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Mostaza JM, Pintó X, Armario P, Masana L, Real JT, Valdivielso P, Arrobas-Velilla T, Baeza-Trinidad R, Calmarza P, Cebollada J, Civera-Andrés M, Cuende Melero JI, Díaz-Díaz JL, Espíldora-Hernández J, Fernández Pardo J, Guijarro C, Jericó C, Laclaustra M, Lahoz C, López-Miranda J, Martínez-Hervás S, Muñiz-Grijalvo O, Páramo JA, Pascual V, Pedro-Botet J, Pérez-Martínez P, Puzo J. SEA 2024 Standards for Global Control of Vascular Risk. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2024; 36:133-194. [PMID: 38490888 DOI: 10.1016/j.arteri.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/03/2024] [Indexed: 03/17/2024]
Abstract
One of the objectives of the Spanish Society of Arteriosclerosis is to contribute to the knowledge, prevention and treatment of vascular diseases, which are the leading cause of death in Spain and entail a high degree of disability and health expenditure. Atherosclerosis is a multifactorial disease and its prevention requires a global approach that takes into account the associated risk factors. This document summarises the current evidence and includes recommendations for patients with established vascular disease or at high vascular risk: it reviews the symptoms and signs to evaluate, the laboratory and imaging procedures to request routinely or in special situations, and includes the estimation of vascular risk, diagnostic criteria for entities that are vascular risk factors, and general and specific recommendations for their treatment. Finally, it presents aspects that are not usually referenced in the literature, such as the organisation of a vascular risk consultation.
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Affiliation(s)
- José María Mostaza
- Servicio de Medicina Interna, Unidad de Lípidos y Arteriosclerosis, Hospital La Paz-Carlos III, Madrid, España.
| | - Xavier Pintó
- Unidad de Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario Bellvitge, Centro de Investigación Biomédica en Red, Fisiopatología de la Obesidad y Nutrición (CIBERobn), Fundación para la Investigación y Prevención de las Enfermedades Cardiovasculares (FIPEC), Universidad de Barcelona, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, España
| | - Pedro Armario
- Servicio de Medicina Interna, Área de Atención Integrada de Riesgo Vascular, Complex Hospitalari Universitari Moisès Broggi, Consorci Sanitari Integral (CSI), Sant Joan Despí, Universidad de Barcelona, Barcelona, España
| | - Luis Masana
- Unidad de Medicina Vascular y Metabolismo (UVASMET), Institut d'Investigació Sanitària Pere Virgili (IISPV), Hospital Universitari Sant Joan de Reus, Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Universitat Rovira i Virgili, Tarragona, España
| | - José T Real
- Servicio de Endocrinología y Nutrición, Hospital Clínico, Universidad de València, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España; CIBER de Diabetes y Enfermedades Metabólicas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - Pedro Valdivielso
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA-Bionand), Universidad de Málaga, Málaga, España
| | - Teresa Arrobas-Velilla
- Laboratorio de Nutrición y RCV, UGC de Bioquímica clínica, Hospital Virgen Macarena, Sevilla, España
| | | | - Pilar Calmarza
- Servicio de Bioquímica Clínica, Hospital Universitario Miguel Servet, Zaragoza, España; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Investigación Sanitaria (ISS) de Aragón, Universidad de Zaragoza, Zaragoza, España
| | - Jesús Cebollada
- Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - Miguel Civera-Andrés
- Servicio de Endocrinología y Nutrición, Hospital Clínico, Universidad de València, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España
| | - José I Cuende Melero
- Consulta de Riesgo Cardiovascular, Servicio de Medicina Interna, Complejo Asistencial Universitario de Palencia, Palencia, España
| | - José L Díaz-Díaz
- Sección de Medicina Interna, Unidad de Lípidos y Riesgo Cardiovascular, Hospital Abente y Lago Complejo Hospitalario Universitario A Coruña, La Coruña, España
| | - Javier Espíldora-Hernández
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA-Bionand), Universidad de Málaga, Málaga, España; Unidad de Lípidos y Unidad Asistencial de Hipertensión Arterial- Riesgo Vascular (HTA-RV), UGC Medicina Interna, Hospital Universitario Virgen de la Victoria, Málaga, España
| | - Jacinto Fernández Pardo
- Servicio de Medicina Interna, Hospital General Universitario Reina Sofía de Murcia, Universidad de Murcia, Murcia, España
| | - Carlos Guijarro
- Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Universidad Rey Juan Carlos, Alcorón, España
| | - Carles Jericó
- Servicio de Medicina Interna, Área de Atención Integrada de Riesgo Vascular, Complex Hospitalari Universitari Moisès Broggi, Consorci Sanitari Integral (CSI), Sant Joan Despí, Universidad de Barcelona, Barcelona, España
| | - Martín Laclaustra
- Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Investigación Sanitaria (ISS) de Aragón, Universidad de Zaragoza, Zaragoza, España
| | - Carlos Lahoz
- Servicio de Medicina Interna, Unidad de Lípidos y Arteriosclerosis, Hospital La Paz-Carlos III, Madrid, España
| | - José López-Miranda
- Unidad de Lípidos y Arteriosclerosis, UGC de Medicina Interna, Hospital Universitario Reina Sofía, Córdoba, España; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, España; CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - Sergio Martínez-Hervás
- Servicio de Endocrinología y Nutrición, Hospital Clínico, Universidad de València, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España; CIBER de Diabetes y Enfermedades Metabólicas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - Ovidio Muñiz-Grijalvo
- Servicio de Medicina Interna, UCERV, UCAMI, Hospital Virgen del Rocío de Sevilla, Sevilla, España
| | - José A Páramo
- Servicio de Hematología, Clínica Universidad de Navarra, Navarra, España; Laboratorio Aterotrombosis, CIMA, Universidad de Navarra, Pamplona, España
| | - Vicente Pascual
- Centro de Salud Palleter, Universidad CEU-Cardenal Herrera, Castellón, España
| | - Juan Pedro-Botet
- Unidad de Lípidos y Riesgo Vascular, Servicio de Endocrinología y Nutrición, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, España
| | - Pablo Pérez-Martínez
- Unidad de Lípidos y Arteriosclerosis, UGC de Medicina Interna, Hospital Universitario Reina Sofía, Córdoba, España; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, España; CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - José Puzo
- Servicio de Bioquímica Clínica, Unidad de Lípidos, Hospital General Universitario San Jorge de Huesca, Huesca, España; Departamento de Medicina, Universidad de Zaragoza, Zaragoza, España
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Zwart B, Bor WL, de Veer AJWM, Mahmoodi BK, Kelder JC, Lip GY, Bhatt DL, Cannon CP, ten Berg JM. A novel risk score to identify the need for triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention: a post hoc analysis of the RE-DUAL PCI trial. EUROINTERVENTION 2022; 18:e292-e302. [PMID: 35105533 PMCID: PMC9912964 DOI: 10.4244/eij-d-21-00165] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Current guidelines recommend treating atrial fibrillation (AF) patients who undergo percutaneous coronary intervention (PCI) with triple antithrombotic therapy (TAT) for up to one month in patients at high thrombotic risk. It is unclear how to select these high-risk patients. AIMS The aim of this study was to identify patients at high thrombotic risk who might benefit from TAT over double antithrombotic therapy (DAT). METHODS This study was a post hoc subanalysis of the RE-DUAL PCI trial. A Cox proportional hazards model was built by stepwise selection of plausible predictor variables for a composite ischaemic endpoint, defined as cardiovascular death, myocardial infarction (MI), stent thrombosis (ST) or ischaemic stroke. The effect of TAT versus DAT was calculated for those patients with the highest proportion of predicted thrombotic risk. A simplified risk score was constructed based on beta-coefficients. RESULTS For 209 patients (7.7%) the composite ischaemic endpoint occurred during the first year. The simplified risk score contained six variables. In patients with a score ≥5 (n=154, 5.7%), a significant reduction in the composite of MI and ST was observed with TAT versus DAT (6.3% vs 21.0%, p=0.041), without a penalty in terms of bleeding. In patients at low thrombotic risk, a significant increase in bleeding was observed without a reduction of ischaemic events. CONCLUSIONS Our findings support the use of DAT in the majority of patients. A small subgroup of patients might benefit from TAT and we propose a novel clinical risk score to select these patients.
