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 04/08/2015] [Accepted: 04/11/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Yohsuke Honda
- Saiseikai Yokohama City Eastern Hospital; Yokohama City Kanagawa Japan
| | - Toshiya Muramatsu
- Saiseikai Yokohama City Eastern Hospital; Yokohama City Kanagawa Japan
| | - Yoshiaki Ito
- Saiseikai Yokohama City Eastern Hospital; Yokohama City Kanagawa Japan
| | - Tsuyoshi Sakai
- Saiseikai Yokohama City Eastern Hospital; Yokohama City Kanagawa Japan
| | - Keisuke Hirano
- Saiseikai Yokohama City Eastern Hospital; Yokohama City Kanagawa Japan
| | - Masahiro Yamawaki
- Saiseikai Yokohama City Eastern Hospital; Yokohama City Kanagawa Japan
| | - Motoharu Araki
- Saiseikai Yokohama City Eastern Hospital; Yokohama City Kanagawa Japan
| | | | - Hideyuki Takimura
- Saiseikai Yokohama City Eastern Hospital; Yokohama City Kanagawa Japan
| | - Yasunari Sakamoto
- Saiseikai Yokohama City Eastern Hospital; Yokohama City Kanagawa Japan
| | - Shinsuke Mouri
- Saiseikai Yokohama City Eastern Hospital; Yokohama City Kanagawa Japan
| | - Masakazu Tsutumi
- Saiseikai Yokohama City Eastern Hospital; Yokohama City Kanagawa Japan
| | - Takuro Takama
- Saiseikai Yokohama City Eastern Hospital; Yokohama City Kanagawa Japan
| | - Hiroya Takafuji
- Saiseikai Yokohama City Eastern Hospital; Yokohama City Kanagawa Japan
| | - Takahiro Tokuda
- Saiseikai Yokohama City Eastern Hospital; Yokohama City Kanagawa Japan
| | - Kenji Makino
- Saiseikai Yokohama City Eastern Hospital; Yokohama City Kanagawa Japan
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161
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Cornel JH, Tricoci P, Lokhnygina Y, Moliterno DJ, Wallentin L, Armstrong PW, Aylward PE, Clare RM, Chen E, Leonardi S, Van de Werf F, White HD, Held C, Strony J, Mahaffey KW, Harrington RA. Glycoprotein IIb/IIIa Receptor Inhibitors in Combination With Vorapaxar, a Platelet Thrombin Receptor Antagonist, Among Patients With Non-ST-Segment Elevation Acute Coronary Syndromes (from the TRACER Trial). Am J Cardiol 2015; 115:1325-32. [PMID: 25776457 DOI: 10.1016/j.amjcard.2015.02.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 02/13/2015] [Accepted: 02/13/2015] [Indexed: 11/29/2022]
Abstract
We evaluated the interaction between protease-activated receptor-1 antagonist vorapaxar and concomitant glycoprotein (GP) IIb/IIIa receptor inhibitors in patients with non-ST-segment elevation acute coronary syndromes who underwent PCI. In Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome trial, 12,944 patients with non-ST-segment elevation acute coronary syndromes were randomized to vorapaxar or placebo. Administration of GP IIb/IIIa receptor inhibitors was allowed at the treating physician's discretion. We investigated whether use of GP IIb/IIIa receptor inhibitors modified vorapaxar's effect on non-coronary artery bypass grafting (CABG)-related bleeding at 7 days and ischemic events at 30 days. In total, 7,455 patients underwent PCI during index hospitalization. Of these, 2,023 patients (27.1%) received inhibitors and 5,432 (72.9%) did not. Vorapaxar was associated with a numerically higher rate of non-CABG-related moderate/severe Global Use of Strategies to Open Occluded Arteries (GUSTO) bleeding at 7 days compared with placebo in those who did (1.3% vs 1.0%) and did not (0.6% vs 0.4%) receive GP IIb/IIIa receptor inhibitors. Ischemic end point rates at 30 days were not significantly lower with vorapaxar versus placebo. Increased rates of non-CABG GUSTO moderate/severe bleeding were observed in patients who received GP IIb/IIIa receptor inhibitors versus those who did not (adjusted hazard ratio [HR] 1.77, 95% confidence interval [CI] 0.43 to 7.35 in placebo arm; adjusted HR 2.02, 95% CI 0.62 to 6.61 in vorapaxar arm) and in those who received vorapaxar versus placebo (adjusted HR 1.54, 95% CI 0.36 to 6.56 in the GP IIb/IIIa group; adjusted HR 1.34, 95% CI 0.44 to 4.07 in the no-GP IIb/IIIa group). No interaction was found between vorapaxar and inhibitor use up to 7 days (P interaction = 0.89) nor at the end of the treatment (P interaction = 0.74); however, the event rate was low. Also, no interaction was observed for efficacy end points after PCI at 30 days or at the end of the treatment. In conclusion, GP IIb/IIIa receptor inhibitor use plus dual antiplatelet therapy in a population with non-ST-segment elevation myocardial infarction planned for PCI was frequent but did not interact with vorapaxar's efficacy or safety. Nonetheless, GP IIb/IIIa receptor inhibitors and vorapaxar were associated with increased bleeding risk, and their combined use may result in additive effects on bleeding rates.
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Affiliation(s)
- Jan H Cornel
- Department of cardiology, Medisch Centrum Alkmaar, Alkmaar, the Netherlands.
| | | | | | - David J Moliterno
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - Philip E Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia
| | - Robert M Clare
- Duke Clinical Research Institute, Durham, North Caroline
| | - Edmond Chen
- Global Clinical Development, Bayer HealthCare Pharmaceuticals Inc., Whippany, New Jersey
| | | | | | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Claes Held
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala, Sweden
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162
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Solinas E, Vignali L, Ortolani P, Guastaroba P, Marzocchi A, Manari A, De Palma R, Mehran R, Paoli G, Notarangelo MF, Caminiti C, Ardissino D, Merlini PA. Association of bleeding, mortality and sex in acute coronary syndromes. J Cardiovasc Med (Hagerstown) 2015; 16:347-54. [DOI: 10.2459/jcm.0000000000000174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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163
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Wagener JF, Rao SV. A comparison of radial and femoral access for cardiac catheterization. Trends Cardiovasc Med 2015; 25:707-13. [PMID: 25912254 DOI: 10.1016/j.tcm.2015.03.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 03/24/2015] [Accepted: 03/24/2015] [Indexed: 01/26/2023]
Abstract
Over the past several years, the transradial approach (TRA) for cardiac catheterization has become increasingly adopted in the United States. The increased utilization of the TRA is grounded on 2 decades of research, showing reduced bleeding and vascular complications to complement improved patient quality of life. However, the concern over cost, radiation exposure, and acknowledged "learning curve" has kept the transfemoral approach (TFA) the mainstay of most US catheterization laboratories. More recent larger multi-centered randomized studies have aimed to address outcomes and these concerns between the TR and TF approaches. This article will review the changing trends in TRA in the US, discuss clinical (bleeding and mortality) and non-clinical (quality of life and cost) outcomes from recent randomized studies, and finally discuss certain aspects when it comes to adopting TRA.
