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Peyracchia M, Saglietto A, Biolè C, Raposeiras-Roubin S, Abu-Assi E, Kinnaird T, Ariza-Solé A, Liebetrau C, Manzano-Fernández S, Boccuzzi G, Henriques JPS, Wilton SB, Velicki L, Xanthopoulou I, Correia L, Rognoni A, Fabrizio U, Nuñez-Gil I, Montabone A, Taha S, Fujii T, Durante A, Gili S, Magnani G, Autelli M, Grosso A, Kawaji T, Blanco PF, Garay A, Quadri G, Queija BC, Huczek Z, Paz RC, González-Juanatey JR, Fernández MC, Nie SP, D’Amico M, Pousa IM, Kawashiri MA, Gallo D, Morbiducci U, Dominguez-Rodriguez A, Lopez-Cuenca A, Cequier A, Alexopoulos D, Iñiguez-Romo A, Grossomarra W, Usmiani T, Rinaldi M, D’Ascenzo F. Efficacy and Safety of Clopidogrel, Prasugrel and Ticagrelor in ACS Patients Treated with PCI: A Propensity Score Analysis of the RENAMI and BleeMACS Registries. Am J Cardiovasc Drugs 2020; 20:259-269. [PMID: 31586336 DOI: 10.1007/s40256-019-00373-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Real-life data comparing clopidogrel, prasugrel, and ticagrelor for unselected patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) are lacking, as are data for the temporal distribution of ischemic and bleeding risks. METHODS A total of 19,825 patients were enrolled from the RENAMI and BleeMACS registries. Both were multicenter, retrospective, observational registries including the data and outcomes of consecutive patients with ACS who underwent primary PCI and were discharged with dual antiplatelet therapy (DAPT). We evaluated the long-term outcome stratified by the different antiplatelet agents. RESULTS A total of 14,105 patients (71.2%) were treated with clopidogrel, 2364 patients (11.9%) with prasugrel and 3356 patients (16.9%) with ticagrelor. After propensity score matching, at 1 year, prasugrel reduced the incidence of net adverse clinical events (NACE; a composite endpoint of all-cause death, myocardial infarction [MI] and Bleeding Academic Research Consortium [BARC] 3-5 bleeding) (4.2% vs.7.6%, p = 0.002) and of major adverse cardiovascular events (MACE; a composite endpoint of death and MI) compared with clopidogrel (2.6% vs. 5.2%, p = 0.007). Ticagrelor decreased rates of MACE compared with clopidogrel (2.7% vs. 6.2%, p < 0.001), but not of NACE (6.6% vs. 8.7%, p = 0.07). Ticagrelor presented similar performance in terms of MACE compared with prasugrel (2.8% vs. 2.4%, p = 0.56), with a trend towards a reduction in MI (0.2% vs. 0.4%, p = 0.56), but with higher risk of BARC 3-5 bleedings (3.8% vs. 1.7%, p = 0.04). In the daily risk analysis, clopidogrel presented a binomial distribution with a peak of ischemic risk at 3 months, which decreased towards bleedings; prasugrel had a constant equivalence between opposite risks; and ticagrelor constantly reduced recurrent MIs despite higher risk of BARC 3-5 events. CONCLUSION In real life, ticagrelor is more effective in reducing ischemic events during the first year after ACS, despite an increased risk of major bleedings, while prasugrel assures a better balance between ischemic and bleeding recurrent events.
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152
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Grieshaber P, Oswald I, Albert M, Reents W, Zacher M, Roth P, Niemann B, Dörr O, Krüger T, Nef H, Sodah A, Hamm C, Schlensak C, Diegeler A, Sedding D, Franke U, Boening A. Risk of perioperative coronary stent stenosis or occlusion in patients with previous percutaneous coronary intervention undergoing coronary artery bypass grafting surgery. Eur J Cardiothorac Surg 2020; 57:1122-1129. [PMID: 32011670 DOI: 10.1093/ejcts/ezaa003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/02/2019] [Accepted: 12/11/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES There is an ongoing discussion about how to treat coronary stents during bypass surgery: Should patent stents be left alone and the stented vessels be ungrafted, or should every stented coronary artery receive a bypass graft? This study aims to determine the relevance of perioperative stent stenosis or occlusion on postoperative outcomes up to 3 years postoperatively. METHODS Patients undergoing coronary artery bypass grafting surgery (CABG) (±concomitant procedures) with previous percutaneous coronary intervention from 4 centres were prospectively included in this observatory study between April 2015 and June 2017. A coronary angiography was conducted between the fifth and seventh postoperative days. The preoperative and postoperative angiograms were assessed in a core laboratory, assessing the patencies of coronary stents and bypass grafts. The core lab investigators were blinded to the patients' characteristics and perioperative course. RESULTS A total of 107 patients were included in the study. In the postoperative coronary angiography, 265 bypass grafts and 189 coronary stents were examined angiographically. Ninety-seven percent of preoperatively patent stents remained patent. New coronary stent stenoses were observed in 5 patients (4.7%). All 5 patients were asymptomatic and managed conservatively. Bypass stenoses were observed in 12 patients (11%), of whom were managed conservatively, 4 underwent percutaneous coronary intervention and 1 underwent redo-CABG. Two years postoperatively, 97% of patients were alive. Patients with new stent stenosis tended to have a better survival compared with patients with bypass stenosis (100% vs 73%; P = 0.09) up to 3 years postoperatively. CONCLUSIONS Perioperative coronary stent stenosis occurs rarely. It is safe to leave a patently stented coronary vessel without bypass grafting.
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Affiliation(s)
- Philippe Grieshaber
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessens, Giessen, Germany
| | - Irina Oswald
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessens, Giessen, Germany
| | - Marc Albert
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Wilko Reents
- Department of Cardiac Surgery, Cardiovascular Center Bad Neustadt, Bad Neustadt a. d. Saale, Germany
| | - Michael Zacher
- Department of Cardiac Surgery, Cardiovascular Center Bad Neustadt, Bad Neustadt a. d. Saale, Germany
| | - Peter Roth
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessens, Giessen, Germany
| | - Bernd Niemann
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessens, Giessen, Germany
| | - Oliver Dörr
- Department of Cardiology and Angiology, University Hospital Giessen, Giessen, Germany
| | - Tobias Krüger
- Department of Cardiothoracic and Vascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Holger Nef
- Department of Cardiology and Angiology, University Hospital Giessen, Giessen, Germany
| | - Ayman Sodah
- Department of Cardiac Surgery, Cardiovascular Center Bad Neustadt, Bad Neustadt a. d. Saale, Germany
| | - Christian Hamm
- Department of Cardiology and Angiology, University Hospital Giessen, Giessen, Germany
| | - Christian Schlensak
- Department of Cardiothoracic and Vascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Anno Diegeler
- Department of Cardiac Surgery, Cardiovascular Center Bad Neustadt, Bad Neustadt a. d. Saale, Germany
| | - Daniel Sedding
- Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine III, University Hospital Halle, Halle (Saale), Germany
| | - Ulrich Franke
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Andreas Boening
- Department of Adult and Pediatric Cardiovascular Surgery, University Hospital Giessens, Giessen, Germany
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153
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Levi A, Simard T, Glover C. Coronary Artery Disease in patients with End-Stage Kidney Disease; Current perspective and gaps of knowledge. Semin Dial 2020; 33:187-197. [PMID: 32449824 DOI: 10.1111/sdi.12886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 04/27/2020] [Indexed: 01/19/2023]
Abstract
Coronary artery disease (CAD) is very common in dialysis patients. One third have preexisting CAD and another one third have significant occult disease at the time of starting dialysis. Symptoms are often absent or are atypical, emphasizing the need for vigorous screening, specifically in patients awaiting transplant. The lesions tend to be heavily calcified, diffuse, and involve multiple vessels, consequently, percutaneous coronary interventions are more complicated to perform, and are less successful in achieving and maintaining short- and long-term patency. Dialysis patients have been excluded from the randomized controlled trials on which the current standards for managing CAD have been established. Due to differences in pathobiology and risks and benefits, it is uncertain that the results of these clinical trials extrapolate to patients with advanced chronic kidney disease (CKD). Here we review the data from observational studies and identify special considerations concerning the diagnosis and management of CAD in dialysis patients, including the use of noninvasive functional testing vs anatomical testing, the management of acute coronary syndromes and of stable coronary artery disease, the role for percutaneous revascularization vs coronary artery bypass grafting, and of platelet inhibitor therapy after coronary stenting. We review the preliminary results of the recently published ISCHEMIA-CKD trial, the only trial to date to involve large numbers of dialysis patients. This is the first of, hopefully, many trials in the pipeline that will examine therapies for CAD specifically in patients with advanced CKD, a growing population that is at particularly high risk for poor outcomes.
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Affiliation(s)
- Amos Levi
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Trevor Simard
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Christopher Glover
- University of Ottawa Heart Institute, Ottawa, ON, Canada.,Rabin Medical Center, Tel-Aviv University, Tel-Aviv, Israel
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154
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No Differences in Gastrointestinal Bleeding Risk among Clopidogrel-, Ticagrelor-, or Prasugrel-Based Dual Antiplatelet Therapy. J Clin Med 2020; 9:jcm9051526. [PMID: 32443621 PMCID: PMC7290690 DOI: 10.3390/jcm9051526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/09/2020] [Accepted: 05/13/2020] [Indexed: 12/25/2022] Open
Abstract
The risk for gastrointestinal bleeding from dual antiplatelet therapy (DAPT) with new antiplatelets (prasugrel/ticagrelor) compared to clopidogrel is unclear. AIM To determine the risk and type of major (gastrointestinal bleeding requiring hospitalization) and minor (anemia and iron deficiency) gastrointestinal events with different types of DAPT. METHODS Retrospective observational cohort study of patients who started DAPT after percutaneous coronary intervention. Follow-up was censored after 12 months of DAPT, when a major gastrointestinal event occurred, or when DAPT was discontinued. RESULTS Among 1,327 patients (54.03% were treated with clopidogrel-based DAPT, 38.13% with ticagrelor-based DAPT, and 7.84% with prasugrel-based DAPT), 29.5% had at least one gastrointestinal event. Patients taking clopidogrel-DAPT were older, with more comorbidities, and higher gastrointestinal risk compared to those taking other DAPT regimens. Adjusted hazard ratios (HRs) showed no between-group differences in the risk for major (clopidogrel vs. new antiplatelets: HR 0.996; 95% confidence interval 0.497-1.996) and minor (HR 0.920; 0.712-1.189) gastrointestinal events. Most patients received proton pump inhibitors while on DAPT (93.3%) and after withdrawal (83.2%). CONCLUSION Prasugrel- or ticagrelor-based DAPT was not associated with increased gastrointestinal bleeding risk when compared to clopidogrel-DAPT. New antiplatelets do not necessarily need to be restricted to patients with low gastrointestinal risk.
