1
|
Castelijns MC, Hageman SHJ, Teraa M, van der Meer MG, Westerink J, Costa F, Ten Berg JM, Visseren FLJ. External validation of bleeding risk models for the prediction of long-term bleeding risk in patients with established cardiovascular disease. Am Heart J 2023; 260:72-81. [PMID: 36841319 DOI: 10.1016/j.ahj.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/14/2023] [Accepted: 02/18/2023] [Indexed: 05/07/2023]
Abstract
OBJECTIVE The long-term predictive performance of existing bleeding risk models in patients with various manifestations of cardiovascular disease (CVD) is not well known. This study aims to assess and compare the performance of relevant existing bleeding risk models in estimating the long-term risk of major bleeding in a cohort of patients with established CVD. METHODS Seven existing bleeding risk models (PRECISE-DAPT, DAPT, Ducrocq et al, de Vries et al, S2TOP-BLEED, Intracranial B2LEED3S and HAS-BLED) were identified and externally validated in 7,249 patients with established CVD included in the Utrecht Cardiovascular Cohort-second manifestations of arterial disease study. Predictive performance was assessed in terms of discrimination and calibration, both at 10 years and the original prediction horizon of the models. Major bleeding was defined as Bleeding Academic Research Consortium type 3 or 5. RESULTS After a median follow-up of 8.4 years (interquartile range 4.5-12.5), a total of 233 (3.2%) major bleeding events occurred. C-statistics for discrimination at 10 years ranged from 0.53 (95%CI 0.49-0.57) to 0.64 (95%CI 0.60-0.68). Calibration plots after recalibration to 10 years showed best agreement between predicted and observed bleeding risk for De Vries et al, S2TOP-BLEED, DAPT and PRECISE-DAPT. CONCLUSIONS The performance of existing bleeding risk models to predict long-term bleeding in patients with CVD varied. Discrimination and calibration were best for the models of de Vries et al, S2TOP-BLEED, DAPT and PRECISE-DAPT. Of these, recalibrated models requiring the least predictors may be preferred for use to personalize prevention with antithrombotic therapy.
Collapse
Affiliation(s)
- Maria C Castelijns
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin Teraa
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Manon G van der Meer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Internal Medicine, Isala Clinics Zwolle, Zwolle, The Netherlands
| | - Francesco Costa
- Department of Cardiology, G. Martino University Hospital Messina, Messina, Italy
| | - Jurriën M Ten Berg
- Department of Cardiology and Platelet Function Research, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| |
Collapse
|
2
|
Saito Y, Wijns W, Baumbach A, Xu B, Kelbaek H, Zheng M, Morel MA, Anderson R, Schächinger V, Lansky A. Differential impact of abluminal groove-filled biodegradable-polymer sirolimus-eluting stent versus durable-polymer everolimus-eluting stent on and off dual antiplatelet therapy. Catheter Cardiovasc Interv 2021; 99:357-365. [PMID: 33502809 DOI: 10.1002/ccd.29468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/08/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Current guidelines recommend dual antiplatelet therapy (DAPT) following percutaneous coronary intervention for 6-12 months in patients with acute coronary syndrome (ACS) and 3-6 months in those with chronic coronary syndromes (CCS). Whether DAPT duration has a differential effect on outcomes following treatment of ischemic coronary disease with durable versus biodegradable drug-eluting stent (DES) is poorly defined. METHODS The TARGET All Comer study was a randomized trial of patients with ischemic coronary artery disease assigned to treatment with either a biodegradable polymer DES (Firehawk) or a durable polymer DES (XIENCE). This pre-specified TARGET AC sub-analysis sought to evaluate the 2-year clinical outcomes before and after DAPT discontinuation. The primary endpoint was target lesion failure (TLF). RESULTS A total of 1,296 (78.4%) of 1,653 randomized patients were included in this substudy, of which 1,210 (93.4%) remained on DAPT at 6 months, 863 (66.6%) at 12 months, and 409 (31.6%) at 2 years. There was no difference in TLF between patients treated with Firehawk and XIENCE stents from index procedure to DAPT discontinuation (8.0 and 7.7%, p > .99) or after DAPT discontinuation (2.9 vs. 3.8%, p = .16). After DAPT discontinuation, target vessel myocardial infarction (1.3 vs. 3.3%, p = .07), and ischemia-driven target lesion revascularization (0.5 vs. 1.9%, p = .06) favored treatment with Firehawk. CONCLUSIONS Although TLF was comparable for both Firehawk and XIENCE stent groups before and after DAPT discontinuation, after DAPT discontinuation, there was a trend for less target vessel myocardial infarction and ischemia-driven revascularization with the biodegradable polymer DES.
