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Amin AN, Kartashov A, Ngai W, Steele K, Rosenthal N. Effectiveness, Safety, and Costs of Thromboprophylaxis with Enoxaparin or Unfractionated Heparin Among Medical Inpatients With Chronic Obstructive Pulmonary Disease or Heart Failure. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2024; 11:44-56. [PMID: 38390025 PMCID: PMC10883471 DOI: 10.36469/001c.92408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/12/2024] [Indexed: 02/24/2024]
Abstract
Background: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are risk factors for venous thromboembolism (VTE). Enoxaparin and unfractionated heparin (UFH) help prevent hospital-associated VTE, but few studies have compared them in COPD or HF. Objectives: To compare effectiveness, safety, and costs of enoxaparin vs UFH thromboprophylaxis in medical inpatients with COPD or HF. Methods: This retrospective cohort study included adults with COPD or HF from the Premier PINC AI Healthcare Database. Included patients received prophylactic-dose enoxaparin or UFH during a >6-day index hospitalization (the first visit/admission that met selection criteria during the study period) between January 1, 2010, and September 30, 2016. Multivariable regression models assessed independent associations between exposures and outcomes. Hospital costs were adjusted to 2017 US dollars. Patients were followed 90 days postdischarge (readmission period). Results: In the COPD cohort, 114 174 (69%) patients received enoxaparin and 51 011 (31%) received UFH. Among patients with COPD, enoxaparin recipients had 21%, 37%, and 10% lower odds of VTE, major bleeding, and in-hospital mortality during index admission, and 17% and 50% lower odds of major bleeding and heparin-induced thrombocytopenia (HIT) during the readmission period, compared with UFH recipients (all P <.006). In the HF cohort, 58 488 (58%) patients received enoxaparin and 42 726 (42%) received UFH. Enoxaparin recipients had 24% and 10% lower odds of major bleeding and in-hospital mortality during index admission, and 13%, 11%, and 51% lower odds of VTE, major bleeding, and HIT during readmission (all P <.04) compared with UFH recipients. Enoxaparin recipients also had significantly lower total hospital costs during index admission (mean reduction per patient: COPD, 1280 ; H F , 2677) and readmission (COPD, 379 ; H F , 1024). Among inpatients with COPD or HF, thromboprophylaxis with enoxaparin vs UFH was associated with significantly lower odds of bleeding, mortality, and HIT, and with lower hospital costs. Conclusions: This study suggests that thromboprophylaxis with enoxaparin is associated with better outcomes and lower costs among medical inpatients with COPD or HF based on real-world evidence. Our findings underscore the importance of assessing clinical outcomes and side effects when evaluating cost-effectiveness.
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Affiliation(s)
| | - Alex Kartashov
- PINC AI™ Applied Sciences, Premier Inc., Charlotte, North Carolina, USA
| | | | | | - Ning Rosenthal
- PINC AI™ Applied Sciences, Premier Inc., Charlotte, North Carolina, USA
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Han D, Kim SH, Shin DG, Kang MK, Choi S, Lee N, Kim BK, Joo HJ, Chang K, Park Y, Song YB, Ahn SG, Suh JW, Lee SY, Her AY, Jeong YH, Kim HS, Kim MH, Lim DS, Shin ES, Cho JR. Prognostic Implication of Platelet Reactivity According to Left Ventricular Systolic Dysfunction Status in Patients Treated With Drug-Eluting Stent Implantation: Analysis of the PTRG-DES Consortium. J Korean Med Sci 2024; 39:e27. [PMID: 38258362 PMCID: PMC10803212 DOI: 10.3346/jkms.2024.39.e27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/08/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Coronary artery disease patients undergoing percutaneous coronary intervention (PCI) often exhibit reduced left ventricular ejection fraction (LVEF). However, the impact of LV dysfunction status in conjunction with platelet reactivity on clinical outcomes has not been previously investigated. METHODS From the multicenter PTRG-DES (Platelet function and genoType-Related long-term prognosis in DES-treated patients) consortium, the patients were classified as preserved-EF (PEF: LVEF ≥ 50%) and reduced-EF (REF: LVEF< 5 0%) group by echocardiography. Platelet reactivity was measured using VerifyNow P2Y12 assay and high platelet reactivity (HPR) was defined as PRU ≥ 252. The major adverse cardiac and cerebrovascular events (MACCEs) were a composite of death, myocardial infarction, stent thrombosis and stroke at 5 years after PCI. Major bleeding was defined as Bleeding Academic Research Consortium bleeding types 3-5. RESULTS A total of 13,160 patients from PTRG-DES, 9,319 (79.6%) patients with the results of both PRU and LVEF were analyzed. The incidence of MACCE and major bleeding was higher in REF group as compared with PEF group (MACCEs: hazard ratio [HR] 2.17, P < 0.001, 95% confidence interval [CI] 1.85-2.55; major bleeding: HR 1.78, P < 0.001, 95% CI 1.39-2.78). The highest rate of MACCEs was found in patients with REF and HPR, and the difference between the groups was statistically significant (HR 3.14 in REF(+)/HPR(+) vs. PEF(+)/HPR(-) group, P < 0.01, 95% CI 2.51-3.91). The frequency of major bleeding was not associated with the HPR in either group. CONCLUSION LV dysfunction was associated with an increased incidence of MACCEs and major bleeding in patients who underwent PCI. The HPR status further exhibited significant increase of MACCEs in patients with LV dysfunction in a large, real-world registry. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04734028.
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Affiliation(s)
- Donghoon Han
- Cardiology Division, Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Sun-Hwa Kim
- Department of Internal Medicine, Seoul National University College of Medicine and Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong Geum Shin
- Cardiology Division, Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Min-Kyung Kang
- Cardiology Division, Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Seonghoon Choi
- Cardiology Division, Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Namho Lee
- Cardiology Division, Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung Joon Joo
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yongwhi Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Gyun Ahn
- Department of Cardiology, Yonsei University Wonju Severance Christian Hospital, Wonju, Korea
| | - Jung-Won Suh
- Department of Internal Medicine, Seoul National University College of Medicine and Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Yeub Lee
- Division of Cardiology, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong and Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine, Kangwon National University College of Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Young-Hoon Jeong
- Division of Cardiology, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong and Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Moo Hyun Kim
- Department of Cardiology, Dong-A University Hospital, Busan, Korea
| | - Do-Sun Lim
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Eun-Seok Shin
- Division of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jung Rae Cho
- Cardiology Division, Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.
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Doehner W, Böhm M, Boriani G, Christersson C, Coats AJS, Haeusler KG, Jones ID, Lip GYH, Metra M, Ntaios G, Savarese G, Shantsila E, Vilahur G, Rosano G. Interaction of heart failure and stroke: A clinical consensus statement of the ESC Council on Stroke, the Heart Failure Association (HFA) and the ESC Working Group on Thrombosis. Eur J Heart Fail 2023; 25:2107-2129. [PMID: 37905380 DOI: 10.1002/ejhf.3071] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 10/06/2023] [Accepted: 10/16/2023] [Indexed: 11/02/2023] Open
Abstract
Heart failure (HF) is a major disease in our society that often presents with multiple comorbidities with mutual interaction and aggravation. The comorbidity of HF and stroke is a high risk condition that requires particular attention to ensure early detection of complications, efficient diagnostic workup, close monitoring, and consequent treatment of the patient. The bi-directional interaction between the heart and the brain is inherent in the pathophysiology of HF where HF may be causal for acute cerebral injury, and - in turn - acute cerebral injury may induce or aggravate HF via imbalanced neural and neurovegetative control of cardiovascular regulation. The present document represents the consensus view of the ESC Council on Stroke, the Heart Failure Association and the ESC Working Group on Thrombosis to summarize current insights on pathophysiological interactions of the heart and the brain in the comorbidity of HF and stroke. Principal aspects of diagnostic workup, pathophysiological mechanisms, complications, clinical management in acute conditions and in long-term care of patients with the comorbidity are presented and state-of-the-art clinical management and current evidence from clinical trials is discussed. Beside the physicians perspective, also the patients values and preferences are taken into account. Interdisciplinary cooperation of cardiologists, stroke specialists, other specialists and primary care physicians is pivotal to ensure optimal treatment in acute events and in continued long-term treatment of these patients. Key consensus statements are presented in a concise overview on mechanistic insights, diagnostic workup, prevention and treatment to inform clinical acute and continued care of patients with the comorbidity of HF and stroke.
