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Benefit and risk of prolonged dual antiplatelet therapy after drug-eluting stent implantation in patients with chronic kidney disease: A nationwide cohort study. Atherosclerosis 2022; 352:69-75. [PMID: 35714431 DOI: 10.1016/j.atherosclerosis.2022.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/06/2022] [Accepted: 05/25/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIMS The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent in patients with chronic kidney disease (CKD) is not clearly established. This study purposed to compare clinical outcomes of patients with 6-12 (standard) versus 12-24 months (prolonged) DAPT according to CKD. METHODS Using a nationwide, claim-based database, we retrospectively evaluated association between DAPT duration and clinical outcomes including death, composite ischemic event, and composite bleeding event between 1 and 3 years after PCI. CKD was defined as estimated glomerular filtration rate <60 mL/min/1.73 m2. Of 73,941 eligible patients, 13,425 (18.2%) had CKD and 49,019 (66%) were prescribed prolonged DAPT. Prolonged DAPT had no significant impact on the risk of clinical outcomes in patients with normal renal function. RESULTS In patients with CKD, prolonged DAPT was associated with a lower risk of all-cause death (HR 0.85, 95% CI 0.76-0.95) and composite ischemic events (HR 0.87, 95% CI 0.78-0.96) and a higher risk of composite bleeding events (HR 1.18, 95% CI 1.02-1.37). Benefit of prolonged DAPT on reducing composite ischemic event increased significantly in patients with worsened renal dysfunction (pinteraction = 0.02) while there was no significant interaction between its bleeding risk and renal dysfunction (pinteraction = 0.22). CONCLUSIONS While standard DAPT would be recommended in patients with normal renal function, tailored decision for DAPT duration would be considered in those with CKD to balance between ischemic and bleeding risks.
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Ho PM, O’Donnell CI, McCreight M, Bavry AA, Bosworth HB, Girotra S, Grossman PM, Helfrich C, Latif F, Lu D, Matheny M, Mavromatis K, Ortiz J, Parashar A, Ratliff DM, Grunwald GK, Gillette M, Jneid H. Multifaceted Intervention to Improve P2Y12 Inhibitor Adherence After Percutaneous Coronary Intervention: A Stepped Wedge Trial. J Am Heart Assoc 2022; 11:e024342. [PMID: 35766258 PMCID: PMC9333389 DOI: 10.1161/jaha.121.024342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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 P2Y12 inhibitor medications are critical following percutaneous coronary intervention (PCI); however, adherence remains suboptimal. Our objective was to assess the effectiveness of a multifaceted intervention to improve P2Y12 inhibitor adherence following PCI. Methods and Results This was a modified stepped wedge trial of 52 eligible hospitals, of which 15 were randomly selected and agreed to participate (29 hospitals declined, and 8 eligible hospitals were not contacted). At each intervention hospital, patient recruitment occurred for 6 months and enrolled patients were followed up for 1 year after PCI. Three control groups were used: patients at intervention hospitals undergoing PCI (1) before the intervention period (preintervention); (2) after the intervention period (postintervention); or (3) at the 8 hospitals not contacted (concurrent controls). The intervention consisted of 4 components: (1) P2Y12 inhibitor delivered to patients' bedside after PCI; (2) education on importance of P2Y12 inhibitors; (3) automated reminder telephone calls to refill medication; and (4) outreach to patients if they delayed refilling P2Y12 inhibitor. The primary outcomes were as follows: (1) proportion of patients with delays filling P2Y12 inhibitor at hospital discharge and (2) proportion of patients who were adherent in the year after PCI using pharmacy refill data. Primary analysis compared intervention with preintervention control patients. There were 1377 (intent-to-treat) potentially eligible patients, of whom 803 (per protocol) were approached at intervention sites versus 5910 preintervention, 2807 postintervention, and 4736 concurrent control patients. In the intent-to-treat analysis, intervention patients were less likely to delay filling P2Y12 at hospital discharge (-3.4%; 98.3% CI, -1.2% to -5.6%) and more likely to be adherent to P2Y12 (4.1%; 98.3% CI, 1.0%-7.1%) at 1 year, but had more clinical events (3.2%; 98.3% CI, 2.3%-4.1%) driven by repeated PCI compared with preintervention patients. In post hoc analysis looking at myocardial infarction, stroke, and death, intervention patients had lower event rates compared with preintervention patients (-1.7%; 98.3% CI, -2.3% to -1.1%). Conclusions A 4-component intervention targeting P2Y12 inhibitor adherence was difficult to implement. The intervention produced mixed results. It improved P2Y12 adherence, but there was also an increase in repeat PCI. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01609842.
