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Nakamura M, Inoue H, Yamashita T, Akao M, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Shimizu W, Suzuki S, Tsutsui H, Toyoda K, Yasaka M, Yamaguchi T, Teramukai S, Morishima Y, Fukuzawa M, Takita A, Hirayama A. Coronary events in elderly patients with non-valvular atrial fibrillation: a prespecified sub-analysis of the ANAFIE registry. Cardiovasc Interv Ther 2024; 39:145-155. [PMID: 38349574 PMCID: PMC10940374 DOI: 10.1007/s12928-024-00984-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/26/2023] [Indexed: 03/16/2024]
Abstract
Real-world data on coronary events (CE) in elderly patients with atrial fibrillation (AF) are lacking in the direct oral anticoagulant era. This prespecified sub-analysis of the ANAFIE Registry, a prospective observational study in > 30,000 Japanese patients aged ≥ 75 years with non-valvular AF (NVAF), investigated CE incidence and risk factors. The incidence and risk factors for new-onset CE (a composite of myocardial infarction [MI] and cardiac intervention for coronary heart diseases other than MI), MI, and cardiac intervention for coronary heart diseases other than MI during the 2-year follow-up were assessed. Bleeding events in CE patients were also examined. Among 32,275 patients, the incidence rate per 100 patient-years was 0.48 (95% confidence interval (CI): 0.42-0.53) for CE during the 2-year follow-up, 0.20 (0.16-0.23) for MI, and 0.29 (0.25-0.33) for cardiac intervention for coronary heart diseases other than MI; that of stroke/systemic embolism was 1.62 (1.52-1.73). Patients with CE (n = 287) likely had lower creatinine clearance (CrCL) and higher CHADS2 and HAS-BLED scores than patients without CE (n = 31,988). Significant risk factors associated with new-onset CE were male sex, systolic blood pressure of ≥ 130 mmHg, diabetes mellitus (glycated hemoglobin ≥ 6.0%), CE history, antiplatelet agent use, and CrCL < 50 mL/min. Major bleeding incidence was significantly higher in patients with new-onset CE vs without CE (odds ratio [95% CI], 3.35 [2.06-5.43]). In elderly patients with NVAF, CE incidence was lower than stroke/systemic embolism incidence. New-onset CE (vs no CE) was associated with a higher incidence of major bleeding.Trial registration: UMIN000024006.
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Affiliation(s)
- Masato Nakamura
- Division of Minimally Invasive Treatment in Cardiovascular Medicine, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro-Ku, Tokyo, 153-8515, Japan.
| | | | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tama Nagayama Hospital, Tokyo, Japan
| | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine, Fukuoka Neurosurgical Hospital, Fukuoka, Japan
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | | | - Masayuki Fukuzawa
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd, Tokyo, Japan
| | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Atsushi Hirayama
- Department of Medicine, Osaka Fukujuji Hospital, Neyagawa, Japan
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Yamashita D, Saito Y, Sato T, Matsumoto T, Suzuki S, Saito K, Wakabayashi S, Kitahara H, Sano K, Kobayashi Y. The Combinations of the Patterns of Non-adherence to Anti-platelet Regimen in Stented Patients (PARIS) and Coronary Revascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) Thrombotic and Bleeding Risk Scores on Clinical Outcomes in Patients with Acute Myocardial Infarction. Intern Med 2024; 63:475-480. [PMID: 37344423 PMCID: PMC10937133 DOI: 10.2169/internalmedicine.2117-23] [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: 04/11/2023] [Accepted: 05/18/2023] [Indexed: 06/23/2023] Open
Abstract
Objective The Patterns of Non-adherence to Anti-platelet Regimen in Stented Patients (PARIS) and Coronary Revascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) thrombotic and bleeding risk scores were established to predict ischemic and bleeding events in patients undergoing percutaneous coronary intervention (PCI). However, whether or not the combination of these risk scores is predictive of clinical outcomes is unclear. Methods This bicenter registry included a total of 1,098 patients with acute myocardial infarction (MI) undergoing primary PCI. Patients were divided into three groups according to the PARIS and CREDO-Kyoto thrombotic and bleeding risk scores. The study endpoints included the rates of both ischemic (cardiovascular death, recurrent MI, and ischemic stroke) and major bleeding (Bleeding Academic Research Consortium type 3 or 5) events at two years. Results Two years after primary PCI, ischemic and major bleeding events occurred in 17.3% and 10.2% of patients, respectively. The higher-risk categories of PARIS and CREDO-Kyoto scores were associated with increased risks of ischemic and bleeding events. The rates of ischemic and major bleeding events progressively increased with the increase in risk categories in the two risk scoring systems. In the receiver operating characteristic curve analysis, the addition of CREDO-Kyoto thrombotic and bleeding risk scores to PARIS scores significantly improved diagnostic ability in predicting ischemic (area under the curve: 0.59 vs. 0.63, p=0.01) and bleeding (area under the curve: 0.65 vs. 0.68, p=0.01) events. Conclusion The combinations of the PARIS and CREDO-Kyoto risk scores might be useful for evaluating ischemic and bleeding risks in patients with acute MI undergoing primary PCI.
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Affiliation(s)
- Daichi Yamashita
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
| | - Takanori Sato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
| | - Tadahiro Matsumoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
| | - Sakuramaru Suzuki
- Department of Cardiovascular Medicine, Eastern Chiba Medical Center, Japan
| | - Kan Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
| | | | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
| | - Koichi Sano
- Department of Cardiovascular Medicine, Eastern Chiba Medical Center, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
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Goto H, Saito Y, Matsumoto T, Sato T, Yamashita D, Suzuki S, Wakabayashi S, Kitahara H, Sano K, Kobayashi Y. Differential Impact of Clinical Factors for Predicting High Platelet Reactivity on Clinical Outcomes in Acute Myocardial Infarction Patients Treated With Clopidogrel and Prasugrel. J Atheroscler Thromb 2023; 30:1791-1802. [PMID: 37316266 DOI: 10.5551/jat.64217] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
AIMS Several scoring systems, including the ABCD-GENE and HHD-GENE scores incorporating clinical and genetic factors, have been developed to identify patients likely to have high platelet reactivity on P2Y12 inhibitors, leading to increased risks of ischemic events. However, genetic testing is not widely available in daily practice. We aimed to evaluate the differential impact of clinical factors in the scores on ischemic outcomes in patients treated with clopidogrel and prasugrel. METHODS This bi-center registry included 789 patients with acute myocardial infarction (MI) undergoing percutaneous coronary intervention and treated with either clopidogrel or prasugrel at discharge. The relations of the number of clinical factors included in the ABCD-GENE (age ≥ 75 years, body mass index >30 kg/m2, chronic kidney disease, and diabetes) and HHD-GENE (hypertension, hemodialysis, and diabetes) scores to the primary endpoint of major cardiovascular events after discharge, a composite of death, recurrent MI, and ischemic stroke, were evaluated. RESULTS The number of clinical factors in the ABCD-GENE score was not predictive of ischemic outcomes after discharge in patients treated with clopidogrel and/or prasugrel, while the increase in the number of clinical factors of the HHD-GENE score was associated with an increased risk of the primary endpoint in a stepwise manner in patients on a P2Y12 inhibitor. CONCLUSIONS Clinical factors listed in the HHD-GENE score may help stratify ischemic risks in patients with acute MI treated with clopidogrel and prasugrel, whereas risk stratification without genetic testing in patients treated with clopidogrel may be challenging.
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Affiliation(s)
- Hiroki Goto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Tadahiro Matsumoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Takanori Sato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Daichi Yamashita
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | | | | | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Koichi Sano
- Department of Cardiovascular Medicine, Eastern Chiba Medical Center
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
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Saito T, Fujisaki T, Aikawa T, Kampaktsis PN, Malik A, Briasoulis A, Takagi H, Wiley J, Slipczuk L, Kuno T. Strategy of dual antiplatelet therapy for patients with ST-elevation myocardial infarction and non-ST-elevation acute coronary syndromes: A systematic review and network meta-analysis. Int J Cardiol 2023; 389:131157. [PMID: 37433404 DOI: 10.1016/j.ijcard.2023.131157] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/06/2023] [Accepted: 07/05/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Various durations and de-escalation strategies of dual antiplatelet therapy (DAPT) after ST-elevation myocardial infarction (STEMI) or non-ST-elevation acute coronary syndromes (NSTE-ACS) have been tested in randomized controlled trials (RCT)s. However, evidence by specific ACS subtype is unknown. METHODS PubMed, EMBASE, and Cochrane CENTRAL were searched in February 2023. RCTs on DAPT strategies included STEMI or NSTE-ACS patients with standard DAPT (12 months) with clopidogrel or potent P2Y12 inhibitors, short-term DAPT (≤6 months) followed by potent P2Y12 inhibitors or aspirin, unguided de-escalation from potent P2Y12 inhibitors to low-dose potent P2Y12 inhibitors or clopidogrel at one month, and guided selection with genotype or platelet function tests were identified. The primary outcome was the net adverse clinical events (NACE) defined as a composite of major adverse cardiovascular events (MACE) and clinically relevant bleeding events. RESULTS Twenty RCTs with a combined total population of 24,745 STEMI and 37,891 NSTE-ACS patients were included. In STEMI patients, unguided de-escalation strategy was associated with a lower rate of NACE compared with standard DAPT using potent P2Y12 inhibitors (HR:0.57; 95% CI:0.34-0.96) without increased risk of MACE. In NSTE-ACS patients, unguided de-escalation strategy was associated with a lower rate of NACE compared with the guided selection strategy (HR:0.65; 95% CI:0.47-0.90), standard DAPT using potent P2Y12 inhibitors (HR:0.62; 95% CI:0.50-0.78) and standard DAPT using clopidogrel (HR:0.73; 95% CI:0.55-0.98) without increased risk of MACE. CONCLUSION Unguided de-escalation strategy was associated with a reduced risk of NACE and may be the most effective DAPT strategy for STEMI and NSTE-ACS.
