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Sundermeyer J, Schock A, Kellner C, Haller PM, Lehmacher J, Thießen N, Toprak B, Scharlemann L, Twerenbold R, Sörensen NA, Clemmensen P, Neumann JT. Pre-hospital admission of heparin in patients with suspected non-ST segment elevation acute coronary syndrome. Clin Res Cardiol 2024:10.1007/s00392-024-02507-1. [PMID: 39102002 DOI: 10.1007/s00392-024-02507-1] [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: 05/02/2024] [Accepted: 07/25/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Evidence supporting pre-hospital heparin administration in patients with suspected non-ST segment elevation acute coronary syndrome (NSTE-ACS) is lacking. We aim to evaluate if pre-hospital heparin administration by emergency medical service improves clinical outcome in patients with suspected NSTE-ACS. METHODS Patients with suspected myocardial infarction (MI) presenting to the emergency department were prospectively enrolled from 2013 to 2021, excluding those with ST segment elevation MI. Patients with and without prehospital heparin administration were compared using propensity score matching. To assess the association between pre-hospital heparin loading, 30-day and 1-year mortality, Kaplan-Meier estimations and Cox regression models were used. RESULTS Among 1,234 patients, median age was 69 years, 755 (61.2%) were male, 867 (70.5%) with known hypertension, 177 (14.4%) had diabetes, 280 (23.1%) were current smokers, and 444 (36.0%) had a history of CAD. Compared to patients without pre-hospital heparin administration, heparin pre-treated patients were more often active smokers (26.5% vs. 20.8%). After propensity matching, 475 patients with vs. without pre-hospital heparin administration were compared, with no significant difference in 30-day mortality (no-heparin 1.3% vs. heparin 0.4%) and 1-year mortality (no-heparin 7.2% vs. heparin 5.5%, adjusted HR 0.98, CI 0.95-1.01, p = 0.22). Bleeding events occurred at a low frequency (< 2%) and did not differ between groups. CONCLUSIONS In this study, pre-hospital heparin administration was not associated with improved clinical outcome in patients with suspected NSTE-ACS. These findings question pre-hospital heparin therapy in this patient population and might potentially warrant a more restricted utilization pending in-hospital risk assessment.
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Affiliation(s)
- Jonas Sundermeyer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Center for Population Health Innovation (POINT), Hamburg, Germany
| | - Alina Schock
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Center for Population Health Innovation (POINT), Hamburg, Germany
| | - Caroline Kellner
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- Center for Population Health Innovation (POINT), Hamburg, Germany
| | - Paul M Haller
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Center for Population Health Innovation (POINT), Hamburg, Germany
| | - Jonas Lehmacher
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Center for Population Health Innovation (POINT), Hamburg, Germany
| | - Niklas Thießen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Center for Population Health Innovation (POINT), Hamburg, Germany
| | - Betül Toprak
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Center for Population Health Innovation (POINT), Hamburg, Germany
| | - Lea Scharlemann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- Center for Population Health Innovation (POINT), Hamburg, Germany
| | - Raphael Twerenbold
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Center for Population Health Innovation (POINT), Hamburg, Germany
| | - Nils Arne Sörensen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Center for Population Health Innovation (POINT), Hamburg, Germany
| | - Peter Clemmensen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Center for Population Health Innovation (POINT), Hamburg, Germany
| | - Johannes T Neumann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.
- Center for Population Health Innovation (POINT), Hamburg, Germany.
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Jourdi G, Hulot JS, Gaussem P. An update on oral antiplatelet drug interactions with proton pump inhibitors: what are the risks? Expert Opin Drug Metab Toxicol 2024:1-16. [PMID: 38980768 DOI: 10.1080/17425255.2024.2378888] [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: 04/24/2024] [Accepted: 07/08/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION Aspirin and anti-P2Y12 are widely prescribed in cardiovascular patients, often in combination with proton pump inhibitors (PPIs) to limit the risk of upper gastrointestinal bleedings. The potential interaction between PPIs and antiplatelet agents has been widely discussed, but doubts remain as to whether PPIs may reduce the cardiovascular protection provided by aspirin, prasugrel, ticagrelor, and clopidogrel. AREAS COVERED Many pharmacokinetic (PK) and pharmacodynamic (PD) studies have confirmed the interaction, especially between PPIs and clopidogrel, but with uncertain consequences on clinical outcomes. Therefore, we aimed to summarize the evidence for the widespread combined use of oral antiplatelet drugs and PPIs, to outline the current evidence supporting or opposing drug-drug interaction, and to discuss the clinical implications of such interactions. EXPERT OPINION A large body of evidence describes the PK/PD interaction of antiplatelet drugs with PPIs and its potential role in increasing clinical cardiovascular adverse events, but no solid clinical data have confirmed these effects. In the light of the published studies, there seems to be no restriction on the choice of PPI with aspirin, prasugrel, and/or ticagrelor. The choice of a PPI with no (or minimal) interference with the hepatic cytochrome P450 2C19 is preferred in patients receiving clopidogrel.
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Affiliation(s)
- Georges Jourdi
- Faculté de Pharmacie de Paris, Université Paris Cité, Inserm, Innovative Therapies in Haemostasis, UMR_S1140, Paris, France
- Laboratory of haematology, Lariboisière University hospital, Paris, France
| | - Jean-Sébastien Hulot
- Université Paris Cité, Inserm, Paris Cardiovascular Research center, UMR_S970, Paris, France
- Clinical investigation center (CIC1418), Hôpital Européen Georges Pompidou, Paris, France
| | - Pascale Gaussem
- Laboratory of haematology, Hôpital Européen Georges Pompidou, Paris, France
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3
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Sandner S. Dual antiplatelet therapy after coronary artery bypass surgery. BMJ 2024; 385:q1083. [PMID: 38862159 DOI: 10.1136/bmj.q1083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Affiliation(s)
- Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Austria
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
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4
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Krittanawong C, Uppalapati L, Virk HUH, Qadeer YK, Irshad U, Wang Z, Sharma S, Jneid H. Complications of Radial vs Femoral Access for Coronary Angiography and Intervention: What Do the Data Tell Us? Am J Med 2024; 137:483-489. [PMID: 38387541 DOI: 10.1016/j.amjmed.2024.02.022] [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: 02/14/2024] [Revised: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 02/24/2024]
Abstract
In the last decades, radial access, as an alternative to femoral access, has rapidly evolved and emerged as the preferred vascular access for coronary angiography and percutaneous coronary intervention (PCI). The use of radial access for PCI can reduce access-site bleeding, particularly retroperitoneal bleeding, and risk of developing pseudoaneurysm, while also improving patient comfort after procedure (eg, early ambulation). However, radial access requires a longer learning curve to develop technical skills, and the data on radial artery graft for coronary artery bypass graft after radial access remain insufficient. Further, recent clinical trials have shown conflicts regarding whether radial access is associated with lower mortality in patients with ST-elevation myocardial infarction. Despite these recent investigations, it is still debated whether there are benefits associated with radial access over femoral access for PCI. In this review, we will evaluate radial access compared with femoral access for PCI on clinical outcomes and further discuss the usefulness of radial access.
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Affiliation(s)
| | | | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Ohio
| | | | - Umer Irshad
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Ohio
| | - Zhen Wang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Samin Sharma
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York, NY
| | - Hani Jneid
- Division of Cardiology, University of Texas Medical Branch, Houston
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5
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Ayyappan S, Shekhawat RS, Meshram VP, Kanchan T. Spontaneous retroperitoneal and intracranial hemorrhage following streptokinase therapy in acute myocardial infarction: An autopsy case report. J Forensic Sci 2024; 69:346-350. [PMID: 37904604 DOI: 10.1111/1556-4029.15418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/14/2023] [Accepted: 10/18/2023] [Indexed: 11/01/2023]
Abstract
Bleeding complications following thrombolytic treatment for acute myocardial infarction (AMI) are not infrequent, among which intracranial hemorrhage is commonly reported. In contrast, retroperitoneal hematoma following the administration of thrombolytics is rarely reported in the literature. We are reporting a case of a middle-aged man, who presented with left-sided chest pain and was diagnosed with acute coronary syndrome with anterior wall ST elevation AMI. The patient was administered with thrombolytic drugs, including streptokinase and heparin. Percutaneous coronary intervention in the form of Coronary angioplasty with stent insertion was done to the left anterior descending artery, given coronary artery disease. The blood investigations showed elevated activated partial thromboplastin time and prothrombin time. The patient developed vomiting, altered sensorium, and left-sided weakness, and a non-contrast computerized tomography brain was done, which showed acute hemorrhage involving the right frontal lobe with intraventricular extension, so the ventricular drain was placed. The patient developed cardiac arrest and died on the third day. On autopsy examination, the brain showed subarachnoid hemorrhage, intraparenchymal hemorrhage over the right frontal lobe, and clotted blood in all the ventricles. A retroperitoneal hematoma of around 1500 cc was seen over the left side of the peritoneal cavity. This case highlights that although intracranial hemorrhage is a known complication after administrating thrombolytic therapy, clinicians should also be aware of the possibility of retroperitoneal hemorrhage. This case emphasizes the value of an autopsy in determining the cause of death in such situations.
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Affiliation(s)
- Sathish Ayyappan
- Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Raghvendra Singh Shekhawat
- Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Vikas P Meshram
- Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Tanuj Kanchan
- Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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6
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Siu HK, Schultz E, LeBrun S, Liou M, Kwan TW. Safety of Retrograde Tibial-Pedal Access and Intervention in Patients with Single Remaining Non-Occluded Infra-Popliteal Runoff Artery. J Cardiovasc Dev Dis 2023; 10:463. [PMID: 37998521 PMCID: PMC10672062 DOI: 10.3390/jcdd10110463] [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: 09/28/2023] [Revised: 10/31/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND The adaptation of retrograde tibial-pedal access for peripheral angiogram and intervention is limited by the lack of operator experience and concern for small distal vessel injury. This study evaluates the safety of the retrograde tibial-pedal access for peripheral angiogram and intervention in patients with two vessel infra-popliteal artery chronic total occlusions, where the access point is the sole remaining non-occluded infra-popliteal artery. METHODS A retrospective analysis of 5687 consecutive patients who underwent peripheral angiograms by retrograde tibial-pedal access via the single remaining non-occluded infra-popliteal artery was performed. Patients who had retrograde tibial-pedal access at the sole remaining infra-popliteal artery confirmed by angiography were included. Clinical and ultrasound data of the accessed infra-popliteal vessel up to 6 months were collected. RESULTS The cohort consisted of 314 patients (152 males; mean age 77.9 years). At 6 months, access vessel complications occurred in 15 patients (4.8%). Access vessel occlusion occurred in 9 out of 314 patients (2.9%), arteriovenous fistula in 4 (1.3%), with spontaneous resolution in 2, pseudoaneurysm requiring thrombin injection in 2 (0.6%) and non-cardiovascular death in 1 (0.3%). No uncontrolled bleeding, procedure-related hospitalizations or limb amputations occurred. CONCLUSIONS Routine primary retrograde tibial-pedal access for lower extremity peripheral artery diagnostic angiography and intervention in patients with single infra-popliteal artery runoff can be safety performed in an outpatient setting with infrequent and manageable complications.
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Affiliation(s)
- Henry K. Siu
- Chinatown Cardiology, P.C., New York, NY 10013, USA (T.W.K.)
- Department of Medicine, Division of Cardiology, Lenox Hill Hospital, New York, NY 10075, USA
| | - Emily Schultz
- Department of Medicine, Division of Cardiology, Lenox Hill Hospital, New York, NY 10075, USA
| | - Sandrine LeBrun
- Department of Medicine, Division of Cardiology, Lenox Hill Hospital, New York, NY 10075, USA
| | - Michael Liou
- Chinatown Cardiology, P.C., New York, NY 10013, USA (T.W.K.)
| | - Tak W. Kwan
- Chinatown Cardiology, P.C., New York, NY 10013, USA (T.W.K.)
- Department of Medicine, Division of Cardiology, Lenox Hill Hospital, New York, NY 10075, USA
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7
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Paradies V, Maurina M, Tonino P, Hofma SH, Vos J, van Kuijk JP, Oemrawsingh RM, Mafragi AA, Spano F, Pisters R, Polad J, Ijsselmuiden S, Cambero MM, Smits PC. Comparison of Supraflex Cruz 60 μm Versus Ultimaster Tansei 80 μm Stent Struts in High Bleeding Risk PCI Patients: Study design and Rational of Compare 60/80 HBR trial. Am J Cardiol 2023; 206:230-237. [PMID: 37708755 DOI: 10.1016/j.amjcard.2023.08.046] [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: 06/09/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 09/16/2023]
Abstract
Up to 45% of patients who underwent percutaneous coronary intervention (PCI) may have a high bleeding risk (HBR), depending on the bleeding risk definition.1 This condition is often associated with an enhanced risk of thrombotic events with a negative impact on short- and long-term outcomes,2-8 making the choice of an appropriate antithrombotic regimen after PCI particularly challenging. Advances in stent technologies, in which the introduction of newer generations of thinner strut drug-eluting stents (DES), have significantly reduced the rate of thrombotic complications and may justify a shorter dual antiplatelet therapy (DAPT) duration. Both in vitro and in vivo studies have shown that local hemodynamic factors may critically affect the natural history of atherosclerosis. Strut thickness correlates with flow disturbances and endothelial shear stress. Flow separation within struts determines areas of recirculation with low endothelial shear stress which promotes local concentration of activated platelets.9 By mitigating inflammation, vessel injury, and neointimal proliferation, thin and streamlined struts have been associated with faster vascular healing and re-endothelization and have resulted in lower rates of thrombotic events after PCI.10,11 The use of thin strut and ultra-thin strut stents may lead to a favorable trade-off in bleeding and ischemic events in patients with HBR. However, dedicated studies evaluating the performance of thin strut versus ultrathin strut stents in patients with HBR are lacking.
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Affiliation(s)
- Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands
| | - Matteo Maurina
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; XXX, Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Pim Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Sjoerd H Hofma
- Department of Cardiology, Medical Centrum Leeuwarden, The Netherlands
| | - Jeroen Vos
- Department of Cardiology, Amphia Hospital, The Netherlands
| | - Jan-Peter van Kuijk
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Rohit M Oemrawsingh
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Amar Al Mafragi
- Department of Cardiology, Zorgsaam Hospital, Terneuzen, The Netherlands
| | - Fabrizio Spano
- Department of Cardiology, Meander Hospital, Amersfoort, The Netherlands
| | - Ron Pisters
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jawed Polad
- Department of Cardiology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | | | | | - Pieter C Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands.
