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Gritti V, Pierini S, Ferlini M, Mauri S, Barbieri L, Castiglioni B, Lettieri C, Mircoli L, Mortara A, Nassiacos D, Oltrona Visconti L, Paggi A, Soriano F, Sponzilli C, Corsini A. Atrial fibrillation and ischemic heart disease: (un)solved therapeutic dilemma? Minerva Cardiol Angiol 2024; 72:225-236. [PMID: 37870421 DOI: 10.23736/s2724-5683.23.06275-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Concomitant presence of atrial fibrillation and coronary artery disease requiring percutaneous coronary intervention is a frequent occurrence. The choice of optimal antithrombotic therapy, in this context, is still challenging. To offer the best protection both in terms of stroke and stent thrombosis, triple therapy with oral anticoagulation and dual antiplatelet therapy would be required. Several drug combinations have been tested in recent years, including direct oral anticoagulants, with the aim of balancing ischemic and bleeding risk. Both pharmacokinetic aspects of the molecules and patient's characteristics should be analyzed in choosing oral anticoagulation. Then, as suggested by guidelines, triple therapy should start with a seven-day duration and the aim to prolong to thirty days in high thrombotic risk patients. Dual therapy should follow to reach twelve months after coronary intervention. Even not fully discussed by the guidelines, in order to balance ischemic and bleeding risk it should also be considered: 1) integrated assessment of coronary artery disease and procedural complexity of coronary intervention; 2) appropriateness to maintain the anticoagulant drug dosage indicated in technical data sheet; the lack of data on the suspension of antiplatelet drugs one year after percutaneous intervention; 3) the possibility of combination therapy with ticagrelor; and 4) the need to treat the occurrence of paroxysmal atrial fibrillation during acute coronary syndrome. With data provided clinician should pursue a therapy as personalized as possible, both in terms of drug choice and treatment duration, in order to balance ischemic and bleeding risk.
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Affiliation(s)
- Valeria Gritti
- Division of Cardiology, Foundation IRCCS Polyclinic San Matteo, Pavia, Italy -
| | - Simona Pierini
- Unit of Cardiology and Cardiac Intensive Care, ASST Nord Milano, Sesto San Giovanni, Milan, Italy
| | - Marco Ferlini
- Division of Cardiology, Foundation IRCCS Polyclinic San Matteo, Pavia, Italy
| | - Silvia Mauri
- Cardiology and Coronary Unit, ASST Ovest Milanese, Milan, Italy
| | - Lucia Barbieri
- Unit of Cardiology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | - Luca Mircoli
- Unit of Cardiology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Mortara
- Department of Clinical Cardiology, Polyclinic of Monza, Monza, Monza-Brianza, Italy
| | - Daniele Nassiacos
- Unit of Cardiology and Cardiac Intensive Care, ASST Valle Olona, Saronno, Varese, Italy
| | | | - Anita Paggi
- Unit of Cardiology and Cardiac Intensive Care, ASST Nord Milano, Sesto San Giovanni, Milan, Italy
| | - Francesco Soriano
- Cardiothoracovascular Department, ASST Niguarda Hospital, Milan, Italy
| | | | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
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Hayek A, MacDonald BJ, Marquis-Gravel G, Bainey KR, Mansour S, Ackman ML, Cantor WJ, Turgeon RD. Antithrombotic Therapy in Patients With Atrial Fibrillation and Coronary Artery Disease With Recent or Remote Events: Systematic Review and Meta-analysis. CJC Open 2024; 6:708-720. [PMID: 38846448 PMCID: PMC11150964 DOI: 10.1016/j.cjco.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/06/2024] [Indexed: 06/09/2024] Open
Abstract
Background Ongoing debate remains regarding optimal antithrombotic therapy in patients with atrial fibrillation (AF) and coronary artery disease. Methods We performed a systematic review and meta-analysis to synthesize randomized controlled trials (RCTs) comparing the following: (i) dual-pathway therapy (DPT; oral anticoagulant [OAC] plus antiplatelet) vs triple therapy (OAC and dual-antiplatelet therapy) after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS), and (iii) OAC monotherapy vs DPT at least 1 year after PCI or ACS. Following a 2-stage process, we identified systematic reviews published between 2019 and 2022 on these 2 clinical questions, and we updated the most comprehensive search for additional RCTs published up to October 2022. Outcomes of interest were major adverse cardiovascular events (MACE), death, stent thrombosis, and major bleeding. We estimated risk ratios (RRs) and 95% confidence intervals (CIs) using a random-effects model. Results Based on 6 RCTs (n = 10,435), DPT reduced major bleeding (RR 0.62, 95% CI 0.52-0.73) and increased stent thrombosis (RR 1.55, 95% CI 1.02-2.36), vs triple therapy after PCI or medically-managed ACS, with no significant differences in MACE and death. In 2 RCTs (n = 2905), OAC monotherapy reduced major bleeding (RR 0.66, 95% CI 0.49-0.91) vs DPT in AF patients with remote PCI or ACS, with no significant differences in MACE or death. Conclusions In patients with AF and coronary artery disease, using less-aggressive antithrombotic treatment (DPT after PCI or ACS, and OAC alone after remote PCI or ACS) reduced major bleeding, with an increase in stent thrombosis with recent PCI. These results support a minimalist yet personalized antithrombotic strategy for these patients.