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Affiliation(s)
| | - Sunil V Rao
- Duke Clinical Research Institute, Durham, NC
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164
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Di Minno A, Spadarella G, Prisco D, Scalera A, Ricciardi E, Di Minno G. Antithrombotic drugs, patient characteristics, and gastrointestinal bleeding: Clinical translation and areas of research. Blood Rev 2015; 29:335-43. [PMID: 25866382 DOI: 10.1016/j.blre.2015.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 03/04/2015] [Indexed: 02/07/2023]
Abstract
Gastrointestinal bleeding (GIB) is a potentially fatal and avoidable medical condition that poses a burden on global health care costs. Current understanding of the roles of platelet activation and thrombin generation/activity in vascular medicine has led to the development of effective antithrombotic treatments. However, in parallel with a sustained coronary and cerebral flow patency, the increasingly intensive treatment with warfarin; direct oral anticoagulant drugs [DOACs], and/or with aspirin ± clopidogrel (or ± prasugrel or ± ticagrelor), has increased the burden of GIBs related to the use of antithrombotic agents. Compelling evidence concerning this issue is accumulating to indicate that: 1) the risk of GIB related to the use of antithrombotic drugs dramatically differs in different clinical settings; and 2) the characteristics of patients (e.g., severity of illness, comorbidities) in whom it is used exert a greater impact on the risk of GIB than the type of antithrombotic agent employed. The latter concept argues for the occurrence of GIB as reflecting the presence of patients at the highest risk for adverse outcomes. The HAS-BLED score identifies subjects at risk of bleeding among those untreated and those treated with warfarin, DOACs and/or low-dose aspirin. Its use within the frame of a severity score (e.g., the CHA2DS2-VASc score in patients with atrial fibrillation) helps balance the benefits and the risks of an antithrombotic treatment and identify those patients in whom the absolute gain (vascular events prevented) outweighs the risk of GIB. Potential implications of the latter information in settings other than atrial fibrillation is thoroughly discussed.
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Affiliation(s)
- Alessandro Di Minno
- Department of Farmacia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Gaia Spadarella
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Domenico Prisco
- Department of Medicina Sperimentale e Clinica, Università degli Studi di Firenze, Largo Brambilla 3, 50134 Firenze, Italy
| | - Antonella Scalera
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Elena Ricciardi
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Giovanni Di Minno
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy.
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Bheemarasetti MK, Shawar S, Chithri S, Khalife WI, Rangasetty UM, Fujise K, Gilani SA. Influence of Access, Anticoagulant, and Bleeding Definition on Outcomes of Primary Percutaneous Coronary Intervention: Early Experience of an US Academic Center. Int J Angiol 2015; 24:11-8. [PMID: 25780323 DOI: 10.1055/s-0034-1394158] [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: 10/24/2022] Open
Abstract
Background We aimed to carry out comparison of different bleeding avoidance strategies in doing primary percutaneous coronary intervention (PPCI) using either radial or femoral as access of choice and either bivalirudin or unfractionated heparin as anticoagulant of choice. In this analysis, we analyzed the influence of major bleeding definition on bleeding outcomes as well. Methods We did a retrospective analysis of 139 patients with ST-segment elevation myocardial infarction (STEMI) who had PPCI in our academic center from January 2010 till October 2013. The primary outcome at 30 days was a composite of death from any cause or stent thrombosis or non-coronary artery bypass grafting (CABG) related major bleeding (CathPCI Registry definition) and secondary outcomes were individual components of primary outcome and the hospital length of stay. Results There was no significant difference among different access/anticoagulant combinations with regards to primary outcome (22% in radial/bivalirudin vs. 5% in radial/heparin vs. 17% in femoral/bivalirudin vs. 28% in femoral/heparin group; p = 0.2) as well as its individual components except the hospital length of stay (2.56 vs. 3 vs. 3.97 vs. 4.4 days each; p < 0.0001). The overall rate of major bleeding was 11.5%. When we use HORIZON-AMI bleeding definition, it went up to 25 % due to one particular component (p < 0.004). Conclusions This single center observational study doing PPCI did not show any superiority of one bleeding avoidance strategy over others with regard to primary outcome and its individual components except the hospital length of stay. It also shows the importance of bleeding definition on bleeding outcomes.
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Affiliation(s)
- M K Bheemarasetti
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - S Shawar
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - S Chithri
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - W I Khalife
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - U M Rangasetty
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - K Fujise
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - S A Gilani
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
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166
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Abtahian F, Waldo S, Jang IK. Comparison of heparin and bivalirudin in patients undergoing percutaneous coronary intervention without use of glycoprotein IIb/IIIa inhibitors. Catheter Cardiovasc Interv 2015; 86:390-6. [PMID: 25753749 DOI: 10.1002/ccd.25911] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 02/28/2015] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The primary objective of this study is the compare the association between bleeding and the use unfractionated heparin (UFH) versus bivalirudin during percutaneous coronary intervention (PCI). BACKGROUND In patients undergoing PCI, the risk of bleeding with use of bivalirudin compared with UFH in the absence of glycoprotein IIb/IIIa inhibitors is not well defined. METHODS Patients undergoing PCI with either UFH or bivalirudin monotherapy at a single institution between 2007 and 2014 were included (n = 6,143). Propensity score matching was used to adjust for baseline characteristics yielding 2,984 well matched patients (1,492 in each group). The primary endpoint was major non-coronary artery bypass graft (non-CABG) related bleeding as defined by a Bleeding Academic Consortium type 3 or 5. Secondary outcomes included combined major and minor bleeding, in-hospital death, periprocedural myocardial infarction, and recurrent ischemia requiring urgent revascularization (repeat PCI). RESULTS In the propensity matched cohort, there was no difference in major bleeding between UFH and bivalirudin monotherapy (1.8% versus 2.4%, P = 0.305). Combined major and minor bleeding was also similar between the two groups (4.3% versus 4.3%, P = 1.0). Likewise, no differences were observed between the bivalirudin and UFH groups in terms of in-hospital death (0.4% versus 0.5%, P = 0.592), periprocedural myocardial infarction (1.5% versus 2.0%, P = 0.332) and repeat PCI (0.7% versus 0.8%, P = 0.669). CONCLUSION Among patients undergoing PCI, there was no significant difference in rate of bleeding between bivalirudin and heparin monotherapy in a real-world setting.
