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Wu T, Huang J, Wang X, Lian H, Guo R, Shi C. Association of Oral Anticoagulant Therapy with the Prevalence and Severity of Vascular Calcification among Patients with Atrial Fibrillation: A Cohort Study. ACS Pharmacol Transl Sci 2024; 7:1262-1269. [PMID: 38751625 PMCID: PMC11092121 DOI: 10.1021/acsptsci.3c00307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/09/2024] [Accepted: 03/22/2024] [Indexed: 05/18/2024]
Abstract
Many patients with atrial fibrillation (AF) requiring long-term use of oral anticoagulants (OACs) are at high risk for vascular calcification and anticoagulation therapy with warfarin exacerbate vascular calcification. However, the effect of nonvitamin K agonists on vascular calcification has not been clearly investigated. This study explored the effects of dabigatran etexilate, rivaroxaban, and warfarin on vascular calcification among 1527 patients with AF. Demographics, comorbidities, laboratory test data, medications, and the prevalence and severity of vascular calcification in different vascular beds were compared. After propensity score matching, the incidence of vascular calcification in the rivaroxaban and warfarin group was significantly higher than that in the nonanticoagulant group, while there was no difference between the dabigatran etexilate group and the nonanticoagulant group. Similarly, we found that the rivaroxaban group had more severe calcification in the overall vascular level (P < 0.001), thoracic aorta (P < 0.001), aortic arch (P = 0.001), and left common carotid artery (P = 0.005) than the nonanticoagulant group. In addition, in the left common carotid artery, there was more severe calcification in the rivaroxaban group than that in the dabigatran group (P = 0.005). Our results suggest that rivaroxaban can significantly increase both the incidence and severity of vascular calcification among patients with AF, while dabigatran etexilate has no such effect. Many patients with AF requiring long-term use of OACs are at high risk for vascular calcification. This is the first study to conduct a head-to-head comparison of the effects of dabigatran etexilate and rivaroxaban on vascular calcification. Rivaroxaban, rather than dabigatran etexilate, promotes vascular calcification in patients with AF, providing important implications to aid clinicians in their choice for OAC selection, especially those at high risk for vascular calcification.
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Affiliation(s)
- Tian Wu
- The
Third Xiangya Hospital, Central South University, Changsha 410013, China
- Department
of Pharmacology, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha 410078, China
| | - Jun Huang
- The
Third Xiangya Hospital, Central South University, Changsha 410013, China
| | - Xia Wang
- The
Third Xiangya Hospital, Central South University, Changsha 410013, China
| | - Huilin Lian
- The
Third Xiangya Hospital, Central South University, Changsha 410013, China
| | - Ren Guo
- The
Third Xiangya Hospital, Central South University, Changsha 410013, China
| | - Can Shi
- The
Third Xiangya Hospital, Central South University, Changsha 410013, China
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Abstract
Direct oral anticoagulants (DOACs) have largely replaced vitamin K antagonists, mostly warfarin, for the main indications for oral anticoagulation, prevention and treatment of venous thromboembolism, and prevention of embolic stroke in atrial fibrillation. While DOACs offer practical, fixed-dose anticoagulation in many patients, specific restrictions or contraindications may apply. DOACs are not sufficiently effective in high-thrombotic risk conditions such as antiphospholipid syndrome and mechanical heart valves. Patients with cancer-associated thrombosis may benefit from DOACs, but the bleeding risk, particularly in those with gastrointestinal or urogenital tumors, must be carefully weighed. In patients with frailty, excess body weight, and/or moderate-to-severe chronic kidney disease, DOACs must be cautiously administered and may require laboratory monitoring. Reversal agents have been developed and approved for life-threatening bleeding. In addition, the clinical testing of potentially safer anticoagulants such as factor XI(a) inhibitors is important to further optimize anticoagulant therapy in an increasingly elderly and frail population worldwide.
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Affiliation(s)
- Renske H Olie
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
| | - Kristien Winckers
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
| | - Bianca Rocca
- Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Hugo Ten Cate
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Murali S, Smith ER, Tiong MK, Tan S, Toussaint ND. Interventions to Attenuate Cardiovascular Calcification Progression: A Systematic Review of Randomized Clinical Trials. J Am Heart Assoc 2023; 12:e031676. [PMID: 38014685 PMCID: PMC10727339 DOI: 10.1161/jaha.123.031676] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/23/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Cardiovascular calcification, characterized by deposition of calcium phosphate in the arterial wall and heart valves, is associated with cardiovascular morbidity and mortality and is commonly seen in aging, diabetes, and chronic kidney disease. Whether evidence-based interventions could significantly attenuate cardiovascular calcification progression remains uncertain. METHODS AND RESULTS We conducted a systematic review of randomized controlled trials involving interventions, compared with placebo, another comparator, or standard of care, to attenuate cardiovascular calcification. Included clinical trials involved participants without chronic kidney disease, and the outcome was cardiovascular calcification measured using radiological methods. Quality of evidence was determined by the Cochrane risk of bias and Grading of Recommendations, Assessment, Development, and Evaluations assessment. Forty-nine randomized controlled trials involving 9901 participants (median participants 104, median duration 12 months) were eligible for inclusion. Trials involving aged garlic extract (n=6 studies) consistently showed attenuation of cardiovascular calcification. Trials involving 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (n=14), other lipid-lowering agents (n=2), hormone replacement therapies (n=3), vitamin K (n=5), lifestyle measures (n=4), and omega-3 fatty acids (n=2) consistently showed no attenuation of cardiovascular calcification with these therapies. Trials involving antiresorptive (n=2), antihypertensive (n=2), antithrombotic (n=4), and hypoglycemic agents (n=3) showed mixed results. Singleton studies involving salsalate, folate with vitamin B6 and 12, and dalcetrapib showed no attenuation of cardiovascular calcification. Overall, Cochrane risk of bias was moderate, and the Grading of Recommendations, Assessment, Development, and Evaluations assessment for a majority of analyses was moderate certainty of evidence. CONCLUSIONS Currently, there are insufficient or conflicting data for interventions evaluated in clinical trials for mitigation of cardiovascular calcification. Therapy involving aged garlic extract appears most promising, but evaluable studies were small and of short duration.