Collapse
Affiliation(s)
- Yuichi Saito
- Yale University School of Medicine, New Haven, Connecticut
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland, Galway, Ireland.,Saolta University Healthcare Group, University College Hospital Galway, Galway, Ireland
| | - Andreas Baumbach
- Yale University School of Medicine, New Haven, Connecticut.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
| | - Bo Xu
- Fu Wai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Henning Kelbaek
- Department of Cardiology, Roskilde University Hospital, Roskilde, Denmark
| | - Ming Zheng
- Shanghai MicroPort Medical (Group) Co., Ltd., Shanghai, China
| | | | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff, UK
| | - Volker Schächinger
- Medizinische Klinik I, Herz-Thorax Zentrum, Klinikum Fulda, Fulda, Germany
| | - Alexandra Lansky
- Yale University School of Medicine, New Haven, Connecticut.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
| | | |
Collapse
|
3
|
Falster MO, Schaffer AL, Wilson A, Nasis A, Jorm LR, Hay M, Leeb K, Pearson SA, Brieger D. Evidence-practice gaps in P2Y 12 inhibitor use after hospitalisation for acute myocardial infarction: findings from a new population-level data linkage in Australia. Intern Med J 2020; 52:249-258. [PMID: 32840951 PMCID: PMC9306967 DOI: 10.1111/imj.15036] [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: 06/01/2020] [Revised: 08/07/2020] [Accepted: 08/19/2020] [Indexed: 11/30/2022]
Abstract
Background P2Y12 inhibitor therapy is recommended for 12 months in patients hospitalised for acute myocardial infarction (AMI) unless the bleeding risk is high. Aims To describe real‐world use of P2Y12 inhibitor therapy following AMI hospitalisation. Methods We used population‐level linked hospital data to identify all patients discharged from a public hospital with a primary diagnosis of AMI between July 2011 and June 2013 in New South Wales and Victoria, Australia. We used dispensing claims to examine dispensing of a P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) within 30 days of discharge and multilevel models to identify predictors of post‐discharge dispensing and persistence of therapy to 1 year. Results We identified 31 848 patients hospitalised for AMI, of whom 56.8% were dispensed a P2Y12 inhibitor within 30 days of discharge. The proportion of patients with post‐discharge dispensing varied between hospitals (interquartile range: 25.0–56.5%), and significant between‐hospital variation remained after adjusting for patient characteristics. Patient factors associated with the lowest likelihood of post‐discharge dispensing were: having undergone coronary artery bypass grafting (odds ratio (OR): 0.17; 95% confidence intervals (CI): 0.15–0.20); having oral anticoagulants dispensed 180 days before or 30 days after discharge (OR: 0.39, 95% CI: 0.35–0.44); major bleeding (OR: 0.68, 95% CI: 0.61–0.76); or being aged ≥85 years (OR: 0.68, 95% CI: 0.62–0.75). A total of 26.8% of patients who were dispensed a P2Y12 inhibitor post‐discharge discontinued therapy within 1 year. Conclusion Post‐hospitalisation use of P2Y12 inhibitor therapy in AMI patients is low and varies substantially by hospital of discharge. Our findings suggest strategies addressing both health system (hospital and physician) and patient factors are needed to close this evidence‐practice gap.