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Affiliation(s)
- Farhad Abtahian
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachuttes
| | - Stephen Waldo
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachuttes
| | - Ik-Kyung Jang
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachuttes
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167
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Esper SA, Bermudez C, Dueweke EJ, Kormos R, Subramaniam K, Mulukutla S, Sappington P, Waters J, Khandhar SJ. Extracorporeal membrane oxygenation support in acute coronary syndromes complicated by cardiogenic shock. Catheter Cardiovasc Interv 2015; 86 Suppl 1:S45-50. [DOI: 10.1002/ccd.25871] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 01/27/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Stephen A. Esper
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Christian Bermudez
- Heart and Vascular Institute, University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Eric J. Dueweke
- Heart and Vascular Institute, University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Robert Kormos
- Heart and Vascular Institute, University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Kathirvel Subramaniam
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Suresh Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Penny Sappington
- Department of Critical Care Medicine; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Jonathan Waters
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Sameer J. Khandhar
- Heart and Vascular Institute at Penn-Presbyterian Medical Center; Philadelphia Pennsylvania
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168
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Dangas G, Chandrasekhar J. Real dilemmas regarding blood transfusion. JACC Cardiovasc Interv 2015; 8:447-449. [PMID: 25703869 DOI: 10.1016/j.jcin.2015.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 01/15/2015] [Indexed: 11/25/2022]
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169
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Austin D, Mackay DF, Morley R, Christie J, Hennigan B, de Belder MA, Pell JP, Oldroyd KG. High-bolus dose tirofiban compared with abciximab in primary percutaneous coronary intervention: a propensity score-matched outcome study. EUROINTERVENTION 2015; 10:1187-94. [DOI: 10.4244/eijy14m05_11] [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: 11/23/2022]
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170
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Kunadian V, Mehran R, Lincoff AM, Feit F, Manoukian SV, Hamon M, Cox DA, Dangas GD, Stone GW. Effect of anemia on frequency of short- and long-term clinical events in acute coronary syndromes (from the Acute Catheterization and Urgent Intervention Triage Strategy Trial). Am J Cardiol 2014; 114:1823-9. [PMID: 25438908 DOI: 10.1016/j.amjcard.2014.09.023] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 09/14/2014] [Accepted: 09/14/2014] [Indexed: 11/25/2022]
Abstract
There are limited data on the impact of anemia on clinical outcomes in unstable angina and non-ST-segment elevation myocardial infarction treated with an early invasive strategy. We sought to determine the short- and long-term clinical events among patients with and without anemia enrolled in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. Anemia was defined as baseline hemoglobin of <13 g/dl for men and <12 g/dl for women. The primary end points were composite ischemia (death, myocardial infarction, or unplanned revascularization for ischemia) and major bleeding assessed in-hospital, at 1 month, and at 1 year. Among the 13,819 patients in the ACUITY trial, information regarding anemia was available in 13,032 (94.3%), 2,199 of whom (16.9%) had anemia. Patients with anemia compared with those without anemia had significantly increased adverse event rates in-hospital (composite ischemia 6.6% vs 4.8%, p = 0.0004; major bleeding 7.3% vs 3.3%, p <0.0001), at 1 month (composite ischemia 10% vs 7.2%, p <0.0001, major bleeding 8.8% vs 3.9%, p <0.0001), and 1 year (composite ischemia 21.7% vs 15.3%, p <0.0001). Anemia was an independent predictor of death at 1 year (hazard ratio 1.77, 95% confidence interval [CI] 1.29 to 2.44, p = 0.0005). Composite ischemia was significantly more common among patients who developed in-hospital non-coronary artery bypass surgery major bleeding compared with those who did not (anemic patients 1-year relative risk 2.19, 95% CI 1.67 to 2.88, p <0.0001; nonanemic patients relative risk 2.16, 95% CI 1.76 to 2.65, p <0.0001). In conclusion, in the ACUITY trial, baseline anemia was strongly associated with adverse early and late clinical events, especially in those who developed major bleeding.
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171
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Goto K, Lansky AJ, Ng VG, Pietras C, Nargileci E, Mehran R, Parise H, Feit F, Ohman EM, White HD, Bertrand ME, Desmet W, Hamon M, Stone GW. Prognostic value of angiographic lesion complexity in patients with acute coronary syndromes undergoing percutaneous coronary intervention (from the acute catheterization and urgent intervention triage strategy trial). Am J Cardiol 2014; 114:1638-45. [PMID: 25312637 DOI: 10.1016/j.amjcard.2014.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 09/02/2014] [Accepted: 09/02/2014] [Indexed: 11/27/2022]
Abstract
Although lesion complexity is predictive of outcomes after balloon angioplasty, it is unclear whether complex lesions continue to portend a worse prognosis in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) with contemporary interventional therapies. We sought to assess the impact of angiographic lesion complexity, defined by the modified American College of Cardiology/American Heart Association classification, on clinical outcomes after PCI in patients with ACS and to determine whether an interaction exists between lesion complexity and antithrombin regimen outcomes after PCI. Among the 3,661 patients who underwent PCI in the Acute Catheterization and Urgent Intervention Triage strategy study, patients with type C lesions (n = 1,654 [45%]) had higher 30-day rates of mortality (1.2% vs 0.6%, p = 0.049), myocardial infarction (9.2% vs 6.3%, p = 0.0006), and unplanned revascularization (4.3% vs 3.1%, p = 0.04) compared with those without type C lesions. In multivariate analysis, type C lesions were independently associated with myocardial infarction (odds ratio [95% confidence interval] = 1.37 [1.04 to 1.80], p = 0.02) and composite ischemia (odds ratio [95% confidence interval] = 1.49 [1.17 to 1.88], p = 0.001) at 30 days. Bivalirudin monotherapy compared with heparin plus a glycoprotein IIb/IIIa inhibitor reduced major bleeding complications with similar rates of composite ischemic events, regardless of the presence of type C lesions. There were no interactions between antithrombotic regimens and lesion complexity in terms of composite ischemia and major bleeding (p [interaction] = 0.91 and 0.80, respectively). In conclusion, patients with ACS with type C lesion characteristics undergoing PCI have an adverse short-term prognosis. Treatment with bivalirudin monotherapy reduces major hemorrhagic complications irrespective of lesion complexity with comparable suppression of adverse ischemic events as heparin plus glycoprotein IIb/IIIa inhibitor.
