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Cohen M, Jones C. Patient and Physician Perspectives on the Benefits and Risks of Antiplatelet Therapy for Acute Coronary Syndrome. Cardiol Ther 2024:10.1007/s40119-024-00372-7. [PMID: 38907182 DOI: 10.1007/s40119-024-00372-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 05/30/2024] [Indexed: 06/23/2024] Open
Abstract
This article is co-authored by a patient with acute coronary syndrome (ACS) who is receiving long-term antiplatelet therapy in the USA and a cardiologist who routinely treats patients with ACS. The patient describes his experience from diagnosis to the present day and discusses his concerns regarding treatment and management of the condition, including the balance between the benefits and risks of antiplatelet therapy. The patient also describes his work as an advocate for cardiac health. The physician perspective on treating and managing patients with ACS is provided by a cardiologist based in the USA who is and was not involved in this patient's care. The physician reviews the benefits and risks of antiplatelet therapies for the treatment of patients with ACS and discusses his own clinical experience of managing these patients, including how issues such as treatment adherence, as well as the potential inertia to prescribing certain medications that may be seen among physicians, could be overcome.
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Affiliation(s)
- Marc Cohen
- Newark Beth Israel Medical Center, 201 Lyons Avenue at Osborne Terrace, Newark, NJ, USA.
- Rutgers New Jersey Medical School, Medical Science Building, 185 South Orange Avenue, Newark, NJ, USA.
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Moon J, Ozaki AF, Chong A, Sud M, Fang J, Austin PC, Ko DT, Jackevicius CA. Comparing Measures of Adherence and Persistence to P2Y12 Inhibitors in Acute Coronary Syndromes. Am J Cardiol 2024:S0002-9149(24)00329-1. [PMID: 38697453 DOI: 10.1016/j.amjcard.2024.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/12/2024] [Accepted: 04/26/2024] [Indexed: 05/05/2024]
Affiliation(s)
- Jungyeon Moon
- College of Pharmacy, Western University of Health Sciences, Pomona, California
| | - Aya F Ozaki
- School of Pharmacy & Pharmaceutical Sciences, University of California Irvine, Irvine, California
| | | | - Maneesh Sud
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Peter C Austin
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Dennis T Ko
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Cynthia A Jackevicius
- College of Pharmacy, Western University of Health Sciences, Pomona, California; ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.
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Yang Y, Yin X, Zhang Y, Ren L. Construction and validation of a predictive model for major adverse cardiovascular events in the long term after percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction. Coron Artery Dis 2024:00019501-990000000-00218. [PMID: 38656258 DOI: 10.1097/mca.0000000000001370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE Construction of a prediction model to predict the risk of major adverse cardiovascular events (MACE) in the long term after percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI). METHOD Retrospective analysis of STEMI patients treated with PCI from April 2018 to April 2021 in Fuyang People's Hospital. Lasso regression was used to screen the risk factors for the first occurrence of MACE in patients, and multifactorial logistic regression analysis was used to construct a prediction model. The efficacy was evaluated by area under the ROC curve (AUC), Hosmer-Lemeshow deviance test, calibration curve, clinical decision curve (DCA) and clinical impact curve (CIC). RESULTS Logistic regression results showed that hypertension, diabetes mellitus, left main plus three branches lesion, estimated glomerular filtration rate and medication adherence were influential factors in the occurrence of distant MACE after PCI in STEMI patients (P < 0.05). The AUC was 0.849 in the modeling group and 0.724 in the validation group; the calibration curve had a good fit to the standard curve, and the result of the Hosmer-Lemeshow test of deviance was x2 = 7.742 (P = 0. 459); the DCA and the CIC indicated that the predictive model could provide a better net clinical benefit for STEMI patients. CONCLUSION A prediction model constructed from a total of five predictor variables, namely hypertension, diabetes, left main + three branches lesions, eGFR and medication adherence, can be used to assess the long-term prognosis after PCI in STEMI patients and help in early risk stratification of patients.
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Affiliation(s)
- Yangyang Yang
- Department of Cardiovascular Medicine, Fuyang People's Hospital Affiliated to Bengbu Medical College, Fuyang, China
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Akamine A, Nagasaki Y, Tomizawa A, Otori K. Risk Factors for Non-Adherence to Pharmacist or Non-Pharmacist Explanations on Preoperative Medication Discontinuation: A Retrospective Japanese Study. Patient Prefer Adherence 2024; 18:255-266. [PMID: 38313826 PMCID: PMC10838503 DOI: 10.2147/ppa.s445474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/20/2024] [Indexed: 02/06/2024] Open
Abstract
Purpose The risk factors for non-adherence to pharmacist or non-pharmacist explanations of preoperative medication discontinuation are unknown. The primary outcome of this study was to determine whether the final explainer's occupation was a risk factor for non-adherence. The secondary outcomes were to determine the risk factors for non-adherence after limiting the departments or adjusting for age. Patients and Methods We retrospectively examined the data (including patient age, sex, prescription medications, comorbidities, presence of roommate, and number of days between receiving explanation and surgery) of 1132 patients on medications that could affect surgery at a Japanese university hospital between April 1, 2017, and March 31, 2020. The primary endpoint was whether the occupation of the last person explaining medication discontinuation to the patient was an independent risk factor for non-adherence (age ≥65 years vs <65 years). Secondary endpoints included subgroup analyses in urological, gastrointestinal, and otolaryngological areas, as well as a sensitivity analysis (age as a continuous variable) to confirm the validity of the primary endpoint results. A multivariate binary logistic regression identified independent non-adherence risk factors. Results The main analysis showed that discontinuing two or more medications was a risk factor for non-adherence (adjusted odds ratio (AOR): 1.67; 95% confidence interval (CI): 1.13-2.47; p = 0.01). However, in analyses coordinated by department (urological, gastrointestinal, and otolaryngological), ≥65 (versus <65) years of age was determined as a risk factor for increased nonadherence (AOR: 2.27, 95% CI: 1.11-4.63; p=0.024). Age-adjusted analysis (continuous variables) showed similar results to the primary endpoint (AOR: 1.68, 95% CI: 1.14-2.49, p = 0.009). Conclusion Two or more medications, and not the final explainer's occupation, were associated with pre-surgery medication non-adherence. To prevent non-adherence, pharmacists and non-pharmacists should educate patients about preoperative medication discontinuation. These findings could help identify high-risk non-adherence patients.
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Affiliation(s)
| | - Yuya Nagasaki
- Department of Pharmacy, Kitasato University Hospital, Kanagawa, Japan
| | - Atsushi Tomizawa
- Department of Pharmacy, Kitasato University Hospital, Kanagawa, Japan
| | - Katsuya Otori
- Department of Pharmacy, Kitasato University Hospital, Kanagawa, Japan
- Research and Education Center for Clinical Pharmacy, Division of Clinical Pharmacy, Laboratory of Pharmacy Practice and Science 1, Kitasato University School of Pharmacy, Tokyo, Japan
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Lin CF, Tsai CL, Chang YH, Lin DY, Chien LN. Sex-based differences in ischemic cardiovascular and bleeding outcomes following implantation of drug-eluting stent in patients at high bleeding risk. Hellenic J Cardiol 2024:S1109-9666(24)00001-0. [PMID: 38218375 DOI: 10.1016/j.hjc.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/28/2023] [Accepted: 01/08/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Patients with high bleeding risk (HBR) may exhibit uncertain adherence to dual antiplatelet therapy (DAPT) following drug-eluting stent (DES) implantation. The current population-based cohort study aimed to investigate the sex-based differences in adverse outcomes among the HBR population by analyzing the National Health Insurance Research Database in Taiwan. METHODS Patients who had HBR features defined by the Academic Research Consortium (ARC) and received DES implantation between January 1, 2007, and December 31, 2017, were enrolled. Propensity score matching was adopted to select 3,981 pairs with similar clinical cardiovascular risks but different sexes. A competing risk model was performed to evaluate the risk of adverse ischemic events (cardiac death, nonfatal myocardial infarction, and ischemic stroke) and any bleeding events in both sexes. Noncardiac death was considered a competing risk. RESULTS Within a 5-year follow-up, the incidence rates (per 1,000 person-year (95% confidence interval (CI)) of composite ischemic events and any bleeding events in males were respectively 44.09 (40.25-48.30) and 42.55 (38.79-46.68), while those in females were respectively 40.18 (36.51-44.23) and 42.35 (38.57-46.51). After adjustment for clinical variables, male patients had a marginally increased risk in the composite ischemic events (adjusted subdistribution hazard ratio (SHR) = 1.15 (1.00-1.31), p = 0.045) and a similar risk of any bleeding events (adjusted SHR = 1.00 (0.88-1.15), p = 0.946) compared with female patients. CONCLUSIONS Of the HBR population, males had an increased risk of ischemic outcomes but a similar risk of bleeding compared with females following DES implantation.
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Affiliation(s)
- Chao-Feng Lin
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan; Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chia-Ling Tsai
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Ya-Hui Chang
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan; Department of Pharmacy, MacKay Memorial Hospital, Taipei, Taiwan
| | - Dai-Yi Lin
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Li-Nien Chien
- Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Moon J, Ozaki AF, Chong A, Sud M, Fang J, Austin PC, Ko DT, Jackevicius CA. Trajectories of P2Y12 inhibitor adherence in patients with acute coronary syndromes. Pharmacoepidemiol Drug Saf 2024; 33:e5704. [PMID: 37771242 DOI: 10.1002/pds.5704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 09/09/2023] [Accepted: 09/14/2023] [Indexed: 09/30/2023]
Abstract
PURPOSE P2Y12 inhibitors (P2Y12i) reduce cardiac events after acute coronary syndromes (ACS). However, suboptimal P2Y12i adherence persists. We aimed to examine P2Y12i non-adherence using group-based trajectory methods and to identify adherence predictors. METHODS We conducted a population-based, retrospective cohort study using administrative data in Ontario, Canada of patients ≥65 years admitted for ACS between April 2014 and March 2018 with a P2Y12i dispensed within 7 days of discharge. We used group-based trajectory models to characterize longitudinal 1-year adherence patterns. Predictors associated with each adherence trajectory were identified by multinomial logistic regression. RESULTS We included 11 917 patients using clopidogrel and 9763 using ticagrelor, aged [mean ± SD]: 77.33 ± 8.31/73.59 ± 6.79 years; men: 56.2%/65.4%, respectively. We identified 3 longitudinal adherence trajectories, that differed by agent: 75% of clopidogrel and 68% of ticagrelor patients showed a consistently adherent trajectory, while 13%/17% were gradually, and 12%/15% were rapidly non-adherent, respectively (p < 0.001). Differing baseline characteristics in each cohort were associated with observed adherence trajectories. Concomitant atrial fibrillation and prior bleeding history were associated with non-adherence among clopidogrel users. Among ticagrelor users, women and older persons were more likely to be rapidly non-adherent, adherence declining steeply starting 1 month post-ACS. CONCLUSIONS We identified distinct adherence trajectories for clopidogrel and ticagrelor post-ACS, with 3 out of 4 clopidogrel patients but only 2 out of 3 ticagrelor patients in the consistently adherent trajectory. Intensive interventions targeted to the period of steep adherence decline post-ACS, particularly for women and older persons initiating ticagrelor, and patients with atrial fibrillation on clopidogrel should be considered and investigated further.
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Affiliation(s)
- Jungyeon Moon
- College of Pharmacy, Western University of Health Sciences, Pomona, California, USA
| | - Aya F Ozaki
- School of Pharmacy & Pharmaceutical Sciences, University of California Irvine, Irvine, California, USA
| | | | - Maneesh Sud
- University of Toronto, Toronto, Ontario, Canada
- Schulich Heart Centre Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Peter C Austin
- ICES, Toronto, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Dennis T Ko
- ICES, Toronto, Canada
- University of Toronto, Toronto, Ontario, Canada
- Schulich Heart Centre Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Cynthia A Jackevicius
- College of Pharmacy, Western University of Health Sciences, Pomona, California, USA
- ICES, Toronto, Canada
- University of Toronto, Toronto, Ontario, Canada
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
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Clerici B, Birocchi S, Podda GM. Non-adherence to chronic treatments: A commitment for Internal Medicine specialists. Eur J Intern Med 2024; 119:34-35. [PMID: 38123420 DOI: 10.1016/j.ejim.2023.11.030] [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: 11/27/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Bianca Clerici
- Dipartimento di Scienza della Salute, S.C. Medicina Generale II, Ospedale San Paolo, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Via di Rudinì, 8, Milano 20142, Italy
| | - Simone Birocchi
- Dipartimento di Scienza della Salute, S.C. Medicina Generale II, Ospedale San Paolo, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Via di Rudinì, 8, Milano 20142, Italy
| | - Gian Marco Podda
- Dipartimento di Scienza della Salute, S.C. Medicina Generale II, Ospedale San Paolo, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Via di Rudinì, 8, Milano 20142, Italy.
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Gutierrez JA, Shannon CM, Chapurin N, Schlosser RJ, Soler ZM. Challenges to medication adherence with intranasal corticosteroid irrigations. Int Forum Allergy Rhinol 2024; 14:32-40. [PMID: 37314391 DOI: 10.1002/alr.23210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/03/2023] [Accepted: 06/08/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND The purpose of this study was to investigate real-world adherence to intranasal corticosteroid irrigations using pharmacy data and assess factors associated with low adherence. METHODS Patients undergoing treatment with corticosteroid irrigations for any diagnosis during a 2-year period were prospectively recruited. Subjects completed a one-time set of questionnaires including the Barriers to Care Questionnaire (BCQ), 22-item Sino-Nasal Outcome Test (SNOT-22), and a questionnaire assessing their experience with corticosteroid irrigations. Pharmacy data was used to calculate the medication possession ratio (MPR), a measure of medication adherence graded from 0 to 1. RESULTS Seventy-one patients were enrolled. Patient diagnoses included chronic rhinosinusitis (CRS) without nasal polyps (n = 37), CRS with nasal polyps (n = 24), or a non-CRS diagnosis, most commonly chronic rhinitis (n = 10). The MPR for the overall group was 0.44 ± 0.33. Just 9.9% of patients had a perfect MPR of 1. Despite low MPR, only 19.7% of patients reported problems taking the medication when directly asked. Lower education resulted in lower MPR (unstandardized B = 0.065, p = 0.046). Increasing BCQ score, indicating higher barriers to care, was associated with lower MPR (unstandardized B = -0.010, p = 0.033). The lower the MPR, the worse the patient SNOT-22 scores (unstandardized B = -15.980, p = 0.036). CONCLUSION Adherence to corticosteroid irrigations was low and patients underreported issues with their medication. Education and barriers to care were associated with lower adherence, which, in turn, was associated with worse sinonasal quality of life.