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Affiliation(s)
- Tetsuya Saito
- Department of Cardiology, Edogawa Hospital, Tokyo, Japan
| | - Tomohiro Fujisaki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Tadao Aikawa
- Department of Cardiology, Hokkaido Cardiovascular Hospital, Sapporo, Japan
| | - Polydoros N Kampaktsis
- Division of Cardiology, Columbia University Irving Medical Center, New York City, NY, United States of America
| | - Aaqib Malik
- Department of Cardiology, Westchester Medical Center, NY, United States of America
| | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, Section of Heart failure and Transplantation, University of Iowa, IA, United States of America
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Jose Wiley
- Section of Cardiology, Department of Medicine, Tulane University School of Medicine, LA, United States of America
| | - Leandro Slipczuk
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, NY, United States of America
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, NY, United States of America; Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, NY, United States of America.
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Kuno T, Watanabe A, Shoji S, Fujisaki T, Ueyama H, Takagi H, Deharo P, Cuisset T, Bangalore S, Mehran R, Stone GW, Kohsaka S, Bhatt DL. Short-Term DAPT and DAPT De-Escalation Strategies for Patients With Acute Coronary Syndromes: A Systematic Review and Network Meta-Analysis. Circ Cardiovasc Interv 2023; 16:e013242. [PMID: 37609850 DOI: 10.1161/circinterventions.123.013242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/13/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Short-term (≤6 months) dual antiplatelet therapy (DAPT) and DAPT de-escalation become attractive for patients with acute coronary syndrome. METHODS A systemic search identified randomized controlled trials that included patients with acute coronary syndrome treated using (1) standard DAPT (12 months) with clopidogrel, prasugrel (standard/low dose), or ticagrelor; (2) extended DAPT (≥18 months); (3) short-term DAPT (≤6 months) followed by P2Y12 inhibitor or aspirin; (4) 12-month DAPT with unguided de-escalation from potent P2Y12 inhibitors to low-dose potent P2Y12 inhibitor or clopidogrel at 1 month; and (5) guided selection DAPT with genotype or platelet function tests. The primary efficacy outcome (major adverse cardiovascular events) was a composite of cardiovascular death, myocardial infarction, or stroke. The primary safety outcome was major or minor bleeding. RESULTS This meta-analysis included 32 randomized controlled trials with 103 497 patients. While there were no differences in efficacy between short, unguided de-escalation and guided selection strategies, unguided de-escalation was associated with reduced risk of major adverse cardiovascular events compared with standard DAPT with clopidogrel or ticagrelor (hazard ratio [95% CI], 0.67 [0.49-0.93] and 0.68 [0.50-0.93]). Both short DAPT followed by P2Y12 inhibitor and unguided de-escalation were associated with reduced risks in safety compared with other strategies, including guided selection (hazard ratio [95% CI], 0.66 [0.47-0.93] and 0.48 [0.33-0.71]). Short DAPT followed by a P2Y12 inhibitor was associated with reduced risk of major bleeding and all-cause death compared with standard, extended DAPT (eg, versus DAPT with clopidogrel; hazard ratio [95% CI], 0.64 [0.42-0.97] and 0.60 [0.44-0.82]). By rankogram, unguided de-escalation strategy was the safest and most effective strategy in reducing major adverse cardiovascular events and major or minor bleeding while short DAPT followed by P2Y12 inhibitor was ranked the best for major bleeding and all-cause death. CONCLUSIONS In patients with acute coronary syndrome, unguided de-escalation was associated with the lowest risk of major adverse cardiovascular events and major or minor bleeding outcomes, while short DAPT followed by P2Y12 inhibitor was associated with the lowest risk of major bleeding and all-cause death.
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Affiliation(s)
- Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center (T.K.), Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY
- Division of Cardiology (T.K.), Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Atsuyuki Watanabe
- Department of Medicine, Mount Sinai Beth Israel (A.W.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Satoshi Shoji
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.S., S.K.)
- Duke Clinical Research Institute, Durham, NC (S.S.)
| | - Tomohiro Fujisaki
- Department of Medicine, Mount Sinai Morningside and West (T.F.), Icahn School of Medicine at Mount Sinai, New York, NY
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (T.F.)
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (T.F.)
| | - Hiroki Ueyama
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA (H.U.)
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Japan (H.T.)
| | - Pierre Deharo
- Département de Cardiologie, CHU Timone, Marseille, France (P.D., T.C.)
- INSERM, INRA, C2VN (P.D., T.C.), Aix-Marseille Université, France
- Faculté de Médecine (P.D., T.C.), Aix-Marseille Université, France
| | - Thomas Cuisset
- Département de Cardiologie, CHU Timone, Marseille, France (P.D., T.C.)
- INSERM, INRA, C2VN (P.D., T.C.), Aix-Marseille Université, France
- Faculté de Médecine (P.D., T.C.), Aix-Marseille Université, France
| | - Sripal Bangalore
- Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine (S.B.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute (R.M., G.W.S.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute (R.M., G.W.S.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.S., S.K.)
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY (D.L.B.)
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Fujisaki T, Kuno T, Briasoulis A, Misumida N, Takagi H, Latib A. P2Y12 Inhibitors for Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis. Tex Heart Inst J 2023; 50:493517. [PMID: 37302149 DOI: 10.14503/thij-22-7916] [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: 06/13/2023]
Abstract
BACKGROUND For patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), prasugrel was recommended over ticagrelor in a recent randomized controlled trial, although more data are needed on the rationale. Here, the effects of P2Y12 inhibitors on ischemic and bleeding events in patients with NSTE-ACS were investigated. METHODS Clinical trials that enrolled patients with NSTE-ACS were included, relevant data were extracted, and a network meta-analysis was performed. RESULTS This study included 37,268 patients with NSTE-ACS from 11 studies. There was no significant difference between prasugrel and ticagrelor for any end point, although prasugrel had a higher likelihood of event reduction than ticagrelor for all end points except cardiovascular death. Compared with clopidogrel, prasugrel was associated with decreased risks of major adverse cardiovascular events (MACE) (hazard ratio [HR], 0.84; 95% CI, 0.71-0.99) and myocardial infarction (HR, 0.82; 95% CI, 0.68-0.99) but not an increased risk of major bleeding (HR, 1.30; 95% CI, 0.97-1.74). Similarly, compared with clopidogrel, ticagrelor was associated with a reduced risk of cardiovascular death (HR, 0.79; 95% CI, 0.66-0.94) and an increased risk of major bleeding (HR, 1.33; 95% CI, 1.00-1.77; P = .049). For the primary efficacy end point (MACE), prasugrel showed the highest likelihood of event reduction (P = .97) and was superior to ticagrelor (P = .29) and clopidogrel (P = .24). CONCLUSION Prasugrel and ticagrelor had comparable risks for every end point, although prasugrel had the highest probability of being the best treatment for reducing the primary efficacy end point. This study highlights the need for further studies to investigate optimal P2Y12 inhibitor selection in patients with NSTE-ACS.
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Affiliation(s)
- Tomohiro Fujisaki
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside, and Mount Sinai West, New York, New York
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Naoki Misumida
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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Antithrombotic Treatment Patterns of Patients with Symptomatic Peripheral Arterial Occlusive Disease in Germany: Evidence from Health Insurance Claims Data. J Clin Med 2022; 11:jcm11185455. [PMID: 36143102 PMCID: PMC9501602 DOI: 10.3390/jcm11185455] [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] [Received: 08/15/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives: Patients with peripheral arterial occlusive disease (PAOD) are at risk of worsening limb symptoms, major adverse cardiovascular events and exhibit an impaired life expectancy. There is a lack of evidence on the extent of pharmacological secondary prevention in PAOD patients. This study assesses treatment patterns of antithrombotic agents in symptomatic PAOD patients. Methods: This is a retrospective cohort study using data from the second largest insurance fund in Germany, BARMER. We included symptomatic PAOD patients undergoing in-hospital treatment with an index admission between 1 January 2010 and 31 December 2017. Outcomes were proportions of single antiplatelets (SAPT), dual antiplatelets (DAPT), vitamin-K antagonists (VKA), or direct oral anticoagulants (DOAC) in the 12 months prior and 6 months after the index hospitalization. Non-parametric cumulative incidence for competing risks was estimated to account for censoring and death after discharge from hospital stay. Patient flows were visualised by alluvial diagrams. All analyses were stratified by intermittent claudication (IC) and chronic limb-threatening ischaemia (CLTI). The protocol was registered to ClinicalTrials.gov (NCT03909022). Results: A total of 80,426 unique patient encounters were identified. Mean age was 72.7 (46.3% female). Amongst all patients, 25.6% were on SAPT, 4.1% on DAPT, 9.1% on VKA, 3.9% on DOAC, 3.9% on both antiplatelets and oral anticoagulation, and 53.3% without any antithrombotic therapy during the 12 months before index stay. The estimated cumulative incidence was 37.9% SAPT, 14.8% DAPT, 7.5% VKA, 4.3% DOAC, 7.4% both, and 28.1% without any antithrombotic therapy during the 6 months after index stay. The considerable increases in antiplatelet therapy were mainly driven by the group of patients without antithrombotics before index stay. As compared with IC, patients who suffered from CLTI received less often antiplatelets but more often anticoagulants both before and after index stay. Conclusions: Utilisation rates of antithrombotic therapy increased considerably after in-hospital treatment for PAOD. Yet, remarkably high rates of symptomatic patients without any blood-thinning therapy constitute a major concern with respect to adequate secondary prevention of PAOD patients.