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Affiliation(s)
- Shashank Murali
- Department of NephrologyThe Royal Melbourne HospitalParkvilleVictoriaAustralia
| | - Edward R. Smith
- Department of NephrologyThe Royal Melbourne HospitalParkvilleVictoriaAustralia
- Department of Medicine (RMH)University of MelbourneParkvilleVictoriaAustralia
| | - Mark K. Tiong
- Department of NephrologyThe Royal Melbourne HospitalParkvilleVictoriaAustralia
- Department of Medicine (RMH)University of MelbourneParkvilleVictoriaAustralia
| | - Sven‐Jean Tan
- Department of NephrologyThe Royal Melbourne HospitalParkvilleVictoriaAustralia
- Department of Medicine (RMH)University of MelbourneParkvilleVictoriaAustralia
| | - Nigel D. Toussaint
- Department of NephrologyThe Royal Melbourne HospitalParkvilleVictoriaAustralia
- Department of Medicine (RMH)University of MelbourneParkvilleVictoriaAustralia
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Aldana-Bitar J, Moore J, Manubolu VS, Dahal S, Verghese D, Lakshmanan S, Hussein L, Crabtree T, Jonas R, Min JK, Earls JP, Budoff MJ. Plaque Progression Differences Between Apixaban and Rivaroxaban in Patients With Atrial Fibrillation Measured With Cardiac Computed Tomography and Plaque Quantification. Am J Ther 2023; 30:e313-e320. [PMID: 36731003 DOI: 10.1097/mjt.0000000000001569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have been associated with less calcification and coronary plaque progression than warfarin. Whether different DOACs have different effects on coronary plaque burden and progression is not known. We compared the 12-month effects of apixaban and rivaroxaban on plaque characteristics and vascular morphology in patients with atrial fibrillation through quantitative cardiac computed tomographic angiography. STUDY QUESTION In patients with nonvalvular atrial fibrillation using apixaban or rivaroxaban, are there differences in plaque quantification and progression measured with cardiac computed tomography? STUDY DESIGN This is a post hoc analysis of 2 paired prospective, single-centered, randomized, open-label trials with blinded adjudication of results. In total, 74 patients were prospectively randomized in parallel trials: 29 to apixaban (2.5-5 mg BID) and 45 to rivaroxaban (20 mg QD). Serial cardiac computed tomographic angiography was performed at baseline and 52 weeks. MEASURES AND OUTCOMES Comprehensive whole-heart analysis was performed for differences in the progression of percent atheroma volume (PAV), calcified plaque (CP) PAV, noncalcified plaque (NCP) PAV, positive arterial remodeling (PR) ≥1.10, and high-risk plaque (Cleerly Labs, New York, NY). RESULTS Both groups had progression of all 3 plaque types (apixaban: CP 8.7 mm 3 , NCP 69.7 mm 3 , and LD-NCP 27.2 mm 3 ; rivaroxaban: CP 22.9 mm 3 , NCP 66.3 mm 3 , and LD-NCP 11.0 mm 3 ) and a total annual plaque PAV change (apixaban: PAV 1.5%, PAV-CP 0.12%, and PAV-NCP 0.92%; rivaroxaban: PAV 2.1%, PAV-CP 0.46%, and PAV-NCP 1.40%). There was significantly lower PAV-CP progression in the apixaban group compared with the rivaroxaban group (0.12% vs. 0.46% P = 0.02). High-risk plaque characteristics showed a significant change in PR of apixaban versus rivaroxaban ( P = 0.01). When the propensity score weighting model is applied, only PR changes are statistically significant ( P = 0.04). CONCLUSIONS In both groups, there is progression of all types of plaque. There was a significant difference between apixaban and rivaroxaban on coronary calcification, with significantly lower calcific plaque progression in the apixaban group, and change in positive remodeling. With weighted modeling, only PR changes are statistically significant between the 2 DOACs.
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Affiliation(s)
- Jairo Aldana-Bitar
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Jeff Moore
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Venkat Sanjay Manubolu
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Suraj Dahal
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Dhiran Verghese
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Suvasini Lakshmanan
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Luay Hussein
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | | | | | | | - James P Earls
- Cleerly, New York, NY
- The George Washington University School of Medicine, Washington, DC
| | - Matthew J Budoff
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
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Nagy M, van der Meijden PEJ, Glunz J, Schurgers L, Lutgens E, ten Cate H, Heitmeier S, Spronk HMH. Integrating Mechanisms in Thrombotic Peripheral Arterial Disease. Pharmaceuticals (Basel) 2022; 15:1428. [PMID: 36422558 PMCID: PMC9695058 DOI: 10.3390/ph15111428] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/12/2022] [Accepted: 11/14/2022] [Indexed: 11/10/2023] Open
Abstract
Peripheral arterial disease (PAD), a manifestation of systemic atherosclerosis, is underdiagnosed in the general population. Despite the extensive research performed to unravel its pathophysiology, inadequate knowledge exists, thus preventing the development of new treatments. This review aims to highlight the essential elements of atherosclerosis contributing to the pathophysiology of PAD. Furthermore, emphasis will be placed on the role of thrombo-inflammation, with particular focus on platelet and coagulation activation as well as cell-cell interactions. Additional insight will be then discussed to reveal the contribution of hypercoagulability to the development of vascular diseases such as PAD. Lastly, the current antithrombotic treatments will be discussed, and light will be shed on promising new targets aiming to aid the development of new treatments.
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Affiliation(s)
- Magdolna Nagy
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Paola E. J. van der Meijden
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, 6229 ER Maastricht, The Netherlands
- Thrombosis Expertise Center, Heart and Vascular Center, Maastricht University Medical Center+, 6229 HX Maastricht, The Netherlands
| | - Julia Glunz
- Cardiovascular Research, Bayer AG, 42117 Wuppertal, Germany
| | - Leon Schurgers
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Esther Lutgens
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, 10785 Munich, Germany
- Institute for Cardiovascular Prevention (IPEK), Ludwig Maximilian’s University, 80539 Munich, Germany
- Experimental Cardiovascular Immunology Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Hugo ten Cate
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, 6229 ER Maastricht, The Netherlands
- Thrombosis Expertise Center, Heart and Vascular Center, Maastricht University Medical Center+, 6229 HX Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Center+, 6229 HX Maastricht, The Netherlands
- Center for Thrombosis and Hemostasis, Gutenberg University Mainz, 55122 Mainz, Germany
| | | | - Henri M. H. Spronk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, 6229 ER Maastricht, The Netherlands
- Thrombosis Expertise Center, Heart and Vascular Center, Maastricht University Medical Center+, 6229 HX Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Center+, 6229 HX Maastricht, The Netherlands
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6
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Kosciuszek ND, Kalta D, Singh M, Savinova OV. Vitamin K antagonists and cardiovascular calcification: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:938567. [PMID: 36061545 PMCID: PMC9437425 DOI: 10.3389/fcvm.2022.938567] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 07/22/2022] [Indexed: 12/02/2022] Open
Abstract
Background Many patients treated with Vitamin K antagonists (VKA) for anticoagulation have concomitant vascular or valvular calcification. This meta-analysis aimed to evaluate a hypothesis that vascular and valvular calcification is a side-effect of VKA treatment. Methods We conducted a systematic literature search to identify studies that reported vascular or valvular calcification in patients treated with VKA. The associations between VKA use and calcification were analyzed with random-effects inverse variance models and reported as odds ratios (OR) and 95% confidence intervals (95% CI). In addition, univariate meta-regression analyses were utilized to identify any effect moderators. Results Thirty-five studies were included (45,757 patients; 6,251 VKA users). The median follow-up was 2.3 years [interquartile range (IQR) of 1.2–4.0]; age 66.2 ± 3.6 years (mean ± SD); the majority of participants were males [77% (IQR: 72–95%)]. VKA use was associated with an increased OR for coronary artery calcification [1.21 (1.08, 1.36), p = 0.001], moderated by the duration of treatment [meta-regression coefficient B of 0.08 (0.03, 0.13), p = 0.0005]. Extra-coronary calcification affecting the aorta, carotid artery, breast artery, and arteries of lower extremities, was also increased in VKA treated patients [1.86 (1.43, 2.42), p < 0.00001] and moderated by the author-reported statistical adjustments of the effect estimates [B: −0.63 (−1.19, −0.08), p = 0.016]. The effect of VKA on the aortic valve calcification was significant [3.07 (1.90, 4.96), p < 0.00001]; however, these studies suffered from a high risk of publication bias. Conclusion Vascular and valvular calcification are potential side effects of VKA. The clinical significance of these side effects on cardiovascular outcomes deserves further investigation.
