1
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Bai Z, Wang Z, Feng Q, Zhang Y, Zhang M, Hou A, Wu Y, Qin Z, Chai L. Bivalirudin vs heparin in cardiac-cerebral ischemic and bleeding events among Chinese STEMI patients during percutaneous coronary intervention: a retrospective cohort study. Braz J Med Biol Res 2023; 56:e13013. [PMID: 37970924 PMCID: PMC10644965 DOI: 10.1590/1414-431x2023e13013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/10/2023] [Indexed: 11/19/2023] Open
Abstract
Although bivalirudin has been recently made available for purchase in China, large-scale analyses on the safety profile of bivalirudin among Chinese patients is lacking. Thus, this study aimed to compare the safety profile of bivalirudin and heparin as anticoagulants in Chinese ST-segment elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI). A total of 1063 STEMI patients undergoing PCI and receiving bivalirudin (n=424, bivalirudin group) or heparin (n=639, heparin group) as anticoagulants were retrospectively enrolled. The net adverse clinical events (NACEs) within 30 days after PCI were recorded, including major adverse cardiac and cerebral events (MACCEs) and bleeding events (bleeding academic research consortium (BARC) grades 2-5 (BARC 2-5)). The incidences of NACEs (10.1 vs 15.6%) (P=0.010), BARC 2-5 bleeding events (5.2 vs 10.3%) (P=0.003), and BARC grades 3-5 (BARC 3-5) bleeding events (2.1 vs 5.5%) (P=0.007) were lower in the bivalirudin group compared to the heparin group, whereas general MACCEs incidence (8.9 vs 6.4%) (P=0.131) and each category of MACCEs (all P>0.05) did not differ between two groups. Furthermore, the multivariate logistic analyses showed that bivalirudin (vs heparin) was independently correlated with lower risk of NACEs (OR=0.508, P=0.002), BARC 2-5 bleeding events (OR=0.403, P=0.001), and BARC 3-5 bleeding events (OR=0.452, P=0.042); other independent risk factors for NACEs, MACCEs, or BARC bleeding events included history of diabetes mellitus, emergency operation, multiple lesional vessels, stent length >33.0 mm, and higher CRUSADE score (all P<0.05). Thus, bivalirudin presented a better safety profile than heparin among Chinese STEMI patients undergoing PCI.
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Affiliation(s)
- Zhichao Bai
- Department of Cardiology, HanDan Central Hospital, Handan, China
| | - Zhenzhen Wang
- Department of Cardiology, HanDan Central Hospital, Handan, China
| | - Qiang Feng
- Department of Cardiology, HanDan Central Hospital, Handan, China
| | - Yapei Zhang
- The Fourth Department of Oncology, HanDan Central Hospital, Handan, China
| | - Mengying Zhang
- Department of Cardiology, HanDan Central Hospital, Handan, China
| | - Aijun Hou
- Department of Cardiology, HanDan Central Hospital, Handan, China
| | - Yiping Wu
- Department of Neurology, HanDan Central Hospital, Handan, China
| | - Zhenpeng Qin
- Information Section, HanDan Central Hospital, Handan, China
| | - Lina Chai
- Department of Cardiology, HanDan Central Hospital, Handan, China
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2
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Zhao YJ, Sun Y, Wang F, Cai YY, Alolga RN, Qi LW, Xiao P. Comprehensive evaluation of time-varied outcomes for invasive and conservative strategies in patients with NSTE-ACS: a meta-analysis of randomized controlled trials. Front Cardiovasc Med 2023; 10:1197451. [PMID: 37745128 PMCID: PMC10516546 DOI: 10.3389/fcvm.2023.1197451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023] Open
Abstract
Background Results from randomized controlled trials (RCTs) and meta-analyses comparing invasive and conservative strategies in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) are highly debatable. We systematically evaluate the efficacy of invasive and conservative strategies in NSTE-ACS based on time-varied outcomes. Methods The RCTs for the invasive versus conservative strategies were identified by searching PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov. Trial data for studies with a minimum follow-up time of 30 days were included. We categorized the follow-up time into six varied periods, namely, ≤6 months, 1 year, 2 years, 3 years, 5 years, and ≥10 years. The time-varied outcomes were major adverse cardiovascular event (MACE), death, myocardial infarction (MI), rehospitalization, cardiovascular death, bleeding, in-hospital death, and in-hospital bleeding. Risk ratios (RRs) and 95% confidence intervals (Cis) were calculated. The random effects model was used. Results This meta-analysis included 30 articles of 17 RCTs involving 12,331 participants. We found that the invasive strategy did not provide appreciable benefits for NSTE-ACS in terms of MACE, death, and cardiovascular death at all time points compared with the conservative strategy. Although the risk of MI was reduced within 6 months (RR 0.80, 95% CI 0.68-0.94) for the invasive strategy, no significant differences were observed in other periods. The invasive strategy reduced the rehospitalization rate within 6 months (RR 0.69, 95% CI 0.52-0.90), 1 year (RR 0.73, 95% CI 0.63-0.86), and 2 years (RR 0.77, 95% CI 0.60-1.00). Of note, an increased risk of bleeding (RR 1.80, 95% CI 1.28-2.54) and in-hospital bleeding (RR 2.17, 95% CI 1.52-3.10) was observed for the invasive strategy within 6 months. In subgroups stratified by high-risk features, the invasive strategy decreased MACE for patients aged ≥65 years within 6 months (RR 0.68, 95% CI 0.58-0.78) and 1 year (RR 0.75, 95% CI 0.62-0.91) and showed benefits for men within 6 months (RR 0.71, 95% CI 0.55-0.92). In other subgroups stratified according to diabetes, ST-segment deviation, and troponin levels, no significant differences were observed between the two strategies. Conclusions An invasive strategy is superior to a conservative strategy in reducing early events for MI and rehospitalizations, but the invasive strategy did not improve the prognosis in long-term outcomes for patients with NSTE-ACS. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021289579, identifier PROSPERO 2021 CRD42021289579.
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Affiliation(s)
- Yi-Jing Zhao
- State Key Laboratory of Natural Medicines, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, China
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Yangyang Sun
- Department of Pharmacy, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Fan Wang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Yuan-Yuan Cai
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Raphael N. Alolga
- State Key Laboratory of Natural Medicines, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, China
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Lian-Wen Qi
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
- College of Traditional Chinese Medicine and Food Engineering, Shanxi University of Chinese Medicine, Taiyuan, China
| | - Pingxi Xiao
- Department of Cardiology, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, China
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3
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Li J, Liu X, Ma S, Na K, Qi Z, Xu Y, Qiu M, Han Y, Li Y. Effectiveness and safety of bivalirudin in elderly patients with coronary artery disease undergoing percutaneous coronary intervention: A real-world study. Catheter Cardiovasc Interv 2022; 99 Suppl 1:1448-1455. [PMID: 35077603 DOI: 10.1002/ccd.30099] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the effectiveness and safety of bivalirudin compared with heparin monotherapy in elderly patients undergoing percutaneous coronary intervention (PCI). BACKGROUND Bivalirudin is recommended for periprocedural use in patients undergoing PCI who are of high bleeding risk. However, its safe and efficacious use in elderly patients, a typical high bleeding risk cohort, in real world practice is yet to be reported. METHODS In this single center, real-world observational study, 4736 consecutive elderly patients who underwent PCI were enrolled. Of these, 1240 were treated with bivalirudin and 3496 with heparin according to the periprocedural anticoagulation strategies of PCI. The primary outcome was 12-month net adverse clinical events (NACE) defined as a composite of cardiac death, myocardial infarction, stroke, revascularization, or any bleeding. Propensity score matching (PSM) was used to balance baseline characteristics between groups. RESULTS After PSM, bivalirudin was found to be associated with lower rates of NACE (19.1% vs. 24.7%, p = 0.002), cardiac death (2.7% vs. 4.3%, p = 0.038), and any bleeding (10.0% vs. 12.9%, p = 0.023) compared to heparin monotherapy. No differences were found in the incidences of myocardial infarction, stroke, revascularization, stent thrombosis (0.1% vs. 0.1%, p = 1.000), and major bleedings (0.5% vs. 0.5%, p = 1.000) between the two patient groups. CONCLUSION In this real-world observational study, periprocedural use of bivalirudin in elderly patients who underwent PCI was associated with less cardiac death and any bleeding compared to heparin monotherapy, without increased risk of stent thrombosis.
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Affiliation(s)
- Jing Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China.,Department of Cardiology, The Graduate School of Harbin Medical University, Harbin, China
| | - Xiying Liu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China.,Shenyang Pharmaceutical University, Shenyang, China
| | - Sicong Ma
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Kun Na
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China.,Shenyang Pharmaceutical University, Shenyang, China
| | - Zizhao Qi
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China.,Department of Cardiology, The Graduate School of Harbin Medical University, Harbin, China
| | - Ying Xu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Miaohan Qiu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
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Kim BG, Hong SJ, Kim BK, Lee SJ, Ahn CM, Shin DH, Kim JS, Ko YG, Choi D, Hong MK, Jang Y. Age-Dependent Effect of Ticagrelor Monotherapy Versus Ticagrelor With Aspirin on Major Bleeding and Cardiovascular Events: A Post Hoc Analysis of the TICO Randomized Trial. J Am Heart Assoc 2021; 10:e022700. [PMID: 34873925 PMCID: PMC9075234 DOI: 10.1161/jaha.121.022700] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background We aimed to evaluate the age‐dependent effect of ticagrelor monotherapy after 3‐month dual‐antiplatelet therapy (DAPT) versus ticagrelor‐based 12‐month DAPT on major bleeding and cardiovascular events in patients with acute coronary syndrome. Methods and Results From the TICO trial (Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus‐eluting Stent for Acute Coronary Syndrome), which randomized 3056 patients (median age, 61 years) to the ticagrelor monotherapy after 3‐month DAPT group or ticagrelor‐based 12‐month DAPT group, this post hoc analysis evaluated the age‐dependent effect of the treatment strategies on the primary end point (a composite of major bleeding, death, myocardial infarction, stent thrombosis, stroke, or target‐vessel revascularization) using the subpopulation treatment effect pattern plot. The cutoff age for distinguishing patients with greater benefit from this strategy was also determined. The risk reduction effect of ticagrelor monotherapy after 3‐month DAPT versus ticagrelor‐based 12‐month DAPT on the primary end point gradually increased with age and was more marked from the subpopulation of age 64 years with the change point. With this cutoff value of 64 years, the occurrence of the primary end point was significantly lower in the ticagrelor monotherapy after 3‐month DAPT group than in the ticagrelor‐based 12‐month DAPT group (4.4% versus 9.0%; P=0.002) in patients aged ≥64 years (n=1278), but it was not different in those aged <64 years (n=1778) with a significant interaction (P‐interaction=0.036). Conclusions The age‐dependent increase in the benefit of ticagrelor monotherapy after 3‐month DAPT versus ticagrelor‐based 12‐month DAPT was observed in the patients with acute coronary syndrome. In elderly patients with acute coronary syndrome, ticagrelor monotherapy after short‐term DAPT might be more optimal than ticagrelor‐based 12‐month DAPT.
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Affiliation(s)
- Byung Gyu Kim
- Division of Cardiology Department of Internal Medicine Sanggye Paik HospitalInje University College of Medicine Seoul Korea
| | - Sung-Jin Hong
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Byeong-Keuk Kim
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Seung-Jun Lee
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Chul-Min Ahn
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Dong-Ho Shin
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Jung-Sun Kim
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Young-Guk Ko
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Donghoon Choi
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Myeong-Ki Hong
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Yangsoo Jang
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
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5
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Tkacheva ON, Vorobyeva NM, Kotovskaya YV, Runikhina NK, Strazhesco ID, Villevalde SV, Drapkina OM, Komarov AL, Orlova YA, Panchenko EP, Pogosova NV, Frolova EV, Yavelov IS. Antithrombotic therapy in the elderly and senile age: the consensus opinion of experts of the Russian Association of Gerontologists and Geriatricians and the National Society of Preventive Cardiology. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2021-2847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
В данном документе обсуждаются особенности АТТ у лиц пожилого и старческого возраста в различных клинических ситуациях.