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Affiliation(s)
- Bastiaan Zwart
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | | | | | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deepak L. Bhatt
- Heart & Vascular Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher P. Cannon
- Heart & Vascular Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jurriën Maria ten Berg
- Dept. of Cardiology, St Antonius Hospital Nieuwegein, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
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SEA 2022 Standards for Global Control of Cardiovascular Risk. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2022; 34:130-179. [PMID: 35090775 DOI: 10.1016/j.arteri.2021.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 10/27/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023]
Abstract
One of the objectives of the Spanish Society of Arteriosclerosis is to contribute to better knowledge of vascular disease, its prevention and treatment. It is well known that cardiovascular diseases are the leading cause of death in our country and entail a high degree of disability and health care costs. Arteriosclerosis is a multifactorial disease and therefore its prevention requires a global approach that takes into account the different risk factors with which it is associated. Therefore, this document summarizes the current level of knowledge and includes recommendations and procedures to be followed in patients with established cardiovascular disease or at high vascular risk. Specifically, this document reviews the main symptoms and signs to be evaluated during the clinical visit, the laboratory and imaging procedures to be routinely requested or requested for those in special situations. It also includes vascular risk estimation, the diagnostic criteria of the different entities that are cardiovascular risk factors, and makes general and specific recommendations for the treatment of the different cardiovascular risk factors and their final objectives. Finally, the document includes aspects that are not usually referenced in the literature, such as the organization of a vascular risk consultation.
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Antithrombotic Strategies in Patients with Atrial Fibrillation and Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention. J Clin Med 2022; 11:jcm11030512. [PMID: 35159964 PMCID: PMC8836736 DOI: 10.3390/jcm11030512] [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: 12/16/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 02/04/2023] Open
Abstract
Patients with atrial fibrillation (AF) are at increased risk for coronary artery disease (CAD). After percutaneous coronary intervention (PCI), the antithrombotic therapy consists of a combination of anticoagulant and antiplatelet agents to reduce the ischemic and thromboembolic risk, at the cost of increased bleeding events. In the past few years, several randomized clinical trials involving over 12,000 patients have been conducted to compare the safety of vitamin K antagonist (VKA) and direct-acting oral anticoagulants (DOACs) in association with a single- or double-antiplatelet agent, in the so-called dual- (DAT) or triple-antithrombotic therapy (TAT). These studies and several meta-analyses showed a consistent benefit for reducing bleeding events of DAT over TAT and of DOAC over VKA, without concerns about ischemic endpoints, except for a trend for increased stent thrombosis risk. The present paper examines current international guidelines’ recommendations and reviews clinical trials, meta-analyses, and observational studies conducted on AF patients treated with DAT or TAT after PCI for acute coronary syndromes.
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AlShoaibi N, Al Harbi M, Modaimegh H, Al Qubbany A, Al Saif S, Connolly DL, Kharabsheh S, Fathy M, Hegazy Y, Tarcha N, Al Fagih A. Use of NOACS in high-risk patients with atrial fibrillation in Saudi Arabia: Perspectives on improving patient care. Expert Rev Cardiovasc Ther 2021; 19:221-236. [PMID: 33475462 DOI: 10.1080/14779072.2021.1878878] [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: 10/22/2022]
Abstract
BACKGROUND Despite the widespread and increasing use of NOACs in Saudi Arabia, there is a lack of contemporary guidance specific to the region. In particular, guidance on NOAC use in high-risk patients who are more likely to experience bleeding with oral anticoagulant therapy is needed. There is an unmet need for a review of contemporary evidence coupled with expert insights on safe and effective NOAC use in high-risk patients with AF in Saudi Arabia. RESEARCH DESIGN AND METHODS This article provides a detailed review of contemporary literature on NOAC use in high-risk patients with AF. Additionally, key gaps in the literature are identified and expert insights are shared to guide effective management of patients and the significance of local data is evaluated with respect to challenges in optimizing the use of NOACs. CONCLUSIONS This article provides information that complements and expands on existing reviews and guidelines on NOAC use in patients with AF, with a focus on challenges specific to the Saudi Arabian context with the potential to make a positive contribution to the medical community in Saudi Arabia and in other nations.
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Affiliation(s)
| | - M Al Harbi
- King Fahad Specialist Hospital, Dammam KSA
| | | | - A Al Qubbany
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Research Center, Jeddah, KSA.,Ministry of National Guard, KSA
| | | | - D L Connolly
- Birmingham City Hospital & the Institute of Cardiovascular Sciences, University of Birmingham, UK
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Liu X, Wang L, Zhou M, Feng L. Efficacy and safety of rivaroxaban and ticagrelor in elderly patients with atrial fibrillation undergoing percutaneous coronary intervention. Contemp Clin Trials 2021; 104:106365. [PMID: 33746024 DOI: 10.1016/j.cct.2021.106365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/28/2021] [Accepted: 03/15/2021] [Indexed: 11/20/2022]
Abstract
AIMS To compare the efficacy and safety of a dual therapy (rivaroxaban and ticagrelor) with a triple therapy (aspirin, clopidogrel and warfarin) in Chinese elderly patients with nonvalvular atrial fibrillation (NVAF) undergoing percutaneous coronary intervention (PCI). METHODS A total of 106 elderly Chinese patients with NAVF after PCI were randomly divided into a dual therapy group treated with ticagrelor 90 mg twice daily and rivaroxaban 15 mg once daily after PCI, and a triple therapy group treated with aspirin 100 mg and clopidogrel 75 mg once daily combined with the dose-adjusted vitamin K antagonist warfarin once daily. The mean follow-up time was 1 year. The primary endpoint was the composite death rate from cardiovascular causes, myocardial infarction, stroke or stent thrombosis. The safety endpoint was clinically significant bleeding (a composite value of major, minor and minimal bleeding). RESULTS There were no significant differences between the 2 groups regarding the basic characteristics of the patients. The primary composite endpoint of the dual therapy group after 1 year was not significantly different from the triple therapy group (16.7% vs 15.2%, P = 0.86; HR 1.02; 95% CI: 0.82-1.24), but there was a significant difference in the incidence of hemorrhage (7.4% vs 26.9% P = 0.01; HR 0.71; 95% CI: 0.62-0.83) between the 2 groups. CONCLUSIONS In elderly Chinese patients with NVAF undergoing PCI, the efficacy of dual (ticagrelor plus rivaroxaban) treatments was comparable to the triple antithrombotic regime (warfarin plus dual antiplatelet therapy). The overall incidence of bleeding was significantly reduced with dual treatment compared to the triple treatment regime.
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Affiliation(s)
- Xinbing Liu
- Department of Cardiology, Shanghai Shi Dong Hospital, Shanghai 200438, China
| | - Linlin Wang
- Department of Critical Care Medicine, Shanghai Shi Dong Hospital, Shanghai 200438, China.
| | - Mingcheng Zhou
- Department of Cardiology, The First Rehabilitation Hospital of Shanghai, Shanghai 200090, China
| | - Liuliu Feng
- Department of Cardiology, Shanghai Shi Dong Hospital, Shanghai 200438, China
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Qiu M, Liu SY, Zhou HR. Double antithrombotic therapy for prevention of bleeding and ischemic events after percutaneous coronary intervention in patients with atrial fibrillation: A meta-analysis. Medicine (Baltimore) 2021; 100:e24188. [PMID: 33429808 PMCID: PMC7793444 DOI: 10.1097/md.0000000000024188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/12/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The efficacy of double antithrombotic therapy (DAT) vs. triple antithrombotic therapy (TAT) for prevention of bleeding and ischemic events in patients with atrial fibrillation following percutaneous coronary intervention (PCI) is unclear in those subgroups defined by the 5 factors (i.e., sex, age, race, history of diabetes, and type of P2Y12 inhibitor). We aimed to assess the efficacy of DAT vs TAT in these patient subgroups. METHODS We searched PubMed and relevant websites to include related randomized controlled trials (RCTs). Two endpoints of interest were clinically significant bleeding and major adverse cardiac events (MACE). Meta-analysis was performed stratified by 5 factors of interest (i.e., sex, age, race, history of diabetes, and type of P2Y12 inhibitor) to obtain pooled hazard ratio (HR) and 95% confidence interval (CI). Meta-regression analysis was conducted to evaluate subgroup effects. We detected publication bias by Egger test and funnel plots. RESULTS We included 4 RCTs for meta-analysis. DAT vs TAT significantly reduced the risk of clinically significant bleeding (HR 0.56, 95% CI 0.50-0.63). This effect of DAT was observed in most subgroups of interest (HR ranged from 0.54 to 0.69), and was consistent across various subgroups defined by each of the 5 factors of interest (Psubgroup ranged from 0.290 to 0.794). DAT vs TAT led to the similar risk of MACE (HR 0.98, 95% CI 0.89-1.08). This effect of DAT was observed in all subgroups of interest (all 95% CIs of HRs were across 1.0), and was consistent across various subgroups defined by each of the 5 factors of interest (Psubgroup ranged from 0.308 to 0.828). Publication bias was found only in one subgroup. CONCLUSIONS Compared with TAT, DAT significantly reduces the risk of clinically significant bleeding and leads to the similar risk of MACE in patients with atrial fibrillation following PCI, irrespective of sex, age, race, history of diabetes, and type of P2Y12 inhibitor used at baseline.
