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Al Said S, Kaier K, Sumaya W, Alsaid D, Duerschmied D, Storey RF, Gibson CM, Westermann D, Alabed S. Non-vitamin-K-antagonist oral anticoagulants (NOACs) after acute myocardial infarction: a network meta-analysis. Cochrane Database Syst Rev 2024; 1:CD014678. [PMID: 38264795 PMCID: PMC10806408 DOI: 10.1002/14651858.cd014678.pub2] [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] [Indexed: 01/25/2024]
Abstract
BACKGROUND Balancing the risk of bleeding and thrombosis after acute myocardial infarction (AMI) is challenging, and the optimal antithrombotic therapy remains uncertain. The potential of non-vitamin K antagonist oral anticoagulants (NOACs) to prevent ischaemic cardiovascular events is promising, but the evidence remains limited. OBJECTIVES To evaluate the efficacy and safety of non-vitamin-K-antagonist oral anticoagulants (NOACs) in addition to background antiplatelet therapy, compared with placebo, antiplatelet therapy, or both, after acute myocardial infarction (AMI) in people without an indication for anticoagulation (i.e. atrial fibrillation or venous thromboembolism). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, the Conference Proceedings Citation Index - Science, and two clinical trial registers in September 2022 with no language restrictions. We checked the reference lists of included studies for any additional trials. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) that evaluated NOACs plus antiplatelet therapy versus placebo, antiplatelet therapy, or both, in people without an indication for anticoagulation after an AMI. DATA COLLECTION AND ANALYSIS Two review authors independently checked the results of searches to identify relevant studies, assessed each included study, and extracted study data. We conducted random-effects pairwise analyses using Review Manager Web, and network meta-analysis using the R package 'netmeta'. We ranked competing treatments by P scores, which are derived from the P values of all pairwise comparisons and allow ranking of treatments on a continuous 0-to-1 scale. MAIN RESULTS We identified seven eligible RCTs, including an ongoing trial that we could not include in the analysis. Of the six RCTs involving 33,039 participants, three RCTs compared rivaroxaban with placebo, two RCTs compared apixaban with placebo, and one RCT compared dabigatran with placebo. All participants in the six RCTs received concomitant antiplatelet therapy. The available evidence suggests that rivaroxaban compared with placebo reduces the rate of all-cause mortality (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.69 to 0.98; number needed to treat for an additional beneficial outcome (NNTB) 250; 3 studies, 21,870 participants; high certainty) and probably reduces cardiovascular mortality (RR 0.83, 95% CI 0.69 to 1.01; NNTB 250; 3 studies, 21,870 participants; moderate certainty). There is probably little or no difference between apixaban and placebo in all-cause mortality (RR 1.09, 95% CI 0.88 to 1.35; number needed to treat for an additional harmful outcome (NNTH) 334; 2 studies, 8638 participants; moderate certainty) and cardiovascular mortality (RR 0.99, 95% CI 0.77 to 1.27; number needed to treat not applicable; 2 studies, 8638 participants; moderate certainty). Dabigatran may reduce the rate of all-cause mortality compared with placebo (RR 0.57, 95% CI 0.31 to 1.06; NNTB 63; 1 study, 1861 participants; low certainty). Dabigatran compared with placebo may have little or no effect on cardiovascular mortality, although the point estimate suggests benefit (RR 0.72, 95% CI 0.34 to 1.52; NNTB 143; 1 study, 1861 participants; low certainty). Two of the investigated NOACs were associated with an increased risk of major bleeding compared to placebo: apixaban (RR 2.41, 95% CI 1.44 to 4.06; NNTH 143; 2 studies, 8544 participants; high certainty) and rivaroxaban (RR 3.31, 95% CI 1.12 to 9.77; NNTH 125; 3 studies, 21,870 participants; high certainty). There may be little or no difference between dabigatran and placebo in the risk of major bleeding (RR 1.74, 95% CI 0.22 to 14.12; NNTH 500; 1 study, 1861 participants; low certainty). The results of the network meta-analysis were inconclusive between the different NOACs at all individual doses for all primary outcomes. However, low-certainty evidence suggests that apixaban (combined dose) may be less effective than rivaroxaban and dabigatran for preventing all-cause mortality after AMI in people without an indication for anticoagulation. AUTHORS' CONCLUSIONS Compared with placebo, rivaroxaban reduces all-cause mortality and probably reduces cardiovascular mortality after AMI in people without an indication for anticoagulation. Dabigatran may reduce the rate of all-cause mortality and may have little or no effect on cardiovascular mortality. There is probably no meaningful difference in the rate of all-cause mortality and cardiovascular mortality between apixaban and placebo. Moreover, we found no meaningful benefit in efficacy outcomes for specific therapy doses of any investigated NOACs following AMI in people without an indication for anticoagulation. Evidence from the included studies suggests that rivaroxaban and apixaban increase the risk of major bleeding compared with placebo. There may be little or no difference between dabigatran and placebo in the risk of major bleeding. Network meta-analysis did not show any superiority of one NOAC over another for our prespecified primary outcomes. Although the evidence suggests that NOACs reduce mortality, the effect size or impact is small; moreover, NOACs may increase major bleeding. Head-to-head trials, comparing NOACs against each other, are required to provide more solid evidence.
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Affiliation(s)
- Samer Al Said
- Department of Cardiology and Angiology, University Heart Center Freiburg Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Wael Sumaya
- Department of Medicine, Faculty of Medicine, Dalhousie University, QE II Health Sciences Centre, Halifax Infirmary, Halifax, Canada
| | - Dima Alsaid
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany, Mannheim, Germany
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - C Michael Gibson
- Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center Freiburg Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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Sharma A, Caldeira D, Razaghizad A, Pinto FJ, van Veldhuisen DJ, Mehra MR, Lam CSP, Cleland J, Anker SD, Greenberg B, Ferreira JP, Zannad F. Cardiovascular effects of rivaroxaban in heart failure patients with sinus rhythm and coronary disease with and without diabetes: a retrospective international cohort study from COMMANDER-HF. BMJ Open 2023; 13:e068865. [PMID: 37567750 PMCID: PMC10423780 DOI: 10.1136/bmjopen-2022-068865] [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: 10/05/2022] [Accepted: 06/02/2023] [Indexed: 08/13/2023] Open
Abstract
OBJECTIVES COMMANDER-HF was a randomised trial comparing rivaroxaban 2.5 mg two times a day to placebo, in addition to antiplatelet therapy, in patients hospitalised for worsening heart failure with coronary artery disease and sinus rhythm. Patients with diabetes are at increased risk of cardiovascular events and therefore have more to gain. METHODS AND RESULTS In this post-hoc analysis, we evaluated the efficacy and safety of rivaroxaban in patients with (n=2052) and without diabetes (n=2970). The primary outcome was the composite of cardiovascular death, myocardial infarction (MI) or ischaemic stroke. HRs and 95% CIs with interaction analyses were used to describe event-rates and treatment effects. Patients with diabetes had a higher prevalence of cardiovascular comorbidities (eg, hypertension, obesity) and increased incidence of cardiovascular events. Adjusted HRs for events in people with versus without diabetes were 1.34 (95% CI 1.19 to 1.50) for the primary outcome, 1.21 (95% CI 0.84 to 1.75) for stroke, 1.51 (95% CI 1.14 to 1.99) for MI, 1.17 (95% CI 1.05 to 1.31) for heart failure hospitalisation and 1.06 (95% CI 0.56 to 2.01) for major bleeding. Rivaroxaban had no significant effect on event-rates in patients with and without diabetes (all interaction p values >0.05). Low-dose rivaroxaban was associated with an overall reduction in ischaemic stroke (HR 0.66; 95% CI 0.47 to 0.95), with no apparent subgroup interaction according to diabetes status (p-int=0.93). CONCLUSIONS In COMMANDER-HF a diagnosis of diabetes conferred higher rates of cardiovascular events that, with exception of ischaemic stroke, was not substantially reduced by rivaroxaban. Rivaroxaban was associated with reduced risk of ischaemic stroke for patients with and without diabetes. TRIAL REGISTRATION NUMBER NCT01877915; Post-results.
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Affiliation(s)
- Abhinav Sharma
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Daniel Caldeira
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, Hospital de Santa Maria, Lisboa, Portugal
- Cardiovascular da Universidade de Lisboa - CCUL (CCUL@RISE), Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
- Centro de Estudos de Medicina Baseada na Evidência (CEMBE), Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Amir Razaghizad
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Fausto J Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, Hospital de Santa Maria, Lisboa, Portugal
- Cardiovascular da Universidade de Lisboa - CCUL (CCUL@RISE), Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | | | - Mandeep R Mehra
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Carolyn S P Lam
- Department of Cardiology, Duke-NUS Medical School, Singapore
| | - John Cleland
- Department of Cardiovascular & Metabolic Health, Glasgow University, Glasgow, Ireland
| | - Stefan D Anker
- Department of Cardiology, Universitätsmedizin Berlin, Berlin, Germany
| | - Barry Greenberg
- Department of Medicine, University of California, San Diego, California, USA
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Girerd N, Cleland J, Anker SD, Byra W, Lam CSP, Lapolice D, Mehra MR, van Veldhuisen DJ, Bresso E, Lamiral Z, Greenberg B, Zannad F. Inflammation and remodeling pathways and risk of cardiovascular events in patients with ischemic heart failure and reduced ejection fraction. Sci Rep 2022; 12:8574. [PMID: 35595781 PMCID: PMC9123183 DOI: 10.1038/s41598-022-12385-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 03/21/2022] [Indexed: 12/22/2022] Open
Abstract
Patients with heart failure (HF) and coronary artery disease (CAD) have a high risk for cardiovascular (CV) events including HF hospitalization, stroke, myocardial infarction (MI) and sudden cardiac death (SCD). The present study evaluated associations of proteomic biomarkers with CV outcome in patients with CAD and HF with reduced ejection fraction (HFrEF), shortly after a worsening HF episode. We performed a case-control study within the COMMANDER HF international, double-blind, randomized placebo-controlled trial investigating the effects of the factor-Xa inhibitor rivaroxaban. Patients with the following first clinical events: HF hospitalization, SCD and the composite of MI or stroke were matched with corresponding controls for age, sex and study drug. Plasma concentrations of 276 proteins with known associations with CV and cardiometabolic mechanisms were analyzed. Results were corrected for multiple testing using false discovery rate (FDR). In 485 cases and 455 controls, 49 proteins were significantly associated with clinical events of which seven had an adjusted FDR < 0.001 (NT-proBNP, BNP, T-cell immunoglobulin and mucin domain containing 4 (TIMD4), fibroblast growth factor 23 (FGF-23), growth differentiation factor-15 (GDF-15), pulmonary surfactant-associated protein D (PSP-D) and Spondin-1 (SPON1)). No significant interactions were identified between the type of clinical event (MI/stroke, SCD or HFH) and specific biomarkers (all interaction FDR > 0.20). When adding the biomarkers significantly associated with the above outcome to a clinical model (including NT-proBNP), the C-index increase was 0.057 (0.033-0.082), p < 0.0001 and the net reclassification index was 54.9 (42.5 to 67.3), p < 0.0001. In patients with HFrEF and CAD following HF hospitalization, we found that NT-proBNP, BNP, TIMD4, FGF-23, GDF-15, PSP-D and SPON1, biomarkers broadly associated with inflammation and remodeling mechanistic pathways, were strong but indiscriminate predictors of a variety of individual CV events.
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Affiliation(s)
- Nicolas Girerd
- Université de Lorraine, Centre d'Investigation Clinique-Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - John Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, Scotland
| | - Stefan D Anker
- Department of Cardiology (CVK), and Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - William Byra
- Janssen Research and Development, Raritan, NJ, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore, Singapore
| | | | - Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Emmanuel Bresso
- Université de Lorraine, Centre d'Investigation Clinique-Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Zohra Lamiral
- Université de Lorraine, Centre d'Investigation Clinique-Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Barry Greenberg
- Cardiology Division, Department of Medicine, University of California, La Jolla, San Diego, USA
| | - Faiez Zannad
- Université de Lorraine, Centre d'Investigation Clinique-Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France.