Collapse
Affiliation(s)
- Michael O Falster
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia
| | - Andrea L Schaffer
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia
| | | | | | - Louisa R Jorm
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia
| | - Melanie Hay
- Victorian Agency for Health Information, Melbourne, Australia
| | - Kira Leeb
- Victorian Agency for Health Information, Melbourne, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia.,Menzies Centre for Health Policy, University of Sydney, Sydney, Australia
| | - David Brieger
- Cardiac Clinical Network, Agency for Clinical Innovation, Sydney, Australia
| |
Collapse
|
4
|
Ma S, Jiang Z, Qiu M, Li Z, Bian L, Li Y, Han Y. Dual Antiplatelet Therapy Duration in Medically Managed Acute Coronary Syndrome Patients: Sub-Analysis of the OPT-CAD Study. Adv Ther 2020; 37:3150-3161. [PMID: 32418142 DOI: 10.1007/s12325-020-01376-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Optimal dual antiplatelet therapy (DAPT) duration for medically managed acute coronary syndrome (ACS) (MMACS) patients is still unknown. We explored the efficacy and safety of ≥ 12-month DAPT among MMACS patients. METHODS In this sub-analysis of the optimal antiplatelet therapy for Chinese Patients with Coronary Artery Disease study (NCT01735305), clinical outcomes among MMACS patients were compared between the < 12-month and ≥ 12-month DAPT groups. The primary efficacy endpoint was a composite of cardiac death, myocardial infarction, and stroke. Safety endpoints included the Bleeding Academic Research Consortium (BARC) 2-5, BARC 3-5, and all bleeding events. Propensity score matching (PSM) was used to compare baseline characteristics between the < 12-month and ≥ 12-month DAPT groups. RESULTS In this cohort of ACS patients (n = 10,016), MMACS patients (n = 2967) were less likely to use DAPT at 12 (31.64% vs. 67.47%, P < 0.0001) and 24 (13.82% vs. 18.71%, P < 0.0001) months and experienced more ischemic events at 12 (4.55% vs. 3.40%, P = 0.006) and 24 (6.88% vs. 5.08%, P = 0.0004) months than those treated with percutaneous coronary intervention (n = 7049). Among MMACS patients, the rate of primary efficacy endpoint occurring within the second year was significantly higher in the < 12-month DAPT group than in the ≥ 12-month group both before (2.88% vs. 1.60%, P = 0.040) and after (3.19% vs. 1.71%, P = 0.045) PSM. After PSM, no significant differences in all bleeding, BARC 2-5, and BARC 3-5 bleeding were found between the groups. CONCLUSION MMACS patients with insufficient DAPT management experienced relatively more ischemic events. DAPT for at least 1 year may be beneficial to this special population without significantly increasing the bleeding risks. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT01735305.
Collapse
|
5
|
Li YH, Chiu YW, Cheng JJ, Hsieh IC, Lo PH, Lei MH, Ueng KC, Chiang FT, Sung SH, Kuo JY, Chen CP, Lai WT, Lee WL, Chen JH. Duration of Clopidogrel-Based Dual Antiplatelet Therapy and Clinical Outcomes in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention - A Real-World Observation in Taiwan From 2012 to 2015. Circ J 2019; 83:1317-1323. [PMID: 31061379 DOI: 10.1253/circj.cj-18-1283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Little information is available in Asia about the real-world practice of dual antiplatelet therapy (DAPT) duration for acute coronary syndrome (ACS) and its influence on clinical outcomes.Methods and Results:The Taiwan ACS STENT Registry was a prospective, multicenter study to observe ACS patients using clopidogrel-based DAPT after percutaneous coronary intervention (PCI). The primary outcome was a composite of cardiovascular death, myocardial infarction, and stroke. Overall, 2,221 ACS patients (62 years, 83% men) were included. DAPT duration was ≤9 months in 935 (42.1%). The incidence of primary outcome was higher in patients receiving DAPT ≤9 months compared with those receiving DAPT >9 months at 1 year (3.5% vs. 1.6%, P=0.0026). The incidence of stent thrombosis (overall 0.5%) was similar between groups. Multivariable analysis showed that DAPT >9 months was associated with a significantly lower risk of primary outcome (odds ratio 0.725, 95% confidence interval 0.545-0.965). CONCLUSIONS Our data showed that short duration of DAPT (≤9 months) was common (42.1%) in Taiwan for ACS patients undergoing PCI. DAPT ≤9 months increased the risk of the primary outcome.
