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Erbay MI, Pyrpyris N, Susarla S, Ulusan S, Mares AC, Wilson TP, Lee D, Sood A, Gupta R. Comparative safety review of antithrombotic treatment options for patients with atrial fibrillation undergoing percutaneous coronary intervention. Expert Opin Drug Saf 2024; 23:149-160. [PMID: 38214282 DOI: 10.1080/14740338.2024.2305367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/10/2024] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Balancing antithrombotic therapy for atrial fibrillation (AF) patients undergoing percutaneous coronary intervention (PCI) remains a clinical challenge due to coexisting thrombogenic risks. This review emphasizes the delicate balance required to prevent ischemic events while minimizing bleeding complications, particularly in the context of risk assessment. AREAS COVERED This review spans from 2010 to October 2023, exploring the complexities of antithrombotic management for AF patients undergoing PCI. It stresses the need for personalized treatment decisions to optimize antithrombotic therapies effectively. EXPERT OPINION The evolving evidence supports double antithrombotic therapy (DAT) over triple antithrombotic therapy (TAT) for these patients, showcasing a more favorable safety profile without compromising efficacy. Non-vitamin K antagonist oral anticoagulant (NOAC)-based DAT strategies exhibit superiority in reducing major bleeding events while effectively preventing ischemic events. Recommendations from the 2023 European Society of Cardiology (ESC) Guidelines advocate for NOAC-based DAT post-PCI, endorsing safer antithrombotic profiles.Challenges persist for specific patient categories requiring both oral anticoagulants and antiplatelets, necessitating personalized approaches. Future advances in intravascular imaging and novel coronary stent technologies offer promising avenues to optimize outcomes and influence antithrombotic strategies in AF-PCI patients.
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Affiliation(s)
- Muhammed Ibrahim Erbay
- Division of Cardiovascular Medicine, Cerrahpasa School of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey
- Department of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Nikolaos Pyrpyris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Shriraj Susarla
- Department of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Sebahat Ulusan
- Faculty of Medicine, Suleyman Demirel University, Isparta, Isparta Province, Turkey
| | - Adriana C Mares
- Division of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven CT, USA
| | - Tasha Phillips Wilson
- Department of Internal Medicine, St. George's University School of Medicine, True Bule, Greneda
| | - Duo Lee
- Department of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Aayushi Sood
- Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, PA USA
| | - Rahul Gupta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA USA
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Zeymer U, Toelg R, Wienbergen H, Hobbach HP, Cuneo A, Bekeredjian R, Ritter O, Hailer B, Hertting K, Hennersdorf M, Scholtz W, Lanzer P, Mudra H, Schwefer M, Schwimmbeck PL, Liebetrau C, Thiele H, Claas C, Riemer T, Zahn R. Current status of antithrombotic therapy and in-hospital outcomes in patients with atrial fibrillation undergoing percutaneous coronary intervention in Germany. Herz 2023; 48:134-140. [PMID: 35243515 DOI: 10.1007/s00059-022-05099-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/06/2021] [Accepted: 01/24/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Little is known about current patterns of antithrombotic therapy in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) in clinical practice in Germany. METHODS The RIVA-PCI is a prospective, non-interventional, multicenter study with follow-up until hospital discharge including consecutive patients with AF undergoing PCI. RESULTS Between January 2018 and March 2020, 1636 patients (elective in 52.6%, non-ST elevation acute coronary syndrome [NSTE-ACS] in 39.3%, ST-elevation myocardial infarction in 8.2%) from 51 German hospitals were enrolled in the study. After PCI a dual antithrombotic therapy (DAT) consisting of OAC and a P2Y12 inhibitor was given to 66.0%, triple antithrombotic therapy (TAT) to 26.0%, dual antiplatelet therapy to 5.5%, and a mono-therapy to 2.5% of the patients. Non-vitamin K antagonist oral anticoagulants (NOACs) were given to 82.4% and vitamin K antagonists to 11.5% of the patients. In-hospital events included death in 12 cases (0.7%), myocardial infarction, stent thrombosis, and ischemic stroke in four (0.2%) patients each, while 2.8% of patients had bleeding complications. The recommended durations for DAT or TAT at discharge were 1 month (1.5%), 3 months (2.1%), 6 months (43.1%), and 12 months (45.6%), with a 6-month course of DAT (47.7%) most often recommended after elective PCI and a 12-month course of DAT (40.1%) after ACS. CONCLUSION The preferred therapy after PCI in patients with AF is DAT with a NOAC and clopidogrel. In-hospital ischemic and bleeding events were rare. The recommended durations for combination therapy vary considerably.