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172
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RUBARTELLI PAOLO, CRIMI GABRIELE, BARTOLINI DAVIDE, BELLOTTI SANDRO, IANNONE ALESSANDRO, FONTANA VINCENZO. Switching from Femoral to Routine Radial Access Site for ST-Elevation Myocardial Infarction:
A Single Center Experience. J Interv Cardiol 2014; 27:591-9. [DOI: 10.1111/joic.12157] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- PAOLO RUBARTELLI
- Department of Cardiology; ASL3 Ospedale Villa Scassi; Genoa Italy
| | - GABRIELE CRIMI
- Department of Cardiology; ASL3 Ospedale Villa Scassi; Genoa Italy
| | - DAVIDE BARTOLINI
- Department of Cardiology; ASL3 Ospedale Villa Scassi; Genoa Italy
| | - SANDRO BELLOTTI
- Department of Cardiology; ASL3 Ospedale Villa Scassi; Genoa Italy
| | | | - VINCENZO FONTANA
- Epidemiology, Biostatistics and Clinical Trials Unit; IRCCS AOU San Martino - IST; Genoa Italy
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173
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Hamon M, Lemesle G, Tricot O, Meurice T, Deneve M, Dujardin X, Brufau JM, Bera J, Lamblin N, Bauters C. Incidence, Source, Determinants, and Prognostic Impact of Major Bleeding in Outpatients With Stable Coronary Artery Disease. J Am Coll Cardiol 2014; 64:1430-6. [DOI: 10.1016/j.jacc.2014.07.957] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 06/21/2014] [Accepted: 07/01/2014] [Indexed: 11/25/2022]
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174
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Boeder NF, Hamm CW, Nef HM. [Procedural aspects in primary PCI: arterial access, stent selection, thrombectomy and treatment of non-culprit lesions]. Herz 2014; 39:685-91. [PMID: 25070211 DOI: 10.1007/s00059-014-4133-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute myocardial infarction was one of the most common causes of death in Germany in 2011. According to the guidelines of the European Society for Cardiology, systemic fibrinolysis and primary percutaneous coronary intervention (PCI) are the methods of choice for acute treatment. Primary PCI should be given priority due to its superiority. The transradial access should be preferred due to the lower bleeding complication rate. In the selection of stents the new generation of drug-eluting stents (DES) are superior to the first generation of bare metal stents (BMS). It has now been demonstrated that the incident rates of DES (e.g. mortality, target vessel revascularization, early and late stent thrombosis and myocardial infarction) are significantly lower. For bioresorbable scaffolds (BRS) long-term results for the use in treatment of ST-elevation myocardial infarction (STEMI) are not yet available but initial results are very promising. However, the selection of a stent needs to be done on an individual basis in order to do justice to all aspects. Data with respect to thrombectomy in acute treatment are heterogeneous. Currently, a thorough consideration of all aspects is necessary because thrombus aspiration can also be associated with an increased rate of incidents. In a state of hemodynamic stability only so-called culprit lesions should currently be treated with a stent. Elective interventions on further stenoses should be carried out after consideration of individual factors and if necessary evaluation of the hemodynamic relevance.
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Affiliation(s)
- N F Boeder
- Medizinische Klinik I, Kardiologie und Angiologie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Klinikstr. 33, 35392, Gießen, Deutschland
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175
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Yoon YH, Kim YH, Kim SO, Lee JY, Park DW, Kang SJ, Lee SW, Lee CW, Park SW, Park SJ. Impact of in-hospital bleeding according to the Bleeding Academic Research Consortium classification on the long-term adverse outcomes in patients undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2014; 85:63-71. [PMID: 24282105 DOI: 10.1002/ccd.25308] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 11/05/2013] [Accepted: 11/22/2013] [Indexed: 01/21/2023]
Abstract
OBJECTIVES The aim of this study was to assess the impact of bleeding after percutaneous coronary intervention (PCI) with drug-eluting stents on long-term clinical events according to the newly proposed Bleeding Academic Research Consortium (BARC) classification. BACKGROUND Current evidence about the impact of the BARC classification is limited. METHODS Out of a total of 6,166 patients who underwent PCI in a prospective IRIS-DES registry, the impact of in-hospital bleeding defined as the BARC classification on major adverse cardiovascular events (MACE) comprising death, myocardial infarction (MI), or stroke was analyzed. RESULTS In-hospital bleeding occurred in 235 patients (3.8%) according to BARC classification. During the 2-year follow-up, MACE occurred in 599 patients (9.7%). The 2-year incidence of MACE was significantly higher in patients with bleeding (16.7% vs. 8.3%; adjusted hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.2-2.3; P = 0.002) than in those without bleeding. We observed a higher risk of MI (12.4% vs. 6.4%; adjusted HR, 1.7; 95% CI, 1.2-2.6, P = 0.005), stroke (3.0% vs. 0.6%; adjusted HR, 2.9; 95% CI, 1.4-6.2, P = 0.005) in patients with bleeding. Death (3.8% vs. 1.6%; adjusted HR, 1.6; 95% CI, 0.9-3.0, P = 0.120) and target vessel revascularization (4.3% vs. 1.9%; adjusted HR, 1.6; 95% CI, 0.9-2.9, P = 0.108) were statistically insignificant. Incidence, adjusted HR and P-value were similar between BARC and TIMI classification. CONCLUSIONS In-hospital bleeding events according to the newly proposed BARC definition were significantly associated with an increased risk of adverse long-term events in patients undergoing PCI with drug-eluting stents. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- Yong-Hoon Yoon
- Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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Improving outcomes in primary percutaneous coronary intervention: Transradial is worth the time. Am Heart J 2014; 168:1-3. [PMID: 24952852 DOI: 10.1016/j.ahj.2014.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 03/19/2014] [Indexed: 11/22/2022]
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177
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Ariza-Solé A, Salazar-Mendiguchía J, Lorente V, Sánchez-Salado JC, Romaguera R, Ferreiro JL, Ñato M, Gómez Hospital JA, Cequier Á. Predictive ability of bleeding risk scores in the routine clinical practice. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:205-10. [DOI: 10.1177/2048872614538405] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 05/04/2014] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | - Marcos Ñato
- Bellvitge University Hospital, Barcelona, Spain
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178
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Coons JC, Miller T. Strategies to Reduce Bleeding Risk in Acute Coronary Syndromes and Percutaneous Coronary Intervention: New and Emerging Pharmacotherapeutic Considerations. Pharmacotherapy 2014; 34:973-90. [DOI: 10.1002/phar.1447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- James C. Coons
- University of Pittsburgh School of Pharmacy; Pittsburgh Pennsylvania
| | - Taylor Miller
- Department of Pharmacy; UPMC-Presbyterian Hospital; Pittsburgh Pennsylvania
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179
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Bangalore S, Pencina MJ, Kleiman NS, Cohen DJ. Heparin Monotherapy or Bivalirudin During Percutaneous Coronary Intervention in Patients With Non–ST-Segment–Elevation Acute Coronary Syndromes or Stable Ischemic Heart Disease. Circ Cardiovasc Interv 2014; 7:365-73. [DOI: 10.1161/circinterventions.113.001126] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sripal Bangalore
- From the Department of Medicine, Division of Cardiology, New York University School of Medicine (S.B.); Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Durham, NC (M.J.P.); Department of Cardiology, The Methodist DeBakey Heart and Vascular Center, Houston, TX (N.S.K.); and Department of Cardiology, Saint-Luke’s Mid America Heart Institute, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Michael J. Pencina
- From the Department of Medicine, Division of Cardiology, New York University School of Medicine (S.B.); Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Durham, NC (M.J.P.); Department of Cardiology, The Methodist DeBakey Heart and Vascular Center, Houston, TX (N.S.K.); and Department of Cardiology, Saint-Luke’s Mid America Heart Institute, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Neal S. Kleiman
- From the Department of Medicine, Division of Cardiology, New York University School of Medicine (S.B.); Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Durham, NC (M.J.P.); Department of Cardiology, The Methodist DeBakey Heart and Vascular Center, Houston, TX (N.S.K.); and Department of Cardiology, Saint-Luke’s Mid America Heart Institute, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - David J. Cohen
- From the Department of Medicine, Division of Cardiology, New York University School of Medicine (S.B.); Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Durham, NC (M.J.P.); Department of Cardiology, The Methodist DeBakey Heart and Vascular Center, Houston, TX (N.S.K.); and Department of Cardiology, Saint-Luke’s Mid America Heart Institute, University of Missouri-Kansas City School of Medicine (D.J.C.)