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Affiliation(s)
- Jorge A Gutierrez
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Christian M Shannon
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nikita Chapurin
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rodney J Schlosser
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Zachary M Soler
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Harris J, Pouwels KB, Johnson T, Sterne J, Pithara C, Mahadevan K, Reeves B, Benedetto U, Loke Y, Lasserson D, Doble B, Hopewell-Kelly N, Redwood S, Wordsworth S, Mumford A, Rogers C, Pufulete M. Bleeding risk in patients prescribed dual antiplatelet therapy and triple therapy after coronary interventions: the ADAPTT retrospective population-based cohort studies. Health Technol Assess 2023; 27:1-257. [PMID: 37435838 PMCID: PMC10363958 DOI: 10.3310/mnjy9014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Background Bleeding among populations undergoing percutaneous coronary intervention or coronary artery bypass grafting and among conservatively managed patients with acute coronary syndrome exposed to different dual antiplatelet therapy and triple therapy (i.e. dual antiplatelet therapy plus an anticoagulant) has not been previously quantified. Objectives The objectives were to estimate hazard ratios for bleeding for different antiplatelet and triple therapy regimens, estimate resources and the associated costs of treating bleeding events, and to extend existing economic models of the cost-effectiveness of dual antiplatelet therapy. Design The study was designed as three retrospective population-based cohort studies emulating target randomised controlled trials. Setting The study was set in primary and secondary care in England from 2010 to 2017. Participants Participants were patients aged ≥ 18 years undergoing coronary artery bypass grafting or emergency percutaneous coronary intervention (for acute coronary syndrome), or conservatively managed patients with acute coronary syndrome. Data sources Data were sourced from linked Clinical Practice Research Datalink and Hospital Episode Statistics. Interventions Coronary artery bypass grafting and conservatively managed acute coronary syndrome: aspirin (reference) compared with aspirin and clopidogrel. Percutaneous coronary intervention: aspirin and clopidogrel (reference) compared with aspirin and prasugrel (ST elevation myocardial infarction only) or aspirin and ticagrelor. Main outcome measures Primary outcome: any bleeding events up to 12 months after the index event. Secondary outcomes: major or minor bleeding, all-cause and cardiovascular mortality, mortality from bleeding, myocardial infarction, stroke, additional coronary intervention and major adverse cardiovascular events. Results The incidence of any bleeding was 5% among coronary artery bypass graft patients, 10% among conservatively managed acute coronary syndrome patients and 9% among emergency percutaneous coronary intervention patients, compared with 18% among patients prescribed triple therapy. Among coronary artery bypass grafting and conservatively managed acute coronary syndrome patients, dual antiplatelet therapy, compared with aspirin, increased the hazards of any bleeding (coronary artery bypass grafting: hazard ratio 1.43, 95% confidence interval 1.21 to 1.69; conservatively-managed acute coronary syndrome: hazard ratio 1.72, 95% confidence interval 1.15 to 2.57) and major adverse cardiovascular events (coronary artery bypass grafting: hazard ratio 2.06, 95% confidence interval 1.23 to 3.46; conservatively-managed acute coronary syndrome: hazard ratio 1.57, 95% confidence interval 1.38 to 1.78). Among emergency percutaneous coronary intervention patients, dual antiplatelet therapy with ticagrelor, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.47, 95% confidence interval 1.19 to 1.82), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.06, 95% confidence interval 0.89 to 1.27). Among ST elevation myocardial infarction percutaneous coronary intervention patients, dual antiplatelet therapy with prasugrel, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.48, 95% confidence interval 1.02 to 2.12), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.10, 95% confidence interval 0.80 to 1.51). Health-care costs in the first year did not differ between dual antiplatelet therapy with clopidogrel and aspirin monotherapy among either coronary artery bypass grafting patients (mean difference £94, 95% confidence interval -£155 to £763) or conservatively managed acute coronary syndrome patients (mean difference £610, 95% confidence interval -£626 to £1516), but among emergency percutaneous coronary intervention patients were higher for those receiving dual antiplatelet therapy with ticagrelor than for those receiving dual antiplatelet therapy with clopidogrel, although for only patients on concurrent proton pump inhibitors (mean difference £1145, 95% confidence interval £269 to £2195). Conclusions This study suggests that more potent dual antiplatelet therapy may increase the risk of bleeding without reducing the incidence of major adverse cardiovascular events. These results should be carefully considered by clinicians and decision-makers alongside randomised controlled trial evidence when making recommendations about dual antiplatelet therapy. Limitations The estimates for bleeding and major adverse cardiovascular events may be biased from unmeasured confounding and the exclusion of an eligible subgroup of patients who could not be assigned an intervention. Because of these limitations, a formal cost-effectiveness analysis could not be conducted. Future work Future work should explore the feasibility of using other UK data sets of routinely collected data, less susceptible to bias, to estimate the benefit and harm of antiplatelet interventions. Trial registration This trial is registered as ISRCTN76607611. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jessica Harris
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Thomas Johnson
- Department of Cardiology, Bristol Heart Institute, Bristol, UK
| | - Jonathan Sterne
- National Institute for Health Research Biomedical Research Centre, Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Christalla Pithara
- National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), Bristol, UK
| | | | - Barney Reeves
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | | | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Daniel Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Brett Doble
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Sabi Redwood
- National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Mumford
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Rogers
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Maria Pufulete
- Bristol Trials Centre, University of Bristol, Bristol, UK
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Case BC, Torguson R, Abramowitz J, Shea C, Zhang C, Sutton JA, Deksissa T, Satler LF, Ben-Dor I, Bernardo NL, Hashim H, Rogers T, Waksman R. Impact of Close Surveillance on Dual-Antiplatelet Therapy Compliance in Myocardial Infarction Patients Post-Percutaneous Coronary Intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 48:7-14. [PMID: 36347732 DOI: 10.1016/j.carrev.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 10/17/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Dual-antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the mainstay regimen for acute coronary syndrome (ACS) patients after percutaneous coronary intervention (PCI). We aimed to investigate DAPT compliance and switching patterns in ACS patients prescribed ticagrelor and aspirin. Secondly, we evaluated the impact of a pilot strategy of close surveillance telephone calls. METHODS The study enrolled 150 consecutive ACS patients who underwent PCI and were prescribed DAPT (aspirin and ticagrelor). This cohort, the "close surveillance arm," then received telephone calls from a healthcare professional to inquire about DAPT for up to one year. These findings, and clinical outcomes, were then compared to a "historical arm" of ACS patients (n = 505) who received PCI and were prescribed DAPT before initiation of the program. Finally, healthcare providers were surveyed about their experience with prescribing DAPT. RESULTS The rate of ticagrelor cessation trended lower in the close surveillance arm (22.00 % versus 31.70 %, p = 0.0783). The most common reasons for ticagrelor cessation were adverse medication reaction (dyspnea), bleeding, and financial burden. Nevertheless, the adverse events were few and similar between the two groups during follow-up. Over 96 % of healthcare providers surveyed stated that they worry about their patients' DAPT compliance post-PCI. CONCLUSION Noncompliance and switching medications are still common for patients who undergo PCI for ACS. A close surveillance program identified patients at risk for medication cessation or switching and could potentially mitigate this phenomenon and improve quality of care.
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Affiliation(s)
- Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Rebecca Torguson
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Jonathan Abramowitz
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Corey Shea
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Cheng Zhang
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Joseph A Sutton
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Teshome Deksissa
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Nelson L Bernardo
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Hayder Hashim
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, United States of America
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America.
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Kim Y, Pacor JM, Do A, Brennan J, Fiellin DA, Edelman EJ. Outcomes of Patients with Opioid-Related Diagnoses in Acute Coronary Syndrome: a National Inpatient Sample-Based Analysis. J Gen Intern Med 2023; 38:563-570. [PMID: 36376632 PMCID: PMC9971420 DOI: 10.1007/s11606-022-07399-3] [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] [Received: 10/20/2020] [Accepted: 01/05/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute coronary syndrome (ACS) and opioid use are both major causes of morbidity and mortality globally. Although epidemiological studies point to increased risk of ACS in opioid users, in-hospital management and outcomes are unknown for this population when presenting with ACS. We sought to determine whether there are differences for in-hospital outcomes and management of ACS for those with and without opioid-related diagnoses (ORD). METHODS AND RESULTS From the National Inpatient Sample database, we extracted patients hospitalized between 2012 and 2016 for ACS. The primary independent variable was ORD by International Classification of Diseases, 9th and 10th Revision, codes. The primary outcome was in-hospital mortality; secondary outcomes were cardiac arrest, receipt of angiogram, and percutaneous coronary intervention (PCI). Statistical comparisons were performed using χ2 test and Student's t test. Multivariable logistic regression was performed to determine the independent association between ORD and outcomes of interest. Among the estimated 5.8 million admissions for ACS, the proportion of patients with ORD increased over the study period (p for trend < 0.01). Compared to patients without ORD presenting with ACS, patients with ORD were younger with fewer cardiovascular risk factors. Yet, in-hospital mortality was higher in patients with ORD presenting with ACS (AOR 1.36, 95% CI 1.26-1.48). Patients with ORD were more likely to experience in-hospital cardiac arrest (AOR 1.42, 95% CI 1.23-1.63) and less likely to undergo angiogram (AOR 0.42, 95% CI 0.38-0.45) or PCI (AOR 0.30, 95% CI 0.28-0.32). CONCLUSION Despite evidence of increased risk of mortality and cardiac arrest, patients with ORD admitted for ACS are less likely to receive ACS management.
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Affiliation(s)
- Yeunjung Kim
- Division of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT USA
| | - Justin M. Pacor
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT USA
| | - Albert Do
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT USA
| | - Joseph Brennan
- Division of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT USA
| | - David A. Fiellin
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT USA
| | - E. Jennifer Edelman
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT USA
- Department of Social and Behavioral Medicine, Yale School of Public Health, New Haven, CT USA
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12
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Shin ES, Jun EJ, Han JK, Kong MG, Kang J, Zheng C, Garg S, Choi YJ, Bae JW, Chun KJ, Kim DI, Rha SW, Lee SY, Rhew JY, Woo SI, Lee HC, Jeong JO, Yang HM, Park KW, Kang HJ, Koo BK, Chae IH, Kim HS. Sex-related impact on clinical outcomes of patients treated with drug-eluting stents according to clinical presentation: Patient-level pooled analysis from the GRAND-DES registry. Cardiol J 2023; 30:105-116. [PMID: 33634845 PMCID: PMC9987552 DOI: 10.5603/cj.a2021.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 10/22/2020] [Accepted: 11/08/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The contribution of sex and initial clinical presentation to the long-term outcomes in patients undergoing percutaneous coronary intervention (PCI) is still debated. METHODS Individual patient data from 5 Korean-multicenter drug-eluting stent (DES) registries (The GRAND-DES) were pooled. A total of 17,286 patients completed 3-year follow-up (5216 women and 12,070 men). The median follow-up duration was 1125 days (interquartile range 1097-1140 days), and the primary endpoint was cardiac death at 3 years. RESULTS The clinical indication for PCI was stable angina pectoris (SAP) in 36.8%, unstable angina pectoris (UAP) or non-ST-segment elevation myocardial infarction (NSTEMI) in 47.4%, and ST-segment elevation myocardial (STEMI) in 15.8%. In all groups, women were older and had a higher proportion of hypertension and diabetes mellitus compared with men. Women presenting with STEMI were older than women with SAP, with the opposite seen in men. There was no sex difference in cardiac death for SAP or UAP/NSTEMI. In STEMI patients, the incidence of cardiac death (7.9% vs. 4.4%, p = 0.001), all-cause mortality (11.1% vs. 6.9%, p = 0.001), and minor bleeding (2.2% vs. 1.2%, p = 0.043) was significantly higher in women. After multivariable adjustment, cardiac death was lower in women for UAP/NSTEMI (HR 0.69, 95% CI 0.53-0.89, p = 0.005), while it was similar for STEMI (HR 0.97, 95% CI 0.65-1.44, p = 0.884). CONCLUSIONS There was no sex difference in cardiac death after PCI with DES for SAP and UAP/NSTEMI patients. In STEMI patients, women had worse outcomes compared with men; however, after the adjustment of confounders, female sex was not an independent predictor of mortality.
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Affiliation(s)
- Eun-Seok Shin
- Department of Cardiology, Ulsan Hospital, Ulsan, Korea; Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Eun Jung Jun
- Department of Cardiology, Ulsan Hospital, Ulsan, Korea; Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jung-Kyu Han
- Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Min Gyu Kong
- Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeehoon Kang
- Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chengbin Zheng
- Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Scot Garg
- East Lancashire Hospitals NHS Trust, Blackburn, Lancashire, United Kingdom
| | - Young Jin Choi
- Division of Cardiology, Department of Internal Medicine, Sejong General Hospital, Bucheon, Republic of Korea
| | - Jang-Whan Bae
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Kook-Jin Chun
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Doo-Il Kim
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Sung Yun Lee
- Division of Cardiology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Jay Young Rhew
- Department of Internal Medicine and Cardiovascular Center, Presbyterian Medical Center, Jeonju, Republic of Korea
| | - Seong-Ill Woo
- Division of Cardiology, Department of Internal Medicine, Inha University Hospital, Incheon, Republic of Korea
| | - Han Cheol Lee
- Division of Cardiology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Jin-Ok Jeong
- Division of Cardiology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejon, Republic of Korea
| | - Han-Mo Yang
- Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung Woo Park
- Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun-Jae Kang
- Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Bon-Kwon Koo
- Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - In-Ho Chae
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Hyo-Soo Kim
- Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea.
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13
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Ratti G, Monda C, Ratti F, Golino M, Fulgione L, Fulgione C, Mallardo M, Tammaro P. Long-term dual antiplatelet therapy and nuisance bleeding: impact on quality of life. Monaldi Arch Chest Dis 2022; 93. [PMID: 36412132 DOI: 10.4081/monaldi.2022.2437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022] Open
Abstract
Long term dual antiplatelet therapy (LTDAPT), with ticagrelor 60 mg and low-dose aspirin, is indicated after acute coronary syndrome (ACS) for the secondary prevention of atherothrombotic events in high-risk patients with a history of ACS of at least 1 year. LTDAPT had a good tolerability and safety profile, but the risk of TIMI major bleeding was increased. However, even non-significant bleeding may be important because it has an effect on the quality of life and therefore may lead to treatment discontinuation. We, therefore, evaluated patients' experiences with LTDAPT and the impact of nuisance bleeding on quality of life and treatment adherence. We retrospectively reviewed 225 patients in follow-up after ACS with at least one high-risk condition, treated with ticagrelor 60 mg twice daily (after 90 mg twice daily for 12 months). The outpatient follow-up program after hospitalization provides a visit on day 30 after discharge, then after 3 months, continuing with six-monthly checks. We assessed the presence and intensity of bleeding, as well as health-related quality of life (HRQoL), at each visit. The TIMI score was used to determine the severity of the bleeding. Any overt bleeding event that did not meet the major and minor criteria was labeled "minimal" and could be framed as "nuisance bleeding." The HRQoL was assessed by the EuroQol-5 and Dimension (EQ-5D) visual analog scale (VAS) score. Minimal bleedings were present in 49 patients (21%), but only in one case (by decision of the patient) there was a cause for discontinuation of therapy. However, 39 (79%) subjects had asked for opinions on stopping the therapy during the telephone consultation. Factors influencing LTDAPT knowledge included access to medication counselling, engaging with information communicated during medication counselling, and access to timely, relevant and expert information and advice after discharge from the hospital. All adverse events, judged to be "not serious" in trials, may have an effect on the quality of life and therefore may lead to treatment discontinuation. The authors underline the importance of careful outpatient follow-up and ongoing counselling, to check out compliance and possible adverse effect of LTDAPT.
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Affiliation(s)
- Gennaro Ratti
- Cardiology/ICU Department, S. Giovanni Bosco Hospital, Naples.
| | - Cinzia Monda
- Cardiology/ICU Department, S. Giovanni Bosco Hospital, Naples.
| | - Federica Ratti
- Pharmacy Department, "Federico II" University of Naples.
| | - Marco Golino
- Cardiology/ICU Department, S. Giovanni Bosco Hospital, Naples.
| | - Ludovica Fulgione
- Advanced Biomedical Science Department, "Federico II" University of Naples.
| | | | | | - Paolo Tammaro
- Cardiology/ICU Department, S. Giovanni Bosco Hospital, Naples.
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14
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Han Y, Li Y. OUP accepted manuscript. Eur Heart J 2022; 43:2314-2316. [PMID: 35296882 DOI: 10.1093/eurheartj/ehac101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yang Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
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15
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Coons JC, Stevenson JM, Patel A, Smith AJC, Prebehalla L, Empey PE. Antiplatelet Therapy and Bleeding Outcomes With CYP2C19 Genotyping. J Cardiovasc Pharmacol Ther 2022; 27:10742484221143246. [PMID: 36503270 DOI: 10.1177/10742484221143246] [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] [Indexed: 12/14/2022]
Abstract
PURPOSE The impact of antiplatelet therapy with availability of CYP2C19 genotyping on bleeding in a real-world setting has not been extensively studied. METHODS Prospective, single-center, cohort study conducted between December 2015 and October 2019 with 1-year follow-up. Patients underwent percutaneous coronary intervention (PCI), CYP2C19 genotyping, and received P2Y12 inhibitor therapy. The primary outcome was time to first bleed of any severity using Bleeding Academic Research Consortium criteria. Secondary outcomes included time to first major bleed and rates of antiplatelet switching. RESULTS The primary outcome occurred in 697 of 2091 (33%) participants at a median of 15 days. Major bleeding occurred in 176 (8%) of patients. Compared to clopidogrel, treatment with ticagrelor or prasugrel was associated with increased risk of any bleeding (adjusted HR [aHR] 2.04, 95% CI 1.69-2.46). For patients without CYP2C19 no function alleles, treatment with prasugrel or ticagrelor was associated with increased risk of any bleeding (aHR 2.31, 95% CI 1.83-2.90). Similar associations were observed for major bleeding. No difference in ischemic events was observed. Among patients discharged on ticagrelor or prasugrel, 199 (36%) were de-escalated to clopidogrel within 1 year. De-escalation was more likely after a bleed if patients did not have a no function allele (35.9% vs 19.1%; P = .02). CONCLUSION Bleeding is common in post-PCI patients on antiplatelet therapy. Patients on high potency agents had higher bleeding risk in the population at-large and in non-carriers of CYP2C19 no function alleles. Genotype-guided antiplatelet de-escalation should be further explored in prospective studies.