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Affiliation(s)
- Uwe Zeymer
- Medizinische Klinik B, Klinikum Ludwigshafen, Bremserstraße 79, 67063, Ludwigshafen, Germany. .,Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany.
| | - Ralph Toelg
- Segeberger Kliniken GmbH, Bad Segeberg, Germany
| | | | | | | | | | | | - Birgit Hailer
- Katholische Kliniken Essen-Nord-West gGmbH, Essen, Germany
| | | | | | | | - Peter Lanzer
- Gesundheitszentrum Bitterfeld Wolfen, Bitterfeld, Germany
| | - Harald Mudra
- Städtisches Krankenhaus Neuperlach-München, München, Germany
| | | | | | | | - Holger Thiele
- Herzzentrum Leipzig und Universität Leipzig, Leipzig, Germany
| | - Christoph Claas
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Thomas Riemer
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Ralf Zahn
- Medizinische Klinik B, Klinikum Ludwigshafen, Bremserstraße 79, 67063, Ludwigshafen, Germany
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Zeymer U, Toelg R, Wienbergen H, Hobbach HP, Cuneo A, Bekeredjian R, Ritter O, Hailer B, Hertting K, Hennersdorf M, Scholtz W, Lanzer P, Mudra H, Schwefer M, Schwimmbeck PL, Liebetrau C, Thiele H, Claas C, Riemer T, Zahn R. Rivaroxaban in Patients With Atrial Fibrillation Who Underwent Percutaneous Coronary Intervention in Clinical Practice. Am J Cardiol 2023; 189:31-37. [PMID: 36493580 DOI: 10.1016/j.amjcard.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/08/2022] [Accepted: 11/04/2022] [Indexed: 12/12/2022]
Abstract
Little is known about the efficacy and safety of rivaroxaban in patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI) in clinical practice. We therefore conducted a prospective observational study to determine the rate of ischemic, embolic, and bleeding events in patients with AF and PCI treated with rivaroxaban in a real-world experience. The RIVA-PCI ("rivaroxaban in patients with AF who underwent PCI") (clinicaltrials.gov NCT03315650) is a prospective, noninterventional, multicenter study with a follow-up until 14 months, including patients with AF who underwent PCI discharged with rivaroxaban. Between January 2018 and March 2020, 700 patients with PCI treated with rivaroxaban (elective in 50.1%, non-ST-elevation acute coronary syndrome 43.0%, ST-elevation myocardial infarction in 6.9%) were enrolled at 51 German hospitals. After PCI, a dual antithrombotic therapy consisting of rivaroxaban and a P2Y12 inhibitor was administered in 70.7% and triple antithrombotic therapy in 27.9%, respectively. Follow-up information could be obtained in 695 patients (99.3%). Rivaroxaban has been stopped prematurely in 21.6% of patients. Clinical events under rivaroxaban during the 14-month follow-up compared with those observed in the PIONEER-AF PCI trial included cardiovascular death (2.0% % vs 2.0%), myocardial infarction (0.9% vs 3.0%), stent thrombosis (0.2% vs 0.8%), stroke (1.3% vs 1.3%), International Society on Thrombosis and Haemostasis major (4.2% vs 3.9%), and International Society on Thrombosis and Haemostasis nonmajor clinically relevant bleeding (15.3% vs 12.9%). Therefore, in this real-world experience, rivaroxaban in patients with AF who underwent PCI is associated with ischemic and bleeding event rates comparable with those observed in the randomized PIONEER-AF PCI trial.
