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Erriquez A, Campo G, Guiducci V, Escaned J, Moreno R, Casella G, Menozzi M, Cerrato E, Sacchetta G, Menozzi A, Santos IA, Ibañes EG, Scarsini R, Vadalà G, Andò G, Díez-Gil JL, d’Amore SM, Capecchi A, Colaiori I, Gallo F, Pavasini R, Marrone A, Pompei G, Lanzilotti V, Dudek D, Barbato E, Tebaldi M, Biscaglia S. Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction and High Bleeding Risk: A Randomized Clinical Trial. JAMA Cardiol 2024; 9:565-573. [PMID: 38717753 PMCID: PMC11079791 DOI: 10.1001/jamacardio.2024.0804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 03/12/2024] [Indexed: 05/12/2024]
Abstract
Importance Patients with high bleeding risk (HBR) have a poor prognosis, and it is not known if they may benefit from complete revascularization after myocardial infarction (MI). Objective To investigate the benefit of physiology-guided complete revascularization vs a culprit-only strategy in patients with HBR, MI, and multivessel disease. Design, Setting, and Participants This was a prespecified analysis of the Functional Assessment in Elderly MI Patients With Multivessel Disease (FIRE) randomized clinical trial data. FIRE was an investigator-initiated, open-label, multicenter trial. Patients 75 years or older with MI and multivessel disease were enrolled at 34 European centers from July 2019 through October 2021. Physiology treatment was performed either by angiography- or wire-based assessment. Patients were divided into HBR or non-HBR categories in accordance with the Academic Research Consortium HBR document. Interventions Patients were randomized to either physiology-guided complete revascularization or culprit-only strategy. Main Outcomes and Measures The primary outcome comprised a composite of death, MI, stroke, or revascularization at 1 year. Secondary outcomes included a composite of cardiovascular death or MI and Bleeding Academic Research Consortium (BARC) types 3 to 5. Results Among 1445 patients (mean [SD] age, 81 [5] years; 917 male [63%]), 1025 (71%) met HBR criteria. Patients with HBR were at higher risk for the primary end point (hazard ratio [HR], 2.01; 95% CI, 1.47-2.76), cardiovascular death or MI (HR, 1.89; 95% CI, 1.26-2.83), and BARC types 3 to 5 (HR, 3.28; 95% CI, 1.40-7.64). The primary end point was significantly reduced with physiology-guided complete revascularization as compared with culprit-only strategy in patients with HBR (HR, 0.73; 95% CI, 0.55-0.96). No indication of interaction was noted between revascularization strategy and HBR status for primary and secondary end points. Conclusions and Relevance HBR status is prevalent among older patients with MI, significantly increasing the likelihood of adverse events. Physiology-guided complete revascularization emerges as an effective strategy, in comparison with culprit-only revascularization, for mitigating ischemic adverse events, including cardiovascular death and MI. Trial Registration ClinicalTrials.gov Identifier: NCT03772743.