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Affiliation(s)
- Mei Qiu
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen
| | - Shu-Yan Liu
- Department of Cardiology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Hai-Rong Zhou
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen
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Ricottini E, Nenna A, Melfi R, Giannone S, Lusini M, Sciascio GD, Chello M, Ussia GP, Grigioni F. Antithrombotic treatment in patients with atrial fibrillation undergoing coronary angioplasty: rational convincement and supporting evidence. Eur J Intern Med 2020; 77:44-51. [PMID: 32063489 DOI: 10.1016/j.ejim.2020.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The management of antithrombotic therapy in patients undergoing percutaneous coronary intervention (PCI) with an indication for long-term oral anticoagulant therapy (OAT) is still a matter of debate. We aim to evaluate the safety and the efficacy of dual therapy (DT) compared to triple therapy (TT) in this clinical setting. METHODS A study level meta-analysis and a review of randomized trials selected using PubMed, Embase, EBSCO, Cochrane database of systematic reviews, Web of Science, and abstract from major cardiology congresses. Six randomized trials with 12,156 patients evaluating the strategy of DT vs. TT in patients treated with PCI with indication for long-term OAT were included. RESULTS Patients treated with DT demonstrated a 45% relative reduction in the risk of TIMI major bleeding (1.71% vs. 2.99%; OR 0.55, 95% CI 0.41-0.71; P<0.0001) and TIMI minor bleeding compared to TT arm (4.67% vs 7.83%, OR 0.55 95% CI 0.39-0.78, P = 0.0007). All-cause mortality was similar in two arms (3.95% vs 3.77%, P = 0.92), as well as cardiovascular mortality (2.21% vs 2.19%, P = 0.97). DT was associated with a borderline increase of ST (1.02% vs 0.67%, P = 0.07). No significant differences were observed in occurrence of MI and stroke. CONCLUSIONS Our findings suggest that DT is safer than TT with regard to occurrence of major bleeding. DT with a direct oral anticoagulant plus clopidogrel at discharge could be effective in most patients, maintaining aspirin in periprocedural phase and as longer "tailored" treatment for patients at higher ischemic risk.
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Affiliation(s)
- Elisabetta Ricottini
- Unit of Cardiovascular Sciences, Department of Medicine Campus Bio-Medico University of Rome, Via Álvaro del Portillo, 200 - 00128 Rome Italy.
| | - Antonio Nenna
- Unit of Heart Surgery, Department of Medicine, Campus Bio-Medico University of Rome, Italy
| | - Rosetta Melfi
- Unit of Cardiovascular Sciences, Department of Medicine Campus Bio-Medico University of Rome, Via Álvaro del Portillo, 200 - 00128 Rome Italy
| | - Sara Giannone
- Unit of Cardiovascular Sciences, Department of Medicine Campus Bio-Medico University of Rome, Via Álvaro del Portillo, 200 - 00128 Rome Italy
| | - Mario Lusini
- Unit of Heart Surgery, Department of Medicine, Campus Bio-Medico University of Rome, Italy
| | - Germano Di Sciascio
- Unit of Cardiovascular Sciences, Department of Medicine Campus Bio-Medico University of Rome, Via Álvaro del Portillo, 200 - 00128 Rome Italy
| | - Massimo Chello
- Unit of Heart Surgery, Department of Medicine, Campus Bio-Medico University of Rome, Italy
| | - Gian Paolo Ussia
- Unit of Cardiovascular Sciences, Department of Medicine Campus Bio-Medico University of Rome, Via Álvaro del Portillo, 200 - 00128 Rome Italy
| | - Francesco Grigioni
- Unit of Cardiovascular Sciences, Department of Medicine Campus Bio-Medico University of Rome, Via Álvaro del Portillo, 200 - 00128 Rome Italy
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Antithrombotic Therapy in Patients With Atrial Fibrillation and Coronary Artery Disease Undergoing Percutaneous Coronary Intervention. J Cardiovasc Pharmacol 2020; 74:82-90. [PMID: 31306367 DOI: 10.1097/fjc.0000000000000697] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AIM The objective of this article is to review the contemporary literature on the use of antithrombotic therapy in patients with atrial fibrillation (AF) and coronary artery disease after undergoing percutaneous coronary intervention (PCI). Special consideration was given to the type and duration of therapy, treatment strategies for the elderly (≥65 years of age), and strategies to reduce bleeding. METHODS Relevant studies were searched through MEDLINE/PubMed, Web of Science, Cochrane Library, ClinicalTrials.gov, and Google Scholar. Of the 236 publications retrieved, 76 were considered relevant including 35 randomized controlled trials, 17 meta-analyses, 16 observational studies, and 8 published major guidelines. RESULTS Most trials, meta-analyses, and guidelines support 1 month of triple therapy (TT) with an oral anticoagulant (OAC), dual antiplatelet agents (DAPT) with aspirin (ASA)/clopidogrel, and, afterward, dual therapy (DT) with OAC and single antiplatelet agent for an additional 11 months, or alternatively DT alone for 12 months after PCI. Individual consideration is given to the risk and impact of stent thrombosis (ST), thromboembolism, and bleeding. Several trials and meta-analyses have also suggested that shorter DAPT duration (≤6 months) may be safer than longer therapy (≥6 months) when weighing the risk of bleeding with ischemic outcomes, especially with newer generation drug-eluting stents. The selective use of proton-pump inhibitors in patients prone to gastrointestinal bleeding who are subjected to prolonged exposure with TT or DT may be beneficial. In the elderly, the risk of bleeding from TT, compared with DT, outweighs the benefit of reducing ischemic events. CONCLUSIONS In conclusion, tailoring therapy to the individual patient is recommended considering the ischemic and bleeding risk as well as the risk of thromboembolism. For most patients with AF, 1 month of TT and subsequently DT for additional 11 months are recommended.
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Omission of aspirin in patients taking oral anticoagulation after percutaneous coronary intervention: a systematic review and meta-analysis. Coron Artery Dis 2020; 30:109-115. [PMID: 30629002 DOI: 10.1097/mca.0000000000000698] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is no consensus on optimal antiplatelet and anticoagulation therapy after coronary stenting. METHODS We identified randomized controlled trials (RCTs) published in PubMed, Cochrane Library, and Embase using the following keywords: 'antiplatelet', 'dual therapy', 'triple therapy', 'antithrombosis', 'indication for anticoagulation', 'percutaneous coronary intervention', and 'RCTs'. Primary safety end points were relative bleeding events, and secondary efficacy end points were major adverse cardiovascular events including stent thrombosis, death, myocardial infarction, and stroke. RESULTS We identified three RCTs including 5387 patients, of whom 2719 (50.5%) received dual therapy (DT) and 2668 (49.5%) received triple therapy. Relative to triple therapy, DT was associated with lower Thrombolysis in Myocardial Infarction major bleeding [risk ratio (RR): 0.58; 95% confidence interval (CI): 0.42-0.82], Thrombolysis in Myocardial Infarction minor bleeding (RR: 0.46; 95% CI: 0.34-0.62), and clinical bleeding events (RR: 0.61; 95% CI: 0.47-0.81). There was no significant difference for the secondary efficacy end point. In subgroup analyses, results were similar by sex, bleeding risk, and stent type; however, DT appeared suitable for patients aged less than 75 years but not more than or equal to 75 years, implying that there may be no ideal therapy for patients older than 75 years to balance the risk of ischemia and bleeding at the same time. CONCLUSION Among patients with an indication for oral anticoagulation after percutaneous coronary intervention, DT appears to be the optimal strategy.
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Galli M, Andreotti F, D'Amario D, Vergallo R, Montone RA, Niccoli G, Crea F. Randomised trials and meta-analyses of double vs triple antithrombotic therapy for atrial fibrillation-ACS/PCI: A critical appraisal. IJC HEART & VASCULATURE 2020; 28:100524. [PMID: 32435688 PMCID: PMC7229495 DOI: 10.1016/j.ijcha.2020.100524] [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: 02/18/2020] [Revised: 04/19/2020] [Accepted: 04/20/2020] [Indexed: 12/21/2022]
Abstract
The optimal antithrombotic regimen to be used in patients with AF and PCI or ACS is still debated. Each of the six randomised controlled trials comparing double to triple therapy has limitations. None was powered to assess differences between treatment arms in ischaemic event rates. The contrasting results regarding ischaemic events within published meta-analyses can be explained by heterogeneity, incompleteness and varying definitions of stent thrombosis. The overall reduced bleeding rates, but increased early definite and probable stent thrombosis rates with double versus triple antithrombotic therapy encourage consideration of triple therapy during the first weeks from PCI followed by double therapy.