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Hussein AA, Alvarez P, Reed G, Heresi GA. Off-Label Use and Inappropriate Dosing of Direct Oral Anticoagulants in Cardiopulmonary Disease. Chest 2022; 161:1360-1369. [PMID: 35101404 DOI: 10.1016/j.chest.2022.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 12/28/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are increasingly used in clinical practice and have become essential in the management of atrial fibrillation and VTE. The enthusiasm for DOACs has fueled the off-label application of these agents in cardiopulmonary disease, and their use has often outpaced the evidence supporting their application. This article reviews the evidence and current off-label use of DOACs in various cardiopulmonary disease states.
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Affiliation(s)
- Ayman A Hussein
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland, OH.
| | - Paulino Alvarez
- Section of Heart Failure, Department of Cardiovascular Medicine, Cleveland, OH
| | - Grant Reed
- Section of Interventional Cardiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH
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Hamad AS. Non-vitamin K antagonist oral anticoagulants for COVID-19 thrombosis. JOURNAL OF ACUTE DISEASE 2022. [DOI: 10.4103/2221-6189.362812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Ferreira JP, Cleland JG, Lam CSP, Anker SD, Mehra MR, van Veldhuisen DJ, Byra WM, LaPolice DA, Greenberg B, Zannad F. New-onset atrial fibrillation in patients with worsening heart failure and coronary artery disease: an analysis from the COMMANDER-HF trial. Clin Res Cardiol 2021; 111:50-59. [PMID: 34128083 DOI: 10.1007/s00392-021-01891-2] [Citation(s) in RCA: 6] [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: 04/06/2021] [Accepted: 06/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) in the presence of heart failure (HF) is associated with poor outcomes including a high-risk of stroke and other thromboembolic events. Identifying patients without AF who are at high-risk of developing this arrhythmia has important clinical implications. AIMS To develop a risk score to identify HF patients at high risk of developing AF. METHODS The COMMANDER-HF trial enrolled 5022 patients with HF and a LVEF ≤ 40%, history of coronary artery disease, and absence of AF at baseline (confirmed with an electrocardiogram). Patients were randomized to either rivaroxaban (2.5 mg bid) or placebo. New-onset AF was confirmed by the investigator at study visits. RESULTS 241 (4.8%) patients developed AF during the follow-up (median 21 months). Older age (≥ 65 years), LVEF < 35%, history of PCI or CABG, White race, SBP < 110 mmHg, and higher BMI (≥ 25 kg/m2) were independently associated with risk of new-onset AF, whereas the use of DAPT was associated with a lower risk of new-onset AF. We then built a risk score from these variables (with good accuracy C-index = 0.71) and calibration across observed and predicted tertiles of risk. New-onset AF events rates increased steeply by increasing tertiles of the risk-score. Compared to tertile 1, the risk of new-onset AF was 2.5-fold higher in tertile 2, and 6.3-fold higher in tertile 3. Rivaroxaban had no effect in reducing new-onset AF. In time-updated models, new-onset AF was associated with a higher risk of subsequent all-cause death: HR (95%CI) 1.38 (1.11-1.73). CONCLUSIONS A well-calibrated risk-score identified patients at risk of new-onset AF in the COMMANDER-HF trial. Patients who developed AF had a higher risk of subsequent death. Risk of new-onset atrial fibrillation in patients with HFrEF and coronary artery disease.
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Affiliation(s)
- João Pedro Ferreira
- Centre D'Investigation Clinique 1433 Module Plurithématique, CHRU Nancy - Hopitaux de Brabois, CHRU de Nancy, FCRIN INI-CRCT, Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, Université de Lorraine, Nancy, France.
| | - John G Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, Scotland
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore, Singapore
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Stefan D Anker
- Berlin-Brandenburg Center for Regenerative Therapies, Berlin, Germany
- Department of Cardiology, German Center for Cardiovascular Research Partner Site Berlin, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Mandeep R Mehra
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | | | - Barry Greenberg
- Cardiology Division, Department of Medicine, University of California, San Diego, La Jolla, USA
| | - Faiez Zannad
- Centre D'Investigation Clinique 1433 Module Plurithématique, CHRU Nancy - Hopitaux de Brabois, CHRU de Nancy, FCRIN INI-CRCT, Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, Université de Lorraine, Nancy, France.
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Heart failure re-hospitalizations and subsequent fatal events in coronary artery disease: insights from COMMANDER-HF, EPHESUS, and EXAMINE. Clin Res Cardiol 2021; 110:1554-1563. [PMID: 33686472 DOI: 10.1007/s00392-021-01830-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/24/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with coronary artery disease (CAD) are at increased risk of developing and being hospitalised for heart failure (HFH). However, the risk of HFH versus ischemic events may vary among patients with CAD, depending on whether acute myocardial infarction (MI), left ventricular dysfunction or decompensated HF is present at baseline. AIMS We aim to explore the risk of non-fatal events (HFH, MI, stroke) and subsequent death in 3 landmark trials, COMMANDER-HF, EPHESUS and EXAMINE that, together, included patients with CAD with and without reduced ejection fraction and acute MI. METHODS Events, person-time metrics and time-updated Cox models. RESULTS In COMMANDER-HF the event-rate for the composite of AMI, stroke or all-cause death was 13.5 (12.8-14.3) events/100 py. Rates for AMI and stroke were much lower (2.2 [2.0-2.6] and 1.3 [1.1-1.6] events/100 py, respectively) than the rate of HFH (16.9 [16.1-17.9] events/100 py). In EPHESUS, the rates of MI and stroke were also lower than the rate of HFH: 7.2 (6.7-7.8), 1.9 (1.7-2.3), and 10.6 (9.9-11.3) events/100 py, but this was not true for EXAMINE with 4.4 (4.0-4.9), 0.7 (0.6-0.9), and 2.4 (2.0-2.7) events/100 py, respectively. In all 3 trials, a non-fatal event (HFH, MI or stroke) during follow-up doubled the risk of subsequent mortality. This most commonly followed a HFH. CONCLUSIONS A first or recurrent HFH is common in patients with CAD and AMI or HFrEF and indicates a poor prognosis. Preventing the development of heart failure after AMI and control of congestion in patients with CAD and HFrEF are key unmet needs and therapeutic targets. REGISTRATION ClinicalTrials.gov Identifier: NCT01877915. URL: https://clinicaltrials.gov/ct2/show/NCT01877915 .
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Ferreira JP, Cleland JGF, Lam CSP, van Veldhuisen DJ, Byra WM, La Police DA, Anker SD, Mehra MR, Leroy C, Eschwege V, Toussaint-Hacquard M, Rossignol P, Greenberg B, Zannad F. Impact of Geographic Region on the COMMANDER-HF Trial. JACC-HEART FAILURE 2021; 9:201-211. [PMID: 33549557 DOI: 10.1016/j.jchf.2020.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/12/2020] [Accepted: 11/16/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This study sought to compare patient characteristics, outcomes, and treatment effects among regions in the COMMANDER-HF trial. BACKGROUND Globalization of cardiovascular trials increases generalizability. However, regional differences may also introduce heterogeneity in results. METHODS Incidence rates and interactions with treatment were recorded in pre-specified regions: Eastern Europe, Western Europe and South Africa, North America, Asia-Pacific, and Latin America. RESULTS Most patients (n = 3,224; 64.2%) were from Eastern Europe; 458 (9.1%) were from Western Europe and South Africa; 149 (3.0%) were from North America; 733 (14.6%) were from Asia-Pacific; and 458 (9.1%) were from Latin America. Compared with patients from Eastern Europe, patients from Western Europe and South Africa, North America, and Asia-Pacific were older and more likely to have coronary interventions and cardiac devices. Patients from Eastern Europe had the lowest event rates. For the primary outcome of myocardial infarction (MI), stroke, or all-cause death, event rates (100/year) were 11.6 in Eastern Europe (10.8 to 12.5); 19.5 (16.5 to 23.0) in Western Europe and South Africa; 14.2 (10.5 to 19.2) in North America; 17.7 (15.4 to 20.3) in Asia-Pacific; and 18.6 (15.6 to 22.1) in Latin America. There was a lower incidence of bleeding in Eastern Europe. Blood concentrations of rivaroxaban (Xarelto, Titusville, New Jersey) at 4 weeks were undetectable in 21% patients from Eastern Europe (n = 128) compared to 5% in other regions (n = 42). There was no evidence of treatment-by-region heterogeneity for the primary outcome (interactionp = 0.14), but a favorable effect on the secondary outcome of MI, stroke, or cardiovascular death was observed in Western Europe and South Africa, North America, and Latin America but not in Eastern Europe and Asia-Pacific (interactionp = 0.017). CONCLUSIONS In the COMMANDER-HF study, patients from Eastern Europe had a lower risk profile and fewer cardiovascular and bleeding events, possibly related to lower treatment adherence. Those differences might have influenced the effect of rivaroxaban therapy. (A Study to Assess the Effectiveness and Safety of Rivaroxaban in Reducing the Risk of Death, Myocardial Infarction or Stroke in Participants With Heart Failure and Coronary Artery Disease Following an Episode of Decompensated Heart Failure [COMMANDER HF]; NCT01877915).
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Affiliation(s)
- João Pedro Ferreira
- Centre d'Investigations Cliniques Plurithématique, Université de Lorraine, Inserm 1433, Nancy, France, Centre Hospitalier Régional Universitaire (CHRU) de Nancy, Inserm U1116, Nancy, France, French Clinical Research Infrastructure Network Investigation Network Initiative - Cardiovascular and Renal Clinical Trialists, Nancy, France.
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, Scotland
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore; Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - William M Byra
- Janssen Research and Development, Raritan, New Jersey, USA
| | | | - Stefan D Anker
- Berlin-Brandenburg Center for Regenerative Therapies, Berlin, Germany; Department of Cardiology, German Center for Cardiovascular Research, partner site Berlin, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Mandeep R Mehra
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Céline Leroy
- Centre d'Investigations Cliniques Plurithématique, Université de Lorraine, Inserm 1433, Nancy, France, Centre Hospitalier Régional Universitaire (CHRU) de Nancy, Inserm U1116, Nancy, France, French Clinical Research Infrastructure Network Investigation Network Initiative - Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Valerie Eschwege
- Laboratoire d'Hématologie Biologique, CHRU de Nancy, Nancy, France
| | | | - Patrick Rossignol
- Centre d'Investigations Cliniques Plurithématique, Université de Lorraine, Inserm 1433, Nancy, France, Centre Hospitalier Régional Universitaire (CHRU) de Nancy, Inserm U1116, Nancy, France, French Clinical Research Infrastructure Network Investigation Network Initiative - Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Barry Greenberg
- Cardiology Division, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique, Université de Lorraine, Inserm 1433, Nancy, France, Centre Hospitalier Régional Universitaire (CHRU) de Nancy, Inserm U1116, Nancy, France, French Clinical Research Infrastructure Network Investigation Network Initiative - Cardiovascular and Renal Clinical Trialists, Nancy, France
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Mehra MR, Vaduganathan M, Fu M, Ferreira JP, Anker SD, Cleland JGF, Lam CSP, van Veldhuisen DJ, Byra WM, Spiro TE, Deng H, Zannad F, Greenberg B. A comprehensive analysis of the effects of rivaroxaban on stroke or transient ischaemic attack in patients with heart failure, coronary artery disease, and sinus rhythm: the COMMANDER HF trial. Eur Heart J 2020; 40:3593-3602. [PMID: 31461239 PMCID: PMC6868495 DOI: 10.1093/eurheartj/ehz427] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 05/24/2019] [Accepted: 06/08/2019] [Indexed: 01/16/2023] Open
Abstract
AIMS Stroke is often a devastating event among patients with heart failure with reduced ejection (HFrEF). In COMMANDER HF, rivaroxaban 2.5 mg b.i.d. did not reduce the composite of first occurrence of death, stroke, or myocardial infarction compared with placebo in patients with HFrEF, coronary artery disease (CAD), and sinus rhythm. We now examine the incidence, timing, type, severity, and predictors of stroke or a transient ischaemic attack (TIA), and seek to establish the net clinical benefit of treatment with low-dose rivaroxaban. METHODS AND RESULTS In this double-blind, randomized trial, 5022 patients who had HFrEF(≤40%), elevated natriuretic peptides, CAD, and who were in sinus rhythm were treated with rivaroxaban 2.5 mg b.i.d. or placebo in addition to antiplatelet therapy, after an episode of worsening HF. The primary neurological outcome for this post hoc analysis was time to first event of any stroke or TIA. Over a median follow-up of 20.5 (25th-75th percentiles 20.0-20.9) months, 150 all-cause stroke (127) or TIA (23) events occurred (ischaemic stroke in 82% and haemorrhagic stroke in 11% of stroke events). Overall, 47.5% of first-time strokes were either disabling (16.5%) or fatal (31%). Prior stroke, low body mass index, geographic region, and the CHA2DS2-VASc score were predictors of stroke/TIA. Rivaroxaban significantly reduced the primary neurological endpoint of all-cause stroke or TIA compared with placebo by 32% (1.29 events vs. 1.90 events per 100 patient-years), adjusted for the time from index HF event to randomization and stratified by geographic region (adjusted hazard ratio 0.68, 95% confidence interval 0.49-0.94), with a number needed to treat of 164 patients per year to prevent one stroke/TIA event. The principal safety endpoint of fatal bleeding or bleeding into a critical space, occurred at a similar rate on rivaroxaban and placebo (0.44 events vs. 0.55 events per 100 patient-years). CONCLUSIONS Patients with HFrEF and CAD are at risk for stroke or TIA in the period following an episode of worsening heart failure in the absence of atrial fibrillation. Most strokes are of ischaemic origin and nearly half are either disabling or fatal. Rivaroxaban at a dose of 2.5 mg b.i.d. reduced rates of stroke or TIA compared with placebo in this population. TRIAL REGISTRATION COMMANDER HF (A Study to Assess the Effectiveness and Safety of Rivaroxaban in Reducing the Risk of Death, Myocardial Infarction, or Stroke in Participants with Heart Failure and Coronary Artery Disease Following an Episode of Decompensated Heart Failure); ClinicalTrials.gov NCT01877915.