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Affiliation(s)
- Andrea Erriquez
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Vincenzo Guiducci
- Cardiology Unit, Azienda USL-IRCCS Reggio Emilia, S. Maria Nuova Hospital, Reggio Emilia, Italy
| | - Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martin Lagos s/n, Madrid, Spain
| | - Raul Moreno
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain, Instituto de Investigación Hospital La Paz, University Hospital La Paz, Madrid, Spain
| | - Gianni Casella
- Cardiology Unit, Ospedale Maggiore, Largo Nigrisoli 2, Bologna, Italy
| | - Mila Menozzi
- Cardiovascular Department, Infermi Hospital, Rimini, Italy
| | - Enrico Cerrato
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano, and Rivoli Infermi Hospital ASLTO3, Rivoli, Turin, Italy
| | | | - Alberto Menozzi
- S. C. Cardiologia, Ospedale Sant’Andrea, ASL5 Liguria, La Spezia, Italy
| | - Ignacio Amat Santos
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Cardiology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Enrique Gutiérrez Ibañes
- Centro de Investigation Biomedica end Red en Enfermedades Cardiovasculares, Cardiology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Roberto Scarsini
- Azienda Ospedaliero Universitaria Integrata di Verona, Verona, Italy
| | - Giuseppe Vadalà
- Azienda Ospedaliero Universitaria Policlinico Paolo Giaccone, Palermo, Italy
| | - Giuseppe Andò
- Azienda Ospedaliero Universitaria Policlinico Gaetano Martino, Messina, Italy
| | - José Luis Díez-Gil
- Centro de Investigation Biomedica en Red en Enfermedades Cardiovasculares, Cardiology Department, H. Universitario y Politécnico La Fe, Valencia, Spain
| | - Sergio Musto d’Amore
- Cardiology Unit, Azienda USL-IRCCS Reggio Emilia, S. Maria Nuova Hospital, Reggio Emilia, Italy
| | | | - Iginio Colaiori
- Cardiology Unit, Ospedale Santa Maria Goretti, Via Lucia Scaravelli, Latina, Italy
| | - Francesco Gallo
- Interventional Cardiology, Department of Cardio-Thoracic and Vascular Sciences, Ospedale dell’Angelo, Via Paccagnella, Venice, Italy
| | - Rita Pavasini
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Andrea Marrone
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Graziella Pompei
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | | | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Roma, Italy
| | - Matteo Tebaldi
- Interventional Cardiology Unit, Presidio Ospedaliero San Salvatore di Pesaro, Pesaro, Italy
| | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
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2
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Liang MY, Feng L, Zhu W, Yang QQ. Effect of frailty on medication deviation during the hospital-family transition period in older patients with cardiovascular disease: An observational study. Medicine (Baltimore) 2024; 103:e36893. [PMID: 38215090 PMCID: PMC10783343 DOI: 10.1097/md.0000000000036893] [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: 07/10/2023] [Accepted: 12/18/2023] [Indexed: 01/14/2024] Open
Abstract
Studies have shown that frailty increases cardiovascular disease (CVD) incidence in older patients and is associated with poor patient prognosis. However, the relationship between medication deviation (MD) and frailty remains unclear. This study aimed to explore the influence of frailty on MD during the hospital-family transition period among older patients with CVD. Between February 2022 and February 2023, 231 older people CVD patients were selected from a class III hospital in Nantong City using a multi-stage sampling method. A general information questionnaire was used to collect the socio-demographic characteristics of the participants prior to discharge, the frailty assessment scale was used to assess the participants frailty, and a medication deviation instrument was used to assess the participants MD on the 10th day after discharge. Propensity score matching was used to examine the effect of frailty on MD in older patients with CVD during the hospital-family transition period. The incidences of frailty and MD were 32.9% (76/231) and 75.8% (175/231), respectively. After propensity score matching, the risk of MD in frail patients with CVD was 4.978 times higher than that in non-frail patients with CVD (95% CI: [1.616, 15.340]; P = .005). Incidences of frailty and MD during the hospital-family transition period are high in older patients with CVD, and frailty has an impact on MD. Medical staff in the ward should comprehensively examine older patients with CVD for frailty and actively promote quality medication management during the hospital-family transition period to reduce MD occurrence and delay disease progression.