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Affiliation(s)
- Mattia Galli
- Department of Cardiovascular Sciences, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Felicita Andreotti
- Department of Cardiovascular Sciences, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico D'Amario
- Department of Cardiovascular Sciences, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Rocco Vergallo
- Department of Cardiovascular Sciences, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Rocco A Montone
- Department of Cardiovascular Sciences, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Giampaolo Niccoli
- Department of Cardiovascular Sciences, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular Sciences, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
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12
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Terlouw LG, Moelker A, Abrahamsen J, Acosta S, Bakker OJ, Baumgartner I, Boyer L, Corcos O, van Dijk LJD, Duran M, Geelkerken RH, Illuminati G, Jackson RW, Kärkkäinen JM, Kolkman JJ, Lönn L, Mazzei MA, Nuzzo A, Pecoraro F, Raupach J, Verhagen HJM, Zech CJ, van Noord D, Bruno MJ. European guidelines on chronic mesenteric ischaemia - joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia. United European Gastroenterol J 2020; 8:371-395. [PMID: 32297566 PMCID: PMC7226699 DOI: 10.1177/2050640620916681] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/08/2020] [Indexed: 12/24/2022] Open
Abstract
Chronic mesenteric ischaemia is a severe and incapacitating disease, causing complaints of post-prandial pain, fear of eating and weight loss. Even though chronic mesenteric ischaemia may progress to acute mesenteric ischaemia, chronic mesenteric ischaemia remains an underappreciated and undertreated disease entity. Probable explanations are the lack of knowledge and awareness among physicians and the lack of a gold standard diagnostic test. The underappreciation of this disease results in diagnostic delays, underdiagnosis and undertreating of patients with chronic mesenteric ischaemia, potentially resulting in fatal acute mesenteric ischaemia. This guideline provides a comprehensive overview and repository of the current evidence and multidisciplinary expert agreement on pertinent issues regarding diagnosis and treatment, and provides guidance in the multidisciplinary field of chronic mesenteric ischaemia.
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Affiliation(s)
- Luke G Terlouw
- Department of Gastroenterology and Hepatology, Erasmus MC
University Medical Center, Rotterdam, the Netherlands
- Department of Radiology, Erasmus MC University Medical Center,
Rotterdam, the Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus MC University Medical Center,
Rotterdam, the Netherlands
| | - Jan Abrahamsen
- Department of Clinical Physiology, Viborg Regional Hospital,
Viborg, Denmark
| | - Stefan Acosta
- Department of Clinical Sciences Malmö, Lund University, Lund,
Sweden
- Department of Cardio‐Thoracic and Vascular Surgery, Skane
University Hospital, Malmö, Sweden
| | - Olaf J Bakker
- Department of Vascular Surgery, Sint Antonius hospital,
Nieuwegein, the Netherlands
- Department of Vascular Surgery, University Hospital Leipzig,
Leipzig, Germany
| | - Iris Baumgartner
- Division of Angiology, Swiss Cardiovascular Center, Inselspital,
Bern University Hospital, University of Bern, Bern, Switzerland
| | - Louis Boyer
- Department of Diagnostic and Interventional Radiology, Montpied
University Hospital, Clermont‐Ferrand, France
| | - Olivier Corcos
- Department of Gastroenterology, Intestinal Stroke Center,
Hopital Beaujon APHP, Clichy, France
| | - Louisa JD van Dijk
- Department of Gastroenterology and Hepatology, Erasmus MC
University Medical Center, Rotterdam, the Netherlands
| | - Mansur Duran
- Department of Vascular and Endovascular Surgery, Marienhospital
Gelsenkirchen, Gelsenkirchen, Germany
| | - 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
| | - Giulio Illuminati
- Department of Surgical Sciences, University of Rome La
Sapienza, Rome, Italy
| | - Ralph W Jackson
- Department of Interventional Radiology, Newcastle upon Tyne
Hospitals NHS Foundation Trust, UK
| | - Jussi M Kärkkäinen
- Heart Center, Kuopio University Hospital, Kuopio, Finland
- Department of Vascular Surgery, Mayo Clinic, Rochester, MN,
USA
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum
Twente, Enschede, the Netherlands
- Department of Gastroenterology and Hepatology, University
Medical Center Groningen, Groningen, the Netherlands
| | - Lars Lönn
- Department of Radiology, University of Copenhagen, Copenhagen,
Denmark
| | - Maria A Mazzei
- Department of Medical, Surgical and Neuro Sciences, Diagnostic
Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena,
Italy
| | - Alexandre Nuzzo
- Department of Gastroenterology, Hopital Beaujon APHP, Clichy,
France
| | - Felice Pecoraro
- Department of Surgical Oncological and Oral Sciences,
University of Palermo, Vascular Surgery Unit, AOUP ‘P. Giaccone’ Palermo,
Palermo, Italy
| | - Jan Raupach
- Department of Radiology, University Hospital Hradec Kralove,
Hradec Kralove, Czech Republic
| | - Hence JM Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical
Center, Rotterdam, the Netherlands
| | - Christoph J Zech
- Radiology and Nuclear Medicine, University of Basel, Basel,
Switzerland
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Franciscus
Gasthuis and Vlietland, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC
University Medical Center, Rotterdam, the Netherlands
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13
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Chua SK, Chen LC, Shyu KG, Cheng JJ, Hung HF, Chiu CZ, Lin CM. Antithrombotic Strategies in Patients with Atrial Fibrillation Following Percutaneous Coronary Intervention: A Systemic Review and Network Meta-Analysis of Randomized Controlled Trials. J Clin Med 2020; 9:jcm9041062. [PMID: 32276535 PMCID: PMC7231136 DOI: 10.3390/jcm9041062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 12/16/2022] Open
Abstract
Up to 10% of patients with atrial fibrillation (AF) undergo percutaneous coronary intervention (PCI). A systematic review and network meta-analysis were conducted by searching PubMed, Embase, and the Cochrane database of systematic reviews for randomized control trials that studied the safety and efficacy of different antithrombotic strategies in these patients. Six studies, including 12,158 patients were included. Compared to that in the triple antithrombotic therapy group (vitamin K antagonist (VKA) plus P2Y12 inhibitor and aspirin), thrombolysis in myocardial infarction (TIMI) major bleeding was significantly reduced in the dual antithrombotic therapy (non-vitamin K oral anticoagulants (NOACs) plus P2Y12 inhibitor) group by 47% (Odds ratio (OR), 0.53; 95% credible interval [CrI], 0.35–0.78; I2 = 0%). Besides, NOAC plus a P2Y12 inhibitor was associated with less intracranial hemorrhage compared to VKA plus single antiplatelet therapy (OR: 0.20, 95% CrI: 0.05–0.77). There was no significant difference in the trial-defined major adverse cardiac events or the individual outcomes of all-cause mortality, cardiovascular death, myocardial infarction, stroke or stent thrombosis among all antithrombotic strategies. In conclusion, antithrombotic strategy of NOACs plus P2Y12 inhibitor is safer than, and as effective as, the strategies including aspirin when used in AF patients undergoing PCI.
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Affiliation(s)
- Su-Kiat Chua
- School of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan;
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Lung-Ching Chen
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Kou-Gi Shyu
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Jun-Jack Cheng
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Huei-Fong Hung
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Chiung-Zuan Chiu
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Correspondence: (C.-Z.C.); (C.-M.L.); Tel.: +886–2–2833–2211 (C.-Z.C. & C.-M.L.)
| | - Chiu-Mei Lin
- School of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan;
- Department of Emergency Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Correspondence: (C.-Z.C.); (C.-M.L.); Tel.: +886–2–2833–2211 (C.-Z.C. & C.-M.L.)