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Affiliation(s)
- P. Michael Ho
- Cardiology SectionRocky Mountain Regional VA Medical CenterAuroraCO,Department of MedicineUniversity of Colorado School of MedicineAuroraCO,Denver‐Seattle Center of Innovation for Veteran Centered and Value Driven CareRocky Mountain Regional VA Medical CenterAuroraCO
| | | | - Marina McCreight
- Denver‐Seattle Center of Innovation for Veteran Centered and Value Driven CareRocky Mountain Regional VA Medical CenterAuroraCO
| | | | - Hayden B. Bosworth
- Departments of Population Health Science, Medicine, Psychiatry, School of NursingDuke University School of MedicineDurhamNC,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham VAMCDurhamNC
| | - Saket Girotra
- University of Iowa Carver College of MedicineIowa CityIA,Iowa City Veterans Affairs Medical CenterIowa CityIA
| | | | - Christian Helfrich
- Seattle‐Denver Center of Innovation for Veteran Centered and Value Driven CarePuget Sound Health Care SystemSeattleWA
| | - Faisal Latif
- Oklahoma City VA Health Care SystemOklahoma CityOK,University of Oklahoma Health Sciences CenterOklahoma CityOK
| | - David Lu
- Washington DC VA Medical CenterWashingtonDC
| | - Michael Matheny
- Geriatric ResearchEducation, and Clinical Care CenterTennessee Valley Healthcare System VANashvilleTN,Department of Biomedical InformaticsVanderbilt University Medical CenterNashvilleTN
| | | | - Jose Ortiz
- VA Northeast Ohio Healthcare SystemClevelandOH
| | - Amitabh Parashar
- Virginia Tech Carilion School of MedicineRoanokeVA,Salem VA Medical CenterSalemVA
| | | | - Gary K. Grunwald
- Denver‐Seattle Center of Innovation for Veteran Centered and Value Driven CareRocky Mountain Regional VA Medical CenterAuroraCO,University of Colorado School of Public HealthAuroraCO
| | - Michael Gillette
- Baylor College of MedicineHoustonTX,Michael E. DeBakey VA Medical CenterHoustonTX
| | - Hani Jneid
- Baylor College of MedicineHoustonTX,Michael E. DeBakey VA Medical CenterHoustonTX
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Park J, Choi EK, Han KD, Kim B, Choi YJ, Lee SR, Kang J, Cha MJ, Park KW, Oh S, Lip GYH. Outcomes in relation to antithrombotic therapy among patients with atrial fibrillation after percutaneous coronary intervention. PLoS One 2020; 15:e0240161. [PMID: 33057407 PMCID: PMC7561121 DOI: 10.1371/journal.pone.0240161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/21/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUNDS We investigated the prognostic impact of antithrombotic regimens at 1-year after percutaneous coronary intervention (PCI) among patients with atrial fibrillation (AF). METHOD AND RESULTS A total of 13,278 AF patients who underwent PCI from 2009 to 2013 were selected from Korean National Health Insurance Service database. Patients were categorized by antithrombotic regimens at 1-year after PCI: (1) OAC with or without single antiplatelet (OAC±SAPT); (2) triple therapy (TT) and (3) antiplatelets (APT) only. After propensity score matching, composite ischaemia (death, myocardial infarction, and stroke), composite bleeding (intracranial hemorrhage and gastrointestinal bleeding), and a composite clinical outcome (composite ischaemia and bleeding) were compared. Of total population, 1,100 (8.3%), 746 (5.6%), and 11,432 (86.1%) were treated with OAC±SAPT, TT, and APT only, respectively. Compared to OAC±SAPT group, the TT group had significantly higher risk of the composite clinical outcome (hazard ratio [HR] 1.46, 95% confidence interval [CI] 1.00-2.13) attributed to a higher trend in both ischaemia (HR 1.63, 95% CI 0.99-2.67) and bleeding (HR 1.22, 95% CI 0.69-2.13). The APT only group showed a higher risk of ischaemia (HR 1.85, 95% CI 1.25-2.74), despite a lower risk of bleeding (HR 0.55, 95% CI 0.32-0.94) compared to OAC±SAPT group. CONCLUSIONS OAC±SAPT was associated with better clinical outcomes compared to TT or APT only treatments, beyond 1-year after PCI among Asians with AF.
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Affiliation(s)
- Jiesuck Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung-Do Han
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bongseong Kim
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - You-Jung Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeehoon Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Myung-Jin Cha
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
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Sun GL, Lei L, Liu L, Liu J, He Y, Guo Z, Dai X, He L, Chen SQ, Liang Y, Ye J, Hu Y, Chen G, Chen JY, Liu Y. Rationale and design of the Web-basEd soCial media tecHnology to improvement in Adherence to dual anTiplatelet Therapy following Drug-Eluting Stent Implantation (WECHAT): protocol for a randomised controlled study. BMJ Open 2020; 10:e033017. [PMID: 31915170 PMCID: PMC6955490 DOI: 10.1136/bmjopen-2019-033017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) is frequently discontinued after drug-eluting stent (DES) implantation, which could increase the risk of major adverse cardiovascular events (MACEs). Few studies have attempted to improve DAPT adherence through web-based social media. OBJECTIVE To explore the effect of social media on DAPT adherence following DES implantation. METHODS/DESIGN The WeChat trial is a multicentre, single-blind, randomised study (1:1). It will recruit 760 patients with DES who require 12 months of DAPT. The control group will only receive usual care and general educational messages on medical knowledge. The intervention group will receive a personalised intervention, including interactive responses and medication and follow-up reminders beyond the general educational messages. The primary endpoint will be the discontinuation rate which is defined as the cessation of any dual antiplatelet drug owing to the participants' discretion within 1 year of DES implantation. The secondary endpoints will include medication adherence and MACEs. Both groups will receive messages or reminders four times a week with follow-ups over 12 months. ETHICS AND DISSEMINATION Ethical approval was granted by Ethics Committee of Guangdong Provincial People's Hospital (GDREC2018327H). Results will be disseminated via peer-reviewed publications and presentations at international conferences. TRIAL REGISTRATION NUMBER NCT03732066.