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Affiliation(s)
- Mandeep R Mehra
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Min Fu
- Janssen Research and Development, Spring House, PA, USA
| | - João Pedro Ferreira
- Universite de Lorraine, INSERM Unite 1116, Vandoeuvre les Nancy, France.,Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Regional et Universitaire de Nancy, Vandoeuvre les Nancy, France
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, Scotland.,National Heart and Lung Institute, Imperial College London, London, England
| | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore.,Duke-National University of Singapore, Singapore.,The George Institute for Global Health, Australia.,Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Theodore E Spiro
- Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Bayer US, LLC, Whippany, NJ, USA
| | | | - Faiez Zannad
- Universite de Lorraine, INSERM Unite 1116, Vandoeuvre les Nancy, France.,Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Regional et Universitaire de Nancy, Vandoeuvre les Nancy, France
| | - Barry Greenberg
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
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Ferreira JP, Lam CSP, Anker SD, Mehra MR, van Veldhuisen DJ, Byra WM, La Police DA, Cleland JGF, Greenberg B, Zannad F. Plasma D-dimer concentrations predicting stroke risk and rivaroxaban benefit in patients with heart failure and sinus rhythm: an analysis from the COMMANDER-HF trial. Eur J Heart Fail 2020; 23:648-656. [PMID: 32959502 DOI: 10.1002/ejhf.2003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 09/11/2020] [Accepted: 09/11/2020] [Indexed: 11/07/2022] Open
Abstract
AIMS D-dimer is a marker of fibrin degradation that reflects intravascular coagulation. Therefore, plasma concentrations of D-dimer might predict thromboembolic risk and rivaroxaban treatment effect. The aims of this study were to investigate the association between D-dimer levels and the risk of stroke and other thrombotic, bleeding and fatal events, and whether D-dimer concentrations could predict rivaroxaban 2.5 mg twice daily (vs. placebo) effect in patients enrolled in the COMMANDER-HF trial who were in sinus rhythm, had heart failure with reduced ejection fraction and coronary artery disease. METHODS AND RESULTS Survival models with treatment-by-plasma D-dimer interaction. Baseline measurement of D-dimer was available in 4107 (82%) of 5022 patients enrolled. Median (percentile25-75 ) follow-up was 21 (12.9-32.8) months. The median (percentile25-75 ) plasma concentration of D-dimer was 360 (215-665) ng/mL. The D-dimer tertiles were: (i) ≤255 ng/mL; (ii) 256-515 ng/mL; and (iii) >515 ng/mL. Patients within the tertile 3 were older, and had lower body mass index, blood pressure, haemoglobin, estimated glomerular filtration rate, and left ventricular ejection fraction. Higher plasma D-dimer concentrations were independently associated with higher rates of death, stroke, and venous thromboembolism. For example, the all-cause death adjusted hazard ratio (HR) (95%CI) of tertile 3 vs. tertile 1 was 1.77 [95% confidence interval (CI) 1.48-2.11; P < 0.001]. The effect of rivaroxaban was similar in each tertile of D-dimer for all outcomes except stroke. Patients within the tertile 3 had the greatest absolute and relative stroke reduction (tertile 1: HR 1.16, 95% CI 0.49-2.74; tertile 2: HR 1.45, 95% CI 0.77-2.73; tertile 3: HR 0.36, 95% CI 0.18-0.70; P for interaction = 0.008). The number-needed-to-treat to prevent one stroke in tertile 3 was 36. CONCLUSIONS In COMMANDER-HF, rivaroxaban reduced the risk of stroke but the benefit may be confined to patients with D-dimer concentrations above 515 ng/mL. Prospective trials are warranted to confirm these findings.
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Affiliation(s)
- João Pedro Ferreira
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique Inserm 1433, Nancy, France; CHRU de Nancy, Inserm U1116, Nancy, France; FCRIN INI-CRCT, Nancy, France
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore.,Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Stefan D Anker
- Berlin-Brandenburg Center for Regenerative Therapies, Berlin, Germany.,Department of Cardiology, German Center for Cardiovascular Research, partner site Berlin, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Mandeep R Mehra
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - William M Byra
- Janssen Research and Development, Raritan, New Jersey, NJ, USA
| | | | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, UK
| | - Barry Greenberg
- Cardiology Division, Department of Medicine, University of California, San Diego, CA, USA
| | - Faiez Zannad
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique Inserm 1433, Nancy, France; CHRU de Nancy, Inserm U1116, Nancy, France; FCRIN INI-CRCT, Nancy, France
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11
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Greenberg B, Neaton JD, Anker SD, Byra WM, Cleland JGF, Deng H, Fu M, La Police DA, Lam CSP, Mehra MR, Nessel CC, Spiro TE, van Veldhuisen DJ, Vanden Boom CM, Zannad F. Association of Rivaroxaban With Thromboembolic Events in Patients With Heart Failure, Coronary Disease, and Sinus Rhythm: A Post Hoc Analysis of the COMMANDER HF Trial. JAMA Cardiol 2020; 4:515-523. [PMID: 31017637 DOI: 10.1001/jamacardio.2019.1049] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Whether anticoagulation benefits patients with heart failure (HF) in sinus rhythm is uncertain. The COMMANDER HF randomized clinical trial evaluated the effects of adding low-dose rivaroxaban to antiplatelet therapy in patients with recent worsening of chronic HF with reduced ejection fraction, coronary artery disease (CAD), and sinus rhythm. Although the primary end point of all-cause mortality, myocardial infarction, or stroke did not differ between rivaroxaban and placebo, there were numerical advantages favoring rivaroxaban for myocardial infarction and stroke. Objective To examine whether low-dose rivaroxaban was associated with reduced thromboembolic events in patients enrolled in the COMMANDER HF trial. Design, Setting, and Participants Post hoc analysis of the COMMANDER HF multicenter, randomized, double-blind, placebo-controlled trial in patients with CAD and worsening HF. The trial randomized 5022 patients postdischarge from a hospital or outpatient clinic after treatment for worsening HF between September 2013 and October 2017. Patients were required to be receiving standard care for HF and CAD and were excluded for a medical condition requiring anticoagulation or a bleeding history. Patients were randomized in a 1:1 ratio. Analysis was conducted from June 2018 and January 2019. Intervention Patients were randomly assigned to receive 2.5 mg of rivaroxaban given orally twice daily or placebo in addition to their standard therapy. Main Outcomes and Measures For this post hoc analysis, a thromboembolic composite was defined as either (1) myocardial infarction, ischemic stroke, sudden/unwitnessed death, symptomatic pulmonary embolism, or symptomatic deep venous thrombosis or (2) all of the previous components except sudden/unwitnessed deaths because not all of these are caused by thromboembolic events. Results Of 5022 patients, 3872 (77.1%) were men, and the overall mean (SD) age was 66.4 (10.2) years. Over a median (interquartile range) follow-up of 19.6 (11.7-30.8) months, fewer patients assigned to rivaroxaban compared with placebo had a thromboembolic event including sudden/unwitnessed deaths: 328 (13.1%) vs 390 (15.5%) (hazard ratio, 0.83; 95% CI, 0.72-0.96; P = .01). When sudden/unwitnessed deaths were excluded, the results analyzing thromboembolic events were similar: 153 (6.1%) vs 190 patients (7.6%) with an event (hazard ratio, 0.80; 95% CI, 0.64-0.98; P = .04). Conclusions and Relevance In this study, thromboembolic events occurred frequently in patients with HF, CAD, and sinus rhythm. Rivaroxaban may reduce the risk of thromboembolic events in this population, but these events are not the major cause of morbidity and mortality in patients with recent worsening of HF for which rivaroxaban had no effect. While consistent with other studies, these results require confirmation in prospective randomized clinical trials. Trial Registration ClinicalTrials.gov identifier: NCT01877915.
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Affiliation(s)
- Barry Greenberg
- Cardiology Division, Department of Medicine, University of California, San Diego, La Jolla
| | - James D Neaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis
| | - Stefan D Anker
- Berlin-Brandenburg Center for Regenerative Therapies, Berlin, Germany.,Department of Cardiology, German Center for Cardiovascular Research partner site Berlin, Charite Universitatsmedizin Berlin, Berlin, Germany
| | | | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, Scotland.,National Heart and Lung Institute, Imperial College London, London, England
| | - Hsiaowei Deng
- Janssen Research and Development, Raritan, New Jersey
| | - Min Fu
- Janssen Research and Development, Spring House, Pennsylvania
| | | | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore.,Duke-National University of Singapore, Singapore.,Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Mandeep R Mehra
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Theodore E Spiro
- Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Bayer US, Whippany, New Jersey
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Faiez Zannad
- Universite de Lorraine, INSERM Unite 1116, Vandoeuvre les Nancy, France.,Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Regional et Universitaire de Nancy, Vandoeuvre les Nancy, France
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12
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Factor Xa Inhibition with Apixaban Does Not Influence Cardiac Remodelling in Rats with Heart Failure After Myocardial Infarction. Cardiovasc Drugs Ther 2020; 35:953-963. [PMID: 32458320 PMCID: PMC8452585 DOI: 10.1007/s10557-020-06999-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Heart failure (HF) is considered to be a prothrombotic condition and it has been suggested that coagulation factors contribute to maladaptive cardiac remodelling via activation of the protease-activated receptor 1 (PAR1). We tested the hypothesis that anticoagulation with the factor Xa (FXa) inhibitor apixaban would ameliorate cardiac remodelling in rats with HF after myocardial infarction (MI). Methods and Results Male Sprague-Dawley rats were either subjected to permanent ligation of the left ascending coronary artery (MI) or sham surgery. The MI and sham animals were randomly allocated to treatment with placebo or apixaban in the chow (150 mg/kg/day), starting 2 weeks after surgery. Cardiac function was assessed using echocardiography and histological and molecular markers of cardiac hypertrophy were assessed in the left ventricle (LV). Apixaban resulted in a fivefold increase in anti-FXa activity compared with vehicle, but no overt bleeding was observed and haematocrit levels remained similar in apixaban- and vehicle-treated groups. After 10 weeks of treatment, LV ejection fraction was 42 ± 3% in the MI group treated with apixaban and 37 ± 2 in the vehicle-treated MI group (p > 0.05). Both vehicle- and apixaban-treated MI groups also displayed similar degrees of LV dilatation, LV hypertrophy and interstitial fibrosis. Histological and molecular markers for pathological remodelling were also comparable between groups, as was the activity of signalling pathways downstream of the PAR1 receptor. Conclusion FXa inhibition with apixaban does not influence pathological cardiac remodelling after MI. These data do not support the use of FXa inhibitor in HF patients with the aim to amend the severity of HF. Graphical Abstract ![]()
Electronic supplementary material The online version of this article (10.1007/s10557-020-06999-7) contains supplementary material, which is available to authorized users.