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Affiliation(s)
- Nina D. Kosciuszek
- New York Institute of Technology, College of Osteopathic Medicine, Academic Medicine Scholar Program, OldWestbury, NY, United States
- Department of Biomedical Sciences, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, United States
| | - Daniel Kalta
- Department of Biomedical Sciences, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, United States
| | - Mohnish Singh
- Department of Biomedical Sciences, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, United States
| | - Olga V. Savinova
- Department of Biomedical Sciences, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, United States
- *Correspondence: Olga V. Savinova
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7
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Russo V, Fabiani D. Put out the fire: The pleiotropic anti-inflammatory action of non-vitamin K oral anticoagulants. Pharmacol Res 2022; 182:106335. [PMID: 35781059 DOI: 10.1016/j.phrs.2022.106335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/15/2022] [Accepted: 06/28/2022] [Indexed: 11/28/2022]
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) should be the preferred anticoagulant strategy for preventing ischemic stroke in patients with atrial fibrillation (AF) at increased thromboembolic risk and for treating deep venous thromboembolism (DVT) in the general population. Beyond their inhibiting action on the activated factor X (FXa) or thrombin (FIIa), NOACs showed some pleiotropic anti-inflammatory effects. The present review aimed to describe the role of FXa and FIIa in the inflammation pathway and the potential anti-inflammatory effects of NOACs.
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Affiliation(s)
- Vincenzo Russo
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy.
| | - Dario Fabiani
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
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de Veer AJWM, Bennaghmouch N, Bor WL, Herrman JPR, Vrolix M, Meuwissen M, Vandendriessche T, Adriaenssens T, de Bruyne B, Magro M, Dewilde WJM, Ten Berg JM. The WOEST 2 registry : A prospective registry on antithrombotic therapy in atrial fibrillation patients undergoing percutaneous coronary intervention. Neth Heart J 2022; 30:302-311. [PMID: 35230636 PMCID: PMC9123099 DOI: 10.1007/s12471-022-01664-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Patients on oral anticoagulants (OACs) undergoing percutaneous coronary intervention (PCI) also require aspirin and a P2Y12 inhibitor (triple therapy). However, triple therapy increases bleeding. The use of non-vitamin K antagonist oral anticoagulants (NOACs) and stronger P2Y12 inhibitors has increased. The aim of our study was to gain insight into antithrombotic management over time. METHODS A prospective cohort study of patients on OACs for atrial fibrillation or a mechanical heart valve undergoing PCI was performed. Thrombotic outcomes were myocardial infarction, stroke, target-vessel revascularisation and all-cause mortality. Bleeding outcome was any bleeding. We report the 30-day outcome. RESULTS The mean age of the 758 patients was 73.5 ± 8.2 years. The CHA2DS2-VASc score was ≥ 3 in 82% and the HAS-BLED score ≥ 3 in 44%. At discharge, 47% were on vitamin K antagonists (VKAs), 52% on NOACs, 43% on triple therapy and 54% on dual therapy. Treatment with a NOAC plus clopidogrel increased from 14% in 2014 to 67% in 2019. The rate of thrombotic (4.5% vs 2.0%, p = 0.06) and bleeding (17% vs. 14%, p = 0.42) events was not significantly different in patients on VKAs versus NOACs. Also, the rate of thrombotic (2.9% vs 3.4%, p = 0.83) and bleeding (18% vs 14%, p = 0.26) events did not differ significantly between patients on triple versus dual therapy. CONCLUSIONS Patients on combined oral anticoagulation and antiplatelet therapy undergoing PCI are elderly and have both a high bleeding and ischaemic risk. Over time, a NOAC plus clopidogrel became the preferred treatment. The rate of thrombotic and bleeding events was not significantly different between patients on triple or dual therapy or between those on VKAs versus NOACs.
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Affiliation(s)
- A J W M de Veer
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - N Bennaghmouch
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - W L Bor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J P R Herrman
- Department of Cardiology, OLVG, Amsterdam, The Netherlands
| | - M Vrolix
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - M Meuwissen
- Department of Cardiology, Amphia Hospital, Breda, The Netherlands
| | - T Vandendriessche
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - T Adriaenssens
- Department of Cardiovascular Medicine, University Hospital Leuven, Leuven, Belgium
| | - B de Bruyne
- Cardiovascular Research Centre Aalst, OLV Clinic, Aalst, Belgium
| | - M Magro
- Department of Cardiology, Elizabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - W J M Dewilde
- Department of Cardiology, Imelda Hospital, Bonheiden, Belgium
| | - J M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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Manubolu VS, Budoff MJ. Achieving coronary plaque regression: a decades-long battle against coronary artery disease. Expert Rev Cardiovasc Ther 2022; 20:291-305. [PMID: 35466832 DOI: 10.1080/14779072.2022.2069559] [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: 10/18/2022]
Abstract
INTRODUCTION Traditionally atherosclerosis was thought to be progressive and medical treatment solely focused on delaying the progression of atherosclerosis rather than treating the disease itself. Multiple recent studies, however, have demonstrated a significant decrease in cardiovascular mortality with the use of additional anti-atherosclerotic therapies beyond statins. Consistent with these observations, mechanistic studies indicate that these additional anti-atherosclerotic therapies have a positive effect on both halting and reversing the course of atherosclerosis. AREAS COVERED We examine the progression of atherosclerosis and the efficacy of various anti-atherosclerotic treatment classes in this review utilizing multimodality imaging techniques. Searches were conducted in electronic databases: PubMed and EMBASE for all peer reviewed publications that examined coronary plaque progression, regression and stabilization using different imaging modalities and antiatherosclerosis therapies. The keywords coronary plaque, coronary angiography, IVUS, intravascular OCT, CCTA in conjunction with the various therapies included in this review were searched in different combinations. All relevant published articles on this topic were identified and their reference lists were screened for relevance. EXPERT COMMENTARY Though lipoprotein levels have traditionally been the target for antiatherosclerosis medication, several newer strategies have emerged creating novel targets in the treatment of coronary atherosclerosis. Using a combination of antiatherosclerosis therapies in conjunction with noninvasive imaging modalities like CCTA to directly visualize the plaque, is currently the focus of the future, with the aim of preventing and reversing atherosclerosis.