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Affiliation(s)
- Meng-Yao Liang
- Department of Nursing, The Sixth People’s Hospital of Nantong, Jiangsu, China
| | - Li Feng
- Department of Nursing, The Sixth People’s Hospital of Nantong, Jiangsu, China
| | - Wuyang Zhu
- Department of Rehabilitation, Yi Jiangmen Community Health Service Center, Gulou District, Nanjing, China
| | - Qing-Qing Yang
- Department of Cardiology, The Sixth People’s Hospital of Nantong, Jiangsu, China
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3
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Rowland B, Batty JA, Dangas GD, Mehran R, Kunadian V. Oral Antiplatelet Agents in Percutaneous Coronary Intervention. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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4
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Ijaz N, Buta B, Xue QL, Mohess DT, Bushan A, Tran H, Batchelor W, deFilippi CR, Walston JD, Bandeen-Roche K, Forman DE, Resar JR, O'Connor CM, Gerstenblith G, Damluji AA. Interventions for Frailty Among Older Adults With Cardiovascular Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:482-503. [PMID: 35115105 PMCID: PMC8852369 DOI: 10.1016/j.jacc.2021.11.029] [Citation(s) in RCA: 136] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/03/2021] [Indexed: 12/15/2022]
Abstract
With the aging of the world's population, a large proportion of patients seen in cardiovascular practice are older adults, but many patients also exhibit signs of physical frailty. Cardiovascular disease and frailty are interdependent and have the same physiological underpinning that predisposes to the progression of both disease processes. Frailty can be defined as a phenomenon of increased vulnerability to stressors due to decreased physiological reserves in older patients and thus leads to poor clinical outcomes after cardiovascular insults. There are various pathophysiologic mechanisms for the development of frailty: cognitive decline, physical inactivity, poor nutrition, and lack of social supports; these risk factors provide opportunity for various types of interventions that aim to prevent, improve, or reverse the development of frailty syndrome in the context of cardiovascular disease. There is no compelling study demonstrating a successful intervention to improve a global measure of frailty. Emerging data from patients admitted with heart failure indicate that interventions associated with positive outcomes on frailty and physical function are multidimensional and include tailored cardiac rehabilitation. Contemporary cardiovascular practice should actively identify patients with physical frailty who could benefit from frailty interventions and aim to deliver these therapies in a patient-centered model to optimize quality of life, particularly after cardiovascular interventions.
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Affiliation(s)
- Naila Ijaz
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Brian Buta
- Johns Hopkins Older Americans Independence Center and the Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Qian-Li Xue
- Division of Geriatrics and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Denise T Mohess
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Division of Geriatric Medicine, Department of Medicine, Inova Heath, Falls Church, Virginia, USA
| | - Archana Bushan
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Division of Geriatric Medicine, Department of Medicine, Inova Heath, Falls Church, Virginia, USA
| | - Henry Tran
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Wayne Batchelor
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Christopher R deFilippi
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Jeremy D Walston
- Johns Hopkins Older Americans Independence Center and the Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland, USA; Division of Geriatrics and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Karen Bandeen-Roche
- Johns Hopkins Older Americans Independence Center and the Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Daniel E Forman
- Geriatric Cardiology Section, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jon R Resar
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Christopher M O'Connor
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Gary Gerstenblith
- Johns Hopkins Older Americans Independence Center and the Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland, USA; Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Abdulla A Damluji
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Johns Hopkins Older Americans Independence Center and the Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland, USA; Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
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5
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Tan JWC, Chew DP, Tsui KL, Tan D, Duplyakov D, Hammoudeh A, Zhang B, Li Y, Xu K, Ong PJ, Firman D, Gamra H, Almahmeed W, Dalal J, Tam LW, Steg G, Nguyen QN, Ako J, Al Suwaidi J, Chan M, Sobhy M, Shehab A, Buddhari W, Wang Z, Fong AYY, Karadag B, Kim BK, Baber U, Chin CT, Han YL. 2021 Asian Pacific Society of Cardiology Consensus Recommendations on the Use of P2Y1 2 Receptor Antagonists in the Asia-Pacific Region: Special Populations. Eur Cardiol 2021; 16:e43. [PMID: 34815751 PMCID: PMC8591619 DOI: 10.15420/ecr.2021.35] [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: 07/13/2021] [Accepted: 09/04/2021] [Indexed: 12/17/2022] Open
Abstract
Advanced age, diabetes, and chronic kidney disease not only increase the risk for ischaemic events in chronic coronary syndromes (CCS) but also confer a high bleeding risk during antiplatelet therapy. These special populations may warrant modification of therapy, especially among Asians, who have displayed characteristics that are clinically distinct from Western patients. Previous guidance has been provided regarding the classification of high-risk CCS and the use of newer-generation P2Y12 inhibitors (i.e. ticagrelor and prasugrel) after acute coronary syndromes (ACS) in Asia. The authors summarise evidence on the use of these P2Y12 inhibitors during the transition from ACS to CCS and among special populations. Specifically, they present recommendations on the roles of standard dual antiplatelet therapy, shortened dual antiplatelet therapy and single antiplatelet therapy among patients with coronary artery disease, who are either transitioning from ACS to CCS; elderly; or with chronic kidney disease, diabetes, multivessel coronary artery disease and bleeding events during therapy.
