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Horne BD, Atreja N, Venditto J, Wilson T, Muhlestein JB, St. Clair JR, Knowlton KU, Khan ND, Bhalla N, Anderson JL. Contemporary Predictors of Major Adverse Cardiovascular Events Following Percutaneous Coronary Intervention: A Nationally Representative US Sample. J Clin Med 2024; 13:2844. [PMID: 38792388 PMCID: PMC11121929 DOI: 10.3390/jcm13102844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Patient outcomes after percutaneous coronary intervention (PCI) have improved over the last 30 years due to better techniques, therapies, and care processes. This study evaluated contemporary predictors of post-PCI major adverse cardiovascular events (MACE) and summarized risk in a parsimonious risk prediction model. Methods: The Cardiovascular Patient-Level Analytical Platform (CLiPPeR) is an observational dataset of baseline variables and longitudinal outcomes from the American College of Cardiology's CathPCI Registry® and national claims data. Cox regression was used to evaluate 2-6 years of patient follow-up (mean: 2.56 years), ending in December 2017, after index PCI between 2012 and 2015 (N = 1,450,787), to examine clinical and procedural predictors of MACE (first myocardial infarction, stroke, repeat PCI, coronary artery bypass grafting, and mortality). Cox analyses of post-PCI MACE were landmarked 28 days after index PCI. Results: Overall, 12.4% (n = 179,849) experienced MACE. All variables predicted MACE, with cardiogenic shock, cardiac arrest, four diseased coronary vessels, and chronic kidney disease having hazard ratios (HRs) ≥ 1.50. Other major predictors of MACE were in-hospital stroke, three-vessel disease, anemia, heart failure, and STEMI presentation. The index revascularization and discharge prescription of aspirin, P2Y12 inhibitor, and lipid-lowering medication had HR ≤ 0.67. The primary Cox model had c-statistic c = 0.761 for MACE versus c = 0.701 for the parsimonious model and c = 0.752 for the parsimonious model plus treatment variables. Conclusions: In a nationally representative US sample of post-PCI patients, predictors of longitudinal MACE risk were identified, and a parsimonious model efficiently encapsulated them. These findings may aid in assessing care processes to further improve care post-PCI outcomes.
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Affiliation(s)
- Benjamin D. Horne
- Intermountain Medical Center Heart Institute, Salt Lake City, UT 84107, USA; (J.B.M.); (K.U.K.); (J.L.A.)
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA 94305, USA
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Nipun Atreja
- AstraZeneca Pharmaceuticals LP, Wilmington, DE 19850, USA; (N.A.); (J.V.); (T.W.); (J.R.S.C.); (N.D.K.); (N.B.)
| | - John Venditto
- AstraZeneca Pharmaceuticals LP, Wilmington, DE 19850, USA; (N.A.); (J.V.); (T.W.); (J.R.S.C.); (N.D.K.); (N.B.)
| | - Thomas Wilson
- AstraZeneca Pharmaceuticals LP, Wilmington, DE 19850, USA; (N.A.); (J.V.); (T.W.); (J.R.S.C.); (N.D.K.); (N.B.)
| | - Joseph B. Muhlestein
- Intermountain Medical Center Heart Institute, Salt Lake City, UT 84107, USA; (J.B.M.); (K.U.K.); (J.L.A.)
- Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, UT 84132, USA
| | - Joshua R. St. Clair
- AstraZeneca Pharmaceuticals LP, Wilmington, DE 19850, USA; (N.A.); (J.V.); (T.W.); (J.R.S.C.); (N.D.K.); (N.B.)
| | - Kirk U. Knowlton
- Intermountain Medical Center Heart Institute, Salt Lake City, UT 84107, USA; (J.B.M.); (K.U.K.); (J.L.A.)
- Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, UT 84132, USA
| | - Naeem D. Khan
- AstraZeneca Pharmaceuticals LP, Wilmington, DE 19850, USA; (N.A.); (J.V.); (T.W.); (J.R.S.C.); (N.D.K.); (N.B.)
| | - Narinder Bhalla
- AstraZeneca Pharmaceuticals LP, Wilmington, DE 19850, USA; (N.A.); (J.V.); (T.W.); (J.R.S.C.); (N.D.K.); (N.B.)
| | - Jeffrey L. Anderson
- Intermountain Medical Center Heart Institute, Salt Lake City, UT 84107, USA; (J.B.M.); (K.U.K.); (J.L.A.)