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Sandner S, Redfors B, Gaudino M. Antiplatelet therapy around CABG: the latest evidence. Curr Opin Cardiol 2023; 38:484-489. [PMID: 37751394 PMCID: PMC10552805 DOI: 10.1097/hco.0000000000001078] [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] [Indexed: 09/28/2023]
Abstract
PURPOSE OF REVIEW The optimal antiplatelet strategy in patients after coronary artery bypass graft (CABG) surgery is unclear. We review the evidence on the efficacy and safety of DAPT after CABG and discuss potential novel antiplatelet strategies that reduce the risk of bleeding without loss of efficacy. RECENT FINDINGS Adding the potent P2Y12 inhibitor ticagrelor to aspirin for 1 year after CABG is associated with a reduction in the risk of vein graft failure, at the expense of an increased risk of clinically important bleeding. Ticagrelor monotherapy is not associated with better efficacy than aspirin alone, but is not associated with increased bleeding risk. SUMMARY Dual antiplatelet therapy (DAPT) is recommended after acute coronary syndrome events, but aspirin as single antiplatelet therapy remains the cornerstone of antithrombotic therapy in stable ischemic heart disease because of a lack of solid evidence on the benefit of DAPT on clinical outcomes. Shorter duration DAPT, based on the pathophysiology of vein graft failure, may be a promising strategy that requires testing in adequately powered randomized trials.
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Affiliation(s)
- Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
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Parco C, Tröstler J, Brockmeyer M, Hoss A, Lin Y, Quade J, Heinen Y, Schulze V, Jung C, Icks A, Kelm M, Wolff G. Risk-adjusted management in catheterization procedures for non-ST-segment elevation myocardial infarction: A standard operating procedure pilot study. Int J Cardiol 2023; 388:131111. [PMID: 37302420 DOI: 10.1016/j.ijcard.2023.06.002] [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: 04/02/2023] [Revised: 05/23/2023] [Accepted: 06/02/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND The effects of standardized risk-adjusted periprocedural management of cardiac catheterization procedures in Non-ST segment elevation myocardial infarction (NSTEMI) remain unknown. We implemented a standard operating procedure (SOP) specifying risk assessment (RA, using National Cardiovascular Data Registry (NCDR) risk models) and risk-adjusted management (RM, e.g. intensified monitoring) in 2018 and aimed to investigate staff SOP adherence and associations with patient outcomes. METHODS AND RESULTS All 430 invasively managed NSTEMI patients (mean age 72y; 70.9% male) in 2018 were analyzed for staff SOP adherence and in-hospital clinical outcomes. 207 patients (48.1%; RM+) received both RA and RM; 92 patients (21.4%; RM-) received RA but no RM; 131 patients (30.5%; RA-) received neither RA nor RM. Lower staff adherence to RA was associated with emergency settings (51.9% (RA-) vs. 22.1% (RA+); p<0.01), presentation in cardiogenic shock (17.6% (RA-) vs. 6.4% (RA+); p<0.01) and invasive mechanical ventilation (12.2% (RA-) vs. 3.3% (RA+); p<0.01). Early sheath removal (87.9% (RM+) vs. 56.5% (RM-); p<0.01) and intensified monitoring (p<0.01) were more frequent in the RM+ group. All-cause mortality was not different (1.4% (RM+) vs. 4.3% (RM-); p=0.13), but there were fewer major bleeding events with associated with RM (2.4% (RM+) vs. 12% (RM-); p<0.01), which remained independently associated with RM in a multivariate logistic regression model correcting for confounders (p<0.01). CONCLUSION In an all-comer patient cohort with NSTEMI, staff adherence to risk-adjusted periprocedural management was independently associated with fewer major bleeding events. Staff adherence to SOP-specified risk assessment was frequently neglected in more critical clinical situations.
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Affiliation(s)
- Claudio Parco
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jennifer Tröstler
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Maximilian Brockmeyer
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Alexander Hoss
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Yingfeng Lin
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Julia Quade
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Yvonne Heinen
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Volker Schulze
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Christian Jung
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany; CARID, Cardiovascular Research Institute Düsseldorf, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Georg Wolff
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
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Kobayashi Y, Otaki Y, Watanabe T, Tachibana S, Sato J, Saito Y, Aono T, Goto J, Kato S, Tamura H, Nishiyama S, Arimoto T, Takahashi H, Watanabe M. Growth Differentiation Factor-15 and Clinical Outcomes in Japanese Patients With Ischemic Heart Disease. JACC. ASIA 2023; 3:457-471. [PMID: 37396418 PMCID: PMC10308123 DOI: 10.1016/j.jacasi.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 07/04/2023]
Abstract
Background Despite a reduction in the rate of thrombotic events, ischemic heart disease (IHD) remains a key medical problem associated with high major bleeding and mortality in Asian patients with IHD. Growth differentiation factor (GDF)-15, a stress-response cytokine belonging to the transforming growth factor beta superfamily, is reportedly associated with poor clinical outcomes in Western patients with IHD. However, the clinical significance of GDF-15 in Asian patients with IHD has not yet been fully elucidated. Objectives The aim of the present study was to examine the impact of serum GDF-15 on clinical outcomes in Japanese patients with IHD. Methods Serum GDF-15 levels were evaluated in 632 consecutive patients with IHD. All patients were followed up for a median period of 2.8 years. The primary endpoint was the all-cause mortality rate. Secondary endpoints were major adverse cardiovascular events (MACE), heart failure (HF)-related rehospitalization, bleeding, and thrombotic events. Results Serum GDF-15 levels were elevated in acute coronary syndrome, severe coronary artery disease, and the major Japanese version of the high bleeding risk criteria. Multivariate Cox proportional hazards regression analysis demonstrated that GDF-15 was an independent predictor of all-cause mortality, MACE, HF-related rehospitalizations, and bleeding events after adjusting for confounding risk factors but not for thrombotic events. Adding GDF-15 to risk factors significantly improved the net reclassification index and integrated discrimination improvement for all-cause deaths, MACE, HF-related rehospitalization, and bleeding events. Conclusions Serum GDF-15 could be a feasible marker for major bleeding and adverse clinical outcomes in Japanese patients with IHD.
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Affiliation(s)
| | - Yoichiro Otaki
- Address for correspondence: Dr Yoichiro Otaki, Department of Cardiology, Pulmonology and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata 990-9585, Japan.
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Kadiyala V, Long S, Has P, Lima FV, Sherrod CF, Heinl R, Williams MU, Nowak E, Kennedy K, Aronow HD, Abbott JD. PRECISE-DAPT and ARC-HBR Predict in-Hospital Outcomes in Patients Who Underwent Percutaneous Coronary Intervention. Am J Cardiol 2023; 191:43-50. [PMID: 36640599 DOI: 10.1016/j.amjcard.2022.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/27/2022] [Accepted: 12/10/2022] [Indexed: 01/13/2023]
Abstract
Bleeding events result in morbidity and mortality in patients who underwent percutaneous coronary intervention (PCI). There are limited data on the predicting bleeding complications in patients who underwent stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) and Academic Research Consortium for High Bleeding Risk (ARC-HBR) scores' ability to predict in-hospital outcomes in patients who underwent PCI. Consecutive patients who underwent PCI at tertiary centers from January 2016 to March 2018 were identified and the bleeding risk scores were calculated. The primary end point was the National Cardiovascular Data Registry-defined in-hospital bleeding stratified by low versus high predicted bleeding risk. The major and net adverse cardiovascular events were also examined. The discriminatory ability of the risk models was determined using receiver operating characteristic curves. Among 3,659 patients studied, the in-hospital major bleeding was 3.3% (n = 121). The patients characterized as high bleeding risk by either criterion had significantly higher bleeding rates than those meeting the low-risk criteria (ARC-HBR 5.4% vs 3.3%, p <0.001; PRECISE-DAPT 5.8% vs 2.4%, p <0.001), and higher major adverse cardiovascular events and net adverse clinical events. These risk estimates showed moderate and similar predictive ability (ARC-HBR high-risk area under the receiver operating characteristic curve [AUC] 0.62, PRECISE-DAPT ≥25 AUC 0.61, p = 0.49), with no incremental benefit to adding the estimates (AUC 0.60). The subgroup analysis revealed that women had higher bleeding rates than men (5.53% vs 2.39%, p <0.001); however, the predictive ability of the criteria were similar in women and men. The patients identified as having a high bleeding risk by the PRECISE-DAPT and the ARC-HBR criteria before PCI are at high risk for in-hospital bleeding and adverse outcomes independent of gender. The 2 scores have moderate predictive ability for bleeds. Further study is needed to determine strategies to reduce risk in this population.
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Affiliation(s)
- Vishnu Kadiyala
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
| | - Sokunvichet Long
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Phinnara Has
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Fabio V Lima
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Charles F Sherrod
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Robert Heinl
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael U Williams
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Elizabeth Nowak
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Kevin Kennedy
- Statistical Consultant, Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - Herbert D Aronow
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - J Dawn Abbott
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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Pinxterhuis TH, Ploumen EH, Zocca P, Doggen CJM, Schotborgh CE, Anthonio RL, Roguin A, Danse PW, Benit E, Aminian A, Stoel MG, Linssen GCM, Geelkerken RH, von Birgelen C. Risk of bleeding after percutaneous coronary intervention and its impact on further adverse events in clinical trial participants with comorbid peripheral arterial disease. Int J Cardiol 2023; 374:27-32. [PMID: 36496036 DOI: 10.1016/j.ijcard.2022.12.009] [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: 09/26/2022] [Revised: 11/15/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Both patients with obstructive coronary artery disease (CAD) and patients with peripheral arterial disease (PADs) have an increased bleeding risk. Information is scarce on bleeding in CAD patients, treated with percutaneous coronary intervention (PCI), who have comorbid PADs. We assessed whether PCI patients with PADs have a higher bleeding risk than PCI patients without PADs. Furthermore, in PCI patients with PADs we evaluated the extent by which bleeding increased the risk of further adverse events. METHODS Three-year pooled patient-level data of two randomized PCI trials (BIO-RESORT, BIONYX) with drug-eluting stents were analyzed to assess mortality and the composite endpoint major adverse cardiac events (MACE: all-cause mortality, any myocardial infarction, emergent coronary artery bypass surgery, or target lesion revascularization). RESULTS Among 5989 all-comer patients, followed for 3 years, bleeding occurred in 7.7% (34/440) with comorbid PADs and 5.0% (279/5549) without PADs (HR: 1.59, 95%CI: 1.11-2.23, p = 0.010). Of all PADs patients, those with a bleeding had significantly higher rates of all-cause mortality (HR: 4.70, 95%CI: 2.37-9.33, p < 0.001) and MACE (HR: 2.39, 95%CI: 1.23-4.31, p = 0.003). Furthermore, PADs patients with a bleeding were older (74.4 ± 6.9 vs. 67.4 ± 9.5, p < 0.001). After correction for age and other potential confounders, bleeding remained independently associated with all-cause mortality (adj.HR: 2.97, 95%CI: 1.37-6.43, p = 0.006) while the relation of bleeding with MACE became borderline non-significant (adj.HR: 1.85, 95%CI: 0.97-3.55, p = 0.06). CONCLUSION PCI patients with PADs had a higher bleeding risk than PCI patients without PADs. In PADs patients, bleeding was associated with all-cause mortality, even after adjustment for potential confounders.
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Affiliation(s)
- Tineke H Pinxterhuis
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands; Health Technology and Services Research, Faculty BMS, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Eline H Ploumen
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands; Health Technology and Services Research, Faculty BMS, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Paolo Zocca
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Carine J M Doggen
- Health Technology and Services Research, Faculty BMS, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | | | - Rutger L Anthonio
- Department of Cardiology, Treant Zorggroep, Scheper Hospital, Emmen, the Netherlands
| | - Ariel Roguin
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera and B. Rappaport-Faculty of Medicine, Israel, Institute of Technology, Haifa, Israel
| | - Peter W Danse
- Department of Cardiology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Edouard Benit
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Martin G Stoel
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Gerard C M Linssen
- Department of Cardiology, Ziekenhuisgroep Twente, Almelo, and Hengelo, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Multi-modality Medical Imaging (M3I) group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Clemens von Birgelen
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands; Health Technology and Services Research, Faculty BMS, Technical Medical Centre, University of Twente, Enschede, the Netherlands.
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13
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Rao SV, Ohman EM. Balancing the Risks and Benefits of Antiplatelet Therapy After Coronary Artery Bypass Graft Surgery. JAMA 2022; 328:532-533. [PMID: 35943481 DOI: 10.1001/jama.2022.12444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sunil V Rao
- The Program for Advanced Coronary Disease, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - E Magnus Ohman
- The Program for Advanced Coronary Disease, Duke Clinical Research Institute, Duke University, Durham, North Carolina
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14
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Kadota K, Nakao K, Nakagawa Y, Shite J, Yokoi H, Kozuma K, Tanabe K, Akasaka T, Shinke T, Ueno T, Hirayama A, Uemura S, Harada A, Kuroda T, Takita A, Iijima R, Murakami Y, Saito S, Nakamura M. Clinical Outcomes After Percutaneous Coronary Intervention in East Asian Patients ― 30-Month Results of the PENDULUM Registry ―. Circ J 2022; 86:1339-1349. [DOI: 10.1253/circj.cj-21-0991] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Junya Shite
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | - Ken Kozuma
- Division of Cardiology, Department of Internal Medicine, Teikyo University
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Takafumi Ueno
- Department of Cardiovascular Medicine, Fukuoka Kinen Hospital
| | | | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | | | - Takeshi Kuroda
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd
| | | | - Raisuke Iijima
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
| | | | - Shigeru Saito
- Division of Cardiology & Catheterization Laboratories, Shonan Kamakura General Hospital
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
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Meng S, Guo L, Ye Z, Wang J, Ding H, Wu S, Huang R. Comparison of Clinical Outcomes Between Ticagrelor and Clopidogrel in Elderly Patients Undergoing Percutaneous Coronary Intervention: A Cohort Study. Clin Interv Aging 2022; 17:331-341. [PMID: 35400997 PMCID: PMC8986484 DOI: 10.2147/cia.s355210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/10/2022] [Indexed: 12/03/2022] Open
Abstract
Background Age is a strong predictor of adverse outcomes due both to a higher risk of bleeding and ischemia. The purpose of this study was to evaluate the safety and efficacy of ticagrelor in elderly patients. Methods Patients ≥75 years of age admitted to our center from January, 2015 to December, 2019 who had undergone percutaneous coronary intervention (PCI) and received dual antiplatelet therapy (DAPT) were included in our study. Eligible patients were divided into clopidogrel and ticagrelor groups according to the P2Y12 receptor inhibitor and were followed up for 1 year. The primary safety endpoint was types 2, 3, and 5 bleeding, as defined by Bleeding Academic Research Consortium (BARC), and the primary efficacy endpoint was combined major adverse cardiovascular and cerebrovascular events (MACCEs). A Cox proportional hazard model and propensity score matching were used to correct confounding factors. Results Of 1505 patients enrolled in this study, 442 were assigned to ticagrelor group and 1063 were assigned to clopidogrel group. The incidence of BARC 2, 3, and 5 bleeding (HR, 2.304; 95% CI, 1.540–3.447), and any bleeding (HR, 2.476; 95% CI, 1.802–3.403) in ticagrelor group was significantly higher than clopidogrel group. There were no significant difference between the two groups with respect to BARC 3 and 5 bleeding (HR, 1.566; 95% CI, 0.767–3.198) and MACCEs (HR, 0.957; 95% CI, 0.702–1.305). Conclusion Compared with clopidogrel, DAPT with ticagrelor significantly increased the risk of BARC 2, 3, and 5 bleeding without reducing MACCEs in elderly patients who underwent PCI. Trial Registration The study was retrospectively registered in clinicaltrials.gov (NCT 04999293).