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Kuno T, Fujisaki T, Shoji S, Sahashi Y, Tsugawa Y, Iwagami M, Takagi H, Briasoulis A, Deharo P, Cuisset T, Latib A, Kohsaka S, Bhatt DL. Comparison of Unguided De-Escalation Versus Guided Selection of Dual Antiplatelet Therapy After Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis. Circ Cardiovasc Interv 2022; 15:e011990. [PMID: 35899618 DOI: 10.1161/circinterventions.122.011990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The benefit of dual antiplatelet therapy (DAPT) for reducing ischemic events is greatest in the early period of acute coronary syndrome, and recent randomized controlled trials have investigated the unguided de-escalation strategy of changing potent P2Y12 inhibitors to less potent or reduced-dose P2Y12 inhibitors 1 month after acute coronary syndrome. However, it remains unclear which strategy is more effective and safer: the uniform unguided de-escalation strategy versus the personalized guided selection of DAPT with genotype or platelet function tests. METHODS PubMed, EMBASE, and Cochrane Central were searched for articles published from database inception to September 10, 2021. Randomized controlled trials investigating DAPT using clopidogrel, low-dose prasugrel, standard-dose prasugrel, ticagrelor, unguided de-escalation strategy, and guided selection strategy for patients with acute coronary syndrome were included. Hazard ratios and relative risk estimates were extracted from each study. The estimates were pooled using a random-effects network meta-analysis. The primary efficacy outcome was major adverse cardiovascular events, defined as a composite of cardiovascular death, myocardial infarction, or stroke. The primary safety outcome was major or minor bleeding. Secondary outcomes were all-cause death, cardiovascular death, myocardial infarction, stroke, stent thrombosis, and major bleeding. RESULTS This study included 19 randomized controlled trials with 69 746 patients. Compared with guided selection of DAPT, unguided de-escalation of DAPT was associated with a decreased risk of the primary safety outcome (hazard ratio, 0.48 [95% CI, 0.33-0.72]) without increased risks of major adverse cardiovascular events (hazard ratio, 0.82 [95% CI, 0.53-1.28]) or any secondary outcomes. The results were similar when the guided selection strategy was divided into platelet function-guided and genotype-guided strategies. CONCLUSIONS Compared with guided selection of DAPT, unguided de-escalation of DAPT decreased bleeding without increasing ischemic events in patients after acute coronary syndrome. If a strategy of de-escalation is chosen, these findings do not support the routine use of personalized guiding tests. REGISTRATION URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021273082.
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Affiliation(s)
- Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY (T.K., A.L.).,Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY (T.K.)
| | - Tomohiro Fujisaki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (T.F.).,Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and West, New York, NY (T.F.)
| | - Satoshi Shoji
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.S., S.K.)
| | - Yuki Sahashi
- Department of Cardiology, Gifu University, Japan (Y.S.)
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA (Y.T.).,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA (Y.T.)
| | - Masao Iwagami
- Department of Health Services Research, University of Tsukuba, Japan (M.I.)
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Japan (H.T.)
| | - Alexandros Briasoulis
- Division of Cardiology, Heart Failure and Transplantation, University of Iowa' Iowa City (A.B.)
| | - Pierre Deharo
- Département de Cardiologie, CHU Timone, Marseille, France (P.D., T.C.).,Center for Cardiovascular and Nutrition Research, INSERM, INRA (P.D., T.C.), Aix-Marseille Université, France.,Faculté de Médecine (P.D., T.C.), Aix-Marseille Université, France
| | - Thomas Cuisset
- Département de Cardiologie, CHU Timone, Marseille, France (P.D., T.C.).,Center for Cardiovascular and Nutrition Research, INSERM, INRA (P.D., T.C.), Aix-Marseille Université, France.,Faculté de Médecine (P.D., T.C.), Aix-Marseille Université, France
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY (T.K., A.L.)
| | - Shun Kohsaka
- Department of Cardiology, Gifu University, Japan (Y.S.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
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9
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Therapeutic Effect and Prognosis of PiCCO in the Treatment of Myocardial Injury Complicated with Septic Shock. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:2910849. [PMID: 35707040 PMCID: PMC9192277 DOI: 10.1155/2022/2910849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/22/2022] [Indexed: 11/23/2022]
Abstract
Objective To explore the effect of pulse-induced contour cardiac output (PiCCO) monitoring on the survival and prognosis of patients with myocardial injury and septic shock. Methods A total of 400 patients with MI and septic shock who were treated in our hospital from May 2018 to June 2021 were included in the study. They were randomly grouped into the PiCCO group (n = 200) and the control group (n = 200) according to whether PiCCO was used for monitoring during the treatment period. The clinical baseline characteristics of all the patients were recorded. For comparison, we recorded hemodynamic parameters including mean arterial pressure (MAP), central venous pressure (CVP), heart rate (HR), troponin I (TnI), brain natriuretic peptide (BNP), oxygen metabolism parameters including systemic central venous oxygen saturation (ScvO2), and lactate before and 6 h after intervention. In addition, white blood cell count (WBC) and C-reactive protein (CPR) levels before and 6 h, 24 h, 48 h, and 72 h after intervention were measured in both groups. Finally, the survival and prognostic parameters were compared between the two groups. Results At 6 h after monitoring intervention, the hemodynamic parameters of the patients in the PiCCO group were significantly increased. Additionally, compared with the control group, the ScvO2 level was higher while the lactate level was lower in the PiCCO group. An intergroup comparison on inflammation also showed that WBC and CPR levels recovered better in the PiCCO group than in the control group. Moreover, patients with PiCCO monitoring showed better performance in outcome measures such as mortality, duration of invasive mechanical ventilation, length of hospital stay, duration of ventilator use, acute physiology and chronic health scores, and postoperative complications. Conclusion With the monitoring and guidance of the PiCCO technique, the nursing outcomes, survival rate, and prognosis of patients with myocardial injury and septic shock can be improved.
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10
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Hanada K, Sasaki S, Seno M, Kimura Y, Ichikawa H, Nishizaki F, Yokoyama H, Yokota T, Okumura K, Tomita H. Reduced Left Ventricular Ejection Fraction Is a Risk for Sudden Cardiac Death in the Early Period After Hospital Discharge in Patients With Acute Myocardial Infarction. Circ J 2022; 86:1490-1498. [DOI: 10.1253/circj.cj-21-0999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kenji Hanada
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | - Shingo Sasaki
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | - Maiko Seno
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | - Yoshihiro Kimura
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | - Hiroaki Ichikawa
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | - Fumie Nishizaki
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | - Hiroaki Yokoyama
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | - Takashi Yokota
- Department of Advanced Cardiovascular Therapeutics, Hirosaki University Graduate School of Medicine
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital
| | - Hirofumi Tomita
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
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11
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Saito K, Saito Y, Muramatsu T, Kitahara H, Fujimoto Y, Isono S, Kobayashi Y. Impact of perioperative antithrombotic strategies on clinical events in non-cardiac surgery. Heart Vessels 2022; 37:1337-1343. [PMID: 35243527 DOI: 10.1007/s00380-022-02044-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/18/2022] [Indexed: 01/01/2023]
Abstract
Antithrombotic therapy including antiplatelet agents and anticoagulants are prescribed for secondary prevention in patients with established cardiovascular disease. Although antithrombotic therapy is often interrupted before non-cardiac surgery with or without perioperative bridging anticoagulation, the impact on thrombotic and bleeding events remains uncertain. A total of 360 patients chronically treated with antithrombotic therapy for secondary prevention underwent elective non-cardiac surgery under general anesthesia, with the complete interruption of antithrombotic agents. The study endpoints included all-cause death, thrombotic events, and major bleeding complications after surgical procedures. Of 360 patients, 190 (52.8%) and 200 (55.6%) received antiplatelet and anticoagulation perioperatively. Atrial fibrillation (32.8%) and coronary artery disease (22.5%) were the major indications for antithrombotic regimens. Antithrombotic therapy was interrupted from 5 [2, 7] days before the surgery to 4 [2, 7] days postoperatively. Perioperative bridging therapy with unfractionated heparin was employed in 113 (31.4%) patients. During the hospitalization, one (0.3%) patient died due to non-cardiovascular causes. Thrombotic events and major bleeding occurred in two (0.6%) and eight (2.2%) patients. Bridging therapy with heparin was significantly associated with an increased risk of bleeding events (5.3% vs. 0.8%, p = 0.02). Pre-operative bridging therapy with heparin and operative duration were significantly associated with bleeding complications. In the present study, complete interruption of antithrombotic therapy resulted in a few thrombotic events in patients undergoing elective non-cardiac surgery. Bridging therapy with heparin and longer operative duration were significantly associated with post-operative bleeding complications.
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Affiliation(s)
- Kan Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan.
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Takahiro Muramatsu
- Department of Anesthesiology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Yoshihide Fujimoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Shiroh Isono
- Department of Anesthesiology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
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12
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Comparison of original and modified Academic Research Consortium for High Bleeding Risk definitions in real-world practice. J Cardiol 2022; 80:155-161. [DOI: 10.1016/j.jjcc.2022.02.018] [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: 12/09/2021] [Revised: 02/13/2022] [Accepted: 02/16/2022] [Indexed: 11/24/2022]
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13
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Gohbara M, Sugano T, Ishikawa T, Tamura K, Kimura K. A case of a coronary covered stent for repeated restenosis at the anastomosis site between saphenous vein graft and graft prosthesis. J Cardiol Cases 2022; 25:110-114. [PMID: 35079311 DOI: 10.1016/j.jccase.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/13/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022] Open
Abstract
A 56-year-old man was admitted with a diagnosis of non-ST-segment elevation myocardial infarction, after surgery for total arch replacement, aortic root replacement with a mechanical aortic valve, and coronary artery reconstruction by the Piehler method for acute aortic dissection. Coronary angiography (CAG) revealed a 99% stenosis of the anastomosis site between the J Graft (Japan Lifeline, Tokyo, Japan) and the saphenous vein graft (SVG), which was distally sutured to his right coronary artery (posterior descending artery). After percutaneous coronary intervention (PCI) with a drug-eluting stent to the anastomosis site, repeated in-stent restenosis unfortunately occurred. Despite repeated PCIs, he was again admitted due to exertional angina pectoris, with proven inferior myocardial ischemia by stress myocardial perfusion imaging. We therefore decided to use a coronary covered stent for the anastomosis site to seal neointimal proliferation. GRAFTMASTER 2.8/19 mm (Abbott, CA, USA) was implanted in the anastomosis site, and a follow-up CAG one-year later revealed that the covered stent was clearly opened. To the best of our knowledge, this is the first paper to demonstrate the usefulness of a covered stent for repeated restenosis of the anastomosis site between SVG and graft prostheses. <Learning objective: A coronary covered stent is a stent with a membrane designed to seal the rupture site in cases with a coronary rupture. However, coronary covered stent implantation is an optional method in cases with repeated restenosis of the anastomosis site between the saphenous vein graft and graft prosthesis.>.