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13
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Cunningham JW, Ferreira JP, Deng H, Anker SD, Byra WM, Cleland JGF, Gheorghiade M, Lam CSP, La Police D, Mehra MR, Neaton JD, Spiro TE, van Veldhuisen DJ, Greenberg B, Zannad F. Natriuretic Peptide-Based Inclusion Criteria in a Heart Failure Clinical Trial: Insights From COMMANDER HF. JACC. HEART FAILURE 2020; 8:359-368. [PMID: 32171760 DOI: 10.1016/j.jchf.2019.12.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study investigated the effects of a mid-trial protocol amendment requiring elevated natriuretic peptides for inclusion in the COMMANDER-HF (A Study to Assess the Effectiveness and Safety of Rivaroxaban in Reducing the Risk of Death, Myocardial Infarction, or Stroke in Participants with Heart Failure and Coronary Artery Disease Following an Episode of Decompensated Heart Failure) trial. BACKGROUND Heart failure (HF) trials that select patients based on history of HF hospitalization alone are susceptible to regional variations in event rates. Elevated plasma concentrations of natriuretic peptides (NPs) as selection criteria may help HF ascertainment and risk enrichment. In the COMMANDER-HF trial, B-type natriuretic peptide ≥200 ng/l or N-terminal pro-B-type natriuretic peptide ≥800 ng/l were added to inclusion criteria as a mid-trial protocol amendment, providing a unique case-study of NP-based inclusion criteria. METHODS We compared the baseline characteristics, event rates, and treatment effects for patients enrolled before and after the NP protocol amendment. The primary endpoint was all-cause death, myocardial infarction, or stroke. Secondary endpoints included HF rehospitalization and cardiovascular death. RESULTS A total of 5,022 patients with left ventricular ejection fraction ≤40% and coronary artery disease were included. Compared to patients enrolled before the NP protocol amendment, those enrolled post-amendment (n = 3,867, 77%) were older, more often had diabetes, and had lower values for body mass index, left ventricular ejection fraction, and estimated glomerular filtration rate, higher heart rate, and higher event rates: primary endpoint (hazard ratio [HR]: 1.32; 95% confidence interval [CI]: 1.16 to 1.50), cardiovascular death (HR: 1.29; 95% CI: 1.11 to 1.50), HF rehospitalization (HR: 1.31; 95% CI: 1.15 to 1.49), and major bleeding (HR: 1.71; 95% CI: 1.11 to 2.65). Differences between pre- and post-amendment rates were confined to and driven by Eastern Europe. This protocol amendment did not modify the neutral effect of rivaroxaban on the primary endpoint (p interaction = 0.36) or secondary endpoints. CONCLUSIONS In a global event-driven trial of rivaroxaban in HF, requiring elevated NPs for inclusion increased event rates allowing earlier completion of the trial but did not modify treatment effect. These data inform future HF trials regarding the expected impact of NP-based inclusion criteria on patient characteristics and event rates. (COMMANDER HF [A Study to Assess the Effectiveness and Safety of Rivaroxaban in Reducing the Risk of Death, Myocardial Infarction, or Stroke in Participants With Heart Failure and Coronary Artery Disease Following an Episode of Decompensated Heart Failure] NCT01877915).
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Affiliation(s)
| | - João Pedro Ferreira
- Centre d'Investigations Cliniques-Plurithématique 1433, and INSERM U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | | | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - John G F Cleland
- Robertson Centre for Biostatistics & Clinical Trials, University of Glasgow, Glasgow, United Kingdom; National Heart & Lung Institute, Imperial College, London, United Kingdom; National Heart & Lung Institute, Imperial College London, United Kingdom
| | | | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore; Duke-National University of Singapore, Singapore; Department of Cardiology, University Medical Center, Groningen, Groningen, the Netherlands; The George Institute for Global Health, Newtown, New South Wales, Australia
| | | | - Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - James D Neaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | | | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Barry Greenberg
- Department of Medicine, Cardiology Division, University of California, San Diego, California
| | - Faiez Zannad
- Centre d'Investigations Cliniques-Plurithématique 1433, and INSERM U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France.
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14
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Sciatti E, Dallapellegrina L, Metra M, Lombardi CM. New drugs for the treatment of chronic heart failure with a reduced ejection fraction. J Cardiovasc Med (Hagerstown) 2019; 20:650-659. [DOI: 10.2459/jcm.0000000000000850] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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15
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Batta A, Kalra BS, Khirasaria R. Critical Issues and Recent Advances in Anticoagulant Therapy: A Review. Neurol India 2019; 67:1200-1212. [PMID: 31744944 DOI: 10.4103/0028-3886.271256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
As the population is aging, clinicians are coming across more patients with atrial fibrillation and venous thromboembolism requiring anticoagulation to prevent stroke and systemic embolisms. Due to a high prevalence and unfavorable consequences, managing thromboembolic diseases have become areas of clinical concern. Traditional anticoagulants like heparin, low molecular weight heparin and warfarin have been used for the prevention and treatment of venous and arterial thromboses. But, issues of bleeding, parenteral route of administration, or the need for frequent monitoring due to variability in response respectively limit their use. The article gives an overview of coagulation along with existing therapy available for anticoagulation and to present an update on utility and recent advances of new oral anticoagulants (NOACs) beginning from their nomenclature, advantages, disadvantages, precautions and contraindications compared with those of vitamin K antagonists (VKAs) based on a large number of recent studies and clinical trials.
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Affiliation(s)
- Angelika Batta
- Department of Pharmacology, Maulana Azad Medical College, New Delhi, India
| | - Bhupinder S Kalra
- Department of Pharmacology, Maulana Azad Medical College, New Delhi, India
| | - Raj Khirasaria
- Department of Pharmacology, Baroda Medical College and SSG Hospital, Vadodara, Gujarat, India
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16
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Ferreira JP, Girerd N, Gregson J, Latar I, Sharma A, Pfeffer MA, McMurray JJV, Abdul-Rahim AH, Pitt B, Dickstein K, Rossignol P, Zannad F. Stroke Risk in Patients With Reduced Ejection Fraction After Myocardial Infarction Without Atrial Fibrillation. J Am Coll Cardiol 2019; 71:727-735. [PMID: 29447733 DOI: 10.1016/j.jacc.2017.12.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/05/2017] [Accepted: 12/06/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND Stroke can occur after myocardial infarction (MI) in the absence of atrial fibrillation (AF). OBJECTIVES This study sought to identify risk factors (excluding AF) for the occurrence of stroke and to develop a calibrated and validated stroke risk score in patients with MI and heart failure (HF) and/or systolic dysfunction. METHODS The datasets included in this pooling initiative were derived from 4 trials: CAPRICORN (Effect of Carvedilol on Outcome After Myocardial Infarction in Patients With Left Ventricular Dysfunction), OPTIMAAL (Optimal Trial in Myocardial Infarction With Angiotensin II Antagonist Losartan), VALIANT (Valsartan in Acute Myocardial Infarction Trial), and EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study); EPHESUS was used for external validation. A total of 22,904 patients without AF or oral anticoagulation were included in this analysis. The primary outcome was stroke, and death was treated as a "competing risk." RESULTS During a median follow-up of 1.9 years (interquartile range: 1.3 to 2.7 years), 660 (2.9%) patients had a stroke. These patients were older, more often female, smokers, and hypertensive; they had a higher Killip class; a lower estimated glomerular filtration rate; and a higher proportion of MI, HF, diabetes, and stroke histories. The final stroke risk model retained older age, Killip class 3 or 4, estimated glomerular filtration rate ≤45 ml/min/1.73 m2, hypertension history, and previous stroke. The models were well calibrated and showed moderate to good discrimination (C-index = 0.67). The observed 3-year event rates increased steeply for each sextile of the stroke risk score (1.8%, 2.9%, 4.1%, 5.6%, 8.3%, and 10.9%, respectively) and were in agreement with the expected event rates. CONCLUSIONS Readily accessible risk factors associated with the occurrence of stroke were identified and incorporated in an easy-to-use risk score. This score may help in the identification of patients with MI and HF and a high risk for stroke despite their not presenting with AF.
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Affiliation(s)
- João Pedro Ferreira
- National Institute of Health and Medical Research (INSERM), Center for Clinical Multidisciplinary Research 1433, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network (F-CRIN) Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France; Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Nicolas Girerd
- National Institute of Health and Medical Research (INSERM), Center for Clinical Multidisciplinary Research 1433, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network (F-CRIN) Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - John Gregson
- Department of Biostatistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ichraq Latar
- National Institute of Health and Medical Research (INSERM), Center for Clinical Multidisciplinary Research 1433, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network (F-CRIN) Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Abhinav Sharma
- Duke Clinical Research Institute, Duke University, Durham, North Carolina; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Marc A Pfeffer
- Division of Cardiovascular Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Azmil H Abdul-Rahim
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Kenneth Dickstein
- Department of Cardiology, University of Bergan, Stavanger University Hospital, Stavanger, Norway
| | - Patrick Rossignol
- National Institute of Health and Medical Research (INSERM), Center for Clinical Multidisciplinary Research 1433, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network (F-CRIN) Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Faiez Zannad
- National Institute of Health and Medical Research (INSERM), Center for Clinical Multidisciplinary Research 1433, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network (F-CRIN) Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France.
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17
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High N-Terminal proB-Type Natriuretic Peptide Indicates Elevated Risk of Death after Percutaneous Coronary Intervention Compared to Coronary Artery Bypass Surgery in Patients with Left Ventricular Dysfunction. J Clin Med 2019; 8:jcm8060898. [PMID: 31234593 PMCID: PMC6617036 DOI: 10.3390/jcm8060898] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/12/2019] [Accepted: 06/20/2019] [Indexed: 11/17/2022] Open
Abstract
Background: Reduced left ventricular function (LVF) is a predictor for stent-thrombosis. In advanced heart failure (characterized by high NT-proBNP) with an activated coagulation system, coronary events clinically perceived as sudden death or death from heart failure may be more common in patients treated by percutaneous coronary intervention (PCI) than in patients treated by coronary artery bypass grafting (CABG). Our study analyses (1) if patients with reduced LVF who require coronary revascularization will have a better survival benefit with CABG or PCI, and (2) if the survival benefit is predicted by NT-proBNP. Methods: This observational retrospective study included patients from the coronary catheter laboratory database of the Medical University of Vienna (CCLD-MUW). Multivariate Cox regression analyses were performed to test the hypothesis that there is an interaction in the risk of death between those with lower or elevated NT-proBNP levels and the revascularization procedure (PCI or CABG). The relative risk of PCI compared to CABG as reference was calculated for patients with low and elevated NT-proBNP levels. Results: In the entire study population with 398 patients (340 PCI and 58 CABG) the revascularization procedure had no predictive value. When the revascularization procedure*NTproBNP interaction was forced into the Cox regression model, this term was an independent predictor of death. The relative risk of PCI compared to CABG was similar in patients with lower NT-proBNP-1.01 (95% confidence interval (CI), 0.45-2.24), but was significantly increased in patients with elevated NT-proBNP-1.58 (95% CI, 1.07-2.33). Conclusion: Death is associated to the revascularization procedure, but only in those patients with elevated NT-proBNP levels. NT-proBNP is a predicting factor for the revascularization procedure: elevated levels showed an increased risk of death after PCI compared to CABG, whereas lower levels were associated with a similar risk after both revascularization procedures.