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Affiliation(s)
- James C Coons
- Heart and Vascular Institute and Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - James M Stevenson
- Departments of Medicine and Pharmacology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ami Patel
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - A J Conrad Smith
- Heart and Vascular Institute and Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Linda Prebehalla
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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16
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Tien Hoang A, Quynh Nhu Tran T, Phuong Duy Le C, Ha Vo T. Adherence to dual antiplatelet therapy after coronary stenting: A study conducted at two Vietnamese hospitals. J Cardiovasc Thorac Res 2021; 13:330-335. [PMID: 35047138 PMCID: PMC8749365 DOI: 10.34172/jcvtr.2021.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 10/04/2021] [Accepted: 11/11/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction: Adherence to dual antiplatelet therapy (DAPT) is critical after drug-eluting stent(DES) placement. We aimed to assess patient’s knowledge, rates of DAPT adherence, trends in DAPT use over time, and patient‐level factors associated with nonadherence in the patient with acute coronary syndrome (ACS). Methods: ACS patients who received one or more DES between May and September 2018from two hospitals in Vietnam and used DAPT after stent placement were eligible for a direct interview to assess patient’s knowledge on disease and DAPT. Telephone interviews were conducted one, three, and six months following discharge. Nonadherence was defined as premature discontinuation of DAPT. Factors related to nonadherent patients were analyzed using the chi-square test. Results: Of the 200 patients identified, 154 (77%) participated. Of the ten questions related to knowledge, the mean score of correct answers was 8.2 ± 2.3, and 71.7% had good knowledge.Adherence to DAPT was high at one month (94.2%) but declined by three months (44.2%) and then by six months (46.8%). Aspirin adherence was 99.3%-100% throughout. Three factors associated with nonadherence of DAPT following DES placement by six months included: rural location, linactive occupation, and inadequate knowledge on disease and DAPT (p<0.05). Conclusion: DAPT adherence is high at one month but is suboptimal at three and six months.Factors associated with the nonadherence of DAPT will be helpful in the planning of patient education strategies.
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Affiliation(s)
- Anh Tien Hoang
- PCI Unit, Hue University Hospital, Hue, 52000, Vietnam
- Department of Internal Medicine, University of Medicine and Pharmacy, Hue University, Hue, 52000, Vietnam
| | - Thi Quynh Nhu Tran
- Department of Pharmacy, University of Medicine and Pharmacy, Hue University, Hue, 52000, Vietnam
| | | | - Thi Ha Vo
- Faculty of Pharmacy, Pham Ngoc Thach University of Medicine, Ho Chi Minh, V-70000, Vietnam
- Department of Pharmacy, Nguyen Tri Phuong Hospital, Ho Chi Minh, V-70000, Vietnam
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17
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Wawruch M, Murin J, Tesar T, Paduchova M, Petrova M, Celovska D, Matalova P, Havelkova B, Trnka M, Aarnio E. Adherence to Antiplatelet Medications among Persistent and Non-Persistent Older Patients with Peripheral Arterial Disease. Biomedicines 2021; 9:biomedicines9121800. [PMID: 34944616 PMCID: PMC8698509 DOI: 10.3390/biomedicines9121800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 11/23/2021] [Accepted: 11/26/2021] [Indexed: 12/24/2022] Open
Abstract
Secondary prevention of peripheral arterial disease (PAD) includes administration of antiplatelet agents, and adherence to medication is a requirement for an effective treatment. The aim of this study was to analyse adherence measured using the proportion of days covered (PDC) index separately in persistent and non-persistent patients, and to identify patient- and medication-related characteristics associated with non-adherence in these patient groups. The study cohort of 9178 patients aged ≥ 65 years in whom PAD was diagnosed in 1/–12/2012 included 6146 persistent and 3032 non-persistent patients. Non-adherence was identified as PDC < 80%. Characteristics associated with non-adherence were determined using the binary logistic regression model. In the group of persistent patients, 15.3% of subjects were identified as non-adherent, while among non-persistent patients, 26.9% of subjects were non-adherent to antiplatelet medication. Administration of dual antiplatelet therapy (aspirin and clopidogrel) and a general practitioner as index prescriber were associated with adherence in both patient groups. Our study revealed a relatively high proportion of adherent patients not only in the group of persistent patients but also in the group of non-persistent patients before discontinuation. These results indicate that most non-persistent PAD patients discontinue antiplatelet treatment rapidly after a certain period of adherence.
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Affiliation(s)
- Martin Wawruch
- Institute of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Comenius University, 811 08 Bratislava, Slovakia;
- Correspondence: (M.W.); (T.T.)
| | - Jan Murin
- 1st Department of Internal Medicine, Faculty of Medicine, Comenius University, 813 69 Bratislava, Slovakia; (J.M.); (D.C.)
| | - Tomas Tesar
- Department of Organisation and Management of Pharmacy, Faculty of Pharmacy, Comenius University, 832 32 Bratislava, Slovakia
- Correspondence: (M.W.); (T.T.)
| | | | - Miriam Petrova
- Institute of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Comenius University, 811 08 Bratislava, Slovakia;
| | - Denisa Celovska
- 1st Department of Internal Medicine, Faculty of Medicine, Comenius University, 813 69 Bratislava, Slovakia; (J.M.); (D.C.)
| | - Petra Matalova
- Department of Pharmacology, Faculty of Medicine and Dentistry, Palacky University, 775 15 Olomouc, Czech Republic;
| | - Beata Havelkova
- General Health Insurance Company, 851 04 Bratislava, Slovakia;
| | - Michal Trnka
- Institute of Medical Physics, Biophysics, Informatics and Telemedicine, Faculty of Medicine, Comenius University, 813 72 Bratislava, Slovakia;
| | - Emma Aarnio
- Institute of Biomedicine, University of Turku, 20014 Turku, Finland;
- School of Pharmacy, University of Eastern Finland, 70211 Kuopio, Finland
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18
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Kim CJ, Park MW, Kim MC, Choo EH, Hwang BH, Lee KY, Choi YS, Kim HY, Yoo KD, Jeon DS, Shin ES, Jeong YH, Seung KB, Jeong MH, Yim HW, Ahn Y, Chang K. Unguided de-escalation from ticagrelor to clopidogrel in stabilised patients with acute myocardial infarction undergoing percutaneous coronary intervention (TALOS-AMI): an investigator-initiated, open-label, multicentre, non-inferiority, randomised trial. Lancet 2021; 398:1305-1316. [PMID: 34627490 DOI: 10.1016/s0140-6736(21)01445-8] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/15/2021] [Accepted: 06/22/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND In patients with acute myocardial infarction receiving potent antiplatelet therapy, the bleeding risk remains high during the maintenance phase. We sought data on a uniform unguided de-escalation strategy of dual antiplatelet therapy (DAPT) from ticagrelor to clopidogrel after acute myocardial infarction. METHODS In this open-label, assessor-masked, multicentre, non-inferiority, randomised trial (TALOS-AMI), patients at 32 institutes in South Korea with acute myocardial infarction receiving aspirin and ticagrelor without major ischaemic or bleeding events during the first month after index percutaneous coronary intervention (PCI) were randomly assigned in a 1:1 ratio to a de-escalation (clopidogrel plus aspirin) or active control (ticagrelor plus aspirin) group. Unguided de-escalation without a loading dose of clopidogrel was adopted when switching from ticagrelor to clopidogrel. The primary endpoint was a composite of cardiovascular death, myocardial infarction, stroke, or bleeding type 2, 3, or 5 according to Bleeding Academic Research Consortium (BARC) criteria from 1 to 12 months. A non-inferiority test was done to assess the safety and efficacy of de-escalation DAPT compared with standard treatment. The hazard ratio (HR) for de-escalation versus active control group in a stratified Cox proportional hazards model was assessed for non-inferiority by means of an HR margin of 1·34, which equates to an absolute difference of 3·0% in the intention-to-treat population and, if significant, a superiority test was done subsequently. To ensure statistical robustness, additional analyses were also done in the per-protocol population. This trial is registered at ClinicalTrials.gov, NCT02018055. FINDINGS From Feb 26, 2014, to Dec 31, 2018, from 2901 patients screened, 2697 patients were randomly assigned: 1349 patients to de-escalation and 1348 to active control groups. At 12 months, the primary endpoints occurred in 59 (4·6%) in the de-escalation group and 104 (8·2%) patients in the active control group (pnon-inferiority<0·001; HR 0·55 [95% CI 0·40-0·76], psuperiority=0·0001). There was no significant difference in composite of cardiovascular death, myocardial infarction, or stroke between de-escalation (2·1%) and the active control group (3·1%; HR 0·69; 95% CI 0·42-1·14, p=0·15). Composite of BARC 2, 3, or 5 bleeding occurred less frequently in the de-escalation group (3·0% vs 5·6%, HR 0·52; 95% CI 0·35-0·77, p=0·0012). INTERPRETATION In stabilised patients with acute myocardial infarction after index PCI, a uniform unguided de-escalation strategy significantly reduced the risk of net clinical events up to 12 months, mainly by reducing the bleeding events. FUNDING ChongKunDang Pharm, Medtronic, Abbott, and Boston Scientific.
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Affiliation(s)
- Chan Joon Kim
- Department of Internal Medicine, Division of Cardiology, Uijeongbu St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Mahn-Won Park
- Department of Internal Medicine, Division of Cardiology, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Min Chul Kim
- Department of Cardiology, Chonnam National University Hospital, Ulsan University Hospital, Seoul, South Korea
| | - Eun-Ho Choo
- Department of Internal Medicine, Division of Cardiology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung-Hee Hwang
- Department of Internal Medicine, Division of Cardiology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kwan Yong Lee
- Department of Internal Medicine, Division of Cardiology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yun Seok Choi
- Department of Internal Medicine, Division of Cardiology, Yeouido St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hee-Yeol Kim
- Department of Internal Medicine, Division of Cardiology, Bucheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ki-Dong Yoo
- Department of Internal Medicine, Division of Cardiology, St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Doo-Soo Jeon
- Department of Internal Medicine, Division of Cardiology, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Eun-Seok Shin
- Department of Internal Medicine, Division of Cardiology, Ulsan University Hospital, Seoul, South Korea
| | - Young-Hoon Jeong
- Department of Internal Medicine, Division of Cardiology, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Ki-Bae Seung
- Department of Internal Medicine, Division of Cardiology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Myung Ho Jeong
- Department of Cardiology, Chonnam National University Hospital, Ulsan University Hospital, Seoul, South Korea
| | - Hyeon Woo Yim
- Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Ulsan University Hospital, Seoul, South Korea.
| | - Kiyuk Chang
- Department of Internal Medicine, Division of Cardiology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
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19
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Arora S, Jaswaney R, Jani C, Zuzek Z, Thakkar S, Patel M, Panaich SS, Tripathi B, Arora N, Josephson R, Osman MN, Hoit BD, Zidar D, Shishehbor MH. Invasive Approaches in the Management of Cocaine-Associated Non-ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Interv 2021; 14:623-636. [PMID: 33736770 DOI: 10.1016/j.jcin.2021.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to determine the impact of invasive approaches and revascularization in patients with cocaine-associated non-ST-segment elevation myocardial infarction (NSTEMI). BACKGROUND The role of invasive approaches in cocaine-associated NSTEMI is uncertain. METHODS This retrospective cohort study identified 3,735 patients with NSTEMI and history of cocaine use from the Nationwide Readmissions Database from 2016 to 2017. Invasive approaches were defined as coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Revascularization was defined as PCI and CABG. The primary efficacy outcome was major adverse cardiac events (MACE), and the primary safety outcome was emergent revascularization. Nonadherence was identified using appropriate International Classification of Diseases-Tenth Revision codes. Two propensity-matched cohorts were generated (noninvasive vs. invasive and noninvasive vs. revascularization) through multivariate logistic regression. RESULTS In the propensity score-matched cohorts, an invasive approach (hazard ratio [HR]: 0.72; 95% confidence interval [CI]: 0.56 to 0.92; p = 0.008) and revascularization (HR: 0.54; 95% CI: 0.40 to 0.73; p < 0.001) (compared with a noninvasive approach) were associated with a lower rate of MACE, without an increase in emergent revascularization. On stratification, PCI and CABG individually were associated with a lower rate of MACE. Emergent revascularization was increased with PCI (HR: 1.78; 95% CI: 1.12 to 2.81; p = 0.014) but not with CABG. Nonadherent patients after PCI and CABG did not have significant difference in rate of MACE. PCI in nonadherent patients was associated with an increase in emergent revascularization (HR: 4.45; 95% CI: 2.07 to 9.57; p < 0.001). CONCLUSIONS Invasive approaches and revascularization for cocaine-associated NSTEMI are associated with lower morbidity. A history of medical nonadherence was not associated with a difference in morbidity but was associated with an increased risk for emergent revascularization with PCI.
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Affiliation(s)
- Shilpkumar Arora
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Rahul Jaswaney
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Chinmay Jani
- Mount Auburn Hospital-Harvard Medical School, Cambridge, Massachusetts, USA
| | - Zachary Zuzek
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Mohini Patel
- Boston University School of Public Health, Boston, Massachusetts, USA
| | | | | | | | - Richard Josephson
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mohammed Najeeb Osman
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Brian D Hoit
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - David Zidar
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mehdi H Shishehbor
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA.
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Olufade T, Atreja N, Bhalla N, Venditto J, Bhandary D, Chafekar K, Cobden D, Khan ND. Hospitalization for Myocardial Infarction with Ticagrelor or Clopidogrel in Patients with Acute Coronary Syndrome: An On-Treatment Comparative Effectiveness Analysis. Cardiol Ther 2021; 10:515-529. [PMID: 34389941 PMCID: PMC8555031 DOI: 10.1007/s40119-021-00236-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 07/27/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Prescribing patterns and suboptimal adherence present methodological challenges for real-world head-to-head comparisons of ticagrelor and clopidogrel in intent-to-treat studies. The aim of this study was to compare ticagrelor and clopidogrel in an on-treatment population. METHODS This retrospective cohort study used the Optum™ Clinformatics™ database to identify patients with acute coronary syndrome (ACS) discharged on ticagrelor or clopidogrel between January 1, 2012 and September 30, 2019. The primary end point was hospitalization for myocardial infarction (MI); the secondary end point was hospitalization for major bleeding. The ticagrelor and clopidogrel cohorts were balanced by propensity score matching (PSM) 1:3 for demographic and clinical characteristics. Outcomes were ascertained from day 31 until day 365 or end of follow-up. RESULTS Of 339,387 patients with ACS, 14,110 ticagrelor- and 57,482 clopidogrel-treated patients met the study criteria. After PSM, 13,373 ticagrelor- and 29,656 clopidogrel-treated patients provided 4945 and 13,895 patient-years of data, respectively, for the primary end point. Hospitalization for MI was significantly lower in the ticagrelor compared to the clopidogrel cohort (2.22 vs. 3.52 per 100 patient-years; 36.8% relative risk reduction [RRR]; P < 0.0001). Hospitalization for major bleeding was similar in the ticagrelor and clopidogrel cohorts (2.04 vs. 2.06 per 100 patient-years; 1.1% RRR, P = 0.9214). CONCLUSIONS In this real-world on-treatment analysis, hospitalization for MI was significantly lower with ticagrelor compared to clopidogrel, with similar rates of hospitalization for major bleeding. Study findings underscore the importance of being on the appropriate guideline-recommended therapy and support the use of ticagrelor over clopidogrel.