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155
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Dangas G, Baber U, Sharma S, Giustino G, Mehta S, Cohen DJ, Angiolillo DJ, Sartori S, Chandiramani R, Briguori C, Dudek D, Escaned J, Huber K, Collier T, Kornowski R, Kunadian V, Kaul U, Oldroyd K, Sardella G, Shlofmitz R, Witzenbichler B, Ya-Ling H, Pocock S, Gibson CM, Mehran R. Ticagrelor With or Without Aspirin After Complex PCI. J Am Coll Cardiol 2020; 75:2414-2424. [DOI: 10.1016/j.jacc.2020.03.011] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/05/2020] [Accepted: 03/09/2020] [Indexed: 01/08/2023]
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156
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Raslau D, Bierle DM, Stephenson CR, Mikhail MA, Kebede EB, Mauck KF. Preoperative Cardiac Risk Assessment. Mayo Clin Proc 2020; 95:1064-1079. [PMID: 32107033 DOI: 10.1016/j.mayocp.2019.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/17/2019] [Accepted: 08/19/2019] [Indexed: 01/18/2023]
Abstract
Major adverse cardiac events are common causes of perioperative mortality and major morbidity. Preventing these complications requires thorough preoperative risk assessment and postoperative monitoring of at-risk patients. Major guidelines recommend assessment based on a validated risk calculator that incorporates patient- and procedure-specific factors. American and European guidelines define when stress testing is needed on the basis of functional capacity assessment. Favoring cost-effectiveness, Canadian guidelines instead recommend obtaining brain natriuretic peptide or N-terminal prohormone of brain natriuretic peptide levels to guide postoperative screening for myocardial injury or infarction. When conditions such as acute coronary syndrome, severe pulmonary hypertension, and decompensated heart failure are identified, nonemergent surgery should be postponed until the condition is appropriately managed. There is an evolving role of biomarkers and myocardial injury after noncardiac surgery to enhance risk stratification, but the effect of interventions guided by these strategies is unclear.
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Affiliation(s)
- David Raslau
- Mayo Clinic Rochester, Division of General Internal Medicine, Rochester, MN.
| | - Dennis M Bierle
- Mayo Clinic Rochester, Division of General Internal Medicine, Rochester, MN
| | | | - Michael A Mikhail
- Mayo Clinic Rochester, Division of General Internal Medicine, Rochester, MN
| | - Esayas B Kebede
- Mayo Clinic Rochester, Division of General Internal Medicine, Rochester, MN
| | - Karen F Mauck
- Mayo Clinic Rochester, Division of General Internal Medicine, Rochester, MN
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157
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Is dual therapy the correct strategy in frail elderly patients with atrial fibrillation and acute coronary syndrome? JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2020; 17:51-57. [PMID: 32133036 PMCID: PMC7008097 DOI: 10.11909/j.issn.1671-5411.2020.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Atrial fibrillation (AF) is a very common arrhythmia in clinical practice. Its incidence and prevalence are age-related and are growing in the last years. Age is a risk factor also for coronary artery disease (CAD), and with the evolution of preventive care, the first event (acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI)) takes place at a later age. If elderly patients with AF and CAD undergo ACS or PCI, they have indication to assume triple therapy. Triple therapy (oral anticoagulation (OAC) plus dual antiplatelet therapy (DAPT)) exposes patients to high bleeding risk. In the last 10 years, several clinical trials have tested dual therapy (OAC plus single antiplatelet therapy) in AF patients who undergo ACS or elective PCI. WOEST trial has tested warfarin + clopidogrel against triple therapy. PIONEER AF-PCI trial has tested low-dose rivaroxaban + P2Y12 inhibitor or very low-dose rivaroxaban + DAPT against standard triple therapy with warfarin. RE-DUAL PCI trial has tested two doses of dabigatran + P2Y12 inhibitor against standard triple therapy with Warfarin. AUGUSTUS trial has tested apixaban against warfarin both in dual therapy with P2Y12 inhibitor and in triple therapy with a P2Y12 inhibitor and aspirin. ENTRUST-AF PCI, last published study, has tested edoxaban + P2Y12 inhibitor against triple therapy. All these trials show dual therapy reduces significantly bleeding risk than triple therapy. In this paper, we analyze these clinical trials to understand if dual therapy results can be applied to elderly patients and what is probably the better approach in elderly AF patients undergo to ACS or PCI.
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158
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the existing evidence for use of long-term antiplatelet therapies for primary and secondary prevention of adverse cardiovascular events. RECENT FINDINGS In the setting of primary prevention, several contemporary trials have shown a lack of net clinical benefit with use of aspirin across different patient groups, including those with diabetes mellitus, older age or high estimated cardiac risk. For secondary prevention, the addition of either ticagrelor or low-dose rivaroxaban to aspirin monotherapy significantly lowered recurrent vascular events, albeit with excess bleeding. Aspirin withdrawal did not result in excess thrombotic risk or less bleeding among patients undergoing percutaneous coronary intervention (PCI) treated with ticagrelor. SUMMARY In the contemporary era, routine use of aspirin is not beneficial in the majority of patients free of cardiac disease. In contrast, for secondary prevention, aspirin monotherapy is not sufficient to lower recurrent vascular risk. Antiplatelet monotherapy with ticagrelor may emerge as an alternative to lower bleeding whereas maintaining ischemic efficacy in selected patients undergoing PCI.
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159
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Sanz M, Marco del Castillo A, Jepsen S, Gonzalez‐Juanatey JR, D’Aiuto F, Bouchard P, Chapple I, Dietrich T, Gotsman I, Graziani F, Herrera D, Loos B, Madianos P, Michel J, Perel P, Pieske B, Shapira L, Shechter M, Tonetti M, Vlachopoulos C, Wimmer G. Periodontitis and cardiovascular diseases: Consensus report. J Clin Periodontol 2020; 47:268-288. [PMID: 32011025 PMCID: PMC7027895 DOI: 10.1111/jcpe.13189] [Citation(s) in RCA: 583] [Impact Index Per Article: 145.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/13/2019] [Accepted: 08/22/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND In Europe cardiovascular disease (CVD) is responsible for 3.9 million deaths (45% of deaths), being ischaemic heart disease, stroke, hypertension (leading to heart failure) the major cause of these CVD related deaths. Periodontitis is also a chronic non-communicable disease (NCD) with a high prevalence, being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease. MATERIAL AND METHODS There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In 2012 a joint workshop was held between the European Federation of Periodontology (EFP) and the American Academy of Periodontology to review the literature relating periodontitis and systemic diseases, including CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations RESULTS AND CONCLUSIONS: The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation (WHF), which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices.
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Affiliation(s)
- Mariano Sanz
- Department of Dental Clinical SpecialtiesETEP Research GroupFaculty of OdontologyUniversity Complutense of MadridMadridSpain
| | | | - Søren Jepsen
- Department of Periodontology, Operative and Preventive DentistryUniversity of BonnBonnGermany
| | - Jose R. Gonzalez‐Juanatey
- Cardiology DepartmentUniversity HospitalIDISCIBERCVUniverity of Santiago de CompostelaSantiago de CompostelaSpain
| | - Francesco D’Aiuto
- Department of PeriodontologyEastman Dental Institute and HospitalUniversity College LondonLondonUK
| | - Philippe Bouchard
- U.F.R. d'odontologieUniversité Paris DiderotHôpital Rothschild AP‐HPParisFrance
| | - Iain Chapple
- School of DentistryInstitute of Clinical SciencesCollege of Medical & Dental SciencesThe University of BirminghamBirminghamUK
| | - Thomas Dietrich
- School of DentistryInstitute of Clinical SciencesCollege of Medical & Dental SciencesThe University of BirminghamBirminghamUK
| | - Israel Gotsman
- Heart InstituteHadassah University HospitalJerusalemIsrael
| | - Filippo Graziani
- Department of Surgical, Medical and Molecular Pathology and Critical Care MedicineUniversity of PisaPisaItaly
| | - David Herrera
- Department of Dental Clinical SpecialtiesETEP Research GroupFaculty of OdontologyUniversity Complutense of MadridMadridSpain
| | | | - Phoebus Madianos
- Department of PeriodontologySchool of DentistryNational and Kapodistrian University of AthensAthensGreece
| | - Jean‐Baptiste Michel
- Inserm Unit 1148Laboratory for Translational CV ScienceX. Bichat HospitalParisFrance
| | - Pablo Perel
- World Heart FederationGenevaSwitzerland
- Centre for Global Chronic ConditionsLondon School of Hygiene & Tropical MedicineLondonUK
| | - Burkert Pieske
- Department of Internal Medicin & CardiologyCharité Universitätsmedizin BerlinBerlinGermany
- DZHK (German Center for Cardiovascular Research) Partnersite BerlinGerman Heart Institut BerlinBerlinGermany
| | - Lior Shapira
- Department of PeriodontologyHebrew University – Hadassah Faculty of Dental MedicineJerusalemIsrael
| | - Michael Shechter
- Leviev Heart CenterChaim Sheba Medical Centertel Hashomer and the Sackler Faculty of MedicineTel Aviv UniversityTel Aviv‐YafoIsrael
| | - Maurizio Tonetti
- Department of PeriodontologyPrince Philip Dental HospitalThe University of Hong KongHong KongHong Kong
| | | | - Gernot Wimmer
- Department of Prosthetic DentistrySchool of Dental MedicineKarl‐Franzens University GrazGrazAustria
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Crimi G, De Rosa R, Mandurino-Mirizzi A, Morici N, Alberti LP, Savonitto S, De Servi S. De-escalating dual antiplatelet therapy in patients with acute coronary syndromes: the right strategy to harmonize time-dependent ischemic and bleeding risk in elderly patients? J Cardiovasc Med (Hagerstown) 2020; 21:281-285. [PMID: 32108125 DOI: 10.2459/jcm.0000000000000929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
: The European Society of Cardiology guidelines for myocardial revascularization state that de-escalation of P2Y12 inhibitor treatment guided by platelet function testing may be considered for acute coronary syndrome (ACS) patients deemed unsuitable for 12-month potent platelet inhibition. De-escalation strategy aim is to harmonize the time-dependency of thrombotic risk, which is high in the first month after ACS, then decreases exponentially, with bleeding risk, which tends to remain more stable after the procedure-related peak. Harmonizing time-dependency of clinical events may be particularly relevant in those at high risk, such as the elderly patients with ACS in whom an individualized antiplatelet therapy may be more appropriate than a 'one-size-fits all' approach. In this review, we outline the current medical evidence on the topic of dual antiplatelet therapy de-escalation. In addition, we include insights from the Elderly ACS 2 study and recently published post-hoc analyses conducted by the authors' consortium, which further expands current knowledge.