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Affiliation(s)
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University Adelaide, Australia
| | - Kin Lam Tsui
- Pamela Youde Nethersole Eastern Hospital Hong Kong, China
| | - Doreen Tan
- Department of Pharmacy, Faculty of Science, National University of Singapore Singapore
| | | | | | - Bo Zhang
- Department of Cardiology, First Affiliated Hospital, Dalian Medical University Dalian, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theatre Command Shenyang, China
| | - Kai Xu
- Department of Cardiology, General Hospital of Shenyang Military Shenyang, China
| | - Paul J Ong
- Heart Specialist International, Mount Elizabeth Novena Hospital Singapore.,Tan Tock Seng Hospital Singapore
| | - Doni Firman
- Harapan Kita National Cardiovascular Center/Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia Harapan Kita Jakarta, Indonesia
| | - Habib Gamra
- Cardiology Department, Fattouma Bourguiba University Hospital and University of Monastir Monastir, Tunisia
| | | | - Jamshed Dalal
- Centre for Cardiac Sciences, Kokilaben Dhirubhai Ambani Hospital Mumbai, India
| | | | - Gabriel Steg
- Department of Cardiology, Hôpital Bichat Paris, France
| | - Quang N Nguyen
- Department of Cardiology, Hanoi Medical University Hanoi, Vietnam
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine Sagamihara, Kanagawa, Japan
| | | | - Mark Chan
- National University Heart Centre Singapore
| | | | - Abdulla Shehab
- College of Medicine and Health Sciences, UAE University, Al Ain United Arab Emirates
| | | | - Zulu Wang
- Department of Cardiology, General Hospital of Shenyang Military Shenyang, China
| | | | - Bilgehan Karadag
- Istanbul University-Cerrahpasa School of Medicine Istanbul, Turkey
| | - Byeong-Keuk Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine Seoul, South Korea
| | - Usman Baber
- University of Oklahoma Health Sciences Center Oklahoma City, OK, US
| | | | - Ya Ling Han
- Department of Cardiology, General Hospital of Northern Theatre Command Shenyang, China
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6
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Qian Y, Xu B, Qian X, Cao L, Cheng Y, Liu X, Bai S, Han Z, Wang J. Incidence and Risk Factors for Antiplatelet Therapy-Related Bleeding Complications Among Elderly Patients After Coronary Stenting: A Multicenter Retrospective Observation. Front Pharmacol 2021; 12:661619. [PMID: 34393770 PMCID: PMC8362353 DOI: 10.3389/fphar.2021.661619] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/30/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: To determine the incidence and risk factors of bleeding events as well as assess the performance of the PRECISE-DAPT score in elderly patients (≥75 years) who underwent percutaneous coronary intervention (PCI) and one-year dual antiplatelet therapy (DAPT). Methods: A total of 940 patients (≥75 years) who received PCI and one-year DAPT were retrospectively enrolled into the study. The multivariable logistic regression analysis was conducted to identify risk factors of antiplatelet-related bleeding complications. The receiver operating characteristic (ROC) curve analysis and the Delong test were performed to obtain the optimized PRECISE-DAPT score. Results: It was observed that 89 (9.47%) patients suffered bleeding complications, while 37 (3.94%) of them had the Bleeding Academic Research Consortium (BARC, type ≥2) bleeding events. We stratified the PRECISE-DAPT score in tertiles (T1: ≤23; T2:24 to 32; T3: ≥33) and found that BARC ≥ 2 type bleeding occurred more frequently in T3 than in T1 and T2 (8.25 vs. 1.46% vs. 2.40%, p <0.05). The ROC curve analysis revealed that the PRECISE-DAPT score cutoff for BARC ≥2 type bleeding prediction was 33. In comparison with the current recommended cutoff score of 25 (AUC: 0.608, based on ROC analysis), the Delong test indicated significantly improved ability for predicting BARC ≥ 2 type bleeding events using the proposed cutoff value of 33, AUC of 0.676 (p = 0.03), and Brier Score of 0.04. The multivariable logistic regression analysis demonstrated that the PRECISE-DAPT score ≥ 33 [OR: 3.772; 95% CI (1.229, 11.578); p = 0.02] was associated with BARC ≥ 2 type bleeding event, along with a history of hemorrhagic stroke [OR: 6.806; 95% CI (1.465, 31.613); p = 0.014], peptic ulcer [OR: 3.871; 95% CI (1.378, 10.871); p = 0.01], and/or myocardial infarction [MI, OR: 3.081; 95% CI (1.140, 8.326); p = 0.027]. Conclusion: A higher PRECISE-DAPT score of 33 might be a more reasonable cutoff value for predicting BARC ≥2 type bleeding risk in CAD patients (≥75 years). In addition, the history of hemorrhagic stroke, peptic ulcer, and myocardial infarction were identified as the risk factors of BARC ≥2 type bleeding events.