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Affiliation(s)
| | - Matthew J Budoff
- Department of Cardiology, Lundquist Institute, Torrance, CA, USA
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10
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Manubolu VS, Roy SK, Budoff MJ. Prognostic Value of Serial Coronary CT Angiography in Atherosclerotic Plaque Modification: What have we learnt? CURRENT CARDIOVASCULAR IMAGING REPORTS 2022; 15:1. [PMID: 35300492 PMCID: PMC8923615 DOI: 10.1007/s12410-022-09564-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose of review To provide an update and to outline the status of coronary computer tomography angiography (CCTA) in evaluation of coronary plaques and discuss the relevance of serial CCTA in guiding cardiovascular risk stratification and anti- atherosclerotic medical therapy. Recent Findings Coronary CTA is now the imaging modality of choice in monitoring changes in coronary plaque. It has been used in innumerable clinical trials which have demonstrated the benefits of several therapeutic agents and has excellent correlation with previously used invasive imaging modalities. It is safe, fast, less cumbersome, and a cost-effective testing method compared to other invasive imaging modalities for coronary plaque analysis. Summary The emergence of a noninvasive imaging modality such as CCTA, now permits quantification not only of plaque burden but also allows for further distinction of plaque components and identification of vulnerable plaques. Application of these findings continues to extend the prospect of coronary CTA in evaluation and management of atherosclerotic coronary artery disease (CAD) in clinical practice. In the future artificial intelligence and machine learning will play a significant role in plaque analysis allowing for high accuracy and reproducibility which will lead to a substantial increase in the utilization of coronary CTA.
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Affiliation(s)
| | - Sion K. Roy
- Lundquist Institute, Department of Cardiology, Torrance, CA, USA
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11
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Kim JS, Hwang HS. Vascular Calcification in Chronic Kidney Disease: Distinct Features of Pathogenesis and Clinical Implication. Korean Circ J 2021; 51:961-982. [PMID: 34854578 PMCID: PMC8636761 DOI: 10.4070/kcj.2021.0995] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/27/2021] [Accepted: 10/13/2021] [Indexed: 01/10/2023] Open
Abstract
Chronic kidney disease (CKD) is associated with a higher prevalence of vascular calcification (VC) and cardiovascular disease. VC in CKD patients showed different pathophysiological features from those of the general population. The pathogenesis of VC in CKD is a highly organized process, and prior studies have suggested that patients with CKD have their own specific contributors to the phenotypic change of vascular smooth muscle cells (VSMCs), including uremic toxins, CKD-mineral and bone disease (CKD-MBD), inflammation, and oxidative stress. For the diagnosis and monitoring of VC in CKD, several imaging modalities, including plain radiography, ultrasound, and computed tomography have been utilized. VC in CKD patients has distinct clinical features and implications. CKD patients revealed a more intense and more prevalent calcification on the intimal and medial layers, whereas intimal calcification is predominantly observed in the general population. While a higher VC score is clearly associated with a higher risk of all-cause mortality and cardiovascular events, a greater VC score in CKD patients does not fully reflect the burden of atherosclerosis, because they have more calcification at equal volumes of atheromatous plaques. The primary goal of VC treatment in CKD is the prevention of VC progression, and the main management is to control the biochemical components of CKD-MBD. Cinacalcet and non-calcium-containing phosphate binders are the mainstay of VC prevention in CKD-MBD management. VC in patients with CKD is an ongoing area of research and is expected to advance soon.
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Affiliation(s)
- Jin Sug Kim
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Korea
| | - Hyeon Seok Hwang
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Korea.
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ten Cate H, Guzik TJ, Eikelboom J, Spronk HMH. Pleiotropic actions of factor Xa inhibition in cardiovascular prevention: mechanistic insights and implications for anti-thrombotic treatment. Cardiovasc Res 2021; 117:2030-2044. [PMID: 32931586 PMCID: PMC8318102 DOI: 10.1093/cvr/cvaa263] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/10/2020] [Accepted: 09/03/2020] [Indexed: 12/12/2022] Open
Abstract
Atherosclerosis is a chronic inflammatory disease in which atherothrombotic complications lead to cardiovascular morbidity and mortality. At advanced stages, myocardial infarction, ischaemic stroke, and peripheral artery disease, including major adverse limb events, are caused either by acute occlusive atherothrombosis or by thromboembolism. Endothelial dysfunction, vascular smooth muscle cell activation, and vascular inflammation are essential in the development of acute cardiovascular events. Effects of the coagulation system on vascular biology extend beyond thrombosis. Under physiological conditions, coagulation proteases in blood are pivotal in maintaining haemostasis and vascular integrity. Under pathological conditions, including atherosclerosis, the same coagulation proteases (including factor Xa, factor VIIa, and thrombin) become drivers of atherothrombosis, working in concert with platelets and vessel wall components. While initially atherothrombosis was attributed primarily to platelets, recent advances indicate the critical role of fibrin clot and plasma coagulation factors. Mechanisms of atherothrombosis and hypercoagulability vary depending on plaque erosion or plaque rupture. In addition to contributing to thrombus formation, factor Xa and thrombin can affect endothelial dysfunction, oxidative stress, vascular smooth muscle cell function as well as immune cell activation and vascular inflammation. By these mechanisms, they promote atherosclerosis and contribute to plaque instability. In this review, we first discuss the postulated vasoprotective mechanisms of protease-activated receptor signalling induced by coagulation enzymes under physiological conditions. Next, we discuss preclinical studies linking coagulation with endothelial cell dysfunction, thromboinflammation, and atherogenesis. Understanding these mechanisms is pivotal for the introduction of novel strategies in cardiovascular prevention and therapy. We therefore translate these findings to clinical studies of direct oral anticoagulant drugs and discuss the potential relevance of dual pathway inhibition for atherothrombosis prevention and vascular protection.
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Affiliation(s)
- Hugo ten Cate
- Department of Internal Medicine, Thrombosis Expertise Center, Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 50, PO Box 616, 6200 MD, Maastricht, The Netherlands
- Department of Biochemistry, Thrombosis Expertise Center, Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 50, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Tomasz J Guzik
- Institute of Cardiovascular & Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, Glasgow, UK
- Department of Medicine, Jagiellonian University, Collegium Medicum, Krakow, Poland
| | - John Eikelboom
- Population Health Research Institute, Hamilton General Hospital and McMaster University, Hamilton, L8L 2x2, ON, Canada
| | - Henri M H Spronk
- Department of Internal Medicine, Thrombosis Expertise Center, Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 50, PO Box 616, 6200 MD, Maastricht, The Netherlands
- Department of Biochemistry, Thrombosis Expertise Center, Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 50, PO Box 616, 6200 MD, Maastricht, The Netherlands
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Nakajima M, Inatomi Y, Ueda A, Ito Y, Kouzaki Y, Takita T, Wada K, Yonehara T, Terasaki T, Hashimoto Y, Ando Y. Preceding direct oral anticoagulant administration reduces the severity of stroke in patients with atrial fibrillation - K-PLUS registry. J Clin Neurosci 2021; 89:106-112. [PMID: 34119252 DOI: 10.1016/j.jocn.2021.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 02/17/2021] [Accepted: 04/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Stroke severity can be mitigated by preceding anticoagulant administration in acute ischemic stroke patients with atrial fibrillation (AF). We investigated if such mitigative effects are different between warfarin and direct oral anticoagulants (DOACs). MATERIAL AND METHODS We collected data from a regional multicenter stroke registry. Ischemic stroke or transient ischemic attack patients with AF were included. Background characteristics, National Institutes of Health Stroke Scale (NIHSS) score on admission, lesion characteristics, and in-hospital death were analyzed according to preceding antithrombotic agents at onset. RESULTS A total of 2173 patients had AF; 628 were prescribed warfarin, 272 DOACs, 429 antiplatelets alone, and 844 no antithrombotics. The NIHSS score on admission was lowest in the DOACs group compared to the other groups. In neuroimaging analysis, small ischemic lesions were observed more frequently in the DOACs group, while large ischemic lesions were less frequent in this group. When the no antithrombotics group was used as a reference, the adjusted odds ratio for moderate to severe stroke was 0.56 (95% confidence interval, 0.40-0.78) in the DOACs group, while it was 0.98 (0.77-1.24) in the warfarin group and 0.94 (0.72-1.22) in the antiplatelets group. In-hospital mortality was lowest in the DOACs group compared to the other groups. CONCLUSION Preceding DOAC administration might mitigate the severity of stroke in AF patients more strongly than other antithrombotics, possibly leading to a better outcome in patients with stroke.