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Affiliation(s)
- Gabriele Crimi
- SC. Cardiologia, Fondazione Policlinico San Matteo, Pavia.,Cardiologia Interventistica, Dipartimento CardioToracoVascolare, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Roberta De Rosa
- Department of Medicine, Surgery and Dentistry, Schola Medica Salernitana, University of Salerno
| | | | - Nuccia Morici
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan
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郑 小, 吴 黎. [The value of cytochrome P4502C19 gene assay for anti-platelet therapy after PCI in stable angina patients with left main coronary artery lesions]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2020; 40:274-278. [PMID: 32376540 PMCID: PMC7086122 DOI: 10.12122/j.issn.1673-4254.2020.02.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of different antiplatelet therapies for stable angina patients with complicated left main coronary artery lesions and intermediate metabolizer Cytochrome P450 2C19 gene (CYP2C19) undergoing PCI. METHODS A total of 247 patients diagnosed with stable angina in cardiology department of Fujian union hospital from February 2015 to February 2017 were retrospectively analyzed, among them, the elective PCI were performed on the left main coronary artery and the CYP2C19 gene poly-morphism were intermediate metabolize, they were divided into ticagrelor treatment group(aspirin combined with ticagrelor, n=95)and clopidogrel treatment group(aspirin combined with clopidogrel, n=152) according to the different antiplatelet treatment programs. Both groups were given aspirin 300 mg and clopidogrel 300 mg orally before PCI; the ticagrelor group were given the maintenance dose of ticagrelor (90 mg orally, twice a day) after PCI, while those in clopidogrel group were clopidogrel 75 mg orally (once a day) after PCI; both groups were given the maintenance dose of aspirin (100 mg orally, once a day)after PCI. The major adverse cardiovascular events (MACE) were observed within 12 months after PCI. RESULTS At 12 months after PCI, the incidence of MACE in the ticagrelor treatment group was significantly lower than that in the clopidogrel treatment group, the difference was statistically significant (2.1% vs 15.1%, P=0.001).There were no significant differences between the two groups in the restenosis rates of non- revascularized target vessel, recurrent rates of angina pectoris(but not myocardial infarction), recurrent rates of myocardial infarction, and revascularization rates of target vessel (P > 0.05). There were also no significant differences between the two groups in bleeding. CONCLUSIONS For stable angina patients with complicated left main coronary artery lesions and intermediate metabolizer CYP2C19 gene, aspirin combined with ticagrelor antiplatelet therapy after PCI is effective, the effect of ticagrelor is better than clopidogrel on MACE, and ticagrelor does not seem to increase the risk of bleeding.
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Affiliation(s)
- 小芳 郑
- 福建医科大学附属第三医院心内科,福建 福州 350108Department of Cardiology, The Third Affiliated Hospital of Fujian Medical University, Fuzhou 350108, China
| | - 黎明 吴
- 福建医科大学附属协和医院心内科,福建 福州 350001Department of Cardiology, Union Hospital affiliated to Fujian Medical University, Fuzhou 350001, China
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162
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Efficacy and Safety of Long-Term and Short-Term Dual Antiplatelet Therapy: A Meta-Analysis of Comparison between Asians and Non-Asians. J Clin Med 2020; 9:jcm9030652. [PMID: 32121235 PMCID: PMC7141296 DOI: 10.3390/jcm9030652] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/20/2020] [Accepted: 02/25/2020] [Indexed: 02/07/2023] Open
Abstract
While dual antiplatelet therapy (DAPT) is essential after percutaneous coronary intervention (PCI), the optimal duration is affected by various factors. However, the effect of ethnicity on DAPT duration has not been fully evaluated. In this study, we evaluated the different effect of DAPT duration by ethnicity. We searched Pubmed, Embase, Cochrane library, and relevant websites to search for randomized clinical trials (RCT) assessing the clinical impact of long term DAPT (L-DAPT) and short term DAPT (S-DAPT). Studies were divided by ethnicity, and we compared the efficacy and safety of DAPT duration in each ethnic group. Thirteen RCTs including 38,255 patients (five East Asian studies and eight non–East Asian studies) were eligible for analysis. For the primary outcome, L-DAPT showed a significantly lower rate of primary outcome only in non–East Asians (S-DAPT vs. L-DAPT, odds ratio (OR) = 1.16, 95% confidence interval (CI): 1.02–1.32, p = 0.02), while in East Asians, the effect of S-DAPT and L-DAPT were comparable. S-DAPT significantly increased ischemic events only in non–East Asians (S-DAPT vs. L-DAPT, OR = 1.24, 95% CI: 1.09–1.42, p <0.01), while bleeding events were decreased by S-DAPT in both ethnicities. These results demonstrate that the adequate DAPT duration after PCI may be different in East Asians.
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Lieschke F, Zheng Y, Schaefer JH, van Leyen K, Foerch C. Measurement of Platelet Function in an Experimental Stroke Model With Aspirin and Clopidogrel Treatment. Front Neurol 2020; 11:85. [PMID: 32117036 PMCID: PMC7026492 DOI: 10.3389/fneur.2020.00085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/23/2020] [Indexed: 01/19/2023] Open
Abstract
Dual antiplatelet treatment (DAPT) increases the risk of tPA-associated hemorrhagic transformation (HT) in ischemic stroke. To investigate the effects of DAPT in rodents, reliable indicators of platelet function utilizing a minimally invasive procedure are required. We here established a fluorescence-based assay to monitor DAPT efficiency in a mouse model of ischemic stroke with HT. Male C57/BL6 mice were fed with aspirin and clopidogrel (ASA+CPG). Venous blood was collected, stimulated with thrombin, labeled with anti-CD41-FITC and anti-CD62P-PE, and analyzed by flow cytometry. Subsequently, animals were subjected to experimental stroke and tail bleeding tests. HT was quantified using NIH ImageJ software. In ASA+CPG mice, the platelet activation marker CD62P was reduced by 40.6 ± 4.2% (p < 0.0001) compared to controls. In vitro platelet function correlated inversely with tail bleeding tests (r = −0.8, p = 0.0033, n = 12). Twenty-four hours after drug withdrawal, platelet activation rates in ASA+CPG mice were still reduced by 20.2 ± 4.1% (p = 0.0026) compared to controls, while tail bleeding volumes were increased by 4.0 ± 1.4 μl (p = 0.004). Conventional tests using light transmission aggregometry require large amounts of blood and thus cannot be used in experimental stroke studies. In contrast, flow cytometry is a highly sensitive method that utilizes small volumes and can easily be incorporated into the experimental stroke workflow. Our test can be used to monitor the inhibitory effects of DAPT in mice. Reduced platelet activation is indicative of an increased risk for tPA-associated cerebral hemorrhage following experimental stroke. The test can be applied to individual animals and implemented flexibly prior and subsequent to experimental stroke.
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Affiliation(s)
- Franziska Lieschke
- Neuroprotection Research Laboratory, Department of Radiology and Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States.,Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Yi Zheng
- Neuroprotection Research Laboratory, Department of Radiology and Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States
| | - Jan Hendrik Schaefer
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Klaus van Leyen
- Neuroprotection Research Laboratory, Department of Radiology and Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States
| | - Christian Foerch
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
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Verdoia M, Rolla R, Negro F, Tonon F, Pergolini P, Nardin M, Marcolongo M, De Luca G. Homocysteine levels and platelet reactivity in coronary artery disease patients treated with ticagrelor. Nutr Metab Cardiovasc Dis 2020; 30:292-299. [PMID: 31780401 DOI: 10.1016/j.numecd.2019.09.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/19/2019] [Accepted: 09/17/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND AIM Recurrent atherothrombotic events have been reported in certain higher risk subsets of patients even with ticagrelor, a potent first-line antiplatelet agent for the management of patients with acute coronary syndrome (ACS). Hyperhomocysteinemia is a known determinant of platelet function abnormalities. Therefore, the aim of our study was to evaluate the impact of homocysteine (Hcy) levels on platelet reactivity in patients receiving Ticagrelor. METHODS AND RESULTS Patients with ACS undergoing percutaneous coronary revascularization and on dual antiplatelet therapy with ASA + Ticagrelor (90mg/twice a day) were scheduled for platelet function assessment 30-90 days post-discharge. Aggregation tests were performed by Multiple Electrode Aggregometry (MEA). Suboptimal platelet inhibition HRPR-high residual platelet reactivity was defined if above the lower limit of normality (417 AU*min). We included 432 patients, divided according to Hcy tertiles. Higher Hcy levels were associated with age, renal failure, creatinine levels and use diuretics (p < 0.001). Patients with higher Hcy levels displayed a higher platelet reactivity at COL test (p = 0.002), and ADP test (p = 0.04), with a linear relationship between Hcy and platelet aggregation after stimulation with collagen (r = 0.202, p < 0.001), thrombin receptor peptide (r = 0.104, p = 0.05) and ADP (r = 0.145, p = 0.006). However, Hcy levels did not significantly affect the rate of HRPR with Ticagrelor (9.9% vs 13.7% vs 10.7%, p = 0.89; adjusted OR [95% CI] = [0.616-1.51], p = 0.99). CONCLUSIONS Among patients with ACS, despite the elevated platelet reactivity associated to hyperhomocysteinemia, DAPT with ticagrelor could overcome such phenomenon, achieving an adequate platelet inhibition in the majority of the patients.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy; Division of Cardiology, Ospedale degli Infermi, ASL Biella, Italy
| | - Roberta Rolla
- Clinical Chemistry, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Federica Negro
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Francesco Tonon
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Patrizia Pergolini
- Clinical Chemistry, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Matteo Nardin
- Department of Internal Medicine, ASST Spedali Civili, Brescia, Italy
| | - Marco Marcolongo
- Division of Cardiology, Ospedale degli Infermi, ASL Biella, Italy
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
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165
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Sanz M, del Castillo AM, Jepsen S, Gonzalez-Juanatey JR, D’Aiuto F, Bouchard P, Chapple I, Dietrich T, Gotsman I, Graziani F, Herrera D, Loos B, Madianos P, Michel JB, Perel P, Pieske B, Shapira L, Shechter M, Tonetti M, Vlachopoulos C, Wimmer G. Periodontitis and Cardiovascular Diseases. Consensus Report. Glob Heart 2020; 15:1. [PMID: 32489774 PMCID: PMC7218770 DOI: 10.5334/gh.400] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 12/20/2019] [Indexed: 12/11/2022] Open
Abstract
Background In Europe cardiovascular disease (CVD) is responsible for 3.9 million deaths (45% of deaths), being ischaemic heart disease, stroke, hypertension (leading to heart failure) the major cause of these CVD related deaths. Periodontitis is also a chronic non-communicable disease (NCD) with a high prevalence, being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease. Material and Methods There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In 2012 a joint workshop was held between the European Federation of Periodontology (EFP) and the American Academy of Periodontology to review the literature relating periodontitis and systemic diseases, including CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations. Results and Conclusions The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation (WHF), which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices.