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Affiliation(s)
- Yanxia Qian
- Department of Cardiology, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
| | - Bing Xu
- Department of Cardiology, Northern Jiangsu Province Hospital and Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Xiaodong Qian
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Lu Cao
- Department of Cardiology, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
| | - Yujia Cheng
- Department of Cardiology, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
| | - Xinjian Liu
- Department of Pathogenic Microorganism, Nanjing Medical University, Nanjing, China.,Key Laboratory of Antibody Technique of National Health Commission of China, Department of Pathogen Biology, Nanjing Medical University, Nanjing, China
| | - Song Bai
- Department of Cardiology, Xuyi People's Hospital, Huai'an, China
| | - Zhijun Han
- Department of Laboratory Medicine, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, Wuxi, China
| | - Junhong Wang
- Department of Cardiology, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China.,Department of Cardiology, Xuyi People's Hospital, Huai'an, China
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Contrast Associated Acute Kidney Injury and Mortality in Older Adults with Acute Coronary Syndrome: A Pooled Analysis of the FRASER and HULK Studies. J Clin Med 2021; 10:jcm10102151. [PMID: 34065642 PMCID: PMC8156026 DOI: 10.3390/jcm10102151] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 12/31/2022] Open
Abstract
Whether contrast-associated acute kidney injury (CA-AKI) is only a bystander or a risk factor for mortality in older patients undergoing percutaneous coronary intervention (PCI) is not well understood. Data from FRASER (NCT02386124) and HULK (NCT03021044) studies have been analysed. All patients enrolled underwent coronary angiography. The occurrence of CA-AKI was defined based on KDIGO criteria. The primary outcome of the study was to test the relation between CA-AKI and 3-month mortality. Overall, 870 older ACS adults were included in the analysis (mean age 78 ± 5 years; 28% females). CA-AKI occurred in 136 (16%) patients. At 3 months, 13 (9.6%) patients with CA-AKI died as compared with 13 (1.8%) without it (p < 0.001). At multivariable analysis, CA-AKI emerged as independent predictor of 3-month mortality (HR 3.51, 95%CI 1.05–7.01). After 3 months, renal function returned to the baseline value in 78 (63%) with CA-AKI. Those without recovered renal function (n = 45, 37%) showed an increased risk of mortality as compared to recovered renal function and no CA-AKI subgroups (HR 2.01, 95%CI 1.55–2.59, p = 0.009 and HR 2.71, 95%CI 1.45–5.89, p < 0.001, respectively). In conclusion, CA-AKI occurs in a not negligible portion of older MI patients undergoing invasive strategy and it is associated with short-term mortality.