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Berger JS, Peterson E, LalibertÉ F, Germain G, Lejeune D, Schein J, Lefebvre P, Zhao Q, Weir MR. Risk of Ischemic Stroke in Patients Newly Diagnosed With Heart Failure: Focus on Patients Without Atrial Fibrillation. J Card Fail 2019; 25:436-447. [DOI: 10.1016/j.cardfail.2018.03.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/08/2018] [Accepted: 03/19/2018] [Indexed: 12/25/2022]
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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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Satish M, Vukka N, Apala D, Mahfood Haddad T, Gupta J. Left Ventricular Thrombus After Acute Decompensated Heart Failure in the Setting of Ischemic Cardiomyopathy. Cureus 2019; 11:e4537. [PMID: 31263645 PMCID: PMC6592471 DOI: 10.7759/cureus.4537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A 70-year-old male with a medical history significant for long-standing ischemic cardiomyopathy (ICM) and heart failure with reduced ejection fraction (HFrEF) was admitted to the hospital with shortness of breath (SOB) five days after an acute heart failure (HF) exacerbation. He had non-radiating chest pressure now at rest, but without evidence of an acute coronary syndrome (ACS). Diagnostic work-up on readmission included a transthoracic echocardiogram (TTE), which revealed worsening left ventricular (LV) systolic dysfunction with new wall motion abnormalities and an incidental echo density in the LV apex, suggestive of an LV thrombus. These findings were unseen on imaging 20 months prior. The patient was initiated on warfarin to be maintained for three months, and discharged in stable condition after optimization of his anginal symptoms. Cardiac catheterization was not attempted secondary to the patient's chronic kidney disease (CKD). The incidental finding of an LV thrombus occurred despite compliance with guideline-directed medical therapy of HFrEF and ICM, including adjunctive use of clopidogrel. With the poor survival associated with thromboembolism, the prevention, risk stratification and appropriate therapeutic approach to LV thrombus are poorly delineated in patients with HFrEF in sinus rhythm. Currently, the screening guidelines for the identification of LV thrombus in patients with HFrEF are also unknown. Given mixed evidence regarding prophylactic anticoagulation, we present this case of an incidental LV thrombus found during an episode of acute decompensated HF in the setting of long-standing ICM to emphasize the need to suspect LV thrombus formation after such presentations with closer follow-up for prompt detection and timely treatment.
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Affiliation(s)
- Mohan Satish
- Internal Medicine, Creighton University School of Medicine, Omaha, USA
| | - Naveen Vukka
- Internal Medicine, Creighton University School of Medicine, Omaha, USA
| | - Dinesh Apala
- Internal Medicine, Creighton University School of Medicine, Omaha, USA
| | | | - Jaya Gupta
- Internal Medicine, Creighton University School of Medicine, Omaha, USA
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Beggs SAS, Rørth R, Gardner RS, McMurray JJV. Anticoagulation therapy in heart failure and sinus rhythm: a systematic review and meta-analysis. Heart 2019; 105:1325-1334. [DOI: 10.1136/heartjnl-2018-314381] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/27/2019] [Accepted: 02/14/2019] [Indexed: 11/03/2022] Open
Abstract
ObjectiveHeart failure is a prothrombotic state, and it has been hypothesised that thrombosis and embolism cause non-fatal and fatal events in heart failure and reduced ejection fraction (HFrEF). We sought to determine the effect of anticoagulant therapy on clinical outcomes in patients with HFrEF who are in sinus rhythm.MethodsWe conducted an updated systematic review and meta-analysis to examine the effect of anticoagulation therapy in patients with HFrEF in sinus rhythm. Our analysis compared patients randomised to anticoagulant therapy with those randomised to antiplatelet therapy, placebo or control, and examined the endpoints of all-cause mortality, (re)hospitalisation for worsening heart failure, non-fatal myocardial infarction, non-fatal stroke of any aetiology and major haemorrhage.ResultsFive trials were identified that met the prespecified search criteria. Compared with control therapy, anticoagulant treatment did not reduce all-cause mortality (risk ratio [RR] 0.99, 95% CI 0.90 to 1.08), (re)hospitalisation for heart failure (RR 0.97, 95% CI 0.82 to 1.13) or non-fatal myocardial infarction (RR 0.92, 95% CI 0.75 to 1.13). Anticoagulation did reduce the rate of non-fatal stroke (RR 0.63, 95% CI 0.49 to 0.81, p=0.001), but this was offset by an increase in the incidence of major haemorrhage (RR 1.88, 95% CI 1.49 to 2.38, p=0.001).ConclusionsOur meta-analysis provides evidence to oppose the hypothesis that thrombosis or embolism plays an important role in the morbidity and mortality associated with HFrEF, with the exception of stroke-related morbidity.
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Zhao Q, Wang L, Kurlansky PA, Schein J, Baser O, Berger JS. Cardiovascular outcomes among elderly patients with heart failure and coronary artery disease and without atrial fibrillation: a retrospective cohort study. BMC Cardiovasc Disord 2019; 19:19. [PMID: 30646855 PMCID: PMC6334438 DOI: 10.1186/s12872-018-0991-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 12/21/2018] [Indexed: 01/30/2023] Open
Abstract
Background Coronary artery disease accelerates heart failure progression, leading to poor prognosis and a substantial increase in morbidity and mortality. This study was aimed to assess the impact of coronary artery disease on all-cause mortality, myocardial infarction (MI), and ischemic stroke (IS) among hospitalized newly-diagnosed heart failure (HF) patients with left ventricular systolic dysfunction (LVSD). Methods This retrospective cohort study included Medicare patients (aged ≥65 years) with ≥1 inpatient heart failure claim (index date = discharge date) during 01JAN2007-31DEC2013. Patients were required to have continuous enrollment for ≥1-year pre-index date (baseline: 1-year pre-index period) without a prior heart failure claim (in the 1 year pre-index prior to the index hospital admission); follow-up ran from the index date to death, disenrollment from the health plan, or the end of the study period, whichever occurred first. HF with LVSD patients, identified with diagnosis codes of systolic dysfunction (excluding baseline atrial fibrillation), were stratified based on prevalent coronary artery disease at baseline into coronary artery disease and non-coronary artery disease cohorts. Main outcomes were occurrence of major adverse cardiovascular events including all-cause mortality, myocardial infarction, and ischemic stroke. Propensity score matching (PSM) was used to balance patient characteristics. Kaplan-Meier curves of ACM and cumulative incidence distribution of MI/IS were presented. Results Of 22,230 HF with LVSD patients, 15,827 (71.2%) had coronary artery disease and were overall more likely to be younger (79.8 vs 80.9 years), male (49.6% vs. 35.6%), white (86.2% vs 81.4%), with more prevalent comorbidities including hypertension (80.7% vs 74.3%), hyperlipidemia (67.7% vs 46.7%), and diabetes (46.3% vs 35.8%) (all p < 0.0001). After propensity score matching, cohorts included 5792 patients each. The coronary artery disease cohort had significantly higher cumulative incidence of myocardial infarction and ischemic stroke at the end of 7-year follow-up vs non-coronary artery disease (myocardial infarction = 50.0% vs 18.0%; ischemic stroke = 23.3% vs 18.7%; all p < 0.0001). Follow-up all-cause mortality rates were similar between the two cohorts. Conclusions HF with LVSD patients with coronary artery disease had significantly higher incidence of ischemic stroke and myocardial infarction, but similar all-cause mortality compared to those without coronary artery disease. Electronic supplementary material The online version of this article (10.1186/s12872-018-0991-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Qi Zhao
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | - Li Wang
- STATinMED Research, Plano, TX, USA.
| | | | - Jeff Schein
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA.
| | - Onur Baser
- The University of Michigan, Ann Arbor, MI, USA
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Popovic B, Zannad F, Louis H, Clerc-Urmès I, Lakomy C, Gibot S, Denis CV, Lacolley P, Regnault V. Endothelial-driven increase in plasma thrombin generation characterising a new hypercoagulable phenotype in acute heart failure. Int J Cardiol 2019; 274:195-201. [DOI: 10.1016/j.ijcard.2018.07.130] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 06/22/2018] [Accepted: 07/24/2018] [Indexed: 12/19/2022]
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Korjian S, Braunwald E, Daaboul Y, Mi M, Bhatt DL, Verheugt FW, Cohen M, Bode C, Burton P, Plotnikov AN, Gibson CM. Usefulness of Rivaroxaban for Secondary Prevention of Acute Coronary Syndrome in Patients With History of Congestive Heart Failure (from the ATLAS-ACS-2 TIMI-51 Trial). Am J Cardiol 2018; 122:1896-1901. [PMID: 30340765 DOI: 10.1016/j.amjcard.2018.08.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/15/2018] [Accepted: 08/21/2018] [Indexed: 12/25/2022]
Abstract
Patients with both acute coronary syndromes (ACS) and congestive heart failure are at an increased risk of recurrent cardiovascular (CV) events attributed in part to both excess thrombin generation and impaired fibrinolysis. We hypothesized that patients with the overlap of ACS and CHF would thus derive particular benefit from antithrombotic therapy with rivaroxaban. ATLAS-ACS-2 Thrombolysis in Myocardial Infarction-51 was a double-blind, multicenter, phase 3 clinical trial that randomized patients within 7 days of an ACS event to standard of care plus either rivaroxaban 2.5 mg BID, 5 mg BID, or placebo (n = 15,526). In this post hoc subgroup analysis, subjects with a history of CHF at randomization (n = 1,694) were evaluated. Among subjects with a history of CHF, both rivaroxaban doses reduced the primary composite end point of CV death, myocardial infarction, or stroke (2.5 mg BID vs placebo: hazard ratio [HR] 0.59, 95% confidence interval [CI] (0.42, 0.81), p = 0.001; 5 mg BID vs placebo: HR 0.61, 95% CI (0.44, 0.84), p = 0.002; p interaction = 0.006). Both doses of rivaroxaban reduced CV mortality (rivaroxaban 2.5 mg BID vs placebo: 4.1% vs 9.0%, HR 0.45, 95% CI [0.27, 0.74], p = 0.002; rivaroxaban 5 mg BID vs placebo: 5.8% vs 9.0%, HR 0.62, 95% CI [0.40, 0.96], p = 0.031) as well as all-cause mortality. There was no significant increase in noncoronary artery bypass graft-related Thrombolysis in Myocardial Infarction major bleeding with either dose of rivaroxaban as compared with placebo (rivaroxaban 2.5 mg BID = 0.4% vs rivaroxaban 5 mg BID = 1.1% vs placebo = 0.5%). Rivaroxaban also did not increase either intracranial hemorrhage or fatal bleeding. In conclusion, in ACS subjects with a history of CHF, secondary prevention with rivaroxaban reduced the composite of CV death, myocardial infarction, or stroke without an increase in noncoronary artery bypass graft-related major bleeding. These findings require further prospective evaluation in an adequately powered phase 3 study.
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Camm AJ, Fox KAA. Oral anticoagulant use in cardiovascular disorders: a perspective on present and potential indications for rivaroxaban. Curr Med Res Opin 2018; 34:1945-1957. [PMID: 29672182 DOI: 10.1080/03007995.2018.1467885] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Four non-vitamin-K-antagonist oral anticoagulants (NOACs) have been approved for use in various cardiovascular indications. The direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors apixaban, edoxaban and rivaroxaban are now increasingly used in clinical practice. For some of these agents, available data from real-world studies support the efficacy and safety data in phase III clinical trials. OBJECTIVES This review aims to summarize the current status of trials and observational studies of oral anticoagulant use over the spectrum of cardiovascular disorders (excluding venous thrombosis), provide a reference source beyond stroke prevention for atrial fibrillation (AF) and examine the potential for novel applications in the cardiovascular field. METHODS We searched the recent literature for data on completed and upcoming trials of oral anticoagulants with a particular focus on rivaroxaban. RESULTS Recent data in specific patient subgroups, such as patients with AF undergoing catheter ablation or cardioversion, have led to an extended approval for rivaroxaban, whereas the other NOACs have ongoing or recently completed trials in this setting. However, there are unmet medical needs for several arterial thromboembolic-related conditions, including patients with: AF and acute coronary syndrome, AF and coronary artery disease undergoing elective percutaneous coronary intervention, coronary artery disease and peripheral artery disease, implanted cardiac devices, and embolic stroke of unknown source. CONCLUSION NOACs may provide alternative treatment options in areas of unmet need, and numerous studies are underway to assess their benefit-risk profiles in these settings.