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Affiliation(s)
- M. Sanz
- Department of Dental Clinical Specialties and ETEP Research Group, Faculty of Odontology, University Complutense of Madrid, Plaza Ramon y Cajal, Madrid, ES
| | | | - S. Jepsen
- Department of Periodontology, Operative and Preventive Dentistry, University of Bonn, Bonn, DE
| | - J. R. Gonzalez-Juanatey
- Cardiology Department, University Hospital, University of Santiago de Compostela, IDIS, CIBERCV, ES
| | - F. D’Aiuto
- Department of Periodontology, Eastman Dental Institute and Hospital, University College London, London, UK
| | - P. Bouchard
- U.F.R. d’odontologie, Université Paris Diderot, Hôpital Rothschild AP-HP, Paris, FR
| | - I. Chapple
- School of Dentistry, Institute of Clinical Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, UK
| | - T. Dietrich
- School of Dentistry, Institute of Clinical Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, UK
| | - I. Gotsman
- Heart Institute, Hadassah University Hospital, Jerusalem, IL
| | - F. Graziani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, IT
| | - D. Herrera
- Department of Dental Clinical Specialties and ETEP Research Group, Faculty of Odontology, University Complutense of Madrid, Plaza Ramon y Cajal, Madrid, ES
| | - B. Loos
- ACTA University, Amsterdam, NL
| | - P. Madianos
- Department of Periodontology, School of Dentistry, National and Kapodistrian University of Athens, GR
| | - J. B. Michel
- Inserm Unit 1148, laboratory for translational CV science, X. Bichat hospital, Paris, FR
| | - P. Perel
- World Heart Federation, Geneva, CH
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, UK
| | - B. Pieske
- Charité Universitätsmedizin Berlin, Department of Internal Medicine and Cardiology, Berlin, DE
- DZHK (German Center for Cardiovascular Research) Partnersite Berlin, German Heart Institut Berlin, DE
| | - L. Shapira
- Department of Periodontology, Hebrew University – Hadassah Faculty of Dental Medicine, Jerusalem, IL
| | - M. Shechter
- Leviev Heart Center, Chaim Sheba Medical Center, tel Hashomer and the Sackler Faculty of Medicine, Tel Aviv University, IL
| | - M. Tonetti
- Department of Periodontology, The University of Hong Kong, Prince Philip Dental Hospital, HK
| | - C. Vlachopoulos
- Department of Cardiology, National and Kapodistrian University of Athens, GR
| | - G. Wimmer
- Department of Prosthetic Dentistry, School of Dental Medicine, Karl-Franzens University Graz, AT
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166
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Comparison of clinical outcomes between Magmaris and Orsiro drug eluting stent at 12 months: Pooled patient level analysis from BIOSOLVE II–III and BIOFLOW II trials. Int J Cardiol 2020; 300:60-65. [DOI: 10.1016/j.ijcard.2019.11.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/30/2019] [Accepted: 11/04/2019] [Indexed: 11/23/2022]
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167
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Franchina AG, Calderone D, D'Arrigo P, Ingala S, Milluzzo RP, Greco A, Spagnolo M, Tamburino C, Capodanno D. Mechanisms of ST-segment elevation myocardial infarction in patients with atrial fibrillation, prior stenting and long-standing chronic coronary syndrome. Cardiol J 2020; 27:8-15. [PMID: 31960945 DOI: 10.5603/cj.a2020.0002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/09/2020] [Accepted: 12/12/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The optimal antithrombotic regimen for patients with atrial fibrillation (AF) and chronic coronary syndromes beyond 1 year after percutaneous coronary intervention (PCI) is a matter of debate. For these patients, guidelines recommend oral anticoagulation (OAC) alone, but the risk of thrombotic complications remains a concern. The aim of this study was to characterize the incidence, presentation and use of antithrombotic therapy in patients with AF, prior stenting > 12 months and new ST-segment elevation myocardial infarction (STEMI). METHODS Consecutive patients were selected from an institutional registry over a 3-year period if they matched the following criteria: 1) STEMI undergoing primary PCI; 2) AF; 3) chronic coronary syndrome with prior stenting > 12 months. RESULTS Among 852 consecutive STEMI patients undergoing primary PCI, the prevalence of AF was 4.1%, and 6 (0.9%) patients met all the inclusion criteria. Substantial heterogeneity in antithrombotic treatment for these patients was noted (e.g., OAC alone, OAC plus a single antiplatelet agent, no antithrombotic therapy). In 50% of patients, the STEMI episode was linked to a previously stented lesion or documented plaque. CONCLUSIONS This case review illustrates the wide heterogeneity in antithrombotic pharmacotherapy among AF patients presenting with STEMI > 12 months after PCI. The underlying reason for STEMI is only partly related to disease progression or stent-related events. This finding suggests that multiple mechanisms of recurrence may be advocated, and are not only limited to antithrombotic therapy but may be explained by the natural history of coronary artery disease in remote vessels.
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168
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Suh JW. Aspirin Monotherapy beyond 12 Months of Dual Antiplatelet Therapy in Patients with Acute Myocardial Infarction: Oldies But Goodies? Korean Circ J 2020; 50:130-132. [PMID: 31960632 PMCID: PMC6974660 DOI: 10.4070/kcj.2019.0390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 12/05/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jung Won Suh
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
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169
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Dual antiplatelet therapy in coronary artery disease: from the past to the future prospective. Cardiovasc Interv Ther 2020; 35:117-129. [DOI: 10.1007/s12928-020-00642-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 01/27/2023]
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170
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Treatment of Acute Nonvariceal Upper Gastrointestinal Bleeding in Chinese Patients on Antithrombotic Therapy. Gastroenterol Res Pract 2019; 2019:9190367. [PMID: 31933633 PMCID: PMC6942860 DOI: 10.1155/2019/9190367] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 10/29/2019] [Accepted: 12/02/2019] [Indexed: 02/07/2023] Open
Abstract
Objective To assess the treatment of acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) in Chinese patients on antithrombotic therapy. Methods The clinical data of patients with ANVUGIB who underwent upper gastrointestinal endoscopy 24 h after bleeding at Beijing Anzhen Hospital, Capital Medical University, from 2016 to 2018, were analyzed retrospectively. The patients were divided into antithrombotic therapy and control groups and into high-risk (Forrest Ia, Ib, IIa, and IIb) and low-risk (Forrest IIc and III) bleeding groups according to the results of endoscopy. Results In all, 230 patients were enrolled, with 99 cases in the antithrombotic group (antiplatelet therapy 80 patients, anticoagulant therapy 19 patients) and 131 cases in the control group (without antithrombotic therapy). A total of 78 and 21 and 84 and 47 patients were at high- and low- risk for bleeding (P = 0.019) in the antithrombotic and control groups, respectively; 12.1% and 4.6% had esophageal bleeding (P = 0.047), and 8 and 2 patients received interventional therapy (P = 0.021). Overall, 21 patients with hemodynamic instability were treated via endoscopy with anesthesia under tracheal intubation and ventilator support: 20 patients in the antithrombotic group (13 patients within 1 month after coronary intervention, 5 patients within 1 month of cardiac-valve replacement, and 2 patients within 4 years of cardiac-valve replacement) and 1 patient with third-degree atrioventricular block in the control group. Ten patients received interventional therapy: eight and two in the two groups, respectively. Multidisciplinary consultation was conducted to regulate the use of antithrombotic drugs. Conclusion Compared to the controls, patients in the antithrombotic group had a significantly higher incidence of critical and active bleeding. Patients with hemodynamic instability should be examined and treated via upper gastrointestinal endoscopy under anesthesia with tracheal intubation and ventilator support.
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171
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Ferretto S, Mattesi G, Migliore F, Susana A, De Lazzari M, Iliceto S, Leoni L, Bertaglia E. Clinical predictors of pocket hematoma after cardiac device implantation and replacement. J Cardiovasc Med (Hagerstown) 2019; 21:123-127. [PMID: 31789710 DOI: 10.2459/jcm.0000000000000914] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AIMS Pocket hematoma is a common complication of cardiac implantable electronic device (CIED) procedures. the aim of the study was to research the clinical factors associated with pocket hematoma formation after CIED implantation or replacement and to identify the best perioperative antithrombotic management. METHODS We retrospectively analyzed 500 consecutive patients who underwent to CIED implantation or replacement at our center from November 2014. RESULTS Among our population, 206 patients (41.2%) were on anticoagulant therapy at the time of the intervention: 68 (13.6%) on ongoing Warfarin; 111 (22.2%) on low-molecular-weight heparin (LMWH); and 27 (5.4%) on ongoing direct oral anticoagulants. Antiplatelet therapy was present in 262 (52.4%) patients: in particular, 50 (10%) were on dual antiplatelet therapy, 64 (12.8%) were on single antiplatelet therapy and anticoagulant therapy, whereas 12 (2.4%) were on anticoagulant with dual antiplatelet therapy.Incidence of pocket hematoma after CIEDs implantation was of 4.6%. Considering the different perioperative anticoagulant strategies, patients on LMWH presented the higher hematoma rate [11/100 patients (11.0%), P < 0.001]. At the multivariate analysis, anticoagulant with dual antiplatelet therapy (P = 0.021, OR 6.3, IC 1.3-30.8), left ventricular ejection fraction (LVEF) less than 30% (P < 0.001, OR 7.4, IC 2.7-20.4), and use of LMWH (P = 0.008, OR 3.8, IC 1.4-10.6) resulted the strongest predictors of pocket hematoma (Hosmer test = 0.899).Considering replacement procedures, incidence of pocket hematoma was of 4.4%. The incidence was higher after ICD/CRT-D replacement. The majority of pocket hematoma occurred in patients with mechanical valve prosthesis (3/4 cases, 75%, P < 0.001). CONCLUSION The use of LMWH and a low LVEF expose patients to a higher risk of pocket hematoma after CIED procedures. Anticoagulant with dual antiplatelet therapy and LMWH should be avoided.
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Affiliation(s)
- Sonia Ferretto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua.,Department of Cardiology, San Donà di Piave Hospital, Venice, Italy
| | - Giulia Mattesi
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua
| | - Federico Migliore
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua
| | - Angela Susana
- Department of Cardiology, Cittadella Hospital, Padua, Italy
| | - Manuel De Lazzari
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua
| | - Loira Leoni
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua
| | - Emanuele Bertaglia
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua
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172
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Krohn J, Gleißner CA, Zirlik A, Staudacher DL. Antikoagulanzien und Blutplättchenaggregationshemmer bei Patienten mit akutem Koronarsyndrom. Notf Rett Med 2019. [DOI: 10.1007/s10049-018-0535-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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173
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Caracciolo A, Mazzone P, Laterra G, Garcia-Ruiz V, Polimeni A, Galasso S, Saporito F, Carerj S, D’Ascenzo F, Marquis-Gravel G, Giustino G, Costa F. Antithrombotic Therapy for Percutaneous Cardiovascular Interventions: From Coronary Artery Disease to Structural Heart Interventions. J Clin Med 2019; 8:jcm8112016. [PMID: 31752292 PMCID: PMC6912795 DOI: 10.3390/jcm8112016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/05/2019] [Accepted: 11/15/2019] [Indexed: 02/02/2023] Open
Abstract
Percutaneous cardiovascular interventions have changed dramatically in recent years, and the impetus given by the rapid implementation of novel techniques and devices have been mirrored by a refinement of antithrombotic strategies for secondary prevention, which have been supported by a significant burden of evidence from clinical studies. In the current manuscript, we aim to provide a comprehensive, yet pragmatic, revision of the current available evidence regarding antithrombotic strategies in the domain of percutaneous cardiovascular interventions. We revise the evidence regarding antithrombotic therapy for secondary prevention in coronary artery disease and stent implantation, the complex interrelation between antiplatelet and anticoagulant therapy in patients undergoing percutaneous coronary intervention with concomitant atrial fibrillation, and finally focus on the novel developments in the secondary prevention after structural heart disease intervention. A special focus on treatment individualization is included to emphasize risk and benefits of each therapeutic strategy.