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Affiliation(s)
- Uwe Zeymer
- Klinikum Ludwigshafen, Ludwigshafen, Germany; Institut für Herzinfarktforschung Ludwigshafen, Germany.
| | - Ralph Toelg
- Segeberger Kliniken GmbH, Bad Segeberg, Germany
| | | | | | | | | | | | - Birgit Hailer
- Katholische Kliniken Essen-Nord-West gGmbH, Essen, Germany
| | | | | | | | - Peter Lanzer
- Gesundheitszentrum Bitterfeld Wolfen, Bitterfeld, Germany
| | - Harald Mudra
- München Klinik, Klinikum Neuperlach, München, Germany
| | | | | | | | - Holger Thiele
- Herzzentrum Leipzig - Universität Leipzig, Leipzig, Germany
| | | | - Thomas Riemer
- Institut für Herzinfarktforschung Ludwigshafen, Germany
| | - Ralf Zahn
- Klinikum Ludwigshafen, Ludwigshafen, Germany
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Al-Maqbali JS, Alawi AMA, Al-Adawi M, Al-Falahi Z, Al-Azizi A, Al Badi K, Rawahi MA. Clinical Associations with the differences in rivaroxaban dosing in patients with atrial fibrillation stratified by three renal function formulae. Pharm Pract (Granada) 2023; 21:2758. [PMID: 37090449 PMCID: PMC10117315 DOI: 10.18549/pharmpract.2023.1.2758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/12/2022] [Indexed: 04/08/2023] Open
Abstract
Background Clinical trials used Cockcroft-Gault (CG) formula to calculate the estimated glomerular filtration rate (eGFR) in order to dose rivaroxaban for patients with atrial fibrillation (AF). Objectives The aim of this study is to evaluate rivaroxaban dosing appropriateness in patients with AF with or without renal impairment based on the CG formula and other formulae, including Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and the isotope dilution mass spectrometry (IDMS) traceable Modification of Diet in Renal Disease (MDRD) Study equation and the associated clinical outcomes. Methodology A retrospective cohort study conducted at Sultan Qaboos University Hospital (SQUH) from 1st January 2016 to 31st December 2020, included all adult patients (≥ 18 years) treated with rivaroxaban for AF and followed up for one year after starting the treatment. Results Based on the CG formula, the rivaroxaban dose was inappropriately prescribed in 27% of the patients (21% overdosed and 6% underdosed). Higher baseline creatinine (P=0.0014) and concurrent use of antiplatelet therapy (P<0.001) were associated with the tendency to rivaroxaban overdosing. Higher Body Mass Index (BMI) (P=0.002), female sex (P=0.032), and CKD (P=0.003) were associated with rivaroxaban underdosing. The degree of agreement between the renal function tests when comparing MDRD vs CG and CKD-EPI vs CG in terms of estimated glomerular filtration rate/creatine clearance (eGFR/CrCl) calculation was moderate (κ=0.46) and poor (κ=0.00), respectively, while, in terms of rivaroxaban dose appropriateness was almost perfect (κ=0.82) and substantial (κ=0.77). Clinical outcomes measured by stroke and bleeding events were not significantly different according to the appropriateness of the rivaroxaban dose. Conclusion This study has shown a relatively high consistency with the gold standard in dosing rivaroxaban in AF patients using CG formula. Treatment efficiency and safety were not affected by the proportion of dose inappropriateness found in this cohort.
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Affiliation(s)
| | - Abdullah M Al Alawi
- Department of Medicine, Sultan Qaboos University Hospital, Oman Medical Specialty Board, Muscat, Oman.
| | | | - Zubaida Al-Falahi
- Department of Medicine, Sultan Qaboos University Hospital, Oman Medical Specialty Board, Muscat, Oman.
| | - Asia Al-Azizi
- Pharmacutical care and medical Store Department, Samail Hospital, Samail, Oman.
| | - Kholoud Al Badi
- Department of Pharmacy, Diwan of the Royal Court Polyclinic, Muscat, Oman.
| | - Mohamed Al Rawahi
- Department of Medicine, Sultan Qaboos University Hospital, Oman Medical Specialty Board, National Heart Center, The Royal Hospital, Muscat, Oman.