- Cardiology Division, Department of Internal Medicine, University of Utah, Salt Lake City, UT 84132, USA
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Lozano I, Vegas JM, Rondan J. Frailty and P2Y12 Inhibitors: Does The Best Approach Need to Be Black or White? Am J Cardiol 2024; 213:186. [PMID: 38142879 DOI: 10.1016/j.amjcard.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/04/2023] [Indexed: 12/26/2023]
Affiliation(s)
- Iñigo Lozano
- Department of Cardiology, Hospital Cabueñes, Gijón, Spain.
| | - Jose M Vegas
- Department of Cardiology, Hospital Cabueñes, Gijón, Spain
| | - Juan Rondan
- Department of Cardiology, Hospital Cabueñes, Gijón, Spain
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Almarzooq ZI, Al-Roub NM, Kinlay S. Antithrombotic treatment following percutaneous coronary intervention in patients with high bleeding risk. Curr Opin Cardiol 2023; 38:515-520. [PMID: 37522805 PMCID: PMC10592282 DOI: 10.1097/hco.0000000000001075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
PURPOSE OF REVIEW Review the clinical outcomes of different antithrombotic strategies in patients with high bleeding risk (HBR) after percutaneous coronary intervention (PCI). RECENT FINDINGS Patients with HBR after PCI include those with advanced age (e.g. >75 years of age), a prior history of major bleeding, anemia, chronic kidney disease, and those with indications for long-term anticoagulation. Strategies that successfully decrease bleeding risk in this population include shorter durations of dual antiplatelet therapy (DAPT; of 1-3 months) followed by single antiplatelet therapy with aspirin or a P2Y 12 inhibitor, or de-escalating from a more potent P2Y 12 inhibitor (prasugrel or ticagrelor) to less potent antiplatelet regimens (aspirin with clopidogrel or half-dose ticagrelor or half-dose prasugrel). Patients on DAPT, and a full dose anticoagulation for other indications, have a lower risk of major bleeding without an increase in 1-2-year adverse ischemic events, when rapidly switched from DAPT to a single antiplatelet therapy (within a week after PCI) with aspirin or clopidogrel. Longer term data on the benefits and risks of these strategies is lacking. SUMMARY In patients with HBR after PCI, shorter durations of DAPT (1-3 months) decrease the risk of major bleeding without increasing the risk of adverse ischemic events.
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Affiliation(s)
- Zaid I. Almarzooq
- Veterans Affairs Boston Healthcare System, West Roxbury
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital
- Harvard Medical School
- Smith Center for Outcomes Research at BIDMC, Boston, Massachusetts, USA
| | - Nora M. Al-Roub
- Smith Center for Outcomes Research at BIDMC, Boston, Massachusetts, USA
| | - Scott Kinlay
- Veterans Affairs Boston Healthcare System, West Roxbury
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital
- Harvard Medical School
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4
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Otieno B, Ibecheozor C, Williams MS. What Is the Optimal Duration of Antiplatelet Therapy for Patients with Coronary Heart Disease? Curr Atheroscler Rep 2023:10.1007/s11883-023-01108-z. [PMID: 37178416 DOI: 10.1007/s11883-023-01108-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE OF REVIEW Optimal duration of antiplatelet therapy continues to attract extensive debates and has been progressively adjusted in the setting of advancements in stent design and assessment of patient clinical characteristics. Given the ever-changing landscape of antiplatelet therapy and the multitude of clinical trials that have examined this duration, there are varying scenarios for optimal duration based on patient presentation and risk profile. This review highlights the current concepts and recommendations regarding duration of antiplatelet therapy in coronary heart disease. RECENT FINDINGS In particular, we review the current data on the use of dual antiplatelet therapy in the different clinical scenarios. Relatively longer dual antiplatelet therapy is perhaps limited to patients with higher risk for cardiovascular events and/or high-risk lesions and shorter durations of dual antiplatelet therapy have been shown to reduce bleeding complications at the same time as stabilization of ischemic endpoints. More recent trials have demonstrated the safety of shorter durations of dual antiplatelet therapy in appropriate patients with coronary heart disease.
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Affiliation(s)
- Beryl Otieno
- Greater Baltimore Medical Center, Towson, MD, USA
| | | | - Marlene S Williams
- Division of Cardiology, The Johns Hopkins University School of Medicine, 301 Mason Lord Drive, Suite 2400, Baltimore, MD, 21224, USA.
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Geisler T, Poli S, Huber K, Rath D, Aidery P, Kristensen SD, Storey RF, Ball A, Collet JP, Berg JT. Resumption of Antiplatelet Therapy after Major Bleeding. Thromb Haemost 2023; 123:135-149. [PMID: 35785817 DOI: 10.1055/s-0042-1750419] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Major bleeding is a common threat in patients requiring antiplatelet therapy. Timing and intensity with regard to resumption of antiplatelet therapy represent a major challenge in clinical practice. Knowledge of the patient's bleeding risk, defining transient/treatable and permanent/untreatable risk factors for bleeding, and weighing these against thrombotic risk are key to successful prevention of major adverse events. Shared decision-making involving various disciplines is essential to determine the optimal strategy. The present article addresses clinically relevant questions focusing on the most life-threatening or frequently occurring bleeding events, such as intracranial hemorrhage and gastrointestinal bleeding, and discusses the evidence for antiplatelet therapy resumption using individual risk assessment in high-risk cardiovascular disease patients.