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Affiliation(s)
- Masaomi Gohbara
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Teruyasu Sugano
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Toshiyuki Ishikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kazuo Kimura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
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14
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Koga S, Honda S, Maemura K, Nishihira K, Kojima S, Takegami M, Asaumi Y, Yamashita J, Saji M, Kosuge M, Takahashi J, Sakata Y, Takayama M, Sumiyoshi T, Ogawa H, Kimura K, Yasuda S. Effect of Infarction-Related Artery Location on Clinical Outcome of Patients With Acute Myocardial Infarction in the Contemporary Era of Percutaneous Coronary Intervention ― Subanalysis From the Prospective Japan Acute Myocardial Infarction Registry (JAMIR) ―. Circ J 2022; 86:651-659. [DOI: 10.1253/circj.cj-21-0698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Seiji Koga
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Satoshi Honda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koji Maemura
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | | | - Sunao Kojima
- Department of General Internal Medicine 3, Kawasaki Medical School
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Jun Yamashita
- Department of Cardiology, Tokyo Medical University Hospital
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University
| | - Yasuhiko Sakata
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | | | | | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University
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15
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Kuno T, Miyamoto Y, Iwagami M, Ishimaru M, So M, Takahashi M, Egorova NN. The association of hemoglobin drop with in-hospital outcomes in COVID-19 patients. QJM 2022; 114:789-794. [PMID: 34597401 PMCID: PMC8500138 DOI: 10.1093/qjmed/hcab251] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/16/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Bleeding events can be critical in hospitalized patients with COVID-19, especially those with aggressive anticoagulation therapy. AIM We aimed to investigate whether hemoglobin drop was associated with increased risk of acute kidney injury (AKI) and in-hospital mortality among patients with COVID-19. DESIGN Retrospective cohort study. METHODS This retrospective study was conducted by review of the medical records of 6683 patients with laboratory-confirmed COVID-19 hospitalized in the Mount Sinai Health system between 1st March 2020 and 30th March 2021. We compared patients with and without hemoglobin drop >3 g/dl during hospitalization within a week after admissions, using inverse probability treatment weighted analysis (IPTW). Outcomes of interest were in-hospital mortality and AKI which was defined as serum creatine change of 0.3 mg/dl increase or 1.5 times baseline. RESULTS Of the 6683 patients admitted due to COVID-19, 750 (11.2%) patients presented with a marked hemoglobin drop. Patients with hemoglobin drop were more likely to receive therapeutic anticoagulation within 2 days after admissions. Patients with hemoglobin drop had higher crude in-hospital mortality (40.8% vs. 20.0%, P < 0.001) as well as AKI (51.4% vs. 23.9%, P < 0.001) compared to those without. IPTW analysis showed that hemoglobin drop was associated with higher in-hospital mortality compared to those without (odds ratio (OR) [95% confidential interval (CI)]: 2.21 [1.54-2.88], P < 0.001) as well as AKI (OR [95% CI]: 2.79 [2.08-3.73], P < 0.001). CONCLUSIONS Hemoglobin drop during COVID-19 related hospitalizations was associated with a higher risk of AKI and in-hospital mortality.
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Affiliation(s)
- Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, NY, USA
- Address for correspondence: Toshiki Kuno, MD, PhD, Division of Cardiology, Montefiore Medical Center, Albert Einsten College of Medicine, 111 East 210th St, Bronx, NY 10467-2401,
| | | | - Masao Iwagami
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
| | - Miho Ishimaru
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
| | - Matsuo So
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, NY, USA
| | - Mai Takahashi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, NY, USA
| | - Natalia N Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, NY, USA
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16
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Saito Y, Nishi T, Wakabayashi S, Ohno Y, Kitahara H, Ariyoshi N, Kobayashi Y. Derivation of a Novel Scoring System Predicting High Platelet Reactivity on Prasugrel in Patients with Coronary Artery Disease. J Atheroscler Thromb 2021; 29:1625-1633. [PMID: 34937827 DOI: 10.5551/jat.63300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIMS High platelet reactivity (HPR) has been associated with an increased risk of thrombotic events in patients undergoing percutaneous coronary intervention. HPR has been well examined in patients treated with clopidogrel; however, HPR on prasugrel is poorly investigated. METHODS Four prospective studies were pooled, in which platelet reactivity on prasugrel was measured using VerifyNow assay; genotyping of CYP2C19 was also performed. Factors associated with HPR on prasugrel were identified using multivariable analysis to develop a risk prediction model. RESULTS In total, 180 patients were examined in this study, of whom 51 (28%) had HPR on prasugrel. The multivariable analysis indicated that hypertension, diabetes, hemodialysis, and the number of CYP2C19 loss-of-function (LOF) alleles are significant factors for HPR on prasugrel. These four factors were then incorporated to develop the HHD-GENE score. The receiver operating characteristic curve analysis showed that the HHD-GENE score predicted HPR on prasugrel (area under the curve (AUC) 0.74, best cutoff value 5, p<0.001). With the best cutoff value, patients with the HHD-GENE score ≥ 5 had a significantly increased risk of HPR on prasugrel than their counterpart (50% vs. 18%, p<0.001). CONCLUSIONS The HHD-GENE score consisting of hypertension, diabetes, hemodialysis, and CYP2C19 LOF alleles may be useful in identifying patients on prasugrel who are at high risk for HPR. External validation is needed to define the clinical utility of this novel scoring system.
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Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Takeshi Nishi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine.,Department of Cardiology, Kawasaki Medical School
| | - Shinichi Wakabayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine.,Department of Cardiology, Eastern Chiba Medical Center
| | - Yuji Ohno
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine.,Department of Cardiovascular Medicine, Narita Red Cross Hospital
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Noritaka Ariyoshi
- Department of Personalized Medicine and Preventive Healthcare Sciences, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
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17
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Extent of lipid core plaque in patients with Achilles tendon xanthoma undergoing percutaneous coronary intervention for coronary artery disease. J Cardiol 2021; 79:559-563. [PMID: 34895790 DOI: 10.1016/j.jjcc.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 10/11/2021] [Accepted: 10/24/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND It has been reported that Achilles tendon xanthoma (ATX), being one of the important diagnostic criteria for familial hypercholesterolemia, is independently associated with the severity of coronary artery disease (CAD). The aim of this study was to investigate plaque vulnerability in CAD patients with ATX. METHODS Patients with CAD who underwent percutaneous coronary intervention (PCI) with near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS) guidance were enrolled. Soft X-ray radiography of the Achilles tendon was performed, and a maximum thickness of 9 mm or more was regarded as ATX. Using NIRS-IVUS, the degree of lipid core plaque (LCP) was evaluated by calculating the maximum value of lipid core burden index (LCBI) for any of the 4-mm segments (maxLCBI4mm) in the target lesion and non-target vessel. RESULTS In a total of 156 patients, 14 patients (9.0%) had ATX. MaxLCBI4mm in the ATX group was significantly greater in the target lesion (p<0.001) and in the non-target vessel (p=0.032) compared to the non-ATX group. When patients were divided into tertiles according to Achilles tendon thickness, maxLCBI4mm was progressively increased in favor of thickness, although there was only a tendency in the target lesion (p=0.062), and no statistical significance in the non-target vessel (p=0.189). Multiple linear regression analysis determined ATX as an independent predictor for maxLCBI4mm in the target lesion and non-target vessel. CONCLUSIONS ATX was associated with the degree of LCP in CAD patients requiring PCI. High-risk patients with lipid-rich vulnerable plaque can possibly be detected by evaluating Achilles tendon thickness.
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18
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Yamashita D, Saito Y, Sato T, Matsumoto T, Saito K, Wakabayashi S, Kitahara H, Sano K, Kobayashi Y. Impact of PARIS and CREDO-Kyoto Thrombotic and Bleeding Risk Scores on Clinical Outcomes in Patients With Acute Myocardial Infarction. Circ J 2021; 86:622-629. [PMID: 34588393 DOI: 10.1253/circj.cj-21-0556] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The PARIS and CREDO-Kyoto risk scores were developed to identify patients at risks of thrombotic and bleeding events individually after percutaneous coronary intervention (PCI). However, these scores have not been well validated in different cohorts.Methods and Results:This 2-center registry enrolled 905 patients with acute myocardial infarction (MI) undergoing primary PCI. Patients were divided into 3 groups according to the PARIS and CREDO-Kyoto thrombotic and bleeding risk scores. The study endpoints included ischemic (cardiovascular death, recurrent MI, and ischemic stroke) and major bleeding events. Of 905 patients, 230 (25%) and 219 (24%) had high thrombotic and bleeding risks, respectively, with the PARIS scores, compared with 78 (9%) and 50 (6%) patients, respectively, with the CREDO-Kyoto scores. According to the 2 scores, >50% of patients with high bleeding risk had concomitant high thrombotic risk. During the mean follow-up period of 714 days, 163 (18.0%) and 95 (10.5%) patients experienced ischemic and bleeding events, respectively. Both PARIS and CREDO-Kyoto scores were significantly associated with ischemic and bleeding events after primary PCI. For ischemic events, the CREDO-Kyoto rather than PARIS thrombotic risk score had better diagnostic ability. CONCLUSIONS In the present Japanese cohort of acute MI patients undergoing contemporary primary PCI, the PARIS and CREDO-Kyoto thrombotic and bleeding risk scores were discriminative for predicting ischemic and bleeding events.