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8
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Ohta M, Hayashi K, Mori Y, Sato H, Noto T, Kawahatsu K, Mita T, Kazuno Y, Sasaki S, Doi T, Hirokami M, Tanaka S, Yuda S. Impact of Frailty on Bleeding Events Related to Anticoagulation Therapy in Patients With Atrial Fibrillation. Circ J 2021; 85:235-242. [PMID: 33504742 DOI: 10.1253/circj.cj-20-0373] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although anticoagulation is the key treatment to prevent stroke in patients with atrial fibrillation (AF), including elderly patients, anticoagulation is sometimes withheld for elderly people because of concerns about frailty. However, it remains unknown whether frailty increases bleeding events.Methods and Results:A total of 120 consecutive non-valvular AF patients admitted with symptoms of AF or congestive heart failure were included in this study. Frailty was assessed using the Cardiovascular Health Study (CHS) frailty index. We performed a retrospective analysis of the risk factors associated with major bleeding events. After a median follow-up of 518 days, major bleeding events occurred in 17 (14.2%) patients. Patients with major bleeding events had a higher CHS frailty index (P=0.015). The cutoff value for high-risk CHS frailty index was 2 (area under the ROC curve: 0.68 [95% confidence interval (CI): 0.57-0.78]). The event-free rates at 2 years were 97.6% (95% CI: 83.9-99.7) in patients with a CHS frailty index <2 and 59.6% (95% CI: 27.9-81.0) for those with a CHS frailty index ≥2 (P<0.001). CONCLUSIONS Frailty is associated with increased bleeding events related to anticoagulant therapy in patients previously hospitalized with AF. Greater care should be taken with patients with a CHS frailty index ≥2.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Takahiro Doi
- Department of Cardiology, Teine Keijinkai Hospital
| | | | | | - Satoshi Yuda
- Department of Cardiology, Teine Keijinkai Hospital
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Bruno RR, Wolff G, Wernly B, Kelm M, Jung C. Frailty Assessment in Patients Undergoing Aortic Valve Replacement: Be Quick and Be Sure. JACC Cardiovasc Interv 2021; 13:1965-1967. [PMID: 32819489 DOI: 10.1016/j.jcin.2020.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/02/2020] [Indexed: 11/17/2022]
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10
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Brinza C, Burlacu A, Tinica G, Covic A, Macovei L. A Systematic Review on Bleeding Risk Scores' Accuracy after Percutaneous Coronary Interventions in Acute and Elective Settings. Healthcare (Basel) 2021; 9:148. [PMID: 33540514 PMCID: PMC7912805 DOI: 10.3390/healthcare9020148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/21/2021] [Accepted: 01/27/2021] [Indexed: 11/17/2022] Open
Abstract
Dual antiplatelet therapy (DAT) is recommended for all patients undergoing percutaneous coronary intervention (PCI), as it significantly reduces the ischemic risk at the cost of increasing the incidence of bleeding events. Several clinical predictive models were developed to better stratify the bleeding risk associated with DAT. This systematic review aims to perform a literature survey of both standard and emerging bleeding risk scores and report their performance on predicting hemorrhagic events, especially in the era of second-generation drug-eluting stents and more potent P2Y12 inhibitors. We searched PubMed, ScienceDirect, and Cochrane databases for full-text studies that developed or validated bleeding risk scores in adult patients undergoing PCI with subsequent DAT. The risk of bias for each study was assessed using the prediction model risk of bias assessment tool (PROBAST). Eighteen studies were included in the present systematic review. Bleeding risk scores showed a modest to good discriminatory power with c-statistic ranging from 0.49 (95% CI, 0.45-0.53) to 0.82 (95% CI, 0.80-0.85). Clinical models that predict in-hospital bleeding events had a relatively good predictive performance, with c-statistic ranging from 0.70 (95% CI, 0.67-0.72) to 0.80 (95% CI, 0.73-0.87), depending on the risk scores and major hemorrhagic event definition used. The knowledge and utilization of the current bleeding risk scores in appropriate clinical contexts could improve the prediction of bleeding events.
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Affiliation(s)
- Crischentian Brinza
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (C.B.); (G.T.); (L.M.)