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Affiliation(s)
- Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls-University Tuebingen, Tuebingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Dominik Rath
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Parwez Aidery
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Steen D Kristensen
- Department of Cardiology, Aarhus University Hospital, Faculty of Health, Aarhus University, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Alex Ball
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Jean-Philippe Collet
- ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Sorbonne Université, Paris, France
| | - Jurriën Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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6
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Simonsson M, Alfredsson J, Szummer K, Jernberg T, Ueda P. Association of Ischemic and Bleeding Events With Mortality Among Patients in Sweden With Recent Acute Myocardial Infarction Receiving Antithrombotic Therapy. JAMA Netw Open 2022; 5:e2220030. [PMID: 36036452 PMCID: PMC9425148 DOI: 10.1001/jamanetworkopen.2022.20030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Antithrombotic treatment after myocardial infarction (MI) should be individualized based on the patient's risk of ischemic and bleeding events. Uncertainty remains regarding the relative prognostic importance of the 2 types of events, and further study would be useful. OBJECTIVES To compare the association of ischemic vs bleeding events with mortality in patients with a recent MI and assess whether the relative mortality risk for the 2 types of events has changed over the past 2 decades. DESIGN, SETTING, AND PARTICIPANTS A cohort study based on nationwide registers in Sweden, 2012-2017, was conducted. Data were analyzed between July 2021 and May 2022. Patients with MI who were discharged alive with antithrombotic therapy (antiplatelet therapy or oral anticoagulation) were included in the analysis. MAIN OUTCOMES AND MEASURES The incidence of a first ischemic event (hospitalization for MI or ischemic stroke) or bleeding event (hospitalization with bleeding) up to 1 year after discharge and the mortality risk up to 1 year after each type of event were assessed. Cox proportional hazards regression models were used to estimate adjusted hazard ratios (aHRs) for 1-year mortality after an ischemic and bleeding event vs no event, and after an ischemic vs bleeding event. Adjusted HRs for mortality after ischemic vs bleeding events were compared among patients discharged in 1997-2000, 2001-2011, and 2012-2017. RESULTS Of 86 736 patients discharged after MI in 2012-2017 (median age, 71 [IQR, 62-80] years; 57 287 [66.0%] men), 4039 individuals experienced a first ischemic event (5.7 per 100 person-years) and 3399 experienced a first bleeding event (4.8 per 100 person-years). The mortality rate was 46.2 per 100 person-years after an ischemic event and 27.1 per 100 person-years after a bleeding event. The aHR for 1-year mortality vs no event was 4.16 (95% CI, 3.91-4.43) after an ischemic event and 3.43 (95% CI, 3.17-3.71) after a bleeding event. When the 2 types of events were compared, the aHR was 1.27 (95% CI, 1.15-1.40) for an ischemic vs bleeding event. There was no statistically significant difference in the aHR of an ischemic vs bleeding event in 1997-2000, 2001-2011, and 2012-2017. CONCLUSIONS AND RELEVANCE In this nationwide cohort study of patients with a recent MI, postdischarge ischemic events were more common and associated with higher mortality risk compared with bleeding events.
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Affiliation(s)
- Moa Simonsson
- Department of Clinical Sciences, Cardiology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Karolina Szummer
- Department of Medicine, Karolinska Institutet, Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Cardiology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Peter Ueda
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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7
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Outcomes after acute coronary syndrome in patients with inflammatory bowel disease. Heart Vessels 2022; 37:1604-1610. [DOI: 10.1007/s00380-022-02061-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/18/2022] [Indexed: 12/01/2022]
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8
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6517162. [DOI: 10.1093/ejcts/ezac036] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/11/2022] [Accepted: 01/17/2022] [Indexed: 11/15/2022] Open
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Matsumura-Nakano Y, Shiomi H, Morimoto T, Yamaji K, Ehara N, Sakamoto H, Takeji Y, Yoshikawa Y, Yamamoto K, Imada K, Tada T, Taniguchi R, Nishikawa R, Tada T, Uegaito T, Ogawa T, Yamada M, Takeda T, Eizawa H, Tamura N, Tambara K, Suwa S, Shirotani M, Tamura T, Inoko M, Nishizawa J, Natsuaki M, Sakai H, Yamamoto T, Kanemitsu N, Ohno N, Ishii K, Marui A, Tsuneyoshi H, Terai Y, Nakayama S, Yamazaki K, Takahashi M, Tamura T, Esaki J, Miki S, Onodera T, Mabuchi H, Furukawa Y, Tanaka M, Komiya T, Soga Y, Hanyu M, Ando K, Kadota K, Minatoya K, Nakagawa Y, Kimura T. Comparison of Outcomes of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting Among Patients With Three-Vessel Coronary Artery Disease in the New-Generation Drug-Eluting Stents Era (From CREDO-Kyoto PCI/CABG Registry Cohort-3). Am J Cardiol 2021; 145:25-36. [PMID: 33454340 DOI: 10.1016/j.amjcard.2020.12.076] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/22/2020] [Accepted: 12/31/2020] [Indexed: 01/14/2023]
Abstract
There is a scarcity of data comparing long-term clinical outcomes between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with three-vessel coronary artery disease (3VD) in the new-generation drug-eluting stents era. CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients who had undergone first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013. We identified 2525 patients with 3VD (PCI: n = 1747 [69%], and CABG: n = 778 [31%]). The primary outcome measure was all-cause death. Median follow-up duration was 5.7 (interquartile range: 4.4 to 6.6) years. The cumulative 5-year incidence of all-cause death was significantly higher in the PCI group than in the CABG group (19.8% vs 13.2%, log-rank p = 0.001). After adjusting confounders, the excess risk of PCI relative to CABG for all-cause death remained significant (HR, 1.45; 95% CI, 1.14 to 1.86; p = 0.003), which was mainly driven by the excess risk for non-cardiovascular death (HR, 1.88; 95% CI, 1.30 to 2.79; p = 0.001), while there was no excess risk for cardiovascular death between PCI and CABG (HR, 1.19; 95% CI, 0.87 to 1.64; p = 0.29). There was significant excess risk of PCI relative to CABG for myocardial infarction (HR, 1.77; 95% CI, 1.19 to 2.69; p = 0.006), whereas there was no excess risk of PCI relative to CABG for stroke (HR, 1.24; 95% CI, 0.83 to 1.88; p = 0.30). In conclusion, in the present study population reflecting real-world clinical practice in Japan, PCI compared with CABG was associated with significantly higher risk for all-cause death, while there was no excess risk for cardiovascular death between PCI and CABG.