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Affiliation(s)
- A John Camm
- a Cardiovascular and Cell Sciences Research Institute , St George's, University of London and Imperial College , London , UK
| | - Keith A A Fox
- b Centre for Cardiovascular Science , University of Edinburgh and Royal Infirmary of Edinburgh , Edinburgh , UK
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Beggs SAS, Jhund PS, McMurray JJV. Anticoagulation, atherothrombosis, and heart failure: lessons from COMMANDER-HF and CORONA. Eur Heart J 2018; 42:5143981. [PMID: 30357375 DOI: 10.1093/eurheartj/ehy609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Simon A S Beggs
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
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Zannad F, Anker SD, Byra WM, Cleland JGF, Fu M, Gheorghiade M, Lam CSP, Mehra MR, Neaton JD, Nessel CC, Spiro TE, van Veldhuisen DJ, Greenberg B. Rivaroxaban in Patients with Heart Failure, Sinus Rhythm, and Coronary Disease. N Engl J Med 2018; 379:1332-1342. [PMID: 30146935 DOI: 10.1056/nejmoa1808848] [Citation(s) in RCA: 242] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Heart failure is associated with activation of thrombin-related pathways, which predicts a poor prognosis. We hypothesized that treatment with rivaroxaban, a factor Xa inhibitor, could reduce thrombin generation and improve outcomes for patients with worsening chronic heart failure and underlying coronary artery disease. METHODS In this double-blind, randomized trial, 5022 patients who had chronic heart failure, a left ventricular ejection fraction of 40% or less, coronary artery disease, and elevated plasma concentrations of natriuretic peptides and who did not have atrial fibrillation were randomly assigned to receive rivaroxaban at a dose of 2.5 mg twice daily or placebo in addition to standard care after treatment for an episode of worsening heart failure. The primary efficacy outcome was the composite of death from any cause, myocardial infarction, or stroke. The principal safety outcome was fatal bleeding or bleeding into a critical space with a potential for causing permanent disability. RESULTS Over a median follow-up period of 21.1 months, the primary end point occurred in 626 (25.0%) of 2507 patients assigned to rivaroxaban and in 658 (26.2%) of 2515 patients assigned to placebo (hazard ratio, 0.94; 95% confidence interval [CI], 0.84 to 1.05; P=0.27). No significant difference in all-cause mortality was noted between the rivaroxaban group and the placebo group (21.8% and 22.1%, respectively; hazard ratio, 0.98; 95% CI, 0.87 to 1.10). The principal safety outcome occurred in 18 patients who took rivaroxaban and in 23 who took placebo (hazard ratio, 0.80; 95% CI, 0.43 to 1.49; P=0.48). CONCLUSIONS Rivaroxaban at a dose of 2.5 mg twice daily was not associated with a significantly lower rate of death, myocardial infarction, or stroke than placebo among patients with worsening chronic heart failure, reduced left ventricular ejection fraction, coronary artery disease, and no atrial fibrillation. (Funded by Janssen Research and Development; COMMANDER HF ClinicalTrials.gov number, NCT01877915 .).
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Affiliation(s)
- Faiez Zannad
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Stefan D Anker
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - William M Byra
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - John G F Cleland
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Min Fu
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Mihai Gheorghiade
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Carolyn S P Lam
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Mandeep R Mehra
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - James D Neaton
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Christopher C Nessel
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Theodore E Spiro
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Dirk J van Veldhuisen
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Barry Greenberg
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
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Metra M. October 2017 at a glance: phenotyping heart failure, co-morbidities, use of evidence-based therapy and new treatments. Eur J Heart Fail 2018; 19:1216-1217. [PMID: 28990347 DOI: 10.1002/ejhf.1034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
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McCarthy CP, Vaduganathan M, McCarthy KJ, Januzzi JL, Bhatt DL, McEvoy JW. Left Ventricular Thrombus After Acute Myocardial Infarction. JAMA Cardiol 2018; 3:642-649. [DOI: 10.1001/jamacardio.2018.1086] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
| | - Muthiah Vaduganathan
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Killian J. McCarthy
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - James L. Januzzi
- Division of Cardiology, Massachusetts General Hospital and Baim Institute for Clinical Research, Boston
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - John W. McEvoy
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Seoane L, Cortés M, Aris Cancela ME, Furmento J, Baranchuk A, Conde D. Rivaroxaban in the cardiovascular world: a direct anticoagulant useful to prevent stroke and venous and arterial thromboembolism. Expert Rev Cardiovasc Ther 2018; 16:501-514. [PMID: 29862875 DOI: 10.1080/14779072.2018.1484281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 05/25/2018] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Until recently, vitamin K antagonists (VKA) were the only drugs available for long-term anticoagulation. The use of these drugs is laborious due to their variable pharmacokinetics and pharmacodynamics. The advent of direct oral anticoagulants has produced a paradigm shift due to their low incidence of drug interactions, their stable plasma levels, and their lack of monitoring. Rivaroxaban, a factor Xa inhibitor, has been tested in different clinical scenarios and has proved to be effective and safe, even increasing the scope of the old VKA. Areas covered: A non-systematic review of the literature was conducted using the PubMed and Cochrane databases, focusing on randomized clinical trials and real-world observational studies that evaluated rivaroxaban in patients with atrial fibrillation, venous thromboembolism, and atherosclerotic coronary and peripheral vascular disease. Expert commentary: The role of rivaroxaban keeps expanding into areas that were unimaginable few years ago, in the light of solid evidence that has eliminated old strict paradigms. Nonetheless, it will be necessary to adjust costs and better understand the perceived barriers to its widespread implementation, to get fully acceptation of rivaroxaban for the different clinical conditions that have been suggested.
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Affiliation(s)
- Leonardo Seoane
- a Department of Cardiology , Instituto cardiovascular de Buenos Aires , Buenos Aires , Argentina
| | - Marcia Cortés
- a Department of Cardiology , Instituto cardiovascular de Buenos Aires , Buenos Aires , Argentina
| | | | - Juan Furmento
- a Department of Cardiology , Instituto cardiovascular de Buenos Aires , Buenos Aires , Argentina
| | - Adrián Baranchuk
- b Department of Cardiology , Kingston General Hospital, Heart Rhythm Service , Kingston , Canada
| | - Diego Conde
- a Department of Cardiology , Instituto cardiovascular de Buenos Aires , Buenos Aires , Argentina
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Sustained atrial fibrillation increases the risk of anticoagulation-related bleeding in heart failure. Clin Res Cardiol 2018; 107:1170-1179. [PMID: 29948286 DOI: 10.1007/s00392-018-1293-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 06/05/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Oral anticoagulation therapy in individuals with atrial fibrillation (AF) reduces the risk of thromboembolic events at cost of an increased bleeding risk. Whether anticoagulation-related outcomes differ between patients with paroxysmal and sustained AF receiving anticoagulation is controversially discussed. METHODS In the present analysis of the prospective multi-center cohort study thrombEVAL, the incidence of anticoagulation-related adverse events was analyzed according to the AF phenotype. Information on outcome was centrally recorded over 3 years, validated via medical records and adjudicated by an independent review panel. Study monitoring was provided by an independent institution. RESULTS Overall, the sample comprised 1089 AF individuals, of whom n = 398 had paroxysmal AF and n = 691 experienced sustained AF. In Cox regression analysis with adjustment for potential confounders, sustained AF indicated an independently elevated risk of clinically relevant bleeding compared to paroxysmal AF [hazard ratio (HR) 1.40 (1.02; 1.93); P = 0.038]. For clinically relevant bleeding, a significant interaction of the pattern of AF type with concomitant heart failure (HF) was detected: HRHF 2.45 (1.51, 3.98) vs. HRno HF 0.85 (0.55, 1.34); Pinteraction = 0.003. In HF patients, sustained AF indicated also an elevated risk of major bleeding [HR 2.25 (1.26, 4.20); P = 0.006]. A simplified HAS-BLED score incorporating only information on age (> 65 years), bleeding history, and HF with sustained AF demonstrated better discriminative performance for clinically relevant bleeding than the original version: AUCHAS-BLED: 0.583 vs. AUCsimplifiedHAS-BLED: 0.642 (P = 0.004). CONCLUSIONS In HF patients receiving oral anticoagulation, sustained AF indicates a substantially elevated risk of bleeding. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov , identifier: NCT01809015.
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Hamatani Y, Nagai T, Nakai M, Nishimura K, Honda Y, Nakano H, Honda S, Iwakami N, Sugano Y, Asaumi Y, Aiba T, Noguchi T, Kusano K, Toyoda K, Yasuda S, Yokoyama H, Ogawa H, Anzai T. Elevated Plasma D-Dimer Level Is Associated With Short-Term Risk of Ischemic Stroke in Patients With Acute Heart Failure. Stroke 2018; 49:1737-1740. [PMID: 29880555 DOI: 10.1161/strokeaha.118.021899] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 04/24/2018] [Accepted: 05/11/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The incidence of heart failure increases the subsequent risk of ischemic stroke, and its risk could be higher in the short-term period after an acute heart failure (AHF) event. However, its determinants remain to be clarified. Plasma D-dimer level reflects fibrin turnover and exhibits unique properties as a biomarker of thrombosis. The aim of this study is to investigate whether D-dimer level is a determinant of short-term incidence of ischemic stroke in patients with AHF. METHODS We examined 721 consecutive hospitalized AHF patients with plasma D-dimer level on admission from our prospective registry between January 2013 and May 2016. The study end points were incidence of ischemic stroke during hospitalization and at 30 days after admission. RESULTS Of the total participants (mean age, 76 years; male, 60%; atrial fibrillation, 54%; mean left ventricular ejection fraction, 38%), in-hospital ischemic stroke occurred in 18 patients (2.5%) during a median hospitalization period of 21 days, and 30-day ischemic stroke occurred in 16 patients (2.2%). Higher D-dimer level on admission was an independent determinant of subsequent risk of in-hospital ischemic stroke even after adjustment by CHA2DS2-VASc score (odds ratio, 2.29; 95% confidence interval, 1.46-3.60; P<0.001) or major confounders, including age, atrial fibrillation, and antithrombotic therapy (odds ratio, 2.31; 95% confidence interval, 1.43-3.74; P<0.001). Subgroup analyses showed consistent findings in patients without atrial fibrillation (odds ratio, 2.46; 95% confidence interval, 1.39-4.54; P=0.002) and those without antithrombotic therapy (odds ratio, 2.79; 95% confidence interval, 1.53-5.57; P<0.001). Similar results were obtained for 30-day ischemic stroke as an alternative outcome. CONCLUSIONS Elevated plasma D-dimer level on admission was significantly associated with increased incidence of ischemic stroke shortly after admission for AHF, suggesting a predictive role of D-dimer for short-term ischemic stroke events in patients with AHF. CLINICAL TRIAL REGISTRATION URL: https://www.umin.ac.jp/ctr/index.htm. Unique identifier: UMIN000017024.
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Affiliation(s)
- Yasuhiro Hamatani
- Department of Cardiovascular Medicine (Y. Hamatani, Y. Honda, H.N., S.H., N.I., Y.S., Y.A., T. Aiba, T. Noguchi, K.K., S.Y., H.Y., H.O.)
| | - Toshiyuki Nagai
- From the Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Japan (T. Nagai, T. Anzai)
| | - Michikazu Nakai
- Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (M.N., K.N.)
| | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information (M.N., K.N.)
| | - Yasuyuki Honda
- Department of Cardiovascular Medicine (Y. Hamatani, Y. Honda, H.N., S.H., N.I., Y.S., Y.A., T. Aiba, T. Noguchi, K.K., S.Y., H.Y., H.O.)
| | - Hiroki Nakano
- Department of Cardiovascular Medicine (Y. Hamatani, Y. Honda, H.N., S.H., N.I., Y.S., Y.A., T. Aiba, T. Noguchi, K.K., S.Y., H.Y., H.O.)
| | - Satoshi Honda
- Department of Cardiovascular Medicine (Y. Hamatani, Y. Honda, H.N., S.H., N.I., Y.S., Y.A., T. Aiba, T. Noguchi, K.K., S.Y., H.Y., H.O.)
| | - Naotsugu Iwakami
- Department of Cardiovascular Medicine (Y. Hamatani, Y. Honda, H.N., S.H., N.I., Y.S., Y.A., T. Aiba, T. Noguchi, K.K., S.Y., H.Y., H.O.)
| | - Yasuo Sugano
- Department of Cardiovascular Medicine (Y. Hamatani, Y. Honda, H.N., S.H., N.I., Y.S., Y.A., T. Aiba, T. Noguchi, K.K., S.Y., H.Y., H.O.)