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180
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Ariza-Solé A, Formiga F, Lorente V, Sánchez-Salado JC, Sánchez-Elvira G, Roura G, Sánchez-Prieto R, Vila M, Moliner P, Cequier A. Eficacia de los scores de riesgo hemorrágico en el paciente anciano con síndrome coronario agudo. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.10.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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181
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Ariza-Solé A, Formiga F, Lorente V, Sánchez-Salado JC, Sánchez-Elvira G, Roura G, Sánchez-Prieto R, Vila M, Moliner P, Cequier A. Efficacy of Bleeding Risk Scores in Elderly Patients with Acute Coronary Syndromes. ACTA ACUST UNITED AC 2014; 67:463-70. [DOI: 10.1016/j.rec.2013.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Accepted: 10/02/2013] [Indexed: 10/25/2022]
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182
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Cabanas-Grandío P, Abu-Assi E, Raposeiras-Roubin S, Alvarez-Alvarez B, González-Cambeiro C, Romaní SG, Pereira-López E, Bouzas-Cruz N, López-López A, Rodríguez-Girondo M, Pedreira M, García-Acuña JM, González-Juanatey JR. Relative performance of three formulas to assess renal function at predicting in-hospital hemorrhagic complications in an acute coronary syndrome population. What does the new CKD-EPI formula provide? EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 3:237-45. [PMID: 24842753 DOI: 10.1177/2048872614521757] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIMS Assessment of renal function is important for bleeding risk stratification in acute coronary syndrome (ACS). There are three formulas routinely used to assess renal function: the Cockroft-Gault (C-G) formula, the MDRD-4 formula and the new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Our aim was to compare the ability of these formulas to predict the risk of in-hospital bleeding in patients with ACS. METHODS The study included 3270 patients with ACS. The performance of each formula with respect to in-hospital TIMI (Thrombolysis In Myocardial Infarction) major or TIMI minor bleeding were assessed using continuous data and by dividing patients into four subgroups according to the estimated glomerular filtration rate (eGFR): ≥90, 89-60, 30-59 and <30 ml/min/1.73 m(2). RESULTS Bleeding predictive ability was significantly higher for the C-G formula than for MDRD-4 and CKD-EPI formulas, as evaluated by the area under the curve (AUC); continuous eGFR AUCs: 0.73, 0.69 and 0.71, respectively; categorical eGFR AUCs: 0.71, 0.66 and 0.68, respectively. Net reclassification improvement based on the eGFR categories was significantly positively favored C-G: 9.5% (95% confidence interval (CI) 1.8-17.2%) and 19.1% (95% CI 11.3-26.9%) compared with CKD-EPI and MDRD-4, respectively. After multivariable adjustment, the C-G formula predicted in-hospital bleeding better than MDRD-4 formula (severe renal dysfunction vs. normal renal function: odds ratio 7.98, 95% CI 2.61-24.38 with C-G; odds ratio 3.76, 95% CI 1.63-8.69 with MDRD-4; and odds ratio 5.77, 95% CI 2.18-15.24 with CKD-EPI. CONCLUSIONS Our findings suggest that the C-G eGFR may improve risk prediction of in-hospital bleeding more than the MDRD-4 equation and the new CKD-EPI equation in patients with ACS.
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Affiliation(s)
| | - Emad Abu-Assi
- Cardiology Department, University Clinical Hospital of Santiago, Spain
| | | | | | | | | | - Eva Pereira-López
- Cardiology Department, University Clinical Hospital of Santiago, Spain
| | | | | | | | - Milagros Pedreira
- Cardiology Department, University Clinical Hospital of Santiago, Spain
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183
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Ndrepepa G, Guerra E, Schulz S, Fusaro M, Cassese S, Kastrati A. Weight of the bleeding impact on early and late mortality after percutaneous coronary intervention. J Thromb Thrombolysis 2014; 39:35-42. [DOI: 10.1007/s11239-014-1084-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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184
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Lee JG, Lee KB, Roh H, Ahn MY, Bae HJ, Lee JS, Woo HY, Hwang HW. Intracranial Arterial Calcification Can Predict Early Vascular Events after Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2014; 23:e331-7. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.12.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 12/08/2013] [Accepted: 12/16/2013] [Indexed: 01/06/2023] Open
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Briguori C, Visconti G, Focaccio A, Donahue M, Golia B, Selvetella L, Ricciarelli B. Novel Approaches for Preventing or Limiting Events (NAPLES III) Trial: Randomised Comparison of Bivalirudin Versus Unfractionated Heparin in Patients at High Risk of Bleeding Undergoing Elective Coronary Stenting Throught The Femoral Approach. Rationale and Design. Cardiovasc Drugs Ther 2014; 28:273-9. [DOI: 10.1007/s10557-014-6518-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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186
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Impact of Red Blood Cell Transfusion on Platelet Aggregation and Inflammatory Response in Anemic Coronary and Noncoronary Patients. J Am Coll Cardiol 2014; 63:1289-1296. [DOI: 10.1016/j.jacc.2013.11.029] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 10/22/2013] [Accepted: 11/12/2013] [Indexed: 01/28/2023]
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187
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Radial versus femoral access for primary percutaneous interventions in ST-segment elevation myocardial infarction patients: a meta-analysis of randomized controlled trials. JACC Cardiovasc Interv 2014; 6:814-23. [PMID: 23968700 DOI: 10.1016/j.jcin.2013.04.010] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/11/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study sought to determine the safety and efficacy of radial access compared with femoral access for primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND Numerous randomized controlled trials, including several new studies, have compared outcomes of these approaches in the context of primary PCI for STEMI patients with inconclusive results. METHODS We performed a meta-analysis of randomized controlled trials to compare outcomes in STEMI patients undergoing radial versus femoral access for primary PCI. Primary outcomes were death and major bleeding evaluated at the longest available follow-up. Secondary outcomes included access site bleeding, stroke, and procedure time. Twelve studies (N = 5,055) were included. All trials were conducted in centers experienced with both approaches. RESULTS Compared with femoral approach, radial approach was associated with decreased risk of mortality (2.7% vs. 4.7%; odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.40 to 0.76; p < 0.001) and decreased risk of major bleeding (1.4% vs. 2.9%; OR: 0.51, 95% CI: 0.31 to 0.85; p = 0.01). Radial access was also associated with reduction in relative risk of access site bleeding (2.1% vs. 5.6%; OR: 0.35, 95% CI: 0.25 to 0.50; p < 0.001). Stroke risk was similar between both approaches (0.5% vs. 0.5%; OR: 1.07, 95% CI: 0.45 to 2.54; p = 0.87). The procedure time was slightly longer in the radial group than in the femoral group (mean difference: 1.52 min; 95% CI: 0.33 to 2.70, p = 0.01). CONCLUSIONS In STEMI patients undergoing primary PCI, the radial approach is associated with favorable outcomes and should be the preferred approach for experienced radial operators.