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6
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Zhang Y, Zhang Y, Chang C, Yan S, Chen Z, Zhang L, Chen K, Liu G. Efficacy and Safety of Bivalirudin During Percutaneous Coronary Intervention in Chronic Total Occlusion: A Retrospective Study. Clin Ther 2021; 43:844-851. [PMID: 33810894 DOI: 10.1016/j.clinthera.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/04/2021] [Accepted: 03/09/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE Bivalirudin as a thrombin inhibitor is proven to have a low risk of bleeding during percutaneous coronary intervention (PCI). Some evidence indicates comparable effectiveness and safety between bivalirudin and unfractionated heparin (UFH). Although bivalirudin during PCI offers more clinical and safety benefits to patients with chronic total occlusion (CTO), mostly via radial access, this has not been confirmed. The objective of this study was to examine the efficacy and safety of bivalirudin during percutaneous coronary intervention (PCI) in patients with CTO. METHODS This trial used a retrospective cohort study design. Medical information from 736 patients with CTO who underwent PCI with bivalirudin or UFH at the First Affiliated Hospital of Zhengzhou University from July 2019 to September 2020 was extracted and analyzed. The primary end point was the 30-day incidence of net adverse clinical events (NACEs), and the secondary end point was the major adverse cardiovascular events (MACEs), which were related to safety and efficacy, respectively. Other end points incorporated each component of the primary outcome, target vessel revascularization, and stent thrombosis. Clinical and procedural characteristics at baseline were adjusted by using a logistic regression model. FINDINGS Overall, 71.5% of patients with CTO used the radial approach. Both groups exhibited nonsignificant differences in the majority of baseline characteristics. The bivalirudin group was associated with a significant reduction in NACEs (12.9% vs 21.5%; P = 0.002) and major bleeding (2.5% vs 8.0%; P = 0.001) versus the UFH group at the end of the 30-day follow-up. The incidence of MACEs, myocardial infarction, death, stroke, stent thrombosis, and target vessel revascularization did not differ significantly between the 2 groups. Moreover, the bivalirudin group also reported a lower incidence of NACEs in the prespecified subgroups. IMPLICATIONS Bivalirudin exhibited comparative efficacy but superior safety compared with UFH among patients with CTO undergoing PCI. Chinese Clinical Trial Registry: ChiCTR2000034771.
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Affiliation(s)
- Yanghui Zhang
- Department of Cardiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Yahao Zhang
- Department of Cardiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Chao Chang
- Department of Cardiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Shumei Yan
- Department of Cardiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Zheng Chen
- Department of Cardiac Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Lishuai Zhang
- Department of Cardiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Kui Chen
- Department of Cardiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Guizhi Liu
- Department of Cardiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
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7
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Impact of renal function in high bleeding risk patients undergoing percutaneous coronary intervention: a patient-level stratified analysis from four post-approval studies. J Thromb Thrombolysis 2021; 52:419-428. [PMID: 33709255 DOI: 10.1007/s11239-020-02321-2] [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] [Accepted: 10/24/2020] [Indexed: 10/21/2022]
Abstract
Data on ischemic and bleeding outcomes after percutaneous coronary intervention (PCI) in high bleeding risk (HBR) patients with chronic kidney disease (CKD) are scarce. We aimed to evaluate the association between CKD and ischemic and bleeding outcomes in HBR patients who underwent PCI. Among 10,502 patients in the four post-approval registries evaluating patients undergoing PCI, 2,300 patients presented with at least one major or two minor ARC-HBR criteria. CKD was defined as eGFR < 60 mL/min/1.73 m2. These HBR patients were divided into 3 groups: eGFR < 30 mL/min/1.73 m2 defined as severe CKD (N = 221), eGFR 30- < 60 mL/min/1.73 m2 defined as moderate CKD (N = 970), eGFR ≥ 60 mL/min/1.73 m2 defined as no CKD (N = 1,109). The primary endpoint was the composite of cardiac death, myocardial infarction, or stent thrombosis, and the safety endpoint was major bleeding up to 4-year follow-up. HBR patients with CKD were more often female and had higher rates of comorbidities compared to those without CKD. Reduced renal function was associated with higher rates of the primary endpoint (severe CKD vs. moderate CKD vs. no CKD: 30.2% vs. 12.5% vs. 9.1%, P < 0.01) as well as major bleeding (10.3% vs. 8.9% vs. 6.4%, P = 0.03). After adjustment, severe CKD and moderate CKD in HBR patients remained independent predictors for the primary endpoint (HR [95%CI] 2.84 [1.94-4.16], P < 0.01, 1.48 [1.10-2.00], P < 0.01) compared to those with no CKD. However, decreased renal function was no longer significantly associated with major bleeding after adjustment. In conclusions, in HBR patients undergoing PCI, CKD has an important impact on major ischemic events after PCI.
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8
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Dillinger JG, Laine M, Bouajila S, Paganelli F, Henry P, Bonello L. Antithrombotic strategies in elderly patients with acute coronary syndrome. Arch Cardiovasc Dis 2021; 114:232-245. [PMID: 33632631 DOI: 10.1016/j.acvd.2020.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 12/22/2022]
Abstract
Elderly patients represent a growing proportion of the acute coronary syndrome population in Western countries. However, their frequent atypical symptoms at presentation often lead to delays in management and to misdiagnosis. Furthermore, their prognosis is poorer than that of younger patients because of physiological changes in platelet function, haemostasis and fibrinolysis, but also a higher proportion of comorbidities and frailty, both of which increase the risk of recurrent thrombotic and bleeding events. This complex situation, with ischaemic and haemorrhagic risk factors often being intertwined, may lead to confusion about the required treatment strategy, sometimes resulting in inadequate management or even to therapeutic nihilism. It is therefore critical to provide a comprehensive overview of our understanding of the pathophysiological processes underlying acute coronary syndrome in elderly patients, and to summarise the results from the latest clinical trials to help decision making for these high-risk patients.
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Affiliation(s)
- Jean-Guillaume Dillinger
- Department of cardiology, Hôpital Lariboisière, AP-HP, Inserm U-942, Université de Paris, 2, rue Ambroise-Paré, 75010 Paris, France.
| | - Marc Laine
- Mediterranean Association for research and studies in cardiology (MARS cardio), Centre for cardiovascular and nutrition research, AP-HM, Aix-Marseille University, INSERM 1263, INRA 1260, 13015 Marseille, France; Cardiology department, Hôpital Nord, 13015 Marseille, France; Mediterranean Association for research and studies in cardiology (MARS cardio), 13015 Marseille, France
| | - Sara Bouajila
- Department of cardiology, Hôpital Lariboisière, AP-HP, Inserm U-942, Université de Paris, 2, rue Ambroise-Paré, 75010 Paris, France
| | - Franck Paganelli
- Mediterranean Association for research and studies in cardiology (MARS cardio), Centre for cardiovascular and nutrition research, AP-HM, Aix-Marseille University, INSERM 1263, INRA 1260, 13015 Marseille, France; Cardiology department, Hôpital Nord, 13015 Marseille, France
| | - Patrick Henry
- Department of cardiology, Hôpital Lariboisière, AP-HP, Inserm U-942, Université de Paris, 2, rue Ambroise-Paré, 75010 Paris, France
| | - Laurent Bonello
- Mediterranean Association for research and studies in cardiology (MARS cardio), Centre for cardiovascular and nutrition research, AP-HM, Aix-Marseille University, INSERM 1263, INRA 1260, 13015 Marseille, France; Cardiology department, Hôpital Nord, 13015 Marseille, France; Mediterranean Association for research and studies in cardiology (MARS cardio), 13015 Marseille, France
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9
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Chen H, Yu X, Kong X, Li L, Wu J, Ma L. Efficacy and safety of bivalirudin application during primary percutaneous coronary intervention in older patients with acute ST-segment elevation myocardial infarction. J Int Med Res 2020; 48:300060520947942. [PMID: 32985292 PMCID: PMC7536496 DOI: 10.1177/0300060520947942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective ST-segment elevation myocardial infarction (STEMI) is the most serious type
of acute coronary syndrome. This study aimed to investigate the efficacy and
safety of bivalirudin application during primary percutaneous coronary
intervention (PPCI) in older patients with acute STEMI. Methods A total of 672 older patients with STEMI (>75 years) who underwent PPCI
were studied. The primary endpoints were 30-day net adverse clinical events
(NACEs) post-emergency percutaneous coronary intervention, including major
adverse cardiac and cerebrovascular events (MACCEs) and Bleeding Academic
Research Consortium grades 2 to 5 (BARC 2–5) bleeding events. Results The incidence of NACEs and BARC 2–5 bleeding events in the bivalirudin group
was significantly lower than that in the unfractionated heparin group.
Multivariate Cox regression analysis showed that bivalirudin significantly
reduced 30-day NACEs (odds ratio: 0.700, 95% confidence interval:
0.492–0.995) and BARC 2–5 bleeding events (odds ratio: 0.561, 95% confidence
interval: 0.343–0.918). At 1-year follow-up, these results were similar. Conclusions Bivalirudin can be safely and effectively used during PPCI in older patients
with STEMI. Bivalirudin reduces the risks of NACEs and bleeding within 30
days after PPCI, without increasing the risks of MACCEs and stent thrombosis
compared with heparin.
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Affiliation(s)
- Hongwu Chen
- Anhui Provincial Cardiovascular Institute, Hefei, Anhui Province, China
| | - Xiaofan Yu
- Anhui Provincial Cardiovascular Institute, Hefei, Anhui Province, China.,Department of Cardiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province, China
| | - Xiangyong Kong
- Anhui Provincial Cardiovascular Institute, Hefei, Anhui Province, China
| | - Longwei Li
- Anhui Provincial Cardiovascular Institute, Hefei, Anhui Province, China
| | - Jiawei Wu
- Anhui Provincial Cardiovascular Institute, Hefei, Anhui Province, China
| | - Likun Ma
- Anhui Provincial Cardiovascular Institute, Hefei, Anhui Province, China
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10
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Zhang Y, Zhang Y, Liu Z, Zhang B, Liu G, Chen K. Bivalirudin versus unfractionated heparin during percutaneous coronary intervention in high-bleeding-risk patients with acute coronary syndrome in contemporary practice. Biomed Pharmacother 2020; 130:110758. [PMID: 34321166 DOI: 10.1016/j.biopha.2020.110758] [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: 07/28/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Bivalirudin, as compared with unfractionated heparin (UFH), has been shown to reduce bleeding complications and supply a better safety profile among low/medium-bleeding-risk patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) in some previous studies. Whether this advantage persists in patients at high risk of bleeding according to contemporary practice characterized by frequent use of radial-artery access and novel P2Y12 inhibitors, and low use of glycoprotein IIb/IIIa inhibitors (GPIs) is unclear. AIM OF THE STUDY This study aimed to assess the efficacy and safety of bivalirudin compared with UFH in high bleeding risk patients with ACS undergoing PCI in current practice. MATERIALS AND METHODS All consecutive high-bleeding-risk patients who underwent PCI for ACS at the First Affiliated Hospital of Zhengzhou University from January to September 2019 were retrospectively analyzed. The 30-day primary outcome was a composite of major bleeding, myocardial infarction, all-cause death, or stroke (net adverse clinical events [NACEs]), and the secondary outcomes at 30 days included a composite of myocardial infarction, stoke, or all-cause death (major adverse cardiovascular events [MACEs]), each component of the primary outcome, target vessel revascularization (TVR) and stent thrombosis (ST). Besides, we assessed angina-related health status at 30 days, the length of hospital stay, and hospitalization costs. A logistic regression model was used to adjust for baseline differences. Consistency of the treatment effect of bivalirudin for NACEs and MACEs compared with UFH was evaluated in 15 prespecified subgroups. RESULTS From January to September 2019, 823 patients (361 treated with bivalirudin and 462 treated with UFH) were enrolled in the study. GPIs, novel P2Y12 inhibitors, and radial approach was used in 5.6 %, 66.1 %, and 89.7 % of the patients, respectively. After adjusting for baseline differences, bivalirudin was associated with significant reduction in NACEs, MACEs, major bleeding, and myocardial infarction at 30 days compared with UFH. The individual endpoints of death, stroke, ST and TVR did not differ significantly between the 2 groups after adjusting for covariates. Furthermore, bivalirudin consistently reduced the rates of NACEs and MACEs in the 15 prespecified subgroups compared with UFH. These benefits of bivalirudin can translate into improved angina-related health status, shorter hospital stays, and lower hospitalization costs. CONCLUSIONS The treatment of bivalirudin showed better efficacy and safety as compared to UFH among patients with ACS undergoing PCI at high risk of bleeding in contemporary practice.