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Affiliation(s)
- Makoto Nakajima
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | | | - Akihiko Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Yasuyuki Ito
- Department of Neurology, Minamata City General Hospital & Medical Center, Minamata, Japan
| | - Yanosuke Kouzaki
- Department of Neurology, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Tomohiro Takita
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Kuniyasu Wada
- Department of Neurology, Kumamoto City Hospital, Kumamoto, Japan.
| | | | - Tadashi Terasaki
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan.
| | | | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; Department of Amyloidosis, Nagasaki International University, Sasebo, Japan.
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14
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van Gorp RH, Dijkgraaf I, Bröker V, Bauwens M, Leenders P, Jennen D, Dweck MR, Bucerius J, Briedé JJ, van Ryn J, Brandenburg V, Mottaghy F, Spronk HMH, Reutelingsperger CP, Schurgers LJ. Off-target effects of oral anticoagulants - vascular effects of vitamin K antagonist and non-vitamin K antagonist oral anticoagulant dabigatran etexilate. J Thromb Haemost 2021; 19:1348-1363. [PMID: 33687782 PMCID: PMC8252511 DOI: 10.1111/jth.15289] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Vitamin K antagonists (VKA) and non-vitamin K oral antagonist anticoagulants (NOAC) are used in the clinic to reduce risk of thrombosis. However, they also exhibit vascular off-target effects. The aim of this study is to compare VKA and NOAC on atherosclerosis progression and calcification in an experimental setup. MATERIAL AND METHODS Female Apoe-/- mice (age 12 weeks) were fed Western-type diet as control or supplemented with dabigatran etexilate or warfarin for 6 or 18 weeks. Vascular calcification was measured in whole aortic arches using µCT and [18 F]-NaF. Atherosclerotic burden was assessed by (immuno)histochemistry. Additionally, in vitro effects of warfarin, thrombin, and dabigatran on primary vascular smooth muscle cells (VSMC) were assessed. RESULTS Short-term treatment with warfarin promoted formation of atherosclerotic lesions with a pro-inflammatory phenotype, and more rapid plaque progression compared with control and dabigatran. In contrast, dabigatran significantly reduced plaque progression compared with control. Long-term warfarin treatment significantly increased both presence and activity of plaque calcification compared with control and dabigatran. Calcification induced by warfarin treatment was accompanied by increased presence of uncarboxylated matrix Gla protein. In vitro, both warfarin and thrombin significantly increased VSMC oxidative stress and extracellular vesicle release, which was prevented by dabigatran. CONCLUSION Warfarin aggravates atherosclerotic disease activity, increasing plaque inflammation, active calcification, and plaque progression. Dabigatran lacks undesired vascular side effects and reveals beneficial effects on atherosclerosis progression and calcification. The choice of anticoagulation impacts atherosclerotic disease by differential off target effect. Future clinical studies should test whether this beneficial effect also applies to patients.
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Affiliation(s)
- Rick H. van Gorp
- Department of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
- Nattopharma ASAOsloNorway
| | - Ingrid Dijkgraaf
- Department of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
| | - Vanessa Bröker
- Department of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
| | - Matthias Bauwens
- Department of Radiology and Nuclear MedicineMaastricht University Medical Center (MUMC+)MaastrichtThe Netherlands
| | - Peter Leenders
- Department of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
| | - Danyel Jennen
- Department of ToxicogenomicsGROW School of Oncology and Developmental BiologyMaastricht UniversityMaastrichtThe Netherlands
| | - Marc R. Dweck
- Centre for Cardiovascular ScienceUniversity of EdinburghEdinburghUK
| | - Jan Bucerius
- Department of Radiology and Nuclear MedicineMaastricht University Medical Center (MUMC+)MaastrichtThe Netherlands
| | - Jacco J. Briedé
- Department of ToxicogenomicsGROW School of Oncology and Developmental BiologyMaastricht UniversityMaastrichtThe Netherlands
| | - Joanne van Ryn
- Department of Cardiometabolic ResearchBoehringer IngelheimBiberachGermany
| | - Vincent Brandenburg
- Klinik Für Kardiologie und NephrologieRhein‐Maas Klinikum WürselenWürselenGermany
| | - Felix Mottaghy
- Department of Radiology and Nuclear MedicineMaastricht University Medical Center (MUMC+)MaastrichtThe Netherlands
- Department of Nuclear MedicineUniversity Hospital RWTH Aachen UniversityAachenGermany
| | - Henri M. H. Spronk
- Department of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
| | - Chris P. Reutelingsperger
- Department of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
| | - Leon J. Schurgers
- Department of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
- Institute of Experimental Medicine and Systems BiologyRWTH Aachen UniversityAachenGermany
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15
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The Effects of Warfarin and Direct Oral Anticoagulants on Systemic Vascular Calcification: A Review. Cells 2021; 10:cells10040773. [PMID: 33807457 PMCID: PMC8066517 DOI: 10.3390/cells10040773] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 12/30/2022] Open
Abstract
Warfarin has been utilized for decades as an effective anticoagulant in patients with a history of strong risk factors for venous thromboembolism (VTE). Established adverse effects include bleeding, skin necrosis, teratogenicity during pregnancy, cholesterol embolization, and nephropathy. One of the lesser-known long-term side effects of warfarin is an increase in systemic arterial calcification. This is significant due to the association between vascular calcification and cardiovascular morbidity and mortality. Direct oral anticoagulants (DOACs) have gained prominence in recent years, as they require less frequent monitoring and have a superior side effect profile to warfarin, specifically in relation to major bleeding. The cost and lack of data for DOACs in some disease processes have precluded universal use. Within the last four years, retrospective cohort studies, observational studies, and randomized trials have shown, through different imaging modalities, that multiple DOACs are associated with slower progression of vascular calcification than warfarin. This review highlights the pathophysiology and mechanisms behind vascular calcification due to warfarin and compares the effect of warfarin and DOACs on systemic vasculature.