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21
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Romagnoli A, Santoleri F, Costantini A. Adherence and persistence analysis in patients treated with double antiplatelet therapy (DAPT) at two years in real life. PATIENT EDUCATION AND COUNSELING 2021; 104:2012-2017. [PMID: 33461875 DOI: 10.1016/j.pec.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 12/09/2020] [Accepted: 01/05/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Double antiplatelet therapy (DAPT) is indicated for the treatment of coronary artery diseases (CAD). The optimal duration of therapy with DAPT continues to be a subject of debate in the scientific community. To improve adherence to DAPT, the FDC (fixed dose combination) of Acetylsalicylic acid (ASA) and clopidogrel was developed into a single pill instead of two separate pills thus facilitating the dosage and administration of the therapy and increasing compliance. The aim of this study was to assess adherence and persistence over a period of two years in patients treated with DAPT composed of: ASA/clopidogrel, ASA/prasugrel, ASA/ticagrelor and FDC with ASA and clopidogrel in real life and to assess whether the use of ASA and clopidogrel FDC is associated with improved adherence. MATERIALS AND METHODS In the following retrospective pharmacological-observational non-interventional study, all patients treated with DAPT in the Hospital of Pescara from January 2010 to October 2019 were considered. Persistence to treatment is defined as the duration of time from initiation to discontinuation of treatment. Adherence was calculated as the ratio between Received Daily Dose (RDD) and Prescribed Daily Dose (PDD). RESULTS 277 patients treated with ASA/clopidogrel, 77 patients treated with ASA/prasugrel, 57 patients treated with ASA/ticagrelor and 108 patients treated with FDC of ASA/clopidogrel were analysed. Persistence curves at two years showed a statistically significant difference (p < 0.001). Adherence to therapy was optimal with an absolute value at two years of 0.96. Adherence was better in patients treated with ASA/prasugrel with a value of 0.98 and with 97 % of patients with an adherence value greater than or equal to 0.8, while, it was worse in patients treated with FDC ASA/clopidogrel with an absolute value of 0.94 and with 88 % of patients with an optimal adherence value. No statistically significant difference was found between the ASA/clopidogrel FDC in comparison to each component taken as a separate pill (p = 0.0752). CONCLUSION DAPT along with ASA/clopidogrel showed a statistically significant better persistence than ASA/ticagrelor and ASA/prasugrel. Whereas, to our knowledge and as per the current literature no statistically significant differences were found, in terms of adherence in real life, between the use of ASA/Clopidogrel FDC and the use of two different pills.
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Affiliation(s)
- Alessia Romagnoli
- Hospital Pharmacy of "SS. Spirito" Hospital of Pescara, Address Renato Paolini 47, 65124, Pescara, Italy.
| | - Fiorenzo Santoleri
- Hospital Pharmacy of "SS. Spirito" Hospital of Pescara, Address Renato Paolini 47, 65124, Pescara, Italy.
| | - Alberto Costantini
- Hospital Pharmacy of "SS. Spirito" Hospital of Pescara, Address Renato Paolini 47, 65124, Pescara, Italy.
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22
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Woo HG, Lee HA, Ryu DR, Song TJ. Association of Mortality with Antiplatelet Treatment in Patients with Stent Placement or Angioplasty: A Population-Based Nested Case-Control Study. Yonsei Med J 2021; 62:75-85. [PMID: 33381937 PMCID: PMC7820450 DOI: 10.3349/ymj.2021.62.1.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/22/2020] [Accepted: 10/19/2020] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Antiplatelet drugs are essential in patients with cardiovascular disease who undergo stent placement. We hypothesized that risks of mortality would differ according to adherence to antiplatelet agents, number of antiplatelet agents, and antiplatelet regimens in patients undergoing stent placement or angioplasty. MATERIALS AND METHODS Between 2002 and 2013, we initially enrolled 8671 subjects who underwent stent placement or angioplasty in the National Health Insurance Service-National Sample Cohort in Korea. Using the International Classification of Diseases, 10th revision, the incidence of all-cause death, including cardiovascular disease, cerebrovascular disease, and cancer, was defined. Using a nested case-control study design, controls were matched to cases at a ratio of 4:1, and a total of 5415 subjects were eligible for this study. RESULTS During a median follow-up period of 3.51 years, the incidence rate of all-cause death was 40 per 1000 person-years. We found that adherence to antiplatelet monotherapy significantly decreased risk of death by cerebro-cardiovascular disease, compared with discontinuation of antiplatelets [adjusted odds ratio (OR) 0.62, 95% confidence interval (CI) (0.41-0.96)]. Compared with dual antiplatelet therapy (DAPT), aspirin and clopidogrel monotherapy significantly reduced death by cerebro-cardiovascular disease [adjusted OR 0.65, 95% CI (0.44-0.95) and adjusted OR 0.58, 95% CI (0.35-0.96), respectively]. There was no significant difference of mortality between aspirin monotherapy and clopidogrel monotherapy. CONCLUSION Our study demonstrated that adherence to antiplatelet therapy and antiplatelet monotherapy, compared with DAPT, in patients with stent placement or angioplasty may have a beneficial effect on mortality in cerebro-cardiovascular disease.
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Affiliation(s)
- Ho Geol Woo
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Hye Ah Lee
- Clinical Trial Center, Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Dong Ryeol Ryu
- Department of Nephrology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Tae Jin Song
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea.
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23
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Hagen B, Griebenow R. Prescription Rates for Antiplatelet Therapy (APT) in Coronary Artery Disease (CAD) - What Benchmark are We Aiming at in Continuing Medical Education (CME)? J Eur CME 2020; 9:1836866. [PMID: 33224627 PMCID: PMC7655043 DOI: 10.1080/21614083.2020.1836866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 11/09/2022] Open
Abstract
Physicians always aim to improve their patients' health. CME should be designed not only to provide knowledge transfer, but also to influence clinical decision-making and to close performance gaps. In aretrospective study we analysed prescription rates for APT in 254,932 CAD patients (male: 64.4%), treated in atotal of 3,405 practices in 2019 in aDMP in the region of North Rhine, Germany. Analyses were run for the whole study population stratified by sex as well as for subgroups of patients suffering from myocardial infarction/acute coronary syndrome, or who have been treated with percutaneous coronary intervention or bypass surgery. Patients mean age was 72.7 ± 11.2 years (mean ± 1SD), mean duration of DMP participation was 7.2 ± 4.7 years, and mean cumulative number of DMP visits was 27 ± 17. APT prescription rates were 85.0% in male and 78.8% in female CAD patients. In subgroups of male CAD patients APT prescription rates were between 89.7% and 92.8%, in the same subgroups of female CAD patients the corresponding rates were between 87.8% and 92.0%. Rates for amissing APT prescription per practice were between .0044% and .0062% for male and female CAD patients, respectively. Rates for amissing APT prescription per practice and DMP visit were .0002% for both sexes. These results suggest that a DMP can achieve high attainment rates for APT in CAD. To further improve attainment rates, consideration of absolute numbers of eligible patients per practice or physician is probably more appropriate than expression of performance as percentage values. This is especially true if attainment rates show substantial variations between subgroups, if subgroups show substantial variation in size, if attainment rates are already in the magnitude of 80% or higher, and if there are disparities in the evidence base underlying treatment recommendations related to subgroups.
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Affiliation(s)
- Bernd Hagen
- Department of Evaluation and Quality Assurance, Central Institute for Statutory Health Care in Germany, Cologne/Berlin, Germany
| | - Reinhard Griebenow
- Praxis Rheingalerie, Cologne, Academic Teaching Practice, University of Cologne, Cologne, Germany
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24
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Pithara C, Pufulete M, Johnson TW, Redwood S. Patient perspectives of nuisance bleeding and adherence to dual antiplatelet therapy: a qualitative study. Open Heart 2020; 7:openhrt-2020-001405. [PMID: 33060141 PMCID: PMC7566423 DOI: 10.1136/openhrt-2020-001405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To understand the experiences of patients with dual antiplatelet therapy (DAPT) and nuisance bleeding, and their perspectives of the impact of nuisance bleeding on medication adherence and information seeking. METHODS We conducted focus groups with patients who had undergone percutaneous coronary intervention, coronary artery bypass graft and conservatively managed acute coronary syndrome patients. Two focus groups were with patients at the early stages of treatment (0-3 months), and two with patients coming to the end of treatment (9-12 months). Group discussions were audio recorded, and recordings were transcribed verbatim, anonymised and analysed using framework analysis. FINDINGS Nine patients taking DAPT for up to 3 months, and 12 taking DAPT between 9 and 12 months participated in the focus groups. We found that: (1) participants adhered to treatment when they believed DAPT was important to health outcomes; (2) those who experienced nuisance bleeding reported symptoms to be mild and manageable; (3) participants' and their family's understanding of DAPT risks and benefits, and their ability to manage symptoms, influenced perspectives of and experiences with adherence. Factors influencing DAPT knowledge included access to medication counselling, engaging with information communicated during medication counselling, and access to timely, relevant and expert information and advice after discharge from hospital. CONCLUSIONS Positive attitudes towards adherence were facilitated by knowledge and understanding of DAPT and confidence in dealing with symptoms caused by DAPT, but hindered by lack of opportunities to access relevant, timely and appropriate medication counselling. Education interventions should aim to support medication literacy through family-centred approaches and involve patients and families at all stages of intervention design and evaluation.
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Affiliation(s)
- Christalla Pithara
- National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK .,Population Health Sciences, University of Bristol, Bristol, UK
| | - Maria Pufulete
- Bristol Trials Centre (Clinical Trials and Evaluation Unit), University of Bristol, Bristol, UK
| | | | - Sabi Redwood
- National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.,Population Health Sciences, University of Bristol, Bristol, UK
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25
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Valgimigli M, Garcia-Garcia HM, Vrijens B, Vranckx P, McFadden EP, Costa F, Pieper K, Vock DM, Zhang M, Van Es GA, Tricoci P, Baber U, Steg G, Montalescot G, Angiolillo DJ, Serruys PW, Farb A, Windecker S, Kastrati A, Colombo A, Feres F, Jüni P, Stone GW, Bhatt DL, Mehran R, Tijssen JGP. Standardized classification and framework for reporting, interpreting, and analysing medication non-adherence in cardiovascular clinical trials: a consensus report from the Non-adherence Academic Research Consortium (NARC). Eur Heart J 2020; 40:2070-2085. [PMID: 29992264 DOI: 10.1093/eurheartj/ehy377] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/20/2018] [Accepted: 07/04/2018] [Indexed: 01/02/2023] Open
Abstract
Non-adherence has been well recognized for years to be a common issue that significantly impacts clinical outcomes and health care costs. Medication adherence is remarkably low even in the controlled environment of clinical trials where it has potentially complex major implications. Collection of non-adherence data diverge markedly among cardiovascular randomized trials and, even where collected, is rarely incorporated in the statistical analysis to test the consistency of the primary endpoint(s). The imprecision introduced by the inconsistent assessment of non-adherence in clinical trials might confound the estimate of the calculated efficacy of the study drug. Hence, clinical trials may not accurately answer the scientific question posed by regulators, who seek an accurate estimate of the true efficacy and safety of treatment, or the question posed by payers, who want a reliable estimate of the effectiveness of treatment in the marketplace after approval. The Non-adherence Academic Research Consortium is a collaboration among leading academic research organizations, representatives from the U.S. Food and Drug Administration and physician-scientists from the USA and Europe. One in-person meeting was held in Madrid, Spain, culminating in a document describing consensus recommendations for reporting, collecting, and analysing adherence endpoints across clinical trials. The adoption of these recommendations will afford robustness and consistency in the comparative safety and effectiveness evaluation of investigational drugs from early development to post-marketing approval studies. These principles may be useful for regulatory assessment, as well as for monitoring local and regional outcomes to guide quality improvement initiatives.
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Affiliation(s)
- Marco Valgimigli
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - Hector M Garcia-Garcia
- Interventional Cardiology Department, MedStar Washington Hospital Center, Washington, DC, USA
| | - Bernard Vrijens
- Department of Biostatistics, University of Liège, Liège, Wallonia, Belgium
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Hasselt, Belgium.,Faculty of Medicine and Life Sciences Hasselt University, Hasselt, Belgium
| | | | - Francesco Costa
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland.,Department of Clinical and Experimental Medicine, Policlinic "G Martino", University of Messina, Italy
| | - Karen Pieper
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - David M Vock
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Pierluigi Tricoci
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Usman Baber
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gabriel Steg
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Bichat Hospital, Paris, France
| | - Gilles Montalescot
- Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Patrick W Serruys
- International Centre for Circulatory Health, NHLI, Imperial College London, London, UK
| | - Andrew Farb
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration
| | - Stephan Windecker
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Antonio Colombo
- Interventional Cardiology Department, San Raffaele Scientific Institute, Milan, Italy.,Interventional Cardiology Department, EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Fausto Feres
- Division of Cardiology, Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Peter Jüni
- Institute of Primary Health Care, Toronto, Canada
| | - Gregg W Stone
- Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Roxana Mehran
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jan G P Tijssen
- European Cardiovascular Research Institute, Rotterdam, The Netherlands.,Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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26
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Mols RE, Hald M, Vistisen HS, Lomborg K, Maeng M. Nurse-led Motivational Telephone Follow-up After Same-day Percutaneous Coronary Intervention Reduces Readmission and Contacts to General Practice. J Cardiovasc Nurs 2020; 34:222-230. [PMID: 30789491 DOI: 10.1097/jcn.0000000000000566] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Same-day discharge of patients undergoing percutaneous coronary intervention (PCI) may challenge preparation of patients for discharge. OBJECTIVE The objective of this study was to investigate whether nurse-led telephone follow-up influenced patients' self-management post-PCI. METHODS We performed a randomized study with an allocation rate of 1:1. A standardized nurse-led motivational telephone consultation was conducted between 2 and 5 days after PCI to support adherence to medical therapy, follow-up activities, emotional well-being, and healthy lifestyle. The control group received usual care and discharge procedures. Primary outcome was adherence to use of P2Y12 inhibitor (clopidogrel or ticagrelor) therapy at 30 days of follow-up. RESULTS We consecutively included 294 elective patients (83%) undergoing PCI and with planned same-day discharge. Adherence to P2Y12 inhibitors was not influenced by the intervention (intervention vs control, 95% vs 93%, respectively; P = .627). However, the proportion of patients readmitted (8% vs 16%, P = .048), as well as self-initiated contacts to general practitioners (29% vs 42%, P = .020), was lower in the intervention group compared with the control group. Patients in the intervention group were more likely to know how to manage symptoms of angina pectoris (90% vs 80%, P = .015), and a higher proportion of patients in the intervention group commenced healthy physical activities (53% vs 41%, P = .043). CONCLUSION Nurse-led motivational telephone follow-up did not influence adherence to antiplatelet medical therapy after PCI. However, the intervention positively influenced self-management of angina pectoris and reduced hospital readmissions and self-initiated contacts to general practitioners and hospitals.
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Affiliation(s)
- Rikke Elmose Mols
- Rikke Elmose Mols, PhD, RN Healthcare Researcher, Department of Cardiology, Aarhus University Hospital, Denmark. Marianne Hald, RNProject Nurse, Department of Cardiology, Aarhus University Hospital, Denmark. Heidi Soenderby Vistisen, MCn, RNDevelopment Nurse, Department of Cardiology, Aarhus University Hospital, Denmark. Kirsten Lomborg, PhD, RNProfessor, Department of Clinical Medicine, Aarhus University; and the Research Program in Patient Involvement, Aarhus University Hospital, Denmark. Michael Maeng, PhD, MD Associated Professor and Invasive Cardiologist, Department of Cardiology, Aarhus University Hospital, Denmark
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27
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Morita F, Wajngarten M, Katz M, Fernandes-Silva MM, Caixeta A, Franken M, Lemos PA, Pesaro AE. Short- and Midterm Adherence to Platelet P2Y12 Receptor Inhibitors After Percutaneous Coronary Intervention With Drug-Eluting Stents. J Cardiovasc Pharmacol Ther 2020; 25:466-471. [PMID: 32419491 DOI: 10.1177/1074248420926667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION/OBJECTIVES In patients who have undergone recent percutaneous coronary intervention (PCI), poor adhesion to antiplatelet agents may increase the risk of stent thrombosis and death. We aimed to investigate the adherence to different P2Y12 receptor inhibitors after PCI with drug-eluting stent in stable and unstable patients and to evaluate the factors associated with low adherence. METHOD In a prospective study conducted between 2014 and 2018, the 8-item Morisky scale was applied at 30 days and 6 months post-PCI to measure P2Y12 receptor inhibitors adherence. Also, we describe the characteristics of patients using different platelet receptor P2Y12 inhibitors. Regression models were used to identify predictors of poor adherence. RESULTS A total of 214 patients were included (65 ± 12 years, 81% man, 61% acute coronary syndromes). Patients in the clopidogrel group were older than those in the prasugrel (68 ± 12 vs 59 ± 11 years, P < .01, respectively) or ticagrelor group (68 ± 12 vs 62 ± 12 years, P < .01). Patients with low/moderate adherence at 30 days and 6 months represented, respectively, 19.8% and 27.5% of our sample. Current smokers and preexisting cardiovascular disease at presentation were associated with lower adherence at 30 days. CONCLUSIONS We found substantial rates of moderate and low adherence to P2Y12 receptor inhibitors early after PCI. Current smokers and preexisting cardiovascular disease at presentation were associated with a lower likelihood of adherence. These results highlight the need of monitoring adherence to medical treatment after PCI.