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Affiliation(s)
- Yukiko Matsumura-Nakano
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kyohei Yamaji
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Natsuhiko Ehara
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hiroki Sakamoto
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Yasuaki Takeji
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ko Yamamoto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazuaki Imada
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Takeshi Tada
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Ryoji Taniguchi
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Ryusuke Nishikawa
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Takashi Uegaito
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Tatsuya Ogawa
- Department of Cardiovascular Surgery, Kishiwada City Hospital, Kishiwada, Japan
| | - Miho Yamada
- Department of Cardiology, Hamamatsu Rosai Hospital; Hamamatsu, Japan
| | - Teruki Takeda
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | - Hiroshi Eizawa
- Department of Cardiology, Kobe City Nishi-Kobe Medical Center, Kobe, Japan
| | - Nobushige Tamura
- Department of Cardiovascular Surgery, Kindai University Nara Hospital, Ikoma, Japan
| | - Keiichi Tambara
- Department of Cardiovascular Surgery, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Manabu Shirotani
- Department of Cardiology, Kindai University Nara Hospital, Ikoma, Japan
| | | | - Moriaki Inoko
- Department of Cardiology, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Junichiro Nishizawa
- Department of Cardiovascular Surgery, Hamamatsu Rosai Hospital; Hamamatsu, Japan
| | | | - Hiroshi Sakai
- Department of Cardiology, Shiga University of Medical Science Hospital, Otsu, Japan
| | - Takashi Yamamoto
- Department of Cardiology, Shiga University of Medical Science Hospital, Otsu, Japan
| | - Naoki Kanemitsu
- Department of Cardiovascular Surgery, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Nobuhisa Ohno
- Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Katsuhisa Ishii
- Department of Cardiology, Kansai Denryoku Hospital, Osaka, Japan
| | - Akira Marui
- Department of Cardiovascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Hiroshi Tsuneyoshi
- Department of Cardiovascular Surgery, Shizuoka General Hospital, Shizuoka, Japan
| | - Yasuhiko Terai
- Department of Cardiovascular Surgery, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Shogo Nakayama
- Department of Cardiovascular Surgery, Osaka Red Cross Hospital, Osaka, Japan
| | - Kazuhiro Yamazaki
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Takashi Tamura
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Jiro Esaki
- Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Shinji Miki
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Tomoya Onodera
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Masaru Tanaka
- Department of Cardiology, Osaka Red Cross Hospital, Osaka, Japan
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yoshiharu Soga
- Department of Cardiovascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Michiya Hanyu
- Department of Cardiovascular Surgery, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiology, Shiga University of Medical Science Hospital, Otsu, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Butala NM, Faridi KF, Secemsky EA, Song Y, Curtis J, Gibson CM, Kazi D, Shen C, Yeh RW. Prognosis of Claims- Versus Trial-Based Ischemic and Bleeding Events Beyond 1 Year After Coronary Stenting. J Am Heart Assoc 2021; 10:e018744. [PMID: 33682431 PMCID: PMC8174225 DOI: 10.1161/jaha.120.018744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/11/2021] [Indexed: 12/15/2022]
Abstract
Background It is unknown whether clinical events identified with administrative claims have similar prognosis compared with trial-adjudicated events in cardiovascular clinical trials. We compared the prognostic significance of claims-based end points in context of trial-adjudicated end points in the DAPT (Dual Antiplatelet Therapy) study. Methods and Results We matched 1336 patients aged ≥65 years who received percutaneous coronary intervention in the DAPT study with the CathPCI registry linked to Medicare claims. We compared death at 21 months post-randomization using Cox proportional hazards models among patients with ischemic events (myocardial infarction or stroke) and bleeding events identified by: (1) both trial adjudication and claims; (2) trial adjudication only; and (3) claims only. A total of 47 patients (3.5%) had ischemic events identified by both trial adjudication and claims, 24 (1.8%) in trial adjudication only, 15 (1.1%) in claims only, and 1250 (93.6%) had no ischemic events, with annualized unadjusted mortality rates of 12.8, 5.5, 14.9, and 1.26 per 100 person-years, respectively. A total of 44 patients (3.3%) had bleeding events identified with both trial adjudication and claims, 13 (1.0%) in trial adjudication only, 65 (4.9%) in claims only, and 1214 (90.9%) had no bleeding events, with annualized unadjusted mortality rates of 11.0, 16.8, 10.7, and 0.95 per 100 person-years, respectively. Among patients with no trial-adjudicated events, patients with events in claims only had a high subsequent adjusted mortality risk (hazard ratio (HR) ischemic events: 31.5; 95% CI, 8.9‒111.9; HR bleeding events 23.9; 95% CI, 10.7‒53.2). Conclusions In addition to trial-adjudicated events, claims identified additional clinically meaningful ischemic and bleeding events that were prognostically significant for death.