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Bai L, Yang XH, Zhou YQ, Cui XR, Fu LZ, Zhang JD. Safety and Efficacy Evaluation of Antithrombotic Therapy with Rivaroxaban and Clopidogrel After PCI in Chinese Patients. Clin Appl Thromb Hemost 2022; 28:10760296221074681. [PMID: 35200040 PMCID: PMC8883290 DOI: 10.1177/10760296221074681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective To investigate the efficacy and safety of the antithrombotic therapy using the oral anticoagulant rivaroxaban and clopidogrel in Chinese patients with acute coronary syndrome complicated with atrial fibrillation after percutaneous coronary intervention. Methods A total of 100 patients were selected. Patients were randomly divided into two groups: the treatment group (rivaroxaban group) received a therapy of rivaroxaban and clopidogrel. The control group (warfarin group) receivied a combined treatment of warfarin, clopidogrel, and aspirin. The primary outcome endpoint was evaluated based on the adverse cardiac and cerebrovascular events within 12 months. Results A total of 8 (8.00%) main adverse cardiac and cerebrovascular events occurred during the 12 months of follow-up, including 5 (9.80%) in the warfarin group and 3 (6.10%) in the rivaroxaban group. The risk of having main adverse cardiac and cerebrovascular events in the two groups was comparable (P = 0.479). A total of 9 patients (9.00%) were found to have bleeding events, among which 8 patients (15.7%) were in the warfarin group, whereas only 1 patient (2.00%) was in the rivaroxaban group. Therefore, the risk of bleeding in the warfarin group was significantly higher than that in the rivaroxaban group (P = 0.047). Conclusions In Chinese patients with acute coronary syndrome complicated with atrial fibrillation, the efficacy of the dual therapy of oral anticoagulant rivaroxaban plus clopidogrel after percutaneous coronary intervention was similar to that of the traditional triple therapy combined with warfarin, aspirin and clopidogrel, but it has a better safety property, which has potential to widely apply to antithrombotic therapy after PCI
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Affiliation(s)
- Long Bai
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiao-Hong Yang
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ya-Qing Zhou
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiao-Ran Cui
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ling-Zhi Fu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ji-Dong Zhang
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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6
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Shen Z, Qin W, Zhu L, Lin Y, Ling H, Zhang Y. Construction of nursing-sensitive quality indicators for cardiac catheterisation: A Delphi study and an analytic hierarchy process. J Clin Nurs 2021; 31:2821-2838. [PMID: 34866256 DOI: 10.1111/jocn.16105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 09/22/2021] [Accepted: 10/05/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Nursing care can profoundly reduce the risk of emergencies related to cardiac catheterisation. Therefore, identifying nursing-sensitive quality indicators (NSQIs) to evaluate nursing quality is critical for optimal cardiac catheterisation. However, studies on NSQIs for cardiac catheterisation are scarce. OBJECTIVES This study was conducted to develop a set of NSQIs for cardiac catheterisation. METHODS Literature retrieval and expert group discussions were conducted to identify potential NSQIs and compile an inquiry questionnaire. Then, Delphi surveys were used to collect opinions from experts in the field of cardiac catheterisation. The consistency of the consultation results formed the basis on which we conducted the next rounds of consultation. Based on the importance given to each NSQI by the consulted experts in the previous round, we determined the weight coefficient of each indicator with the analytic hierarchy process. This study was performed according to the SRQR guidelines. RESULTS We conducted two rounds of expert inquiry. The recovery rates of the first and second questionnaires were 100% and 66.67%, respectively. The average authoritative coefficients were 0.86 and 0.91. The Kendall W values ranged from 0.214~0.361 (p < .001). Consensus was reached on 3 primary indicators, 8 secondary indicators and 20 tertiary indicators. CONCLUSIONS A set of NSQIs for cardiac catheterisation was developed. However, the effects of these NSQIs on the evaluation and continuous improvement of nursing quality in cardiac catheterisation need to be verified in clinical practice.