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Affiliation(s)
- Yahao Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Yanghui Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Zhiyu Liu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Bin Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Guizhi Liu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Kui Chen
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
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11
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Wester A, Attar R, Mohammad MA, Isma N, James S, Omerovic E, Erlinge D, Koul S. Bivalirudin Versus Heparin Monotherapy in Elderly Patients With Myocardial Infarction: A Prespecified Subgroup Analysis of the VALIDATE-SWEDEHEART Trial. Circ Cardiovasc Interv 2020; 13:e008671. [PMID: 32216471 DOI: 10.1161/circinterventions.119.008671] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Elderly patients with acute myocardial infarction undergoing percutaneous coronary intervention are at increased risk of both ischemic and bleeding complications. The optimal anticoagulation strategy in these patients is uncertain. Therefore, we compared bivalirudin to heparin monotherapy in a contemporary cohort of such patients. METHODS A prespecified subgroup analysis of elderly patients with myocardial infarction (≥75 years) from the VALIDATE-SWEDEHEART trial (Bivalirudin Versus Heparin in ST-Segment and Non-ST-Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies Registry Trial) was performed. In the trial, patients were randomized to either bivalirudin or heparin monotherapy during percutaneous coronary intervention, with mandatory potent P2Y12 inhibition, routine radial artery access, and only bail-out glycoprotein IIb/IIIa inhibition. Kaplan-Meier event rates were assessed for the primary end point, consisting of a composite of all-cause death, myocardial reinfarction, or major bleeding, within 180 days. RESULTS The elderly (n=1592) had more than twice the risk of all events compared with younger patients (n=4406). Baseline and periprocedural characteristics were equal between bivalirudin (n=799) and heparin (n=793) treated patients ≥75 years. No differences were found in the elderly between bivalirudin and heparin monotherapy regarding the primary end point (180-day all-cause death, myocardial reinfarction, or major bleeding), the individual components of the primary end point, definite stent thrombosis, or stroke. CONCLUSIONS In this prespecified subgroup analysis of the VALIDATE-SWEDEHEART trial, elderly patients with myocardial infarction had a highly increased risk of all events. However, no difference in outcomes could be observed with an anticoagulation strategy with either bivalirudin or heparin as monotherapy in this patient group.
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Affiliation(s)
- Axel Wester
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (A.W., R.A., M.A.M., N.I., D.E., S.K.)
| | - Rubina Attar
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (A.W., R.A., M.A.M., N.I., D.E., S.K.).,Department of Cardiology, Clinical Medicine, Aalborg University, Denmark (R.A.)
| | - Moman A Mohammad
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (A.W., R.A., M.A.M., N.I., D.E., S.K.)
| | - Nazim Isma
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (A.W., R.A., M.A.M., N.I., D.E., S.K.)
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Sweden (S.J.)
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.O.)
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (A.W., R.A., M.A.M., N.I., D.E., S.K.)
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (A.W., R.A., M.A.M., N.I., D.E., S.K.)
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12
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Verdoia M, Nardin M, Negro F, Tonon F, Gioscia R, Rolla R, De Luca G. Impact of aging on immature platelet count and its relationship with coronary artery disease. Platelets 2020; 31:1060-1068. [PMID: 31973643 DOI: 10.1080/09537104.2020.1714572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Despite the fact that elderly patients represent a prevalent and challenging population in the current practice, few data exist on the impact of platelet parameters on cardiovascular risk in these patients. Therefore, the aim of the present study was to evaluate the impact of age on the immature platelet count (IPC) and their relationship with CAD. We included a total of 2236 consecutive patients undergoing coronary angiography in a single center. Elderly patients (age ≥ 75 years) were 756 (33.7%). IPC was measured at admission. Elderly patients were more often females (p < .001), with lower BMI and prevalence of smokers (p < .001), and a more complex cardiovascular risk profile and coronary disease (p = .02). Platelet count decreased with aging (p = .05), whereas no difference in the mean IPC was found between patients < or ≥75 years. In fact, advanced age did not emerge as an independent predictor of IPC above III tertile (≥8.6*10^6/ml), (adjusted OR[95%CI] = 0.97[0.78-1.21], p = .79). When considering elderly patients according to tertiles values of IPC (<5.1,5.1-8.59; ≥8.6*10^6/ml), we found no impact of IPC on the prevalence of CAD (81.1% vs 84.5% vs 81.5%, p = .92; adjusted OR[95%CI] = 1.08[0.67-1.72], p = .75) and its extent (37.7% vs 34.5% vs 40.2%, p = .57; adjusted OR[95%CI] = 1.22[0.85-1.73], p = .28). However, we observed a higher rate of calcified and type C lesions in elderly patients with higher IPC (p = .03 and p < .001, respectively). Therefore, advanced age is not associated with higher immature platelet count and the prevalence and severity of CAD. Moreover, IPC does not contribute to explain the higher prevalence and extent of coronary artery disease observed in elderly patients.
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Affiliation(s)
- Monica Verdoia
- Department of Cardiology, Ospedale "Maggiore della Carità", Eastern Piedmont University , Novara, Italy
| | - Matteo Nardin
- Department of Cardiology, Ospedale "Maggiore della Carità", Eastern Piedmont University , Novara, Italy.,Department of Medicine, ASST "Spedali Civili", University of Brescia , Brescia, Italy
| | - Federica Negro
- Department of Cardiology, Ospedale "Maggiore della Carità", Eastern Piedmont University , Novara, Italy
| | - Francesco Tonon
- Department of Cardiology, Ospedale "Maggiore della Carità", Eastern Piedmont University , Novara, Italy
| | - Rocco Gioscia
- Department of Cardiology, Ospedale "Maggiore della Carità", Eastern Piedmont University , Novara, Italy
| | - Roberta Rolla
- Department of Clinical Chemistry, Ospedale "Maggiore della Carità", Eastern Piedmont University , Novara, Italy
| | - Giuseppe De Luca
- Department of Cardiology, Ospedale "Maggiore della Carità", Eastern Piedmont University , Novara, Italy
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13
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Tu Y, Hu L, Yang C, Nemat A, Xian G, Zhang J, Zeng Q. Optimal Antithrombotic Therapy for Patients with STEMI Undergoing PCI at High Risk of Bleeding. Curr Atheroscler Rep 2019; 21:22. [DOI: 10.1007/s11883-019-0782-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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14
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Verdoia M, Pergolini P, Nardin M, Rolla R, Barbieri L, Marino P, Carriero A, Suryapranata H, De Luca G. Prevalence and predictors of high-on treatment platelet reactivity during prasugrel treatment in patients with acute coronary syndrome undergoing stent implantation. J Cardiol 2019; 73:198-203. [DOI: 10.1016/j.jjcc.2018.10.005] [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: 05/14/2018] [Revised: 09/06/2018] [Accepted: 10/04/2018] [Indexed: 02/03/2023]
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15
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Wang Y, Zhao HW, Wang CF, Fan CY, Zhang XJ, Zhu Y, Luo DF, Yu GN, Hou AJ, Luan B. Efficacy and safety of bivalirudin during percutaneous coronary intervention in high‐bleeding‐risk elderly patients with chronic total occlusion: A prospective randomized controlled trial. Catheter Cardiovasc Interv 2019; 93:825-831. [PMID: 30724035 DOI: 10.1002/ccd.28087] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 12/29/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Yong Wang
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Hong-Wei Zhao
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Cheng-Fu Wang
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Chun-Yu Fan
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Xiao-Jiao Zhang
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Yu Zhu
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - De-Feng Luo
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Guo-Ning Yu
- Department of Science and Education, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Ai-Jie Hou
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Bo Luan
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
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16
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Jeger RV, Pfisterer M, Vogt DR, Galatius S, Abildgaard U, Naber C, Alber H, Eberli F, Kurz DJ, Pedrazzini G, Vuilliomenet A, Weilenmann D, Rickli H, Hansen KW, Rickenbacher P, Conen D, Müller C, Osswald S, Gilgen N, Kaiser C. Competing risks of major bleeding and thrombotic events with prasugrel-based dual antiplatelet therapy after stent implantation - An observational analysis from BASKET-PROVE II. PLoS One 2019; 14:e0210821. [PMID: 30645635 PMCID: PMC6333357 DOI: 10.1371/journal.pone.0210821] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 12/24/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) prevents thrombotic events after coronary stent implantation but may induce bleedings, specifically in elderly patients. However, a competitive risk analysis is lacking. OBJECTIVES To assess the determinants of major bleeding and the balance between the competing risks of major bleeding and thrombotic events during prasugrel-based DAPT after stent implantation. METHODS Overall, 2,291 patients randomized to drug-eluting or bare metal stents and treated with prasugrel 10mg/day for 1 year were followed over 2 years for major bleeding (BARC 3/5) and thrombotic events (cardiac death, myocardial infarction, definitive/probable stent thrombosis). Prasugrel dose was reduced to 5mg in patients >75 years and/or <60kg. Predictors of major bleeding and competing risks of major bleeding and thrombotic events were assessed. RESULTS Two-year rates of major bleeding and thrombotic events were 2.9% and 9.0%, respectively. The only independent predictor of major bleeding was age (hazard ratio per year increase 1.05 [1.02,1.07], p<0.001). The relationship between major bleeding and age was non-linear, with lowest hazard ratios at 57 years and an exponential increase only above 65 years. In contrast, the relationship between thrombotic events and age was linear and continuously increasing with older age. While the competing risk of thrombotic events was higher than that of major bleeding in younger patients, the two risks were similar in older patients. After discontinuation of prasugrel, bleeding events leveled off in all patients, while thrombotic events continued to increase. CONCLUSIONS In prasugrel-based DAPT, age is the strongest risk factor for major bleeding, increasing exponentially >65 years. In younger patients, thrombotic events represent a higher risk than bleeding, while thrombotic and bleeding risks were similar in older patients. Important clinical implications relate to prasugrel dose in the elderly, duration of DAPT and the competing risk balance necessitating individualized treatment decisions.
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Affiliation(s)
- Raban V. Jeger
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
- * E-mail:
| | - Matthias Pfisterer
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Deborah R. Vogt
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Søren Galatius
- Cardiology, Gentofte University Hospital Copenhagen, Hellerup, Denmark
| | - Ulrik Abildgaard
- Cardiology, Gentofte University Hospital Copenhagen, Hellerup, Denmark
| | | | - Hannes Alber
- Cardiology, University Hospital Innsbruck and Klinikum Klagenfurt am Wörthersee, Innsbruck and Klagenfurt am Wörthersee, Austria
| | - Franz Eberli
- Cardiology, Triemli Hospital, Zürich, Switzerland
| | | | | | | | | | - Hans Rickli
- Cardiology, State Hospital, St. Gallen, Switzerland
| | - Kim Wadt Hansen
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | | | - David Conen
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
- Population Health Research Institute, McMaster University, Hamilton ON, Canada
| | - Christian Müller
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Stefan Osswald
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Nicole Gilgen
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Christoph Kaiser
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
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17
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Neupane S, Khawaja O, Edla S, Singh H, Othman H, Bossone E, Yamasaki H, Rosman HS, Eggebrecht H, Mehta RH. Meta-analysis of drug eluting stents compared with bare metal stents in high bleeding risk patients undergoing percutaneous coronary interventions. Catheter Cardiovasc Interv 2018; 94:98-104. [DOI: 10.1002/ccd.28045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 11/03/2018] [Accepted: 12/01/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Saroj Neupane
- Division of Cardiology, Department of Internal Medicine; Henry Ford Hospital; Detroit Michigan
| | - Owais Khawaja
- Division of Cardiology, Department of Internal Medicine; St John Hospital and Medical Center; Detroit Michigan
| | - Sushruth Edla
- Division of Cardiology, Department of Internal Medicine; St John Hospital and Medical Center; Detroit Michigan
| | - Hemindermeet Singh
- Cardiovascular Fellowship Program; Mercy-Health St Vincent Medical Center; Toledo Ohio
| | - Hussein Othman
- Division of Cardiology, Department of Internal Medicine; St John Hospital and Medical Center; Detroit Michigan
| | - Eduardo Bossone
- Cava de' Tirreni and Amalfi Coast Hospital; University of Salerno; Amalfi Italy
| | - Hiroshi Yamasaki
- Division of Cardiology, Department of Internal Medicine; St John Hospital and Medical Center; Detroit Michigan
| | - Howard S. Rosman
- Division of Cardiology, Department of Internal Medicine; St John Hospital and Medical Center; Detroit Michigan
| | - Holger Eggebrecht
- Cardioangiological Center Bethanien (CCB) and AGAPLESION Bethanien Hospital; Frankfurt Germany
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18
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Morttada A, Shahin S. Incidence and predictors of bleeding among Egyptian patients presenting with acute coronary syndrome: Using CRUSADE risk score. Egypt Heart J 2018; 70:135-142. [PMID: 30190637 PMCID: PMC6123232 DOI: 10.1016/j.ehj.2018.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 01/20/2018] [Indexed: 11/28/2022] Open
Abstract
Background Early invasive strategies; in management of acute coronary syndrome; has led to improvement of patient outcomes. However, these invasive therapies have their own risks, namely bleeding and blood transfusion. The aim of this study was to determine the incidence of bleeding, its location and severity among the study population, to correlate between the patients' characteristics and the risk profile of the patients based upon the CRUSADE risk score and increased bleeding events, and lastly; to identify the predictors of increased bleeding risk among Egyptian patients who presented with acute coronary syndrome. Methods The study had included eight hundred and twenty-three patients referred to coronary care unit (CCU), to (Ain Shams University hospital, Specialized Ain Shams hospital, and 6th October insurance hospital) with diagnosis of Acute Coronary Syndrome “ACS” within a period from 1/2014 till 7/2014, and they were followed up for additional three months following discharge with assessment of their bleeding risk and risk scores. Results More bleeding events had been witnessed among the study population who were older, diabetics, had renal impairment, had peripheral vascular disease, had congestive heart failure picture at presentation; more among female sex category and more among patients receiving GPIIbIIIa antagonists. Those bleeding events had been experienced during hospital stay. Conclusion Risk of bleeding can be evaluated using a simple risk score in both STEMI & NSTEMI patients, and across anti-coagulant strategies, providing important prognostic information. Variability in the rates of bleeding is likely based on differences in baseline characteristics, comorbidities, and invasive treatment strategies rather than specific anti-coagulation regimens. Patients at highest risk of bleeding are also at highest risk of ischaemia and thrombotic complications. Thus higher risk patients need a more careful treatment approach to maximize the efficacy of therapy and to reduce thrombotic risk while reducing the bleeding risk.