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Affiliation(s)
- Neel M. Butala
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyDivision of Cardiovascular MedicineBeth Israel Deaconess Medical CenterBostonMA
- Cardiology DivisionDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Kamil F. Faridi
- Section of Cardiovascular MedicineDepartment of MedicineYale School of MedicineNew HavenCT
| | - Eric A. Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyDivision of Cardiovascular MedicineBeth Israel Deaconess Medical CenterBostonMA
| | - Yang Song
- Baim Institute for Clinical ResearchBostonMA
| | - Jeptha Curtis
- Section of Cardiovascular MedicineDepartment of MedicineYale School of MedicineNew HavenCT
| | | | - Dhruv Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyDivision of Cardiovascular MedicineBeth Israel Deaconess Medical CenterBostonMA
| | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyDivision of Cardiovascular MedicineBeth Israel Deaconess Medical CenterBostonMA
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyDivision of Cardiovascular MedicineBeth Israel Deaconess Medical CenterBostonMA
- Baim Institute for Clinical ResearchBostonMA
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11
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Biscaglia S, Guiducci V, Santarelli A, Amat Santos I, Fernandez-Aviles F, Lanzilotti V, Varbella F, Fileti L, Moreno R, Giannini F, Colaiori I, Menozzi M, Redondo A, Ruozzi M, Gutiérrez Ibañes E, Díez Gil JL, Maietti E, Biondi Zoccai G, Escaned J, Tebaldi M, Barbato E, Dudek D, Colombo A, Campo G. Physiology-guided revascularization versus optimal medical therapy of nonculprit lesions in elderly patients with myocardial infarction: Rationale and design of the FIRE trial. Am Heart J 2020; 229:100-109. [PMID: 32822656 PMCID: PMC7434365 DOI: 10.1016/j.ahj.2020.08.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 08/11/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Myocardial infarction (MI) in elderly patients is associated with unfavorable prognosis, and it is becoming an increasingly prevalent condition. The prognosis of elderly patients is equally impaired in ST-segment elevation (STE) or non-STE (NSTE), and it is markedly worsened by the common presence of multivessel disease (MVD). Given the limited evidence available for elderly patients, it has not yet been established whether, as for younger patients, a complete revascularization strategy in MI patients with MVD should be advocated. We present the design of a dedicated study that will address this research gap. METHODS AND DESIGN The FIRE trial is a prospective, randomized, international, multicenter, open-label study with blinded adjudicated evaluation of outcomes. Patients aged 75 years and older, with MI (either STE or NSTE), MVD at coronary artery angiography, and a clear culprit lesion will be randomized to culprit-only treatment or to physiology-guided complete revascularization. The primary end point will be the patient-oriented composite end point of all-cause death, any MI, any stroke, and any revascularization at 1 year. The key secondary end point will be the composite of cardiovascular death and MI. Quality of life and physical performance will be evaluated as well. All components of the primary and key secondary outcome will be tested also at 3 and 5 years. The sample size for the study is 1,400 patients. IMPLICATIONS The FIRE trial will provide evidence on whether a specific revascularization strategy should be applied to elderly patients presenting MI and MVD to improve their clinical outcomes.
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12
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Nakamura M, Kadota K, Takahashi A, Kanda J, Anzai H, Ishii Y, Shibata Y, Yasaka Y, Takamisawa I, Yamaguchi J, Takeda Y, Harada A, Motohashi T, Iijima R, Uemura S, Murakami Y. Relationship Between Platelet Reactivity and Ischemic and Bleeding Events After Percutaneous Coronary Intervention in East Asian Patients: 1-Year Results of the PENDULUM Registry. J Am Heart Assoc 2020; 9:e015439. [PMID: 32394794 PMCID: PMC7660889 DOI: 10.1161/jaha.119.015439] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The balance between ischemic and bleeding events and their association with platelet reactivity in patients receiving antiplatelet therapy after percutaneous coronary intervention (PCI), which differs among regions, is not fully evaluated for East Asians. We examined ischemic/bleeding events and platelet reactivity in Japanese patients undergoing PCI and determined associations between high/low platelet reactivity and clinical outcomes. Methods and Results PENDULUM (Platelet Reactivity in Patients with Drug Eluting Stent and Balancing Risk of Bleeding and Ischemic Event) is a prospective, multicenter registry of Japanese patients with PCI. Primary end points were incidence of first major adverse cardiac and cerebrovascular events (MACCE) and first major bleeding events at 12 months post-PCI. Platelet reactivity (P2Y12 reaction unit [PRU] value) was measured at 12 to 48 hours post-PCI; patients were grouped as having high PRU (>208), optimal PRU (>85 to ≤208), and low PRU (≤85). MACCE and major bleeding occurred in 4.4% and 2.8% of 6267 patients, respectively. The mean±SD PRU value was 182.1±77.1. MACCE was significantly higher in the high PRU (5.7%; n=2227) versus the optimal PRU group (3.6%; n=3002). The hazard ratio (HR) for high PRU versus optimal PRU level was significantly higher for MACCE (adjusted HR, 1.53; 95% CI, 1.14-2.06 [P=0.004]); stent thrombosis followed the same trend. Incidence of major bleeding did not differ significantly between groups. A high PRU level was significantly associated with MACCE in both patients with and patients without acute coronary syndrome. Conclusions These real-world data suggest an association between high platelet reactivity and cardiovascular events in Japanese patients undergoing PCI. The trend was the same in both patients with and patients without acute coronary syndrome. REGISTRATION URL: https://www.umin.ac.jp/ctr. Unique identifier: UMIN 000020332.