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Affiliation(s)
- Daichi Yamashita
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Takanori Sato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Tadahiro Matsumoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Kan Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | | | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Koichi Sano
- Department of Cardiovascular Medicine, Eastern Chiba Medical Center
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
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19
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Saito Y, Nishi T, Wakabayashi S, Ohno Y, Kitahara H, Ariyoshi N, Kobayashi Y. Differential Impact of Clinical and Genetic Factors on High Platelet Reactivity in Patients with Coronary Artery Disease Treated with Clopidogrel and Prasugrel. J Atheroscler Thromb 2021; 29:1031-1039. [PMID: 34234079 PMCID: PMC9252642 DOI: 10.5551/jat.63035] [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] [Indexed: 11/11/2022] Open
Abstract
AIM High platelet reactivity (HPR) is associated with increased risks of thrombotic events in patients with coronary artery disease. The recently developed ABCD-GENE score identified five clinical and genetic factors (age, body mass index, chronic kidney disease, diabetes, and the CYP2C19 loss-of-function allele) for HPR, although the significance of various stages of each factor is unclear. METHODS Four prospective studies were pooled, in which platelet reactivity was measured using the VerifyNow assay with clopidogrel and prasugrel; genotyping of CYP2C19 was also performed. Each component of the ABCD-GENE score was divided into three subcategories. VerifyNow P2Y12 reactivity units >208 were defined as HPR. RESULTS A total of 184 patients were included, of which 111 (60%) and 51 (28%) had HPR with clopidogrel and prasugrel. Chronic kidney disease had an impact on HPR on both clopidogrel and prasugrel, whereas the impact of diabetes was more evident in patients treated with prasugrel. Although the number of CYP2C19 loss-of-function alleles was clearly associated with a likelihood of HPR with clopidogrel, P2Y12 reactivity units with prasugrel treatment were also significantly and progressively higher in patients with more CYP2C19 loss-of-function alleles. CONCLUSIONS Clinical and genetic factors had a differential effect on a P2Y12 inhibitor reactivity with clopidogrel and prasugrel in patients with coronary artery disease. The severity of the factors also had a different impact on HPR.
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Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Takeshi Nishi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine.,Division of Cardiovascular Medicine, Stanford University School of Medicine and Stanford Cardiovascular Institute
| | - Shinichi Wakabayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine.,Department of Cardiology, Eastern Chiba Medical Center
| | - Yuji Ohno
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine.,Department of Cardiovascular Medicine, Narita Red Cross Hospital
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Noritaka Ariyoshi
- Department of Personalized Medicine and Preventive Healthcare Sciences, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
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20
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Marazzato J, Verdecchia P, Golino M, Blasi F, Crippa M, De Ponti R, Angeli F. An update on antithrombotic therapy in atrial fibrillation patients in long-term ambulatory setting after percutaneous coronary intervention: where do we go from here? Expert Opin Pharmacother 2021; 22:2033-2051. [PMID: 34074195 DOI: 10.1080/14656566.2021.1937119] [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] [Indexed: 10/21/2022]
Abstract
INTRODUCTION In the treatment of patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI), it is unclear which combination of antithrombotic drugs is preferable and which is the optimal duration of treatment. AREAS COVERED The authors review the available evidence in this area resulting from single studies and meta-analyses. In the absence of direct head-to-head comparisons between different non-vitamin K oral anticoagulants (NOAC), the authors review the available studies with NOACS in these patients and derived indirect comparisons. EXPERT OPINION In patients with AF who undergo PCI, a dual antithrombotic strategy which includes a NOAC plus single antiplatelet therapy with a P2Y12 inhibitor (preferably clopidogrel) should be considered as the preferred treatment option in most cases. Oral anticoagulation associated with dual antiplatelet therapy (triple antithrombotic therapy) should be offered for no longer than 30 days to patients with very high thrombotic and low hemorrhagic risk. It is unclear whether the dual antithrombotic strategy should be continued beyond 12 months in patients at high risk of thrombotic events. Additional data from adequately powered controlled studies are needed to support the long-term efficacy of this strategy and to establish the best patient-tailored approach in this complex scenario.
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Affiliation(s)
- Jacopo Marazzato
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Paolo Verdecchia
- Fondazione Umbra Cuore E Ipertensione-ONLUS and Division of Cardiology, Hospital S. Maria Della Misericordia, Perugia, Italy
| | - Michele Golino
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Federico Blasi
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Matteo Crippa
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Roberto De Ponti
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, Varese, Italy.,Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institutes, IRCCS, Tradate, Varese, Italy
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21
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Fujisaki T, Kuno T, Ando T, Briasoulis A, Takagi H, Bangalore S. Potent P2Y12 inhibitors versus Clopidogrel in elderly patients with acute coronary syndrome: Systematic review and meta-analysis. Am Heart J 2021; 237:34-44. [PMID: 33737060 DOI: 10.1016/j.ahj.2021.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/09/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Potent P2Y12 inhibitors reduce cardiovascular events but increase bleeding in patients presenting with acute coronary syndrome (ACS). Elderly patients are at increased risk of bleeding and whether the benefit-risk ratio of potent P2Y12 inhibitors remains favorable is not known. OBJECTIVES To investigate the efficacy and safety of potent P2Y12 inhibitors versus clopidogrel in elderly patients with ACS. METHODS PUBMED and EMBASE were searched through July 2020 for randomized control trials (RCTs) or subgroup analyses of RCTs investigating potent P2Y12 inhibitors (prasugrel or ticagrelor) or clopidogrel in elderly (age ≥ 65 years) patients with ACS. The primary outcome was major adverse cardiovascular events (MACE). RESULTS Our search identified 9 RCTs with a total of 10,792 elderly patients. When compared with clopidogrel, potent P2Y12 inhibitors had similar risk of MACE (hazard ratio (HR): 0.94; 95%; confidence interval (CI) [0.85-1.06], P = .31, I2 = 9%), all-cause mortality (HR: 0.89; 95% CI [0.74-1.07], P = .22, I2 = 29%), reduced the risk of cardiovascular death (HR: 0.82; 95% CI [0.68-0.98], P = .03, I2 = 16%) but increased the risk of major bleeding (HR: 1.27; 95% CI [1.04-1.56], P = .02, I2 = 0%). In a subgroup analysis, ticagrelor reduced all-cause mortality (HR: 0.73; 95% CI [0.55-0.98]) and cardiovascular death (HR: 0.70; 95% CI [0.54-0.90]) compared with clopidogrel. CONCLUSIONS Among elderly patients with ACS, potent P2Y12 inhibitors reduce cardiovascular death but increase bleeding with no difference in MACE or all-cause death when compared with clopidogrel. Further RCTs are needed to refine P2Y12 inhibitor selection for elderly patients with ACS.
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Affiliation(s)
- Tomohiro Fujisaki
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and West, New York, NY
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY.
| | - Tomo Ando
- Department of Cardiology, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Sripal Bangalore
- Division of Cardiovascular Medicine, New York University Grossman School of Medicine, NY
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22
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Saito K, Kondo Y, Takahashi M, Kitahara H, Nakayama T, Fujimoto Y, Kobayashi Y. Factors that predict ventricular arrhythmias in the late phase after acute myocardial infarction. ESC Heart Fail 2021; 8:4152-4160. [PMID: 34173350 PMCID: PMC8497219 DOI: 10.1002/ehf2.13499] [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: 03/18/2021] [Revised: 05/25/2021] [Accepted: 06/16/2021] [Indexed: 11/07/2022] Open
Abstract
Aims Little is known regarding factors that predict the occurrence of lethal ventricular arrhythmias (VAs) occurring after acute myocardial infarction (AMI). This observational cohort study aimed to identify factors that predicted lethal VAs during the late phase after AMI in patients with reduced left ventricular ejection fraction (LVEF). Methods and results Data were collected from our AMI database regarding consecutive patients with an LVEF of ≤40% after AMI (January 2012 to July 2018). The ‘late phase’ was defined as ≥7 days after AMI onset, and the primary endpoint was defined as lethal VAs in the late phase. The study included 136 patients (82% men; mean age: 66 ± 13 years). The average LVEF at admission was 32.7 ± 8.2%. During a mean follow‐up period of 20.7 months, 14 patients (10%) experienced lethal VAs, including ventricular fibrillation (n = 8) and sustained ventricular tachycardia (n = 10). Univariate analyses revealed that lethal VAs were predicted by age and LVEF at admission. Receiver operating characteristic curve analysis indicated that the optimal cut‐off value was 23% for using the LVEF at admission to predict the primary endpoint (area under the curve: 0.77, P < 0.0001). Multivariable analysis also demonstrated that LVEF at admission was an independent predictor of the primary endpoint (risk ratio = 7.12, P = 0.001). Conclusions Lethal VAs in the late phase are common in patients with AMI, and reduced LVEF and cardiac function at admission play a significant role in the risk stratification for future lethal VAs in this population.