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19
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Ahmad Y, Demir O, Rajkumar C, Howard JP, Shun-Shin M, Cook C, Petraco R, Jabbour R, Arnold A, Frame A, Sutaria N, Ariff B, Kanaganayagam G, Francis D, Mayet J, Mikhail G, Malik I, Sen S. Optimal antiplatelet strategy after transcatheter aortic valve implantation: a meta-analysis. Open Heart 2018; 5:e000748. [PMID: 29387433 PMCID: PMC5786926 DOI: 10.1136/openhrt-2017-000748] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 12/13/2017] [Accepted: 12/29/2017] [Indexed: 01/09/2023] Open
Abstract
Objective International guidelines recommend the use of dual antiplatelet therapy (DAPT) after transcatheter aortic valve implantation (TAVI). The recommended duration of DAPT varies between guidelines. In this two-part study, we (1) performed a structured survey of 45 TAVI centres from around the world to determine if there is consensus among clinicians regarding antiplatelet therapy after TAVI; and then (2) performed a systematic review of all suitable studies (randomised controlled trials (RCTs) and registries) to determine if aspirin monotherapy can be used instead of DAPT. Methods A structured electronic survey regarding antiplatelet use after TAVI was completed by 45 TAVI centres across Europe, Australasia and the USA. A systematic review of TAVI RCTs and registries was then performed comparing DAPT duration and incidence of stroke, bleeding and death. A variance weighted least squared metaregression was then performed to determine the relationship of antiplatelet therapy and adverse events. Results 82.2% of centres routinely used DAPT after TAVI. Median duration was 3 months. 13.3% based their practice on guidelines. 11 781 patients (26 studies) were eligible for the metaregression. There was no benefit of DAPT over aspirin monotherapy for stroke (P=0.49), death (P=0.72) or bleeding (P=0.91). Discussion Aspirin monotherapy appears to be as safe and effective as DAPT after TAVI.
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Affiliation(s)
- Yousif Ahmad
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Ozan Demir
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Christopher Rajkumar
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - James P Howard
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Matthew Shun-Shin
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Christopher Cook
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Ricardo Petraco
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Richard Jabbour
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Ahran Arnold
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Angela Frame
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Nilesh Sutaria
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Ben Ariff
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Gajen Kanaganayagam
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Darrel Francis
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Jamil Mayet
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Ghada Mikhail
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Iqbal Malik
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
| | - Sayan Sen
- International Centre for Circulatory Health, Hammersmith Hospital, Imperial College London, London, UK
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Bleeding outcomes after non-emergency percutaneous coronary intervention in the very elderly. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2017; 14:624-631. [PMID: 29238363 PMCID: PMC5721197 DOI: 10.11909/j.issn.1671-5411.2017.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Octogenarians constitute an increasing proportion of patients presenting for non-emergency percutaneous coronary intervention (PCI). Methods This study evaluated the in-hospital procedural characteristics and outcomes, including the bleeding events of 293 octogenarians presenting between January 2010 and December 2012 for non-emergency PCI to a single large volume tertiary care Australian center. Comparisons were made with 293 consecutive patients aged less than or equal to 60 years, whose lesions were matched with the octogenarians. Results Non-ST elevation myocardial infarction was the most frequent indication for non-emergency PCI in octogenarians. Compared to the younger cohort, they had a higher prevalence of co-morbidities and more complex coronary disease, comprising more type C and calcified lesions. Peri-procedural use of low molecular weight heparin (LMWH; 1.0% vs. 5.8%; P < 0.001) and glycoprotein IIb/IIIa inhibitors (2.1% vs. 9.6%; P < 0.001) was lower, while femoral arterial access was used more commonly than in younger patients (80.9% vs. 67.6%; P < 0.001). Overall, there was a non-significant trend towards higher incidence of all bleeding events in the elderly (9.2% vs. 5.8%; P = 0.12). There was no significant difference in access site or non-access site bleeding and major or minor bleeding between the two cohorts. Sub-analysis did not reveal any significant influence on bleeding rates by the use of LMWH, glycoprotein IIb/IIIa inhibitors or femoral arterial access. In addition, there were no significant differences in the rates of in-hospital mortality, stroke or acute stent thrombosis between the two groups. Conclusions In this single center study, we did not observe significant increases in adverse in-hospital outcomes including the incidence of bleeding in octogenarians undergoing non-emergency PCI.
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Qaderdan K, Vos GJA, McAndrew T, Steg PG, Hamm CW, van‘t Hof A, Mehran R, Deliargyris EN, Bernstein D, Stone GW, ten Berg JM. Outcomes in elderly and young patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention with bivalirudin versus heparin: Pooled analysis from the EUROMAX and HORIZONS-AMI trials. Am Heart J 2017; 194:73-82. [PMID: 29223437 DOI: 10.1016/j.ahj.2017.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 08/07/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Since older age is a strong predictor of not only bleeding but also of ischemic events, understanding the risk:benefit profile of bivalirudin in the elderly undergoing primary percutaneous coronary intervention (pPCI) for ST-segment elevation (STEMI) is important. For this, we aim to compare elderly with young patients, who all underwent pPCI for STEMI and randomly received either bivalirudin or heparin. METHODS We performed a patient-level pooled analysis (n=5800) of two large randomized trials. A total of 2149 (37.1%) elderly patients (>65 years of age) with STEMI were enrolled and randomly assigned to either bivalirudin or heparin with or without a GPI (control group) before pPCI. Clinical outcomes at 30 days were analyzed. RESULTS In elderly patients, bivalirudin significantly reduced non-CABG major bleeding (7.1% vs 10.4%; P<.01), subacute ST (0.4% vs 1.5%; P<.01), and net adverse clinical events (NACE; composite of all-cause mortality, reinfarction, IDR, stroke or protocol-defined non-CABG major bleeding [13.7% vs 17.2%; P=.03]) with comparable rates of stroke, MI, acute ST, or all-cause death, when compared with heparin with or without GPI. CONCLUSIONS In a large group of elderly patients enrolled in the EUROMAX and HORIZONS-AMI trials, bivalirudin was associated with lower 30-day rates of non-CABG major bleeding, subacute ST and NACE, with similar 30-day rates of acute ST and mortality.
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Abstract
BACKGROUND Patients over 75 account for more than one third of those presenting with myocardial infarction and more than 50% of intrahospital mortality. There are no specific guidelines for the management of acute coronary syndromes (ACS) in the elderly. SETTING Although antithrombotic therapy seems to be effective and safe in such patients, it requires specific precautions and treatment adjustments because of the higher bleeding risk due to comorbidities such as renal function impairment and malnutrition. RESULTS Scientific evidence concerning elderly patients is scarce as they are either excluded or underrepresented in most randomized trials. Overall, the antithrombotic therapy needs to be adapted to avoid complications, mainly bleeding complications, without compromising the effectiveness of the treatment in this high-risk population. CONCLUSION In the present paper, we review the current treatment strategies in ACS while focusing on data concerning the elderly, according to available data in pivotal trials and in both AHA/ACC and ESC guidelines.
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Hu L, Guo K, Guo Z. Bivalirudin for patients with STEMI at high risk of bleeding undergoing PPCI. Nat Rev Cardiol 2017; 14:626. [PMID: 28905940 DOI: 10.1038/nrcardio.2017.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Lu Hu
- Department of Cardiology, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838 North Guangzhou Avenue, Baiyun District, Guangzhou 510515, Guangdong Province, China
| | - Kai Guo
- Department of Cardiology, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838 North Guangzhou Avenue, Baiyun District, Guangzhou 510515, Guangdong Province, China
| | - Zhigang Guo
- Department of Cardiology, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838 North Guangzhou Avenue, Baiyun District, Guangzhou 510515, Guangdong Province, China
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Ma W, Liang Y, Zhu J. Early Invasive Versus Initially Conservative Strategy in Elderly Patients Older Than 75 Years with Non-ST-Elevation Acute Coronary Syndrome: A Meta-Analysis. Heart Lung Circ 2017; 27:611-620. [PMID: 28802810 DOI: 10.1016/j.hlc.2017.06.725] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 04/11/2017] [Accepted: 06/19/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fear of complications related to the procedure and unclear benefits in elderly patients are common reasons for invasive angiography being withheld. METHODS We searched PubMed and Embase from inception until February 2016 for studies that enrolled individuals older than 75 years with non-ST-elevation acute coronary syndrome (NSTE-ACS) and allocated patients to either an invasive or conservative strategy. RESULTS Thirteen studies (four randomised controlled trials (RCTs) and nine observational studies) enrolling 832,007 elderly NSTE-ACS patients were analysed. Compared with the conservative treatment, the early invasive approach does significantly reduce the risk of death at follow-up from 6 months to 5 years (risk ratio [RR] 0.65, 95% confidence interval [CI] 0.59-0.73, p<0.001); the definite benefit was mainly observed in observational studies (RR 0.63, 95% CI 0.57-0.70, p<0.001), and the risk of death also showed a strong trend toward reduction with invasive approach (RR 0.82, 95% CI 0.64-1.05, p=0.119) in RCTs. For the outcome of bleeding complications, there was a higher risk of any bleeding occurring in-hospital (RR 2.51, 95% CI 1.53-4.11, p<0.001) in patients treated with invasive strategy than those treated with conservative strategy. However, no difference of in-hospital major bleeding (RR 1.78, 95% CI 0.31-10.13, p=0.514) was observed between the two strategies. CONCLUSION Elderly patients with NSTE-ACS might benefit from an early invasive strategy but with increasing risk of any bleeding complications. More RCTs are needed to assess early invasive strategies in the elderly.