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16
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Hasific S, Øvrehus KA, Gerke O, Hallas J, Busk M, Lambrechtsen J, Urbonaviciene G, Sand NPR, Nielsen JS, Diederichsen L, Pedersen KB, Carter-Storch R, Ilangkovan N, Mickley H, Rasmussen LM, Lindholt JS, Diederichsen A. Extent of arterial calcification by conventional vitamin K antagonist treatment. PLoS One 2020; 15:e0241450. [PMID: 33119722 PMCID: PMC7595268 DOI: 10.1371/journal.pone.0241450] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 10/14/2020] [Indexed: 12/18/2022] Open
Abstract
Background and aims Vitamin K antagonists (VKA) remain the most frequently prescribed oral anticoagulants worldwide despite the introduction of non-vitamin K antagonist oral anticoagulants (NOAC). VKA interfere with the regeneration of Vitamin K1 and K2, essential to the activation of coagulation factors and activation of matrix-Gla protein, a strong inhibitor of arterial calcifications. This study aimed to clarify whether VKA treatment was associated with the extent of coronary artery calcification (CAC) in a population with no prior cardiovascular disease (CVD). Methods We collected data on cardiovascular risk factors and CAC scores from cardiac CT scans performed as part of clinical examinations (n = 9,672) or research studies (n = 14,166) in the period 2007–2017. Data on use of anticoagulation were obtained from the Danish National Health Service Prescription Database. The association between duration of anticoagulation and categorized CAC score (0, 1–99, 100–399, ≥400) was investigated by ordered logistic regression adjusting for covariates. Results The final study population consisted of 17,254 participants with no prior CVD, of whom 1,748 and 1,144 had been treated with VKA or NOAC, respectively. A longer duration of VKA treatment was associated with higher CAC categories. For each year of VKA treatment, the odds of being in a higher CAC category increased (odds ratio (OR) = 1.032, 95%CI 1.009–1.057). In contrast, NOAC treatment duration was not associated with CAC category (OR = 1.002, 95%CI 0.935–1.074). There was no significant interaction between VKA treatment duration and age on CAC category. Conclusions Adjusted for cardiovascular risk factors, VKA treatment–contrary to NOAC—was associated to higher CAC category.
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Affiliation(s)
- Selma Hasific
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- * E-mail:
| | | | - Oke Gerke
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
| | - Martin Busk
- Department of Cardiology, Little Belt Hospital Vejle, Vejle, Denmark
| | - Jess Lambrechtsen
- Department of Cardiology, Odense University Hospital Svendborg, Svendborg, Denmark
| | - Grazina Urbonaviciene
- Department of Cardiology, Regional Hospital Central Jutland Silkeborg, Silkeborg, Denmark
| | | | - Jens Steen Nielsen
- DD2, Steno Diabetes Centre Odense, Odense University Hospital, Odense, Denmark
- OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
| | | | | | - Rasmus Carter-Storch
- Department of Cardiology, Odense University Hospital Svendborg, Svendborg, Denmark
| | | | - Hans Mickley
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | - Jes Sandal Lindholt
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital,Odense, Denmark
| | - Axel Diederichsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
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17
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Position paper on the safety/efficacy profile of direct oral anticoagulants in patients with chronic kidney disease. Consensus document from the SIN, FCSA and SISET. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:478-485. [PMID: 33000751 DOI: 10.2450/2020.0156-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022]
Abstract
Direct oral anticoagulants (DOAC) are mostly prescribed to prevent cardioembolic stroke in patients with non-valvular atrial fibrillation (AF). An increasing number of guidelines recommend DOAC in AF patients with preserved renal function for the prevention of thromboembolism, and an increased use of DOAC in daily practice has been recorded also in elderly patients. Ageing is associated with a reduction in glomerular filtration rate, and impaired renal function, regardless of the cause, increases the risk of bleeding. Multiple medication use (polypharmacy) for treating superimposed co-morbidities is common in both elderly and chronic kidney disease (CKD) patients and drug-drug interaction may cause accumulation of DOAC, thereby increasing the risk of bleeding. The safety profile of DOAC in patients with CKD has not been defined with any certainty, particularly in those with severely impaired renal function or end stage renal disease. This has been due to the heterogeneity of studies and the relative paucity of data. This document reports the position of three Italian scientific societies engaged in the management of patients with atrial fibrillation who are treated with DOAC and present with CKD.
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18
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Ashley J, McArthur E, Bota S, Harel Z, Battistella M, Molnar AO, Jun M, Badve SV, Garg AX, Manuel D, Tanuseputro P, Wells P, Mavrakanas T, Rhodes E, Sood MM. Risk of Cardiovascular Events and Mortality Among Elderly Patients With Reduced GFR Receiving Direct Oral Anticoagulants. Am J Kidney Dis 2020; 76:311-320. [DOI: 10.1053/j.ajkd.2020.02.446] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 02/11/2020] [Indexed: 02/01/2023]
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19
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Oikonomou E, Leopoulou M, Theofilis P, Antonopoulos AS, Siasos G, Latsios G, Mystakidi VC, Antoniades C, Tousoulis D. A link between inflammation and thrombosis in atherosclerotic cardiovascular diseases: Clinical and therapeutic implications. Atherosclerosis 2020; 309:16-26. [PMID: 32858395 DOI: 10.1016/j.atherosclerosis.2020.07.027] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/22/2020] [Accepted: 07/29/2020] [Indexed: 12/22/2022]
Abstract
The association between thrombosis and acute coronary syndromes is well established. Inflammation and activation of innate and adaptive immunity are another important factor implicated in atherosclerosis. However, the exact interactions between thrombosis and inflammation in atherosclerosis are less well understood. Accumulating data suggest a firm interaction between these two key pathophysiologic processes. Pro-inflammatory cytokines, such as tumor necrosis factor α, interleukin-6 and interleukin-1, have been implicated in the thrombotic cascade following plaque rupture and myocardial infarction. Furthermore, cell adhesion molecules accelerate not only atheromatosis but also thrombosis formation while activated platelets are able to trigger leukocyte adhesion and accumulation. Additionally, tissue factor, thrombin, and activated coagulation factors induce the release of pro-inflammatory cytokines such as prostaglandin and C reactive protein, which may further induce von Willebrand factor secretion. Treatments targeting immune activation (i.e. interleukin-1 inhibitors, colchicine, statins, etc.) may also beneficially modulate platelet activation while common anti-thrombotic therapies appear to attenuate the inflammatory process. Taken together in the context of cardiovascular diseases, thrombosis and inflammation should be studied and managed as a common entity under the concept of thrombo-inflammation.
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Affiliation(s)
- Evangelos Oikonomou
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece.
| | - Marianna Leopoulou
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Panagiotis Theofilis
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Alexios S Antonopoulos
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Gerasimos Siasos
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - George Latsios
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Vasiliki Chara Mystakidi
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Charalambos Antoniades
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Dimitris Tousoulis
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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20
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Grandone E, Aucella F, Barcellona D, Brunori G, Forneris G, Gresele P, Marietta M, Poli D, Testa S, Tripodi A, Genovesi S. Position paper on the safety/efficacy profile of Direct Oral Anticoagulants in patients with Chronic Kidney Disease: Consensus document of Società Italiana di Nefrologia (SIN), Federazione Centri per la diagnosi della trombosi e la Sorveglianza delle terapie Antitrombotiche (FCSA) and Società Italiana per lo Studio dell'Emostasi e della Trombosi (SISET). J Nephrol 2020; 34:31-38. [PMID: 32757171 PMCID: PMC7881955 DOI: 10.1007/s40620-020-00768-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/29/2020] [Indexed: 12/20/2022]
Abstract
Direct oral anticoagulants (DOAC) are mostly prescribed to prevent cardioembolic stroke in patients with non-valvular atrial fibrillation (AF). An increasing number of guidelines recommend DOAC in AF patients with preserved renal function for the prevention of thromboembolism and an increased use of DOAC in daily practice is recorded also in elderly patients. Aging is associated with a reduction of glomerular filtration rate and impaired renal function, regardless of the cause, increases the risk of bleeding. Multiple medication use (polypharmacy) for treating superimposed co-morbidities is common in both elderly and chronic kidney disease (CKD) patients and drug-drug interaction may cause accumulation of DOAC, thereby increasing the risk of bleeding. There is uncertainty on the safety profile of DOAC in patients with CKD, particularly in those with severely impaired renal function or end stage renal disease, due to the heterogeneity of studies and the relative paucity of data. This document reports the position of three Italian scientific societies engaged in the management of patients with atrial fibrillation who are treated with DOAC and present with CKD.