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Affiliation(s)
- Fernando Morita
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Mauricio Wajngarten
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcelo Katz
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Adriano Caixeta
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcelo Franken
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Pedro A Lemos
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Antonio E Pesaro
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
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28
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Alrabiah Z, Wajid S, Alsulaihim I, Alghadeer S, Alhossan A, Babelghaith SD, Al-Arifi M. Adherence to prophylactic dual antiplatelet therapy in patients with acute coronary syndrome - A study conducted at a Saudi university hospital. Saudi Pharm J 2020; 28:369-373. [PMID: 32194339 PMCID: PMC7078558 DOI: 10.1016/j.jsps.2020.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 01/29/2020] [Indexed: 11/26/2022] Open
Abstract
Objectives The aim of this study was to evaluate patients’ self-reported adherence to dual antiplatelet therapy (DAPT) and determine the factors associated with premature discontinuation of DAPT. Methods The cross-sectional interview-based study was conducted among adult outpatients who visited the outpatient department of King Khalid University Hospital, Cardiac Center in Riyadh, Saudi Arabia, over a period of 3 months from May to July of 2016. Medication adherence was assessed using the Self-efficacy for Appropriate Medication Use Scale (SEAMS), which is composed of 13 items with a 3-point Likert scale. Results A total of 192 patients participated in the study. The majority of the participants were male (82.1%), and the mean age was 55.66 ± 10.80 years. More than 84% (84.4%) of the patients reported that they were “confident” in taking several medications each day. The minimum and maximum SEAMS scores were 22 and 39, respectively, with the mean score being 30.8 ± 3.5. Almost all patients had moderate scores and adherence; only one patient got a score of 39. Among sociodemographic characteristics, only health insurance and income were significantly associated with the medication adherence score (p < 0.05). Conclusions Study results concluded that patients had a moderate level of adherence towards DAPT in Saudi Arabia, however Patient education on DAPT is essential to improve adherence to medication treatment. More effective intentions and education methods should be developed to improve long-term DAPT adherence.
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Affiliation(s)
- Ziyad Alrabiah
- Clinical Pharmacy Department, College of Pharmacy King Saud University, Saudi Arabia
| | - Syed Wajid
- Clinical Pharmacy Department, College of Pharmacy King Saud University, Saudi Arabia
| | - Ibrahim Alsulaihim
- Clinical Pharmacy Department, College of Pharmacy King Saud University, Saudi Arabia
| | - Sultan Alghadeer
- Clinical Pharmacy Department, College of Pharmacy King Saud University, Saudi Arabia
| | - Abdulaziz Alhossan
- Clinical Pharmacy Department, College of Pharmacy King Saud University, Saudi Arabia
| | - Salmeen D Babelghaith
- Clinical Pharmacy Department, College of Pharmacy King Saud University, Saudi Arabia
| | - Mohamed Al-Arifi
- Clinical Pharmacy Department, College of Pharmacy King Saud University, Saudi Arabia
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Turgeon RD, Koshman SL, Youngson E, Har B, Wilton SB, James MT, Graham MM. Association of Ticagrelor vs Clopidogrel With Major Adverse Coronary Events in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention. JAMA Intern Med 2020; 180:420-428. [PMID: 31930361 PMCID: PMC6990835 DOI: 10.1001/jamainternmed.2019.6447] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE Guidelines currently recommend ticagrelor over clopidogrel for patients with acute coronary syndrome (ACS) based on randomized clinical trial data in which ticagrelor reduced major adverse coronary events (MACE) vs clopidogrel but increased bleeding and dyspnea. OBJECTIVE To compare the risk of MACE with ticagrelor vs clopidogrel in patients with ACS treated with percutaneous coronary intervention (PCI), to compare major bleeding and dyspnea, and to evaluate the association between P2Y12 inhibitor adherence and MACE. DESIGN, SETTING, AND PARTICIPANTS Population-based cohort study using data of patients discharged alive after PCI for ACS from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry from April 1, 2012, to March 31, 2016, with follow-up to 1 year. Analysis began April 2018. EXPOSURES Outpatient prescription for ticagrelor or clopidogrel within 31 days after PCI. Adherence was defined as a medication refill adherence value of 80% or higher. MAIN OUTCOMES AND MEASURES Major adverse coronary events, a composite of all-cause death, hospitalization for ACS, unplanned coronary revascularization, or stent thrombosis within 365 days after index PCI. Secondary outcomes included hospitalization for major bleeding and emergency department visit for dyspnea. RESULTS Of 11 185 individuals who underwent PCI, the median (interquartile range) age was 61 (54-71) years, and 2760 (24.7%) were women. Ticagrelor users (4076 [36.4%]) were generally younger and had fewer cardiac and noncardiac comorbidities than clopidogrel users. Ticagrelor was not associated with lower risk of MACE (adjusted hazard ratio [aHR], 0.97; 95% CI, 0.85-1.10); however, it was associated with an increased risk of major bleeding (aHR, 1.51; 95% CI, 1.29-1.78) and dyspnea (aHR, 1.98; 95% CI, 1.47-2.65). A total of 3328 ticagrelor users (81.6%) were adherent during the study vs 5256 of clopidogrel users (73.9%) (P < .001; χ2 = 86.4). In the full cohort, adherence was associated with a lower MACE risk (aHR, 0.79; 95% CI, 0.69-0.90 for adherence of ≥80% vs <80%). Differences in other secondary outcomes were not statistically significant. Sensitivity and subgroup analyses were consistent with primary analyses. CONCLUSIONS AND RELEVANCE In this population-based cohort study of patients with ACS who underwent PCI, outpatient use of ticagrelor was not associated with a statistically significant reduction in MACE vs clopidogrel; however, it was associated with more major bleeding and dyspnea.
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Affiliation(s)
- Ricky D Turgeon
- Department of Pharmacy, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sheri L Koshman
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Erik Youngson
- Alberta SPOR Support Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Bryan Har
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Stephen B Wilton
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Matthew T James
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michelle M Graham
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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30
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Dhruva SS, Parzynski CS, Gamble GM, Curtis JP, Desai NR, Yeh RW, Masoudi FA, Kuntz R, Shaw RE, Marinac-Dabic D, Sedrakyan A, Normand SLT, Krumholz HM, Ross JS. Attribution of Adverse Events Following Coronary Stent Placement Identified Using Administrative Claims Data. J Am Heart Assoc 2020; 9:e013606. [PMID: 32063087 PMCID: PMC7070203 DOI: 10.1161/jaha.119.013606] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background More than 600 000 coronary stents are implanted during percutaneous coronary interventions (PCIs) annually in the United States. Because no real‐world surveillance system exists to monitor their long‐term safety, claims data are often used for this purpose. The extent to which adverse events identified with claims data can be reasonably attributed to a specific medical device is uncertain. Methods and Results We used deterministic matching to link the NCDR (National Cardiovascular Data Registry) CathPCI Registry to Medicare fee‐for‐service claims for patients aged ≥65 years who underwent PCI with drug‐eluting stents (DESs) between July 1, 2009 and December 31, 2013. We identified subsequent PCIs within 1 year of the index procedure in Medicare claims as potential safety events. We linked these subsequent PCIs back to the NCDR CathPCI Registry to ascertain how often the revascularization could be reasonably attributed to the same coronary artery as the index PCI (ie, target vessel revascularization). Of 415 306 DES placements in 368 194 patients, 33 174 repeat PCIs were identified in Medicare claims within 1 year. Of these, 28 632 (86.3%) could be linked back to the NCDR CathPCI Registry; 16 942 (51.1% of repeat PCIs) were target vessel revascularizations. Of these, 8544 (50.4%) were within a previously placed DES: 7652 for in‐stent restenosis and 1341 for stent thrombosis. Of 16 176 patients with a claim for acute myocardial infarction in the follow‐up period, 4446 (27.5%) were attributed to the same coronary artery in which the DES was implanted during the index PCI (ie, target vessel myocardial infarction). Of 24 288 patients whose death was identified in claims data, 278 (1.1%) were attributed to the same coronary artery in which the DES was implanted during the index PCI. Conclusions Most repeat PCIs following DES stent implantation identified in longitudinal claims data could be linked to real‐world registry data, but only half could be reasonably attributed to the same coronary artery as the index procedure. Attribution among those with acute myocardial infarction or who died was even less frequent. Safety signals identified using claims data alone will require more in‐depth examination to accurately assess stent safety.
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Affiliation(s)
- Sanket S Dhruva
- University of California, San Francisco, School of Medicine and San Francisco Veterans Affairs Healthcare System San Francisco CA.,National Clinician Scholars Program Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Craig S Parzynski
- Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Ginger M Gamble
- Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Jeptha P Curtis
- Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT.,Section of Cardiovascular Medicine Department of Medicine, and National Clinician Scholars Program Yale School of Medicine New Haven CT
| | - Nihar R Desai
- Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT.,Section of Cardiovascular Medicine Department of Medicine, and National Clinician Scholars Program Yale School of Medicine New Haven CT
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology Boston MA.,Division of Cardiovascular Medicine Beth Israel Deaconess Medical Center Boston MA.,Harvard Medical School Boston MA.,Baim Institute for Clinical Research Boston MA
| | - Frederick A Masoudi
- Division of Cardiology Department of Medicine University of Colorado Anschutz Medical Campus Aurora CO
| | | | - Richard E Shaw
- Department of Clinical Informatics California Pacific Medical Center San Francisco CA
| | - Danica Marinac-Dabic
- Office of Clinical Evidence and Analysis Center for Devices and Radiological Health U.S. Food and Drug Administration Silver Spring MD
| | - Art Sedrakyan
- Department of Health Policy and Research Weill Cornell Medicine New York Presbyterian Hospital New York NY
| | - Sharon-Lise T Normand
- Department of Health Care Policy Harvard Medical School Boston MA.,Department of Biostatistics Harvard T.H. Chan School of Public Health Harvard University Boston MA
| | - Harlan M Krumholz
- National Clinician Scholars Program Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT.,Section of Cardiovascular Medicine Department of Medicine, and National Clinician Scholars Program Yale School of Medicine New Haven CT.,Department of Health Policy and Management Yale School of Public Health New Haven CT
| | - Joseph S Ross
- National Clinician Scholars Program Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT.,Department of Health Policy and Management Yale School of Public Health New Haven CT.,Section of General Medicine Department of Medicine, and National Clinician Scholars Program Yale School of Medicine New Haven CT
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31
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Merkler AE, Diaz I, Wu X, Murthy SB, Gialdini G, Navi BB, Yaghi S, Weinsaft JW, Okin PM, Safford MM, Iadecola C, Kamel H. Duration of Heightened Ischemic Stroke Risk After Acute Myocardial Infarction. J Am Heart Assoc 2019; 7:e010782. [PMID: 30571491 PMCID: PMC6404432 DOI: 10.1161/jaha.118.010782] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background The duration of heightened stroke risk after acute myocardial infarction (MI) remains uncertain. Methods and Results We performed a retrospective cohort study using claims between 2008 and 2015 from a nationally representative 5% sample of Medicare beneficiaries aged ≥66 years. Both acute MI and ischemic stroke were ascertained using previously validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM), diagnosis codes. To exclude periprocedural strokes from percutaneous coronary intervention, we did not count strokes occurring during an acute MI hospitalization. Patients were censored at the time of ischemic stroke, death, end of Medicare coverage, or September 30, 2015. We fit Cox regression models separately for the groups with and without acute MI to examine its association with ischemic stroke after adjustment for demographics, stroke risk factors, and Charlson comorbidities. We used the corresponding survival probabilities to compute the hazard ratio in each 4‐week interval after discharge. Confidence intervals were computed using the nonparametric bootstrap method. Among 1 746 476 eligible beneficiaries, 46 182 were hospitalized for acute MI and 80 466 for ischemic stroke. After adjustment for demographics, stroke risk factors, and Charlson comorbidities, the risk of ischemic stroke was highest in the first 4 weeks after discharge from the MI hospitalization (hazard ratio: 2.7; 95% confidence interval, 2.3–3.2), remained elevated during weeks 5 to 8 (hazard ratio: 2.0; 95% confidence interval, 1.6–2.4) and weeks 9 to 12 (hazard ratio: 1.6; 95% confidence interval, 1.3–2.0), and was no longer significantly elevated afterward. Conclusions Acute MI is associated with an elevated risk of ischemic stroke that appears to extend beyond the 1‐month window that is currently considered the at‐risk period.
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Affiliation(s)
- Alexander E Merkler
- 1 Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute Weill Cornell Medical College New York NY.,2 Department of Neurology Weill Cornell Medical College New York NY
| | - Ivan Diaz
- 2 Department of Neurology Weill Cornell Medical College New York NY.,3 Department of Healthcare Policy and Research Weill Cornell Medical College New York NY
| | - Xian Wu
- 2 Department of Neurology Weill Cornell Medical College New York NY.,3 Department of Healthcare Policy and Research Weill Cornell Medical College New York NY
| | - Santosh B Murthy
- 1 Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute Weill Cornell Medical College New York NY.,2 Department of Neurology Weill Cornell Medical College New York NY
| | - Gino Gialdini
- 2 Department of Neurology Weill Cornell Medical College New York NY
| | - Babak B Navi
- 1 Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute Weill Cornell Medical College New York NY.,2 Department of Neurology Weill Cornell Medical College New York NY
| | - Shadi Yaghi
- 4 Department of Neurology Warren Alpert Medical School of Brown University Providence RI
| | | | - Peter M Okin
- 5 Department of Medicine Weill Cornell Medical College New York NY
| | - Monika M Safford
- 5 Department of Medicine Weill Cornell Medical College New York NY
| | - Costantino Iadecola
- 1 Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute Weill Cornell Medical College New York NY.,2 Department of Neurology Weill Cornell Medical College New York NY
| | - Hooman Kamel
- 1 Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute Weill Cornell Medical College New York NY.,2 Department of Neurology Weill Cornell Medical College New York NY
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32
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Hou Y, Yue Y, Zhao M, Jiang S. Prevalence and association of medication nonadherence with major adverse cardiovascular events in patients with myocardial infarction. Medicine (Baltimore) 2019; 98:e17826. [PMID: 31689870 PMCID: PMC6946490 DOI: 10.1097/md.0000000000017826] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Current study was to evaluate the prevalence of guideline recommended medications adherence in myocardial infarction (MI) patients postpercutaneous coronary intervention (PCI) and the association of medication nonadherence and major adverse cardiovascular events (MACEs).MI patients who underwent PCI in the last 12 months were enrolled. Demographic and clinical characteristics were collected and guideline recommended medications were evaluated. Patients were divided into with and without MACEs groups.Compared to patients without MACEs, those with MACEs were older (54.8 ± 16.4 vs 51.1 ± 15.2 years), more likely to be smoker (40.2% vs 31.9%), have higher body mass index (BMI; 25.0 ± 6.1 vs 23.8 ± 5.7 kg/m), diabetes (47.5% vs 37.8%), ischemic stroke (34.4% vs 25.6%), and estimated lower glomerular filtration rate (85.4 ± 9.6 vs 92.6 ± 10.7 mL/minute/1.73 m). Patients with MACEs were also more likely to present with ST-elevation MI (STEMI; 54.1% vs 48.4%) and to undergo urgent PCI (62.3% vs 56.3%). Furthermore, patients with MACEs were less likely to adhere to dual antiplatelet therapy (77.9% vs 85.9%), renin-angiotensin system inhibitor (62.3% vs 69.7%), and beta-blocker (69.7% vs 72.8%) treatment. In unadjusted model, medication nonadherence was associated with 2-fold higher odds of MACEs. After adjustment for demographics, risk factors, comorbidities, and peri-PCI characteristics, medications nonadherence remained independently associated with MACEs, with odds ratio of 1.40 (95% confidence interval: 1.29-1.87).Medications adherence rate among MI patients post-PCI is suboptimal in China, which is independently associated with MACEs.