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Affiliation(s)
- Wenfang Ma
- State Key Laboratory of Cardiovascular Disease, Emergency and Critical Care Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
| | - Yan Liang
- State Key Laboratory of Cardiovascular Disease, Emergency and Critical Care Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
| | - Jun Zhu
- State Key Laboratory of Cardiovascular Disease, Emergency and Critical Care Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Mischie AN, Andrei CL, Sinescu C, Bajraktari G, Ivan E, Chatziathanasiou GN, Schiariti M. Antithrombotic treatment tailoring and risk score evaluation in elderly patients diagnosed with an acute coronary syndrome. J Geriatr Cardiol 2017; 14:442-456. [PMID: 28868073 PMCID: PMC5545187 DOI: 10.11909/j.issn.1671-5411.2017.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Age is an important prognostic factor in the outcome of acute coronary syndromes (ACS). A substantial percentage of patients who experience ACS is more than 75 years old, and they represent the fastest-growing segment of the population treated in this setting. These patients present different patterns of responses to pharmacotherapy, namely, a higher ischemic and bleeding risk than do patients under 75 years of age. Our aim was to identify whether the currently available ACS ischemic and bleeding risk scores, which has been validated for the general population, may also apply to the elderly population. The second aim was to determine whether the elderly benefit more from a specific pharmacological regimen, keeping in mind the numerous molecules of antiplatelet and antithrombotic drugs, all validated in the general population. We concluded that the GRACE (Global Registry of Acute Coronary Events) risk score has been extensively validated in the elderly. However, the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) bleeding score has a moderate correlation with outcomes in the elderly. Until now, there have not been head-to-head scores that quantify the ischemic versus hemorrhagic risk or scores that use the same end point and timeline (e.g., ischemic death rate versus bleeding death rate at one month). We also recommend that the frailty score be considered or integrated into the current existing scores to better quantify the overall patient risk. With regard to medical treatment, based on the subgroup analysis, we identified the drugs that have the least adverse effects in the elderly while maintaining optimal efficacy.
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Affiliation(s)
| | | | - Crina Sinescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Gani Bajraktari
- Clinic of Cardiology, University Clinical Centre of Kosova, Prishtina, Republic of Kosovo
| | | | | | - Michele Schiariti
- Department of Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
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Hasunuma T, Fukase H, Miyazaki A, Nishikawa Y. Evaluation of the Pharmacokinetics and Pharmacodynamics of Prasugrel in Japanese Elderly Subjects. Clin Drug Investig 2017; 37:679-685. [PMID: 28417436 PMCID: PMC5488074 DOI: 10.1007/s40261-017-0525-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background and Objective An increased incidence in bleeding events has been reported in Western elderly patients receiving prasugrel. Therefore, doses in Japanese elderly subjects need to be carefully determined. We assessed the pharmacokinetic and pharmacodynamic effects of prasugrel at the clinical dose used in Japan in healthy Japanese elderly subjects compared with non-elderly subjects. Methods In an open-label parallel-group study conducted in Japan, two groups (elderly, aged >75 years; non-elderly, aged 45–65 years) received a 20-mg loading dose and a 3.75-mg maintenance dose of prasugrel for 7 days. Plasma concentration of its active metabolite, R-138727, and pharmacokinetic parameters were determined on days 1 and 7 after dosing. Pharmacodynamic response to 20 µM of adenosine diphosphate-induced platelet aggregation was measured by light transmission aggregometry. Results A total of 47 subjects were enrolled (23 elderly, 24 non-elderly). There was no statistically significant difference in pharmacokinetic parameters between groups: area under the plasma concentration–time curve up to the last quantifiable time and maximum plasma concentration were about 174–175 ng·h/mL and 134–153 ng/mL, respectively, after the loading dose; and about 25–26 ng·h/mL and 25 ng/mL, respectively, after the maintenance dose. Inhibition of platelet aggregation was higher in the elderly subjects than in the non-elderly subjects, with a statistically significant difference from 24 h after the loading dose. No serious adverse events (bleeding or non-bleeding) occurred. Conclusions Prasugrel (20-mg loading dose; 3.75-mg maintenance dose) produced a slight increase in antiplatelet efficacy in elderly compared with non-elderly subjects, despite no statistically significant difference in the pharmacokinetics. Electronic supplementary material The online version of this article (doi:10.1007/s40261-017-0525-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tomoko Hasunuma
- Kitasato University Research Center for Clinical Pharmacology, Tokyo, Japan.,Department of Research, Clinical Trial Center, Kitasato University Kitasato Institute Hospital, Tokyo, Japan.,Kitasato Clinical Research Center (KCRC), Kitasato University School of Medicine, Tokyo, Japan
| | - Hiroyuki Fukase
- CPC Clinical Trial Hospital, Medipolis Medical Research Institute, Kagoshima, Japan
| | - Atsuhiro Miyazaki
- Clinical Development Department, Daiichi Sankyo Co., Ltd., 1-2-58 Hiromachi, Shinagawa-ku, Tokyo, 140-8710, Japan.
| | - Yasuhiro Nishikawa
- Safety and Risk Management Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
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Naber CK, Urban P, Ong PJ, Valdes-Chavarri M, Abizaid AA, Pocock SJ, Fabbiocchi F, Dubois C, Copt S, Greene S, Morice MC. Biolimus-A9 polymer-free coated stent in high bleeding risk patients with acute coronary syndrome: a Leaders Free ACS sub-study. Eur Heart J 2017; 38:961-969. [PMID: 27190095 PMCID: PMC5837685 DOI: 10.1093/eurheartj/ehw203] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 04/27/2016] [Accepted: 05/03/2016] [Indexed: 01/11/2023] Open
Abstract
Aims Although a true clinical challenge, high bleeding risk patients with an acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) have never been specifically studied. Leaders Free ACS, a pre-specified Leaders Free sub-study, determined efficacy, and safety of a combination of 1-month dual anti-platelet therapy (DAPT) with implantation of either a polymer-free Biolimus-A9-coated stent (BA9-DCS) or a bare-metal stent (BMS) in these patients. Methods and results Leaders Free included 2466 patients undergoing PCI who had at least 1 of 13 pre-defined factors for an increased bleeding risk. Of these, 659 ACS patients were included in this analysis (BA9-DCS 330, BMS 329). At 12-month follow-up, treatment with the BA9-DCS was more effective (clinically driven target-lesion revascularization 3.9 vs. 9.0%, P = 0.009) and safer (cumulative incidence of cardiac death, myocardial infarction, or definite or probable stent thrombosis 9.3 vs. 18.5%, P = 0.001), driven by significantly lower rates of cardiac mortality (3.4 vs. 6.9%, P = 0.049) and myocardial infarction (6.9 vs. 13.8%, P = 0.005). Conclusion We believe that the results of this sub-analysis from the Leaders Free trial are likely to significantly impact clinical practice for high bleeding risk patients presenting with an ACS: the use of a BMS can, in our view, no longer be recommended, and, given the paucity of available data for second-generation DES with shortened DAPT in these patients, the BA9-DCS should currently be considered as the device with the strongest evidence to support its use for this indication.
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Affiliation(s)
- Christoph K. Naber
- Contilia Heart and Vascular Centre, Elisabeth Krankenhaus Essen, Klara-Kopp-Weg 1, 45138 Essen, Germany
| | | | | | | | | | | | | | - Christophe Dubois
- Department of Cardiovascular Medicine, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
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Omran J, Abdullah O, Abu-Fadel M, Gray WA, Firwana B, Drachman DE, Mahmud E, Aronow HD, White CJ, Al-Dadah AS. Hemorrhagic and ischemic outcomes of Heparin vs. Bivalirudin in carotid artery stenting: A meta-analysis of studies. Catheter Cardiovasc Interv 2017; 89:746-753. [PMID: 27526953 DOI: 10.1002/ccd.26685] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 05/16/2016] [Accepted: 07/02/2016] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Bivalirudin, has been shown to have comparable efficacy and better safety profile when compared to unfractionated heparin (UFH) in percutaneous coronary interventions. Bivalirudin's safety in carotid artery stenting (CAS) was associated with better outcomes than heparin in some studies. In this Meta analysis we examine the hemorrhagic and ischemic outcomes associated with Bivalirudin compared to UFH during CAS. METHODS A comprehensive literature search was conducted with the electronic databases MEDLINE, EMBASE, and CENTRAL. Random-effects meta-analysis method was used to pool risk ratio (RR) for both Heparin and Bivalirudin with 95% confidence interval (CI). Study outcomes included hemorrhagic complications; major/minor bleeding and intracranial hemorrhage (ICH) as well as ischemic complications including ischemic stroke, myocardial infarction, and 30 day mortality. RESULTS A total of four studies were included enrolling 7,784 patients. Compared to UFH, Bivalirudin was associated with significantly lower major bleeding events with a relative risk (RR) of 0.53 (95% CI: 0.35-0.80; I2 = 0%). Minor bleeding events were significantly lower in the Bivalirudin group with a RR of 0.41 (95% CI: 0.2-0.82; I2 = 0%). Looking into other outcomes, there were no significant differences between anticoagulation strategies in terms of ischemic stroke (RR 0.8, with 95% CI: 0.60-1.06), intracranial hemorrhage (RR 0.73 with 95% CI: 0.27-1.98), myocardial infarction (RR 1.01 with 95% CI: 0.59-1.73) or 30 day mortality (RR 0.83 with 95% CI: 0.47-1.47). CONCLUSION Compared to UFH, Bivalirudin is associated with lower bleeding risk when used during CAS. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Jad Omran
- Cardiovascular Medicine Department at the University of Missouri-Columbia School of Medicine, Columbia, Missouri
| | - Obai Abdullah
- Internal Medicine Department, University of Florida Collage of Medicine, Gainesville, Florida
| | - Mazen Abu-Fadel
- Internal Medicine Department, Section of Cardiovascular Disease, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - William A Gray
- Department of Cardiology, Columbia University Medical Center, New York, New York
| | - Belal Firwana
- Department of Hematology and Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Douglas E Drachman
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ehtisham Mahmud
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California-San Diego, La Jolla, California
| | - Herebert D Aronow
- Department of Cardiology, Lifespan Cardiovascular Institue, Providence, Rhode Island
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de la Torre Hernández JM, Brugaletta S, Gómez Hospital JA, Baz JA, Pérez de Prado A, López Palop R, Cid B, García Camarero T, Diego A, Gimeno de Carlos F, Fernández Díaz JA, Sanchis J, Alfonso F, Blanco R, Botas J, Navarro Cuartero J, Moreu J, Bosa F, Vegas Valle JM, Elízaga J, Arrebola AL, Ruiz Arroyo JR, Hernández-Hernández F, Salvatella N, Monteagudo M, Gómez Jaume A, Carrillo X, Martín Reyes R, Lozano F, Rumoroso JR, Andraka L, Domínguez AJ. Angioplastia primaria en mayores de 75 años. Perfil de pacientes y procedimientos, resultados y predictores pronósticos en el registro ESTROFA IM + 75. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2016.06.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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de la Torre Hernández JM, Brugaletta S, Gómez Hospital JA, Baz JA, Pérez de Prado A, López Palop R, Cid B, García Camarero T, Diego A, Gimeno de Carlos F, Fernández Díaz JA, Sanchis J, Alfonso F, Blanco R, Botas J, Navarro Cuartero J, Moreu J, Bosa F, Vegas Valle JM, Elízaga J, Arrebola AL, Ruiz Arroyo JR, Hernández-Hernández F, Salvatella N, Monteagudo M, Gómez Jaume A, Carrillo X, Martín Reyes R, Lozano F, Rumoroso JR, Andraka L, Domínguez AJ. Primary Angioplasty in Patients Older Than 75 Years. Profile of Patients and Procedures, Outcomes, and Predictors of Prognosis in the ESTROFA IM+75 Registry. ACTA ACUST UNITED AC 2016; 70:81-87. [PMID: 27840148 DOI: 10.1016/j.rec.2016.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 06/13/2016] [Indexed: 01/20/2023]
Abstract
INTRODUCTION AND OBJECTIVES The proportion of elderly patients undergoing primary angioplasty is growing. The present study describes the clinical profile, procedural characteristics, outcomes, and predictors of outcome. METHODS A 31-center registry of consecutive patients older than 75 years treated with primary angioplasty. Clinical and procedural data were collected, and the patients underwent clinical follow-up. RESULTS The study included 3576 patients (39.3% women, 48.5% with renal failure, 11.5% in Killip III or IV, and 29.8% with>6hours of chest pain). Multivessel disease was present in 55.4% and nonculprit lesions were additionally treated in 24.8%. Radial access was used in 56.4%, bivalirudin in 11.8%, thromboaspiration in 55.9%, and drug-eluting stents in 26.6%. The 1-month and 2-year incidences of cardiovascular death were 10.1% and 14.7%, respectively. The 2-year rates of definite or probable thrombosis, repeat revascularization, and BARC bleeding>2 were 3.1%, 2.3%, and 4.2%, respectively. Predictive factors were diabetes mellitus, renal failure, atrial fibrillation, delay to reperfusion>6hours, ejection fraction<45%, Killip class III-IV, radial access, bivalirudin, drug-eluting stents, final TIMI flow of III, and incomplete revascularization at discharge. CONCLUSIONS Notable registry findings include frequently delayed presentation and a high prevalence of adverse factors such as renal failure and multivessel disease. Positive procedure-related predictors include shorter delay, use of radial access, bivalirudin, drug-eluting stents, and complete revascularization before discharge.