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Kikkert WJ, van Geloven N, van der Laan MH, Vis MM, Baan J, Koch KT, Peters RJ, de Winter RJ, Piek JJ, Tijssen JGP, Henriques JPS. The prognostic value of bleeding academic research consortium (BARC)-defined bleeding complications in ST-segment elevation myocardial infarction: a comparison with the TIMI (Thrombolysis In Myocardial Infarction), GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries), and ISTH (International Society on Thrombosis and Haemostasis) bleeding classifications. J Am Coll Cardiol 2014; 63:1866-75. [PMID: 24657697 DOI: 10.1016/j.jacc.2014.01.069] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 01/14/2014] [Accepted: 01/17/2014] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The aim of the present analysis was to compare 1-year mortality prediction of Bleeding Academic Research Consortium (BARC)-defined bleeding complications with existing bleeding definitions in patients with ST-segment elevation myocardial infarction (STEMI) and to investigate the prognostic value of the individual data elements of the bleeding classifications for 1-year mortality. BACKGROUND BARC recently proposed a novel standardized bleeding definition. METHODS The in-hospital occurrence of bleeding defined according to the BARC, TIMI (Thrombolysis In Myocardial Infarction), GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries), and ISTH (International Society on Thrombosis and Haemostasis) bleeding classifications was assessed in 2,002 STEMI patients undergoing primary percutaneous coronary intervention between January 1, 2003, and July 31, 2008. RESULTS BARC types 2, 3, 4, and 5 bleeding occurred in 4.4%, 14.2%, 1.4%, and 0.3% of patients, respectively. By multivariable analysis, GUSTO- and ISTH-defined bleeding was not significantly associated with 1-year mortality, whereas TIMI major and BARC type 3b or 3c bleeding conferred a 2-fold higher risk of 1-year mortality (hazard ratios [HRs]: 2.00 [95% confidence interval (CI): 1.32 to 3.01] and 1.84 [95% CI: 1.23 to 2.77], respectively). Data elements most strongly associated with mortality were a hemoglobin decrease ≥5 g/dl (HR: 1.94 [95% CI: 1.26 to 2.98]), the use of vasoactive agents for bleeding (HR: 2.01 [95% CI: 0.91 to 4.44]), cardiac tamponade (HR: 2.38 [95% CI: 0.56 to 10.1]), and intracranial hemorrhage (HRs for 1-year mortality were not computable because there was only 1 patient with intracranial bleeding). CONCLUSIONS Both the BARC and TIMI bleeding classification identified STEMI patients at risk of 1-year mortality.
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Affiliation(s)
- Wouter J Kikkert
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Nan van Geloven
- Clinical Research Unit, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Mariet H van der Laan
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Marije M Vis
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan Baan
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Karel T Koch
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Ron J Peters
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan J Piek
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan G P Tijssen
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - José P S Henriques
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
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189
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Zhang L, Li Y, Jing QM, Wang XZ, Ma YY, Wang G, Xu B, Gao RL, Han YL. Dual antiplatelet therapy over 6 months increases the risk of bleeding after biodegradable polymer-coated sirolimus eluting stents implantation: insights from the CREATE study. J Interv Cardiol 2014; 27:119-26. [PMID: 24617336 PMCID: PMC4235462 DOI: 10.1111/joic.12104] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation remains controversial. The primary aim of our study was to evaluate the impact of optimal DAPT duration on bleeding events between 6 and 12 months after biodegradable polymer-coated DES implantation. The secondary aim is to determine the predictors and prognostic implications of bleeding. METHODS This study is a post hoc analysis of the Multi-Center Registry of EXCEL Biodegradable Polymer Drug Eluting Stents (CREATE) study population. A total of 2,040 patients surviving at 6 months were studied, including 1,639 (80.3%) who had received 6-month DAPT and 401 (19.7%) who had received DAPT greater than 6 months. Bleeding events were defined according to the bleeding academic research consortium (BARC) definitions as described previously and were classified as major/minor (BARC 2-5) and minimal (BARC 1). A left censored method with a landmark at 6 months was used to determine the incidence, predictors, and impact of bleeding on clinical prognosis between 6 and 12 months. RESULTS At 1-year follow-up, patients who received prolonged DAPT longer than 6 months had a significantly higher incidence of overall (3.0% vs. 5.5%, P = 0.021) and major/minor bleeding (1.1% vs. 2.5%, P = 0.050) compared to the patients who received 6-month DAPT. Multivariate analysis showed that being elderly (OR = 1.882, 95% CI: 1.109-3.193, P = 0.019), having diabetes (OR = 1.735, 95% CI: 1.020-2.952, P = 0.042), having a history of coronary artery disease (OR = 2.163, 95% CI: 1.097-4.266, P = 0.026), and duration of DAPT longer than 6 months (OR = 1.814, 95% CI: 1.064-3.091, P = 0.029) were independent predictors of bleeding. Patients with bleeding events had a significantly higher incidence of cardiac death, myocardial infarction, target lesion revascularization, and stent thrombosis. CONCLUSIONS Prolonged DAPT (greater than 6 months) after biodegradable polymer-coated DES increases the risk of bleeding, and is associated with adverse cardiac events at 1-year follow-up. (J Interven Cardiol 2014;27:119-126).
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Affiliation(s)
- Lei Zhang
- Department of Cardiology, Shenyang Northern Hospital, Shenyang, China
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Ice DS, Shapiro TA, Gnall EM, Kowey PR. Unanswered questions in patients with concurrent atrial fibrillation and acute coronary syndrome. Am J Cardiol 2014; 113:888-96. [PMID: 24528617 DOI: 10.1016/j.amjcard.2013.11.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 11/14/2013] [Accepted: 11/14/2013] [Indexed: 11/19/2022]
Abstract
The best regimen for the long-term management of patients with atrial fibrillation who present with an acute coronary syndrome or require placement of a coronary stent remains unclear. Clinicians need to understand the risk of stroke, stent thrombosis, and major bleeding associated with treating these patients. Numerous studies and risk assessment schemes provide clinicians with an estimation of the risk of stroke, stent thrombosis, and major bleeding that may be associated with the use or avoidance of dual antiplatelet therapy with concurrent anticoagulation therapy (triple therapy). This review discusses the special antithrombotic needs in patients who have atrial fibrillation and either acute coronary syndrome or a requirement for percutaneous coronary intervention, including the published evidence for non-vitamin K oral anticoagulants, and the unanswered questions in this patient population. In conclusion, until the results of additional ongoing or planned randomized trials are known, clinicians must continue to rely on expert opinion and their own clinical judgment when treating these patients.