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14
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Sychev DA, Baturina OA, Mirzaev KB, Rytkin E, Ivashchenko DV, Andreev DA, Ryzhikova KA, Grishina EA, Bochkov PO, Shevchenko RV. CYP2C19*17 May Increase the Risk of Death Among Patients with an Acute Coronary Syndrome and Non-Valvular Atrial Fibrillation Who Receive Clopidogrel and Rivaroxaban. Pharmgenomics Pers Med 2020; 13:29-37. [PMID: 32158254 PMCID: PMC6986167 DOI: 10.2147/pgpm.s234910] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/03/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION The aim of this study is to assess the influence of gene CYP2C19, CYP3A4, CYP3A5 and ABCB1 polymorphisms on clopidogrel antiplatelet activity, rivaroxaban concentration equilibrium, and clinical outcomes among patients with acute coronary syndrome and non-valvular atrial fibrillation. METHODS In the multicenter prospective registry study of the efficacy and safety of a combined antithrombotic therapy 103 patients with non-valvular atrial fibrillation both undergoing or not a percutaneous coronary intervention were enrolled. The trial assessed the primary outcomes (major bleeding, in-hospital death, cardiovascular death, stroke\transient ischaemic attack, death/renal insufficiency) and secondary outcomes (platelet reactivity units (PRU), rivaroxaban concentration). RESULTS For none of the clinical outcomes when combined with other covariates, the carriership of polymorphisms CYP3A5*3 rs776746, CYP2C19*2 rs4244285;*17 rs12248560, ABCB1 3435 C>T, ABCB1 rs4148738 was significant. None of the markers under study (CYP3A5*3 rs776746, CYP2C19*2 rs4244285, *17 rs12248560, ABCB1 3435 C>T, ABCB1 rs4148738) has proven to affect rivaroxaban equilibrium concentration in blood plasma among patients with atrial fibrillation and acute coronary syndrome. CONCLUSION In situations of double or triple antithrombotic rivaroxaban and clopidogrel therapy among patients with atrial fibrillation and acute coronary syndrome, the genetic factors associated with bleeding complications risk (CYP2C19*17) may prove to be clinically relevant.
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Affiliation(s)
- D A Sychev
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | | | - K B Mirzaev
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - E Rytkin
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - D V Ivashchenko
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - D A Andreev
- Sechenov University, Moscow, Russian Federation
| | - K A Ryzhikova
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - E A Grishina
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - P O Bochkov
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - R V Shevchenko
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
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15
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Agarwal N, Mahmoud AN, Mojadidi MK, Golwala H, Elgendy IY. Dual versus triple antithrombotic therapy in patients undergoing percutaneous coronary intervention-meta-analysis and meta-regression. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:1134-1139. [DOI: 10.1016/j.carrev.2019.02.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 01/06/2019] [Accepted: 02/19/2019] [Indexed: 11/27/2022]
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16
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Sullivan AE, Nanna MG, Rao SV, Cantrell S, Gibson CM, Verheugt FWA, Peterson ED, Lopes RD, Alexander JH, Granger CB, Yee MK, Kong DF. A systematic review of randomized trials comparing double versus triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2019; 96:E102-E109. [PMID: 31713326 DOI: 10.1002/ccd.28535] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/24/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Prior randomized controlled trials (RCT) evaluating the optimal antithrombotic therapies for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) have not been powered to evaluate ischemic outcomes. We compared double therapy with oral anticoagulation (OAC) and a P2Y12 inhibitor to triple therapy with an OAC + dual antiplatelet therapy in patients with AF requiring PCI. METHODS Using PRISMA guidelines, we searched for RCTs including patients with AF as an indication for OAC and undergoing PCI or medical management of acute coronary syndrome. The results were pooled using fixed-effects and random-effects models to estimate the overall effect of double therapy versus triple therapy on ischemic and bleeding outcomes. RESULTS We identified four RCTs, comprising 10,238 patients (5,498 double therapy, 4,740 triple therapy). Trial-reported major adverse cardiovascular events were similar between double therapy and triple therapy (fixed effect model OR 1.09, 95% CI 0.94-1.26). However, stent thrombosis (61/5,496 double therapy vs. 33/4738 triple therapy; fixed effect model OR 1.57, 95% CI 1.02-2.40; number needed to treat with triple therapy = 242) favored triple therapy. Bleeding outcomes were less frequent with double therapy (746/5470 vs. 950/4710; fixed effect model OR 0.59, 95% CI 0.53-0.65; number needed to harm with triple therapy = 16), but with significant heterogeneity (Q = 8.33, p = .04; I2 = 64%), as were intracranial hemorrhages (19/5470 vs. 30/4710; fixed effect model OR 0.54, 95% CI 0.31-0.96). CONCLUSIONS Double therapy in patients with AF requiring OAC following PCI or Acute coronary syndrome has a significantly better safety profile than triple therapy but may be associated with a modest increased risk of stent thrombosis.
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Affiliation(s)
- Alexander E Sullivan
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sunil V Rao
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sarah Cantrell
- Duke University School of Medicine, Durham, North Carolina
| | - C Michael Gibson
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Eric D Peterson
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Renato D Lopes
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - John H Alexander
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Christopher B Granger
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Megan K Yee
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - David F Kong
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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17
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Atti V, Turagam MK, Garg J, Velagapudi P, Patel NJ, Basir MB, Mujer MTP, Rayamajhi S, Abela GS, Koerber S, Gopinnathanair R, Lakkireddy D. Efficacy and safety of single vs dual antiplatelet therapy in patients on anticoagulation undergoing percutaneous coronary intervention: A systematic review and meta‐analysis. J Cardiovasc Electrophysiol 2019; 30:2460-2472. [DOI: 10.1111/jce.14132] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/23/2019] [Accepted: 07/29/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Varunsiri Atti
- Department of Medicine Michigan State University‐Sparrow Hospital East Lansing Michigan
| | - Mohit K. Turagam
- Department of Cardiovascular Diseases Icahn School of Medicine at Mount Sinai New York City New York
| | - Jalaj Garg
- Department of Cardiovascular Diseases Icahn School of Medicine at Mount Sinai New York City New York
| | - Poonam Velagapudi
- Department of Cardiovascular Diseases University of Nebraska Medical Center Omaha Nebraska
| | - Nileshkumar J Patel
- Department of Cardiovascular Diseases Icahn School of Medicine at Mount Sinai New York City New York
| | - Mir B Basir
- Department of Cardiovascular Diseases Henry Ford Health System Detroit Michigan
| | - Mark TP Mujer
- Department of Medicine Michigan State University‐Sparrow Hospital East Lansing Michigan
| | - Supratik Rayamajhi
- Department of Medicine Michigan State University‐Sparrow Hospital East Lansing Michigan
| | - George S Abela
- Division of Cardiovascular Diseases, Department of Medicine Michigan State University East Lansing Michigan
| | - Scott Koerber
- Department of Cardiovascular Diseases University of South Carolina Medical Center Charleston South Carolina
| | - Rakesh Gopinnathanair
- Department of Cardiovascular Diseases Kansas City Heart Rhythm Institute and Research Foundation Kansas City Missouri
| | - Dhanunjaya Lakkireddy
- Department of Cardiovascular Diseases Kansas City Heart Rhythm Institute and Research Foundation Kansas City Missouri
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18
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Siddiqi R, Yamani N, Alnaimat S, Khurshid A, Siddiqui S, Khan MS, Khan SU. Meta-analysis of antithrombotic therapy with new oral anticoagulants in patients with atrial fibrillation after percutaneous coronary intervention. Eur J Prev Cardiol 2019; 27:2119-2122. [PMID: 31349774 DOI: 10.1177/2047487319865048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rabbia Siddiqi
- Dow Medical College, Dow University of Health Sciences, Pakistan
| | - Naser Yamani
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Saed Alnaimat
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Aiman Khurshid
- Department of Medicine, Jinnah Sindh Medical University, Pakistan
| | - Sadia Siddiqui
- Department of Medicine, Jinnah Sindh Medical University, Pakistan
| | - Mohammad Saud Khan
- Department of Internal Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Safi U Khan
- Department of Internal Medicine, West Virginia University, Morgantown, WV, USA
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19
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Andrade JG, Verma A, Mitchell LB, Parkash R, Leblanc K, Atzema C, Healey JS, Bell A, Cairns J, Connolly S, Cox J, Dorian P, Gladstone D, McMurtry MS, Nair GM, Pilote L, Sarrazin JF, Sharma M, Skanes A, Talajic M, Tsang T, Verma S, Wyse DG, Nattel S, Macle L. 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2019; 34:1371-1392. [PMID: 30404743 DOI: 10.1016/j.cjca.2018.08.026] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 11/19/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) Atrial Fibrillation Guidelines Committee provides periodic reviews of new data to produce focused updates that address clinically important advances in atrial fibrillation (AF) management. This 2018 Focused Update addresses: (1) anticoagulation in the context of cardioversion of AF; (2) the management of antithrombotic therapy for patients with AF in the context of coronary artery disease; (3) investigation and management of subclinical AF; (4) the use of antidotes for the reversal of non-vitamin K antagonist oral anticoagulants; (5) acute pharmacological cardioversion of AF; (6) catheter ablation for AF, including patients with concomitant AF and heart failure; and (7) an integrated approach to the patient with AF and modifiable cardiovascular risk factors. The recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards. Individual studies and literature were reviewed for quality and bias; the literature review process and evidence tables are included as Supplementary Material and are available on the CCS Web site. Details of the updated recommendations are presented, along with their background and rationale. This document is linked to an updated summary of all CCS AF guidelines recommendations, from 2010 to the present 2018 Focused Update, which is provided in the Supplementary Material.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - L Brent Mitchell