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Affiliation(s)
- Kan Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, Chuo-ku, 260-8677, Japan
| | - Yusuke Kondo
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, Chuo-ku, 260-8677, Japan
| | | | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, Chuo-ku, 260-8677, Japan
| | - Takashi Nakayama
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, Chuo-ku, 260-8677, Japan
| | - Yoshihide Fujimoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, Chuo-ku, 260-8677, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, Chuo-ku, 260-8677, Japan
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23
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Kodaira M, Sawano M, Tanaka M, Kuno T, Numasawa Y, Ueda I, Fukuda K, Kohsaka S. Female sex as an independent predictor of high bleeding risk among East Asian percutaneous coronary intervention patients: A sex difference analysis. J Cardiol 2021; 78:431-438. [PMID: 34172350 DOI: 10.1016/j.jjcc.2021.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/12/2021] [Accepted: 05/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Sex differences in the outcomes following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) have been identified in Western countries. However, data on the long-term outcomes for bleeding events, particularly in East Asia where the aging population is growing rapidly and consists predominantly of women, remain scarce. METHODS We analyzed 2,494 ACS survivors from a multicenter PCI registry who underwent PCI between 2009 and 2012. The primary outcome was readmission for major bleeding at 2 years. Survival curves were generated with the cumulative incidence function. The adjusted hazard ratios were evaluated for the primary outcomes by sex using (1) Fine-Gray models and (2) Cox regression models. RESULTS There were 548 women (22.0%) in this cohort. The women were older (73.7 ± 10.8 years vs. 65.4 ± 11.8 years, p < 0.001), had a lower body mass index (23.0 ± 3.9 vs. 24.3 ± 3.6, p < 0.001), and had more comorbidities such as renal failure (49.4% vs. 36.3%, p < 0.001) and previous heart failure (8.4% vs. 4.5%, p < 0.001). Fewer women were discharged with statins (81.9% vs. 86.5%, p = 0.025) or beta blockers (70.6% vs. 77.1%, p = 0.007). During the 2-year follow-up, the unadjusted readmission rates for bleeding were higher among women (4.9% versus 2.4% at 2 years after discharge). Multivariable competing risk analysis with the Fine-Gray model and Cox regression model further demonstrated that female sex was associated with a higher risk of bleeding. CONCLUSIONS Among patients treated with PCI, women had a higher incidence of bleeding events requiring readmission. Sex disparities in the etiologies of readmission following PCI suggest the need for targeted treatment strategies. A strict follow-up after discharge could be beneficial for women to further reduce their risk.
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Affiliation(s)
- Masaki Kodaira
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan; Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Tochigi, Japan.
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Tanaka
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Tochigi, Japan
| | - Toshiki Kuno
- Department of Medicine, Mount Sinai Beth Israel Medical Center, New York, NY, USA
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Tochigi, Japan
| | - Ikuko Ueda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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24
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Miura K, Shima Y, Okabe K, Taguchi Y, Ikuta A, Takahashi K, Kubo S, Tada T, Tanaka H, Fuku Y, Kadota K. Academic Research Consortium for High Bleeding Risk Definitions for Early, Late, and Very Late Bleeding Events. Circ J 2021; 85:797-805. [PMID: 33853992 DOI: 10.1253/circj.cj-21-0120] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The validity of the Academic Research Consortium for High Bleeding Risk (ARC-HBR) definitions of early (<1 year), late (1-4 years), and very late (>4 years) bleeding events is unknown.Methods and Results:This study was performed on patients (n=3,453) implanted with second-generation drug-eluting stents (DES) between 2010 and 2013. Data on all criteria of the ARC-HBR definition were collected retrospectively. The primary endpoint was Bleeding Academic Research Consortium Type 3 or 5 bleeding events; the ischemic endpoint was a composite of cardiac death, myocardial infarction, and ischemic stroke. The mean follow-up period was 7.5 years. Compared with non-high bleeding risk (HBR) patients, HBR patients (n=1,840; 53.3%) had an increased risk of the primary endpoint (early events, 3.6% vs. 0.5% [P<0.0001]; late events, 5.3% vs. 2.5% [P<0.0001]; very late events, 5.5% vs. 2.1% [P<0.0001]) and of ischemic events during follow-up. The discrimination ability of the ARC-HBR definition for late and very late bleeding events was comparable to that of early bleeding events (C statistics 0.679, 0.621, and 0.620, respectively) with high negative predictive value (96.6%, 95.1%, and 93.1%, respectively). Multivariate analysis revealed the different effects of individual criteria on bleeding events in each follow-up period. CONCLUSIONS The ARC-HBR definition consistently identified patients at risk of long-term bleeding and ischemic events after second-generation DES implantation.
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Affiliation(s)
- Katsuya Miura
- Department of Cardiology, Kurashiki Central Hospital
| | - Yuki Shima
- Department of Cardiology, Kurashiki Central Hospital
| | - Koya Okabe
- Department of Cardiology, Kurashiki Central Hospital
| | - Yuya Taguchi
- Department of Cardiology, Kurashiki Central Hospital
| | - Akihiro Ikuta
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Shunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital
| | - Takeshi Tada
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Yasushi Fuku
- Department of Cardiology, Kurashiki Central Hospital
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25
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Saito Y, Kobayashi Y. Academic Research Consortium Definition of High Bleeding Risk in Clinical Practice - Validation and Beyond. Circ J 2021; 85:806-807. [PMID: 33853999 DOI: 10.1253/circj.cj-21-0192] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
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26
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Saito Y, Wijns W, Baumbach A, Xu B, Kelbaek H, Zheng M, Morel MA, Anderson R, Schächinger V, Lansky A. Differential impact of abluminal groove-filled biodegradable-polymer sirolimus-eluting stent versus durable-polymer everolimus-eluting stent on and off dual antiplatelet therapy. Catheter Cardiovasc Interv 2021; 99:357-365. [PMID: 33502809 DOI: 10.1002/ccd.29468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/08/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Current guidelines recommend dual antiplatelet therapy (DAPT) following percutaneous coronary intervention for 6-12 months in patients with acute coronary syndrome (ACS) and 3-6 months in those with chronic coronary syndromes (CCS). Whether DAPT duration has a differential effect on outcomes following treatment of ischemic coronary disease with durable versus biodegradable drug-eluting stent (DES) is poorly defined. METHODS The TARGET All Comer study was a randomized trial of patients with ischemic coronary artery disease assigned to treatment with either a biodegradable polymer DES (Firehawk) or a durable polymer DES (XIENCE). This pre-specified TARGET AC sub-analysis sought to evaluate the 2-year clinical outcomes before and after DAPT discontinuation. The primary endpoint was target lesion failure (TLF). RESULTS A total of 1,296 (78.4%) of 1,653 randomized patients were included in this substudy, of which 1,210 (93.4%) remained on DAPT at 6 months, 863 (66.6%) at 12 months, and 409 (31.6%) at 2 years. There was no difference in TLF between patients treated with Firehawk and XIENCE stents from index procedure to DAPT discontinuation (8.0 and 7.7%, p > .99) or after DAPT discontinuation (2.9 vs. 3.8%, p = .16). After DAPT discontinuation, target vessel myocardial infarction (1.3 vs. 3.3%, p = .07), and ischemia-driven target lesion revascularization (0.5 vs. 1.9%, p = .06) favored treatment with Firehawk. CONCLUSIONS Although TLF was comparable for both Firehawk and XIENCE stent groups before and after DAPT discontinuation, after DAPT discontinuation, there was a trend for less target vessel myocardial infarction and ischemia-driven revascularization with the biodegradable polymer DES.
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Affiliation(s)
- Yuichi Saito
- Yale University School of Medicine, New Haven, Connecticut
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland, Galway, Ireland.,Saolta University Healthcare Group, University College Hospital Galway, Galway, Ireland
| | - Andreas Baumbach
- Yale University School of Medicine, New Haven, Connecticut.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
| | - Bo Xu
- Fu Wai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Henning Kelbaek
- Department of Cardiology, Roskilde University Hospital, Roskilde, Denmark
| | - Ming Zheng
- Shanghai MicroPort Medical (Group) Co., Ltd., Shanghai, China
| | | | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff, UK
| | - Volker Schächinger
- Medizinische Klinik I, Herz-Thorax Zentrum, Klinikum Fulda, Fulda, Germany
| | - Alexandra Lansky
- Yale University School of Medicine, New Haven, Connecticut.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
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27
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Koga S, Ikeda S, Akashi R, Yonekura T, Kawano H, Maemura K. Effects of Vonoprazan on the Antiplatelet Function of Prasugrel Assessed by the VerifyNow P2Y<sub>12</sub> Assay in Patients With Coronary Artery Disease. Circ Rep 2021; 3:26-33. [PMID: 33693287 PMCID: PMC7939790 DOI: 10.1253/circrep.cr-20-0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Seiji Koga
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Ryohei Akashi
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Tsuyoshi Yonekura
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Hiroaki Kawano
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | - Koji Maemura
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
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28
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Kuno T, Ueyama H, Takagi H, Bangalore S. Choosing between aspirin or P2Y12 monotherapy after short course of DAPT. Am Heart J 2020; 230:100. [PMID: 33248474 DOI: 10.1016/j.ahj.2020.09.003] [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] [Indexed: 01/31/2023]
Affiliation(s)
- Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY.
| | - Hiroki Ueyama
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Sripal Bangalore
- Division of Cardiovascular Medicine, New York University Grossman School of Medicine, New York, NY
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29
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Saito Y, Nishi T, Wakabayashi S, Ohno Y, Kitahara H, Ariyoshi N, Kobayashi Y. Validation of the ABCD-GENE score to identify high platelet reactivity in east Asian patients undergoing percutaneous coronary intervention. Int J Cardiol 2020; 327:15-18. [PMID: 33221348 DOI: 10.1016/j.ijcard.2020.11.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/11/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND High platelet reactivity (HPR) is associated with subsequent thrombotic events in patients undergoing percutaneous coronary intervention (PCI). Recently, the ABCD-GENE score was developed to identify patients at risk for HPR, incorporating both clinical and genetic factors. However, this score was derived and validated in mostly Caucasian subjects and it has not been validated in an East Asian population. METHOD Individual patient data from 4 prospective studies were pooled, in which platelet reactivity was measured using the VerifyNow assay on clopidogrel and genotyping of CYP2C19 was performed after PCI. Study populations included patients with general stable coronary artery disease, hemodialysis, age ≥75 and/or body weight <50 kg, and acute coronary syndrome. VerifyNow P2Y12 reactivity units >208 was defined as HPR. RESULTS Of 184 patients, 111 (60%) had HPR on clopidogrel. In the receiver operating characteristics curve analyses, the ABCD-GENE score significantly predicted HPR on clopidogrel (AUC 0.78, best cut-off value 9, p < 0.001). Across the 4 studies and their combinations, the diagnostic ability and cut-off values of ABCD-GENE score for HPR on clopidogrel were consistent. CONCLUSIONS The ABCD-GENE score had significant and moderate diagnostic ability for HPR on clopidogrel in Japanese patients undergoing PCI. The predictivity was consistent across a broad spectrum of patient populations, suggesting the applicability of this novel scoring system in clinical practice worldwide.