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Affiliation(s)
- Zhiyun Shen
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei Qin
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li Zhu
- Cardiac catheterization laboratory, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Lin
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Huaxing Ling
- Cardiac catheterization laboratory, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuxia Zhang
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
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Aplin M, Andersen A, Brandes A, Dominguez H, Dahl JS, Damgaard D, Iversen HK, Iversen KK, Nielsen E, Risum N, Schmidt MR, Andersen NH. Assessment of patients with a suspected cardioembolic ischemic stroke. A national consensus statement. SCAND CARDIOVASC J 2021; 55:315-325. [PMID: 34470566 DOI: 10.1080/14017431.2021.1973085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Several cardiovascular, structural, and functional abnormalities have been considered as potential causes of cardioembolic ischemic strokes. Beyond atrial fibrillation, other sources of embolism clearly exist and may warrant urgent action, but they are only a minor part of the many stroke mechanisms and strokes that seem to be of embolic origin remain without a determined source. The associations between stroke and findings like atrial fibrillation, valve calcification, or heart failure are confounded by co-existing risk factors for atherosclerosis and vascular disease. In addition, a patent foramen ovale which is a common abnormality in the general population is mostly an innocent bystander in patients with ischemic stroke. For these reasons, experts from the national Danish societies of cardiology, neurology, stroke, and neuroradiology sought to develop a consensus document to provide national recommendations on how to manage patients with a suspected cardioembolic stroke. Design: Comprehensive literature search and analyses were done by a panel of experts and presented at a consensus meeting. Evidence supporting each subject was vetted by open discussion and statements were adjusted thereafter. Results: The most common sources of embolic stroke were identified, and the statement provides advise on how neurologist can identify cases that need referral, and what is expected by the cardiologist. Conclusions: A primary neurological and neuroradiological assessment is mandatory and neurovascular specialists should manage the initiation of secondary prophylactic treatment. If a cardioembolic stroke is suspected, a dedicated cardiologist experienced in the management of cardioembolism should provide a tailored clinical and echocardiographic assessment.
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Affiliation(s)
- Mark Aplin
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, Odense, Denmark.,Department of Internal Medicine - Cardiology, University Hospital of Southern Denmark - Esbjerg, Esbjerg, Denmark
| | - Helena Dominguez
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Jordi S Dahl
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark
| | - Helle K Iversen
- Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kasper K Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Herlev, Denmark
| | - Edith Nielsen
- Department of Neuroradiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Niels Risum
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Michael R Schmidt
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Niels H Andersen
- Department of Cardiology, Odense University Hospital, Odense, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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Zhao S, Hong X, Cai H, Liu M, Li B, Ma P. Antithrombotic Management for Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention or With Acute Coronary Syndrome: An Evidence-Based Update. Front Cardiovasc Med 2021; 8:660986. [PMID: 34262952 PMCID: PMC8273244 DOI: 10.3389/fcvm.2021.660986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/27/2021] [Indexed: 12/13/2022] Open
Abstract
Combined antithrombotic regimens for atrial fibrillation (AF) patients with coronary artery disease, particularly for those who have acute coronary syndrome (ACS) and/or are undergoing percutaneous coronary intervention (PCI), presents a great challenge in the real-world clinical scenario. Conventionally, a triple antithrombotic therapy (TAT), which consists of combined oral anticoagulant therapy to prevent systemic embolism or stroke along with dual antiplatelet therapy to prevent coronary arterial thrombosis (CAT), is used. However, TAT has been associated with a significantly increased risk of bleeding. With the emergence of non-vitamin K antagonist oral anticoagulants (NOACs), randomized controlled trials have demonstrated a better risk-to-benefit ratio of dual antithrombotic therapy (DAT) in combination of a NOAC and with a P2Y12 inhibitor than vitamin K antagonist-based TAT. The results of these studies have impacted the recommendations of current international guidelines, which favor a DAT with a NOAC and P2Y12 inhibitor (especially clopidogrel) in this clinical setting. Additionally, aspirin can be administered during the periprocedural period, while the treatment duration of TAT should be as short as possible. In this article, we summarize the up-to-date evidence regarding antithrombotic regimens for AF patients with PCI or ACS, with a specific focus on the optimal approach and critical discussions of key scientific data and future developments for antithrombotic management in these patients.