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Ratika Parkash
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kori Leblanc
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Clare Atzema
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Jeff S Healey
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Stuart Connolly
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Jafna Cox
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Gladstone
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - M Sean McMurtry
- University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Louise Pilote
- McGill University Health Centre, Montréal, Quebec, Canada
| | | | - Mike Sharma
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Allan Skanes
- London Heart Institute, Western University, London, Ontario, Canada
| | - Mario Talajic
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Teresa Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Subodh Verma
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D George Wyse
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Stanley Nattel
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Laurent Macle
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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20
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Murai K, Sakata K, Gamou T, Nagata Y, Tada H, Shimojima M, Okada H, Hayashi K, Kawashiri MA. Acute myocardial infarction in a patient positive for lupus anticoagulant: a case report. BMC Cardiovasc Disord 2019; 19:167. [PMID: 31299896 PMCID: PMC6626341 DOI: 10.1186/s12872-019-1153-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 07/09/2019] [Indexed: 11/16/2022] Open
Abstract
Background Autoimmune diseases, such as systemic lupus erythematosus (SLE), are associated with thrombosis and atherosclerosis. Presence of lupus anticoagulant is an independent risk factor for atherosclerotic diseases. Case presentation A 56-year-old man with past history of hypertension, and cerebral infarction was admitted to our hospital owing to acute chest pain. He was diagnosed with acute myocardial infarction based on his symptoms and electrocardiogram results, which demonstrated ST elevation in the precordial leads. Coronary angiography images revealed total occlusion at the proximal site of the left anterior descending artery. A drug-eluting stent was deployed, which successfully recovered coronary blood flow. The patient had fever of unknown cause when he was 30 years old; on admission, he presented with a low-grade fever and reddish exanthema affecting both cheeks. Based on his physical signs as well as elevated antinuclear antibodies (anti-double-stranded DNA), decreased lymphocytes, and a positive direct Coombs test, he was diagnosed with SLE. Owing to a positive lupus anticoagulant test, he was also suspected to have antiphospholipid syndrome (APS). Triple antithrombotic therapy, including dual antiplatelet therapy with aspirin and clopidogrel during coronary stenting and single anticoagulation therapy with warfarin, was initiated. Conclusions Careful diagnosis of autoimmune diseases should be performed in patients with thrombosis and atherosclerosis. Moreover, risk factors for coronary artery disease should be strictly controlled in patients with APS.
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Affiliation(s)
- Kota Murai
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1 Takara-machi, Kanazawa, 920-8640, Japan
| | - Kenji Sakata
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1 Takara-machi, Kanazawa, 920-8640, Japan
| | - Tadatsugu Gamou
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1 Takara-machi, Kanazawa, 920-8640, Japan
| | - Yoji Nagata
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1 Takara-machi, Kanazawa, 920-8640, Japan
| | - Hayato Tada
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1 Takara-machi, Kanazawa, 920-8640, Japan.
| | - Masaya Shimojima
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1 Takara-machi, Kanazawa, 920-8640, Japan
| | - Hirofumi Okada
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1 Takara-machi, Kanazawa, 920-8640, Japan
| | - Kenshi Hayashi
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1 Takara-machi, Kanazawa, 920-8640, Japan
| | - Masa-Aki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1 Takara-machi, Kanazawa, 920-8640, Japan
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21
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Wernly B, Lichtenauer M, Erlinge D, Jung C. Antithrombotic therapy in atrial fibrillation: stop triple therapy and start optimizing dual therapy? Clin Res Cardiol 2019; 109:128-130. [PMID: 31144062 DOI: 10.1007/s00392-019-01496-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 05/16/2019] [Indexed: 01/09/2023]
Affiliation(s)
- Bernhard Wernly
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Michael Lichtenauer
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany.
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22
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Gao X, Ge Z, Kong X, Wang Z, Zuo G, Wang F, Chen S, Zhang J. Clinical Outcomes of Antithrombotic Strategies for Patients with Atrial Fibrillation After Percutaneous Coronary Intervention. Int Heart J 2019; 60:546-553. [PMID: 31105152 DOI: 10.1536/ihj.18-464] [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: 11/18/2022]
Abstract
Antithrombotic strategies for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) remain challenging. This study aims to explore the best antithrombotic strategy for AF patients after PCI based on a network meta-analysis. This study was registered in PROSPERO (CRD42018093928). The PubMed, Cochrane, and EMBASE databases were searched to identify clinical trials concerning antithrombotic therapy for AF patients with PCI from inception to April 2018. Pairwise and network meta-analysis were conducted to compare clinical outcomes of different antithrombotic therapy. The primary endpoint was major bleeding. Fifteen studies including 16,382 patients were identified with follow-up ranging from 3 to 12 months. Non-vitamin K oral anticoagulants (NOAC) plus P2Y12 inhibitor ranked first with a reduced risk of major bleeding compared with vitamin K antagonist (VKA) plus dual antiplatelet therapy (OR: 0.57, 95% CI: 0.43-0.75) but with no significant difference compared with VKA plus single platelet therapy (OR: 0.85, 95% CI: 0.62-1.16). Similar thrombotic events were evident among these groups. Subgroup analysis showed that VKA plus aspirin exhibited a similar risk of major bleeding compared with VKA plus clopidogrel (OR: 0.94, 95% CI: 0.73-1.23) but was associated with increased risks of ischaemic stroke (OR: 2.10, 95% CI: 1.33-3.32) and all-cause death (OR: 1.77, 95% CI: 1.15-2.74) versus VKA plus clopidogrel. In AF patients undergoing PCI, NOAC plus P2Y12 inhibitor and VKA plus clopidogrel, but not VKA plus aspirin, were associated with reduced risk of major bleeding compared with the recommended VKA-based triple therapy, while thrombotic events were similar among these treatments.
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Affiliation(s)
- Xiaofei Gao
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University.,Department of Cardiology, Nanjing Heart Centre
| | - Zhen Ge
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University
| | - Xiangquan Kong
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University
| | - Zhimei Wang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University
| | - Guangfeng Zuo
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University
| | - Feng Wang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University
| | - Shaoliang Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University.,Department of Cardiology, Nanjing Heart Centre
| | - Junjie Zhang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University.,Department of Cardiology, Nanjing Heart Centre
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23
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Kwak S, Yang HM. Antithrombotic Strategy in Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention. J Lipid Atheroscler 2019; 8:8-14. [PMID: 32821695 PMCID: PMC7379079 DOI: 10.12997/jla.2019.8.1.8] [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: 01/31/2019] [Accepted: 04/07/2019] [Indexed: 11/17/2022] Open
Abstract
Choosing antithrombotic regimens for patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI) with stent placement is challenging. Until recently, the guidelines recommended warfarin-based triple therapy, which causes frequent major bleeding events in up to 12% of patients during the first year of treatment. The WOEST trial, however, revealed that dual therapy, by without aspirin, resulted in significantly lower bleeding risks with similar thromboembolic events to triple therapy. Subsequently, efforts to seek the optimal dual therapy regimens, especially with the combination of a non-vitamin K antagonist oral anticoagulant (NOAC), were initiated. This review highlights the evidence for dual therapy using an NOAC for patients with AF who underwent PCI, with an emphasis on reduced bleeding risk.
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Affiliation(s)
- Soongu Kwak
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Han-Mo Yang
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
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24
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Standards for global cardiovascular risk management arteriosclerosis. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2019; 31 Suppl 1:1-43. [PMID: 30981542 DOI: 10.1016/j.arteri.2019.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
One of the main goals of the Spanish Society of Arteriosclerosis is to contribute to a wider and greater knowledge of vascular disease, its prevention and treatment. Cardiovascular diseases are the leading cause of death in our country and also lead to a high degree of disability and health expenditure. Arteriosclerosis is a multifactorial disease, this is why its prevention requires a global approach that takes into account the different risk factors with which it is associated. Thus, this document summarizes the current level of knowledge and integrates recommendations and procedures to be followed for patients with established cardiovascular disease or high vascular risk. Specifically, this document reviews the main symptoms and signs to be evaluated during the clinical visit, the laboratory and imaging procedures to be routinely requested or those in special situations. It also includes the estimation of vascular risk, the diagnostic criteria of the different entities that are cardiovascular risk factors, and presents general and specific recommendations for the treatment of the different cardiovascular risk factors and their final objectives. Finally, the document includes aspects that are not often mentioned in the literature, such as the organisation of a vascular risk consultation.