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Affiliation(s)
- Ahmad Hayek
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Blair J. MacDonald
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Samer Mansour
- Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Margaret L. Ackman
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Warren J. Cantor
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ricky D. Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Zeymer U, Toelg R, Wienbergen H, Hobbach HP, Cuneo A, Bekeredjian R, Ritter O, Hailer B, Hertting K, Hennersdorf M, Scholtz W, Lanzer P, Mudra H, Schwefer M, Schwimmbeck PL, Liebetrau C, Thiele H, Claas C, Riemer T, Zahn R. Rivaroxaban in Patients With Atrial Fibrillation Who Underwent Percutaneous Coronary Intervention in Clinical Practice. Am J Cardiol 2023; 189:31-37. [PMID: 36493580 DOI: 10.1016/j.amjcard.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/08/2022] [Accepted: 11/04/2022] [Indexed: 12/12/2022]
Abstract
Little is known about the efficacy and safety of rivaroxaban in patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI) in clinical practice. We therefore conducted a prospective observational study to determine the rate of ischemic, embolic, and bleeding events in patients with AF and PCI treated with rivaroxaban in a real-world experience. The RIVA-PCI ("rivaroxaban in patients with AF who underwent PCI") (clinicaltrials.gov NCT03315650) is a prospective, noninterventional, multicenter study with a follow-up until 14 months, including patients with AF who underwent PCI discharged with rivaroxaban. Between January 2018 and March 2020, 700 patients with PCI treated with rivaroxaban (elective in 50.1%, non-ST-elevation acute coronary syndrome 43.0%, ST-elevation myocardial infarction in 6.9%) were enrolled at 51 German hospitals. After PCI, a dual antithrombotic therapy consisting of rivaroxaban and a P2Y12 inhibitor was administered in 70.7% and triple antithrombotic therapy in 27.9%, respectively. Follow-up information could be obtained in 695 patients (99.3%). Rivaroxaban has been stopped prematurely in 21.6% of patients. Clinical events under rivaroxaban during the 14-month follow-up compared with those observed in the PIONEER-AF PCI trial included cardiovascular death (2.0% % vs 2.0%), myocardial infarction (0.9% vs 3.0%), stent thrombosis (0.2% vs 0.8%), stroke (1.3% vs 1.3%), International Society on Thrombosis and Haemostasis major (4.2% vs 3.9%), and International Society on Thrombosis and Haemostasis nonmajor clinically relevant bleeding (15.3% vs 12.9%). Therefore, in this real-world experience, rivaroxaban in patients with AF who underwent PCI is associated with ischemic and bleeding event rates comparable with those observed in the randomized PIONEER-AF PCI trial.
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Affiliation(s)
- Uwe Zeymer
- Klinikum Ludwigshafen, Ludwigshafen, Germany; Institut für Herzinfarktforschung Ludwigshafen, Germany.