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Affiliation(s)
- Shaoke Meng
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, People’s Republic of China
| | - Lei Guo
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, People’s Republic of China
| | - Zhishuai Ye
- Cardiac Center/Division of Cardiovascular Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing City, People’s Republic of China
| | - Junjie Wang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, People’s Republic of China
| | - Huaiyu Ding
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, People’s Republic of China
| | - Shanshan Wu
- Department of Clinical Epidemiology and EBM, Beijing Friendship Hospital, Capital Medical University, Beijing City, People’s Republic of China
| | - Rongchong Huang
- Cardiac Center/Division of Cardiovascular Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing City, People’s Republic of China
- Correspondence: Rongchong Huang, Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, 95 Yong’an Road, Beijing City, 100053, People’s Republic of China, Email
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16
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Persampieri S, Castini D, Lupi A, Guazzi M. Untangling the difficult interplay between ischemic and hemorrhagic risk: The role of risk scores. World J Cardiol 2022; 14:96-107. [PMID: 35316974 PMCID: PMC8900521 DOI: 10.4330/wjc.v14.i2.96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/01/2021] [Accepted: 01/23/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Bleedings are an independent risk factor for subsequent mortality in patients with acute coronary syndromes (ACS) and in those undergoing percutaneous coronary intervention. This represents a hazard equivalent to or greater than that for recurrent ACS. Dual antiplatelet therapy (DAPT) represents the cornerstone in the secondary prevention of thrombotic events, but the benefit of such therapy is counteracted by the increased hemorrhagic complications. Therefore, an early and individualized patient risk stratification can help to identify high-risk patients who could benefit the most from intensive medical therapies while minimizing unnecessary treatment complications in low-risk patients.
AIM To review existing literature and gain better understanding of the role of ischemic and hemorrhagic risk scores in patients with ischemic heart disease (IHD).
METHODS We used a combination of terms potentially used in literature describing the most common ischemic and hemorrhagic risk scores to search in PubMed as well as references of full-length articles.
RESULTS In this review we briefly describe the most important ischemic and bleeding scores that can be adopted in patients with IHD, focusing on GRACE, CHA2DS2-Vasc, PARIS CTE, DAPT, CRUSADE, ACUITY, HAS-BLED, PARIS MB and PRECISE-DAPT score. In the second part of this review, we try to define a possible approach to the IHD patient, using the most suitable scores to stratify patient risk and decide the most appropriate patient treatment.
CONCLUSION It becomes evident that risk scores by themselves can’t be the solution to balance the ischemic/bleeding risk of an IHD patient. Instead, some risk factors that are commonly associated with an elevated risk profile and that are already included in risk scores should be the focus of the clinician while he/she is taking care of a patient affected by IHD.
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Affiliation(s)
| | - Diego Castini
- Division of Cardiology, Ospedale San Paolo, Milan 20142, Italy
- Department of Clinical Sciences, University of Milan, Milan 20122, Italy
| | - Alessandro Lupi
- Division of Cardiology, Ospedale San Biagio, Verbania 28845, Italy
| | - Marco Guazzi
- Department of Clinical Sciences, University of Milan, Milan 20122, Italy
- Division of Cardiology, San Paolo Hospital, ASST Santi Paolo e Carlo, Milan 20142, Italy
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17
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Roh JW, Lee SJ, Kim BK, Hong SJ, Kim HY, Ahn CM, Cho DK, Kim JS, Ko YG, Choi D, Hong MK, Jang Y. Ticagrelor vs. Clopidogrel in Acute Coronary Syndrome Patients With Chronic Kidney Disease After New-Generation Drug-Eluting Stent Implantation. Front Cardiovasc Med 2022; 8:707722. [PMID: 35083294 PMCID: PMC8785207 DOI: 10.3389/fcvm.2021.707722] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 12/15/2021] [Indexed: 12/31/2022] Open
Abstract
Background: The impact of ticagrelor-based dual antiplatelet therapy (DAPT) on acute coronary syndrome (ACS) in patients with chronic kidney disease (CKD) remains unclear. Methods: Data on a total of 1,067 ACS patients with CKD including end-stage renal disease (ESRD) who underwent new-generation drug-eluting stent implantation were extracted from a multicenter registry. This study aimed to compare outcomes of patients treated with ticagrelor- (n = 449) and those treated with clopidogrel-based (n = 618) DAPT. Outcomes of interest included major adverse cardiac and cerebrovascular events (MACCEs) and bleeding (Bleeding Academic Research Consortium grade 3 or 5) at 12 months. Propensity-score matching (346 pairs) analysis was performed. Results: The patients with ESRD showed the highest MACCE and bleeding rates (P < 0.001). There was no difference in the rate of MACCEs between the treatment groups (7.8% vs. 8.4%; hazard ratio [HR] = 0.95, 95% confidence interval [CI] = 0.56–1.61, P = 0.855); however, a trend toward an increased bleeding rate was observed in the ticagrelor-based DAPT group (6.8% vs. 3.8%, HR = 1.84, 95% CI = 0.93–3.63, P = 0.079). Among patients with CKD stage III/IV but without ESRD (277 pairs), the ticagrelor-based DAPT group showed a reduced MACCE rate (3.6% vs. 8.7%, HR = 0.41, 95% CI = 0.19–0.86, P = 0.018) and a similar bleeding rate (5.1% vs. 3.2%, HR = 1.61, 95% CI = 0.70–3.71, P = 0.267), compared with those of the clopidogrel-based DAPT group. Conclusion: The effects of ticagrelor-based DAPT on ischemic and bleeding outcomes of ACS patients with CKD varied according to CKD stage; in ACS patients with CKD without ESRD, ticagrelor-based DAPT reduced MACCE risk without increasing bleeding risks, relative to those observed with clopidogrel-based DAPT.
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Affiliation(s)
- Ji Woong Roh
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Yongin Severance Hospital, Yongin, South Korea
- Department of Cardiology, The Catholic University College of Medicine, Bucheon St. Mary's Hospital, Bucheon, South Korea
| | - Seung-Jun Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Cardiovascular Hospital, Seoul, South Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Cardiovascular Hospital, Seoul, South Korea
- *Correspondence: Byeong-Keuk Kim
| | - Sung-Jin Hong
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Cardiovascular Hospital, Seoul, South Korea
| | - Hee-Yeol Kim
- Department of Cardiology, The Catholic University College of Medicine, Bucheon St. Mary's Hospital, Bucheon, South Korea
| | - Chul-Min Ahn
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Cardiovascular Hospital, Seoul, South Korea
| | - Deok-Kyu Cho
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Yongin Severance Hospital, Yongin, South Korea
| | - Jung-Sun Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Cardiovascular Hospital, Seoul, South Korea
| | - Young-Guk Ko
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Cardiovascular Hospital, Seoul, South Korea
| | - Donghoon Choi
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Yongin Severance Hospital, Yongin, South Korea
| | - Myeong-Ki Hong
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Cardiovascular Hospital, Seoul, South Korea
| | - Yangsoo Jang
- Department of Cardiology, CHA Bundang Medical Centre, CHA University, Seongnam, South Korea
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GÜNDÜZ R, YİLDİZ BS, ÖZDEMIR İH, ÖZEN MB, ÇETIN N, YAVUZGİL O. ST segment yükselmesi olmayan miyokard infarktüsü olgularında enoksoparin tedavisinin etkinliğinin değerlendirilmesinde AntiFXa aktivitesi ve tromboleastogram yönteminin karşılaştırılması. CUKUROVA MEDICAL JOURNAL 2021. [DOI: 10.17826/cumj.977136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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19
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Salisbury AC, Safley DM, Kennedy KF, Bhardwaj B, Aronow HD, Jones WS, Feldman DN, Secemsky E, Tsai TT, Attaran RR, Spertus JA. Development and validation of a predictive model for bleeding after peripheral vascular intervention: A report from the National Cardiovascular Data Registry Peripheral Vascular Interventions Registry. Catheter Cardiovasc Interv 2021; 98:1363-1372. [PMID: 34569709 DOI: 10.1002/ccd.29961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/08/2021] [Accepted: 09/18/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To develop a model to predict risk of in-hospital bleeding following endovascular peripheral vascular intervention. BACKGROUND Peri-procedural bleeding is a common, potentially preventable complication of catheter-based peripheral vascular procedures and is associated with increased mortality. We used the National Cardiovascular Data Registry (NCDR) Peripheral Vascular Interventions (PVI) Registry to develop a novel risk-prediction model to identify patients who may derive the greatest benefit from application of strategies to prevent bleeding. METHODS We examined all patients undergoing lower extremity PVI at 76 NCDR PVI hospitals from 2014 to 2017. Patients with acute limb ischemia (n = 1600) were excluded. Major bleeding was defined as overt bleeding with a hemoglobin (Hb) drop of ≥ 3 g/dl, any Hb decline of ≥ 4 g/dl, or a blood transfusion in patients with pre-procedure Hb ≥ 8 g/dl. Hierarchical multivariable logistic regression was used to develop a risk model to predict major bleeding. Model validation was performed using 1000 bootstrapped replicates of the population after sampling with replacement. RESULTS Among 25,382 eligible patients, 1017 (4.0%) developed major bleeding. Predictors of bleeding included age, female sex, critical limb ischemia, non-femoral access, prior heart failure, and pre-procedure hemoglobin. The model demonstrated good discrimination (optimism corrected c-statistic = 0.67), calibration (corrected slope = 0.98, intercept of -0.04) and range of predicted risk (1%-18%). CONCLUSIONS Post-procedural PVI bleeding risk can be predicted based upon pre- and peri-procedural patient characteristics. Further studies are needed to determine whether this model can be utilized to improve procedural safety through developing and targeting bleeding avoidance strategies.
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Affiliation(s)
- Adam C Salisbury
- University of Missouri-Kansas City, Kansas City, Missouri, USA
- Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
| | - David M Safley
- University of Missouri-Kansas City, Kansas City, Missouri, USA
- Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
| | - Kevin F Kennedy
- Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
| | | | - Herbert D Aronow
- Lifespan Cardiovascular Institute, Brown University, Providence, Rhode, USA
| | - William Schuyler Jones
- Division of Cardiology, Duke Heart Center, Duke University Health System, Durham, North Carolina, USA
| | - Dmitriy N Feldman
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
| | - Eric Secemsky
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Thomas T Tsai
- University of Colorado Institute for Health Research and Kaiser Permanente, Denver, Colorado, USA
| | | | - John A Spertus
- University of Missouri-Kansas City, Kansas City, Missouri, USA
- Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
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20
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Giri J, Fanaroff AC. 1 Month of Dual Antiplatelet Therapy in Patients Undergoing Percutaneous Coronary Intervention: The New Standard? J Am Coll Cardiol 2021; 78:2073-2075. [PMID: 34794688 DOI: 10.1016/j.jacc.2021.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 09/23/2021] [Accepted: 09/27/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Jay Giri
- Cardiovascular Outcomes Quality and Evaluative Research Center, Leonard Davis Institute for Health Economics, and Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Alexander C Fanaroff
- Cardiovascular Outcomes Quality and Evaluative Research Center, Leonard Davis Institute for Health Economics, and Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA. https://twitter.com/ACFanaroff
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21
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Graipe A, Ulvenstam A, Irevall AL, Söderström L, Mooe T. Incidence and predictors of serious bleeding during long-term follow-up after acute coronary syndrome in a population-based cohort study. Sci Rep 2021; 11:21967. [PMID: 34754030 PMCID: PMC8578330 DOI: 10.1038/s41598-021-01525-7] [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: 05/27/2021] [Accepted: 10/28/2021] [Indexed: 11/13/2022] Open
Abstract
Progress in decreasing ischemic complications in acute coronary syndrome (ACS) has come at the expense of increased bleeding risk. We estimated the long-term, post-discharge incidence of serious bleeding, characterized bleeding type, and identified predictors of bleeding and its impact on mortality in an unselected cohort of patients with ACS. In this population-based study, we included 1379 patients identified with an ACS, 2010–2014. Serious bleeding was defined as intracranial hemorrhage (ICH), bleeding requiring hospital admission, or bleeding requiring transfusion or surgery. During a median 4.6-year follow-up, 85 patients had ≥ 1 serious bleed (cumulative incidence, 8.6%; 95% confidence interval (CI) 8.3–8.9). A subgroup of 557 patients, aged ≥ 75 years had a higher incidence (13.4%) than younger patients (6.0%). The most common bleeding site was gastrointestinal (51%), followed by ICH (27%). Sixteen percent had a recurrence. Risk factors for serious bleeding were age ≥ 75 years, lower baseline hemoglobin (Hb) value, previous hypertension or heart failure. Serious bleeding was associated with increased mortality. Bleeding after ACS was fairly frequent and the most common bleeding site was gastrointestinal. Older age, lower baseline Hb value, hypertension and heart failure predicted bleeding. Bleeding did independently predict mortality.