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25
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Bleeding risk assessment in elderly patients with acute coronary syndrome. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2019; 16:145-150. [PMID: 30923546 PMCID: PMC6431601 DOI: 10.11909/j.issn.1671-5411.2019.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Nowadays, elderly people represent a growing population segment with a well known increased risk of both ischemic and bleeding events. Current acute coronary syndrome guidelines, strongly recommend dual antiplatelet therapy (DAPT) with few specific references for aged patients due to lack of evidence. Patients aged ≥ 75 years are misrepresented in the classic derivation trials cohorts. Strategies to reduce the bleeding risk in this group of patients are urgently needed for the daily clinical practice. Identify the specific age related bleeding risk factors and the importance of an integral geriatric assessment remains challenging. Some of the available in-hospital and out-hospital bleeding risk scores have shown a lower to moderate predictive ability in older patients and no specific tools are developed in elderly population. The importance of an appropriate vascular access choice, type and duration of antiplatelet drugs is crucial to reduce the bleeding risk. Increase radial approaches and short DAPT duration leads to reduce hemorrhages. One interesting subgroup of patients is those who need chronic anticoagulation therapy after percutaneous coronary intervention, due to their very high risk of bleeding. New alternatives as dual therapy with oral anticoagulation and only one antiplatlet drug should be considered. In current review, we evaluate the available evidence about bleeding risk in elderly.
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26
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Galli M, Andreotti F, Savarese G, D'Amario D, Vergallo R, Della Bona R, Calò L, Porto I, Crea F. Dropping aspirin in patients with atrial fibrillation undergoing percutaneous coronary intervention: a jump with a weak parachute? EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 5:55-56. [PMID: 30289484 DOI: 10.1093/ehjcvp/pvy039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Mattia Galli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, Rome, Italy
| | - Felicita Andreotti
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, Rome, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Solnavägen 1, Solna, Sweden
| | - Domenico D'Amario
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, Rome, Italy
| | - Rocco Vergallo
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, Rome, Italy
| | - Roberta Della Bona
- Department of Cardiovascular Diseases, Policlinico Casilino, Via Casilina, 1049, Rome, Italy
| | - Leonardo Calò
- Department of Cardiovascular Diseases, Policlinico Casilino, Via Casilina, 1049, Rome, Italy
| | - Italo Porto
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, Rome, Italy.,Department of Cardiovascular Disease, Ospedale Policlinico San Martino, IRCSS, University of Genova, Largo Rosanna Benzi, 10, Genova GE, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, Rome, Italy
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27
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Antithrombotic Strategies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:3. [DOI: 10.1007/s11936-019-0705-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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28
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Gallet R, Teiger E. [Oral anticoagulants in elderly patients with coronary artery disease and atrial fibrillation]. Ann Cardiol Angeiol (Paris) 2018; 67:404-410. [PMID: 30342831 DOI: 10.1016/j.ancard.2018.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Anti-thrombotic management of percutaneous coronary intervention and atrial fibrillation relies on dual antiplatelet therapy and anticoagulation respectively. Because of people ageing, the coexistence of coronary artery disease and atrial fibrillation is increasing. This coexistence raises concerns about the anti-thrombotic strategy, particularly about the association of dual antiplatelet therapy and anticoagulation, known as triple therapy. This triple therapy is responsible for a dramatic increase in bleeding risk (3-4 fold) especially in elderlies. However, older patients are also at increased risk of ischemic events. In this setting, dual anti-thrombotic strategies combining non-vitamin K oral anticoagulants and a P2Y12 inhibitor have been developed. These strategies provide a net benefit by reducing bleeding events. Therefore, they are becoming an attractive alternative, especially for frailer patient. This article reviews the rational, risks and strategies of anti-thrombotic therapy in elderly people with coronary artery disease and atrial fibrillation.
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Affiliation(s)
- R Gallet
- Unité de cardiologie interventionnelle, CHU de Henri-Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France.
| | - E Teiger
- Unité de cardiologie interventionnelle, CHU de Henri-Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
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29
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Cavallari I, Patti G. Clinical effects with inhibition of multiple coagulative pathways in patients admitted for acute coronary syndrome. Intern Emerg Med 2018; 13:1019-1028. [PMID: 29564693 DOI: 10.1007/s11739-018-1834-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 03/16/2018] [Indexed: 12/01/2022]
Abstract
Platelets and the coagulation cascade play key roles in initiation, amplification, and perpetuation of acute coronary syndromes (ACS). In the past few years, there has been great progress in ACS antithrombotic treatment with the introduction of novel anticoagulants (fondaparinux and bivalirudin), more potent P2Y12 inhibitors (prasugrel and ticagrelor) and protease-activated receptor antagonists (vorapaxar). Nonetheless, patients with ACS frequently have recurrent ischemic events despite the use of currently recommended dual antiplatelet therapy, revascularization procedures as appropriate, and other evidence-based secondary preventive measures. This is the rationale beyond intensification of antiplatelet therapy. However, the major downside of intensive antithrombotic therapy is bleeding. When treating ACS patients, clinicians should find the adequate balance between the reduction of thrombotic events by effective drug treatment and the induction of bleeding that is linked to the use of potent or multiple antithrombotic agents. Numerous antithrombotic cocktails including oral anticoagulants with or without aspirin have been tested in large clinical trials with the goal of further reduction of ischemia and bleeding risk. The aim of this review is to discuss clinical outcomes resulting from inhibition of multiple coagulative pathways in patients with ACS in light of evidence from large randomized controlled clinical trials.
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Affiliation(s)
- Ilaria Cavallari
- Department of Cardiovascular Science, Campus Bio-Medico University of Rome, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Giuseppe Patti
- Department of Cardiovascular Science, Campus Bio-Medico University of Rome, Via Alvaro del Portillo, 200, 00128, Rome, Italy.
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30
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Esmonde S, Sharma D, Peace A. Antiplatelet agents in uncertain clinical scenarios-a bleeding nightmare. Cardiovasc Diagn Ther 2018; 8:647-662. [PMID: 30498688 PMCID: PMC6232352 DOI: 10.21037/cdt.2018.06.09] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 06/28/2018] [Indexed: 12/14/2022]
Abstract
Despite over 40 years since the first percutaneous coronary intervention (PCI) was performed, the optimal dual antiplatelet therapy (DAPT) regime poses a significant challenge for clinicians, especially in certain scenarios. DAPT is the standard of care in PCI following an acute coronary syndrome (ACS) or for elective patients with obstructive coronary artery disease (CAD). There remains significant uncertainty regarding DAPT in patients at high risk of bleeding, such as the elderly and patients requiring anticoagulation. More and more clinicians are faced with a dilemma of weighing risks and benefits from the increasing list of potent, new antiplatelet agents and direct oral anticoagulants (DOACs) in a growing, aging population. Historically, most studies failed to recognize bleeding risk, instead focusing on ischemic risk. In recent years however, bleeding has been recognized as a very significant driver of morbidity and mortality in patients undergoing PCI. There is a paucity of data in this cohort leading to divergent and sometimes conflicting recommendations, largely based on expert consensus of opinion. In the current review, we critically evaluate the available evidence in these uncertain scenarios.
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Affiliation(s)
- Sean Esmonde
- Department of Cardiology, Altnagelvin Area Hospital, Western Health and Social Care Trust, Derry/Londonderry, Northern Ireland, UK
| | - Divyesh Sharma
- Department of Cardiology, Altnagelvin Area Hospital, Western Health and Social Care Trust, Derry/Londonderry, Northern Ireland, UK
| | - Aaron Peace
- Department of Cardiology, Altnagelvin Area Hospital, Western Health and Social Care Trust, Derry/Londonderry, Northern Ireland, UK
- Northern Ireland Centre for Stratified Medicine, Ulster University, C-TRIC, Derry/Londonderry, Northern Ireland, UK
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31
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Dual versus triple antithrombotic therapy after percutaneous coronary intervention or acute coronary syndrome in patients with indication for anticoagulation: an updated meta-analysis. Coron Artery Dis 2018; 29:670-680. [PMID: 30222595 DOI: 10.1097/mca.0000000000000660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND For patients who have an indication for anticoagulation, it is controversial whether dual therapy with an oral anticoagulant and single antiplatelet agent can be used after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS) instead of triple therapy with an oral anticoagulant and dual antiplatelet therapy. PARTICIPANTS AND METHODS Twelve observational studies and four clinical trials were identified from three electronic databases from their inception to December, 2017. Pooled estimates were calculated using a random-effects model for meta-analysis. RESULTS Compared with the triple therapy, dual therapy was associated with significantly lower risk of major bleeding [relative risk (RR), 0.63; 95% confidence interval (CI), 0.50-0.80] without statistically significant increase in major adverse cardiac events (RR, 1.04; 95% CI, 0.84-1.29), all-cause death (RR, 1.15; 95% CI, 0.77-1.71), cardiac death (RR, 1.04; 95% CI, 0.67-1.61), myocardial infarction (RR, 1.25; 95% CI, 0.98-1.59), stroke (RR, 1.27; 95% CI, 0.79-2.06), stent thrombosis (RR, 1.52; 95% CI, 0.96-2.41), and repeat revascularization (RR, 1.15; 95% CI, 0.87-1.52). Although risks of myocardial infarction and stent thrombosis were marginally higher in the dual therapy group, this trend was attenuated after excluding studies that exclusively included patients undergoing PCI for ACS, but not stable coronary artery disease. CONCLUSION Dual therapy may be a reasonable alternative to triple therapy after PCI in patients with indication for chronic anticoagulation. However, further studies are needed to investigate efficacy of dual therapy, especially in the patients with higher ischemic risk, such as in ACS.