| | - Alexandru Burlacu
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (C.B.); (G.T.); (L.M.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania;
- Medical Sciences Academy, 030167 Bucharest, Romania
| | - Grigore Tinica
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (C.B.); (G.T.); (L.M.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania;
| | - Adrian Covic
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania;
- Nephrology Clinic, Dialysis, and Renal Transplant Center—‘C.I. Parhon’ University Hospital, 700503 Iasi, Romania
| | - Liviu Macovei
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (C.B.); (G.T.); (L.M.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania;
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Christersson C, Ståhle E, Lindhagen L, James S. Haemorrhagic stroke and major bleeding after intervention with biological aortic valve prosthesis: risk factors and antithrombotic treatment. Eur Heart J Suppl 2020; 22:C26-C33. [PMID: 32368196 PMCID: PMC7189738 DOI: 10.1093/eurheartj/suaa007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The majority of patients with severe aortic stenosis are recommended intervention with a surgical biological prosthesis (bioSAVR) or a transcatheter aortic valve intervention (TAVI). The antithrombotic strategies after aortic valve intervention vary and include drugs targeting both platelets and the coagulation cascade. Long-term exposure and changes of antithrombotic treatment influence the risk of both bleeding and thromboembolic events.The aim was to describe an unselected sample of patients who have experienced haemorrhagic stroke and other major bleeding events after biological aortic prosthesis, their antithrombotic treatment and changes of treatments in relation to the bleeding event.All patients performing an bioSAVR or a TAVI 2008–2014 were identified in the SWEDEHEART registry and included in the study (n = 10 711). The outcome events were haemorrhagic stroke and other major bleeding event. Information of drug exposure was collected from the dispensed drug registry.The incidence rate of any bleeding event was 2.85/100 patient-years the first year after aortic valve intervention. Heart failure and atrial fibrillation were present more often in patients with a first haemorrhagic stroke or other major bleeding event compared to without. The proportion of exposure to warfarin was 28.7% vs. 21.3% in patients with and without a haemorrhagic stroke. Comparable figures were 31.2% vs. 19.0% in patients with and without other major bleeding event. During 1 month prior a haemorrhagic stroke or other major bleeding event 39.4% and 38.0%, respectively, of the patients not previously exposed to antithrombotic treatment started warfarin or single antiplatelet therapy.Major bleeding events are not uncommon after aortic valve intervention with a biological prosthesis. Evaluation of comorbidities and previous bleeding might improve risk stratification for bleeding in these elderly patients. The pattern of change of antithrombotic treatment was similar in the groups with and without a bleeding event and in most patients the antithrombotic regime was unchanged the month before an event.
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Affiliation(s)
- Christina Christersson
- Department of Medical Sciences, Cardiology, Uppsala University, SE 75185 Uppsala, Sweden
| | - Elisabeth Ståhle
- Department of Surgical Sciences, Thoracic surgery, Uppsala University, SE 75185 Uppsala, Sweden
| | - Lars Lindhagen
- Uppsala Clinical Research Center, Uppsala University, SE 75185 Uppsala, Sweden
| | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University, SE 75185 Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, SE 75185 Uppsala, Sweden
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12
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Choi KH, Song YB, Lee JM, Park TK, Yang JH, Choi JH, Choi SH, Oh JH, Cho DK, Lee JB, Doh JH, Kim SH, Jeong JO, Bae JH, Kim BO, Cho JH, Suh IW, Kim DI, Park HK, Park JS, Choi WG, Lee WS, Gwon HC, Hahn JY. Clinical Usefulness of PRECISE-DAPT Score for Predicting Bleeding Events in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: An Analysis From the SMART-DATE Randomized Trial. Circ Cardiovasc Interv 2020; 13:e008530. [PMID: 32354228 DOI: 10.1161/circinterventions.119.008530] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although the current guidelines endorse the PRECISE-DAPT score (Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy) to inform clinical decisions regarding duration of DAPT in patients undergoing percutaneous coronary intervention, use of the PRECISE-DAPT score to guide duration of DAPT has not been properly validated by randomized trials focused on the population with acute coronary syndrome. This