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Affiliation(s)
- Alessandro Caracciolo
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (P.M.); (G.L.); (S.G.); (F.S.); (S.C.)
| | - Paolo Mazzone
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (P.M.); (G.L.); (S.G.); (F.S.); (S.C.)
| | - Giulia Laterra
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (P.M.); (G.L.); (S.G.); (F.S.); (S.C.)
| | - Victoria Garcia-Ruiz
- UGC del Corazón, Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Victoria, 29010 Málaga, Spain;
| | - Alberto Polimeni
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy;
| | - Salvatore Galasso
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (P.M.); (G.L.); (S.G.); (F.S.); (S.C.)
| | - Francesco Saporito
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (P.M.); (G.L.); (S.G.); (F.S.); (S.C.)
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (P.M.); (G.L.); (S.G.); (F.S.); (S.C.)
| | - Fabrizio D’Ascenzo
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, 10124 Turin, Italy;
| | - Guillaume Marquis-Gravel
- Duke Clinical Research Institute, Durham, NC 27708, USA;
- Montreal Heart Institute, Montreal, QC H1T 1C8, Canada
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574, USA;
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574, USA
| | - Francesco Costa
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98100 Messina, Italy; (A.C.); (P.M.); (G.L.); (S.G.); (F.S.); (S.C.)
- Correspondence: ; Tel.: +39-090-221-23-41; Fax: +39-090-221-23-81
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174
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Ahmed J, Hasnain N, Malik F, Siddiqi TJ, Usman MS, Alkhouli M. Ticagrelor versus prasugrel for secondary prevention after percutaneous coronary intervention: A systematic review and meta-analysis. Eur J Prev Cardiol 2019; 27:2267-2271. [PMID: 31698964 DOI: 10.1177/2047487319885194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jawad Ahmed
- Internal Medicine, Dow University of Health Sciences, Pakistan
| | - Nimra Hasnain
- Internal Medicine, Dow University of Health Sciences, Pakistan
| | - Farheen Malik
- Internal Medicine, Dow University of Health Sciences, Pakistan
| | | | | | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, USA
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175
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Zhang S, Zhou H, Zhuang X, Yang D, Sun X, Zhong X, Lin X, Hu X, Huang Y, Liao X, Du Z. Critical appraisal of guidelines for coronary artery disease on dual antiplatelet therapy: More consensus than controversies. Clin Cardiol 2019; 42:1170-1180. [PMID: 31609463 PMCID: PMC6906997 DOI: 10.1002/clc.23275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/11/2019] [Accepted: 09/17/2019] [Indexed: 01/05/2023] Open
Abstract
Background Dual antiplatelet therapy (DAPT) in the form of aspirin plus a P2Y12 inhibitor, when indicated, is one of the key treatments in coronary artery disease (CAD). Many recommendations on DAPT in patients with CAD based on current guidelines are largely inconsistent. In our current study, we aimed at systematically reviewing DAPT‐relevant clinical practice guidelines, and highlighting their commonalities and differences for better informed decision‐making. Methods Contemporary guidelines in English were searched in MEDLINE, Embase and websites of guideline organizations and professional societies. Guidelines with recommendations on DAPT for CAD patients were included. Guideline quality was appraised with the 6‐domain Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. The reporting of conflicts of interest (COI) was assessed individually with supplementary items from the RIGHT (Reporting Item for Practice Guidelines in Healthcare) checklist. Meanwhile, extraction of recommendations was performed. Results A total of 18 guidelines fulfilled our inclusion criteria. Most of them were graded with relatively good scores averaging from 42% to 74%. Domains for lower scores were in “stakeholder involvement” and “application.” The reporting of COI was satisfactory. For the recommendations on DAPT, most guidelines with high AGREE II scores included consistent recommendations on the timing and P2Y12 inhibitor selection. Nonetheless, conflicts still exist on the duration of DAPT. Conclusions Quality of guidelines for DAPT in CAD was relatively high, though defects existed in “Applicability” and “Stakeholder Involvement.” As these guidelines developed, DAPT recommendations gradually converged on a consensus. Clinical decision should be made on an individual basis.
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Affiliation(s)
- Shaozhao Zhang
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Huimin Zhou
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Xiaodong Zhuang
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Daya Yang
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Xiuting Sun
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Xiangbin Zhong
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Xiaoyu Lin
- Department of AnesthesiologyThe Third Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Xun Hu
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Yiquan Huang
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Xinxue Liao
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Zhimin Du
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
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176
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Lomakin NV, Buryachkovskaya LI, Sumarokov AB, Gabbasov ZA, Gerasimov AN. [Relation of Functional Activity of Platelets to Prognosis of Unfavorable Cardiovascular Events in Patients with Acute Coronary Syndrome. Results of a Registry Study]. ACTA ACUST UNITED AC 2019; 59:5-13. [PMID: 31615383 DOI: 10.18087/cardio.2019.10.n678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/16/2019] [Accepted: 09/17/2019] [Indexed: 11/18/2022]
Abstract
AIM to assess relation ofhigh functional activity ofplatelets to prognosis ofunfavorable cardiovascular events in patients with Acute Coronary Syndrome (ACS). MATERIALS The study was based on the data of a single center ACS registry conducted in the Central Clinical Hospital of the Presidential Affairs Department of Russian Federation. Of 529 included patients in 425 without contraindications to double antiplatelet therapy we carried out analysis of dependence of 30 days level of unfavorable events on parameters of functional activity of platelets. RESULTS High on-treatment platelet reactivity (HTPR) was found to be associated with 3.5 increase of mortality in the group of patients with high cardiovascular risk. Logistic model of prognosis of unfavorable events based on multifactorial analysis of data from patients with measured platelet aggregation included chronic kidney disease, type of myocardial infarction, and degree ofplatelet aggregation >45%. C -statistic was equal to 0.77. We also present in this paper discussion of problems related to studying approaches to individualization of anti-aggregation therapy in real clinical practice and problems of organization ofsimilar studies. CONCLUSION The study showed that patients with ACS increased platelet aggregation, as well as chronic kidney disease and type 2 MI are associated with a 30 day prognosis of adverse events.
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Affiliation(s)
- N V Lomakin
- Central Clinical Hospital of the Management Affair of President RF
| | | | | | | | - A N Gerasimov
- Sechenov First Moscow State Medical University (Sechenov University)
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177
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Simonsson M, Wallentin L, Alfredsson J, Erlinge D, Hellström Ängerud K, Hofmann R, Kellerth T, Lindhagen L, Ravn-Fischer A, Szummer K, Ueda P, Yndigegn T, Jernberg T. Temporal trends in bleeding events in acute myocardial infarction: insights from the SWEDEHEART registry. Eur Heart J 2019; 41:833-843. [DOI: 10.1093/eurheartj/ehz593] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/15/2019] [Accepted: 08/07/2019] [Indexed: 12/11/2022] Open
Abstract
Abstract
Aims
To describe the time trends of in-hospital and out-of-hospital bleeding parallel to the development of new treatments and ischaemic outcomes over the last 20 years in a nationwide myocardial infarction (MI) population.
Methods and results
Patients with acute MI (n = 371 431) enrolled in the SWEDEHEART registry from 1995 until May 2018 were selected and evaluated for in-hospital bleeding and out-of-hospital bleeding events at 1 year. In-hospital bleeding increased from 0.5% to a peak at 2% 2005/2006 and thereafter slightly decreased to a new plateau around 1.3% by the end of the study period. Out-of-hospital bleeding increased in a stepwise fashion from 2.5% to 3.5 % in the middle of the study period and to 4.8% at the end of the study period. The increase in both in-hospital and out-of-hospital bleeding was parallel to increasing use of invasive strategy and adjunctive antithrombotic treatment, dual antiplatelet therapy (DAPT), and potent DAPT, while the decrease in in-hospital bleeding from 2007 to 2010 was parallel to implementation of bleeding avoidance strategies. In-hospital re-infarction decreased from 2.8% to 0.6% and out-of-hospital MI decreased from 12.6% to 7.1%. The composite out-of-hospital MI, cardiovascular death, and stroke decreased in a similar fashion from 18.4% to 9.1%.
Conclusion
During the last 20 years, the introduction of invasive and more intense antithrombotic treatment has been associated with an increase in bleeding events but concomitant there has been a substantial greater reduction of ischaemic events including improved survival.
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Affiliation(s)
- Moa Simonsson
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Wallentin
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Joakim Alfredsson
- Department of Cardiology, Linkoping University Hospital, Linkoping, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Karin Hellström Ängerud
- Department of Cardiology, Heart Centre, Umea University, Umea, Sweden
- Department of Nursing, Umea University, Umea, Sweden
| | - Robin Hofmann
- Division of Cardiology, Department of Clinical Science and Education, Karolinska Institutet, Sodersjukhuset, Stockholm, Sweden
| | - Thomas Kellerth
- Department of Cardiology, Orebro University Hospital, Orebro, Sweden
| | - Lars Lindhagen
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Annica Ravn-Fischer
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden
| | - Karolina Szummer
- Department of Medicine, Karolinska Institute, Huddinge, Stockholm, Sweden
| | - Peter Ueda
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Troels Yndigegn
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
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178
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Hee L, Gibbs OJ, Assad JG, Sharma LD, Hopkins A, Juergens CP, Lo S, Mussap CJ. Real-world use of ticagrelor versus clopidogrel in percutaneous coronary intervention-treated ST-elevation myocardial infarction patients: A single-center registry study. J Saudi Heart Assoc 2019; 31:151-160. [PMID: 31296977 PMCID: PMC6599087 DOI: 10.1016/j.jsha.2019.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 05/25/2019] [Accepted: 05/26/2019] [Indexed: 12/30/2022] Open
Abstract
Objectives The primary aim was to investigate the efficacy and safety of dual antiplatelet therapy (DAPT) using ticagrelor (T-DAPT) versus clopidogrel (C-DAPT) in a real-world ST-elevation myocardial infarction (STEMI) population. Methods We retrospectively analyzed 655 consecutive patients having primary percutaneous coronary intervention (PCI) for STEMI at Liverpool Hospital, Sydney, Australia (from January 2013 to April 2016). Medical and procedural therapies were at clinician discretion. Patient data were retrieved from hospital records and primary clinicians. Results T-DAPT (65%) was used more frequently, and in patients with lower mean CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) score, than C-DAPT (24.6 vs. 32.2; p < 0.0001, respectively). All-cause mortality was 9.0% at 2.7 years follow-up, with fewer deaths for T-DAPT (4.5% vs. 17.2%; p < 0.0001). T-DAPT incurred less BARC (Bleeding Academic Research Consortium) 3-5 major bleeding (5.0% vs. 12.4%; p < 0.0001). Multivariate regression showed that C-DAPT, GRACE (Global Registry of Acute Cardiac Events) score, and renal insufficiency were independently associated with mortality. Intra-aortic balloon pump (IABP) and GRACE score independently predicted BARC 3-5 bleeding. Early DAPT discontinuation (1.7%) and ticagrelor intolerance (7.6%) was rare. Switching DAPT regimen was infrequent (21.7%) and mostly attributed to clinician preference (73.2%). Independent determinants of C-DAPT selection were older age, diabetes, prior PCI, IABP, and higher CRUSADE score. Conclusion Ticagrelor was preferred in low bleeding risk patients, which may have contributed to less BARC 3-5 bleeding and lower mortality for T-DAPT. Thus, bleeding mitigation is a clinical priority when selecting DAPT for PCI-treated STEMI patients. Continuation of initial DAPT regimen was typical, but early switching from clopidogrel to ticagrelor shows willingness to optimize DAPT. Patients with very low CRUSADE scores (<21.5) may be appropriate for switching to a potent P2Y12 inhibitor.