Collapse
Affiliation(s)
- Yi-Heng Li
- National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Yu-Wei Chiu
- Department of Computer Science and Engineering, Yuan Ze University, Far Eastern Memorial Hospital
| | | | - I-Chang Hsieh
- Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Ping-Han Lo
- China Medical University Hospital and College of Medicine
| | | | | | - Fu-Tien Chiang
- National Taiwan University Hospital and Fu-Jen Catholic University Hospital
| | - Shih-Hsien Sung
- Taipei Veterans General Hospital and National Yang Ming University
| | | | | | | | | | | | | |
Collapse
|
6
|
Bueno H, Pocock S, Danchin N, Annemans L, Gregson J, Medina J, Van de Werf F. International patterns of dual antiplatelet therapy duration after acute coronary syndromes. Heart 2016; 103:132-138. [PMID: 27504002 PMCID: PMC5284475 DOI: 10.1136/heartjnl-2016-309509] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 07/05/2016] [Accepted: 07/13/2016] [Indexed: 12/19/2022] Open
Abstract
Objective To describe international patterns of dual antiplatelet therapy (DAPT) duration after acute coronary syndrome (ACS), and explore its determinants and correlation with clinical events. Methods EPICOR (long-tErm follow-uP of anti-thrombotic management patterns In acute CORonary syndrome patients) is a prospective, international, observational study of 10 568 ACS hospital survivors enrolled in 555 centres from 20 countries across Europe and Latin America between 2010 and 2011, with telephone follow-up at quarterly intervals up to 24 months to assess treatment continuation and clinical events. Results Of 8593 patients discharged on DAPT, 4859 (57%) remained on uninterrupted DAPT at end of follow-up. There were minor differences in rates of DAPT discontinuation according to age, gender, risk factors, therapeutic strategy or region, but major differences between countries. By study end, 555 of evaluable patients (5.7%) died, 727 (10.0%) experienced new cardiovascular (CV) events, 496 new coronary events (6.82%) and 154 (2.11%) clinically relevant bleeding (14 (6.7%) fatal). Most CV events and deaths (85%) occurred while on DAPT. DAPT interruption was associated with increased risk of CV events in the following week (HR 2.29; 95% CI 1.08 to 4.84) but not specifically with time to first coronary event or mortality. Conclusions Despite guideline recommendations, most patients with ACS in Europe and Latin America remained on DAPT beyond 12 months, country being the most important determinant of DAPT duration. Increase in short-term CV risk was seen after switching from DAPT to less medication, as compared with continued DAPT, with no long-term effect on coronary or mortality risk. Trial registration number NCT01171404; Results.
Collapse
Affiliation(s)
- Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Cardiology Department, Hospital Universitario 12 de Octubre, and Instituto de investigación i+12.,Universidad Complutense de Madrid, Spain
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, UK
| | - Nicolas Danchin
- Hôpital Européen Georges Pompidou & René Descartes University, Paris, France
| | - Lieven Annemans
- I-CHER Interuniversity Centre for Health Economics Research UGent, VUB, Ghent, Belgium
| | - John Gregson
- London School of Hygiene and Tropical Medicine, London, UK
| | - Jesús Medina
- Medical Evidence and Observational Research, Global Medical Affairs, AstraZeneca, Madrid, Spain
| | | |
Collapse
|
7
|
Patti G, Cavallari I. Extended duration dual antiplatelet therapy in patients with myocardial infarction: A study-level meta-analysis of controlled randomized trials. Am Heart J 2016; 176:36-43. [PMID: 27264218 DOI: 10.1016/j.ahj.2016.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 03/07/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Whether dual antiplatelet therapy (DAPT) is beneficial beyond 1 year after myocardial infarction (MI) is not demonstrated; in particular, available studies may be individually underpowered for end points at low incidence, that is, major and fatal bleeding or mortality. We thus assessed the effectiveness and safety of prolonged DAPT after MI over the long term. METHODS We conducted a systematic search to identify randomized trials on the topic; 3 studies and 21,534 post-MI patients receiving placebo or aspirin plus P2Y12 inhibition for ≥2 years were included. Incidence of the following outcome measures was evaluated: major adverse cardiac events (MACE), major bleeding, fatal bleeding, and cardiovascular and noncardiovascular death. RESULTS Occurrence of MACE was lower in patients treated with prolonged DAPT: 6.3% vs 7.9% in those without prolonged DAPT (odds ratios 0.74, 95% CI 0.60-0.91, P = .005); in the former, there was also a significant 16% reduction in cardiovascular mortality. Increase in major bleeding with extended duration DAPT was not significant in the overall analysis (1.5% vs 1.0%; P = .10), but became significant in the analysis restricted to patients receiving ticagrelor or prasugrel as second antiplatelet agent (odds ratios 2.16, 95% CI 1.63-2.86); prolonged use of DAPT did not raise rates of fatal bleeding or noncardiovascular mortality. CONCLUSION Prolonged DAPT after MI reduces MACE and cardiovascular mortality over the long term; this was paralleled by higher risk of nonfatal major bleeding mainly with the newer, more potent P2Y12 antagonists. Tailoring duration of DAPT after MI on the comparative evaluation of both ischemic and bleeding risk is mandatory in this setting.