study aimed to evaluate the usefulness of the PRECISE-DAPT score for predicting future bleeding and ischemic events and to compare clinical outcomes of short-term and long-term DAPT duration according to the PRECISE-DAPT score in patients with acute coronary syndrome. METHODS This was a substudy of the SMART-DATE trial (6- Versus 12-Month or Longer Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome), in which patients with acute coronary syndrome undergoing percutaneous coronary intervention were randomly assigned to either 6- (n=1357) or 12-month or longer DAPT (n=1355). Major bleeding (Bleeding Academic Research Consortium type 3-5) and ischemic (myocardial infarction, stent thrombosis, or ischemic stroke) events at 18 months after the index procedure were compared between the 6- and 12-month or longer DAPT groups, according to PRECISE-DAPT score. RESULTS The PRECISE-DAPT score was moderately effective at predicting bleeding events (area under the curve, 0.754 [95% CI, 0.655-0.854]; P<0.001). In patients with nonhigh PRECISE-DAPT score (<25, n=1967 [72.5%]), 6-month DAPT was associated with higher ischemic risk (2.7% versus 1.3%; HR, 2.01 [95% CI, 1.03-3.91]; P=0.040; absolute risk difference, +1.3%; P=0.035) with similar bleeding risk (0.4% versus 0.3%; HR, 2.00 [95% CI, 0.37-10.94]; P=0.422; absolute risk difference, +0.2%; P=0.498), compared with 12-month or longer DAPT. Among patients with high PRECISE-DAPT score (≥25, n=745 [27.5%]), 6-month DAPT presented a similar ischemic risk (4.8% versus 3.4%; HR, 1.43 [95% CI, 0.68-2.98], P=0.348; absolute risk difference, +1.5%; P=0.327) but significantly reduced major bleeding risk (0.6% versus 2.3%; HR, 0.25 [95% CI, 0.05-1.17]; P=0.079; absolute risk difference, -1.7%; P=0.045). CONCLUSIONS Consistent with current guidelines, determination of the duration of DAPT according to PRECISE-DAPT score could improve the clinical outcomes in patients with acute coronary syndrome after percutaneous coronary intervention with current-generation drug-eluting stents. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01701453.
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Affiliation(s)
- Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-H.C., S.-H.C., H.-C.G., J.-Y.H.)
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-H.C., S.-H.C., H.-C.G., J.-Y.H.)
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-H.C., S.-H.C., H.-C.G., J.-Y.H.)
| | - Taek Kyu Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-H.C., S.-H.C., H.-C.G., J.-Y.H.)
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-H.C., S.-H.C., H.-C.G., J.-Y.H.)
| | - Jin-Ho Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-H.C., S.-H.C., H.-C.G., J.-Y.H.)
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-H.C., S.-H.C., H.-C.G., J.-Y.H.)
| | - Ju-Hyeon Oh
- Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Korea (J.-H.O.)
| | - Deok-Kyu Cho
- Division of Cardiology, Department of Internal Medicine, Myongji Hospital, Goyang, Korea (D.-K.C.)
| | - Jin Bae Lee
- Division of Cardiology, Department of Internal Medicine, Daegu Catholic University Medical Center, Korea (J.B.L.)
| | - Joon-Hyung Doh
- Division of Cardiology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.)
| | - Sang-Hyun Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University Boramae Medical Center, Korea (S.-H.K.)
| | - Jin-Ok Jeong
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea (J.-O.J.)
| | - Jang-Ho Bae
- Division of Cardiology, Department of Internal Medicine, Konyang University Hospital, Daejon, Korea (J.-H.B.)
| | - Byung-Ok Kim
- Division of Cardiology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea (B.-O.K.)
| | - Jang Hyun Cho
- Division of Cardiology, Department of Internal Medicine, St. Carollo General Hospital, Suncheon, Korea (J.H.C.)
| | - Il-Woo Suh
- Division of Cardiology, Department of Internal Medicine, SAM Medical Center, Anyang, Korea (I.-W.S.)
| | - Doo-Il Kim
- Division of Cardiology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Korea (D.-i.K.)
| | - Hoon-Ki Park
- Division of Cardiology, Department of Internal Medicine, Seoul Veterans Hospital, Korea (H.-K.P.)
| | - Jong-Seon Park
- Division of Cardiology, Department of Internal Medicine, Yeungnam University Hospital, Daegu, Korea (J.-S.P.)
| | - Woong Gil Choi
- Division of Cardiology, Department of Internal Medicine, Chungju Konkuk University Medical Center, Korea (W.G.C.)
| | - Wang Soo Lee
- Division of Cardiology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Korea (W.S.L.)
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-H.C., S.-H.C., H.-C.G., J.-Y.H.)
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (K.H.C., Y.B.S., J.M.L., T.K.P., J.H.Y., J.-H.C., S.-H.C., H.-C.G., J.-Y.H.)
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