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine (Y. Hamatani, Y. Honda, H.N., S.H., N.I., Y.S., Y.A., T. Aiba, T. Noguchi, K.K., S.Y., H.Y., H.O.)
| | - Takeshi Aiba
- Department of Cardiovascular Medicine (Y. Hamatani, Y. Honda, H.N., S.H., N.I., Y.S., Y.A., T. Aiba, T. Noguchi, K.K., S.Y., H.Y., H.O.)
| | - Teruo Noguchi
- Department of Cardiovascular Medicine (Y. Hamatani, Y. Honda, H.N., S.H., N.I., Y.S., Y.A., T. Aiba, T. Noguchi, K.K., S.Y., H.Y., H.O.)
| | - Kengo Kusano
- Department of Cardiovascular Medicine (Y. Hamatani, Y. Honda, H.N., S.H., N.I., Y.S., Y.A., T. Aiba, T. Noguchi, K.K., S.Y., H.Y., H.O.)
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine (Y. Hamatani, Y. Honda, H.N., S.H., N.I., Y.S., Y.A., T. Aiba, T. Noguchi, K.K., S.Y., H.Y., H.O.)
| | - Hiroyuki Yokoyama
- Department of Cardiovascular Medicine (Y. Hamatani, Y. Honda, H.N., S.H., N.I., Y.S., Y.A., T. Aiba, T. Noguchi, K.K., S.Y., H.Y., H.O.)
| | - Hisao Ogawa
- Department of Cardiovascular Medicine (Y. Hamatani, Y. Honda, H.N., S.H., N.I., Y.S., Y.A., T. Aiba, T. Noguchi, K.K., S.Y., H.Y., H.O.)
| | - Toshihisa Anzai
- From the Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Japan (T. Nagai, T. Anzai)
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Yuan J. Efficacy and safety of adding rivaroxaban to the anti-platelet regimen in patients with coronary artery disease: a systematic review and meta-analysis of randomized controlled trials. BMC Pharmacol Toxicol 2018; 19:19. [PMID: 29720261 PMCID: PMC5932859 DOI: 10.1186/s40360-018-0209-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/23/2018] [Indexed: 01/27/2023] Open
Abstract
Background Rivaroxaban, a direct factor Xa inhibitor, has seldom been used in patients with coronary artery disease. In this analysis, we aimed to systematically compare the efficacy and safety of rivaroxaban in addition to the anti-platelet regimen in patients with coronary artery disease. Methods Online databases (MEDLINE, EMBASE, Cochrane database, www.ClinicalTrials.gov and Google scholar were searched for randomized controlled trials which were exclusively based on patients with coronary artery disease; and which compared efficacy (cardiovascular outcomes) and safety (bleeding outcomes) outcomes with the addition of rivaroxaban to the other anti-platelet agents. Analysis was carried out by the RevMan 5.3 software whereby odds ratios (OR) and 95% confidence intervals (CI) were generated following data input. Results Four trials with a total number of 40,148 patients were included (23,231 participants were treated with rivaroxaban whereas 16,919 participants were treated with placebo) in this analysis. Patients’ enrollment period varied from years 2006 to 2016. The current results showed addition of rivaroxaban to significantly lower composite endpoints (OR: 0.81, 95% CI: 0.74–0.88; P = 0.00001). In addition, all-cause death, cardiac death, myocardial infarction, and stent thrombosis were also significantly reduced (OR: 0.82, 95% CI: 0.72–0.92; P = 0.0009), (OR: 0.80, 95% CI: 0.69–0.92; P = 0.002), (OR: 0.87, 95% CI: 0.77–0.98; P = 0.03) and (OR: 0.73, 95% CI: 0.55–0.97; P = 0.03) respectively. However, stroke was not significantly different. However, TIMI defined minor and major bleeding were significantly higher with rivaroxaban (OR: 2.27, 95% CI: 1.47–3.49; P = 0.0002) and (OR: 3.44, 95% CI: 1.13–10.52; P = 0.03) respectively. In addition, intracranial hemorrhage and bleeding which was defined according to the International Society on Thrombosis and Hemostasis criteria were also significantly higher with rivaroxaban (OR: 1.63, 95% CI: 1.04–2.56; P = 0.03) and (OR: 1.80, 95% CI: 1.45–2.22; P = 0.00001) respectively. Nevertheless, fatal bleeding was not significantly different. Conclusions Addition of rivaroxaban to the anti-platelet regimen was effective in patients with coronary artery disease, but the safety outcomes were doubtful. Further future trials will be able to completely solve this issue.
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Affiliation(s)
- Jun Yuan
- Department of Cardiology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530021, Guangxi, China.
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van Veldhuisen DJ, Rienstra M, van der Meer P. Value of digoxin in patients with heart failure: new pieces to the puzzle. Eur J Heart Fail 2018; 20:1146-1147. [DOI: 10.1002/ejhf.1200] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Dirk J. van Veldhuisen
- Department of Cardiology; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
| | - Michiel Rienstra
- Department of Cardiology; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
| | - Peter van der Meer
- Department of Cardiology; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
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35
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Siliste R, Antohi E, Pepoyan S, Nakou E, Vardas P. Anticoagulation in heart failure without atrial fibrillation: gaps and dilemmas in current clinical practice. Eur J Heart Fail 2018; 20:978-988. [DOI: 10.1002/ejhf.1153] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 12/31/2017] [Accepted: 01/15/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
| | - Elena‐Laura Antohi
- Department of Cardiology Emergency Cardiovascular Disease Institute ‘Prof. Dr. C.C. Iliescu’ Bucharest Romania
| | - Sergey Pepoyan
- Department of Cardiology Yerevan State Medical University (YSMU), University Clinical Hospital Yerevan Armenia
| | - Eleni Nakou
- Department of Cardiology Heraklion University Hospital Crete Greece
| | - Panos Vardas
- Department of Cardiology Heraklion University Hospital Crete Greece
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36
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Madelaire C, Gislason G, Kristensen SL, Fosbøl EL, Bjerre J, D’Souza M, Gustafsson F, Kober L, Torp-Pedersen C, Schou M. Low-Dose Aspirin in Heart Failure Not Complicated by Atrial Fibrillation. JACC-HEART FAILURE 2018; 6:156-167. [DOI: 10.1016/j.jchf.2017.09.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 09/14/2017] [Accepted: 09/19/2017] [Indexed: 10/18/2022]
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37
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Cleland JG. Physicians Addicted to Prescribing Aspirin-a Disorder Of Cardiologists (PAPA-DOC) Syndrome. JACC-HEART FAILURE 2018; 6:168-171. [DOI: 10.1016/j.jchf.2017.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 11/30/2022]
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38
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Kim W, Kim EJ. Heart Failure as a Risk Factor for Stroke. J Stroke 2018; 20:33-45. [PMID: 29402070 PMCID: PMC5836579 DOI: 10.5853/jos.2017.02810] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 12/26/2017] [Accepted: 01/08/2018] [Indexed: 12/14/2022] Open
Abstract
Heart failure (HF) is one of the major causes of death worldwide. Despite the high incidence of stroke in patients with HF, there has been a controversy as to whether HF itself is a risk factor for stroke. Recently, there is a great deal of evidence that HF itself increases the risk of stroke. In previous studies, the benefit of warfarin for stroke prevention in patients with HF was offset by the risk of bleeding. In the era of non-vitamin K antagonist oral anticoagulants with low bleeding profiles, we can expect a more effective stroke prevention in patients with HF by selective anticoagulation. The purpose of this review is to describe the relationship between stroke and HF, which could be an unconventional risk factor and a potential intervention target for stroke prevention.
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Affiliation(s)
- Woohyeun Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Eung Ju Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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39
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Doehner W, Ural D, Haeusler KG, Čelutkienė J, Bestetti R, Cavusoglu Y, Peña-Duque MA, Glavas D, Iacoviello M, Laufs U, Alvear RM, Mbakwem A, Piepoli MF, Rosen SD, Tsivgoulis G, Vitale C, Yilmaz MB, Anker SD, Filippatos G, Seferovic P, Coats AJS, Ruschitzka F. Heart and brain interaction in patients with heart failure: overview and proposal for a taxonomy. A position paper from the Study Group on Heart and Brain Interaction of the Heart Failure Association. Eur J Heart Fail 2017; 20:199-215. [PMID: 29280256 DOI: 10.1002/ejhf.1100] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 10/23/2017] [Accepted: 11/08/2017] [Indexed: 12/16/2022] Open
Abstract
Heart failure (HF) is a complex clinical syndrome with multiple interactions between the failing myocardium and cerebral (dys-)functions. Bi-directional feedback interactions between the heart and the brain are inherent in the pathophysiology of HF: (i) the impaired cardiac function affects cerebral structure and functional capacity, and (ii) neuronal signals impact on the cardiovascular continuum. These interactions contribute to the symptomatic presentation of HF patients and affect many co-morbidities of HF. Moreover, neuro-cardiac feedback signals significantly promote aggravation and further progression of HF and are causal in the poor prognosis of HF. The diversity and complexity of heart and brain interactions make it difficult to develop a comprehensive overview. In this paper a systematic approach is proposed to develop a comprehensive atlas of related conditions, signals and disease mechanisms of the interactions between the heart and the brain in HF. The proposed taxonomy is based on pathophysiological principles. Impaired perfusion of the brain may represent one major category, with acute (cardio-embolic) or chronic (haemodynamic failure) low perfusion being sub-categories with mostly different consequences (i.e. ischaemic stroke or cognitive impairment, respectively). Further categories include impairment of higher cortical function (mood, cognition), of brain stem function (sympathetic over-activation, neuro-cardiac reflexes). Treatment-related interactions could be categorized as medical, interventional and device-related interactions. Also interactions due to specific diseases are categorized. A methodical approach to categorize the interdependency of heart and brain may help to integrate individual research areas into an overall picture.
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Affiliation(s)
- Wolfram Doehner
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Germany.,Division of Cardiology and Metabolism, Department of Cardiology (CVK), Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Charité - Universitätsmedizin Berlin, Germany.,Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Germany
| | - Dilek Ural
- Department of Cardiology, Koc University School of Medicine, Istanbul, Turkey
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Germany
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Centre of Cardiology, Vilnius University, Lithuania
| | - Reinaldo Bestetti
- Department of Medicine, University of Ribeirão Preto, Ribeirão Preto, Brazil
| | - Yuksel Cavusoglu
- Cardiology Department, Eskisehir Osmangazi University, Eskisehir, Turkey
| | | | - Duska Glavas
- Cardiology Department, University Hospital Split, Croatia
| | - Massimo Iacoviello
- University Cardiology Unit, Cardiothoracic Department, University Hospital, Bari, Italy
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | | | - Amam Mbakwem
- College of Medicine, University of Lagos, Lagos, Nigeria
| | - Massimo F Piepoli
- Heart Failure Unit, Cardiology, G. da Saliceto Hospital, Piacenza, Italy
| | - Stuart D Rosen
- Ealing and Royal Brompton Hospitals and NHLI, Imperial College, London, UK
| | | | - Cristiana Vitale
- Department of Medical Science, IRCCS San Raffaele Pisana, Rome, Italy
| | - M Birhan Yilmaz
- Department of Cardiology, Faculty of Medicine Cumhuriyet University, Sivas, Turkey
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK), Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Charité - Universitätsmedizin Berlin, Germany.,Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Germany.,Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany
| | - Gerasimos Filippatos
- Attikon University Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Petar Seferovic
- University of Belgrade, Faculty of Medicine, Clinical Center of Serbia, Belgrade, Serbia
| | - Andrew J S Coats
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy
| | - Frank Ruschitzka
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
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40
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Cappato R, Welsh R. Exploring unmet needs in venous and arterial thromboembolism with rivaroxaban. Thromb Haemost 2017; 116:S2-S12. [DOI: 10.1160/th16-06-0484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/10/2016] [Indexed: 11/05/2022]
Abstract
SummaryThe vast clinical research programme for the direct, oral factor Xa inhibitor rivaroxaban has generated a wealth of data since the first rivaroxaban approval in 2008 for the prevention of venous thrombo embolism (VTE) in patients undergoing elective hip or knee replacement surgery. While rivaroxaban is widely used across a spectrum of seven indications, there is continuous commitment to investigating its wider benefits in new indications and attempts to refine current evidence. Key data from recently completed randomised controlled trials (RCTs) have shown that rivaroxaban is a feasible anticoagulation option for patients with non-valvular atrial fibrillation (NVAF) undergoing cardioversion or catheter ablation. Now, a number of Phase II and III RCTs are underway that seek to uncover further roles for rivaroxaban in patients at risk of thrombosis and aim to improve quality of life. This article will introduce and provide context for these RCTs in the contemporary management of arterial and venous thromboembolism in the following underserved areas: Patients with both NVAF and acute coronary syndrome (ACS) requiring percutaneous coronary intervention (PCI); patients with embolic stroke of undetermined source (ESUS); patients who require transcatheter aortic valve replacement (TAVR); patients with acute or chronic coronary artery disease (CAD; including those with heart failure [HF]); those at risk of or suffering from cancer-associated thrombosis (CAT) and those requiring long-term anticoagulation. It is hoped that this collection of studies provides clarity around the use of rivaroxaban as a fundamental component of antithrombotic therapy in an array of clinical situations.