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Affiliation(s)
- Leia Hee
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Oliver J Gibbs
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Joseph G Assad
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Lokesh D Sharma
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Hopkins
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Christian J Mussap
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
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179
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Linden K, McQuillan C, Brennan P, Menown IBA. Advances in Clinical Cardiology 2018: A Summary of Key Clinical Trials. Adv Ther 2019; 36:1549-1573. [PMID: 31065993 PMCID: PMC6824396 DOI: 10.1007/s12325-019-00962-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Many important clinical trials in cardiology were published or presented at major international meetings throughout 2018. This paper aims to offer a concise overview of these significant advances and to put them into clinical context. METHODS Trials presented at the major international cardiology meetings during 2018 were reviewed including The American College of Cardiology, EuroPCR, The European Society of Cardiology, PCR London Valves, Transcatheter Cardiovascular Therapeutics, and the American Heart Association. In addition to this a literature search identified several other publications eligible for inclusion based on their relevance to clinical cardiology, their potential impact on clinical practice and on future guidelines. RESULTS A total of 78 trials met the inclusion criteria. New interventional and structural data include trials examining novel stent designs (Biofreedom™, COMBO), use of drug-coated balloons in patients with high bleeding risk, intervention in stable coronary artery disease, revascularisation strategy in ST elevation myocardial infarction, transcatheter aortic valve replacement in low-risk patients, and percutaneous mitral or tricuspid valve interventions. Preventative cardiology data included the use of sodium glucose cotransporter-2 inhibitors (empagliflozin, dapagliflozin, canagliflozin), proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors (alirocumab) and approaches of hypertension management. Antiplatelet data included trials evaluating both the optimal length of course and combination of antiplatelet agents. Heart failure data included trials of sacubitril-valsartan during acute hospital admission and the management of chemotherapy-induced cardiotoxicity. Electrophysiology data included trials examining atrial fibrillation ablation, wearable cardiac defibrillators (LifeVest) and His-bundle pacing. CONCLUSION This article presents key clinical trials completed during 2018 and should be valuable to both cardiology clinicians and researchers.
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Affiliation(s)
- Katie Linden
- Craigavon Cardiac Centre, SHSCT, Craigavon, Northern Ireland, UK.
| | - Conor McQuillan
- Craigavon Cardiac Centre, SHSCT, Craigavon, Northern Ireland, UK
| | - Paul Brennan
- Craigavon Cardiac Centre, SHSCT, Craigavon, Northern Ireland, UK
| | - Ian B A Menown
- Craigavon Cardiac Centre, SHSCT, Craigavon, Northern Ireland, UK
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181
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Pyka L, Gasior M. Atrial fibrillation and myocardial infarction – in constant need for new data. Eur J Prev Cardiol 2019; 26:1370-1372. [DOI: 10.1177/2047487319849509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Lukasz Pyka
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Silesian Centre for Heart Diseases in Zabrze, Poland
| | - Mariusz Gasior
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Silesian Centre for Heart Diseases in Zabrze, Poland
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182
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Wang C, Zheng W, Shaqdan A, Wang C, Qin X, Zhao X, Wang X, Yuan L, Nie S, Liu R. Efficacy and safety of switching from ticagrelor to clopidogrel during the early and late phase in acute coronary syndrome patients after percutaneous coronary intervention. Platelets 2019; 31:337-343. [PMID: 31043110 DOI: 10.1080/09537104.2019.1609668] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
In patients with acute coronary syndrome (ACS), treatment using ticagrelor demonstrated significant ischemic benefits over clopidogrel; however, it was associated with increased bleeding complications leading to frequent de-escalation to clopidogrel. The objective of the present study was to investigate the efficacy and safety of de-escalation in early and late phase after percutaneous coronary intervention (PCI). We performed a retrospective study of 4678 ACS patients from March 2016 to April 2017 who initially received ticagrelor then de-escalated to clopidogrel and categorized them into Group 1: early phase (1-30 days) and Group 2: late phase (>30 days-1 year) switching groups. The primary efficacy endpoints included cardiovascular death, definite/probable stent thrombosis, myocardial infarction, unplanned revascularization, and stroke. The safety endpoint was Bleeding Academic Research Consortium classification 3 or 5 bleeding events within 1 year after PCI. The incidence of switching occurred in 1019 patients; 380 (37.3%) in Group 1 (median 14 days, interquartile range 4-30 days) versus 639 (62.7%) in Group 2 (median 180 days, interquartile range 90-270 days). The ischemic endpoints occurred in 53 (13.9%) patients in Group 1 versus 35 (5.4%) in Group 2 (HR 1.93,95%CI 1.22-3.08, p < .0001). There were no significant differences of major bleeding events (HR 0.91; 95%CI, 0.58-1.43, p = .90) seen between the groups. The main cause for switching between the two groups was due to BARC 1 or 2 bleeding types. Early de-escalation from ticagrelor to clopidogrel during the initial 30 days after ACS was associated with higher risk of ischemic events when compared with switching beyond 30 days.
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Affiliation(s)
- Chenggang Wang
- Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Wen Zheng
- Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Ayman Shaqdan
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Chunmei Wang
- Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Xiuchuan Qin
- Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Xuedong Zhao
- Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Xu Wang
- Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Lin Yuan
- Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Shaoping Nie
- Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Ran Liu
- Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
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183
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Windecker S. Interventional cardiology’s golden age of contributions to evidence-based medicine. EUROINTERVENTION 2019; 15:31-34. [DOI: 10.4244/eijv15i1a6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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184
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Zientara A, Rings L, Bruijnen H, Dzemali O, Odavic D, Häussler A, Gruszczynski M, Genoni M. Early silent graft failure in off-pump coronary artery bypass grafting: a computed tomography analysis†. Eur J Cardiothorac Surg 2019; 56:919-925. [DOI: 10.1093/ejcts/ezz112] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 02/05/2019] [Accepted: 03/06/2019] [Indexed: 12/12/2022] Open
Abstract
Abstract
OBJECTIVES
The purpose was to assess predictors of early silent graft failure prior to discharge by multislice computed tomography in patients after off-pump coronary artery bypass grafting.
METHODS
From January 2017 until April 2018, 192 computed tomographic scans of consecutive asymptomatic patients were performed (seventh postoperative day ± 4 days) and analysed retrospectively. In total, 359 arterial and 278 venous anastomoses were evaluated. Two patient groups (overall patent anastomoses versus at least 1 occluded anastomosis) were compared. Cardiovascular risk factors, collateralization according to Rentrop, grade of native vessel stenosis and intraoperative flow measurements were analysed. Inferential statistics were performed with the Mann–Whitney U-test. Nominal and categorical variables were tested with the Fisher–Freeman–Halton exact test.
RESULTS
In 33 patients, at least 1 occluded anastomosis could be identified, predominantly in women (P = 0.04). The patency of the arterial anastomoses was 96.4% and 88.9% for the venous anastomoses. In 14 patients with occluded anastomoses, a successful interventional revascularization was performed before discharge. There were significant differences in lower bypass flow [P = 0.02, odds ratio 3.2, 95% confidence interval (CI) 1.7–6.0] and higher pulsatility index (P < 0.001, odds ratio 4.5, 95% CI 2.4–8.5) in the occluded group. A calculated cut-off value identified an increased probability for graft occlusion at a flow under 23 ml/min and a pulsatility index greater than 2.3.
CONCLUSIONS
Early silent graft failure occurred predominantly in venous grafts, with a tendency to female gender. A lower flow rate and a higher pulsatility index were significantly associated with graft occlusion, whereas collateralization and the degree of native vessel stenosis seem to play a tangential role. Fourteen patients had a successful percutaneous revascularization before discharge.
Clinical trial registration number
NCT03657199.
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Affiliation(s)
- Alicja Zientara
- Department of Cardiac Surgery, Triemli Hospital, Zurich, Switzerland
| | - Laura Rings
- Department of Cardiac Surgery, Triemli Hospital, Zurich, Switzerland
| | - Hans Bruijnen
- Department of Vascular Surgery, University of Augsburg, Augsburg, Germany
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli Hospital, Zurich, Switzerland
| | - Dragan Odavic
- Department of Cardiac Surgery, Triemli Hospital, Zurich, Switzerland
| | - Achim Häussler
- Department of Cardiac Surgery, Triemli Hospital, Zurich, Switzerland
| | | | - Michele Genoni
- Department of Cardiac Surgery, University of Zurich, Zurich, Switzerland
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185
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Petricevic M, Jeppsson A, Kolh P. Optimal timing to discontinue ticagrelor before cardiac surgery: do we need additional evidence? Eur J Cardiothorac Surg 2019; 55:720-721. [PMID: 30715309 DOI: 10.1093/ejcts/ezy420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Mate Petricevic
- Department of Cardiac Surgery, School of Medicine University of Zagreb, University Hospital Center Zagreb-Rebro, Zagreb, Croatia
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University of Liège, Liège, Belgium
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186
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Ahn KT, Seong SW, Choi UL, Jin SA, Kim JH, Lee JH, Choi SW, Jeong MH, Chae SC, Kim YJ, Kim CJ, Kim HS, Cho MC, Gwon HC, Jeong JO, Seong IW. Comparison of 1-year clinical outcomes between prasugrel and ticagrelor versus clopidogrel in type 2 diabetes patients with acute myocardial infarction underwent successful percutaneous coronary intervention. Medicine (Baltimore) 2019; 98:e14833. [PMID: 30882670 PMCID: PMC6426627 DOI: 10.1097/md.0000000000014833] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Although the new oral P2Y12 inhibitors, prasugrel/ticagrelor have shown greater efficacy than clopidogrel in patients with the acute coronary syndrome, but they have not shown better efficacy in Korean patients. So we evaluated the efficacy of the prasugrel/ticagrelor in patients with myocardial infarction (MI) and diabetes, a more high-risk patients group.From the Korea Acute Myocardial Infarction Registry-National Institute of Health, 3985 patients with MI and diabetes who underwent PCI were enrolled between November 2011 and December 2015. The patients were divided into 2 groups: clopidogrel (n = 2985) and prasugrel/ticagrelor (n = 1000).After propensity score matching, prasugrel/ticagrelor group showed a no significant difference in risk of the composite of cardiac death (CD), recurrent MI or stroke (hazard ratio [HR], 0.705; 95% confidence interval [CI], 0.474-1.048; P = .084). However, the risk of major bleeding was significantly higher in the prasugrel/ticagrelor group. (HR; 2.114, 95% CI; [1.027-4.353], P = .042). In subgroup analysis, major bleeding was significantly increased in the subgroup of creatinine clearance <60 ml/min/1.73 m, hypertension, underwent a trans-femoral approach and diagnosed as NSTEMI among the prasugrel/ticagrelor group.The use of prasugrel/ticagrelor did not improve the composite of CD, recurrent MI or stroke, however, significantly increased major bleeding events in Korean patients with MI and diabetes undergoing PCI.