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Affiliation(s)
- Yunfeng Hou
- Intensive Care Unit, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong
| | | | - Meiling Zhao
- Department of Critical Care Medicine Zibo Central Hospital, Zibo City, Shandong, China
| | - Shumin Jiang
- Intensive Care Unit, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong
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33
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Claassens DMF, Vos GJA, Bergmeijer TO, Hermanides RS, van 't Hof AWJ, van der Harst P, Barbato E, Morisco C, Tjon Joe Gin RM, Asselbergs FW, Mosterd A, Herrman JPR, Dewilde WJM, Janssen PWA, Kelder JC, Postma MJ, de Boer A, Boersma C, Deneer VHM, Ten Berg JM. A Genotype-Guided Strategy for Oral P2Y 12 Inhibitors in Primary PCI. N Engl J Med 2019; 381:1621-1631. [PMID: 31479209 DOI: 10.1056/nejmoa1907096] [Citation(s) in RCA: 377] [Impact Index Per Article: 75.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is unknown whether patients undergoing primary percutaneous coronary intervention (PCI) benefit from genotype-guided selection of oral P2Y12 inhibitors. METHODS We conducted a randomized, open-label, assessor-blinded trial in which patients undergoing primary PCI with stent implantation were assigned in a 1:1 ratio to receive either a P2Y12 inhibitor on the basis of early CYP2C19 genetic testing (genotype-guided group) or standard treatment with either ticagrelor or prasugrel (standard-treatment group) for 12 months. In the genotype-guided group, carriers of CYP2C19*2 or CYP2C19*3 loss-of-function alleles received ticagrelor or prasugrel, and noncarriers received clopidogrel. The two primary outcomes were net adverse clinical events - defined as death from any cause, myocardial infarction, definite stent thrombosis, stroke, or major bleeding defined according to Platelet Inhibition and Patient Outcomes (PLATO) criteria - at 12 months (primary combined outcome; tested for noninferiority, with a noninferiority margin of 2 percentage points for the absolute difference) and PLATO major or minor bleeding at 12 months (primary bleeding outcome). RESULTS For the primary analysis, 2488 patients were included: 1242 in the genotype-guided group and 1246 in the standard-treatment group. The primary combined outcome occurred in 63 patients (5.1%) in the genotype-guided group and in 73 patients (5.9%) in the standard-treatment group (absolute difference, -0.7 percentage points; 95% confidence interval [CI], -2.0 to 0.7; P<0.001 for noninferiority). The primary bleeding outcome occurred in 122 patients (9.8%) in the genotype-guided group and in 156 patients (12.5%) in the standard-treatment group (hazard ratio, 0.78; 95% CI, 0.61 to 0.98; P = 0.04). CONCLUSIONS In patients undergoing primary PCI, a CYP2C19 genotype-guided strategy for selection of oral P2Y12 inhibitor therapy was noninferior to standard treatment with ticagrelor or prasugrel at 12 months with respect to thrombotic events and resulted in a lower incidence of bleeding. (Funded by the Netherlands Organization for Health Research and Development; POPular Genetics ClinicalTrials.gov number, NCT01761786; Netherlands Trial Register number, NL2872.).
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Affiliation(s)
- Daniel M F Claassens
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Gerrit J A Vos
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Thomas O Bergmeijer
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Renicus S Hermanides
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Arnoud W J van 't Hof
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Pim van der Harst
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Emanuele Barbato
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Carmine Morisco
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Richard M Tjon Joe Gin
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Folkert W Asselbergs
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Arend Mosterd
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Jean-Paul R Herrman
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Willem J M Dewilde
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Paul W A Janssen
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Johannes C Kelder
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Maarten J Postma
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Anthonius de Boer
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Cornelis Boersma
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Vera H M Deneer
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
| | - Jurriën M Ten Berg
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (D.M.F.C., G.J.A.V., T.O.B., P.W.A.J., J.C.K., J.M.B.), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H., A.W.J.H.), the Department of Cardiology, University Medical Center Maastricht, Maastricht (A.W.J.H.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), the Department of Cardiology, University Medical Center Groningen (P.H., J.M.B.), the Department of Pharmacy, University of Groningen (M.J.P.), and the Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen (M.J.P., C.B.), Groningen, the Department of Cardiology, Rijnstate Hospital, Arnhem (R.M.T.J.G.), the Department of Cardiology, Division of Heart and Lungs (F.W.A.), and the Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics (V.H.M.D.), University Medical Center Utrecht, and the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (A.B.), Utrecht University, Utrecht, the Department of Cardiology, Meander Medical Center, Amersfoort (A.M.), the Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam (J.-P.R.H.), and the Department of Cardiology, Amphia Hospital, Breda (W.J.M.D.) - all in the Netherlands; the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (E.B., C.M.); the Cardiovascular Research Center, Onze Lieve Vrouwe Hospital, Aalst (E.B.), and the Department of Cardiology, Imelda Hospital, Bonheiden (W.J.M.D.) - both in Belgium; and the Institute of Cardiovascular Science, Faculty of Population Health Sciences, and Health Data Research UK and Institute of Health Informatics, University College London, London (F.W.A.)
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Comparison of the Thrombogenicity of a Bare and Antithrombogenic Coated Flow Diverter in an In Vitro Flow Model. Cardiovasc Intervent Radiol 2019; 43:140-146. [PMID: 31410532 PMCID: PMC6940313 DOI: 10.1007/s00270-019-02307-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/05/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Dual antiplatelet therapy is a pre-requisite for flow diverter (FD) implantation. The purpose of this study was to assess the thrombogenicity of the p48 FD, coated with the newly developed phenox Hydrophilic Polymer Coating (p48_HPC, phenox GmbH, Germany) in comparison with uncoated p48 FDs in an in vitro flow model (Chandler Loop). METHODS p48 and p48_HPC FDs were implanted into silicon tubes filled with whole human blood and incubated at 37 °C under pulsating flow. After 120 min, platelet count was determined in the blood. Platelet activation markers (PAR1) and formation of microparticles were analyzed in a flow cytometer. Fluorescence microscopy of CD42a positive cells and scanning electron microscopy was used to detect adherent platelets on the wire surface. RESULTS Platelets in contact with the uncoated p48 FDs are significantly more activated than those incubated with p48_HPC (73 ± 9% vs. 65 ± 6%, p < 0.05) and release more microparticles (1.8 ± 0.5 vs. 1.4 ± 0.4, p < 0.05). The platelet count after 120-min circulation in the Chandler Loop was significantly lower for the uncoated p48 compared to the p48_HPC indicating significantly greater adherence of the platelets to the p48 (71 ± 8% vs. 87 ± 5%, p < 0.05). SEM and fluorescent antibody imaging revealed minimal platelet adherence to the surface of the p48_HPC compared to the uncoated p48. CONCLUSION The pHPC coating significantly reduces thrombogenicity of the p48 FD. This may help to reduce the risk of thromboembolic complications when using these devices. A reduction in antiplatelet therapy may be possible.
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Hein R, Gross L, Aradi D, Rieber J, Hadamitzky M, Merkely B, Huczek Z, Ince H, Hummel A, Baylacher M, Massberg S, Trenk D, Sibbing D. Diabetes and outcomes following guided de-escalation of antiplatelet treatment in acute coronary syndrome patients undergoing percutaneous coronary intervention: a pre-specified analysis from the randomised TROPICAL-ACS trial. EUROINTERVENTION 2019; 15:e513-e521. [PMID: 31012853 DOI: 10.4244/eij-d-18-01077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS A guided de-escalation of P2Y12 inhibitor treatment is considered an alternative treatment strategy in ACS patients undergoing PCI. However, the safety and efficacy of this strategy may differ in diabetic vs non-diabetic patients. The aim of this study was to compare the outcomes of platelet function testing (PFT)-guided de-escalation of dual antiplatelet therapy (DAPT) in ACS patients with and without diabetes mellitus. METHODS AND RESULTS The TROPICAL-ACS trial randomised 2,610 biomarker-positive ACS patients 1:1 to either standard treatment with prasugrel for 12 months (control group) or PFT-guided DAPT de-escalation. The association and interaction of diabetes on clinical endpoints across treatment groups and on platelet reactivity was investigated. In diabetic patients (n=527, 20.2%), the overall event rates were high and the one-year incidence of the primary endpoint (cardiovascular death, myocardial infarction, stroke or bleeding ≥grade 2) did not differ between guided de-escalation and control group patients (12.5% vs 10.8%; HR 1.17, 95% CI: 0.71-1.93, p=0.55). In non-diabetic patients (n=2,083, 79.8%), the one-year incidence of the primary endpoint was lower in the guided de-escalation vs control group (6.1% vs 8.5%; HR 0.71, 95% CI: 0.52-0.99, p=0.04, pint=0.10). Diabetic patients showed higher platelet reactivity levels in both control (=on prasugrel, p=0.01) and guided de-escalation group (=on clopidogrel, p=0.005) patients. CONCLUSIONS Although diabetic status did not significantly interfere with the treatment effects of guided DAPT de-escalation, our results suggest that this approach might be safe and effective in non-diabetic patients. Further investigation is definitely warranted in diabetic patients.
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Affiliation(s)
- Ralph Hein
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
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Dawwas GK, Dietrich E, Winchester DE, Winterstein AG, Segal R, Park H. Comparative Effectiveness and Safety of Ticagrelor versus Prasugrel in Patients with Acute Coronary Syndrome: A Retrospective Cohort Analysis. Pharmacotherapy 2019; 39:912-920. [DOI: 10.1002/phar.2311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Ghadeer K. Dawwas
- Department of Biostatistics, Epidemiology and Informatics Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania
| | - Erich Dietrich
- Department of Pharmacotherapy and Translational Research College of Pharmacy University of Florida Gainesville Florida
| | - David E. Winchester
- Division of Cardiovascular Medicine College of Medicine University of Florida Gainesville Florida
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy College of Pharmacy University of Florida Gainesville Florida
| | - Richard Segal
- Department of Pharmaceutical Outcomes and Policy College of Pharmacy University of Florida Gainesville Florida
| | - Haesuk Park
- Department of Pharmaceutical Outcomes and Policy College of Pharmacy University of Florida Gainesville Florida
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Ribera A, Ferreira-Gonzalez I, Marsal JR, Oristrell G, Faixedas MT, Rosas A, Tizón-Marcos H, Rojas S, Labata C, Cardenas M, Homs S, Tomas-Querol C, Garcia-Picart J, Gomez-Hospital JA, Pijoan JI, Masotti M, Mauri J, Garcia Dorado D. Persistence with dual antiplatelet therapy after percutaneous coronary intervention for ST-segment elevation acute coronary syndrome: a population-based cohort study in Catalonia (Spain). BMJ Open 2019; 9:e028114. [PMID: 31340964 PMCID: PMC6661631 DOI: 10.1136/bmjopen-2018-028114] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Guidelines recommending 12-month dual antiplatelet therapy (DAPT) in patients with ST-elevation acute coronary syndrome (STEACS) undergoing percutaneous coronary intervention (PCI) were published in year 2012. We aimed to describe the influence of guideline implementation on the trend in 12-month persistence with DAPT between 2010 and 2015 and to evaluate its relationship with DAPT duration regimens recommended at discharge from PCI hospitals. DESIGN Observational study based on region-wide registry data linked to pharmacy billing data for DAPT follow-up. SETTING All PCI hospitals (10) belonging to the acute myocardial infarction (AMI) code network in Catalonia (Spain). PARTICIPANTS 10 711 STEACS patients undergoing PCI between 2010 and 2015 were followed up. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome was 12-month persistence with DAPT. Calendar year quarter, publication of guidelines, DAPT duration regimen recommended in the hospital discharge report, baseline patient characteristics and significant interactions were included in mixed-effects logistic regression based interrupted time-series models. RESULTS The proportion of patients on-DAPT at 12 months increased from 58% (56-60) in 2010 to 73% (71-75) in 2015. The rate of 12-month persistence with DAPT significantly increased after the publication of clinical guidelines with a time lag of 1 year (OR=1.20; 95% CI 1.11 to 1.30). A higher risk profile, more extensive and complex coronary disease, use of drug-eluting stents (OR=1.90; 95% CI 1.50 to 2.40) and a 12-month DAPT regimen recommendation at discharge from the PCI hospital (OR=5.76; 95% CI 3.26 to 10.2) were associated with 12-month persistence. CONCLUSION Persistence with 12-month DAPT has increased since publication of clinical guidelines. Even though most patients were discharged on DAPT, only 73% with potential indication were on-DAPT 12 months after PCI. A guideline-based recommendation at PCI hospital discharge was highly associated with full persistence with DAPT. Establishing evidence-based, common prescribing criteria across hospitals in the AMI-network would favour adherence and reduce variability.
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Affiliation(s)
- Aida Ribera
- Cardiology Department, Vall d’Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública CIBERESP, The Spanish Health Institute (ISCIII), Spain
| | - Ignacio Ferreira-Gonzalez
- Cardiology Department, Vall d’Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública CIBERESP, The Spanish Health Institute (ISCIII), Spain
| | - Josep Ramon Marsal
- Cardiology Department, Vall d’Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública CIBERESP, The Spanish Health Institute (ISCIII), Spain
| | - Gerard Oristrell
- Cardiology Department, Vall d’Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red para Enfermedades Cardiovasculares CIBERCV, Spanish Health Institute (ISCIII), Spain
| | | | - Alba Rosas
- Departament de Salut, Generalitat de Catalunya, Barcelona, Spain
| | - Helena Tizón-Marcos
- Cardiology Department, Hospital del Mar, and Heart Diseases Biomedical Research Group and IMIM (Hospital del Mar Medical Research Institute), Faculty of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Sergio Rojas
- Cardiology Department, Hospital Universitari de Tarragona Joan XXIII, IISPV, Universidad Rovira Virgili, Tarragona, Spain
| | - Carlos Labata
- Cardiology Department, Hospital Germans Trias i Pujol, Badalona, Spain
| | | | - Silvia Homs
- Cardiology Department, Hospital Mútua de Terrassa, Barcelona, Spain
| | | | - Joan Garcia-Picart
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Jose Ignacio Pijoan
- Clinical Epidemiology Unit, Hospital Universitario de Cruces. Biocruces Bizkaia Health Research Institute, Bilbao, Spain
- Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública CIBERESP, The Spanish Health Institute (ISCIII), Spain
| | - Monica Masotti
- Institut Clínic Cardio vascular (ICCV), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Josepa Mauri
- Departament de Salut, Generalitat de Catalunya, Barcelona, Spain
- Cardiology Department, Hospital Germans Trias i Pujol, Badalona, Spain
| | - David Garcia Dorado
- Cardiology Department, Vall d’Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red para Enfermedades Cardiovasculares CIBERCV, Spanish Health Institute (ISCIII), Spain
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Pufulete M, Harris J, Sterne JAC, Johnson TW, Lasserson D, Mumford A, Doble B, Wordsworth S, Benedetto U, Rogers CA, Loke Y, Pithara C, Redwood S, Reeves BC. Comprehensive ascertainment of bleeding in patients prescribed different combinations of dual antiplatelet therapy (DAPT) and triple therapy (TT) in the UK: study protocol for three population-based cohort studies emulating 'target trials' (the ADAPTT Study). BMJ Open 2019; 9:e029388. [PMID: 31167875 PMCID: PMC6561407 DOI: 10.1136/bmjopen-2019-029388] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/04/2019] [Accepted: 03/12/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION 'Real world' bleeding in patients exposed to different regimens of dual antiplatelet therapy (DAPT) and triple therapy (TT, DAPT plus an anticoagulant) have a clinical and economic impact but have not been previously quantified. METHODS AND ANALYSIS We will use linked Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) data to assemble populations eligible for three 'target trials' in patient groups: percutaneous coronary intervention (PCI); coronary artery bypass grafting (CABG); conservatively managed (medication only) acute coronary syndrome (ACS). Patients ≥18 years old will be eligible if, in CPRD records, they have: ≥1 year of data before the index event; no prescription for DAPT or anticoagulants in the preceding 3 months; a prescription for aspirin or DAPT within 2 months after discharge from the index event. The primary outcome will be any bleeding event (CPRD or HES) up to 12 months after the index event. We will estimate adjusted HR for time to first bleeding event comparing: aspirin and clopidogrel (reference) versus aspirin and prasugrel or aspirin and ticagrelor after PCI; and aspirin (reference) versus aspirin and clopidogrel after CABG and ACS. We will describe rates of bleeding in patients prescribed TT (DAPT plus an anticoagulant). Potential confounders will be identified systematically using literature review, semistructured interviews with clinicians and a short survey of clinicians. We will conduct sensitivity analyses addressing the robustness of results to the study's main limitation-that we will not be able to identify the intervention group for patients whose bleeding event occurs before a DAPT prescription in CPRD. ETHICS AND DISSEMINATION This protocol was approved by the Independent Scientific Advisory Committee for the UK Medicines and Healthcare Products Regulatory Agency Database Research (protocol 16_126R) and the South West Cornwall and Plymouth Research Ethics Committee (17/SW/0092). The findings will be presented in peer-reviewed journals, lay summaries and briefing papers to commissioners/other stakeholders. TRIAL REGISTRATION NUMBER 76607611; Pre-results.