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Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine Toho University Ohashi Medical Center Tokyo Japan
| | - Kazushige Kadota
- Department of Cardiology Kurashiki Central Hospital Kurashiki Japan
| | | | - Junji Kanda
- Department of Cardiology Asahi General Hospital Asahi Japan
| | - Hitoshi Anzai
- Department of Cardiology Ota Memorial Hospital Ota Japan
| | - Yasuhiro Ishii
- Department of Cardiology Cardiovascular Center Ogikubo Hospital Tokyo Japan
| | - Yoshisato Shibata
- Department of Cardiology Miyazaki Medical Association Hospital Miyazaki Japan
| | - Yoshinori Yasaka
- Department of Cardiology Himeji Cardiovascular Center Himeji Japan
| | | | - Junichi Yamaguchi
- Department of Cardiology Tokyo Women's Medical University Tokyo Japan
| | - Yoshihiro Takeda
- Department of Cardiology Rinku General Medical Center Izumisano Japan
| | - Atsushi Harada
- Medical Science Department Daiichi Sankyo Co., Ltd. Tokyo Japan
| | - Tomoko Motohashi
- Medical Affairs Planning Department Daiichi Sankyo Co., Ltd. Tokyo Japan
| | - Raisuke Iijima
- Division of Cardiovascular Medicine Toho University Ohashi Medical Center Tokyo Japan
| | - Shiro Uemura
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Yoshitaka Murakami
- Department of Medical Statistics School of Medicine Toho University Tokyo Japan
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13
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Roopmani P, Satheesh S, Raj DC, Krishnan UM. Development of Dual Drug Eluting Cardiovascular Stent with Ultrathin Flexible Poly(l-lactide- co-caprolactone) Coating. ACS Biomater Sci Eng 2019; 5:2899-2915. [PMID: 33405593 DOI: 10.1021/acsbiomaterials.9b00303] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The pleiotropic effects of the atorvastatin-fenofibrate combination can be effectively harnessed for site-specific therapy to minimize stent-related complications. The present study aims to utilize the pleiotropic effects of these two drugs entrapped in a uniform and defect-free coating of poly(l-lactide-co-caprolactone) (PLCL) on a stainless steel stent to overcome stent-associated limitations. The stent coating parameters were optimized using ultrasonic spray coating technique to achieve a thin, smooth, and defect-free dual drug-loaded polymer coating on the stent. The dual drug-loaded polymer coated stent was characterized for surface morphology, thickness and coating integrity. In vitro drug release kinetics of the fabricated stent reveals a sustained release of both drugs for more than 60 days. Significant reduction of thrombus formation and adhesion of lipopolysaccharide-stimulated macrophages on the dual drug containing polymer-coated stent indicates that the drug combination possesses antithrombotic and anti-inflammatory effects. The combination did not adversely influence endothelialization but significantly retarded smooth muscle cell proliferation indicating its potential to overcome restenosis. No bacterial biofilm formation was observed on the stent due to the antibacterial activity of atorvastatin. A rat subcutaneous model was used to evaluate the biocompatibility of the coated stent and compared with the commercial stent. MicroCT, scanning electron microscopy, and morphometric analyses revealed that the coated stents exhibited excellent histocompatibility with no inflammatory response as evidenced from the cytokine levels measured 28 days postimplantation. Our data demonstrates for the first time that the combination of atorvastatin and fenofibrate can be successfully employed in cardiovascular stents to overcome the current limitations of conventional drug-eluting stents.