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Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Takeshi Nishi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan; Division of Cardiovascular Medicine, Stanford University School of Medicine and Stanford Cardiovascular Institute, CA, USA
| | - Shinichi Wakabayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan; Department of Cardiology, Eastern Chiba Medical Center, Togane, Japan
| | - Yuji Ohno
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan; Department of Cardiovascular Medicine, Narita Red Cross Hospital, Narita, Japan
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Noritaka Ariyoshi
- Department of Personalized Medicine and Preventive Healthcare Sciences, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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30
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Kuno T, Ueyama H, Takagi H, Fox J, Bangalore S. Optimal Duration of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome: Insights From a Network Meta-Analysis of Randomized Trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 28:50-56. [PMID: 32893157 DOI: 10.1016/j.carrev.2020.07.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/26/2020] [Accepted: 07/28/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND With newer generation drug eluting stents (DES), the minimal duration of dual antiplatelet therapy (DAPT) recommended by guidelines has been reduced to 6 months in patients with stable coronary artery disease. Whether shorter duration of DAPT is safe in patients presenting with acute coronary syndrome (ACS) remains controversial. Our aim of this study was to investigate the optimal DAPT duration (≤3 months vs. 6 months vs. 12 months vs. >12 months) among patients with ACS undergoing percutaneous coronary intervention (PCI). METHODS PUBMED and EMBASE were searched through January 2020 for randomized controlled trials of DAPT duration in patients with ACS. The ischemic outcomes were all-cause death, myocardial infarction, and stent thrombosis. The safety outcome was major and/or clinically relevant bleeding. RESULTS Our search identified 14 eligible trials enrolling a total of 31,837 patients comparing different DAPT duration in patients with ACS. Short-term DAPT (≤3 months or 6 months) did not increase ischemic outcomes compared to long-term DAPT (12 months and >12 months). For bleeding outcomes, ≤3 months DAPT was associated with significant reduction in bleeding compared to 6 months, 12 months or >12 months DAPT (OR [95% CI]: 0.60 [0.37-0.98]; 0.68 [0.54-0.85] and 0.43 [0.34-0.54], respectively). These findings were similar when limited to 2nd generation DES. CONCLUSIONS Data from this meta-analysis of randomized trials support short-term (≤3 months and 6 months) DAPT in patients with ACS undergoing PCI. Guidelines might need to consider short-term DAPT even in patients presenting with ACS, especially in this era of newer generation DES.
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Affiliation(s)
- Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, NY, USA.
| | - Hiroki Ueyama
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, NY, USA
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - John Fox
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, NY, USA
| | - Sripal Bangalore
- Division of Cardiovascular Medicine, New York University School of Medicine, NY, USA
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31
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P2Y12 inhibitor monotherapy versus aspirin monotherapy after short-term dual antiplatelet therapy for percutaneous coronary intervention: Insights from a network meta-analysis of randomized trials. Am Heart J 2020; 227:82-90. [PMID: 32693196 DOI: 10.1016/j.ahj.2020.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND A number of trials have assessed the efficacy and safety of short-term dual antiplatelet therapy (DAPT) in patients who undergo percutaneous coronary intervention (PCI). However, whether to continue aspirin or a P2Y12 inhibitor after a short course of DAPT is actively debated. METHODS PUBMED and EMBASE were searched through March 2020 for randomized controlled trials evaluating short-term DAPT (≤6 months) when compared with longer-term (≥12 months) DAPT among patients undergoing PCI. The ischemic outcomes were all-cause death, myocardial infarction, stent thrombosis, and stroke. The safety outcome was major and/or clinically relevant bleeding. The primary objective was to investigate the outcomes with aspirin monotherapy (Aspirin group) versus P2Y12 inhibitor monotherapy (P2Y12i group) after short-term DAPT. RESULTS Our search identified 17 eligible trials enrolling a total of 54,625 patients comparing different DAPT duration. Either of the 2 monotherapy groups did not increase the risk of ischemic outcomes when compared with the long-term DAPT group, without difference between the Aspirin versus the P2Y12i groups. However, both monotherapy groups significantly reduced bleeding when compared with long-term DAPT (Aspirin group: hazard ratio [95% CI]: 0.62 [0.45-0.86], P=.004 and P2Y12i group: 0.68 [0.50-0.93], P=.015). There was no difference in bleeding between the Aspirin versus P2Y12i groups (hazard ratio=0.91 [0.58-1.43], P=.70). CONCLUSIONS Among patients undergoing PCI, short-term DAPT with continuation of either aspirin or P2Y12i reduced bleeding without increasing ischemic outcomes when compared with long-term DAPT. The choice of antiplatelet therapy after short-term DAPT should be evaluated in well-powered trials.
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Miura K, Shimada T, Ohya M, Murai R, Amano H, Kubo S, Tada T, Tanaka H, Fuku Y, Goto T, Kadota K. Prevalence of the Academic Research Consortium for High Bleeding Risk Criteria and Prognostic Value of a Simplified Definition. Circ J 2020; 84:1560-1567. [PMID: 32669530 DOI: 10.1253/circj.cj-20-0395] [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: 11/09/2022]
Abstract
BACKGROUND The Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria have been suggested as the standard definition of HBR. However, the prevalence of individual criteria and their prognostic value for long-term bleeding events after percutaneous coronary intervention are scarcely studied.Methods and Results:The study population comprised 1,193 patients treated with everolimus-eluting stents between 2010 and 2011. Data on all 17 major and minor criteria of the ARC-HBR definition were retrospectively collected, and applied to this study population. Major bleeding was defined as the occurrence of a BARC type 3 or 5 bleeding event. A simplified definition was developed by excluding the low-frequency criterion, and the prognostic value was assessed by a receiver-operating characteristic curve. Mean follow-up was 2,996±433 days and there were 656 HBR patients (55.0%). The cumulative incidence of major bleeding was significantly higher in the HBR group than in the non-HBR group (16.2% vs. 5.7% at 8 years, P<0.001). The frequencies of 6 of the 17 criteria were less than 1%. The prognostic value of the simplified definition made by excluding these 6 criteria for major bleeding was comparable to that of the original (c-statistic=0.598 and 0.600, P=0.08). CONCLUSIONS Some risk criteria of the ARC-HBR definition are observed infrequently. Our simplified definition identified patients with long-term bleeding risk as successfully as the original definition.
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Affiliation(s)
- Katsuya Miura
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Masanobu Ohya
- Department of Cardiology, Kurashiki Central Hospital
| | - Ryosuke Murai
- Department of Cardiology, Kurashiki Central Hospital
| | - Hidewo Amano
- Department of Cardiology, Kurashiki Central Hospital
| | - Shunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital
| | - Takeshi Tada
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Yasushi Fuku
- Department of Cardiology, Kurashiki Central Hospital
| | - Tsuyoshi Goto
- Department of Cardiology, Kurashiki Central Hospital
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Gower MN, Ratner LR, Williams AK, Rossi JS, Stouffer GA, Lee CR. Clinical Utility of CYP2C19 Genotype-Guided Antiplatelet Therapy in Patients at Risk of Adverse Cardiovascular and Cerebrovascular Events: A Review of Emerging Evidence. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2020; 13:239-252. [PMID: 32821149 PMCID: PMC7419635 DOI: 10.2147/pgpm.s231475] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/29/2020] [Indexed: 12/19/2022]
Abstract
In patients undergoing percutaneous coronary intervention (PCI), the standard of care is dual antiplatelet therapy with a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) and aspirin. Current clinical practice guidelines now recommend more potent P2Y12 inhibitors (prasugrel or ticagrelor) over clopidogrel in acute coronary syndrome (ACS). However, clopidogrel remains the most commonly prescribed P2Y12 inhibitor in the setting of PCI and is also the preferred agent in the treatment and secondary prevention of stroke. Clopidogrel is a prodrug that requires bioactivation by the CYP2C19 enzyme. It has been shown that clopidogrel use in patients who are CYP2C19 no function allele carriers are associated with impaired antiplatelet inhibition and a higher risk of major adverse cardiovascular and cerebrovascular events. Compared to clopidogrel, prasugrel and ticagrelor clinical response is not impacted by CYP2C19 genotype. Even with a demonstrated increased risk of adverse outcomes in CYP2C19 no function allele carriers treated with clopidogrel, routine implementation of CYP2C19 genotyping to guide antiplatelet therapy selection has remained controversial and has not been widely adopted. Recent results from multiple prospective randomized and nonrandomized clinical trials investigating the use of CYP2C19 genotype-guided antiplatelet therapy following PCI have advanced the evidence base demonstrating the clinical utility of this strategy. Multiple recent studies have examined the effects of CYP2C19 genotype on clopidogrel outcomes in the setting of stroke and neurointerventional procedures. In this review, we discern the clinical utility of using CYP2C19 genotype testing to guide antiplatelet therapy prescribing by evaluating the impact of CYP2C19 genotype-guided selection of antiplatelet therapy on clinical outcomes, summarizing emerging data from cardiovascular and neurology clinical studies, and discussing implications for clinical practice guidelines, remaining knowledge gaps and future research directions.