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Affiliation(s)
- José M de la Torre Hernández
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain.
| | - Salvatore Brugaletta
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Clínic, Barcelona, Spain
| | - Joan A Gómez Hospital
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - José A Baz
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital de Vigo, Vigo, Pontevedra, Spain
| | - Armando Pérez de Prado
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital de León, León, Spain
| | - Ramón López Palop
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital de San Juan, San Juan de Alicante, Alicante, Spain
| | - Belén Cid
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Tamara García Camarero
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Alejandro Diego
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Clínico de Salamanca, Salamanca, Spain
| | - Federico Gimeno de Carlos
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Clínico de Valladolid, Valladolid, Spain
| | - José A Fernández Díaz
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Juan Sanchis
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Clínico de Valencia, Valencia, Spain
| | - Fernando Alfonso
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital de La Princesa, Madrid, Spain
| | - Roberto Blanco
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital de Cruces, Bilbao, Vizcaya, Spain
| | - Javier Botas
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Fundación Alcorcón, Alcorcón, Madrid, Spain
| | - Javier Navarro Cuartero
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital General de Albacete, Albacete, Spain
| | - José Moreu
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Virgen de la Salud, Toledo, Spain
| | - Francisco Bosa
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - José M Vegas Valle
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital de Cabueñes, Gijón, Asturias, Spain
| | - Jaime Elízaga
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Gregorio Marañón, Madrid, Spain
| | - Antonio L Arrebola
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Virgen de las Nieves, Granada, Spain
| | - José R Ruiz Arroyo
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Clínico de Zaragoza, Zaragoza, Spain
| | | | - Neus Salvatella
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital del Mar, Grup de Recerca Biomèdica en Malalties del Cor, IMIM (Hospital del Mar Research Institute), Barcelona, Spain
| | - Marta Monteagudo
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Dr. Peset, Valencia, Spain
| | - Alfredo Gómez Jaume
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Son Espases, Palma de Mallorca, Baleares, Spain
| | - Xavier Carrillo
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Roberto Martín Reyes
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Fundación Jiménez Díaz, Madrid, Spain
| | - Fernando Lozano
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital de Ciudad Real, Ciudad Real, Spain
| | - José R Rumoroso
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital de Galdakao, Vizcaya, Spain
| | - Leire Andraka
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital de Basurto, Bilbao, Vizcaya, Spain
| | - Antonio J Domínguez
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital Virgen de la Victoria, Málaga, Spain
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Savonitto S, Colombo D, Franco N, Misuraca L, Lenatti L, Romano IJ, Morici N, Lo Jacono E, Leuzzi C, Corrada E, Aranzulla TC, Petronio AS, Bellia G, Romagnoli E, Cagnacci A, Zoccai GB, Prati F. Age at Menopause and Extent of Coronary Artery Disease Among Postmenopausal Women with Acute Coronary Syndromes. Am J Med 2016; 129:1205-1212. [PMID: 27321972 DOI: 10.1016/j.amjmed.2016.05.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 05/30/2016] [Accepted: 05/31/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Epidemiological studies have shown a higher risk of cardiovascular mortality associated with early menopause, but the relation between menopausal age and extent of coronary artery disease after menopause is unknown. We assessed the relation between menopausal age and extent of coronary disease in postmenopausal women with an acute coronary syndrome. METHODS A prospective study was conducted in patients ≥55 years old undergoing coronary angiography for an acute coronary syndrome. Enrollment was stratified by sex (women/men ratio 2:1) and age (55-64, 65-74, 75-85, and >85 years). Women were administered menopause questionnaires during admission. An independent core lab quantified coronary artery disease extent using the Gensini Score, which classifies both significant (>50%) and nonsignificant lesions. Linear correlation was used to appraise the association between the Gensini score and menopausal age. RESULTS We enrolled 675 patients, 249 men and 426 women (mean age 74 years). The mean Gensini score was 60 ± 36 in men vs 50 ± 32 in women (P <.001), being higher among men at any age. The median menopausal age of women was 50 years. Risk factors and age at first acute coronary syndrome were identical among women below and above the median menopausal age. The Gensini score in women showed a weak association with age (R = 0.127; P = .0129), but not with menopausal age (R = 0.063; P = .228). At multivariable analysis, ejection fraction, female sex, and ST elevation myocardial infarction were independent predictors of the Gensini score in the overall population. CONCLUSIONS Menopausal age was not associated with the extent of coronary artery disease. Age at first acute coronary syndrome presentation, risk factors, and prior cardiovascular events were not affected by menopausal age. (The LADIES ACS study: NCT01997307).
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Affiliation(s)
| | | | | | - Leonardo Misuraca
- Division of Cardiology, Ospedale della Misericordia, Grosseto, Italy
| | - Laura Lenatti
- Division of Cardiology, Ospedale Manzoni, Lecco, Italy
| | | | - Nuccia Morici
- Cardiologia Prima, Emodinamica, Ospedale Niguarda, Milano, Italy
| | - Emilia Lo Jacono
- Division of Cardiology, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - Chiara Leuzzi
- Division of Cardiology, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - Elena Corrada
- Cardiovascular Department, Humanitas Clinical and Research Center, Rozzano, Italy
| | | | - A Sonia Petronio
- Cardiovascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | | | - Enrico Romagnoli
- Division of Cardiology, Ospedale Belcolle, Viterbo, and Centro per la Lotta Contro L'Infarto - CLI Foundation, Rome, Italy
| | - Angelo Cagnacci
- Department of Obstetrics, Gynecology and Pediatricss, Obstetrics and Gynecology Unit, Azienda Ospedaliero-Universitaria of Modena, Italy
| | - Giuseppe Biondi Zoccai
- Department of Medico Surgical Sciences and Biotechnology, Sapienza University of Rome, Latina, Italy
| | - Francesco Prati
- Division of Cardiology, Ospedale San Giovanni Addolorata, and Centro per la Lotta contro l' Infarto - CLI Foundation, Roma, Italy
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Rocca B, Husted S. Safety of Antithrombotic Agents in Elderly Patients with Acute Coronary Syndromes. Drugs Aging 2016; 33:233-48. [PMID: 26941087 DOI: 10.1007/s40266-016-0359-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
There are unique challenges in the treatment and prevention of acute coronary syndromes (ACS) with antithrombotics in elderly patients: elderly patients usually require multiple drugs due to comorbidities, are highly susceptible to adverse drug reactions and drug-drug interactions, may have cognitive problems affecting compliance and complications, are especially exposed to the risk of falls and, most importantly, ageing is an independent risk factor for bleeding. Antithrombotic drugs, alone or in association, further and variously amplify age-related bleeding risk. Moreover, age-related changes in primary haemostasis may potentially affect the pharmacodynamics of some antiplatelet drugs. Thus, elderly subjects might be more or less sensitive to standard antiplatelet regimens depending on individual characteristics affecting antiplatelet drug response. Importantly, elderly patients are a rapidly growing population worldwide, have the highest incidence of ACS, but are poorly represented in clinical trials. As a consequence, evidence on antithrombotic drug benefits and risks is limited. Thus, in the real-world setting, older people are often denied antithrombotic drugs because of unjustified concerns, or might be over-treated and exposed to excessive bleeding risk. Personalized antithrombotic therapy in elderly patients is particularly critical, to minimize risks without affecting efficacy.
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Affiliation(s)
- Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Largo F.Vito 1, 00168, Rome, Italy.
| | - Steen Husted
- Medical Department, Hospital Unit West, Herning/Holstebro and Institute of Biomedicine, Aarhus University, Aarhus, Denmark
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Al-Daydamony MM, Farag ESM. CRUSADE bleeding score as a predictor of bleeding events in patients with acute coronary syndrome in Zagazig University Hospital. Indian Heart J 2016; 68:632-638. [PMID: 27773401 PMCID: PMC5079139 DOI: 10.1016/j.ihj.2016.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 02/27/2016] [Accepted: 03/07/2016] [Indexed: 12/03/2022] Open
Abstract
AIM To examine the value of CRUSADE bleeding score in predicting bleeding events in our local patients with acute coronary syndrome (ACS) in Zagazig University Hospitals. METHODS Our study included 240 patients with ACS. They underwent history and clinical examination; 12-lead electrocardiography; echocardiography; troponin I, hematocrit value; estimated glomerular filtration rate (eGFR); application of CRUSADE score; and follow-up of the hospital stay and documentations of events. Patients were classified into two groups: Group I: patients with major bleeding, and Group II: patients without major bleeding. RESULTS Patients with major bleeding were significantly older, with more diabetic and hypertensive patients, more prior vascular disease, heart failure, and less patients with unstable angina, higher heart rate and systolic blood, lower eGFR, and higher CRUSADE risk score. CRUSADE bleeding score was the strongest predictor of major bleeding. Sensitivity of CRUSADE score ≥33 in prediction of major bleeding in the whole study group was 80%, specificity was 73.4%, positive predictive value was 26.9%, negative predictive value was 96.9%, overall accuracy was 74.1%. Sensitivity of CRUSADE score ≥38.5 in prediction of major bleeding in the STEMI patients was 70%, specificity was 84.8%, positive predictive value was 50%, negative predictive value was 92.9%, and overall accuracy was 82.1%. CONCLUSION CRUSADE score is a good predictor for major bleeding in Egyptian patients with ACS. It is applicable in UA/NSTEMI as well as in STEMI patients and in women as well as in men.
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Affiliation(s)
| | - El-Sayed M Farag
- Cardiology Department, Faculty of Medicine, Zagazig University, Egypt
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Armaganijan LV, Alexander KP, Huang Z, Tricoci P, Held C, Van de Werf F, Armstrong PW, Aylward PE, White HD, Moliterno DJ, Wallentin L, Chen E, Harrington RA, Strony J, Mahaffey KW, Lopes RD. Effect of age on efficacy and safety of vorapaxar in patients with non-ST-segment elevation acute coronary syndrome: Insights from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) trial. Am Heart J 2016; 178:176-84. [PMID: 27502866 DOI: 10.1016/j.ahj.2016.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 05/27/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Antithrombotic therapy plays an important role in the treatment of non-ST-segment elevation acute coronary syndromes (NSTE ACS) but is associated with bleeding risk. Advanced age may modify the relationship between efficacy and safety. METHODS Efficacy and safety of vorapaxar (a protease-activated receptor 1 antagonist) was analyzed across ages as a continuous and a categorical variable in the 12,944 patients with NSTE ACS enrolled in the TRACER trial. To evaluate the effect of age, Cox regression models were developed to estimate hazard ratios (HRs) with the adjustment of other baseline characteristics and randomized treatment for the primary efficacy composite of cardiovascular death, myocardial infarction (MI), stroke, recurrent ischemia with rehospitalization, or urgent coronary revascularization, and the primary safety composite of moderate or severe Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) bleeding. RESULTS The median age of the population was 64years (25th, 75th percentiles = 58, 71). Also, 1,791 patients (13.8%) were ≤54years of age, 4,968 (38.4%) were between 55 and 64 years, 3,979 (30.7%) were between 65 and 74 years, and 2,206 (17.1%) were 75years or older. Older patients had higher rates of hypertension, renal insufficiency, and previous stroke and worse Killip class. The oldest age group (≥75years) had substantially higher 2-year rates of the composite ischemic end point and moderate or severe GUSTO bleeding compared with the youngest age group (≤54years). The relationships between treatment assignment (vorapaxar vs placebo) and efficacy outcomes did not vary by age. For the primary efficacy end point, the HRs (95% CIs) comparing vorapaxar and placebo in the 4 age groups were as follows: 1.12 (0.88-1.43), 0.88 (0.76-1.02), 0.89 (0.76-1.04), and 0.88 (0.74-1.06), respectively (P value for interaction = .435). Similar to what was observed for efficacy outcomes, we did not observe any interaction between vorapaxar and age on bleeding outcomes. For the composite of moderate or severe bleeding according to the GUSTO classification, the HRs (95% CIs) comparing vorapaxar and placebo in the 4 age groups were 1.73 (0.89-3.34), 1.39 (1.04-1.86), 1.10 (0.85-1.42), and 1.73 (1.29-2.33), respectively (P value for interaction = .574). CONCLUSION Older patients had a greater risk for ischemic and bleeding events; however, the efficacy and safety of vorapaxar in NSTE ACS were not significantly influenced by age.