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Affiliation(s)
- Kye Taek Ahn
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University, School of Medicine, Daejeon
| | - Seok-Woo Seong
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University, School of Medicine, Daejeon
| | - Ung Lim Choi
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University, School of Medicine, Daejeon
| | - Seon-Ah Jin
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University, School of Medicine, Daejeon
| | - Jun Hyung Kim
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University, School of Medicine, Daejeon
| | - Jae-Hwan Lee
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University, School of Medicine, Daejeon
| | - Si Wan Choi
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University, School of Medicine, Daejeon
| | - Myung Ho Jeong
- Chonnam National University Hospital, Chonnam National University, School of Medicine, Gwangju
| | - Shung Chull Chae
- Kyungpook National University Hospital, Kyungpook National University, School of Medicine
| | | | | | - Hyo-Soo Kim
- Seoul National University Hospital, Seoul National University, School of Medicine, Seoul
| | - Myeong-Chan Cho
- Chungbuk National University Hospital, Chungbuk National University, School of Medicine, Cheongju
| | - Hyeon-Cheol Gwon
- Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Republic of Korea
| | - Jin-Ok Jeong
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University, School of Medicine, Daejeon
| | - In-Whan Seong
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University, School of Medicine, Daejeon
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187
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Milojevic M, Pisano A, Sousa-Uva M, Landoni G. Perioperative Medication Management in Adult Cardiac Surgery: The 2017 European Association for Cardio-Thoracic Surgery Guidelines. J Cardiothorac Vasc Anesth 2019; 33:304-306. [PMID: 30385193 DOI: 10.1053/j.jvca.2018.09.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Indexed: 12/15/2022]
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188
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Hansson EC, Geirsson A, Hjortdal V, Mennander A, Olsson C, Gunn J, Zindovic I, Ahlsson A, Nozohoor S, Chemtob RA, Pivodic A, Gudbjartsson T, Jeppsson A. Preoperative dual antiplatelet therapy increases bleeding and transfusions but not mortality in acute aortic dissection type A repair. Eur J Cardiothorac Surg 2019; 56:182-188. [DOI: 10.1093/ejcts/ezy469] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 11/14/2018] [Accepted: 12/13/2018] [Indexed: 01/16/2023] Open
Affiliation(s)
- Emma C Hansson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Arnar Geirsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Vibeke Hjortdal
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Denmark
| | - Ari Mennander
- Department of Cardiothoracic Surgery, Heart Center Tampere University Hospital, Tampere, Finland
| | - Christian Olsson
- Department of Thoracic and Cardiovascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Jarmo Gunn
- Department of Surgery, Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Igor Zindovic
- Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
- Department of Cardiothoracic Surgery, Lund University, Skane University Hospital, Lund, Sweden
| | - Anders Ahlsson
- Department of Heart and Vascular Theme, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Shahab Nozohoor
- Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
- Department of Cardiothoracic Surgery, Lund University, Skane University Hospital, Lund, Sweden
| | - Raphaelle A Chemtob
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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189
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Ako J, Okumura K, Nakao K, Kozuma K, Morino Y, Okazaki K, Fukaya T, Kimura T. Dual Anti-Thrombotic Therapy With Dabigatran After Percutaneous Coronary Intervention in Atrial Fibrillation - Japanese and East-Asian Subgroup Analysis of the RE-DUAL PCI Trial. Circ J 2019; 83:327-333. [PMID: 30643079 DOI: 10.1253/circj.cj-18-0874] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND In the RE-DUAL PCI trial, dual anti-thrombotic therapy with dabigatran and a P2Y12inhibitor had a lower risk of bleeding and similar risk reduction of thromboembolic events, compared with warfarin triple therapy, in patients with NVAF undergoing PCI. This subanalysis investigated whether the efficacy and safety of dabigatran dual therapy in Japanese and East-Asian patients enrolled in the RE-DUAL PCI trial were similar to those of the overall patient population of the trial. Methods and Results: RE-DUAL PCI was a multicenter, randomized trial. The primary endpoint was the time to first International Society on Thrombosis and Hemostasis major or clinically relevant non-major bleeding events. Of the East-Asian patients (n=240) enrolled in the RE-DUAL PCI trial, 111 were Japanese and received dabigatran 110 mg (n=50) or 150 mg (n=13) dual therapy, or warfarin triple therapy (n=48). The incidence of the primary endpoint in Japanese patients was 26.0% and 29.2% with dabigatran 110-mg dual therapy and the corresponding warfarin triple therapy, and 23.1% and 30.8% with dabigatran 150-mg dual therapy and the corresponding warfarin triple therapy, respectively. Similar results were observed in the East-Asian population. CONCLUSIONS This subanalysis of the RE-DUAL PCI trial demonstrated that, like in the overall patient population, dabigatran dual therapy may offer physicians additional options for managing Japanese and East-Asian patients with NVAF receiving PCI.
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Affiliation(s)
- Junya Ako
- Department of Cardiovascular Medicine, Kitasato University
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Ken Kozuma
- Department of Cardiology, Teikyo University School of Medicine
| | | | | | - Taku Fukaya
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
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190
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Toba T, Shinke T, Otake H, Sugizaki Y, Takeshige R, Onishi H, Nagasawa A, Tsukiyama Y, Yanaka K, Nagano Y, Yamamoto H, Kawamori H, Matsuura A, Ishihara T, Matsumoto D, Igarashi N, Hayashi T, Yasaka Y, Kadotani M, Fujii T, Shite J, Okada M, Sakakibara T, Hirata KI. Impact of dual antiplatelet therapy with adjusted-dose prasugrel on mid-term vascular response in patients undergoing elective percutaneous coronary intervention with everolimus-eluting stents. Heart Vessels 2019; 34:936-947. [PMID: 30599059 DOI: 10.1007/s00380-018-1322-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 12/07/2018] [Indexed: 11/30/2022]
Abstract
The impact of dual antiplatelet therapy (DAPT) with adjusted-dose (3.75 mg/day) prasugrel for Japanese patients has not been fully investigated in terms of local arterial healing following the elective percutaneous coronary intervention (PCI). The ROUTE-01 elective study was a prospective, 12-center and single-arm registry that enrolled 123 patients who underwent elective PCI with everolimus-eluting stents (EESs) under DAPT with a combination of adjusted-dose prasugrel and aspirin. Serial optical coherence tomography (OCT) was performed at the index PCI and 9-month follow-up to assess the relationship between in-stent thorombus (IST) and residual platelet reactivity measuring platelet reactivity unit (PRU). The patients were classified as extensive, intermediate, and poor metabolizers by cytochrome P450 2C19 (CYP2C19) loss-of-function polymorphisms. The prevalence of IST was 9.0% by 9-month OCT, with no difference amongst the three groups (p = 0.886). The incidences of malapposed and uncovered struts were not different among the groups. PRU was not statistically different among the groups. In multivariate logistic regression analysis, the independent predictor for IST on 9-month OCT was irregular protrusion (odds ratio = 8.952, p = 0.037) on post-PCI OCT, not CYP2C19 loss-of-function polymorphisms. An adequate anti-thrombotic effect with an acceptable incidence of IST was observed irrespective of CYP2C19 loss-of-function polymorphisms. Our data suggests that adjusted-dose prasugrel and aspirin is a feasible treatment option in Japanese patients treated with EESs in elective PCI.
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Affiliation(s)
- Takayoshi Toba
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | - Toshiro Shinke
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan. .,Showa University School of Medicine, Tokyo, Japan.
| | - Hiromasa Otake
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | - Yoichiro Sugizaki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | - Ryo Takeshige
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | - Hiroyuki Onishi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | - Akira Nagasawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | - Yoshiro Tsukiyama
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | - Kenichi Yanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | - Yuichiro Nagano
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | - Hiroyuki Yamamoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | - Hiroyuki Kawamori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | | | | | | | | | | | | | | | | | | | | | | | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
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191
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Neupane S, Khawaja O, Edla S, Singh H, Othman H, Bossone E, Yamasaki H, Rosman HS, Eggebrecht H, Mehta RH. Meta-analysis of drug eluting stents compared with bare metal stents in high bleeding risk patients undergoing percutaneous coronary interventions. Catheter Cardiovasc Interv 2018; 94:98-104. [DOI: 10.1002/ccd.28045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 11/03/2018] [Accepted: 12/01/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Saroj Neupane
- Division of Cardiology, Department of Internal Medicine; Henry Ford Hospital; Detroit Michigan
| | - Owais Khawaja
- Division of Cardiology, Department of Internal Medicine; St John Hospital and Medical Center; Detroit Michigan
| | - Sushruth Edla
- Division of Cardiology, Department of Internal Medicine; St John Hospital and Medical Center; Detroit Michigan
| | - Hemindermeet Singh
- Cardiovascular Fellowship Program; Mercy-Health St Vincent Medical Center; Toledo Ohio
| | - Hussein Othman
- Division of Cardiology, Department of Internal Medicine; St John Hospital and Medical Center; Detroit Michigan
| | - Eduardo Bossone
- Cava de' Tirreni and Amalfi Coast Hospital; University of Salerno; Amalfi Italy
| | - Hiroshi Yamasaki
- Division of Cardiology, Department of Internal Medicine; St John Hospital and Medical Center; Detroit Michigan
| | - Howard S. Rosman
- Division of Cardiology, Department of Internal Medicine; St John Hospital and Medical Center; Detroit Michigan
| | - Holger Eggebrecht
- Cardioangiological Center Bethanien (CCB) and AGAPLESION Bethanien Hospital; Frankfurt Germany
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192
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Björklund E, Hansson EC, Romlin BS, Jeppsson A, Malm CJ. Postoperative platelet function is associated with severe bleeding in ticagrelor-treated patients. Interact Cardiovasc Thorac Surg 2018; 28:709-715. [DOI: 10.1093/icvts/ivy336] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/04/2018] [Accepted: 11/09/2018] [Indexed: 11/15/2022] Open
Affiliation(s)
- Erik Björklund
- Department of Internal Medicine, Södra Älvsborg Hospital, Borås, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Emma C Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Birgitta S Romlin
- Department of Paediatric Anaesthesia and Intensive Care, Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Carl Johan Malm
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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193
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Choi SY, Kim MH, Cho YR, Sung Park J, Min Lee K, Park TH, Yun SC. Performance of PRECISE-DAPT Score for Predicting Bleeding Complication During Dual Antiplatelet Therapy. Circ Cardiovasc Interv 2018; 11:e006837. [DOI: 10.1161/circinterventions.118.006837] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Sun Young Choi
- Department of Biomedical Laboratory Science, Daegu Health College, South Korea (S.Y.C.)
| | - Moo Hyun Kim
- Department of Cardiology, Dong-A University Hospital, Busan, South Korea (M.H.K., Y.-R.C., J.S.P., K.M.L., T.-H.P.)
| | - Young-Rak Cho
- Department of Cardiology, Dong-A University Hospital, Busan, South Korea (M.H.K., Y.-R.C., J.S.P., K.M.L., T.-H.P.)
| | - Jong Sung Park
- Department of Cardiology, Dong-A University Hospital, Busan, South Korea (M.H.K., Y.-R.C., J.S.P., K.M.L., T.-H.P.)
| | - Kwang Min Lee
- Department of Cardiology, Dong-A University Hospital, Busan, South Korea (M.H.K., Y.-R.C., J.S.P., K.M.L., T.-H.P.)
| | - Tae-Ho Park
- Department of Cardiology, Dong-A University Hospital, Busan, South Korea (M.H.K., Y.-R.C., J.S.P., K.M.L., T.-H.P.)
| | - Sung-Cheol Yun
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.-C.Y.)