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Affiliation(s)
| | - Santhosh Satheesh
- Department of Cardiology, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Pondicherry-605006, India
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14
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Mavrakanas TA, Chatzizisis YS, Gariani K, Kereiakes DJ, Gargiulo G, Helft G, Gilard M, Feres F, Costa RA, Morice MC, Georges JL, Valgimigli M, Bhatt DL, Mauri L, Charytan DM. Duration of Dual Antiplatelet Therapy in Patients with CKD and Drug-Eluting Stents: A Meta-Analysis. Clin J Am Soc Nephrol 2019; 14:810-822. [PMID: 31010936 PMCID: PMC6556713 DOI: 10.2215/cjn.12901018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 03/27/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Whether prolonged dual antiplatelet therapy (DAPT) is more protective in patients with CKD and drug-eluting stents compared with shorter DAPT is uncertain. The purpose of this meta-analysis was to examine whether shorter DAPT in patients with drug-eluting stents and CKD is associated with lower mortality or major adverse cardiovascular event rates compared with longer DAPT. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A Medline literature research was conducted to identify randomized trials in patients with drug-eluting stents comparing different DAPT duration strategies. Inclusion of patients with CKD was also required. The primary outcome was a composite of all-cause mortality, myocardial infarction, stroke, or stent thrombosis (definite or probable). Major bleeding was the secondary outcome. The risk ratio (RR) was estimated using a random-effects model. RESULTS Five randomized trials were included (1902 patients with CKD). Short DAPT (≤6 months) was associated with a similar incidence of the primary outcome, compared with 12-month DAPT among patients with CKD (48 versus 50 events; RR, 0.93; 95% confidence interval [95% CI], 0.64 to 1.36; P=0.72). Twelve-month DAPT was also associated with a similar incidence of the primary outcome compared with extended DAPT (≥30 months) in the CKD subgroup (35 versus 35 events; RR, 1.04; 95% CI, 0.67 to 1.62; P=0.87). Numerically lower major bleeding event rates were detected with shorter versus 12-month DAPT (9 versus 13 events; RR, 0.69; 95% CI, 0.30 to 1.60; P=0.39) and 12-month versus extended DAPT (9 versus 12 events; RR, 0.83; 95% CI, 0.35 to 1.93; P=0.66) in patients with CKD. CONCLUSIONS Short DAPT does not appear to be inferior to longer DAPT in patients with CKD and drug-eluting stents. Because of imprecision in estimates (few events and wide confidence intervals), no definite conclusions can be drawn with respect to stent thrombosis.
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Affiliation(s)
- Thomas A Mavrakanas
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; .,Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | | | - Karim Gariani
- Division of Diabetes and Endocrinology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Dean J Kereiakes
- The Christ Hospital Heart and Vascular Center and The Lindner Center for Research and Education, Cincinnati, Ohio
| | - Giuseppe Gargiulo
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Advanced Biomedical Sciences, University Federico II of Naples, Naples, Italy
| | - Gérard Helft
- Institute of Cardiology, University Hospitals Pitié-Salpêtrière- Charles Foix (Public Assistance- Hospitals of Paris), Sorbonne University, Paris, France
| | - Martine Gilard
- Division of Cardiology, Regional University Hospital La Cavale Blanche, Brest, France
| | - Fausto Feres
- Institute Dante Pazzanese de Cardiologia, Sao Paulo, Sao Paulo, Brazil
| | - Ricardo A Costa
- Institute Dante Pazzanese de Cardiologia, Sao Paulo, Sao Paulo, Brazil
| | | | | | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Laura Mauri
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - David M Charytan
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Baim Institute for Clinical Research, Boston, Massachusetts; and.,Division of Nephrology, New York University Langone Medical Center, New York, New York
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15
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Flannery L, Liu R, Elmariah S. Dual Antiplatelet Therapy: How Long Is Long Enough? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:17. [PMID: 30929096 DOI: 10.1007/s11936-019-0721-8] [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] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW The optimal duration of dual antiplatelet therapy (DAPT) has been a topic of considerable interest in recent years, as the risk of stent thrombosis has decreased with newer generation stents and the impact of significant bleeding events on clinical outcomes is increasingly apparent. The purpose of this review is to highlight the landmark studies examining short-duration (6 months or less) and extended-duration (greater than 12 months) DAPT as well as provide information about prediction tools to help guide individualized patient treatment decisions. RECENT FINDINGS Short-duration DAPT is acceptably safe when clinically necessary, though recent trials demonstrate non-significant trends towards increased risk of ischemic events with shorter durations. Extended-duration DAPT clearly confers a reduced risk of subsequent ischemic events but at an increased risk of bleeding. Understanding the perceived ischemic and bleeding risks for each individual patient is paramount in deciding targeted DAPT duration. For patients at a higher bleeding risk with a low ischemic risk, short-duration DAPT (6 months) is acceptable. For patients with continued ischemic risk factors and a low bleeding risk, extended-duration DAPT (up to 30 months) is recommended. The PRECISE DAPT and DAPT prediction tools are helpful in making this determination.
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Affiliation(s)
- Laura Flannery
- Cardiology Division, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St GRB 800, Boston, MA, 02114, USA
| | - Ran Liu
- Cardiology Division, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St GRB 800, Boston, MA, 02114, USA
| | - Sammy Elmariah
- Cardiology Division, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St GRB 800, Boston, MA, 02114, USA.