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Affiliation(s)
- Anna Graipe
- Institution of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden.
| | - Anders Ulvenstam
- Institution of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden
| | - Anna-Lotta Irevall
- Institution of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden
| | - Lars Söderström
- Institution of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden
| | - Thomas Mooe
- Institution of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden
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22
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Lu W, Wang Y, Chen L, Li Y, Zhang R, Chen Z, Yan J, Yang M, Han B, Wang Z, He S, Chen L, Wu X, Zeng H, Ma L, Shi G, Yin J, Chen J, Ma G. Antithrombotic Therapy With Ticagrelor in Atrial Fibrillation Subjects After Percutaneous Coronary Intervention. Front Cardiovasc Med 2021; 8:745549. [PMID: 34712714 PMCID: PMC8545975 DOI: 10.3389/fcvm.2021.745549] [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: 07/22/2021] [Accepted: 09/20/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Warfarin, along with aspirin and clopidogrel, has long been recommended for patients with atrial fibrillation (AF) who are undergoing percutaneous coronary intervention with a drug-eluting stent (PCI-DES). However, this triple therapy has been known to increase the risk of bleeding complications. Meanwhile, there is no evidence from prospective trials on the use of ticagrelor in a dual therapy. We here aimed to compare the antiplatelet drug ticagrelor as a dual antithrombotic agent to aspirin and clopidogrel in bleeding events. Methods: In this multicenter, active-controlled, open-label, randomized trial, patients with AF taking warfarin who had undergone PCI-DES were randomly assigned to the ticagrelor therapy group (Dual group) or the clopidogrel plus aspirin therapy group (Triple group). The primary and secondary endpoints were overall bleeding events and major bleeding events, respectively, according to the Thrombolysis in Myocardial Infarction (TIMI) criteria at 6 months. Cardiovascular events [re-PCI, surgical bypass, myocardial infarction (MI), heart failure, rehospitalization due to angina pectoris, stent thrombosis and death due to cardiovascular causes] at 6 months were also recorded. Results: A total of 296 patients from 12 medical centers in China were randomized after PCI-DES to either the Dual therapy group (n = 148) or the Triple group (n = 146) for 6 months. The overall incidence of bleeding events at 6 months was 36.49% in the Dual therapy group and 35.62% in the Triple group [hazard ratio, 0.930; 95% confidence interval (CI), 0.635 to 1.361; P = 0.7088]. The incidence of the secondary endpoint over 6 months was 4.73% in the Dual therapy group and 1.37% in the Triple group (hazard ratio, 0.273; 95% CI, 0.057 to 1.315; P = 0.1056). Cardiovascular event occurrence was also comparable in both groups at 6 months (18.24 vs. 16.44%; hazard ratio, 0.845; 95% CI, 0.488 to 1.465; P = 0.5484). Conclusions: The incidence of total bleeding events in AF patients treated with ticagrelor was comparable to that in patients treated with clopidogrel plus aspirin at 6 month; Meanwhile, the incidence of cardiovascular events were also comparable between the groups. Clinical Trial Registration: MANJUSRI, ClinicalTrials.gov# NCT02206815, 2014, August 1st
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Affiliation(s)
- Wenbin Lu
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Yu Wang
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Lijuan Chen
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Yongjun Li
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Rui Zhang
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Zhongpu Chen
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Jinchuan Yan
- Department of Cardiology, Affiliated Hospital of Jiangsu University, Jiangsu, China
| | - Mingming Yang
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Bing Han
- Department of Cardiology, Central Hospital of Xuzhou City, Xuzhou, China
| | - Zhirong Wang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Shenghu He
- Department of Cardiology, Northern Jiangsu People's Hospital Affiliated With Yangzhou University, Yangzhou, China
| | - Lianglong Chen
- Department of Cardiology, Union Hospital Affiliated With Fujian Medical University, Fuzhou, China
| | - Xiang Wu
- Department of Cardiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Hesong Zeng
- Department of Cardiology, Tongji Hospital Affiliated With Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Likun Ma
- Department of Cardiology, Anhui Provincial Hospital, Hefei, China
| | - Guoping Shi
- Department of Cardiology, Rugao People's Hospital, Nantong, China
| | - Jianrong Yin
- Department of Cardiology, Pizhou People's Hospital Affiliated With Xuzhou Medical University, Xuzhou, China
| | - Jiyan Chen
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong, China
| | - GenShan Ma
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
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23
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Björklund E, Malm CJ, Nielsen SJ, Hansson EC, Tygesen H, Romlin BS, Martinsson A, Omerovic E, Pivodic A, Jeppsson A. Comparison of Midterm Outcomes Associated With Aspirin and Ticagrelor vs Aspirin Monotherapy After Coronary Artery Bypass Grafting for Acute Coronary Syndrome. JAMA Netw Open 2021; 4:e2122597. [PMID: 34436610 PMCID: PMC8391102 DOI: 10.1001/jamanetworkopen.2021.22597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Guidelines recommend dual antiplatelet therapy after coronary artery bypass grafting (CABG) for patients with acute coronary syndrome (ACS). However, the evidence for these recommendations is weak. OBJECTIVE To compare midterm outcomes after CABG in patients with ACS treated postoperatively with acetylsalicylic acid (ASA) and ticagrelor or with ASA monotherapy. DESIGN, SETTING, AND PARTICIPANTS This cohort study used merged data from several national registries of Swedish patients who were diagnosed with ACS and subsequently underwent CABG. All included patients underwent isolated CABG in Sweden between 2012 and 2017 with an ACS diagnosis less than 6 weeks before the procedure, survived 14 days after discharge from hospital, and were treated postoperatively with ASA plus ticagrelor or ASA monotherapy. A multivariable Cox regression model was used for the main analysis, and propensity score-matched models were performed as sensitivity analysis. Data were analyzed between May and September 2020. EXPOSURES Postoperative antiplatelet treatment, defined as filled prescriptions, with either ASA and ticagrelor or ASA only. MAIN OUTCOMES AND MEASURES Major adverse cardiovascular events (MACE), defined as all-cause mortality, myocardial infarction, and stroke, and major bleeding, at 12 months and at the end of follow-up. RESULTS A total of 6558 patients (5281 [80.5%] men; mean [SD] age at surgery, 67.6 [9.3] years) were included; 1813 (27.6%) were treated with ASA plus ticagrelor and 4745 (72.4%) were treated with ASA monotherapy. Crude MACE rate was 3.0 per 100 person years (95% CI, 2.5-3.6 per 100 person years) in the ASA plus ticagrelor group and 3.8 per 100 person years (95% CI, 3.5-4.1 per 100 person years) in the ASA group. After adjustment, there was no significant difference in MACE risk between ASA plus ticagrelor vs ASA only, neither during the first 12 months (adjusted hazard ratio [aHR], 0.84; 95% CI, 0.58-1.21; P = .34) or during total follow-up (aHR, 0.89; 95% CI, 0.71-1.11; P = .29). The use of ASA plus ticagrelor was associated with a significantly increased risk for major bleeding during the first 12 months (aHR, 1.90; 95% CI, 1.16-3.13; P = .011). Sensitivity analyses confirmed the results. CONCLUSIONS AND RELEVANCE In patients with ACS who survived 2 weeks after CABG, no significant difference in the risk of death or ischemic events could be demonstrated between ASA plus ticagrelor and patients treated with ASA only, while the risk for major bleeding was higher in patients treated with ASA plus ticagrelor. Sufficiently powered prospective randomized trials comparing different antiplatelet therapy strategies after CABG are warranted.
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Affiliation(s)
- Erik Björklund
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Medicine, South Älvsborg Hospital, Borås, Sweden
| | - Carl Johan Malm
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Susanne J. Nielsen
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Emma C. Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hans Tygesen
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Medicine, South Älvsborg Hospital, Borås, Sweden
| | - Birgitta S. Romlin
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Martinsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elmir Omerovic
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Aldina Pivodic
- Statistiska Konsultgruppen, Gothenburg, Sweden
- Department of Ophthalmology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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24
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Singh H, Mehta RH, O'Neill W, Kapur NK, Lalonde T, Ohman M, Ghiu I, Chen-Hsing Y, Dutcheshen K, Schreiber T, Rosman H, Kaki A. Clinical features and outcomes in patients with cardiogenic shock complicating acute myocardial infarction: early vs recent experience with impella. Am Heart J 2021; 238:66-74. [PMID: 33848505 DOI: 10.1016/j.ahj.2021.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To compare clinical features and outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) treated in the early experience with Impella percutaneous ventricular assist device and patients treated recently. BACKGROUND Since pre-market approval (PMA) of Impella device as treatment for AMICS, use of the device has grown considerably. METHODS We retrospectively analyzed 649 AMICS patients treated with perioperative Impella, with 291 patients treated from 2008 to 2014 comprising the early experience cohort and 358 patients treated from 2017 to 2019 comprising the recent experience cohort. The primary end point was risk adjusted in-hospital mortality. RESULTS Mean age and gender distribution of patients was similar in the two cohorts. The recent cohort had more invasive hemodynamic monitoring (64% vs 46%; P < .001) and less use of an intra-aortic balloon pump prior to Impella (15% vs 41%; P < .001). Recently treated patients were significantly more likely to receive Impella support prior to PCI (58% vs 44%; P = .005). In-hospital mortality was lower in the recent cohort (48% vs 56%; P = .043). This difference was however no longer significant after risk adjustment (adjusted OR 0.89, 95% CI 0.59-1.34, P = .59). Rates of acute kidney injury, major bleeding, and vascular complications requiring surgery were also significantly lower in the recent cohort. CONCLUSIONS Use of Impella for AMICS during recent years is associated with lower unadjusted in-hospital mortality, which may reflect better patient selection, earlier device implantation, and improved management algorithms. In-depth understanding of these factors may inform the development of future treatment protocols.
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25
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Ng AKY, Ng PY, Ip A, Jim MH, Siu CW. Association Between Radial Versus Femoral Access for Percutaneous Coronary Intervention and Long-Term Mortality. J Am Heart Assoc 2021; 10:e021256. [PMID: 34325533 PMCID: PMC8475672 DOI: 10.1161/jaha.121.021256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Percutaneous coronary intervention with radial arterial access has been associated with fewer occurrences of major bleeding. However, published data on the long‐term mortality and major adverse cardiac events after percutaneous coronary intervention with radial or femoral arterial access are inconclusive. Method and Results This was a territory‐wide retrospective cohort study including 26 022 patients who underwent first‐ever percutaneous coronary intervention between January 1, 2010 and December 31, 2017 in Hong Kong. Among the 14 614 patients matched by propensity score (7307 patients in each group), 558 (7.6%) and 787 (10.8%) patients died during the observation period in the radial group and femoral group, respectively, resulting in annualized all‐cause mortality rates of 2.69% and 3.87%, respectively. The radial group had a lower risk of all‐cause mortality compared with the femoral group up to 3 years after percutaneous coronary intervention (hazard ratio [HR], 0.70; 95% CI, 0.63–0.78; P<0.001). Radial access was associated with a lower risk of major adverse cardiac events (HR, 0.78; 95% CI, 0.73–0.83, P<0.001), myocardial infarction after hospital discharge (HR, 0.78; 95% CI, 0.70–0.87, P<0.001), and unplanned revascularization (HR, 0.76; 95% CI, 0.68–0.85, P<0.001). The risks of stroke were similar across the 2 groups (HR, 0.96; 95% CI, 0.82–1.13, P=0.655). Conclusions Radial access was associated with a significant reduction in all‐cause mortality at 3 years compared with femoral access. Radial access was associated with reduced risks of myocardial infarction and unplanned revascularization, but not stroke. The benefits were sustained beyond the early postoperative period.
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Affiliation(s)
| | - Pauline Yeung Ng
- Department of Adult Intensive Care Queen Mary Hospital Hong Kong SAR, China.,Division of Respiratory and Critical Care Medicine Department of Medicine Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong SAR, China
| | - April Ip
- Division of Respiratory and Critical Care Medicine Department of Medicine Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong SAR, China
| | - Man-Hong Jim
- Cardiac Medical Unit Grantham Hospital Hong Kong SAR, China
| | - Chung-Wah Siu
- Department of Medicine Queen Mary HospitalThe University of Hong Kong Hong Kong SAR, China
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26
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Bloom JE, Andrew E, Nehme Z, Dinh DT, Fernando H, Shi WY, Vriesendorp P, Nanayakarra S, Dawson LP, Brennan A, Noaman S, Layland J, William J, Al-Fiadh A, Brooks M, Freeman M, Hutchinson A, McGaw D, Van Gaal W, Willson W, White A, Prakash R, Reid C, Lefkovits J, Duffy SJ, Chan W, Kaye DM, Stephenson M, Bernard S, Smith K, Stub D. Pre-hospital heparin use for ST-elevation myocardial infarction is safe and improves angiographic outcomes. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:1140-1147. [PMID: 34189566 DOI: 10.1093/ehjacc/zuab032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/12/2021] [Accepted: 04/30/2021] [Indexed: 11/12/2022]
Abstract
AIMS This study aims to evaluate if pre-hospital heparin administration by paramedics is safe and improves clinical outcomes. METHODS AND RESULTS Using the multicentre Victorian Cardiac Outcomes Registry, linked with state-wide ambulance records, we identified consecutive patients undergoing primary percutaneous coronary intervention for STEMI between January 2014 and December 2018. Information on thrombolysis in myocardial infarction (TIMI) flow at angiography was available in a subset of cases. Patients receiving pre-hospital heparin were compared to those who did not receive heparin. Findings at coronary angiography and 30-day clinical outcomes were compared between groups. Propensity-score matching was performed for risk adjustment. We identified a total of 4720 patients. Of these, 1967 patients had TIMI flow data available. Propensity-score matching in the entire cohort yielded 1373 matched pairs. In the matched cohort, there was no observed difference in 30-day mortality (no-heparin 3.5% vs. heparin 3.0%, P = 0.25), MACCE (no-heparin 7% vs. heparin 6.2%, P = 0.44), and major bleeding (no-heparin 1.9% vs. heparin 1.4%, P = 0.64) between groups. Propensity-score analysis amongst those with TIMI data produced 552 matched pairs. The proportion of cases with TIMI 0 or 1 flow in the infarct-related artery (IRA) was lower among those receiving pre-hospital heparin (66% vs. 76%, P < 0.001) compared to those who did not. CONCLUSION In this multicentre, propensity-score matched study, the use of pre-hospital heparin by paramedics was safe and is associated with fewer occluded IRAs in patients presenting with STEMI.