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Affiliation(s)
- Maria Pufulete
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Jessica Harris
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Jonathan A C Sterne
- NIHR Biomedical Research Centre, Department of Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Daniel Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Andrew Mumford
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Brett Doble
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford UK
| | | | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Christalla Pithara
- Ethnography Research Team, National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), Bristol, UK
| | - Sabi Redwood
- Ethnography Research Team, National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
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Dhindsa DS, Khambhati J, Schultz WM, Tahhan AS, Quyyumi AA. Marital status and outcomes in patients with cardiovascular disease. Trends Cardiovasc Med 2019; 30:215-220. [PMID: 31204239 DOI: 10.1016/j.tcm.2019.05.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 04/28/2019] [Accepted: 05/28/2019] [Indexed: 11/15/2022]
Abstract
The national burden of cardiovascular disease (CVD) continues to impose significant risk of morbidity, mortality and increased costs. While traditional risk factors have been well-established, the evolving role of non-traditional risk factors, including socioeconomic and psychosocial factors, is increasingly being recognized. Several studies have acknowledged an association between marital status and the presence of CVD and its associated adverse outcomes. Across multiple U.S. and international cohorts, patients who are unmarried, including those who are divorced, separated, widowed, or never married, have an increased rate of adverse cardiovascular events when compared to their married counterparts. Some studies suggest that marriage may have a more protective role for men compared to women. Furthermore, dissatisfaction in a marriage and marriage quality have significant impact on cardiovascular risk. Psychosocial and socioeconomic factors, as well as other acute stressors, may contribute to the association between marital status and CVD outcomes, but the underlying mechanisms are not completely clear. Further investigation is required to identify potential targets for intervention and to determine whether more aggressive targeting of standard anti-atherosclerotic therapies can favorably impact CVD risk in unmarried patients.
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Affiliation(s)
- Devinder Singh Dhindsa
- Emory Clinical Cardiovascular Resaerch Institute, Emory University School of Medicine, Atlanta, GA, United States
| | - Jay Khambhati
- Emory Clinical Cardiovascular Resaerch Institute, Emory University School of Medicine, Atlanta, GA, United States
| | - William M Schultz
- Division of Cardiology, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, United States
| | - Ayman Samman Tahhan
- Emory Clinical Cardiovascular Resaerch Institute, Emory University School of Medicine, Atlanta, GA, United States
| | - Arshed A Quyyumi
- Emory Clinical Cardiovascular Resaerch Institute, Emory University School of Medicine, Atlanta, GA, United States.
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Adherence to Antiplatelet Therapy after Coronary Intervention among Patients with Myocardial Infarction Attending Vietnam National Heart Institute. BIOMED RESEARCH INTERNATIONAL 2019; 2019:6585040. [PMID: 31179331 PMCID: PMC6507076 DOI: 10.1155/2019/6585040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 03/26/2019] [Accepted: 04/14/2019] [Indexed: 11/17/2022]
Abstract
Adherence to antiplatelet therapy is critical to successful treatment of cardiovascular conditions. However, little has been known about this issue in the context of constrained resources such as in Vietnam. The objective of this study was to examine the adherence to antiplatelet therapy among patients receiving acute myocardial infarction interventions and its associated factors. In a cross-sectional survey design, 175 adult patients revisiting Vietnam National Heart Institute diagnosed with acute myocardial infarction were approached for data collection from October 2014 to June 2015. Adherence to antiplatelet therapy was assessed by asking patients whether they took taking antiplatelet regularly as per medication (do not miss any dose at the specified time) for any type of antiplatelet (aspirin, clopidogrel, ticlopidine...) during the last month before the participants came back to take re-examinations. The results indicated that the adherence to antiplatelet therapy among patients was quite high at 1 month; it begins to decline by 6 months, 12 months, and more than 12 months (less than 1 month was 90.29%; from 1 to 6 months 88.0%, from 6 to 12 months 75.43%, and after 12 months only 46.29% of patients). Multivariable logistic regression was utilized to detect factors associated with the adherence to antiplatelet therapy. It showed that patients with average income per month of $300 or more (OR=2.92, 95% CI=1.24-6.89), distance to the hospital of less than 50km (OR=2.48, 95% CI: 1.12-5.52), taking medicine under doctor's instructions (OR=3.65; 95% CI=1.13-11.70), and timely re-examination (OR=3.99, 95% CI=1.08-14.73) were more likely to follow the therapy. In general, the study suggested that to increase the likelihood of adherence to antiplatelet therapy it is important to establish a continuous care system after discharging from hospital.
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Wang TY, Kaltenbach LA, Cannon CP, Fonarow GC, Choudhry NK, Henry TD, Cohen DJ, Bhandary D, Khan ND, Anstrom KJ, Peterson ED. Effect of Medication Co-payment Vouchers on P2Y12 Inhibitor Use and Major Adverse Cardiovascular Events Among Patients With Myocardial Infarction: The ARTEMIS Randomized Clinical Trial. JAMA 2019; 321:44-55. [PMID: 30620370 PMCID: PMC6583585 DOI: 10.1001/jama.2018.19791] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Despite guideline recommendations, many patients discontinue P2Y12 inhibitor therapy earlier than the recommended 1 year after myocardial infarction (MI), and higher-potency P2Y12 inhibitors are underutilized. Cost is frequently cited as an explanation for both of these observations. OBJECTIVE To determine whether removing co-payment barriers increases P2Y12 inhibitor persistence and lowers risk of major adverse cardiovascular events (MACE). DESIGN, SETTING, AND PARTICIPANTS Cluster randomized clinical trial among 301 hospitals enrolling adult patients with acute MI (June 5, 2015, through September 30, 2016); patients were followed up for 1 year after discharge (final date of follow-up was October 23, 2017), with blinded adjudication of MACE; choice of P2Y12 inhibitor was per clinician discretion. INTERVENTIONS Hospitals randomized to the intervention (n = 131 [6436 patients]) provided patients with co-payment vouchers for clopidogrel or ticagrelor for 1 year (median voucher value for a 30-day supply, $137 [25th-75th percentile, $20-$339]). Hospitals randomized to usual care (n = 156 [4565 patients]) did not provide study vouchers. MAIN OUTCOMES AND MEASURES Independent coprimary outcomes were patient-reported persistence with P2Y12 inhibitor (defined as continued treatment without gap in use ≥30 days) and MACE (death, recurrent MI, or stroke) at 1 year among patients discharged with a prescription for clopidogrel or ticagrelor. RESULTS Among 11 001 enrolled patients (median age, 62 years; 3459 [31%] women), 10 102 patients were discharged with prescriptions for clopidogrel or ticagrelor (clopidogrel prescribed to 2317 [36.0%] in the intervention group and 2497 [54.7%] in the usual care group), 4393 of 6135 patients (72%) in the intervention group used the voucher, and follow-up data at 1 year were available for 10 802 patients (98.2%). Patient-reported persistence with P2Y12 inhibitors at 1 year was higher in the intervention group than in the control group (unadjusted rates, 5340/6135 [87.0%] vs 3324/3967 [83.8%], respectively; P < .001; adjusted difference, 2.3% [95% CI, 0.4% to 4.1%]; adjusted odds ratio, 1.19 [95% CI, 1.02 to 1.40]). There was no significant difference in MACE at 1 year between intervention and usual care groups (unadjusted cumulative incidence, 10.2% vs 10.6%; P = .65; adjusted difference, 0.66% [95% CI, -0.73% to 2.06%]; adjusted hazard ratio, 1.07 [95% CI, 0.93 to 1.25]). CONCLUSIONS AND RELEVANCE Among patients with MI, provision of vouchers to offset medication co-payments for P2Y12 inhibitors, compared with no vouchers, resulted in a 3.3% absolute increase in patient-reported persistence with P2Y12 inhibitors and no significant reduction in 1-year MACE outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02406677.
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Affiliation(s)
- Tracy Y. Wang
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | | | | | - David J. Cohen
- Saint Luke’s Mid America Heart Institute, University of Missouri–Kansas City School of Medicine
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Schröder SL, Fink A, Richter M. Socioeconomic differences in experiences with treatment of coronary heart disease: a qualitative study from the perspective of elderly patients. BMJ Open 2018; 8:e024151. [PMID: 30429146 PMCID: PMC6252635 DOI: 10.1136/bmjopen-2018-024151] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES This qualitative study aims to analyse socioeconomic differences in patients' experiences along the treatment pathway for coronary heart disease (CHD). DESIGN A longitudinal qualitative study using in-depth semistructured interviews to explore patients' experiences with treatment was conducted. We analysed the transcripts of the records according to qualitative content analysis and identified differences between patients with lower and higher socioeconomic status (SES) by comparing and contrasting the narratives. SETTING The University Hospital in Halle (Saale), Germany. PARTICIPANTS 41 elderly patients (aged 59-80 years) who suffered from CHD. RESULTS From various patient's experiences along the pathway of care which were found to differ according to SES we derived three major themes: (1) information: patients with higher SES had greater knowledge about treatment and could use medical records as sources of information; (2) illness perception: patients with lower SES focused on improving symptoms and survival, while patients with higher SES focused on physical performance and disease management; and (3) perceived role in healthcare: patients with lower SES tended to delegate responsibility to healthcare professionals. CONCLUSIONS Differences in the patient's knowledge about treatment, their perceived role in healthcare and illness perception can be the factors and mechanisms that contribute to explain socioeconomic inequalities in the treatment of CHD. These factors should be considered in quantitative studies to better understand the disparities in treatment and mortality. We suggest that improving patient-physician communication and patient knowledge can change the patient's understanding of CHD and their perceived role in healthcare and reduce inequalities in CHD treatment. TRIAL REGISTRATION NUMBER DRKS00007839.
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Affiliation(s)
- Sara Lena Schröder
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Medical Faculty, Halle (Saale), Germany
| | - Astrid Fink
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Medical Faculty, Halle (Saale), Germany
| | - Matthias Richter
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Medical Faculty, Halle (Saale), Germany
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Kheiri B, Osman M, Abdalla A, Chahine A, Ahmed S, Osman K, Bachuwa G, Hassan M, Bhatt DL. De-Escalation of Antiplatelet Therapy in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Clinical Trials. J Cardiovasc Pharmacol Ther 2018; 24:153-159. [PMID: 30419754 DOI: 10.1177/1074248418809098] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AIMS Patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI) are recommended to be placed on potent P2Y12 blockade. However, the long-term bleeding risk is high. Therefore, despite no definitive evidence, switching to clopidogrel beyond the acute phase is common. We aimed to evaluate the clinical outcomes of antiplatelet de-escalation compared with continuation in patients treated with PCI. METHODS We searched databases for randomized clinical trials (RCTs) that evaluated the safety and efficacy of antiplatelet de-escalation compared with continuation in patients treated with PCI. Pooled summary estimates were calculated. RESULTS We included 3 RCTs with 3391 patients (median follow-up: 12 months). Compared with the continued group, the net clinical outcome (composite of bleeding or thrombotic events) was significantly reduced in the group switched to clopidogrel (8.7% vs 12.1%; risk ratio [RR]: 0.64; 95% confidence interval [CI]: 0.43-0.97; P = .03). However, there were similar clinical outcomes between groups for major adverse cardiovascular events (MACE; RR: 0.78; 95% CI: 0.55-1.11; P = .17), all Bleeding Academic Research Consortium (BARC) types bleeding (RR: 0.61; 95% CI: 0.33-1.11; P = .10), or BARC types ≥2 bleeding (RR: 0.49; 95% CI: 0.19-1.26; P = .14). CONCLUSIONS Our results suggest a net clinical benefit of de-escalation therapy shortly after PCI, without increased risk of MACE. Larger randomized trials will be necessary to confirm these findings.
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Affiliation(s)
- Babikir Kheiri
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Mohammed Osman
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Ahmed Abdalla
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Adam Chahine
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Sahar Ahmed
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Khansa Osman
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Ghassan Bachuwa
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Mustafa Hassan
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
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44
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Ferrières J, Lautsch D, Ambegaonkar BM, De Ferrari GM, Vyas A, Baxter CA, Bash LD, Velkovski-Rouyer M, Horack M, Almahmeed W, Chiang FT, Poh KK, Elisaf M, Brudi P, Gitt AK. Use of guideline-recommended management in established coronary heart disease in the observational DYSIS II study. Int J Cardiol 2018; 270:21-27. [DOI: 10.1016/j.ijcard.2018.06.008] [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: 01/05/2018] [Revised: 05/02/2018] [Accepted: 06/04/2018] [Indexed: 10/14/2022]
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45
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Tri S, Albers L, Koshman S, Bucci C, Kertland H, Semchuk B. Dual antiplatelet therapy: A new whiteboard video for patient education. Can Pharm J (Ott) 2018; 151:368-371. [PMID: 30559910 DOI: 10.1177/1715163518802866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Samantha Tri
- Department of Pharmacy Services (Tri, Albers, Semchuk), Regina General Hospital and Pasqua Hospital, Regina, Saskatchewan.,Division of Cardiology (Koshman), Department of Medicine, University of Alberta, Edmonton, Alberta.,Department of Pharmacy (Bucci), Sunnybrook Health Sciences Centre, Toronto.,Department of Pharmacy (Kertland), St. Michael's Hospital, Toronto, Ontario
| | - Lori Albers
- Department of Pharmacy Services (Tri, Albers, Semchuk), Regina General Hospital and Pasqua Hospital, Regina, Saskatchewan.,Division of Cardiology (Koshman), Department of Medicine, University of Alberta, Edmonton, Alberta.,Department of Pharmacy (Bucci), Sunnybrook Health Sciences Centre, Toronto.,Department of Pharmacy (Kertland), St. Michael's Hospital, Toronto, Ontario
| | - Sheri Koshman
- Department of Pharmacy Services (Tri, Albers, Semchuk), Regina General Hospital and Pasqua Hospital, Regina, Saskatchewan.,Division of Cardiology (Koshman), Department of Medicine, University of Alberta, Edmonton, Alberta.,Department of Pharmacy (Bucci), Sunnybrook Health Sciences Centre, Toronto.,Department of Pharmacy (Kertland), St. Michael's Hospital, Toronto, Ontario
| | - Claudia Bucci
- Department of Pharmacy Services (Tri, Albers, Semchuk), Regina General Hospital and Pasqua Hospital, Regina, Saskatchewan.,Division of Cardiology (Koshman), Department of Medicine, University of Alberta, Edmonton, Alberta.,Department of Pharmacy (Bucci), Sunnybrook Health Sciences Centre, Toronto.,Department of Pharmacy (Kertland), St. Michael's Hospital, Toronto, Ontario
| | - Heather Kertland
- Department of Pharmacy Services (Tri, Albers, Semchuk), Regina General Hospital and Pasqua Hospital, Regina, Saskatchewan.,Division of Cardiology (Koshman), Department of Medicine, University of Alberta, Edmonton, Alberta.,Department of Pharmacy (Bucci), Sunnybrook Health Sciences Centre, Toronto.,Department of Pharmacy (Kertland), St. Michael's Hospital, Toronto, Ontario
| | - Bill Semchuk
- Department of Pharmacy Services (Tri, Albers, Semchuk), Regina General Hospital and Pasqua Hospital, Regina, Saskatchewan.,Division of Cardiology (Koshman), Department of Medicine, University of Alberta, Edmonton, Alberta.,Department of Pharmacy (Bucci), Sunnybrook Health Sciences Centre, Toronto.,Department of Pharmacy (Kertland), St. Michael's Hospital, Toronto, Ontario
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46
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Pettersen TR, Fridlund B, Bendz B, Nordrehaug JE, Rotevatn S, Schjøtt J, Norekvål TM. Challenges adhering to a medication regimen following first-time percutaneous coronary intervention: A patient perspective. Int J Nurs Stud 2018; 88:16-24. [PMID: 30165236 DOI: 10.1016/j.ijnurstu.2018.07.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 07/19/2018] [Accepted: 07/24/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Percutaneous coronary intervention is the most common therapeutic intervention for patients with narrowed coronary arteries due to coronary artery disease. Although it is known that patients with coronary artery disease often do not adhere to their medication regimen, little is known about what patients undergoing percutaneous coronary interventions find challenging in adhering to their medication regimen after hospital discharge. OBJECTIVES To explore patients' experiences in adhering to medications following early post-discharge after first-time percutaneous coronary intervention. DESIGN An abductive qualitative approach was used to conduct in-depth interviews of patients undergoing first-time percutaneous coronary intervention. SETTINGS Participants were recruited from a single tertiary university hospital, which services a large geographical area in western Norway. Patients fulfilling the inclusion criteria were identified through the Norwegian Registry for Invasive Cardiology. PARTICIPANTS Participants were patients aged 18 years or older who had their first percutaneous coronary intervention six to nine months earlier, were living at home at the time of study inclusion, and were prescribed dual antiplatelet therapy. Patients who were cognitively impaired, had previously undergone cardiac surgery, and/or were prescribed anticoagulation therapy with warfarin or novel oral anticoagulants were excluded. Purposeful sampling was used to include patients of different gender, age, and geographic settings. Twenty-two patients (12 men) were interviewed between December 2016 and April 2017. METHODS Face-to-face semi-structured interviews were conducted, guided by a set of predetermined open-ended questions to gather patient experiences on factors relating to medication adherence or non-adherence. Transcribed interviews were analysed by qualitative content analysis. FINDINGS Patients failed to adhere to their medication regimen for several reasons; intentional and unintentional reasons, multifaceted side effects from heart medications, scepticism towards generic drugs, lack of information regarding seriousness of disease after percutaneous coronary intervention, psychological impact of living with coronary artery disease, and these interacted. There were patients who felt that the medication information they received from physicians and nurses was uninformative and inadequate. Side effects from heart medications were common, ranging from minor ones to more disabling side effects, such as severe muscle and joint pain and fatigue. Patients found well established medication taking routines and aids to be necessary, and these improved adherence. CONCLUSION Patients undergoing first-time percutaneous coronary intervention face multiple, interacting challenges in trying to adhere to prescribed medications following discharge. This study highlights the need for a more structured follow-up care in order to improve medication adherence and to maximise their self-care abilities.