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Affiliation(s)
- Daniel S Ice
- Division of Cardiovascular Diseases, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, Jefferson Medical College, Philadelphia, Pennsylvania.
| | - Timothy A Shapiro
- Division of Cardiovascular Diseases, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, Jefferson Medical College, Philadelphia, Pennsylvania
| | - Eric M Gnall
- Division of Cardiovascular Diseases, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, Jefferson Medical College, Philadelphia, Pennsylvania
| | - Peter R Kowey
- Division of Cardiovascular Diseases, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, Jefferson Medical College, Philadelphia, Pennsylvania
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191
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Radial Access for Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol 2014; 63:973-5. [DOI: 10.1016/j.jacc.2013.09.066] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 09/22/2013] [Indexed: 11/22/2022]
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192
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Tarantini G, Brener SJ, Barioli A, Gratta A, Parodi G, Rossini R, Navarese EP, Niccoli G, Frigo AC, Musumeci G, Iliceto S, Stone GW. Impact of baseline hemorrhagic risk on the benefit of bivalirudin versus unfractionated heparin in patients treated with coronary angioplasty: a meta-regression analysis of randomized trials. Am Heart J 2014; 167:401-412.e6. [PMID: 24576526 DOI: 10.1016/j.ahj.2013.11.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 11/24/2013] [Indexed: 01/26/2023]
Abstract
BACKGROUND Bivalirudin significantly reduces 30-day major and minor bleeding compared with unfractionated heparin (UFH), while resulting in similar or lower rates of ischemic events in both patients with stable and unstable coronary disease undergoing percutaneous coronary intervention. We performed a meta-analysis of randomized trials to evaluate the impact of bivalirudin compared with UFH, with or without glycoprotein IIb/IIIa receptor inhibitors (GPI), on the rates of mortality, myocardial infarction (MI), and major bleeding. METHODS We searched electronic databases for randomized controlled trials with >100 patients comparing bivalirudin (±provisional GPI) with UFH with either routine or provisional GPI in patients undergoing percutaneous coronary intervention. The principal efficacy end points were mortality and MI within 30 day, whereas major bleeding was the principal safety end point. We assessed the benefit of bivalirudin for each efficacy end point relative to the baseline bleeding risk, using the control (UFH) major bleeding rate as proxy for that risk. RESULTS A total of 12 randomized trials that enrolled 33,261 patients were included. Overall, there was no significant difference in mortality and MI between bivalirudin monotherapy and UFH (±GPI), whereas major bleeding was significantly lower with bivalirudin. Bivalirudin reduced major and minor bleeding across the entire bleeding risk spectrum. CONCLUSIONS Bivalirudin significantly reduces major and minor bleeding regardless of the estimated baseline hemorrhagic risk.
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193
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Kwok CS, Rao SV, Myint PK, Keavney B, Nolan J, Ludman PF, de Belder MA, Loke YK, Mamas MA. Major bleeding after percutaneous coronary intervention and risk of subsequent mortality: a systematic review and meta-analysis. Open Heart 2014; 1:e000021. [PMID: 25332786 PMCID: PMC4195929 DOI: 10.1136/openhrt-2013-000021] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 01/11/2014] [Accepted: 01/18/2014] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVES To examine the relationship between periprocedural bleeding complications and major adverse cardiovascular events (MACEs) and mortality outcomes following percutaneous coronary intervention (PCI) and study differences in the prognostic impact of different bleeding definitions. METHODS We conducted a systematic review and meta-analysis of PCI studies that evaluated periprocedural bleeding complications and their impact on MACEs and mortality outcomes. A systematic search of MEDLINE and EMBASE was conducted to identify relevant studies. Data from relevant studies were extracted and random effects meta-analysis was used to estimate the risk of adverse outcomes with periprocedural bleeding. Statistical heterogeneity was assessed by considering the I(2) statistic. RESULTS 42 relevant studies were identified including 533 333 patients. Meta-analysis demonstrated that periprocedural major bleeding complications was independently associated with increased risk of mortality (OR 3.31 (2.86 to 3.82), I(2)=80%) and MACEs (OR 3.89 (3.26 to 4.64), I(2)=42%). A differential impact of major bleeding as defined by different bleeding definitions on mortality outcomes was observed, in which the REPLACE-2 (OR 6.69, 95% CI 2.26 to 19.81), STEEPLE (OR 6.59, 95% CI 3.89 to 11.16) and BARC (OR 5.40, 95% CI 1.74 to 16.74) had the worst prognostic impacts while HORIZONS-AMI (OR 1.51, 95% CI 1.11 to 2.05) had the least impact on mortality outcomes. CONCLUSIONS Major bleeding after PCI is independently associated with a threefold increase in mortality and MACEs outcomes. Different contemporary bleeding definitions have differential impacts on mortality outcomes, with 1.5-6.7-fold increases in mortality observed depending on the definition of major bleeding used.
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Affiliation(s)
- Chun Shing Kwok
- Cardiovascular Institute, University of Manchester, Manchester, UK
| | - Sunil V Rao
- Department of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Phyo K Myint
- Division of Applied Health Sciences, School of Medicine & Dentistry, University of Aberdeen, Aberdeen, Scotland, UK
| | - Bernard Keavney
- Cardiovascular Institute, University of Manchester, Manchester, UK
| | - James Nolan
- Department of Cardiology, University Hospital North Staffordshire, Stoke-on-Trent, UK
| | - Peter F Ludman
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK
| | - Mark A de Belder
- Cardiothoracic Division, The James Cook University Hospital, Middlesbrough, UK
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Mamas A Mamas
- Cardiovascular Institute, University of Manchester, Manchester, UK
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194
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Increased risk of minor bleeding and antiplatelet therapy cessation in patients with acute coronary syndromes and low on-aspirin platelet reactivity. A prospective cohort study. J Thromb Thrombolysis 2014; 36:22-30. [PMID: 22987197 PMCID: PMC3682102 DOI: 10.1007/s11239-012-0808-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Bleeding negatively affects prognosis and adherence to antiplatelet therapy after acute coronary syndromes (ACSs). The potential association of on-aspirin platelet reactivity and bleeding is not established. We sought to determine whether low on-aspirin platelet reactivity (LAPR) is associated with bleeding events and antiplatelet therapy compliance in patients with ACSs receiving coronary stenting. On-aspirin platelet reactivity was measured by the VerifyNow™ Aspirin assay (Accumetrics Inc., San Diego, CA, USA) in 531 patients with ACS. Cut-offs for LAPR were calculated by receiver-operating characteristic curve (ROC) analysis. Bleeding was reported according to Bleeding Academic Research Consortium (BARC) definition. The endpoints were minor bleeding (BARC types 1 or 2), major bleeding (BARC types 3 or 5) and antiplatelet therapy cessation during 6-months follow-up. By ROC analysis the VerifyNow™ Aspirin assay was able to distinguish between patients with and without minor bleeding (area under the curve [AUC] 0.66, 95 % confidence interval [CI] 0.62-0.70, P < 0.0001) whereas major bleeding could not be predicted by the assay (AUC 0.54, 95 % CI 0.49-0.58, P = 0.473). By logistic regression, LAPR was associated with increased risk of minor bleeding (odds ratio [OR] 4.32, 95 % CI 2.78-6.71, P < 0.0001) but not major bleeding (OR 2.05, 95 % CI 0.83-5.06, P = 0.117). Antiplatelet therapy discontinuation was more frequent in patients with LAPR as compared to those with no LAPR (21.6 vs. 9.1 %, P = 0.0008). In conclusion, early point-of-care on-aspirin platelet reactivity testing in ACS may identify patients with increased risk of minor bleeding events and subsequent discontinuation of antiplatelet therapy. The possible impact of LAPR on major bleeding needs to be determined in larger trials.