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Affiliation(s)
- Guo-Li Sun
- Department of Cardiology, Guangdong Provincial People's Hospital affiliated with South China University of Technology, Guangzhou, China
| | - Li Lei
- Department of Cardiology, Guangdong Provincial People's Hospital affiliated with South China University of Technology, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Liwei Liu
- Department of Cardiology, Guangdong Provincial People's Hospital affiliated with South China University of Technology, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Jin Liu
- Department of Cardiology, Guangdong Provincial People's Hospital affiliated with South China University of Technology, Guangzhou, China
| | - Yibo He
- Department of Cardiology, Guangdong Provincial People's Hospital affiliated with South China University of Technology, Guangzhou, China
| | - Zhaodong Guo
- Department of Cardiology, Guangdong Provincial People's Hospital affiliated with South China University of Technology, Guangzhou, China
| | - Xiaohua Dai
- School of Pharmacy, Guangdong Pharmaceutical University, Guangzhou, China
| | - Lihao He
- Department of Cardiology, Guangdong Provincial People's Hospital affiliated with South China University of Technology, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Shi-Qun Chen
- Department of Cardiology, Guangdong Provincial People's Hospital affiliated with South China University of Technology, Guangzhou, China
| | - Yan Liang
- Department of Cardiology, Maoming General Hospital, Guangzhou, China
| | - Jianfeng Ye
- Department of Cardiology, Dongguan People's Hospital, Dongguan, China
| | - Yunzhao Hu
- Department of Cardiology, First People's Hospital, Shunde, China
| | - Guoqin Chen
- Department of Cardiology, Guangzhou Panyu Central Hospital, Guangzhou, China
| | - Ji-Yan Chen
- Department of Cardiology, Guangdong Provincial People's Hospital affiliated with South China University of Technology, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yong Liu
- Department of Cardiology, Guangdong Provincial People's Hospital affiliated with South China University of Technology, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
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Li YH, Chiu YW, Cheng JJ, Hsieh IC, Lo PH, Lei MH, Ueng KC, Chiang FT, Sung SH, Kuo JY, Chen CP, Lai WT, Lee WL, Chen JH. Duration of Clopidogrel-Based Dual Antiplatelet Therapy and Clinical Outcomes in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention - A Real-World Observation in Taiwan From 2012 to 2015. Circ J 2019; 83:1317-1323. [PMID: 31061379 DOI: 10.1253/circj.cj-18-1283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Little information is available in Asia about the real-world practice of dual antiplatelet therapy (DAPT) duration for acute coronary syndrome (ACS) and its influence on clinical outcomes.Methods and Results:The Taiwan ACS STENT Registry was a prospective, multicenter study to observe ACS patients using clopidogrel-based DAPT after percutaneous coronary intervention (PCI). The primary outcome was a composite of cardiovascular death, myocardial infarction, and stroke. Overall, 2,221 ACS patients (62 years, 83% men) were included. DAPT duration was ≤9 months in 935 (42.1%). The incidence of primary outcome was higher in patients receiving DAPT ≤9 months compared with those receiving DAPT >9 months at 1 year (3.5% vs. 1.6%, P=0.0026). The incidence of stent thrombosis (overall 0.5%) was similar between groups. Multivariable analysis showed that DAPT >9 months was associated with a significantly lower risk of primary outcome (odds ratio 0.725, 95% confidence interval 0.545-0.965). CONCLUSIONS Our data showed that short duration of DAPT (≤9 months) was common (42.1%) in Taiwan for ACS patients undergoing PCI. DAPT ≤9 months increased the risk of the primary outcome.
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Affiliation(s)
- Yi-Heng Li
- National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Yu-Wei Chiu
- Department of Computer Science and Engineering, Yuan Ze University, Far Eastern Memorial Hospital
| | | | - I-Chang Hsieh
- Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Ping-Han Lo
- China Medical University Hospital and College of Medicine
| | | | | | - Fu-Tien Chiang
- National Taiwan University Hospital and Fu-Jen Catholic University Hospital
| | - Shih-Hsien Sung
- Taipei Veterans General Hospital and National Yang Ming University
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