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Affiliation(s)
| | | | - Zhen Huang
- Duke Clinical Research Institute, Durham, NC
| | | | - Claes Held
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Frans Van de Werf
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Philip E Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Center, Adelaide, Australia
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland, New Zealand
| | | | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Edmond Chen
- Bayer HealthCare Pharmaceuticals Inc, Whippany, NJ
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Vora AN, Peterson ED, McCoy LA, Garratt KN, Kutcher MA, Marso SP, Roe MT, Messenger JC, Rao SV. The Impact of Bleeding Avoidance Strategies on Hospital-Level Variation in Bleeding Rates Following Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2016; 9:771-779. [DOI: 10.1016/j.jcin.2016.01.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 01/14/2016] [Indexed: 11/24/2022]
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Verdoia M, Pergolini P, Rolla R, Nardin M, Schaffer A, Barbieri L, Marino P, Bellomo G, Suryapranata H, De Luca G. Advanced age and high-residual platelet reactivity in patients receiving dual antiplatelet therapy with clopidogrel or ticagrelor. J Thromb Haemost 2016; 14:57-64. [PMID: 26512550 DOI: 10.1111/jth.13177] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Indexed: 11/29/2022]
Abstract
UNLABELLED ESSENTIALS: Dual antiplatelet therapy (DAPT) in elderly patients requires balancing bleedings and thrombosis. Impact of age on high residual on-treatment platelet reactivity (HRPR) on DAPT was studied. A reduced effectiveness of adenosine diphosphate antagonists was observed over 70 years of age. The occurrence of HRPR was increased among elderly patients with both clopidogrel and ticagrelor. BACKGROUND The aim of the present study was to evaluate the impact of age on platelet function and the occurrence of high residual on-treatment platelet reactivity (HRPR) in patients treated with dual antiplatelet therapy (DAPT) using acetylsalicilic acid (ASA) and clopidogrel or ticagrelor. METHODS Patients treated with DAPT (ASA and clopidogrel or ticagrelor) were scheduled for platelet function assessment at 30-90 days post-discharge. By whole blood impedance aggregometry, HRPR was considered for ASPI test values > 862 AU*min (for ASA) and adenosine diphosphate (ADP) test values > 417 AU*min (for ADP antagonists). Elderly patients were defined as those aged ≥ 70 years. RESULTS Among 494 patients on DAPT, 224 (45.3%) were ≥ 70 years old. ADP-mediated platelet aggregation increased with decades of age (279.3 ± 148.6 vs. 319.6 ± 171.1 vs. 347.3 ± 190.1 vs. 345.7 ± 169.2), whereas no difference was observed for ASA response. A reduced effectiveness of ADP antagonists was observed among elderly patients; in fact, among the 117 patients displaying HRPR (23.7%), a higher prevalence was observed among patients over 70 years old (30.4% vs. 18.1%; adjusted odds ratio (OR) [95% confidence interval (CI)] = 2.19 [1.29-3.71]). Similar results were obtained among the 266 clopidogrel-treated patients (38.5% vs. 27.9%; adjusted OR [95% CI] = 2.91 [1.46-5.8]) and in the 228 patients receiving ticagrelor (19.1% vs. 8.1%; adjusted OR [95% CI] = 2.55 [1.02-8.59]). CONCLUSION In patients receiving dual antiplatelet therapy, advanced age is independently associated with a reduced effectiveness of ADP antagonists and a higher rate of HRPR with both clopidogrel and ticagrelor.
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Affiliation(s)
- M Verdoia
- Department of Cardiology, Ospedale 'Maggiore della Carità', Eastern Piedmont University, Novara, Italy
| | - P Pergolini
- Clinical Chemistry, Ospedale 'Maggiore della Carità', Eastern Piedmont University, Novara, Italy
| | - R Rolla
- Clinical Chemistry, Ospedale 'Maggiore della Carità', Eastern Piedmont University, Novara, Italy
| | - M Nardin
- Department of Cardiology, Ospedale 'Maggiore della Carità', Eastern Piedmont University, Novara, Italy
| | - A Schaffer
- Department of Cardiology, Ospedale 'Maggiore della Carità', Eastern Piedmont University, Novara, Italy
| | - L Barbieri
- Department of Cardiology, Ospedale 'Maggiore della Carità', Eastern Piedmont University, Novara, Italy
| | - P Marino
- Department of Cardiology, Ospedale 'Maggiore della Carità', Eastern Piedmont University, Novara, Italy
| | - G Bellomo
- Clinical Chemistry, Ospedale 'Maggiore della Carità', Eastern Piedmont University, Novara, Italy
| | | | - G De Luca
- Department of Cardiology, Ospedale 'Maggiore della Carità', Eastern Piedmont University, Novara, Italy
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Urban P, Meredith IT, Abizaid A, Pocock SJ, Carrié D, Naber C, Lipiecki J, Richardt G, Iñiguez A, Brunel P, Valdes-Chavarri M, Garot P, Talwar S, Berland J, Abdellaoui M, Eberli F, Oldroyd K, Zambahari R, Gregson J, Greene S, Stoll HP, Morice MC. Polymer-free Drug-Coated Coronary Stents in Patients at High Bleeding Risk. N Engl J Med 2015; 373:2038-47. [PMID: 26466021 DOI: 10.1056/nejmoa1503943] [Citation(s) in RCA: 597] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Patients at high risk for bleeding who undergo percutaneous coronary intervention (PCI) often receive bare-metal stents followed by 1 month of dual antiplatelet therapy. We studied a polymer-free and carrier-free drug-coated stent that transfers umirolimus (also known as biolimus A9), a highly lipophilic sirolimus analogue, into the vessel wall over a period of 1 month. METHODS In a randomized, double-blind trial, we compared the drug-coated stent with a very similar bare-metal stent in patients with a high risk of bleeding who underwent PCI. All patients received 1 month of dual antiplatelet therapy. The primary safety end point, tested for both noninferiority and superiority, was a composite of cardiac death, myocardial infarction, or stent thrombosis. The primary efficacy end point was clinically driven target-lesion revascularization. RESULTS We enrolled 2466 patients. At 390 days, the primary safety end point had occurred in 112 patients (9.4%) in the drug-coated-stent group and in 154 patients (12.9%) in the bare-metal-stent group (risk difference, -3.6 percentage points; 95% confidence interval [CI], -6.1 to -1.0; hazard ratio, 0.71; 95% CI, 0.56 to 0.91; P<0.001 for noninferiority and P=0.005 for superiority). During the same time period, clinically driven target-lesion revascularization was needed in 59 patients (5.1%) in the drug-coated-stent group and in 113 patients (9.8%) in the bare-metal-stent group (risk difference, -4.8 percentage points; 95% CI, -6.9 to -2.6; hazard ratio, 0.50; 95% CI, 0.37 to 0.69; P<0.001). CONCLUSIONS Among patients at high risk for bleeding who underwent PCI, a polymer-free umirolimus-coated stent was superior to a bare-metal stent with respect to the primary safety and efficacy end points when used with a 1-month course of dual antiplatelet therapy. (Funded by Biosensors Europe; LEADERS FREE ClinicalTrials.gov number, NCT01623180.).
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Affiliation(s)
- Philip Urban
- From Hôpital de la Tour, Geneva (P.U.), Triemli Hospital, Zurich (F.E.), and Biosensors Europe, Morges (S.G., H.-P.S.) - all in Switzerland; MonashHeart and Monash University, Melbourne, VIC, Australia (I.T.M.); Instituto Dante Pazzanese de Cardiologia, São Paulo (A.A.); London School of Hygiene and Tropical Medicine, London (S.J.P., J.G.), the Dorset Heart Centre Royal Bournemouth Hospital, Bournemouth (S.T.), and West of Scotland Regional Heart and Lung Centre Golden Jubilee National Hospital, Glasgow (K.O.) - all in the United Kingdom; Toulouse Rangueil Hospital, Toulouse (D.C.), Pôle Santé République, Clermont-Ferrand (J.L.), Clinique de la Fontaine, Dijon (P.B.), Hôpital Claude Galien, Institut Cardiovasculaire Paris Sud (ICPS), Générale de Santé, Quincy-sous-Sénart (P.G.), Clinique Saint Hilaire, Rouen (J.B.), Groupe Hospitalier Mutualiste de Grenoble, Grenoble (M.A.), and ICPS, Générale de Santé, Massy (M.-C.M.) - all in France; Contilia Heart and Vascular Center, Elisabeth Krankenhaus, Essen (C.N.), and Herzzentrum Segeberger Kliniken, Bad Segeberg (G.R.) - both in Germany; Complejo Hospital Meixoeiro, Vigo, (A.I.), and Arrixaca University Hospital, Murcia (M.V.-C.) - both in Spain; and the Institute Jantung Negara, Kuala Lumpur, Malaysia (R.Z.)
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Antiplatelet and Anticoagulation Treatment in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: Comparison of the Updated North American and European Guidelines. Cardiol Rev 2015; 24:170-6. [PMID: 26186386 DOI: 10.1097/crd.0000000000000080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
In 2014, the American Heart Association and the American College of Cardiology (AHA/ACC) published their guideline for the management of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), whereas the European Society of Cardiology published their latest guideline for the management of patients with NSTE-ACS in 2011. In this article, we review the main updates in antiplatelet and anticoagulation therapy in the 2014 AHA/ACC guideline and compare them with the 2011 European guidelines. Key recommendations in the AHA/ACC guidelines include the addition of ticagrelor to a broad spectrum of patients with NSTE-ACS, narrowing of the role of prasugrel to patients who undergo coronary stenting, and limiting the use of glycoprotein IIb/IIIa receptor inhibitors mainly to high-risk patients during percutaneous coronary intervention. These modifications bring the North American and the European guidelines closer together. The recommendations regarding anticoagulants still differ between the 2 guidelines, although all 4 parenteral agents (unfractionated heparin, low-molecular-weight heparin, bivalirudin, and fondaparinux) are now considered acceptable by both guidelines. We also review new data from clinical trials that became available after the 2014 guidelines were finalized, including studies with cangrelor, rivaroxaban, vorapaxar, ticagrelor, and long-term use of dual antiplatelets that will be considered in future guidelines. As the 2014 guidelines represent the most comprehensive and authoritative document for the management of patients with NSTE-ACS, clinicians who manage these patients should be familiar with their recommendations to ensure optimal patient care.
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Shanmugam VB, Harper R, Meredith I, Malaiapan Y, Psaltis PJ. An overview of PCI in the very elderly. J Geriatr Cardiol 2015; 12:174-84. [PMID: 25870621 PMCID: PMC4394333 DOI: 10.11909/j.issn.1671-5411.2015.02.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 01/04/2015] [Accepted: 01/16/2015] [Indexed: 12/18/2022] Open
Abstract
Cardiovascular disease, and in particular ischemic heart disease (IHD), is a major cause of morbidity and mortality in the very elderly (> 80 years) worldwide. These patients represent a rapidly growing cohort presenting for percutaneous coronary intervention (PCI), now constituting more than one in five patients treated with PCI in real-world practice. Furthermore, they often have greater ischemic burden than their younger counterparts, suggesting that they have greater scope of benefit from coronary revascularization therapy. Despite this, the very elderly are frequently under-represented in clinical revascularization trials and historically there has been a degree of physician reluctance in referring them for PCI procedures, with perceptions of disappointing outcomes, low success and high complication rates. Several issues have contributed to this, including the tendency for older patients with IHD to present late, with atypical symptoms or non-diagnostic ECGs, and reservations regarding their procedural risk-to-benefit ratio, due to shorter life expectancy, presence of comorbidities and increased bleeding risk from antiplatelet and anticoagulation medications. However, advances in PCI technology and techniques over the past decade have led to better outcomes and lower risk of complications and the existing body of evidence now indicates that the very elderly actually derive more relative benefit from PCI than younger populations. Importantly, this applies to all PCI settings: elective, urgent and emergency. This review discusses the role of PCI in the very elderly presenting with chronic stable IHD, non ST-elevation acute coronary syndrome, and ST-elevation myocardial infarction. It also addresses the clinical challenges met when considering PCI in this cohort and the ongoing need for research and development to further improve outcomes in these challenging patients.