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Affiliation(s)
- Trond R Pettersen
- Department of Heart Disease, Haukeland University Hospital, Box 1400, 5021 Bergen, Norway.
| | - Bengt Fridlund
- Department of Heart Disease, Haukeland University Hospital, Box 1400, 5021 Bergen, Norway; Centre of Interprofessional Cooperation within Emergency Care (CICE), Linnaeus University, 351 95 Växjö, Sweden.
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital, Sognsvannsveien 20, 0372 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, P.O. Box 1171, Blindern, 0318 Oslo, Norway.
| | - Jan Erik Nordrehaug
- Department of Cardiology, Stavanger University Hospital, P.O. Box 8100, 4068 Stavanger, Norway; Department of Clinical Science, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway.
| | - Svein Rotevatn
- Department of Heart Disease, Haukeland University Hospital, Box 1400, 5021 Bergen, Norway.
| | - Jan Schjøtt
- Department of Clinical Science, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway; Section of Clinical Pharmacology, Laboratory of Clinical Biochemistry, Haukeland University Hospital, Box 1400, 5021 Bergen, Norway.
| | - Tone M Norekvål
- Department of Heart Disease, Haukeland University Hospital, Box 1400, 5021 Bergen, Norway; Department of Clinical Science, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway.
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47
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Krumme AA, Glynn RJ, Schneeweiss S, Choudhry NK, Tong AY, Gagne JJ. Defining Exposure in Observational Studies Comparing Outcomes of Treatment Discontinuation. Circ Cardiovasc Qual Outcomes 2018; 11:e004684. [DOI: 10.1161/circoutcomes.118.004684] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/21/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Alexis A. Krumme
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
- Harvard TH Chan School of Public Health, Boston, MA (A.A.K., S.S., J.J.G.)
| | - Robert J. Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
- Harvard TH Chan School of Public Health, Boston, MA (A.A.K., S.S., J.J.G.)
| | - Niteesh K. Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
| | - Angela Y. Tong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
| | - Joshua J. Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
- Harvard TH Chan School of Public Health, Boston, MA (A.A.K., S.S., J.J.G.)
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48
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Dayoub EJ, Seigerman M, Tuteja S, Kobayashi T, Kolansky DM, Giri J, Groeneveld PW. Trends in Platelet Adenosine Diphosphate P2Y12 Receptor Inhibitor Use and Adherence Among Antiplatelet-Naive Patients After Percutaneous Coronary Intervention, 2008-2016. JAMA Intern Med 2018; 178:943-950. [PMID: 29799992 PMCID: PMC6145718 DOI: 10.1001/jamainternmed.2018.0783] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Current guidelines recommend prasugrel hydrochloride and ticagrelor hydrochloride as preferred therapies for patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI). However, it is not well known how frequently these newer agents are being used in clinical practice or how adherence varies among the platelet adenosine diphosphate P2Y12 receptor (P2Y12) inhibitors. OBJECTIVES To determine trends in use of the different P2Y12 inhibitors in patients who underwent PCI from 2008 to 2016 in a large cohort of commercially insured patients and differences in patient adherence and costs among the P2Y12 inhibitors. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study used administrative claims from a large US national insurer (ie, UnitedHealthcare) from January 1, 2008, to December 1, 2016, comprising patients aged 18 to 64 years hospitalized for PCI who had not received a P2Y12 inhibitor for 90 days preceding PCI. The P2Y12 inhibitor filled within 30 days of discharge was identified from pharmacy claims. MAIN OUTCOMES AND MEASURES Proportion of patients filling prescriptions for P2Y12 inhibitors within 30 days of discharge by year, as well as medication possession ratios (MPRs) and total P2Y12 inhibitor copayments at 6 and 12 months for patients who received drug-eluting stents. RESULTS A total of 55 340 patients (12 754 [23.0%] women; mean [SD] age, 54.4 [7.1] years) who underwent PCI were included in this study. In 2008, 7667 (93.6%) patients filled a prescription for clopidogrel bisulfate and 521 (6.4%) filled no P2Y12 inhibitor prescription within 30 days of hospitalization. In 2016, 2406 (44.0%) patients filled clopidogrel prescriptions, 2015 (36.9%) filled either prasugrel or ticagrelor prescriptions, and 1045 (19.1%) patients filled no P2Y12 inhibitor prescription within 30 days of hospitalization. At 6 months, mean MPRs for patients who received a drug-eluting stent filling clopidogrel, prasugrel, and ticagrelor prescriptions were 0.85 (interquartile range [IQR], 0.82-1.00), 0.79 (IQR, 0.66-1.00), and 0.76 (IQR, 0.66-0.98) (P < .001), respectively; mean copayments for a 6 months' supply were $132 (IQR, $47-$203), $287 (IQR, $152-$389), and $265 (IQR, $53-$387) (P < .001), respectively. At 12 months, mean MPRs for clopidogrel, prasugrel, and ticagrelor were 0.76 (IQR, 0.58-0.99), 0.71 (IQR, 0.49-0.98), and 0.68 (IQR, 0.41-0.94) (P < .001), respectively; mean total copayments were $251 (IQR, $100-$371), $556 (IQR, $348-$730), and $557 (IQR, $233-$744) (P < .001), respectively. CONCLUSIONS AND RELEVANCE Between 2008 and 2016, increased use of prasugrel and ticagrelor was accompanied by increased nonfilling of prescriptions for P2Y12 inhibitors within 30 days of discharge. Prasugrel and ticagrelor had higher patient costs and lower adherence in the year following PCI compared with clopidogrel. The introduction of newer, more expensive P2Y12 inhibitors was associated with lower adherence to these therapies.
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Affiliation(s)
- Elias J Dayoub
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Matthew Seigerman
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Sony Tuteja
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Taisei Kobayashi
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia.,Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Daniel M Kolansky
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Jay Giri
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia.,Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Peter W Groeneveld
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia.,Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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Gulizia MM, Colivicchi F, Abrignani MG, Ambrosetti M, Aspromonte N, Barile G, Caporale R, Casolo G, Chiuini E, Di Lenarda A, Faggiano P, Gabrielli D, Geraci G, La Manna AG, Maggioni AP, Marchese A, Massari FM, Mureddu GF, Musumeci G, Nardi F, Panno AV, Pedretti RFE, Piredda M, Pusineri E, Riccio C, Rossini R, di Uccio FS, Urbinati S, Varbella F, Zito GB, De Luca L. Consensus Document ANMCO/ANCE/ARCA/GICR-IACPR/GISE/SICOA: Long-term Antiplatelet Therapy in Patients with Coronary Artery Disease. Eur Heart J Suppl 2018; 20:F1-F74. [PMID: 29867293 PMCID: PMC5978022 DOI: 10.1093/eurheartj/suy019] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of pharmacologic management of patients with acute coronary syndrome (ACS) and/or those receiving coronary stents. Long-term (>1 year) DAPT may further reduce the risk of stent thrombosis after a percutaneous coronary intervention (PCI) and may decrease the occurrence of non-stent-related ischaemic events in patients with ACS. Nevertheless, compared with aspirin alone, extended use of aspirin plus a P2Y12 receptor inhibitor may increase the risk of bleeding events that have been strongly linked to adverse outcomes including recurrent ischaemia, repeat hospitalisation and death. In the past years, multiple randomised trials have been published comparing the duration of DAPT after PCI and in ACS patients, investigating either a shorter or prolonged DAPT regimen. Although the current European Society of Cardiology guidelines provide a backup to individualised treatment, it appears to be difficult to identify the ideal patient profile which could safely reduce or prolong the DAPT duration in daily clinical practice. The aim of this consensus document is to review contemporary literature on optimal DAPT duration, and to guide clinicians in tailoring antiplatelet strategies in patients undergoing PCI or presenting with ACS.
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Affiliation(s)
- Michele Massimo Gulizia
- U.O.C. di Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Furio Colivicchi
- U.O.C. Cardiologia e UTIC, Ospedale San Filippo Neri, Roma, Italy
| | | | - Marco Ambrosetti
- Servizio di Cardiologia Riabilitativa, Clinica Le Terrazze Cunardo, Varese, Italy
| | - Nadia Aspromonte
- U.O. Scompenso e Riabilitazione Cardiologica, Polo Scienze Cardiovascolari, Toraciche, Policlinico Agostino Gemelli, Roma, Italy
| | | | - Roberto Caporale
- U.O.C. Cardiologia Interventistica, Ospedale Annunziata, Cosenza, Italy
| | - Giancarlo Casolo
- S.C. Cardiologia, Nuovo Ospedale Versilia, Lido di Camaiore (LU), Italy
| | - Emilia Chiuini
- Specialista Ambulatoriale Cardiologo, ASL Umbria 1, Perugia, Italy
| | - Andrea Di Lenarda
- S.C. Cardiovascolare e Medicina dello Sport, Azienda Sanitaria Universitaria Integrata di Trieste, Italy
| | | | - Domenico Gabrielli
- ASUR Marche - Area Vasta 4 Fermo, Ospedale Civile Augusto Murri, Fermo, Italy
| | - Giovanna Geraci
- U.O.C. Cardiologia Azienda Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | | | | | | | - Ferdinando Maria Massari
- U.O.C. Malattie Cardiovascolari "Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | | | | | - Federico Nardi
- S.C. Cardiologia, Ospedale Santo Spirito, Casale Monferrato (AL), Italy
| | | | | | - Massimo Piredda
- Centro Cardiotoracico, Divisione di Cardiologia, Istituto Clinico Sant'Ambrogio, Milano, Italy
| | - Enrico Pusineri
- U.O.C. di Cardiologia, Ospedale Civile di Vigevano, A.S.S.T., Pavia, Italy
| | - Carmine Riccio
- Prevenzione e Riabilitazione Cardiopatico, AZ. Ospedaliera S. Anna e S. Sebastiano, Caserta, Italy
| | | | | | - Stefano Urbinati
- U.O.C. Cardiologia, Ospedale Bellaria, AUSL di Bologna, Bologna, Italy
| | | | | | - Leonardo De Luca
- U.O.C. Cardiologia, Ospedale San Giovanni Evangelista, Tivoli, Roma, Italy
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50
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Ghosh‐Swaby OR, Tan M, Bagai A, Yan AT, Goodman SG, Mehta SR, Fisher HN, Cohen EA, Huynh T, Cantor WJ, Le May MR, Déry J, Welsh RC, Udell JA. Marital status and outcomes after myocardial infarction: Observations from the Canadian Observational Antiplatelet Study (COAPT). Clin Cardiol 2018; 41:285-292. [PMID: 29574993 PMCID: PMC6490065 DOI: 10.1002/clc.22901] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 11/10/2022] Open
Abstract
While divorced or living alone, patients with stable cardiovascular disease are at increased risk for adverse cardiovascular events. The importance of marital status following a myocardial infarction (MI) is less clear. We hypothesized that marital status may affect cardiovascular outcomes following MI. We analyzed outcomes among patients with MI who underwent percutaneous coronary intervention from the Canadian Observational Antiplatelet Study (COAPT). Marital status was categorized into 3 groups: married/common-law patients living together; never married; and divorced, separated, or widowed patients. Patients were followed for 15 months and our primary outcome was the occurrence of a major adverse cardiovascular event (MACE), defined as a composite of mortality, repeat acute MI, stroke, or urgent coronary revascularization. Multivariable logistic regression models were performed, with married/common-law patients living together considered the reference group. Among 2100 patients included in analyses, 1519 (72.3%) were married/common-law patients living together, 358 (17.1%) were separated/divorced/widowed, and 223 (10.6%) patients were never married. Dual antiplatelet therapy use after 15 months was similar across groups (75.4%, 77.8%, and 73.6%, respectively). The risk of MACE after 15 months was similar among married patients living together (12.7%; referent) compared with patients who were never married (13.9%; adjusted odds ratio: 1.09, 95% confidence interval: 0.58-2.07, P = 0.79) and patients separated/divorced/widowed (14.3%; adjusted odds ratio: 0.71, 95% confidence interval: 0.40-1.25, P = 0.23). Similarly, the risk of individual endpoints, including mortality, was similar across the 3 groups. Among patients stabilized following an MI, we found no association between marital status and 15-month outcomes.
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Affiliation(s)
- Olivia R. Ghosh‐Swaby
- Cardiovascular Division, Department of Medicine and Women's College Research InstituteWomen's College HospitalTorontoOntario
- Faculty of Medical Science, Schulich School of Medicine and DentistryWestern UniversityLondonOntario
| | - Mary Tan
- Canadian Heart Research CentreTorontoOntario
| | - Akshay Bagai
- Terrence Donnelly Heart CenterSt. Michael's Hospital, University of TorontoTorontoOntario
| | - Andrew T. Yan
- Terrence Donnelly Heart CenterSt. Michael's Hospital, University of TorontoTorontoOntario
| | - Shaun G. Goodman
- Canadian Heart Research CentreTorontoOntario
- Terrence Donnelly Heart CenterSt. Michael's Hospital, University of TorontoTorontoOntario
| | - Shamir R. Mehta
- Population Health Research Institute, Hamilton General HospitalMcMaster UniversityHamiltonOntario
| | - Harold N. Fisher
- Department of Clinical Research, Eli Lilly Canada Inc.TorontoOntario
| | - Eric A. Cohen
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntario
| | - Thao Huynh
- Department of Medicine, McGill University Health CentreMcGill UniversityMontréalQuébec
| | - Warren J. Cantor
- Division of Cardiology, Department of MedicineSouthlake Regional Health Centre and University of TorontoTorontoOntario
| | - Michel R. Le May
- Division of Cardiology, Department of MedicineUniversity of Ottawa Heart InstituteOttawaOntario
| | - Jean‐Pierre Déry
- Division of Cardiology, Québec Heart and Lung InstituteLaval HospitalQuébec CityQuébec
| | - Robert C. Welsh
- Department of Medicine, Mazankowski Alberta Heart InstituteUniversity of Alberta Hospital, Canadian VIGOUR CentreEdmontonAlberta
| | - Jacob A. Udell
- Cardiovascular Division, Department of Medicine and Women's College Research InstituteWomen's College HospitalTorontoOntario
- Peter Munk Cardiac CentreUniversity Health NetworkTorontoOntario
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