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Affiliation(s)
- Jason E Bloom
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Emily Andrew
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Ziad Nehme
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Diem T Dinh
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Himawan Fernando
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - William Y Shi
- Melbourne Medical School, Ground Floor, Medical Building, Grattan Street, University of Melbourne, VIC 3010, Australia.,Division of Cardiac Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Pieter Vriesendorp
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Shane Nanayakarra
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Luke P Dawson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Angela Brennan
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Melbourne Medical School, Ground Floor, Medical Building, Grattan Street, University of Melbourne, VIC 3010, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, VIC 3021, Australia
| | - Jamie Layland
- Department of Cardiology, Peninsula Health, 2 Hastings Road, Frankston, VIC 3199, Australia
| | - Jeremy William
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Ali Al-Fiadh
- Department of Cardiology, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia
| | - Matthew Brooks
- Department of Cardiology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, 5 Arnold Street, Box Hill, VIC 3128, Australia
| | - Adam Hutchinson
- Department of Cardiology, Geelong University Hospital, Bellerine Street, Geelong, VIC 3220, Australia
| | - David McGaw
- Department of Cardiology, Monash Health, 246 Clayton Road, Clayton, VIC 3168, Australia
| | - William Van Gaal
- Department of Cardiology, Northern Health, 185 Cooper Street, Epping, VIC 3076, Australia
| | - William Willson
- Department of Cardiology, Eastern Health, 5 Arnold Street, Box Hill, VIC 3128, Australia
| | - Anthony White
- Curtain University, Kent Street, Bentley, WA 6102, Australia
| | - Roshan Prakash
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Christopher Reid
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Curtain University, Kent Street, Bentley, WA 6102, Australia
| | - Jeffrey Lefkovits
- Melbourne Medical School, Ground Floor, Medical Building, Grattan Street, University of Melbourne, VIC 3010, Australia.,Department of Cardiology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.,Melbourne Medical School, Ground Floor, Medical Building, Grattan Street, University of Melbourne, VIC 3010, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, VIC 3021, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Michael Stephenson
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Stephen Bernard
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, VIC 3021, Australia
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27
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Comparison of Performance between ARC-HBR Criteria and PRECISE-DAPT Score in Patients Undergoing Percutaneous Coronary Intervention. J Clin Med 2021; 10:jcm10122566. [PMID: 34200528 PMCID: PMC8229493 DOI: 10.3390/jcm10122566] [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: 04/18/2021] [Revised: 05/13/2021] [Accepted: 05/15/2021] [Indexed: 12/02/2022] Open
Abstract
The proper management of bleeding risk in patients undergoing percutaneous coronary intervention (PCI) is critical. Recently, the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria have been proposed as a standardized tool for predicting bleeding risk. We sought to compare the predictive performance of ARC-HBR criteria and the PRECISE-DAPT score for bleeding in Korean patients undergoing PCI. We recruited 1418 consecutive patients undergoing PCI from January 2012 through December 2018 (Dong-A University Medical Center, Busan, Korea). The ARC-HBR and PRECISE-DAPT scores showed a high AUC for three bleeding definitions (AUC 0.75 and 0.77 for BARC 3 to 5; AUC 0.68 and 0.71 for TIMI minor to major; AUC 0.81 and 0.82 for GUSTO moderate to severe, respectively) and all-cause death (AUC 0.82 and 0.82, respectively). When compared with the ARC-HBR score, the discriminant ability of the PRECISE-DAPT score was not significantly different for bleeding events and all-cause death. The ARC-HBR criteria and PRECISE-DAPT scores demonstrated reasonably good discriminatory capacity with respect to 1-year bleeding events in Korean patients treated with DAPT, regardless of the bleeding definition. Our findings also suggest that the simple PRECISE-DAPT score is as useful as ARC-HBR criteria in predicting bleeding and all-cause death after PCI.
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28
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Clarkson SA, Heindl B, Cai A, Beasley M, Dillon C, Limdi N, Brown TM. Outcomes of Individuals With and Without Heart Failure Presenting With Acute Coronary Syndrome. Am J Cardiol 2021; 148:1-7. [PMID: 33667441 DOI: 10.1016/j.amjcard.2021.02.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/17/2021] [Accepted: 02/23/2021] [Indexed: 01/24/2023]
Abstract
Major adverse cardiac event (MACE) and bleeding risks following percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) are not well defined in individuals with heart failure (HF). We followed 1,145 individuals in the Pharmacogenomic Resource to improve Medication Effectiveness Genotype Guided Antiplatelet Therapy cohort for MACE and bleeding events following PCI for ACS. We constructed Cox proportional hazards models to compare MACE and bleeding in those with versus without HF, adjusting for sociodemographics, comorbidities, and medications. We also determined predictors of MACE and bleeding events in both groups. 370 (32%) individuals did and 775 (68%) did not have HF prior to PCI. Mean age was 61.7 ± 12.2 years, 31% were female, and 24% were African American. After a median follow-up of 0.78 years, individuals with HF had higher rates of MACE compared to those without HF (48 vs. 24 events per 100 person years) which remained significant after multivariable adjustment (hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.00 to 1.72). Similarly, bleeding was higher in those with versus without HF (22 vs. 11 events per 100 person years), although this was no longer statistically significant after multivariable adjustment (HR 1.29, 95% CI 0.86 to 1.93). Diabetes and peripheral vascular disease were predictors of MACE, and end-stage renal disease was a predictor of bleeding among participants with HF. MACE risk is higher in individuals with versus without HF following PCI for ACS. However, the risk of bleeding, especially among those with end-stage renal disease , must be considered when determining post-PCI anticoagulant strategies.
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Das D, Savu A, Bainey KR, Welsh RC, Kaul P. Temporal Trends in in-Hospital Bleeding and Transfusion in a Contemporary Canadian ST-Elevation Myocardial Infarction Patient Population. CJC Open 2021; 3:479-487. [PMID: 34027351 PMCID: PMC8129449 DOI: 10.1016/j.cjco.2020.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/05/2020] [Indexed: 02/06/2023] Open
Abstract
Background Although ST-elevation myocardial infarction (STEMI) management has evolved substantially over the past decade, its effect on bleeding and transfusion rates are largely unknown in a contemporary population. Methods Our study cohort included patients 20 years of age or older who were hospitalized for STEMI between 2007 and 2016 across all Canadian provinces, except Quebec. Unadjusted rates of bleeding and of transfusion during STEMI episodes were calculated overall and for each province according to fiscal year. Patients were stratified into 4 groups according to their bleeding/transfusion. Characteristics, treatment, and outcomes were compared between groups. Multivariate logistic regression modelling was used to assess the association between bleeding and transfusion on in-hospital mortality. Results Using 108,832 STEMI episodes, rates of in-hospital bleeding and transfusion declined between 2007 and 2016 from 3.9% to 2.8% (P < 0.0001) and 4.7% to 3.8% (P < 0.0001), respectively. However, variation in bleeding and transfusion rates were observed across Canadian provinces. Patients with bleeding or transfusion, were older, female, and had more comorbidities. Compared with patients who did not bleed or receive a transfusion, individuals who bled, were transfused, or bled and were transfused, had higher in-hospital mortality (18.6%, 30.3%, and 30.4%, respectively [P < 0.0001]). The association remained after adjustment: bleeding (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.8-2.4), transfusion (OR, 4.4; 95% CI, 3.9-4.9), and bleeding and transfusion (OR, 3.8; 95% CI, 3.2-4.6). Conclusions The proportion of Canadian STEMI patients who experienced in-hospital bleeding and transfusion has decreased over the past 9 years. However, patients with bleed or transfusion remain at higher risk of adverse outcomes.
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Affiliation(s)
- Debraj Das
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Anamaria Savu
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin R Bainey
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Robert C Welsh
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
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Bajraktari G, Rexhaj Z, Elezi S, Zhubi-Bakija F, Bajraktari A, Bytyçi I, Batalli A, Henein MY. Radial Access for Coronary Angiography Carries Fewer Complications Compared with Femoral Access: A Meta-Analysis of Randomized Controlled Trials. J Clin Med 2021; 10:jcm10102163. [PMID: 34067672 PMCID: PMC8156941 DOI: 10.3390/jcm10102163] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND AIM In patients undergoing diagnostic coronary angiography (CA) and percutaneous coronary interventions (PCI), the benefits associated with radial access compared with the femoral access approach remain controversial. The aim of this meta-analysis was to compare the short-term evidence-based clinical outcome of the two approaches. METHODS The PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched for randomized controlled trials (RCTs) comparing radial versus femoral access for CA and PCI. We identified 34 RCTs with 29,352 patients who underwent CA and/or PCI and compared 14,819 patients randomized for radial access with 14,533 who underwent procedures using femoral access. The follow-up period for clinical outcome was 30 days in all studies. Data were pooled by meta-analysis using a fixed-effect or a random-effect model, as appropriate. Risk ratios (RRs) were used for efficacy and safety outcomes. RESULTS Compared with femoral access, the radial access was associated with significantly lower risk for all-cause mortality (RR: 0.74; 95% confidence interval (CI): 0.61 to 0.88; p = 0.001), major bleeding (RR: 0.53; 95% CI:0.43 to 0.65; p ˂ 0.00001), major adverse cardiovascular events (MACE)(RR: 0.82; 95% CI: 0.74 to 0.91; p = 0.0002), and major vascular complications (RR: 0.37; 95% CI: 0.29 to 0.48; p ˂ 0.00001). These results were consistent irrespective of the clinical presentation of ACS or STEMI. CONCLUSIONS Radial access in patients undergoing CA with or without PCI is associated with lower mortality, MACE, major bleeding and vascular complications, irrespective of clinical presentation, ACS or STEMI, compared with femoral access.
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Affiliation(s)
- Gani Bajraktari
- Department of Public Health and Clinical Medicine, Umeå University, 90187 Umeå, Sweden; (A.B.); (I.B.); (M.Y.H.)
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (Z.R.); (S.E.); (F.Z.-B.); (A.B.)
- Medical Faculty, University of Prishtina “Hasan Prishtina”, 10000 Prishtina, Kosovo
- UBT College, 10000 Prishtina, Kosovo
- Correspondence:
| | - Zarife Rexhaj
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (Z.R.); (S.E.); (F.Z.-B.); (A.B.)
| | - Shpend Elezi
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (Z.R.); (S.E.); (F.Z.-B.); (A.B.)
- Medical Faculty, University of Prishtina “Hasan Prishtina”, 10000 Prishtina, Kosovo
| | - Fjolla Zhubi-Bakija
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (Z.R.); (S.E.); (F.Z.-B.); (A.B.)
| | - Artan Bajraktari
- Department of Public Health and Clinical Medicine, Umeå University, 90187 Umeå, Sweden; (A.B.); (I.B.); (M.Y.H.)
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (Z.R.); (S.E.); (F.Z.-B.); (A.B.)
| | - Ibadete Bytyçi
- Department of Public Health and Clinical Medicine, Umeå University, 90187 Umeå, Sweden; (A.B.); (I.B.); (M.Y.H.)
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (Z.R.); (S.E.); (F.Z.-B.); (A.B.)
| | - Arlind Batalli
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (Z.R.); (S.E.); (F.Z.-B.); (A.B.)
- Medical Faculty, University of Prishtina “Hasan Prishtina”, 10000 Prishtina, Kosovo
| | - Michael Y. Henein
- Department of Public Health and Clinical Medicine, Umeå University, 90187 Umeå, Sweden; (A.B.); (I.B.); (M.Y.H.)
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Sattar Y, Majmundar M, Ullah W, Mamtani S, Kumar A, Robinson S, Zghouzi M, Mir T, Dhamrah U, Al-Khadra Y, Pacha HM, Darmoch F, Soud M, Hakim Z, Bagur R, Kaul P, Ijioma N, Panchal A, Shroff AR, Alraies MC. Outcomes of Transradial Versus Transfemoral Access of Percutaneous Coronary Intervention in STEMI: Systematic Review and Updated Meta-analysis. Expert Rev Cardiovasc Ther 2021; 19:433-444. [PMID: 33896335 DOI: 10.1080/14779072.2021.1915768] [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] [Indexed: 01/11/2023]
Abstract
BACKGROUND Transradial (TR) percutaneous coronary intervention (PCI) is a preferable PCI route. The complication difference between TR and TF approaches is controversial. METHODS PubMed, Embase, and the Cochrane databases were queried for PCI outcomes of TR TF in STEMI for major cardiac and cerebrovascular events (MACCE), major bleeding, and mortality. The odds ratio (OR) was calculated using the random-effect model. RESULTS We included 56 studies comprising of 68,733 patients (TR, n = 26,179; TF, n = 42,537). TR-PCI was associated with statistically significant lower odds of MACCE (OR = 0.66, 95% CI: 0.49-0.88, p-value = 0.005), major bleeding (OR = 0.47, 95% CI 0.32-0.68, p-value<0.001), mortality (OR = 0.59, 95% CI 0.43-0.80, p-value<0.001) at in hospital follow-up. TR-PCI was associated with statistically significant lower MACCE (OR = 0.59, 95% CI 0.43-0.80, p-value<0.001), major bleeding (OR = 0.58, 95% CI 0.49-0.68, p-value<0.001), and mortality (OR = 0.61, 95% CI 0.44-0.86, p-value = 0.005) at 30-day follow-up. The same difference was seen at 1-year. CONCLUSION TR-PCI was associated with lower odds of MACCE, major bleeding, and mortality during short- and long-term follow-up.