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Affiliation(s)
- Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy.,Ob/Gyn Department of the First I.M. Sechenov, Moscow State Medical University, Moscow, Russia
| | - Filippo Aucella
- Nephrology and Dialysis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,SHRO Temple University, Philadelphia, USA
| | | | - Giacomo Forneris
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Marco Marietta
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy
| | - Daniela Poli
- Center for Atherothrombotic Diseases, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Sophie Testa
- Haemostasis and Thrombosis Center, ASST Cremona, Cremona, Italy
| | - Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Simonetta Genovesi
- University of Milan-Bicocca, Milano, Italy. .,Nephrology Unit, San Gerardo Hospital, Monza, Italy.
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21
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Ravera M, Bussalino E, Fusaro M, Di Lullo L, Aucella F, Paoletti E. Systematic DOACs oral anticoagulation in patients with atrial fibrillation and chronic kidney disease: the nephrologist's perspective. J Nephrol 2020; 33:483-495. [PMID: 32200488 DOI: 10.1007/s40620-020-00720-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/12/2020] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) is highly prevalent among patients with chronic kidney disease (CKD), and also associated with unfavorable outcome. Anticoagulant therapy is the mainstep of management in such patients, aimed at reducing the high risk of systemic thromboembolism and especially of ischemic stroke, which is reportedly associated with increased mortality in CKD patients. Even though new direct oral anticoagulant agents (DOACs) proved to be effective in patients with non valvular chronic AF, and are therefore recommended by recent guidelines for their treatment, warfarin is currently used in more than one-half of subjects needing oral anticoagulation, and only 30% of them are converted from a vitamin K antagonist- to a DOAC-based regimen. The main reason for not prescribing DOACs is often a reduction in renal function, even if mild. Aim of this review was therefore to evaluate the impact of DOAC therapy in the setting of CKD, from a nephrological perspective, by comparing available evidence on the role of DOACs in patients with CKD and AF with that emerging from traditional warfarin-based therapy. Both the pathogenesis of AF in CKD, and available findings of renal, cardiovascular and bone effects of DOACs in CKD are discussed, leading to the conclusion that DOAC therapy should be considered as the first line therapy for non valvular AF in patients with mild and moderate reduction of renal function, and could also be adopted for patients with severe CKD not on hemodialysis treatment, whereas there is insufficient evidence for ESRD patients on dialysis.
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Affiliation(s)
- Maura Ravera
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy.
| | - Elisabetta Bussalino
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy
- Department of Medicine, University of Padova, Padua, Italy
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, Colleferro, Rome, Italy
| | - Filippo Aucella
- Nephrology and Dialysis Unit, IRCCS "Casa Sollievo della Sofferenza" Scientific Institute for Research and Health Care, San Giovanni Rotondo, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy
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22
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Olie RH, van der Meijden PEJ, Spronk HMH, Ten Cate H. Antithrombotic Therapy: Prevention and Treatment of Atherosclerosis and Atherothrombosis. Handb Exp Pharmacol 2020; 270:103-130. [PMID: 32776281 DOI: 10.1007/164_2020_357] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Atherosclerosis is a multifactorial vascular disease that develops in the course of a lifetime. Numerous risk factors for atherosclerosis have been identified, mostly inflicting pro-inflammatory effects. Vessel injury, such as occurring during erosion or rupture of atherosclerotic lesions triggers blood coagulation, in attempt to maintain hemostasis (protect against bleeding). However, thrombo-inflammatory mechanisms may drive blood coagulation such that thrombosis develops, the key process underlying myocardial infarction and ischemic stroke (not due to embolization from the heart). In the blood coagulation system, platelets and coagulation proteins are both essential elements. Hyperreactivity of blood coagulation aggravates atherosclerosis in preclinical models. Pharmacologic inhibition of blood coagulation, either with platelet inhibitors, or better documented with anticoagulants, or both, limits the risk of thrombosis and may potentially reverse atherosclerosis burden, although the latter evidence is still based on animal experimentation.Patients at risk of atherothrombotic complications should receive a single antiplatelet agent (acetylsalicylic acid, ASA, or clopidogrel); those who survived an atherothrombotic event will be prescribed temporary dual antiplatelet therapy (ASA plus a P2Y12 inhibitor) in case of myocardial infarction (6-12 months), or stroke (<6 weeks), followed by a single antiplatelet agent indefinitely. High risk for thrombosis patients (such as those with peripheral artery disease) benefit from a combination of an anticoagulant and ASA. The price of gained efficacy is always increased risk of (major) bleeding; while tailoring therapy to individual needs may limit the risks to some extent, new generations of agents that target less critical elements of hemostasis and coagulation mechanisms are needed to maintain efficacy while reducing bleeding risks.
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Affiliation(s)
- R H Olie
- Internal Medicine and CARIM School for Cardiovascular Research, Maastricht University Medical Center, Maastricht, The Netherlands.,Thrombosis Expertise Center, Heart+ Cardiovascular Center, and Department of Biochemistry, Maastricht University Medical Center, Maastricht, The Netherlands
| | - P E J van der Meijden
- Thrombosis Expertise Center, Heart+ Cardiovascular Center, and Department of Biochemistry, Maastricht University Medical Center, Maastricht, The Netherlands
| | - H M H Spronk
- Thrombosis Expertise Center, Heart+ Cardiovascular Center, and Department of Biochemistry, Maastricht University Medical Center, Maastricht, The Netherlands
| | - H Ten Cate
- Internal Medicine and CARIM School for Cardiovascular Research, Maastricht University Medical Center, Maastricht, The Netherlands. .,Thrombosis Expertise Center, Heart+ Cardiovascular Center, and Department of Biochemistry, Maastricht University Medical Center, Maastricht, The Netherlands.
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23
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Di Fusco SA, Lucà F, Gulizia MM, Gabrielli D, Colivicchi F. Emerging clinical setting of direct oral anticoagulants. J Cardiovasc Med (Hagerstown) 2020; 21:1-5. [DOI: 10.2459/jcm.0000000000000894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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24
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Petsophonsakul P, Furmanik M, Forsythe R, Dweck M, Schurink GW, Natour E, Reutelingsperger C, Jacobs M, Mees B, Schurgers L. Role of Vascular Smooth Muscle Cell Phenotypic Switching and Calcification in Aortic Aneurysm Formation. Arterioscler Thromb Vasc Biol 2019; 39:1351-1368. [PMID: 31144989 DOI: 10.1161/atvbaha.119.312787] [Citation(s) in RCA: 209] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Aortic aneurysm is a vascular disease whereby the ECM (extracellular matrix) of a blood vessel degenerates, leading to dilation and eventually vessel wall rupture. Recently, it was shown that calcification of the vessel wall is involved in both the initiation and progression of aneurysms. Changes in aortic wall structure that lead to aneurysm formation and vascular calcification are actively mediated by vascular smooth muscle cells. Vascular smooth muscle cells in a healthy vessel wall are termed contractile as they maintain vascular tone and remain quiescent. However, in pathological conditions they can dedifferentiate into a synthetic phenotype, whereby they secrete extracellular vesicles, proliferate, and migrate to repair injury. This process is called phenotypic switching and is often the first step in vascular pathology. Additionally, healthy vascular smooth muscle cells synthesize VKDPs (vitamin K-dependent proteins), which are involved in inhibition of vascular calcification. The metabolism of these proteins is known to be disrupted in vascular pathologies. In this review, we summarize the current literature on vascular smooth muscle cell phenotypic switching and vascular calcification in relation to aneurysm. Moreover, we address the role of vitamin K and VKDPs that are involved in vascular calcification and aneurysm. Visual Overview- An online visual overview is available for this article.