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194
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Rosano GMC, Seferovic P. 2017 ESC guidelines focus on dual antiplatelet therapy. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2018; 4:131-132. [PMID: 30052849 DOI: 10.1093/ehjcvp/pvy007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Giuseppe M C Rosano
- Clinical Academic Group Cardiovascular, St George's Hospitals NHS Trust University of London, UK.,IRCCS San Raffaele, Roma, Italy
| | - Petar Seferovic
- Department of Cardiology, University of Belgrade, Belgrade, Serbia
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195
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Sorrentino S, Giustino G, Baber U, Sartori S, Cohen DJ, Henry TD, Farhan S, Sharma M, Ariti C, Dangas G, Gibson M, Faggioni M, Krucoff MW, Aquino M, Chandrasekhar J, Moliterno DJ, Colombo A, Vogel B, Chieffo A, Kini AS, Witzenbichler B, Weisz G, Steg PG, Pocock S, Mehran R. Dual Antiplatelet Therapy Cessation and Adverse Events After Drug-Eluting Stent Implantation in Patients at High Risk for Atherothrombosis (from the PARIS Registry). Am J Cardiol 2018; 122:1638-1646. [PMID: 30270177 DOI: 10.1016/j.amjcard.2018.07.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/25/2018] [Accepted: 07/31/2018] [Indexed: 01/12/2023]
Abstract
The impact of dual antiplatelet therapy (DAPT) cessation after percutaneous coronary intervention with drug eluting stent implantation in patients at high atherothrombotic risk remains unclear. We aimed to characterize the risk for adverse events, and its relation with the mode of DAPT cessation in patients at high atherothrombotic risk (HATR). Considering patients treated with drug-eluting stents among those enrolled in the Patterns of Non-Adherence to Anti-Platelet Regimens in Stented Patients registry, we defined subjects with prior myocardial infarction (MI), prior stroke or peripheral vascular disease at HATR, while patients without any of these conditions were classified as atherothrombotic risk (LATR). DAPT cessation-modes were defined as physician-recommended discontinuation, temporary interruption, and disruption due to bleeding or poor compliance. Compared to patients with LATR (n = 2867; 68.2%), patients with HATR (n = 1340; 31.8%) were older with a higher prevalence of cardiovascular risk factors. Over 2 years, HATR patients had lower rates of physician-recommended discontinuation (32.5% vs 39.4%; p = 0.002) and trend for disruption (11.5% vs 13.7%, p = 0.051), though no significant difference in the rate of DAPT interruption. Patients with HATR had higher 2-year rates of cardiac death, MI, or stent thrombosis compared with those at LATR (8.7% vs 4.0%; adjusted hazard ratio [aHR]: 1.80; 95% confidence interval [CI]: 1.36-2.39; p < 0.0001). Disruption of DAPT was associated with greater risk for cardiac death, MI, or stent thrombosis in both HATR (aHR: 1.86; 95% CI: 1.05 to 3.46) and LATR (aHR: 2.84; 95% CI: 1.68 to 4.80) patients (pinteraction = 0.40). The degree of atherothrombotic risk influences the pattern and mode of DAPT cessation with less discontinuation among patients considered HATR. Atherothrombotic risk status does not influence the association between DAPT cessation and cardiac risk.
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Affiliation(s)
- Sabato Sorrentino
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY; Division of Cardiology, Department of Medical and Surgical Sciences, University Magna Graecia, Catanzaro, Italy
| | - Gennaro Giustino
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Usman Baber
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Samantha Sartori
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David J Cohen
- St. Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO
| | - Timothy D Henry
- Minneapolis Heart Institute Foundation, University of Minnesota, Minneapolis, MN
| | - Serdar Farhan
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Madhav Sharma
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Cono Ariti
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George Dangas
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael Gibson
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Michela Faggioni
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Melissa Aquino
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jaya Chandrasekhar
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Antonio Colombo
- Cardio-Thoracic Department, San Raffaele Scientific Institute, Milan, Italy
| | - Birgit Vogel
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alaide Chieffo
- Cardio-Thoracic Department, San Raffaele Scientific Institute, Milan, Italy
| | - Annapoorna S Kini
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Giora Weisz
- Columbia University Medical Center, New York, NY; Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
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196
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Kremke M, Gissel MS, Jensen MJ, Thomassen SA, Jakobsen CJ. The association between a three-day ticagrelor discontinuation and perioperative bleeding complications. Eur J Cardiothorac Surg 2018; 55:714-720. [DOI: 10.1093/ejcts/ezy355] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 08/17/2018] [Accepted: 09/20/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Michael Kremke
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Marie Storebjerg Gissel
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Margrethe Jermiin Jensen
- Department of Anaesthesiology and Intensive Care Medicine, Odense University Hospital, Odense, Denmark
| | - Sisse Anette Thomassen
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Carl-Johan Jakobsen
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
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197
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Chen H, Power D, Giustino G. Optimal duration of dual antiplatelet therapy after PCI: integrating procedural complexity, bleeding risk and the acuteness of clinical presentation. Expert Rev Cardiovasc Ther 2018; 16:735-748. [DOI: 10.1080/14779072.2018.1523718] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Huazhen Chen
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David Power
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
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198
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Collet C, Mizukami T, Grundeken MJ. Contemporary techniques in percutaneous coronary intervention for bifurcation lesions. Expert Rev Cardiovasc Ther 2018; 16:725-734. [PMID: 30221565 DOI: 10.1080/14779072.2018.1523717] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Treatment of coronary bifurcation lesions with contemporary state-of-the-art percutaneous coronary intervention (PCI) is still associated with higher rate of adverse cardiovascular events compared to non-bifurcation lesions. Bench testing and virtual computer modeling have increased our understanding of bifurcation PCI guiding refinement in bifurcation techniques. New insights on bifurcation PCI have the potential to further improve clinical outcomes in patients presenting with bifurcation lesions. Areas covered: The present manuscript aims to review the methods for bifurcation lesion assessment and treatment strategy step by step supported on bench and clinical evidence. Expert commentary: Invasive pressure-wire evaluation is essential to determine the appropriateness of bifurcation PCI, particularly in intermediate coronary stenosis. Treatment strategy relies on four parameters: diameters of the three segments of the bifurcation; lesion length and plaque distribution; and bifurcation angle. The optimal technique for bifurcation PCI is still debated, an individualized approach with an initial provisional side branch stenting strategy seems to be suitable in the 75 to 95% of patients. For more complex bifurcations, two-stent techniques may be required with increasing evidence supporting the usefulness of the double kissing balloon crush (DK-crush) technique.
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Affiliation(s)
- Carlos Collet
- a Amsterdam Heart Center, Department of Cardiology , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands.,b Universitair Ziekenhuis Brussels , University of Brussels , Brussel , Belgium
| | - Takuya Mizukami
- b Universitair Ziekenhuis Brussels , University of Brussels , Brussel , Belgium
| | - Maik J Grundeken
- a Amsterdam Heart Center, Department of Cardiology , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands.,c Department of Cardiology , Academic Medical Center , Amsterdam , The Netherlands
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199
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Kaya A, Keskin M, Tatlisu MA, Kayapinar O. More About the Effect of Dynamic Potassium Change in STEMI. Angiology 2018; 70:89-90. [PMID: 30231627 DOI: 10.1177/0003319718801089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Adnan Kaya
- 1 Cardiology, Duzce University School of Medicine, Konuralp, Duzce, Turkey
| | - Muhammed Keskin
- 2 Cardiology, Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
| | | | - Osman Kayapinar
- 1 Cardiology, Duzce University School of Medicine, Konuralp, Duzce, Turkey
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200
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Komarov AL, Shakhmatova OO, Muraseeva VG, Novikova ES, Guskova EV, Panchenko EP. Proton pump inhibitors receiving and prognosis of patients after scheduled percutaneous coronary interventions. TERAPEVT ARKH 2018; 90:92-100. [PMID: 30701742 DOI: 10.26442/terarkh201890992-100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
AIM The urgency of the study is determined by the lack of data necessary in order to assess the safety of prolonged use of proton pump inhibitors (PPI) in patients with IHD combined with anti-aggregant therapy. The aim of the study was to study the relationship between the use of PPI and the risk of thrombotic complications in patients undergoing planned procedures of percutaneous coronary interventions (PCI) and receiving dual antiplatelet therapy. MATERIALS AND METHODS The study is a prospective register of patients who successfully underwent planned percutaneous coronary intervention (PCI). The effect of PPI (omeprazole and pantoprazole) on the frequency of the combined end point cardiovascular death, ACS, AI, TIA, peripheral arterial thrombosis and PE was assessed using the Log-Rank criterion, as well as in a multivariate analysis (Cox proportional risk regression model). RESULTS A total of 391 patients were included in the study (23.1% women, mean age 61.2 years ± 10.4 years). The median duration of follow-up was 18 months. During this period of time, 34 adverse events were recorded. Log-Rank analysis showed that the proportion of patients without adverse events in the omeprazole group was significantly lower in comparison with patients who did not receive PPI (0.56 vs. 0.84, Log-Rank p=0.003), and for pantoprazole no such pattern was found (0.89 against 0.84, Log-Rank p=0.21). The average level of residual platelet reactivity (ORT), as well as the number of patients with high ORT (> 208 PRU), did not differ significantly between the groups of omeprazole, pantoprazole and the group of patients not receiving PPI. According to multivariate analysis, omeprazole was an independent predictor of thrombotic complications after a planned PCI (OR 3.75, 95% confidence interval 1.72-8.17, p=----0.0009). CONCLUSION Long-term use of omeprazole (at least 30 days) is an independent predictor of thrombotic complications in patients who underwent planned PCI.
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Affiliation(s)
- A L Komarov
- Department of Clinical Problems of Atherothrombosis of the National Medical Research Center for Cardiology, Moscow, Russia
| | - O O Shakhmatova
- Department of Clinical Problems of Atherothrombosis of the National Medical Research Center for Cardiology, Moscow, Russia
| | - V G Muraseeva
- Department of Clinical Problems of Atherothrombosis of the National Medical Research Center for Cardiology, Moscow, Russia
| | - E S Novikova
- Department of Clinical Problems of Atherothrombosis of the National Medical Research Center for Cardiology, Moscow, Russia
| | - E V Guskova
- Pirogov National Medical and Surgical Center, Moscow, Russia
| | - E P Panchenko
- Department of Clinical Problems of Atherothrombosis of the National Medical Research Center for Cardiology, Moscow, Russia
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