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Affiliation(s)
- Shujuan Zhao
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Xuejiao Hong
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Haixia Cai
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Mingzhou Liu
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Bing Li
- Department of General Practice, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Peizhi Ma
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
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9
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Schäfer A, Flierl U, Bauersachs J. Anti-thrombotic strategies in patients with atrial fibrillation undergoing PCI. Clin Res Cardiol 2020; 110:759-774. [PMID: 32696081 PMCID: PMC8166702 DOI: 10.1007/s00392-020-01708-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/06/2020] [Indexed: 12/27/2022]
Abstract
Triple anti-thrombotic therapy combining oral anticoagulation and dual anti-platelet therapy following percutaneous coronary intervention in patients with atrial fibrillation was considered as standard and recommended by guidelines. While bleeding risk is considerable with that approach, data for efficacy are scare. Several trials assessed the possibility of reducing anti-thrombotic treatment by mainly shortening the exposure to acetylsalicylic acid. Dropping one of the anti-platelet components might increase the risk of stent thrombosis, myocardial infarction or stroke. Despite that fear, the recent trials' primary endpoint was major and/or clinically-relevant non-major bleeding. We review data on major bleedings, intracranial bleedings and major adverse cardiovascular events from the published reports. We demonstrate that Non-Vitamin K oral anticoagulant (NOAC)-based strategies compared to VKA-based triple therapies significantly reduce the risk for TIMI-major bleedings by 39% and for intracranial bleedings by 66%, while they did not increase the risk for overall ischemic or embolic events. However, recent meta-analyses indicate an increased risk for stent thrombosis with less intense anti-thrombotic therapy. While the overall incidence rate for stent thrombosis is rather low, relative increases by about 30-60% are reported, but they did not translate into adverse clinical net-benefit ratios. This review highlights that using certain NOAC regimens proven effective for stroke prevention in AF can reduce the rate of bleeding without increasing ischemic or embolic events. Furthermore, additive ASA in triple anti-thrombotic regimens should be limited to 1 month and individual weighing of ischemic versus bleeding risk during the first 30 days seems to be reasonable.
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Affiliation(s)
- Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Ulrike Flierl
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
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10
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Wang Z, Korantzopoulos P, Liu T. Carotid Atherosclerosis in Patients with Atrial Fibrillation. Curr Atheroscler Rep 2019; 21:55. [PMID: 31781980 DOI: 10.1007/s11883-019-0808-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW This review aims to explore the relationship between AF and carotid atherosclerosis, and the impact on the outcomes of cardiovascular and cerebrovascular events. Also, our aim is to critically review current knowledge and delineate future directions for effective treatment or prevention as well as strategies for improvement of the quality of life and survival. RECENT FINDINGS Atrial fibrillation (AF) is the most common arrhythmia, increasing the risk of stroke and cardiovascular morbidity and mortality representing a significant worldwide public health problem. On the other hand, carotid artery atherosclerosis can also significantly increase the risk of stroke, transient ischemic attack (TIA), and death. Firstly, we report epidemiological data on AF patients in different countries and regions having carotid artery abnormalities such as carotid artery plaque formation, atherosclerotic, and even stenosis. Despite geographical variations, these abnormalities were more frequent in AF patients and correlated with the duration of AF and the value of CHA2DS2-VASc score. Moreover, it is evident that AF patients with carotid artery abnormalities have significantly increased risk of adverse outcomes from the heart and brain. According to the CHA(2)DS2 (-VASc) score, AF patients are managed with anticoagulation therapy. Reviewing existing data on the treatment for stroke prevention in patients with AF, carotid artery disease, or both, we found that antiplatelet therapy could be combined with anticoagulant therapy appropriately in certain circumstances. In addition, some emerging technologies, such as the percutaneous permanent carotid filter, may be used safely and effectively to prevent the occurrence of stroke in patients both with AF and carotid artery atherosclerosis.
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Affiliation(s)
- Zhaojia Wang
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | | | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China.
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Drug interactions with oral anticoagulants in German nursing home residents: comparison between vitamin K antagonists and non-vitamin K antagonist oral anticoagulants based on two nested case-control studies. Clin Res Cardiol 2019; 109:465-475. [PMID: 31286199 DOI: 10.1007/s00392-019-01526-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/03/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Vitamin K antagonists (VKAs) are susceptible to drug-drug interactions. Non-VKA oral anticoagulants (NOACs) have a decreased sensitivity to pharmacokinetic interactions and might be therefore considered superior in patients treated with multiple drugs. The objective of this study was to compare the risk of serious bleeding associated with interacting drugs in German nursing home residents treated with VKA or NOAC. METHODS Using claims data of new nursing home residents aged ≥ 65 years (2010-2014) we conducted separate nested case-control analyses within two cohorts of patients treated with VKA or NOAC, respectively. Cases were defined as patients hospitalized for serious bleeding. For each case, up to 20 controls were selected by risk-set sampling. Conditional logistic regression was used to obtain confounder-adjusted odds ratios (aORs) and 95% confidence intervals (CI) for the risk of bleeding associated with VKA or NOAC use and interacting drugs compared with the use of the respective oral anticoagulant alone. RESULTS Among 127,227 new nursing home residents, 16,804 patients received oral anticoagulation. Based on 372 cases and 7281 matched controls, the highest risk of bleeding in VKA users was observed for the concomitant use of antibiotics (aOR 3.00; CI 2.11-4.27) vs. VKA use alone, followed by non-steroidal anti-inflammatory drugs (1.66; 1.13-2.43). Among 243 NOAC cases and 4776 matched controls, elevated risks for bleeding were observed for the use of heparins (2.05; 1.25-3.36) and platelet inhibitors (1.92; 1.36-2.72). CONCLUSIONS Concomitant medication needs to be prescribed cautiously and monitored closely in nursing home residents treated with oral anticoagulants.