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Affiliation(s)
- Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Herzzentrum der Charité, Department of Cardiology (Campus Virchow) and German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Böhm
- Universitätsklinikum des Saarlandes, Klinik für Innere Medizin III, Saarland University (Kardiologie, Angiologie und Internistische Intensivmedizin), Homburg, Germany
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | | | | | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | - Ian D Jones
- Liverpool Centre for Cardiovascular Science, School of Nursing and Allied Health, Liverpool John Moores University, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Eduard Shantsila
- Department of Primary Care, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gemma Vilahur
- Institut de Recerca de l'Hospital de la Santa Creu i Sant Pau and CIBERCV, Barcelona, Spain
| | - Giuseppe Rosano
- St George's University Hospital, London, UK, San Raffaele Cassino, Rome, Italy
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Cittadini A, Bossone E, Ventura HO. Emerging Comorbidities in Heart Failure. Cardiol Clin 2022; 40:xi-xiv. [DOI: 10.1016/j.ccl.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
PURPOSE Ischemic stroke significantly contributes to morbidity and mortality in heart failure (HF). The risk of stroke increases significantly, with coexisting atrial fibrillation (AF). An aggravating factor could be asymptomatic paroxysms of AF (so-called silent AF), and therefore, the risk stratification in these patients remains difficult. This review provides an overview of stroke risk in HF, its risk stratification, and stroke prevention in these patients. RECENT FINDINGS Stroke risk stratification in HF patients remains an important issue. Recently, the CHA2DS2-VASc score, originally developed to predict stroke risk in AF patients, had been reported to be a predictive for strokes in HF patients regardless of AF being present. Furthermore, there are several independent risk factors (e.g., hypertension, diabetes mellitus, prior stroke) described. Based on the current evidence, HF should be considered as an independent risk factor for stroke. The CHA2DS2-VASc score might be useful to predict stroke risk in HF patients with or without AF in clinical routine. However, there is only a recommendation for the oral anticoagulation use in patients with concomitant HF and AF, while in patients with HF and no AF, individualized risk stratification is preferred. Current guidelines recommend to prefer non-vitamin Kantagonist anticoagulants over warfarin.
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Affiliation(s)
- Katja Schumacher
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Heart Center, Department of Electrophysiology, University of Leipzig, Leipzig, Germany
| | - Jelena Kornej
- Heart Center, Department of Electrophysiology, University of Leipzig, Leipzig, Germany.,Institute for Medical Informatics, Statistics and Epidemiology (IMISE), Leipzig University, Leipzig, Germany
| | - Eduard Shantsila
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.
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Correa S, Bonaca MP, Scirica BM, Murphy SA, Goodrich EL, Morrow DA, O’Donoghue ML. Efficacy and safety of more potent antiplatelet therapy with vorapaxar in patients with impaired renal function. J Thromb Thrombolysis 2018; 47:353-360. [DOI: 10.1007/s11239-018-1779-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Benito-González T, Estévez-Loureiro R, de Prado AP, Minguito-Carazo C, Del Castillo García S, Garrote-Coloma C, Iglesias-Gárriz I, Alonso-Rodríguez D, Cardona JG, Ramón CC, Benito ML, Estévez JV, Fernández-Vázquez F. Incidence and prognostic implications of late bleeding events after percutaneous mitral valve repair. IJC HEART & VASCULATURE 2018; 21:16-21. [PMID: 30255126 PMCID: PMC6148729 DOI: 10.1016/j.ijcha.2018.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/04/2018] [Accepted: 09/11/2018] [Indexed: 11/26/2022]
Abstract