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Dual versus triple therapy in patients on oral anticoagulants and undergoing coronary stent implantation: A systematic review and meta-analysis. Int J Cardiol 2018; 273:80-87. [PMID: 30115419 DOI: 10.1016/j.ijcard.2018.08.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/29/2018] [Accepted: 08/08/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIMS There is contrasting evidence regarding the optimal antithrombotic regimen after percutaneous coronary stent implantation in patients on oral anticoagulants. A systematic review and meta-analysis was performed to explore the comparative efficacy and safety of dual (an antiplatelet plus an oral anticoagulant) versus triple therapy (dual antiplatelet therapy plus an oral anticoagulant). METHODS We searched the literature for randomized controlled trials (RCTs) or observational studies (OSs) addressing this issue. The efficacy outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction and stent thrombosis. The safety outcomes were major bleeding events and all bleeding events. The analyses were stratified by type of anticoagulant and of antiplatelet used in dual therapy. RESULTS Four RCTs and ten OSs met our inclusion criteria including a total of 10,126 patients. 5671 patients received triple therapy whereas 4455 received dual therapy. Median follow up was 12 months. There was no difference between dual therapy and triple therapy regarding efficacy outcomes. Dual therapy significantly reduced the risk of major bleeding (RR 0.66; CI 95% 0.52-0.83; P = 0.0005) and of all bleeding events (RR 0.67, CI 95% 0.55-0.80; P < 0.0001). The effect was consistent regardless of the type of antiplatelet and anticoagulant used in dual therapy. CONCLUSION Dual antithrombotic therapy after coronary stenting in anticoagulated patients significantly reduces bleeding events compared with triple therapy. Dual therapy might be considered in this setting especially when bleeding risk outweighs ischemic risk, although our study was not sufficiently powered to detect a difference in ischemic endpoints.
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33
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Angiolillo DJ, Goodman SG, Bhatt DL, Eikelboom JW, Price MJ, Moliterno DJ, Cannon CP, Tanguay JF, Granger CB, Mauri L, Holmes DR, Gibson CM, Faxon DP. Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention. Circulation 2018; 138:527-536. [DOI: 10.1161/circulationaha.118.034722] [Citation(s) in RCA: 184] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The optimal antithrombotic treatment regimen for patients with atrial fibrillation undergoing percutaneous coronary intervention with stent implantation represents a challenge in clinical practice. In 2016, an updated opinion of selected experts from the United States and Canada on the treatment of patients with atrial fibrillation undergoing percutaneous coronary intervention was reported. After the 2016 North American consensus statement on the management of antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention, results of pivotal clinical trials assessing the type of oral anticoagulant agent and the duration of antiplatelet treatment have been published. On the basis of these results, this focused update on the antithrombotic management of patients with atrial fibrillation undergoing percutaneous coronary intervention recommends that a non–vitamin K antagonist oral anticoagulant be preferred over a vitamin K antagonist as the oral anticoagulant of choice. Moreover, a double-therapy regimen (oral anticoagulant plus single antiplatelet therapy with a P2Y
12
inhibitor) by the time of hospital discharge should be considered for most patients, whereas extending the use of aspirin beyond hospital discharge (ie, triple therapy) should be considered only for selected patients at high ischemic/thrombotic and low bleeding risks and for a limited period of time. The present document provides a focused updated on the rationale for the new expert consensus–derived recommendations on the antithrombotic management of patients with atrial fibrillation treated with oral anticoagulation undergoing percutaneous coronary intervention.
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Affiliation(s)
| | - Shaun G. Goodman
- St. Michael’s Hospital, University of Toronto, and the Canadian Heart Research Centre, Canada (S.G.G.)
- Canadian Virtual Coordinating Centre for Global Collaborative Cardiovascular Research Centre, University of Alberta, Canada (S.G.G.)
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., L.M., D.P.F.)
| | - John W. Eikelboom
- Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, Canada (J.W.E.)
| | - Matthew J. Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA (M.J.P.)
| | - David J. Moliterno
- Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.)
| | - Christopher P. Cannon
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., L.M., D.P.F.)
| | - Jean-Francois Tanguay
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Canada (J.-F.T.)
| | | | - Laura Mauri
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., L.M., D.P.F.)
| | | | - C. Michael Gibson
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - David P. Faxon
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., L.M., D.P.F.)
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34
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Maki DG. Review: After PCI in AF, OAC plus single vs dual antiplatelets reduces major bleeding; no difference for MACE. Ann Intern Med 2018; 169:JC8. [PMID: 30014097 DOI: 10.7326/acpjc-2018-169-2-008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Dennis G. Maki
- University of Wisconsin School of Medicine and Public HealthMadison, Wisconsin, USA
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Bencivenga L, Komici K, Corbi G, Cittadini A, Ferrara N, Rengo G. The Management of Combined Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Particularly Complex Challenge, Especially in the Elderly. Front Physiol 2018; 9:876. [PMID: 30038586 PMCID: PMC6046549 DOI: 10.3389/fphys.2018.00876] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 06/19/2018] [Indexed: 12/31/2022] Open
Abstract
Anticoagulation is superior to dual antiplatelet therapy (DAPT) in the prevention of thromboembolic events in patients with atrial fibrillation (AF), otherwise the prevention of ischemic risk and stent thrombosis after percutaneous coronary intervention (PCI) is warranted by DAPT. The coexistence of conditions requiring combined antithrombotic therapies is becoming an increasing relevant clinical problem, whose therapeutic management has long been found in the medical experience rather than in guidelines and consensus. Recently, updates in guidelines and relevant studies have been published in order to better clarify the best management of combined antithrombotic therapy. In the present review, we have analyzed the recent literature, underlining the progresses and the residual limits of the most up-to-date evidence on the management of patients requiring dual or triple antithrombotic therapy, due to coexisting AF and coronary artery disease. An in-depth overview is also focused on the management of antithrombotic therapy in the elderly patient, which represents an even more complex challenge for the clinician. This is due to the high prevalence, among over 65 years aged people, of conditions requiring association of antiplatelet and anticoagulant drugs, the numerous comorbidities, the higher risk of complications, such as bleedings, and the lack of specific evidence, especially for the frail elderly. Nowadays, triple therapy [oral anticoagulation (OAC) plus dual antiplatelet agents] for the shortest possible time should be the treatment for AF patients undergoing PCI, whereas dual therapy (single antiplatelet plus OAC) may be preferred for patients at high bleeding risk.
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Affiliation(s)
- Leonardo Bencivenga
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Klara Komici
- Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Graziamaria Corbi
- Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Antonio Cittadini
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Nicola Ferrara
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- Istituti Clinici Scientifici Maugeri SpA Società Benefit (ICS Maugeri SpA SB), Telese Terme, Italy
| | - Giuseppe Rengo
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- Istituti Clinici Scientifici Maugeri SpA Società Benefit (ICS Maugeri SpA SB), Telese Terme, Italy
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Capodanno D, Mehran R, Valgimigli M, Baber U, Windecker S, Vranckx P, Dangas G, Rollini F, Kimura T, Collet JP, Gibson CM, Steg PG, Lopes RD, Gwon HC, Storey RF, Franchi F, Bhatt DL, Serruys PW, Angiolillo DJ. Aspirin-free strategies in cardiovascular disease and cardioembolic stroke prevention. Nat Rev Cardiol 2018; 15:480-496. [DOI: 10.1038/s41569-018-0049-1] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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