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Tetta C, Moula AI, Matteucci F, Parise O, Maesen B, Johnson D, La Meir M, Gelsomino S. Association between atrial fibrillation and Helicobacter pylori. Clin Res Cardiol 2019; 108:730-740. [PMID: 30737531 PMCID: PMC6584225 DOI: 10.1007/s00392-019-01418-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 01/22/2019] [Indexed: 12/13/2022]
Abstract
The connection between atrial fibrillation (AF) and H. pylori (HP) infection is still matter of debate. We performed a systematic review and metanalysis of studies reporting the association between AF and HF. A systematic review of all available reports in literature of the incidence of HP infection in AF and comparing this incidence with subjects without AF were analysed. Risk ratio and 95% confidence interval (CI) and risk difference with standard error (SE) were the main statistics indexes. Six retrospective studies including a total of 2921 were included at the end of the selection process. Nine hundred-fifty-six patients (32.7%) were in AF, whereas 1965 (67.3%) were in normal sinus rhythm (NSR). Overall, 335 of 956 patients with AF were HP positive (35%), whereas 621 were HP negative (65%). In addition, 643 of 1965 NSR patients (32.7%) were HP positive while 1,322 were negative (67.3%; Chi-square 2.15, p = 0.21). The Cumulative Risk Ratio for AF patients for developing an HP infection was 1.19 (95% CI 1.08-1.41). In addition, a small difference risk towards AF was found (0.11 [SE = 0.04]). Moreover, neither RR nor risk difference were influenced by the geographic area at meta-regression analysis. Finally, there was a weak correlation between AF and HP (coefficient = 0.04 [95% CI -0.01-0.08]). We failed to find any significant correlation between H. pylori infection and AF and, based on our data, it seems unlikely than HP can be considered a risk factor for AF. Further larger research is warranted.
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Affiliation(s)
- Cecilia Tetta
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht -CARIM, Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - Amalia Ioanna Moula
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht -CARIM, Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - Francesco Matteucci
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht -CARIM, Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - Orlando Parise
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht -CARIM, Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht -CARIM, Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - Daniel Johnson
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht -CARIM, Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - Mark La Meir
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht -CARIM, Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - Sandro Gelsomino
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht -CARIM, Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands.
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Wernly B, Lichtenauer M, Erlinge D, Jung C. Antithrombotic therapy in atrial fibrillation: stop triple therapy and start optimizing dual therapy? Clin Res Cardiol 2019; 109:128-130. [PMID: 31144062 DOI: 10.1007/s00392-019-01496-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 05/16/2019] [Indexed: 01/09/2023]
Affiliation(s)
- Bernhard Wernly
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Michael Lichtenauer
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany.
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Incidence, predictors, and outcomes of DAPT disruption due to non-compliance vs. bleeding after PCI: insights from the PARIS Registry. Clin Res Cardiol 2019; 108:643-650. [DOI: 10.1007/s00392-018-1392-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/05/2018] [Indexed: 12/20/2022]
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Zhao C, Zhang C, Xing Z, Ahmad Z, Li JS, Chang MW. Pharmacological effects of natural Ganoderma and its extracts on neurological diseases: A comprehensive review. Int J Biol Macromol 2019; 121:1160-1178. [DOI: 10.1016/j.ijbiomac.2018.10.076] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 10/06/2018] [Accepted: 10/14/2018] [Indexed: 01/13/2023]
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