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41
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McDonald MA, Ashley EA, Fedak PW, Hawkins N, Januzzi JL, McMurray JJ, Parikh VN, Rao V, Svystonyuk D, Teerlink JR, Virani S. Mind the Gap: Current Challenges and Future State of Heart Failure Care. Can J Cardiol 2017; 33:1434-1449. [DOI: 10.1016/j.cjca.2017.08.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/30/2017] [Accepted: 08/30/2017] [Indexed: 11/24/2022] Open
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Venner C, Huttin O, Selton-Suty C, Juillière Y. [New treatments for heart failure]. SOINS; LA REVUE DE REFERENCE INFIRMIERE 2017; 62:22-25. [PMID: 29153212 DOI: 10.1016/j.soin.2017.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
New direct oral anticoagulants are recommended as first-line therapy in case of atrial fibrillation within a heart failure. In the absence of atrial fibrillation, the role for new direct oral anticoagulants would have to be confirmed in the next years. Sacubitril/valsartan, angiotansin II receptor neprilysin inhibitor, presents with an efficacy superior to that of angiotensin converting enzyme inhibitors. It is now recommended in the treatment of heart failure as a third-line therapy. Modalities of prescription are strict, and safety is good.
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Affiliation(s)
- Clément Venner
- Département de cardiologie, Institut lorrain du cœur et des vaisseaux, CHU Nancy-Brabois, 5, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - Olivier Huttin
- Département de cardiologie, Institut lorrain du cœur et des vaisseaux, CHU Nancy-Brabois, 5, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - Christine Selton-Suty
- Département de cardiologie, Institut lorrain du cœur et des vaisseaux, CHU Nancy-Brabois, 5, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - Yves Juillière
- Département de cardiologie, Institut lorrain du cœur et des vaisseaux, CHU Nancy-Brabois, 5, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France.
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Abstract
Heart failure is common in adults, accounting for substantial morbidity and mortality worldwide. Its prevalence is increasing because of ageing of the population and improved treatment of acute cardiovascular events, despite the efficacy of many therapies for patients with heart failure with reduced ejection fraction, such as angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), β blockers, and mineralocorticoid receptor antagonists, and advanced device therapies. Combined angiotensin receptor blocker neprilysin inhibitors (ARNIs) have been associated with improvements in hospital admissions and mortality from heart failure compared with enalapril, and guidelines now recommend substitution of ACE inhibitors or ARBs with ARNIs in appropriate patients. Improved safety of left ventricular assist devices means that these are becoming more commonly used in patients with severe symptoms. Antidiabetic therapies might further improve outcomes in patients with heart failure. New drugs with novel mechanisms of action, such as cardiac myosin activators, are under investigation for patients with heart failure with reduced left ventricular ejection fraction. Heart failure with preserved ejection fraction is a heterogeneous disorder that remains incompletely understood and will continue to increase in prevalence with the ageing population. Although some data suggest that spironolactone might improve outcomes in these patients, no therapy has conclusively shown a significant effect. Hopefully, future studies will address these unmet needs for patients with heart failure. Admissions for acute heart failure continue to increase but, to date, no new therapies have improved clinical outcomes.
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Affiliation(s)
- Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - John R Teerlink
- School of Medicine, University of California, San Francisco, CA, USA; Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
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44
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Metra M. September 2017 at a glance: epidemiology, prognosis, Mediterranean diet and different viewpoints on aspirin. Eur J Heart Fail 2017; 19:1084-1085. [DOI: 10.1002/ejhf.947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/22/2017] [Accepted: 07/25/2017] [Indexed: 11/07/2022] Open
Affiliation(s)
- Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health; University of Brescia; Italy
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45
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Palamaner Subash Shantha G, Mentias A, Inampudi C, Kumar AA, Chaikriangkrai K, Bhise V, Deshmukh A, Patel N, Pancholy S, Horwitz PA, Mickelsen S, Bhave PD, Giudici M, Oral H, Vaughan Sarrazin MS. Sex-Specific Associations of Oral Anticoagulant Use and Cardiovascular Outcomes in Patients With Atrial Fibrillation. J Am Heart Assoc 2017; 6:e006381. [PMID: 28862952 PMCID: PMC5586467 DOI: 10.1161/jaha.117.006381] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/06/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sex-specific effectiveness of rivaroxaban (RIVA), dabigatran (DABI), and warfarin in reducing myocardial infarction (MI), heart failure (HF), and all-cause mortality among patients with atrial fibrillation are not known. We assessed sex-specific associations of RIVA, DABI, or warfarin use with the risk of MI, HF, and all-cause mortality among patients with atrial fibrillation. METHODS AND RESULTS Medicare beneficiaries (men: 65 734 [44.8%], women: 81 135 [55.2%]) with atrial fibrillation who initiated oral anticoagulants formed the study cohort. Inpatient admissions for MI, HF, and all-cause mortality were compared between the 3 drugs separately for men and women using 3-way propensity-matched samples. In men, RIVA use was associated with a reduced risk of MI admissions compared with warfarin use (hazard ratio [95% confidence interval (CI): 0.59 [0.38-0.91]), with a trend towards reduced risk compared with DABI use (0.67 [0.44-1.01]). In women, there were no significant differences in the risk of MI admissions across all 3 anticoagulants. In both sexes, RIVA use and DABI use were associated with reduced risk of HF admissions (men: RIVA; 0.75 [0.63-0.89], DABI; 0.81 [0.69-0.96]) (women: RIVA; 0.64 [0.56-0.74], DABI; 0.73 [0.63-0.83]) and all-cause mortality (men: RIVA; 0.66 [0.53-0.81], DABI; 0.75 [0.61-0.93]) (women: RIVA; 0.76 [0.63-0.91], DABI; 0.77 [0.64-0.93]) compared with warfarin use. CONCLUSIONS RIVA use and DABI use when compared with warfarin use was associated with a reduced risk of HF admissions and all-cause mortality in both sexes. However, reduced risk of MI admissions noted with RIVA use appears to be limited to men.
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Affiliation(s)
- Ghanshyam Palamaner Subash Shantha
- Division of Cardiovascular Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Amgad Mentias
- Division of Cardiovascular Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Chakradhari Inampudi
- Division of Cardiovascular Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Anita A Kumar
- Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Kongkiat Chaikriangkrai
- Division of Cardiovascular Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Viraj Bhise
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center at Houston, TX
| | | | - Nileshkumar Patel
- Department of Cardiology, Jackson Memorial Hospital, University of Miami, FL
| | - Samir Pancholy
- Department of Cardiovascular Medicine, The Wright Center for Graduate Medical Education, Scranton, PA
| | - Phillip A Horwitz
- Division of Cardiovascular Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Steven Mickelsen
- Division of Cardiovascular Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Prashant D Bhave
- Cardiology Division/Electrophysiology Section, Wake Forest Baptist Hospital, Winston-Salem, NC
| | - Michael Giudici
- Division of Cardiovascular Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Hakan Oral
- Department of Electrophysiology, University of Michigan, Ann Arbor, MI
| | - Mary S Vaughan Sarrazin
- Department of Internal Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa, Iowa City, IA
- Comprehensive Access and Delivery Research and Evaluation Center (CADRE), Iowa City VA Medical Center, Iowa City, IA
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46
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Cleland JGF. What Do Cardiology and Homeopathy Have in Common?: A Belief in Aspirin? JACC. HEART FAILURE 2017; 5:611-614. [PMID: 28774397 DOI: 10.1016/j.jchf.2017.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 06/21/2017] [Indexed: 06/07/2023]
Affiliation(s)
- John G F Cleland
- Robertson Centre for Biostatistics & Clinical Trials, University of Glasgow, Glasgow, Scotland, United Kingdom; National Heart & Lung Institute, Imperial College, London, United Kingdom.
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47
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De Caterina R. Aspirin in heart failure: don't throw the baby (aspirin) out with the bathwater. Eur J Heart Fail 2017; 19:1089-1094. [PMID: 28560745 DOI: 10.1002/ejhf.894] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/24/2017] [Accepted: 04/24/2017] [Indexed: 12/19/2022] Open
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Abstract
Heart failure continues to be a leading cause of morbidity and mortality throughout the United States. The pathophysiology of heart failure involves the activation of complex neurohormonal pathways, many of which mediate not only hypertrophy and fibrosis within ventricular myocardium and interstitium, but also activation of platelets and alteration of vascular endothelium. Platelet activation and vascular endothelial dysfunction may contribute to the observed increased risk of thromboembolic events in patients with chronic heart failure. However, current data from clinical trials do not support the routine use of chronic antiplatelet or oral anticoagulation therapy for ambulatory heart failure patients without other indications (atrial fibrillation and/or coronary artery disease) as the risk of bleeding seems to outweigh the potential benefit related to reduction in thromboembolic events. In this review, we consider the potential clinical utility of targeting specific pathophysiological mechanisms of platelet and vascular endothelial activation to guide clinical decision making in heart failure patients.
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Affiliation(s)
- Daniel J Quinlan
- From Department of Radiology, Kings College Hospital, London, United Kingdom (D.J.Q.); and Population Health Research Institute, Hamilton Health Sciences and Department of Medicine, McMaster University, Ontario, Canada (J.W.E., R.G.H.).
| | - John W Eikelboom
- From Department of Radiology, Kings College Hospital, London, United Kingdom (D.J.Q.); and Population Health Research Institute, Hamilton Health Sciences and Department of Medicine, McMaster University, Ontario, Canada (J.W.E., R.G.H.)
| | - Robert G Hart
- From Department of Radiology, Kings College Hospital, London, United Kingdom (D.J.Q.); and Population Health Research Institute, Hamilton Health Sciences and Department of Medicine, McMaster University, Ontario, Canada (J.W.E., R.G.H.)
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50
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Cuthbert JJ, Pellicori P, Shah P, Clark AL. New pharmacological approaches in heart failure therapy: developments and possibilities. Future Cardiol 2017; 13:173-188. [PMID: 28181443 DOI: 10.2217/fca-2016-0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
There have been few major breakthroughs in heart failure (HF) drug therapies in recent years yet HF morbidity and mortality remain high, and there is a clear need for further research. Several newer agents that appear promising in Phase I and II trials do not progress to show clinical benefit in later trials. Part of the failure to find new therapies may lie in flawed trial design compounded by the need for ever-increasing patient numbers in order to prove outcome benefit. We summarize some of the most recent and promising medical therapies for HF.
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Affiliation(s)
- Joseph J Cuthbert
- Department of Cardiology, Hull York Medical School, Hull & East Yorkshire Medical Research & Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull HU16 5JQ, UK
| | - Pierpaolo Pellicori
- Department of Cardiology, Hull York Medical School, Hull & East Yorkshire Medical Research & Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull HU16 5JQ, UK
| | - Parin Shah
- Department of Cardiology, Hull York Medical School, Hull & East Yorkshire Medical Research & Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull HU16 5JQ, UK
| | - Andrew L Clark
- Department of Cardiology, Hull York Medical School, Hull & East Yorkshire Medical Research & Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull HU16 5JQ, UK
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