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Affiliation(s)
- Yasar Sattar
- Internal Medicine , Icahn School of Medicine at Mount Sinai Elmhurst Hospital, NY, New York, USA
| | - Monil Majmundar
- New York Medical College, Metropolitan Hospital Center, New York, NY, USA
| | - Waqas Ullah
- Internal Medicine, Abington Jefferson Health, Abington, PA, USA
| | - Sahil Mamtani
- Internal Medicine, Atlantic Care Regional Medical Center, Atlantic City, NJ, USA
| | - Ashish Kumar
- Internal Medicine, St John's Medical College Hospital, Bangalore, India
| | - Sam Robinson
- Internal Medicine , Icahn School of Medicine at Mount Sinai Elmhurst Hospital, NY, New York, USA
| | - Mohamed Zghouzi
- Department of Cardiology, Detroit Medical Center, Detroit, MI, USA
| | - Tanveer Mir
- Department of Cardiology, Detroit Medical Center, Detroit, MI, USA
| | - Umaima Dhamrah
- Internal Medicine , Icahn School of Medicine at Mount Sinai Elmhurst Hospital, NY, New York, USA
| | - Yasser Al-Khadra
- Department of Cardiology, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Homam Moussa Pacha
- McGovern Medical School, University of Texas Health Science Center, Memorial Hermann Heart & Vascular Institute, Houston, TX, USA
| | - Fahed Darmoch
- Internal Medicine, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Mohamad Soud
- Department of Cardiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Zaher Hakim
- Department of Cardiology, Detroit Medical Center, Detroit, MI, USA
| | - Rodrigo Bagur
- London Health Science Centre, Western University, London, Canada
| | - Prashant Kaul
- Department of Cardiology, Piedmont Heart Institute, Atlanta, GA, USA
| | | | - Ankur Panchal
- Department of Cardiology, University of Pittsburgh Medical Center, PA, USA
| | - Adhir R Shroff
- Department of Cardiology, University of Illinois at Chicago/Jesse Brown VA Medical Center, Chicago, IL, USA
| | - M Chadi Alraies
- Department of Cardiology, Detroit Medical Center, Detroit, MI, USA
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32
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Galusko V, Protty M, Haboubi HN, Verhemel S, Bundhoo S, Yeoman AD. Endoscopy findings in patients on dual antiplatelet therapy following percutaneous coronary intervention. Postgrad Med J 2021; 98:591-597. [PMID: 33879553 DOI: 10.1136/postgradmedj-2021-139928] [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: 02/09/2021] [Revised: 04/01/2021] [Accepted: 04/06/2021] [Indexed: 11/04/2022]
Abstract
PURPOSE OF STUDY This study examines the associations between dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) and gastrointestinal bleeding (GIB), to explore possible predictors of outcomes. STUDY DESIGN Retrospective analysis of 3342 patients who underwent PCI between 1 August 2011 and 31 December 2018 in a single centre was carried out. Oesophagogastroduodenoscopies (OGDs) for patients 12 months post-PCI were analysed. RESULTS Blood loss occurred in 2% of all (3342) patients post-PCI within 12 months. 128 patients (63% male, mean age (SD) of 69.8 (10) years) who had PCI subsequently underwent an OGD within 12 months of the index PCI procedure. GIB occurred within the first 30 days of DAPT in 36% (n=13/36) of cases. There were no thrombotic events associated with cessation of one antiplatelet agent. Increased age, haemoglobin (Hb) ≤109 g/L and Glasgow-Blatchford score ≥8 were associated with increased 12-month mortality. An Hb drop of ≥30 g/L was a sensitive and specific marker for significant pathology and evidence of bleeding on OGD (sensitivity=0.83, specificity=0.81). CONCLUSIONS GIB bleeding occurred infrequently in the patients post-PCI on DAPT. Risk assessment scores (such as Glasgow-Blatchford and Rockall scores) are useful tools to assess the urgency of OGD and need for endoscopic therapy.
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Affiliation(s)
- Victor Galusko
- Department of Cardiology, Royal Gwent Hospital, Newport, UK
| | - Majd Protty
- Department of Cardiology, Royal Gwent Hospital, Newport, UK.,Systems Immunity University Research Institute, Cardiff University, Cardiff, UK
| | - Hasan N Haboubi
- Department of Gastroenterology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Sarah Verhemel
- Department of Cardiology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Shantu Bundhoo
- Department of Cardiology, Royal Gwent Hospital, Newport, UK
| | - Andrew D Yeoman
- Department of Gastroenterology, Royal Gwent Hospital, Newport, UK
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Holm A, Henriksson M, Alfredsson J, Janzon M, Johansson T, Swahn E, Vial D, Sederholm Lawesson S. Long term risk and costs of bleeding in men and women treated with triple antithrombotic therapy-An observational study. PLoS One 2021; 16:e0248359. [PMID: 33764988 PMCID: PMC7993563 DOI: 10.1371/journal.pone.0248359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 02/24/2021] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Bleeding is the most common non-ischemic complication in patients with coronary revascularisation procedures, associated with prolonged hospitalisation and increased mortality. Many factors predispose for bleeds in these patients, among those sex. Anyhow, few studies have characterised the population receiving triple antithrombotic therapy (TAT) as well as long term bleeds from a sex perspective. We investigated the one year rate of bleeds in patients receiving TAT, potential sex disparities and premature discontinuation of TAT. We also assessed health care costs in bleeders vs non-bleeders. SETTING Three hospitals in the County of Östergötland, Sweden during 2009-2015. PARTICIPANTS All patients discharged with TAT registered in the SWEDEHEART registry. PRIMARY AND SECONDARY OUTCOME MEASURES All bleeds receiving medical attention during one-year follow-up were collected by retrieving relevant information about each patient from medical records. Resource use associated with bleeds was assigned unit cost to estimate the health care costs associated with bleeding episodes. RESULTS Among 272 patients, 156 bleeds occurred post-discharge, of which 28.8% were gastrointestinal. In total 54.4% had at least one bleed during or after the index event and 40.1% bled post discharge of whom 28.7% experienced a TIMI major or minor bleeding. Women discontinued TAT prematurely more often than men (52.9 vs 36.1%, p = 0.01) and bled more (48.6 vs. 37.1%, p = 0.09). One-year mean health care costs were EUR 575 and EUR 5787 in non-bleeding and bleeding patients, respectively. CONCLUSION The high bleeding incidence in patients with TAT, especially in women, is a cause of concern. There is a need for an adequately sized randomised, controlled trial to determine a safe but still effective treatment for these patients.
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Affiliation(s)
- Anna Holm
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping University Hospital, Linköping, Sweden
| | - Martin Henriksson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Joakim Alfredsson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping University Hospital, Linköping, Sweden
| | - Magnus Janzon
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping University Hospital, Linköping, Sweden
| | - Therese Johansson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Eva Swahn
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping University Hospital, Linköping, Sweden
| | - Dominique Vial
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Sofia Sederholm Lawesson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping University Hospital, Linköping, Sweden
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Liu Y, Wang LF, Liu LH, Yang XC, Ren ZH, Li KB, Chen ML, Wang HS, Zhong JC, Xu L, Ni ZH, Li WM, Xia K, Zhang DP, Sun H, Guo ZS, Chi YH, He JF, Zhang ZY, Jiang F. Impact of Prior Digestive System Disease on In-Hospital Gastrointestinal Bleeding in Patients with Acute Myocardial Infarction. Risk Manag Healthc Policy 2021; 14:1233-1239. [PMID: 33790668 PMCID: PMC7997586 DOI: 10.2147/rmhp.s299169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/24/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE Patients presenting with acute myocardial infarction (AMI) with prior digestive system disease are more likely to suffer from gastrointestinal (GI) bleeding than those without these diseases. However, few articles reported how the different conditions of the digestive tract produced different risks of GI bleeding. METHODS A single-center study on 7464 patients admitted for AMI from December 2010 to June 2019 in the Beijing Chaoyang Heart Center was retrospectively examined. Patients with major GI bleeding (n = 165) were compared with patients without (n = 7299). Univariate and multivariate logistic regression models were constructed to test the association between GI bleeding and prior diseases of the digestive tract, including gastroesophageal reflux disease, chronic gastritis, peptic ulcer, hepatic function damage, diseases of the colon and rectum, and gastroenterological tract tumors. RESULTS Of the 7464 patients (mean age, 63.4; women, 25.6%; STEMI, 58.6%), 165 (2.2%) experienced major GI bleeding, and 1816 (24.3%) had a history of digestive system disease. The risk of GI bleeding was significantly associated with peptic ulcer (OR = 4.19, 95% CI: 1.86-9.45) and gastroenterological tumor (OR = 2.74, 95% CI: 1.07-7.04), indicated by multivariate logistic regression analysis. CONCLUSION Preexisting peptic ulcers and gastroenterological tract tumors rather than other digestive system diseases were indicators of gastrointestinal bleeding in patients with AMI who undergo standard antithrombotic treatment during hospitalization.
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Affiliation(s)
- Yu Liu
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Le-Feng Wang
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Li-Hong Liu
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xin-Chun Yang
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zheng-Hong Ren
- School of Public Health, Peking University Health Science Center, Beijing, People’s Republic of China
| | - Kui-Bao Li
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Mu-Lei Chen
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Hong-Shi Wang
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jiu-Chang Zhong
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Li Xu
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zhu-Hua Ni
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wei-Ming Li
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Kun Xia
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Da-Peng Zhang
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Hao Sun
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zong-Sheng Guo
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yong-Hui Chi
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Ji-Fang He
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zhi-Yong Zhang
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Feng Jiang
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
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Fondaparinux versus enoxaparin in the contemporary management of non-ST-elevation acute coronary syndromes. Insights from a multicenter registry. Int J Cardiol 2021; 332:29-34. [PMID: 33667576 DOI: 10.1016/j.ijcard.2021.02.081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/29/2021] [Accepted: 02/26/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Fondaparinux is thought to have the most favorable risk-benefit profile among all anticoagulants in non-ST-elevation acute coronary syndrome (NSTE-ACS). However, conflicting findings exist whether this holds true in current clinical practice. We aimed to assess the net clinical benefit of fondaparinux versus enoxaparin in the contemporary management of NSTE-ACS. METHODS Analysis of prospective multicenter registry data of NSTE-ACS patients who received fondaparinux or enoxaparin from February 2015, through December 2017. Survival models within a competing risks framework including site-specific random effects, were used to assess the composite of clinically relevant bleedings and major adverse cardiovascular events at 30 days. RESULTS Of 2094 patients, 1724 (82%) received enoxaparin and 370 (18%) fondaparinux. Both groups were comparable except for a lower prevalence of diabetes and renal impairment, and greater use of transradial approach in the fondaparinux group. Multivariate analysis revealed a net clinical benefit in favour of fondaparinux versus enoxaparin (Subhazard Ratio [SHR] 0.59; 95%CI 0.37-0.92), mainly driven by a reduction in bleeding (SHR 0.57; 95%CI 0.37-0.89). Exploratory analysis suggested greater reductions in bleeding with fondaparinux among patients undergoing transradial approach, revealing a significant interaction between treatment and vascular access on the multiplicative scale (Pinteraction = 0.0056), but not on an additive scale (P = 0.457). Propensity-score-matching analysis yielded similar results. CONCLUSIONS In contemporary management of NSTE-ACS, fondaparinux seems to provide a favorable net clinical benefit compared with enoxaparin, primarily driven by a bleeding reduction. Effect modification on the safety profile of fondaparinux by the vascular access approach warrants further investigation.
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36
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Nguyen KA, Eadon MT, Yoo R, Milway E, Kenneally A, Fekete K, Oh H, Duong K, Whipple EC, Schleyer TK. Risk Factors for Bleeding and Clinical Ineffectiveness Associated With Clopidogrel Therapy: A Comprehensive Meta-Analysis. Clin Transl Sci 2021; 14:645-655. [PMID: 33202084 PMCID: PMC7993261 DOI: 10.1111/cts.12926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/05/2020] [Indexed: 01/13/2023] Open
Abstract
Although clopidogrel is a frequently used antiplatelet medication to treat and prevent atherothrombotic disease, clinicians must balance its clinical effectiveness with the potential side effect of bleeding. However, many previous studies have evaluated beneficial and adverse factors separately. The objective of our study was to perform a comprehensive meta-analysis of studies of clopidogrel's clinical effectiveness and/or risk of bleeding in order to identify and assess all reported risk factors, thus helping clinicians to balance patient safety with drug efficacy. We analyzed randomized controlled trials (RCTs) of maintenance use in four stages: search for relevant primary articles; abstract and full article screening; quality assessment and data extraction; and synthesis and data analysis. Screening of 7,109 articles yielded 52 RCTs that met the inclusion criteria. Twenty-seven risk factors were identified. "Definite risk factors" were defined as those with aggregated odds ratios (ORs) > 1 and confidence intervals (CIs) > 1 if analyzed in more than one study. Definite risk factors for major bleeding were concomitant aspirin use (OR 2.83, 95% CI 2.04-3.94) and long duration of clopidogrel therapy (> 6 months) (OR 1.74, 95% CI 1.21-2.50). Dual antiplatelet therapy, extended clopidogrel therapy, and high maintenance dose (150 mg/day) of clopidogrel were definite risk factors for any bleeding. Reduced renal function, both mild and severe, was the only definite risk factor for clinical ineffectiveness. These findings can help clinicians predict the risks and effectiveness of clopidogrel use for their patients and be used in clinical decision support tools.
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Affiliation(s)
- Khoa A. Nguyen
- College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- Regenstrief InstituteIndianapolisIndianaUSA
| | | | - Ryan Yoo
- College of PharmacyPurdue UniversityWest LafayetteIndianaUSA
| | - Evan Milway
- College of PharmacyPurdue UniversityWest LafayetteIndianaUSA
| | | | - Kevin Fekete
- College of PharmacyPurdue UniversityWest LafayetteIndianaUSA
| | - Hyun Oh
- College of PharmacyPurdue UniversityWest LafayetteIndianaUSA
| | - Khanh Duong
- College of PharmacyPurdue UniversityWest LafayetteIndianaUSA
| | | | - Titus K. Schleyer
- Regenstrief InstituteIndianapolisIndianaUSA
- School of MedicineIndiana UniversityIndianapolisIndianaUSA
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37
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Fanaroff AC, Lopes RD. Anticoagulation dosing in atherosclerotic cardiovascular disease: Is less more? Eur J Intern Med 2021; 83:8-9. [PMID: 33341321 DOI: 10.1016/j.ejim.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 12/05/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute, and Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, PA
| | - Renato D Lopes
- Duke Clinical Research Institute, and Division of Cardiology, Duke University School of Medicine, Durham, NC.