Objectives MitraClip is an established therapy for patients with mitral regurgitation (MR) that are considered of high-risk or inoperable. However, late bleeding events (BE) after hospital discharge and their impact on prognosis in this cohort of patients have been poorly investigated. Our purpose is to address the incidence, related factors and clinical implications of BE after hospital discharge in patients treated with MitraClip. Methods Prospective registry of all consecutive patients (n = 80) who underwent MitraClip implantation in our Institution between June 2014 and December 2017. BE were defined according to MVARC definitions. A combined clinical end-point including admission for heart failure (HF) and all-cause mortality was established to analyze prognostic implications of BE. Results During a median follow up of 523.5 days, 41 BE were reported in 21 patients. Atrial fibrillation (AF, HR 4.54, CI95% 1.20–17.10) and combined antithrombotic therapy at discharge (HR 3.52, CI95% 1.03–11.34) were independently associated with BE. In the study period, 15 (18.8%) patients died, 20 (25%) were admitted for HF and 29 (36.3%) presented the combined end-point. After multivariable adjustment BE remained independently associated with an adverse outcome (HR 3.80, CI 95% 1.66–8.72). In the subgroup of patients with AF, HAS-BLED score was higher among subjects with BE (3.1 ± 1.3 vs 2.1 ± 0.9, p = 0.003). HAS-BLED score had a significant discrimination power for the occurrence BE (AUC: 0.677 [0.507–0.848]) in this subgroup. Conclusions BE are common after MitraClip and are associated with an impaired outcome. Strategies to reduce bleeding events are paramount in this cohort of patients.
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Affiliation(s)
| | - Rodrigo Estévez-Loureiro
- Department of Cardiology, University Hospital of León, León, Spain.,Department of Cardiology, University Hospital Puerta de Hierro-Majadahonda, Madrid, Spain
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Melgaard L, Overvad TF, Skjøth F, Christensen JH, Larsen TB, Lip GYH. Risk of stroke and bleeding in patients with heart failure and chronic kidney disease: a nationwide cohort study. ESC Heart Fail 2018; 5:319-326. [PMID: 29383860 PMCID: PMC5880668 DOI: 10.1002/ehf2.12256] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/23/2017] [Accepted: 12/06/2017] [Indexed: 11/30/2022] Open
Abstract
Aims The aim of this study was to assess the prognostic value of chronic kidney disease (CKD) in relation to ischaemic stroke, intracranial haemorrhage, major bleeding, and all‐cause death in heart failure patients without atrial fibrillation. Methods and results In this observational cohort study, heart failure patients without atrial fibrillation were identified using Danish nationwide registries. Risk of stroke, major haemorrhage, and death were calculated after 1 and 5 years to compare patients with and without CKD, ±dialysis [dialysis: CKD with renal replacement therapy (CKD‐RRT); no dialysis: CKD‐no RRT]. A total of 43 199 heart failure patients were included, among which 0.8% had CKD‐RRT and 5.9% had CKD‐no RRT. When compared with heart failure patients without CKD, both CKD‐RRT and CKD‐no RRT were associated with a higher 5 year rate of major bleeding (CKD‐RRT: adjusted hazard ratio (aHR): 2.91, 95% confidence interval (CI): 2.29 to 3.70; CKD‐no RRT: aHR: 1.28, 95% CI: 1.13 to 1.45) and all‐cause death (CKD‐RRT: aHR: 2.40, 95% CI: 2.07 to 2.77; CKD‐no RRT: aHR: 1.63, 95% CI: 1.55 to 1.73). For the endpoints of ischaemic stroke and intracranial bleeding, only CKD‐no RRT was associated with significantly higher 5 year rates (ischaemic stroke: aHR: 1.31, 95% CI: 1.13 to 1.52; intracranial haemorrhage: aHR: 1.66, 95% CI: 1.04 to 2.65). Conclusions Compared with patients without CKD, among incident heart failure patients without atrial fibrillation, CKD both with and without dialysis was associated with a higher rate of major bleeding and all‐cause death. Only CKD‐no RRT was associated with a higher rate of ischaemic stroke and intracranial bleeding.
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Affiliation(s)
- Line Melgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Thure Filskov Overvad
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Flemming Skjøth
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | | | - Torben Bjerregaard Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Thrombosis and Drug Research Unit, Aalborg University Hospital, Søndre Skovvej 15, DK-9000, Aalborg, Denmark
| | - Gregory Y H Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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