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Bassand JP, Richard-Lordereau I, Cadroy Y. Efficacy and safety of fondaparinux in patients with acute coronary syndromes. Expert Rev Cardiovasc Ther 2014; 5:1013-26. [DOI: 10.1586/14779072.5.6.1013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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196
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Valgimigli M, Calabrò P, Cortese B, Frigoli E, Garducci S, Rubartelli P, Andò G, Santarelli A, Galli M, Garbo R, Repetto A, Ierna S, Briguori C, Limbruno U, Violini R, Gagnor A. Scientific foundation and possible implications for practice of the Minimizing Adverse Haemorrhagic Events by Transradial Access Site andSystemic Implementation of AngioX (MATRIX) trial. J Cardiovasc Transl Res 2014; 7:101-11. [PMID: 24395497 DOI: 10.1007/s12265-013-9537-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 12/13/2013] [Indexed: 12/12/2022]
Abstract
Early invasive management and the use of combined antithrombotic therapies have decreased the risk of recurrent ischaemia in patients with acute coronary syndrome (ACS) but have also increased the bleeding risk. Transradial intervention (TRI) and bivalirudin infusion compared to transfemoral intervention (TFI) or unfractionated heparin (UFH) plus glycoprotein IIb/IIIa inhibitors (GPI) decrease bleeding complications in patients with ACS. To what extent, a bleeding preventive strategy incorporating at least one of these two treatment options translates into improved outcomes is a matter of debate. The Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of AngioX study is a large-scale, multicenter, prospective, open-label trial, conducted at approximately 100 sites in Europe aiming to primarily assess whether TRI and bivalirudin infusion, as compared to TFI and UFH plus provisional GPI, decrease the 30-day incidence of death, myocardial infarction or stroke across the whole spectrum of ACS patients.
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197
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Sciahbasi A, Rigattieri S, Cortese B, Belloni F, Russo C, Ferraironi A, Tespili M, Angeletti C, Ricci R, Bondanini F, Pugliese FR. Bivalirudin or heparin in primary angioplasty performed through the transradial approach: results from a multicentre registry. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 3:268-74. [DOI: 10.1177/2048872613519331] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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198
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Nazif TM, Mehran R, Lee EA, Fahy M, Parise H, Stone GW, Kirtane AJ. Comparative effectiveness of upstream glycoprotein IIb/IIIa inhibitors in patients with moderate- and high-risk acute coronary syndromes: an Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) substudy. Am Heart J 2014; 167:43-50. [PMID: 24332141 DOI: 10.1016/j.ahj.2013.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 10/04/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Tirofiban and eptifibatide are both small-molecule, competitive glycoprotein IIb/IIIa receptor inhibitors (GPIs) that are guideline-supported for upstream therapy in acute coronary syndromes (ACS). This study sought to compare the efficacy and safety of tirofiban and eptifibatide in patients with ACS. METHODS Within the ACUITY trial, 4,323 patients with moderate- and high-risk ACS received upstream, adjunctive GPI (tirofiban or eptifibatide) in addition to an antithrombin. Primary outcomes included 30-day rates of composite major adverse cardiac events (MACE), major bleeding (not related to coronary artery bypass grafting), and composite net adverse clinical events (NACE). The outcomes were compared based on the upstream GPI administered. RESULTS There were significant differences in the baseline characteristics of patients treated with tirofiban vs eptifibatide, particularly related to country/region. In unadjusted analyses, treatment with upstream tirofiban vs eptifibatide was associated with similar rates of major bleeding (5.8% vs 6.5%, P = .39) and nonsignificantly lower rates of MACE (6.1% vs 7.6%, P = .06) and NACE (10.6% vs 12.6%, P = .06). After propensity-based multivariable adjustment, there were no significant differences between tirofiban and eptifibatide with respect to 30-day major bleeding, MACE, or NACE. CONCLUSIONS Among more than 4,000 patients with moderate- and high-risk ACS treated with upstream GPI as part of an early invasive management strategy, the use of tirofiban and eptifibatide resulted in similar clinical outcomes. These data suggest equivalence of these 2 agents for upstream use, while highlighting some of the difficulties of nonrandomized comparative effectiveness analyses, specifically the difficulty in addressing geographic differences in the use of nonrandomized treatments.
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199
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Mendoza F, Mendoza F, Jaramillo C, Ardila C. Evaluación del puntaje de sangrado “CRUSADE” como prueba diagnóstica para determinar sangrado mayor en pacientes con síndrome coronario agudo sin elevación del ST. REVISTA COLOMBIANA DE CARDIOLOGÍA 2014. [DOI: 10.1016/s0120-5633(14)70005-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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200
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de Andrade PB, E Mattos LAP, Tebet MA, Rinaldi FS, Esteves VC, Nogueira EF, França JÍD, de Andrade MVA, Barbosa RA, Labrunie A, Abizaid AAC, Sousa AGDMR. Design and rationale of the AngioSeal versus the Radial approach In acute coronary SyndromE (ARISE) trial: a randomized comparison of a vascular closure device versus the radial approach to prevent vascular access site complications in non-ST-segment elevation acute coronary syndrome patients. Trials 2013; 14:435. [PMID: 24345099 PMCID: PMC3878328 DOI: 10.1186/1745-6215-14-435] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 12/02/2013] [Indexed: 01/31/2023] Open
Abstract
Background Arterial access is a major site of bleeding complications after invasive coronary procedures. Among strategies to decrease vascular complications, the radial approach is an established one. Vascular closure devices provide more comfort to patients and decrease hemostasis and need for bed rest. However, the inconsistency of data proving their safety limits their routine adoption as a strategy to prevent vascular complications, requiring evidence through adequately designed randomized trials. The aim of this study is to compare the radial versus femoral approach using a vascular closure device for the incidence of arterial puncture site vascular complications among non-ST-segment elevation acute coronary syndrome patients submitted to an early invasive strategy. Methods ARISE is a national, multicenter, non-inferiority randomized clinical trial. Two hundred patients with non-ST-segment elevation acute coronary syndrome will be randomized to either radial or femoral access using a vascular closure device. The primary outcome is the occurrence of vascular complications at an arterial puncture site 30 days after the procedure, including major bleeding, retroperitoneal hematoma, compartment syndrome, hematoma ≥ 5 cm, pseudoaneurysm, arterio-venous fistula, infection, limb ischemia, arterial occlusion, adjacent nerve injury or the need for vascular surgical repair. Results Enrollment was initiated in September 2012, and until October 2013 91 patients were included. The inclusion phase is expected to last until the second half of 2014. Conclusions The ARISE trial will help define the role of a vascular closure device as a bleeding avoidance strategy in patients with NSTEACS. Trial registration ClinicalTrials.gov identifier: NCT01653587
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Affiliation(s)
- Pedro Beraldo de Andrade
- Invasive Cardiology, Santa Casa de Marília, Avenida Vicente Ferreira, 828 - Cascata, Marília, São Paulo 17515-900, Brazil.
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