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16
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Vidula MK, McCarthy CP, Butala NM, Kennedy KF, Wasfy JH, Yeh RW, Secemsky EA. Causes and predictors of early readmission after percutaneous coronary intervention among patients discharged on oral anticoagulant therapy. PLoS One 2018; 13:e0205457. [PMID: 30379868 PMCID: PMC6209191 DOI: 10.1371/journal.pone.0205457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 09/25/2018] [Indexed: 11/19/2022] Open
Abstract
Patients discharged on oral anticoagulant (OAC) therapy after percutaneous coronary intervention (PCI) represent a complex population and are at higher risk of early readmission. The reasons and predictors of early readmission in this group have not been well characterized. We identified patients in an integrated health care system who underwent PCI between 2009 and 2014 and were readmitted within 30 days within this health care system. Of the 9,357 patients surviving to discharge after the index PCI, 692 were readmitted within 30 days (7.4%). At the time of readmission, 143 had been discharged from the index PCI hospitalization on OACs (96.5% on warfarin) and 549 had not been discharged on OACs, with readmission rates of 12.9% and 6.7%, respectively (p<0.01). The most common reason for readmission among all patients was chest pain syndromes (21.7% on OACs, 34.4% not on OACs). However, bleeding represented the next most frequent cause of readmission among patients on OACs (14.0% on OACs vs 6.0% not on OACs, p<0.01). Among patients on OAC therapy, peripheral arterial disease (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.07-2.57, p = 0.02) and nonelective PCI (OR 1.91, 95% CI 1.17-3.12, p<0.01) were found to be independent predictors of 30-day readmission. During rehospitalization, compared to patients not on OACs, patients on OACs suffered a higher unadjusted rate of mortality (6.3% vs 1.8%, p<0.01) and a longer length of stay (6.4 ± 7.1 days vs 4.9 ± 6.8 days, p = 0.02). In conclusion, patients discharged on OAC therapy after PCI are commonly readmitted, with bleeding representing a major reason. These readmissions are associated with high mortality and longer lengths of stay. Interventions targeted towards optimizing discharge planning for these complex patients are needed to potentially reduce readmissions.
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Affiliation(s)
- Mahesh K. Vidula
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Cian P. McCarthy
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Neel M. Butala
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Kevin F. Kennedy
- Saint Luke's Mid America Heart Institute/University of Missouri–Kansas City, Kansas City, Missouri, United States of America
| | - Jason H. Wasfy
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Robert W. Yeh
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Eric A. Secemsky
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- * E-mail:
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17
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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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18
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Lugo LM, Ferreiro JL. Dual antiplatelet therapy after coronary stent implantation: Individualizing the optimal duration. J Cardiol 2018; 72:94-104. [DOI: 10.1016/j.jjcc.2018.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 02/27/2018] [Indexed: 01/06/2023]
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19
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Gargiulo G, Valgimigli M, Capodanno D, Bittl JA. State of the art: duration of dual antiplatelet therapy after percutaneous coronary intervention and coronary stent implantation - past, present and future perspectives. EUROINTERVENTION 2018; 13:717-733. [PMID: 28844033 DOI: 10.4244/eij-d-17-00468] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Evidence from studies published more than 10 years ago suggested that patients receiving first-generation drug-eluting stents (DES) needed dual antiplatelet therapy (DAPT) for at least 12 months. Current evidence from randomised controlled trials (RCT) reported within the past five years suggests that patients with stable ischaemic heart disease who receive newer-generation DES need DAPT for a minimum of three to six months. Patients who undergo stenting for an acute coronary syndrome benefit from DAPT for at least 12 months, but a Bayesian network meta-analysis confirms that extending DAPT beyond 12 months confers a trade-off between reduced ischaemic events and increased bleeding. However, the network meta-analysis finds no credible increase in all-cause mortality if DAPT is lengthened from three to six months to 12 months (posterior median odds ratio [OR] 0.98; 95% Bayesian credible interval [BCI]: 0.73-1.43), from 12 months to 18-48 months (OR 0.87; 95% BCI: 0.64-1.17), or from three to six months to 18-48 months (OR 0.86; 95% BCI: 0.63-1.21). Future investigation should focus on identifying scoring systems that have excellent discrimination and calibration. Although predictive models should be incorporated into systems of care, most decisions about DAPT duration will be based on clinical judgement and patient preference.
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Affiliation(s)
- Giuseppe Gargiulo
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
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20
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Tahir UA, Yeh RW. Individualizing dual antiplatelet therapy duration after percutaneous coronary intervention: from randomized control trials to personalized medicine. Expert Rev Cardiovasc Ther 2017; 15:681-693. [PMID: 28764572 DOI: 10.1080/14779072.2017.1362980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Improved stent technologies have lead to reduced minimum durations of dual antiplatelet therapy (DAPT) to prevent stent thrombosis. However, the anti-ischemic benefits seen in extended DAPT in both stent and non-stent related lesions have called into question the optimum duration of DAPT after stent placement. Areas covered: We review the evidence for varying durations of DAPT after drug eluting stent placement including for patients on oral anticoagulation; decision tools available for clinicians to optimize patient selection for extended therapy and insight into application of these risk assessment tools in clinical practice. Expert commentary: The use of risk assessment tools in optimizing DAPT duration after stent placement provides an opportunity for improved outcomes by means of a personalized approach to care while allowing clinicians to engage with patients in shared-decision making.
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Affiliation(s)
- Usman A Tahir
- a Smith Center for Outcomes Research in Cardiology , Beth Israel Deaconess Medical Center , Boston , MA , USA
| | - Robert W Yeh
- a Smith Center for Outcomes Research in Cardiology , Beth Israel Deaconess Medical Center , Boston , MA , USA
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