| | - Ralph Toelg
- Segeberger Kliniken GmbH, Bad Segeberg, Germany
| | | | | | | | | | | | - Birgit Hailer
- Katholische Kliniken Essen-Nord-West gGmbH, Essen, Germany
| | | | | | | | - Peter Lanzer
- Gesundheitszentrum Bitterfeld Wolfen, Bitterfeld, Germany
| | - Harald Mudra
- München Klinik, Klinikum Neuperlach, München, Germany
| | | | | | | | - Holger Thiele
- Herzzentrum Leipzig - Universität Leipzig, Leipzig, Germany
| | | | - Thomas Riemer
- Institut für Herzinfarktforschung Ludwigshafen, Germany
| | - Ralf Zahn
- Klinikum Ludwigshafen, Ludwigshafen, Germany
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De Luca L, Rubboli A, Lettino M, Tubaro M, Leonardi S, Casella G, Valente S, Rossini R, Sciahbasi A, Natale E, Trambaiolo P, Navazio A, Cipriani M, Corda M, De Nardo A, Francese GM, Napoletano C, Tizzani E, Nardi F, Roncon L, Caldarola P, Riccio C, Gabrielli D, Oliva F, Massimo Gulizia M, Colivicchi F. ANMCO position paper on antithrombotic treatment of patients with atrial fibrillation undergoing intracoronary stenting and/or acute coronary syndromes. Eur Heart J Suppl 2022; 24:C254-C271. [PMID: 35663586 PMCID: PMC9155223 DOI: 10.1093/eurheartj/suac020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) with or without acute coronary syndromes (ACS) represent a subgroup with a challenging pharmacological management. Indeed, if on the one hand, antithrombotic therapy should reduce the risk related to recurrent ischaemic events and/or stent thrombosis; on the other hand, care must be taken to avoid major bleeding events. In recent years, several trials, which overall included more than 12 000 patients, have been conducted demonstrating the safety of different therapeutic combinations of oral antiplatelet and anticoagulant agents. In the present ANMCO position paper, we propose a decision-making algorithm on antithrombotic strategies based on scientific evidence and expert consensus to be adopted in the periprocedural phase, at the time of hospital discharge, and in the long-term follow-up of patients with AF undergoing PCI with/without ACS.
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Affiliation(s)
- Leonardo De Luca
- Cardiology, Department of Cardio-Thoraco-Vascular, Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense, 87, 00152 Roma, Italy
| | - Andrea Rubboli
- Cardiology, Cardiovascular Department, Ospedale S. Maria delle Croci, Ravenna, Italy
| | - Maddalena Lettino
- Department of Cardiology, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Marco Tubaro
- CCU, Intensive and Interventional Cardiology Department, P.O. San Filippo Neri, Roma, Italy
| | - Sergio Leonardi
- University of Pavia and IRCCS S. Matteo Foundation General Hospital, Pavia, Italy
| | - Gianni Casella
- Cardiology Department, Ospedale Maggiore, Azienda USL di Bologna, Bologna, Italy
| | - Serafina Valente
- Cardio-Thoracic Department, A.O.U. Senese, Ospedale Santa Maria alle Scotte, Siena, Italy
| | - Roberta Rossini
- Emergency Department and Critical Areas, Azienda Ospedaliera Santa Croce e Carle, Cuneo, Italy
| | | | - Enrico Natale
- Cardiology, Department of Cardio-Thoraco-Vascular, Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense, 87, 00152 Roma, Italy
| | - Paolo Trambaiolo
- Cardiology Department, Ospedale Sandro Pertini, ASL RM2, Roma, Italy
| | - Alessandro Navazio
- Hospital Cardiology Department, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, Italy
| | - Manlio Cipriani
- Cardiology 2-Heart Failure and Transplants, Dipartimento Cardiotoracovascolare “A. De Gasperis”, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Marco Corda
- Cardiology Department, Azienda Ospedaliera G. Brotzu, Cagliari, Italy
| | - Alfredo De Nardo
- Cardiology-ICU Department, Ospedale Civile “G. Jazzolino”, Vibo Valentia, Italy
| | - Giuseppina Maura Francese
- Cardiology Department, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Cosimo Napoletano
- Cardiology-ICU Department—Cath Lab, Presidio Ospedaliero “G. Mazzini”, Teramo, Italy
| | | | - Federico Nardi
- Cardiology Department, Ospedale Santo Spirito, Casale Monferrato (AL), Italy
| | - Loris Roncon
- Cardiology Department, Ospedale Santa Maria della Misericordia, Rovigo, Italy
| | | | - Carmine Riccio
- Follow-up of the Post-Acute Patient, Cardio-Vascular Department, AORN Sant'Anna and San Sebastiano, Caserta, Italy
| | - Domenico Gabrielli
- Cardiology, Department of Cardio-Thoraco-Vascular, Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense, 87, 00152 Roma, Italy
| | - Fabrizio Oliva