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Zdanyte M, Wrazidlo RW, Kaltenbach S, Groga-Bada P, Gawaz M, Geisler T, Rath D. Predicting 1-, 3- and 5-year outcomes in patients with coronary artery disease: A comparison of available risk assessment scores. Atherosclerosis 2020; 318:1-7. [PMID: 33341519 DOI: 10.1016/j.atherosclerosis.2020.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/14/2020] [Accepted: 12/10/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND AIMS Thromboischemic and bleeding events are rare but life-threatening complications after percutaneous coronary intervention (PCI). Various risk assessment models have been established to predict short- and long-term adverse events in patients with chronic and acute coronary syndromes (CCS, ACS). The aim of the present study was to compare available risk assessment systems based on their performance in identifying high-risk patients with symptomatic coronary artery disease (CAD). METHODS We enrolled 1565 consecutive patients with symptomatic CAD (n = 821 CCS, n = 744 ACS). CALIBER, DAPT, GRACE 2.0, PARIS-CTE, PARIS-MB, PRECISE-DAPT and PREDICT-STABLE scores were calculated in appropriate patient subgroups. All patients were followed-up for 1, 3 and 5 years for all-cause death (ACD), myocardial infarction (MI), ischemic stroke (IS) and bleeding. The primary combined ischemic endpoint (CE) consisted of ACD, MI and/or IS. Secondary endpoints were defined as single occurrence of either ACD, MI, IS, or bleeding. RESULTS GRACE 2.0 score showed good discrimination performance (AUC>0.7) for CE in a 3- and 5-year follow-up. CALIBER, GRACE 2.0 and PARIS-CTE showed best performance (AUC>0.7) in predicting ACD throughout the follow-up, whereas IS was best predicted by PARIS-CTE and CALIBER scores. None of the scores performed well (AUC>0.7) in predicting MI or bleeding. CONCLUSIONS In a consecutive German CAD cohort, CALIBER, GRACE 2.0 and PARIS-CTE scores performed best in predicting CE, ACD and/or IS whereas none of the selected scores could predict MI and bleeding efficiently.
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Affiliation(s)
- Monika Zdanyte
- Department of Cardiology and Angiology, University Hospital Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Robin W Wrazidlo
- Department of Cardiology and Angiology, University Hospital Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Sarah Kaltenbach
- Eberhard-Karls-Universität Tübingen, Geschwister-Scholl-Platz, 72074, Tübingen, Germany
| | - Patrick Groga-Bada
- Department of Cardiology and Angiology, University Hospital Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology and Angiology, University Hospital Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Dominik Rath
- Department of Cardiology and Angiology, University Hospital Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany.
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Çetin M, Duman H, Özer S, Kırış T, Çinier G, Usta E, Satılmış S, Erdoğan T. Mitral annular calcification predicted major cardiovascular events in patients presented with acute coronary syndrome and underwent percutaneous coronary intervention. Acta Cardiol 2020; 75:767-773. [PMID: 31846583 DOI: 10.1080/00015385.2019.1700337] [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: 10/25/2022]
Abstract
Background: Despite the presence of several clinical studies evaluating the association of atherosclerosis and MAC, no data is present regarding the value of MAC in predicting CV adverse events in patients with acute coronary syndrome (ACS).Methods: Prospective, observational cohort study including 314 patients presented with ACS and underwent percutaneous coronary intervention (PCI). MAC was defined by increased echodensity located at the junction of the atrioventricular groove and posterior mitral leaflet on the parasternal long-axis, short-axis, or apical four-chamber view. Patients were followed for a median 25.1 (23.1-26.5) months for any occurrence of major adverse cardiovascular events (MACE).Results: Among 316 patients 46 (14%) had MAC. Seventy (22.1%) patients had MACE during the follow-up. Patients with MACE had higher creatinine, white blood cell count (WBC), C-reactive protein (CRP), peak troponin I, glucose level at admission compared to those without MACE. Age (HR = 1.026, 95% CI = 1.004-1.049; p = .023), myocardial blush grade (HR = 0.637, 95% CI = 0.480-0.846; p = .008), MAC (HR = 2.429, 95% CI = 1.126-5.239; p = .026), and WBC at admission (HR = 1.079, 95% CI = 1.007-1.157; p = .031) were independent predictors for MACE.Conclusion: In patients presented with ACS and underwent PCI, MAC detected by TTE was an independent predictor for MACE during the long-term follow-up.
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Affiliation(s)
- Mustafa Çetin
- Medical Faculty, Department of Cardiology, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Hakan Duman
- Medical Faculty, Department of Cardiology, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Savaş Özer
- Department of Cardiology, Rize Education and Research Hospital, Rize, Turkey
| | - Tuncay Kırış
- Department of Cardiology, Katip Çelebi University, Atatürk Education and Research Hospital, İzmir, Turkey
| | - Göksel Çinier
- Department of Cardiology, Kaçkar State Hospital, Rize, Turkey
| | - Ece Usta
- Medical Faculty, Department of Cardiology, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Seçkin Satılmış
- Department of Cardiology, Acıbadem Atakent University Hospital, Istanbul, Turkey
| | - Turan Erdoğan
- Medical Faculty, Department of Cardiology, Recep Tayyip Erdoğan University, Rize, Turkey
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Ocsan RJ, Doost A, Marley P, Farshid A. The Rise of Transradial Artery Access for Percutaneous Coronary Intervention in Patients with Acute Coronary Syndromes in Australia. J Interv Cardiol 2020; 2020:4397697. [PMID: 33312077 PMCID: PMC7719530 DOI: 10.1155/2020/4397697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/06/2020] [Accepted: 11/11/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the outcomes of acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) via transradial artery access (TRA) or transfemoral artery access (TFA). BACKGROUND Over the last decade, evidence for the benefit of TRA for PCI has grown, leading to a steady uptake of TRA around the world. Despite this, the topic remains controversial with contrary evidence to suggest no significant benefit over TFA. METHODS A retrospective study of consecutive ACS patients from 2011 to 2017 who underwent PCI via TRA or TFA. The primary outcome was Major Adverse Cardiovascular Events (MACE), a composite of death, myocardial infarction (MI), target lesion revascularisation (TLR), or coronary artery bypass graft surgery (CABG) at 12 months. Secondary outcomes included Bleeding Academic Research Consortium (BARC) bleeding events scored 2 or higher, haematoma formation, and stent thrombosis, in addition to all individual components of MACE. RESULTS We treated 3624 patients (77% male), with PCI via TFA (n = 2391) or TRA (n = 1233). Transradial artery access was associated with a reduction in mortality (3% vs 6.3%; p < 0.0001), MI (1.8% vs 3.9%; p=0.0004), CABG (0.6% vs 1.5%; p=0.0205), TLR (1% vs 2.9%; p < 0.0001), large haematoma (0.4% vs 1.8%; p=0.0003), BARC 2 (0.2% vs 1.1%; p=0.0029), and BARC 3 events (0.4% vs 1.0%; p=0.0426). On multivariate Cox regression analysis, TFA, age ≥ 75, prior PCI, use of bare metal stents, cardiogenic shock, cardiac arrest, and multivessel coronary artery disease were associated with an increased risk of MACE. CONCLUSION Despite the limitations secondary to the observational nature of our study and multiple confounders, our results are in line with results of major trials and, as such, we feel that our results support the use of TRA as the preferred access site in patients undergoing PCI for ACS to improve patient outcomes.
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Affiliation(s)
- Ryan James Ocsan
- College of Health and Medicine, The Australian National University, Canberra, ACT, Australia
| | - Ata Doost
- College of Health and Medicine, The Australian National University, Canberra, ACT, Australia
- Department of Cardiology, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Paul Marley
- Department of Cardiology, The Canberra Hospital, Canberra, ACT, Australia
| | - Ahmad Farshid
- College of Health and Medicine, The Australian National University, Canberra, ACT, Australia
- Department of Cardiology, The Canberra Hospital, Canberra, ACT, Australia
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Brazhnik VA, Minushkina LO, Averkova AO, Zubova EA, Khasanov NR, Galyavich AS, Chichkova MA, Kosmacheva ED, Zateyshchikov DA. Bleeding risk scales in patients with acute coronary syndrome: place of the ORACUL scale. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2020. [DOI: 10.15829/1728-8800-2020-2333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- V. A. Brazhnik
- Central State Medical Academy, Administrative Directorate of the President of the Russian Federation; City Clinical Hospital № 51
| | - L. O. Minushkina
- Central State Medical Academy, Administrative Directorate of the President of the Russian Federation
| | - A. O. Averkova
- Central State Medical Academy, Administrative Directorate of the President of the Russian Federation
| | | | | | | | - M. A. Chichkova
- Central State Medical Academy, Administrative Directorate of the President of the Russian Federation
| | | | - D. A. Zateyshchikov
- Central State Medical Academy, Administrative Directorate of the President of the Russian Federation; City Clinical Hospital № 51
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Nabi H, Rørth R, Tajchman DH, Holmvang L, Torp-Pedersen C, Gislason G, Fosbøl EL, Køber L, Sørensen R. Antithrombotic treatment and major adverse cardiac events after bleeding in patients with myocardial infarction: a retrospective analysis of nationwide registry data. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 6:14-21. [PMID: 31274145 DOI: 10.1093/ehjcvp/pvz025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/10/2019] [Accepted: 07/03/2019] [Indexed: 11/14/2022]
Abstract
AIMS The aim of this study was to describe the use of antithrombotic therapy following a bleeding event among patients with myocardial infarction (MI), and the associated risk of major adverse cardiac events (MACE). METHODS AND RESULTS Using Danish nationwide registries, patients hospitalized with a bleeding event within 1 year after MI were identified. Antithrombotic treatment with aspirin, clopidogrel, and/or vitamin K antagonists (VKA) was determined at the bleeding and at Day 90 and 180 post-bleed. Based on guidelines, patients were stratified into four groups: expected, reduced, discontinued, or intensified treatment. Risk of MACE (ischaemic stroke, MI, or death) within the first year was assessed by Cox proportional hazard models. A total of 3324 patients with a bleeding after MI were included. At Day 90 post-bleed, 1052 (31.7%) received expected antithrombotic treatment, 1301 (39.2%) reduced, 164 (4.9%) intensified, and 807 (24.3%) no treatment. Major adverse cardiac events occurred in 637 (19.2%) patients. With dual antiplatelet therapy as reference, adjusted hazard ratios for MACE were: aspirin 1.81 (1.06-3.09), clopidogrel 1.08 (0.64-1.82), VKA 1.08 (0.47-2.48), VKA + aspirin 1.97 (0.95-4.07), VKA + clopidogrel 0.26 (0.03-1.91), triple 1.73 (0.50-5.95), and no treatment 1.93 (1.11-3.36). CONCLUSION The majority of MI patients reduced or discontinued their antithrombotic therapy post-bleed. Patients in monotherapy with aspirin or no treatment post-bleed had a higher risk of MACE Further studies of optimal antithrombotic treatments after a bleed are needed.
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Affiliation(s)
- Hafsah Nabi
- Department of Cardiology, Copenhagen University Hospital, Afsnit 2142, Opgang 2, 14. Sal, Inge Lehmanns vej 7, København Ø, Denmark
| | - Rasmus Rørth
- Department of Cardiology, Copenhagen University Hospital, Afsnit 2142, Opgang 2, 14. Sal, Inge Lehmanns vej 7, København Ø, Denmark
| | - Daniel H Tajchman
- Department of Cardiology, Copenhagen University Hospital, Afsnit 2142, Opgang 2, 14. Sal, Inge Lehmanns vej 7, København Ø, Denmark
| | - Lene Holmvang
- Department of Cardiology, Copenhagen University Hospital, Afsnit 2142, Opgang 2, 14. Sal, Inge Lehmanns vej 7, København Ø, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Hobrovej 18-22, Aalborg, Denmark.,Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7 D2, Aalborg Øst, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Gentofte Hospitalsvej 6, 3. Sal, Hellerup, Denmark.,The Danish Heart Foundation, Vognmagergade 7, 3.sal, 1120 København K, Denmark.,The National Institute of Public Health, University of Southern Denmark, Studiestræde 6, København K, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Copenhagen University Hospital, Afsnit 2142, Opgang 2, 14. Sal, Inge Lehmanns vej 7, København Ø, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital, Afsnit 2142, Opgang 2, 14. Sal, Inge Lehmanns vej 7, København Ø, Denmark
| | - Rikke Sørensen
- Department of Cardiology, Copenhagen University Hospital, Afsnit 2142, Opgang 2, 14. Sal, Inge Lehmanns vej 7, København Ø, Denmark
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Jaures M, Pigatti NMMN, Rodrigues RDR, Fernandes FP, Guerra JCDC. Bleeding management after implementation of the Hemorrhage Code (Code H) at the Hospital Israelita Albert Einstein, São Paulo, Brazil. EINSTEIN-SAO PAULO 2020; 18:eAO5032. [PMID: 32876090 PMCID: PMC9586425 DOI: 10.31744/einstein_journal/2020ao5032] [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: 02/27/2019] [Accepted: 02/09/2020] [Indexed: 11/18/2022] Open
Abstract
Objective To describe the implementation of a care protocol based on rapid response teams, for management and resolution of bleeding. Methods A hospital protocol called Hemorrhage Code (Code H) was devised and developed. In a flow line, a multidisciplinary team provides comprehensive, fast and effective care to the patient with a severe hemorrhagic condition. In another flow line, professionals based at the hospital pharmacy focus on identifying patients at risk of bleeding, to avoid this event. Several hospital professionals and sectors were trained, each with specific roles, ensuring full support to the medical and nursing staffs. Results After implementing this protocol, we were able to significantly reduce the number of catastrophic events related to failure in bleeding management. Conclusion Code H is an example of a value-based medicine and precision medicine project by delivering comprehensive and multidisciplinary care, in addition to point-of-care testing introduced in clinical practice, optimizing patient safety and care practices at the hospital. Furthermore, it will be possible to minimize the risk of lawsuits for the hospital and physicians, as well as rationalizing resources with benefits for administrators and payers.