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Affiliation(s)
- Megan N Gower
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Lindsay R Ratner
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Alexis K Williams
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Joseph S Rossi
- Division of Cardiology, UNC School of Medicine, Chapel Hill, NC, USA
| | - George A Stouffer
- Division of Cardiology, UNC School of Medicine, Chapel Hill, NC, USA.,UNC McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA.,UNC McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Miura T, Sonoda S, Sanuki Y, Naka Y, Okabe H, Setoyama K, Inoue K, Shimizu A, Anai R, Tsuda Y, Araki M, Otsuji Y. Comparison of post-stent irregular protrusion and subsequent neointimal characteristics between second- and third-generation drug-eluting stent implantation. J Cardiol 2020; 76:464-471. [PMID: 32636130 DOI: 10.1016/j.jjcc.2020.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/25/2020] [Accepted: 05/03/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Third-generation drug-eluting-stents (3rd DES) may improve coronary arterial healing and reduce neoatherosclerosis formation. We evaluated post-stent findings and subsequent vascular healing of 3rd DES by comparing to second-generation drug-eluting-stents (2nd DES) at intermediate-term follow-up using optical coherence tomography (OCT). METHOD We evaluated 170 patients with 170 lesions who underwent DES implantation (2nd DES, n = 98; 3rd DES, n = 72) and OCT-guided follow-up examination. After propensity score (PS) matching for baseline clinical characteristics, OCT findings from 56 pairs of patients with 2nd DES and 3rd DES implants were compared. Post-stent irregular protrusion (IP) was defined as the protrusion of material with an irregular surface into the lumen between the stent struts. Neoatheroscleosis was defined as neointima contained heterogeneous pattern, rupture, lipid-laden, thin-cap fibroatheroma, or calcification. The presence of peri-strut low-intensity area (PLIA) and in-stent neointimal tissue characteristics were also analyzed at 6- to 8-month follow-up. RESULTS There were no significant differences between the incidence of post-stent IP or neoatherosclerosis formation in the 2nd DES and the 3rd DES (45% vs. 38%, p = 0.44; 30% vs. 20%, p = 0.19, respectively). However, the incidences of PLIA and layered neointimal pattern, which indicate immature neointimal healing, were significantly lower in the 3rd DES compared to the 2nd DES (41% vs. 61%, p = 0.04; 2% vs. 11%, p = 0.04, respectively). As comparing intermediate-term follow-up OCT neointimal findings in patients with IP between 2nd DES and 3rd DES, most neointima tended to have a homogeneous pattern (95% versus 76%, p = 0.06) in the 3rd DES than in the 2nd DES. CONCLUSIONS The incidence of post-stent IP and subsequent neoatherosclerosis formation at intermediate-term follow-up after stent implantation were similar between patients with 2nd DES and 3rd DES, however, vascular healing might be favorable when using 3rd DES.
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Affiliation(s)
- Toshiya Miura
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shinjo Sonoda
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan.
| | - Yoshinori Sanuki
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yutaro Naka
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Hiroki Okabe
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Koshi Setoyama
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Konosuke Inoue
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Akiyoshi Shimizu
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Reo Anai
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yuki Tsuda
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Masaru Araki
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Ishimatsu T, Sasaki KI, Kakuma T, Harada A, Hirakawa Y, Fukumoto Y, Ueno T. Serum interleukin-18 levels as a predictor for patients with genetic dysfunction of cytochrome P450 2C19 in dual antiplatelet therapy with clopidogrel. J Cardiol 2020; 76:479-486. [PMID: 32616329 DOI: 10.1016/j.jjcc.2020.06.008] [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] [Received: 01/28/2020] [Revised: 05/18/2020] [Accepted: 05/21/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND P2Y12 reaction unit (PRU) is an index of platelet activity upon treatment with clopidogrel. In spite of suitable P2Y12 reactions in dual antiplatelet therapy (DAPT) with clopidogrel after percutaneous coronary intervention (PCI), cardiovascular events actually occur in some patients, possibly due to a genetic dysfunction of cytochrome P450 2C19 (CYP2C19), which is a major metabolic enzyme of clopidogrel. As testing the CYP2C19 phenotypes to predict such patients may lack general versatility in daily clinical practice, the aim of this study was to examine whether measuring the blood levels of some cytokines in patients showing desirable PRUs in DAPT with clopidogrel could be a substitute for testing the CYP2C19 phenotypes. METHODS We analyzed relationships among PRU, serum levels of 51 cytokines, and CYP2C19 phenotypes in 22 patients receiving DAPT with aspirin and clopidogrel after PCI. RESULTS Seventeen, 18, and 19 of 22 patients indicated PRU ≤ 208, PRU ≤ 230, and PRU ≤ 262, respectively. Approximately 60% of the patients had a genetically metabolic dysfunction of CYP2C19, and the serum levels of interleukin-18 were independently increased in those patients (p = 0.024 in patients with PRU ≤ 208, p = 0.021 with PRU ≤ 230, and p = 0.020 with PRU ≤ 262). The area under the curves in plot receiver operating characteristics curves for the serum levels of interleukin-18 were 0.94, 0.96, and 0.90 in the non-extensive metabolizer patients with PRU ≤ 208, PRU ≤ 230, and PRU ≤ 262, respectively. CONCLUSIONS The serum levels of interleukin-18 may be a predictor to diagnose patients who receive undesirable DAPT with clopidogrel, possibly due to the genetic dysfunction of CYP2C19 in spite of suitable P2Y12 reactions after PCI.
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Affiliation(s)
- Takashi Ishimatsu
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Ken-Ichiro Sasaki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan.
| | | | | | | | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Takafumi Ueno
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
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Numasawa Y, Sawano M, Fukuoka R, Ejiri K, Kuno T, Shoji S, Kohsaka S. Antithrombotic Strategy for Patients with Acute Coronary Syndrome: A Perspective from East Asia. J Clin Med 2020; 9:jcm9061963. [PMID: 32585929 PMCID: PMC7356748 DOI: 10.3390/jcm9061963] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/14/2020] [Accepted: 06/18/2020] [Indexed: 12/21/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention has become the standard of care, particularly in patients with acute coronary syndrome (ACS). Current clinical guidelines recommend novel P2Y12 inhibitors (e.g., prasugrel or ticagrelor) in addition to aspirin based on the results of representative randomized controlled trials conducted predominantly in Western countries. These agents were superior to clopidogrel in reducing the composite ischemic events, with a trade-off of the increased bleeding events. However, multiple differences exist between East Asian and Western patients, especially with respect to their physique, thrombogenicity, hemorrhagic diathesis, and on-treatment platelet reactivity. Recent studies from East Asian countries (e.g., Japan or South Korea) have consistently demonstrated that use of novel P2Y12 inhibitors is associated with a higher risk of bleeding events than use of clopidogrel, despite borderline statistical difference in the incidence of composite ischemic events. Additionally, multiple studies have shown that the optimal duration of DAPT may be shorter in East Asian than Western patients. This review summarizes clinical studies of antithrombotic strategies in East Asian patients with ACS. Understanding these differences in antithrombotic strategies including DAPT and their impacts on clinical outcomes will aid in selection of the optimal tailored antithrombotic therapy for patients with ACS.
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Affiliation(s)
- Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga 326-0843, Japan
- Correspondence: ; Tel.: +81-284-21-0121; Fax: +81-284-21-6810
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (M.S.); (R.F.); (S.S.); (S.K.)
| | - Ryoma Fukuoka
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (M.S.); (R.F.); (S.S.); (S.K.)
| | - Kentaro Ejiri
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan;
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY 10003, USA;
| | - Satoshi Shoji
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (M.S.); (R.F.); (S.S.); (S.K.)
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (M.S.); (R.F.); (S.S.); (S.K.)
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Antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome undergoing percutaneous coronary intervention; insights from a meta-analysis. Coron Artery Dis 2020; 32:31-35. [PMID: 32310855 DOI: 10.1097/mca.0000000000000900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The optimal antithrombotic regimen for patients undergoing percutaneous coronary intervention in acute coronary syndrome with concomitant atrial fibrillation is largely under investigation. METHOD PUBMED and EMBASE were searched through October 2019 for randomized trials or subgroup analyses of randomized trials investigating different antithrombotic strategies in patients with atrial fibrillation and acute coronary syndrome undergoing percutaneous coronary intervention. We compared dual antithrombotic therapy versus triple antithrombotic therapy. Dual antithrombotic therapy was defined as vitamin K antagonist or direct oral anticoagulant plus P2Y12 inhibitor. Triple antithrombotic therapy was defined as vitamin K antagonist or direct oral anticoagulant plus dual antiplatelet therapy (aspirin plus P2Y12 inhibitor). The primary safety outcome was trial outcome was trial defined major adverse cardiovascular events. RESULTS Our search identified 5 eligible subgroup analyses of randomized controlled trials that enrolled a total of 4733 patients. Dual antithrombotic therapy significantly decreased the bleeding risk when compared with triple antithrombotic therapy (hazard ratio: 0.61; 95% confidential interval [0.51-0.71], P < 0.001, I = 31%). However, there were no significant differences in major adverse cardiovascular event between dual antithrombotic therapy versus triple antithrombotic therapy (hazard ratio: 1.08; 95% confidential interval: 0.89-1.31, P = 0.44, I = 0%). CONCLUSION In patients with atrial fibrillation and acute coronary syndrome undergoing percutaneous coronary intervention, dual antithrombotic therapy was associated with lower bleeding risk compared with triple antithrombotic therapy while conferring similar major adverse cardiovascular event risk. Our results should be interpreted cautiously because we did not analyze the risk of stent thrombosis.
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