- Cardiology 2-Heart Failure and Transplants, Dipartimento Cardiotoracovascolare “A. De Gasperis”, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, Presidio Ospedaliero San Filippo Neri, ASL Roma 1, Roma, Italy
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Mugosa S, Radosavljevic I, Sahman M, Djordjevic N, Todorovic Z. Risk factors for adverse drug reactions associated with clopidogrel therapy. Open Med (Wars) 2022; 17:694-701. [PMID: 35480401 PMCID: PMC8990878 DOI: 10.1515/med-2021-0371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 08/20/2021] [Accepted: 09/13/2021] [Indexed: 11/15/2022] Open
Abstract
Abstract
This study aimed to investigate the possible influence of genetic and non-genetic factors on the incidence of clopidogrel adverse drug reactions (ADRs) in cardiology patients, including the most important CYP2C19 alleles, namely *2 and *17, as well as compliance, dose, drug interactions, and clinical factors. A total of 102 clopidogrel-treated adult Caucasian patients hospitalized at the Cardiology Department of the Clinical Center of Montenegro were enrolled in the study. Data on clinical outcomes of interest were obtained by intensive monitoring ADRs during hospitalization and one year after hospital discharge. Genotyping for CYP2C19*2 and *17 was conducted using the real-time polymerase chain reaction method. ADRs were characterized using the Rawlins and Thompson classification and the World Health Organization criteria. Causality was assessed using the Naranjo probability scale. ADRs to clopidogrel were observed in 9 of 102 patients (8.8%). The observed frequencies of CYP2C19*2 and *17 were 13.2 and 25.5%, respectively. Our study, which is the first to report the frequency of CYP2C19 polymorphism in the Montenegrin population, as well as to link the pharmacovigilance of clopidogrel with CYP2C19 gene variability, shows that the incidence of ADRs of clopidogrel in cardiac patients is high and depends on CYP2C19 polymorphisms, comedication/drug interactions, and gastrointestinal comorbidity.
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Affiliation(s)
- Snezana Mugosa
- Department of Pharmacology, Faculty of Medicine, University of Montenegro , 81000 Podgorica , Montenegro
- Clinical Trials Department, Institute for Medicines and Medical Devices of Montenegro , 81000 Podgorica , Montenegro
| | - Ivan Radosavljevic
- Department of Surgery, Faculty of Medical Sciences, University of Kragujevac , 34000 Kragujevac , Serbia
| | - Majda Sahman
- Department of Pharmacology, Faculty of Medicine, University of Montenegro , 81000 Podgorica , Montenegro
- Clinical Trials Department, Institute for Medicines and Medical Devices of Montenegro , 81000 Podgorica , Montenegro
| | - Natasa Djordjevic
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac , 34000 Kragujevac , Serbia
| | - Zoran Todorovic
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade , Belgrade , Serbia
- University Medical Center “Bežanijska kosa” , Belgrade , Serbia
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Al Said S, Ellscheid M, Beltsios ET, Frey N. Non-Vitamin K Antagonist Oral Anticoagulants in Coronary Artery Disease. Hamostaseologie 2021; 42:201-209. [PMID: 34662918 DOI: 10.1055/a-1606-7523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The prevention of atherothrombotic events is the primary goal in the treatment of patients with arteriosclerotic disorders. Despite recent improvements in the management of coronary artery disease (CAD) with revascularization techniques and antiplatelet therapy, some patients remain at risk of recurrent cardiovascular events. This could be related to additional thrombin generation. As a result, there has been interest in developing novel therapies to prevent thromboembolic events, targeting thrombin-mediated pathways. These include non-vitamin K antagonist oral anticoagulants (NOACs). This article aims to summarize the recent clinical studies that investigated the role of NOACs in CAD.
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Affiliation(s)
- Samer Al Said
- Department of Internal Medicine III Cardiology Angiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany.,DZHK (German Centre for Cardiovascular Research), University of Heidelberg, Heidelberg/Mannheim, Germany
| | - Michael Ellscheid
- Department of Internal Medicine III Cardiology Angiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Norbert Frey
- Department of Internal Medicine III Cardiology Angiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany.,DZHK (German Centre for Cardiovascular Research), University of Heidelberg, Heidelberg/Mannheim, Germany
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