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Bhardwaj B, Spertus JA, Kennedy KF, Jones WS, Safley D, Tsai TT, Aronow HD, Vora AN, Pokharel Y, Kumar A, Attaran RR, Feldman DN, Armstrong E, Prasad A, Gray B, Salisbury AC. Bleeding Complications in Lower-Extremity Peripheral Vascular Interventions: Insights From the NCDR PVI Registry. JACC Cardiovasc Interv 2020; 12:1140-1149. [PMID: 31221303 DOI: 10.1016/j.jcin.2019.03.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study sought to assess periprocedural bleeding complications in lower-extremity peripheral vascular interventions (PVIs). BACKGROUND Few studies have examined the incidence, predictors, or outcomes of periprocedural bleeding after lower-extremity PVI. METHODS The study examined patients undergoing PVI at 76 hospitals in the National Cardiovascular Data Registry PVI registry from 2014 to 2016. Post-PVI major bleeding was defined as any overt bleeding with a hemoglobin (Hb) drop of ≥3 g/dl, any Hb decline of ≥4 g/dl, or blood transfusion in patients with pre-procedure Hb >8 g/dl within 72 h of their procedure. Hierarchical multivariable logistic regression was used to identify factors independently associated with post-PVI bleeding. The study also examined adjusted in-hospital mortality among patients with or without major bleeding complications. RESULTS Among 18,289 PVI procedures, major bleeding occurred in 744 (4.10%). Patient characteristics independently associated with bleeding included age, female sex, heart failure, pre-procedural hemoglobin <12 g/dl, nonelective PVI, and critical limb ischemia on presentation. Procedural characteristics associated with bleeding included nonfemoral vascular access, use of thrombolytic therapy, PVI of the aortoiliac segment, and multilesion interventions, whereas use of closure devices was associated with less bleeding. All-cause in-hospital mortality was higher in patients who experienced bleeding than in those who did not (6.60% vs. 0.30%; p < 0.001; adjusted hazard ratio: 10.9; 95% confidence interval: 6.9 to 17.0). CONCLUSIONS Major bleeding occurred in 4.10% of lower-extremity PVI procedures and was associated with several patient and procedural characteristics, as well as in-hospital mortality. These insights can be incorporated into strategies to reduce periprocedural bleeding after PVI.
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Affiliation(s)
- Bhaskar Bhardwaj
- Division of Cardiovascular Diseases, University of Missouri, Columbia, Missouri; Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - John A Spertus
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri; Division of Cardiovascular Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri
| | - Kevin F Kennedy
- Division of Cardiovascular Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri
| | - W Schuyler Jones
- Division of Cardiology, Duke University Health System, Duke Heart Center, Durham, North Carolina
| | - David Safley
- Division of Cardiovascular Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri
| | - Thomas T Tsai
- Division of Cardiovascular Medicine, University of Colorado and Institute for Health Research, Kaiser Permanente, Denver, Colorado
| | - Herbert D Aronow
- Division of Cardiovascular Medicine, Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - Amit N Vora
- Division of Cardiology, Duke University Health System, Duke Heart Center, Durham, North Carolina
| | - Yashashwi Pokharel
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri; Division of Cardiovascular Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri
| | - Arun Kumar
- Division of Cardiovascular Diseases, University of Missouri, Columbia, Missouri
| | - Robert R Attaran
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Dmitriy N Feldman
- Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Ehrin Armstrong
- Division of Cardiovascular Medicine, University of Colorado, Denver, Colorado and Denver Veterans Affairs Medical Center, Denver, Colorado
| | - Anand Prasad
- Division of Cardiology, Department of Medicine, UT Health San Antonio, San Antonio, Texas
| | - Bruce Gray
- Department of Surgery at Greenville Health System, Greenville, South Carolina
| | - Adam C Salisbury
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri; Division of Cardiovascular Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri.
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Tersalvi G, Biasco L, Cioffi GM, Pedrazzini G. Acute Coronary Syndrome, Antiplatelet Therapy, and Bleeding: A Clinical Perspective. J Clin Med 2020; 9:E2064. [PMID: 32630233 PMCID: PMC7408729 DOI: 10.3390/jcm9072064] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 06/27/2020] [Accepted: 06/29/2020] [Indexed: 02/06/2023] Open
Abstract
Inhibition of platelet function by means of dual antiplatelet therapy (DAPT) is the cornerstone of treatment of acute coronary syndrome (ACS). While preventing ischemic recurrences, inhibition of platelet function is clearly associated with an increased bleeding risk, a feared complication that may lead to significant morbidity and mortality. Since bleeding risk management is intrinsically associated with therapeutic adjustments undertaken during the whole clinical history of patients with acute coronary syndrome, single decisions taken from the very first day to years of follow-up might be decisive. This review aims at providing a clinically oriented, patient-tailored approach in reducing the risk and manage bleeding complications in ACS patients treated with DAPT. The steps in clinical decision making from the day of ACS to follow-up are analyzed. New treatment strategies to enhance the safety of DAPT are also described.
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Affiliation(s)
- Gregorio Tersalvi
- Division of Cardiology, Fondazione Cardiocentro Ticino, 6900 Lugano, Switzerland;
- Department of Internal Medicine, Hirslanden Klinik St. Anna, 6006 Lucerne, Switzerland
| | - Luigi Biasco
- Azienda Sanitaria Locale Torino 4, Ospedale di Ciriè, 10073 Ciriè, Italy;
- Department of Biomedical Sciences, University of Italian Switzerland, 6900 Lugano, Switzerland
| | - Giacomo Maria Cioffi
- Division of Cardiology, Fondazione Cardiocentro Ticino, 6900 Lugano, Switzerland;
- Department of Cardiology, Kantonsspital Luzern, 6000 Lucerne, Switzerland
| | - Giovanni Pedrazzini
- Division of Cardiology, Fondazione Cardiocentro Ticino, 6900 Lugano, Switzerland;
- Department of Biomedical Sciences, University of Italian Switzerland, 6900 Lugano, Switzerland
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Cao D, Mehran R, Dangas G, Baber U, Sartori S, Chandiramani R, Stefanini GG, Angiolillo DJ, Capodanno D, Urban P, Morice MC, Krucoff M, Goel R, Roumeliotis A, Sweeny J, Sharma SK, Kini A. Validation of the Academic Research Consortium High Bleeding Risk Definition in Contemporary PCI Patients. J Am Coll Cardiol 2020; 75:2711-2722. [DOI: 10.1016/j.jacc.2020.03.070] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 01/08/2023]
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Radial or femoral access in primary percutaneous coronary intervention (PCI): Does the choice matters? Indian Heart J 2020; 72:166-171. [PMID: 32768015 PMCID: PMC7411101 DOI: 10.1016/j.ihj.2020.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 05/07/2020] [Accepted: 05/10/2020] [Indexed: 12/31/2022] Open
Abstract
Background This study was conducted with the aim of providing a quantitative appraisal of clinical outcomes of trans-radial access for primary percutaneous coronary interventions (PCI) in patients with ST-segment evaluation myocardial infarction (STEMI). Methods In this study, we compared two propensity-matched cohorts of patients who underwent primary PCI via trans-radial (TRA) and trans-femoral access (TFA) in a 1:1 ratio. The profile of two cohorts was matched for gender, age, and body mass index, diabetes, hypertension, family history, and smoking. The outcomes of primary PCI were compared for the two cohorts which included all-cause in-hospital mortality, heart failure, re-infarction, cardiogenic shock, bleeding, transfusion, cerebrovascular accident, and dialysis. Results This analysis was performed on a total of 2316 patients with 1158 patients each in the TRA and TFA group. We observed significantly lower rates of mortality, 0.8% (9) vs. 3.5% (41); p < 0.001 and bleeding, 0.5% (6) vs.1.6% (19); p = 0.009 with shorter hospital stay, 1.61 ± 1.39 vs. 1.98 ± 1.5 days, in trans-radial vs. trans-femoral. However, both fluoroscopic time and contrast volume were significantly higher in the TRA as compared to TFA group 15.57 ± 8.16 vs. 12.79 ± 7.82 min; p < 0.001 and 143.22 ± 45.33 vs. 133.78 ± 45.97; p < 0.001 respectively. Conclusions Compared with TFA access, TRA for primary PCI is safe for patients with STEMI, it was found to be associated with a significant reduction in in-hospital mortality and bleeding complications.
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Nakamura M, Kadota K, Takahashi A, Kanda J, Anzai H, Ishii Y, Shibata Y, Yasaka Y, Takamisawa I, Yamaguchi J, Takeda Y, Harada A, Motohashi T, Iijima R, Uemura S, Murakami Y. Relationship Between Platelet Reactivity and Ischemic and Bleeding Events After Percutaneous Coronary Intervention in East Asian Patients: 1-Year Results of the PENDULUM Registry. J Am Heart Assoc 2020; 9:e015439. [PMID: 32394794 PMCID: PMC7660889 DOI: 10.1161/jaha.119.015439] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The balance between ischemic and bleeding events and their association with platelet reactivity in patients receiving antiplatelet therapy after percutaneous coronary intervention (PCI), which differs among regions, is not fully evaluated for East Asians. We examined ischemic/bleeding events and platelet reactivity in Japanese patients undergoing PCI and determined associations between high/low platelet reactivity and clinical outcomes. Methods and Results PENDULUM (Platelet Reactivity in Patients with Drug Eluting Stent and Balancing Risk of Bleeding and Ischemic Event) is a prospective, multicenter registry of Japanese patients with PCI. Primary end points were incidence of first major adverse cardiac and cerebrovascular events (MACCE) and first major bleeding events at 12 months post-PCI. Platelet reactivity (P2Y12 reaction unit [PRU] value) was measured at 12 to 48 hours post-PCI; patients were grouped as having high PRU (>208), optimal PRU (>85 to ≤208), and low PRU (≤85). MACCE and major bleeding occurred in 4.4% and 2.8% of 6267 patients, respectively. The mean±SD PRU value was 182.1±77.1. MACCE was significantly higher in the high PRU (5.7%; n=2227) versus the optimal PRU group (3.6%; n=3002). The hazard ratio (HR) for high PRU versus optimal PRU level was significantly higher for MACCE (adjusted HR, 1.53; 95% CI, 1.14-2.06 [P=0.004]); stent thrombosis followed the same trend. Incidence of major bleeding did not differ significantly between groups. A high PRU level was significantly associated with MACCE in both patients with and patients without acute coronary syndrome. Conclusions These real-world data suggest an association between high platelet reactivity and cardiovascular events in Japanese patients undergoing PCI. The trend was the same in both patients with and patients without acute coronary syndrome. REGISTRATION URL: https://www.umin.ac.jp/ctr. Unique identifier: UMIN 000020332.
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Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine Toho University Ohashi Medical Center Tokyo Japan
| | - Kazushige Kadota
- Department of Cardiology Kurashiki Central Hospital Kurashiki Japan
| | | | - Junji Kanda
- Department of Cardiology Asahi General Hospital Asahi Japan
| | - Hitoshi Anzai
- Department of Cardiology Ota Memorial Hospital Ota Japan
| | - Yasuhiro Ishii
- Department of Cardiology Cardiovascular Center Ogikubo Hospital Tokyo Japan
| | - Yoshisato Shibata
- Department of Cardiology Miyazaki Medical Association Hospital Miyazaki Japan
| | - Yoshinori Yasaka
- Department of Cardiology Himeji Cardiovascular Center Himeji Japan
| | | | - Junichi Yamaguchi
- Department of Cardiology Tokyo Women's Medical University Tokyo Japan
| | - Yoshihiro Takeda
- Department of Cardiology Rinku General Medical Center Izumisano Japan
| | - Atsushi Harada
- Medical Science Department Daiichi Sankyo Co., Ltd. Tokyo Japan
| | - Tomoko Motohashi
- Medical Affairs Planning Department Daiichi Sankyo Co., Ltd. Tokyo Japan
| | - Raisuke Iijima
- Division of Cardiovascular Medicine Toho University Ohashi Medical Center Tokyo Japan
| | - Shiro Uemura
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Yoshitaka Murakami
- Department of Medical Statistics School of Medicine Toho University Tokyo Japan
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Freund A, Jobs A, Lurz P, Feistritzer HJ, de Waha-Thiele S, Meyer-Saraei R, Montalescot G, Huber K, Noc M, Windecker S, Zeymer U, Ouarrak T, Schneider S, Thiele H, Desch S. Frequency and Impact of Bleeding on Outcome in Patients With Cardiogenic Shock. JACC Cardiovasc Interv 2020; 13:1182-1193. [DOI: 10.1016/j.jcin.2020.02.042] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/04/2020] [Accepted: 02/27/2020] [Indexed: 01/17/2023]
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Alfredsson J, Omar K, Csog J, Venetsanos D, Janzon M, Ekstedt M. Bleeding complications with clopidogrel or ticagrelor in ST-elevation myocardial infarction patients - A real life cohort study of two treatment strategies. IJC HEART & VASCULATURE 2020; 27:100495. [PMID: 32309533 PMCID: PMC7154313 DOI: 10.1016/j.ijcha.2020.100495] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 02/22/2020] [Accepted: 02/25/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT), including potent P2Y12 inhibition after ST-elevation myocardial infarction (STEMI) is recommended in clinical guidelines. However, bleeding complications are common, and associated with worse outcomes. The aim of this study was to assess incidence of bleeding events with a clopidogrel-based compared to a ticagrelor-based DAPT strategy, in a real world population. Secondary aims were to assess ischemic complications and mortality. METHODS AND RESULTS We identified 330 consecutive STEMI patients with a clopidogrel-based and 330 with a ticagrelor-based DAPT strategy. Patientś medical records were searched for bleeding and ischemic complications, over 6 months follow-up.The two groups were well balanced in baseline characteristics, age (69 years inboth groups), sex (31% vs 32% females), history of diabetes (19% vs 21%), hypertension (43% in both) and MI (17% vs 15%). There was no difference in CRUSADE bleeding score (28 vs 29). After discharge, there were more than twice as many bleeding events with a ticagrelor-based compared with a clopidogrel-based strategy (13.3% vs. 6.5%, p = 0.005). Bleeding events included significantly more severe bleeding complications (TIMI major/minor [5.8 vs 1.0, p = 0.001]) during the ticagrelor-based period. There was no significant difference in the composite of death, MI or stroke (7.8% vs 7.1%, p = 0.76). CONCLUSIONS In this observational study, a ticagrelor-based DAPT strategy was associated with significantly more bleeding complications, without any significant change in death, MI or stroke. Larger studies are needed to determine whether bleeding complications off-sets benefits with a more potent DAPT strategy in older and more comorbid real-life patients.
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Affiliation(s)
- Joakim Alfredsson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Kime Omar
- Department of Oncology, Västmanland County Hospital, Västerås, Sweden
| | - József Csog
- Department of Medicine, Vrinnevi Hospital, Norrköping, Sweden
| | - Dimitrios Venetsanos
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Magnus Janzon
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Mattias Ekstedt
- Department of Gastroenterology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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