Collapse
|
8
|
Marrugat J, Elosua R, Grau M, Sayols-Baixeras S, Dégano IR. Prevalence and Prognosis of High-risk Myocardial Infarction Patient Candidates to Extended Antiplatelet Therapy. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2016; 69:480-7. [PMID: 27062680 DOI: 10.1016/j.rec.2015.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 12/18/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION AND OBJECTIVES Secondary prevention in myocardial infarction patients is paramount to prevent recurrences. Dual antiplatelet therapy has been shown to reduce the risk of subsequent events up to 1 year and beyond in the PEGASUS-TIMI 54 trial. This study aimed to estimate the annual number of myocardial infarction patients with PEGASUS characteristics in Spain and to analyze short- and long-term outcomes in these patients. METHODS The number of myocardial infarction patients was estimated assuming a Poisson distribution. Myocardial infarction incidence and mortality rates obtained from population registries (IBERICA and REGICOR) were properly adjusted. The proportion of myocardial infarction patients with PEGASUS characteristics was estimated with a REGICOR cohort of consecutive patients from 2003-2009 (n=1391). This cohort follow-up was used to compare the occurrence of reinfarction and death at 1 year and at the end of the follow-up (4.7 years) in patients with and without PEGASUS characteristics by Cox regression. RESULTS The estimated annual number of stable myocardial infarction patients aged ≥ 50 years and without bleeding events was 41 311. Of these, 22 493 had at least 1 PEGASUS characteristic (diabetes, previous myocardial infarction, or chronic kidney disease). At 4.7 years of follow-up, having any PEGASUS characteristic or age ≥ 65 years was associated with a higher risk of cardiovascular and all-cause death in adjusted analyses (hazard ratio=3.44 and 2.21, 95% confidence interval, 1.22-9.74 and 1.11-4.42, respectively). CONCLUSIONS In Spain, more than 50% of the stable myocardial infarction patients aged ≥ 50 years are estimated to have at least 1 PEGASUS characteristic, which substantially increases the long-term risk of cardiovascular and all-cause death.
Collapse
Affiliation(s)
- Jaume Marrugat
- Grupo de Investigación en Epidemiología y Genética Cardiovascular, Programa de Epidemiología y Salud Pública, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain
| | - Roberto Elosua
- Grupo de Investigación en Epidemiología y Genética Cardiovascular, Programa de Epidemiología y Salud Pública, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain
| | - María Grau
- Grupo de Investigación en Epidemiología y Genética Cardiovascular, Programa de Epidemiología y Salud Pública, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain
| | - Sergi Sayols-Baixeras
- Grupo de Investigación en Epidemiología y Genética Cardiovascular, Programa de Epidemiología y Salud Pública, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain
| | - Irene R Dégano
- Grupo de Investigación en Epidemiología y Genética Cardiovascular, Programa de Epidemiología y Salud Pública, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain.
| |
Collapse
|
9
|
Marrugat J, Elosua R, Grau M, Sayols-Baixeras S, Dégano IR. Prevalencia y pronóstico de los pacientes con infarto de miocardio de alto riesgo candidatos a doble tratamiento antiagregante prolongado. Rev Esp Cardiol 2016. [DOI: 10.1016/j.recesp.2015.12.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|