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Affiliation(s)
- Ploingarm Petsophonsakul
- From the Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (P.P., M.F., C.R., L.S.)
| | - Malgorzata Furmanik
- From the Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (P.P., M.F., C.R., L.S.)
| | - Rachael Forsythe
- Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (R.F., M.D.)
| | - Marc Dweck
- Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (R.F., M.D.)
| | - Geert Willem Schurink
- Department of Vascular Surgery (G.W.S., M.J., B.M.), Maastricht University Medical Center (MUMC), Maastricht, the Netherlands
| | - Ehsan Natour
- Department of Cardiovascular Surgery (E.N.), Maastricht University Medical Center (MUMC), Maastricht, the Netherlands.,European Vascular Center Aachen-Maastricht, Maastricht, the Netherlands (E.N., M.J., B.M.)
| | - Chris Reutelingsperger
- From the Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (P.P., M.F., C.R., L.S.)
| | - Michael Jacobs
- Department of Vascular Surgery (G.W.S., M.J., B.M.), Maastricht University Medical Center (MUMC), Maastricht, the Netherlands.,European Vascular Center Aachen-Maastricht, Maastricht, the Netherlands (E.N., M.J., B.M.)
| | - Barend Mees
- Department of Vascular Surgery (G.W.S., M.J., B.M.), Maastricht University Medical Center (MUMC), Maastricht, the Netherlands.,European Vascular Center Aachen-Maastricht, Maastricht, the Netherlands (E.N., M.J., B.M.)
| | - Leon Schurgers
- From the Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (P.P., M.F., C.R., L.S.)
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25
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Papadaki S, Tselepis AD. Nonhemostatic Activities of Factor Xa: Are There Pleiotropic Effects of Anti-FXa Direct Oral Anticoagulants? Angiology 2019; 70:896-907. [PMID: 31010298 DOI: 10.1177/0003319719840861] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Factor Xa (FXa) is the key serine protease of the coagulation cascade as it is the point of convergence of the intrinsic and extrinsic pathways, leading to the formation of thrombin. Factor Xa is an established target of anticoagulation therapy, due to its central role in coagulation. Over the past years, several direct oral anticoagulants (DOACs) targeting FXa have been developed. Rivaroxaban, apixaban, and edoxaban are used in clinical practice for prevention and treatment of thrombotic diseases. Increasing evidence suggests that FXa exerts nonhemostatic cellular effects that are mediated mainly through protease-activated receptors-1 and -2 and are involved in pathophysiological conditions, such as atherosclerosis, inflammation, and fibrosis. Direct inhibition of FXa by DOACs could be beneficial in these conditions. This is a narrative review that focuses on the cellular effects of FXa in various cell types and conditions, as well as on the possible pleiotropic effects of FXa-targeting DOACs.
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Affiliation(s)
- Styliani Papadaki
- 1 Department of Chemistry, Atherothrombosis Research Centre/Laboratory of Biochemistry, University of Ioannina, Ioannina, Greece
| | - Alexandros D Tselepis
- 1 Department of Chemistry, Atherothrombosis Research Centre/Laboratory of Biochemistry, University of Ioannina, Ioannina, Greece
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Cordero A, Rodriguez-Mañero M, García-Acuña JM, Bertomeu-González V, Agra-Bermejo R, Cid B, Alvarez B, Bertomeu-Martínez V, González-Juanatey JR. Incidence and predictors of stroke in patients discharged with the diagnosis of acute coronary syndrome. Int J Cardiol 2019; 276:20-25. [DOI: 10.1016/j.ijcard.2018.10.082] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 09/03/2018] [Accepted: 10/23/2018] [Indexed: 11/17/2022]
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27
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Holden RM, Hétu MF, Li TY, Ward EC, Couture LE, Herr JE, Christilaw E, Adams MA, Johri AM. Circulating Gas6 is associated with reduced human carotid atherosclerotic plaque burden in high risk cardiac patients. Clin Biochem 2018; 64:6-11. [PMID: 30508521 DOI: 10.1016/j.clinbiochem.2018.11.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Pre-clinical studies suggest that growth arrest-specific protein 6 (Gas6), a member of the vitamin K dependent family of proteins, is implicated in atherosclerosis. A role for Gas6 in stabilizing atherosclerotic plaque has been suggested. Our aim was to determine the association between Gas6 and measures of carotid artery atherosclerosis in humans undergoing elective coronary angiography. Secondary aims were to determine the association between Gas6 and sex, diabetes, and obesity. METHODS In 204 outpatients referred for coronary angiography, EDTA plasma was collected and a focused carotid ultrasound performed. Degree of angiographic coronary artery disease was scored. Carotid intima media thickness as well as maximum plaque height, plaque area, and grayscale median were measured by vascular sonography. Gas6 was assessed by enzyme-linked immunosorbent assay. RESULTS We found that Gas6 concentrations were lower in males and were associated with diabetes, obesity, and lower kidney function. After adjustment for age, sex, kidney function, BMI and traditional cardiac risk factors; diabetes was associated with higher levels of Gas6, whilst there was a significant inverse relationship between Gas6 and total plaque area. Gas6 was inversely associated with maximum plaque height and total plaque area in adjusted multi-variable models. CONCLUSIONS We observed higher levels of Gas6 in participantswith adverse cardiovascular risk profiles (e.g. diabetes, obesity) yet Gas6 was independently associated with reduced plaque height and total plaque area. These findings suggest that Gas6 may play a role in human atherosclerotic plaque remodeling.
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Affiliation(s)
- Rachel M Holden
- Department of Medicine, Queen's University, Kingston, Ontario, Canada; Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario, Canada
| | - Marie-France Hétu
- Department of Medicine, Division of Cardiology, Cardiovascular Imaging Network at Queen's, Queen's University, Kingston, Ontario, Canada
| | - Terry Y Li
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario, Canada
| | - Emilie C Ward
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario, Canada
| | - Laura E Couture
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario, Canada
| | - Julia E Herr
- Department of Medicine, Division of Cardiology, Cardiovascular Imaging Network at Queen's, Queen's University, Kingston, Ontario, Canada
| | - Erin Christilaw
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Michael A Adams
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario, Canada
| | - Amer M Johri
- Department of Medicine, Division of Cardiology, Cardiovascular Imaging Network at Queen's, Queen's University, Kingston, Ontario, Canada; Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario, Canada.
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