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Affiliation(s)
- Vimalraj Bogana Shanmugam
- Cardiovascular Research Centre, Monash University, 246, Clayton Road, Clayton, Victoria 3168, Australia
| | - Richard Harper
- Cardiovascular Research Centre, Monash University, 246, Clayton Road, Clayton, Victoria 3168, Australia
| | - Ian Meredith
- Cardiovascular Research Centre, Monash University, 246, Clayton Road, Clayton, Victoria 3168, Australia
| | - Yuvaraj Malaiapan
- Cardiovascular Research Centre, Monash University, 246, Clayton Road, Clayton, Victoria 3168, Australia
| | - Peter J Psaltis
- Cardiovascular Research Centre, Monash University, 246, Clayton Road, Clayton, Victoria 3168, Australia
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Dobies DR, Barber KR, Cohoon AL. Validity of a PCI Bleeding Risk Score in patient subsets stratified for body mass index. Open Heart 2015; 2:e000088. [PMID: 25745565 PMCID: PMC4346578 DOI: 10.1136/openhrt-2014-000088] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 11/24/2014] [Accepted: 01/12/2015] [Indexed: 12/29/2022] Open
Abstract
Objective An accurate tool with good discriminative for bleeding would be useful to clinicians for improved management of all their patients. Bleeding risk models have been published but not externally validated in independent clinical data set. We chose the National Cardiovascular Data Registry (NCDR) percutaneous coronary intervention (PCI) score to validate within a large, multisite community data set. The aim of the study was validation of this Bleeding Risk Score (BRS) tool among a subgroup of patients based on body mass index. Methods This is a large-scale retrospective analysis of a current registry utilising data from a 37-hospital health system. The central repository of patients with coronary heart disease undergoing PCI between 1 June 2009 and 30 June 2012 was utilised to validate the NCDR PCI BRS among 4693 patients. The primary end point was major bleeding. Validation analysis calculating the receiver operating characteristic curve was performed. Results There were 143 (3%) major bleeds. Mean BRS was 14.7 (range 3–42). Incidence of bleeding by risk category: low (0.5%), intermediate (1.7%) and high risk (7.6%). Tool accuracy was poor to fair (area-under-the curve (AUC) 0.78 heparin, 0.65 bivalirudin). Overall accuracy was 0.71 (CI 0.66 to 0.76). Accuracy did not improve when confined to just the intermediate risk group (AUC 0.58; CI 0.55 to 0.67). Tool accuracy was the lowest among the low BMI group (AUC 0.62) though they are at increased risk of bleeding following PCI. Conclusions Bleeding risk tools have low predictive value even among subgroups of patients at higher risk. Adjustment for anticoagulation use resulted in poor discrimination because bivalirudin differentially biases outcomes toward no bleeding. The current state of bleeding risk tools provide little support for diagnostic utility in regards to major bleeding and therefore have limited clinical applicability.
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Affiliation(s)
- David R Dobies
- Regional Cardiology Associates , Grand Blanc, Michigan , USA
| | - Kimberly R Barber
- Genesys Regional Medical Center , Office of Research , Grand Blanc, Michigan , USA
| | - Amanda L Cohoon
- Genesys Regional Medical Center , Cardiac Cath Lab , Grand Blanc, Michigan , USA
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: Executive Summary. J Am Coll Cardiol 2014. [DOI: 10.1016/j.jacc.2014.09.016] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Cayla G, Cuisset T, Silvain J, Henry P, Leclercq F, Carrié D, Etienne CS, Belle L, Rangé G, Pouillot C, Varenne O, Van Belle E, Boueri Z, Motreff P, Elhadad S, Delarche N, El Mahmoud R, Vicaut E, Collet JP, Montalescot G. Platelet function monitoring in elderly patients on prasugrel after stenting for an acute coronary syndrome: design of the randomized antarctic study. Am Heart J 2014; 168:674-81. [PMID: 25440795 DOI: 10.1016/j.ahj.2014.07.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 07/18/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Elderly patients are at high risk for both ischemic and bleeding events. Platelet monitoring offers the opportunity to individualized antiplatelet therapy to optimize the therapeutic risk/benefit ratio. STUDY DESIGN The ANTARCTIC study is designed to demonstrate the superiority of a strategy of platelet function monitoring with dose and drug adjustment in patients initially on prasugrel 5 mg as compared with a more conventional strategy using prasugrel 5 mg without monitoring and without adjustment (Conventional Treatment Arm) to reduce the primary end point evaluated 1 year after stent percutaneous coronary intervention in elderly patients presenting with an acute coronary syndrome (ACS). ANTARCTIC is a multicenter, prospective, open-label study with 2 parallel arms. A total of 852 elderly patients (≥ 75 years) undergoing stent percutaneous coronary intervention for ACS are to be enrolled. The primary end point is the time to first occurrence of cardiovascular death, myocardial infarction, stroke, definite stent thrombosis, urgent revascularization, and bleeding complications (Bleeding Academic Research Consortium definition 2, 3, or 5). Platelet function analyses will be performed 14 days after randomization and repeated 14 days later in patients who require a change in treatment. CONCLUSION ANTARCTIC is a nationwide, prospective, open-label study testing a strategy of platelet function monitoring with dose and drug adjustment to reduce ischemic and bleeding complications in elderly ACS patients undergoing coronary stenting.
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Affiliation(s)
| | - Thomas Cuisset
- Departement de Cardiologie, Hôpital de la Timone, Marseille, France
| | - Johanne Silvain
- Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Patrick Henry
- Service de Cardiologie, Hôpital Lariboisière, Paris, France
| | | | | | | | - Loic Belle
- Service de Cardiologie, CH, Annecy, France
| | - Grégoire Rangé
- Service de Cardiologie, Hôpital Louis Pasteur, Le Coudray, France
| | | | | | | | | | | | - Simon Elhadad
- Service de Cardiologie, CH, de Lagny, Marne-la-Vallée, France
| | | | | | - Eric Vicaut
- Unité de Recherche Clinique Lariboisère, Hôpital Fernand Widal, Paris, France
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 64:e139-e228. [PMID: 25260718 DOI: 10.1016/j.jacc.2014.09.017] [Citation(s) in RCA: 2089] [Impact Index Per Article: 208.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2354-94. [PMID: 25249586 DOI: 10.1161/cir.0000000000000133] [Citation(s) in RCA: 747] [Impact Index Per Article: 74.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:e344-426. [PMID: 25249585 DOI: 10.1161/cir.0000000000000134] [Citation(s) in RCA: 636] [Impact Index Per Article: 63.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Pershad A, Fraij G, Massaro JM, David SW, Kleiman NS, Denktas AE, Wilson BH, Dixon SR, Ohman EM, Douglas PS, Moses JW, O'Neill WW. Comparison of the use of hemodynamic support in patients ≥80 years versus patients <80 years during high-risk percutaneous coronary interventions (from the Multicenter PROTECT II Randomized Study). Am J Cardiol 2014; 114:657-64. [PMID: 25037676 DOI: 10.1016/j.amjcard.2014.05.055] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/30/2014] [Accepted: 05/30/2014] [Indexed: 10/25/2022]
Abstract
The outcomes of hemodynamic support during high-risk percutaneous coronary intervention in the very elderly are unknown. We sought to compare outcomes between the patients ≥80 years versus patients <80 years enrolled in the PROTECT II (Prospective Randomized Clinical Trial of Hemodynamic Support with the Impella 2.5 versus Intra-Aortic Balloon Pump in Patients undergoing High Risk Percutaneous Coronary Intervention) randomized trial. Patients who underwent high-risk percutaneous coronary intervention with an unprotected left main or last patent conduit and a left ventricular ejection fraction ≤35% or with 3-vessel disease and a left ventricular ejection fraction ≤30% were randomized to receive an intra-aortic balloon pump or the Impella 2.5; 90-day (or the longest follow-up) outcomes were compared between patients ≥80 years (n = 59) and patients <80 years (n = 368). At 90 days, the composite end point of major adverse events and major adverse cerebral and cardiac events were similar between patients ≥80 and <80 years (45.6% vs 44.1%, p = 0.823, and 23.7% vs 26.8%, p = 0.622, respectively). There were no differences in death, stroke, or myocardial infarction rates between the 2 groups, but fewer repeat revascularization procedures were required in patients ≥80 years (1.7% vs 10.4%, p = 0.032). Bleeding and vascular complication rates were low and comparable between the 2 age groups (3.4% vs 2.4%, p = 0.671, and 6.8% vs 5.4%, p = 0.677, respectively). Multivariate analysis confirmed that age was not an independent predictor of major adverse events (odds ratio = 1.031, 95% confidence interval 0.459-2.315, p = 0.941), whereas Impella 2.5 was an independent predictor for improved outcomes irrespective of age (odds ratio = 0.601, 95% confidence interval 0.391-0.923, p = 0.020). In conclusion, the use of percutaneous circulatory support is reasonable and feasible in a selected octogenarian population with similar outcomes as those of younger selected patients. Irrespective of age, the use of Impella 2.5 was an independent predictor of favorable outcomes.
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Dobies DR, Barber KR, Cohoon AL. The effect of bivalirudin and closure device on bleeding outcomes after percutaneous coronary interventions. Open Heart 2014; 1:e000087. [PMID: 25332807 PMCID: PMC4189288 DOI: 10.1136/openhrt-2014-000087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 06/20/2014] [Accepted: 07/15/2014] [Indexed: 01/25/2023] Open
Abstract
Introduction Studies have demonstrated bivalirudin efficacy in some patients at increased risk of bleeding. The aim of this study was to determine the extent to which bleeding reduction is achieved among all patients using bivalirudin as compared with a heparin with or without 2B3A inhibitor strategy. Methods This is a real-world, large-scale retrospective study utilising the American College of Cardiology (ACC) data from a 37-hospital Ascension Health System. The registry represents routine clinical practice between 1 June 2009 and 30 June 2012. End points included major bleeding, major adverse cardiac events and death. Multivariate regression analysis modelled on predictors of end points. Results This study included 58 862 PCI procedures. Major bleeding rates were lowest for bivalirudin plus closure device overall (OR=0.53, CI 0.21 to 0.84, p=0.001). The use of a device for access closure contributed to the greatest declines in major bleeding. Compared with heparin with device, bivalirudin with device had a significantly lower rate of bleeding (OR=0.37, CI 0.18 to 0.74, p=0.005). The use of device had a greater effect on decreasing bleeding among patients receiving bivalirudin compared with heparin, especially among women (p=0.001). After adjustment for 2B3A use, this advantage was no longer significant in ST segment elevation myocardial infarction patients (OR=1.8, CI 0.5 to 6.0, p=0.34). Conclusions All risk groups in this real world database representing current clinical practice benefited from the use of bivalirudin and device closure with lower risk groups benefiting the most. This robust analysis of real-world clinical data supports a combined treatment strategy of bivalirudin and closure device.
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Affiliation(s)
- David R Dobies
- Department of Cardiology , Regional Cardiology Associates , Grand Blanc, Michigan , USA
| | - Kimberly R Barber
- Clinical Research, Genesys Regional Medical Center, Office of Research , Grand Blanc, Michigan , USA
| | - Amanda L Cohoon
- Cardiac Catheterization Laboratory , Genesys Regional Medical Center , Grand Blanc, Michigan , USA
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Pasala T, Sattayaprasert P, Bhat PK, Athappan G, Gandhi S. Clinical and economic studies of eptifibatide in coronary stenting. Ther Clin Risk Manag 2014; 10:603-14. [PMID: 25120366 PMCID: PMC4128842 DOI: 10.2147/tcrm.s35664] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Platelet adhesion and aggregation at the site of coronary stenting can have catastrophic clinical and economic consequences. Therefore, effective platelet inhibition is vital during and after percutaneous coronary intervention. Eptifibatide is an intravenous antiplatelet agent that blocks the final common pathway of platelet aggregation and thrombus formation by binding to glycoprotein IIb/IIIa receptors on the surface of platelets. In clinical studies, eptifibatide was associated with a significant reduction of mortality, myocardial infarction, or target vessel revascularization in patients with acute coronary syndrome undergoing percutaneous coronary intervention. However, recent trials conducted in the era of dual antiplatelet therapy and newer anticoagulants failed to demonstrate similar results. The previously seen favorable benefit of eptifibatide was mainly offset by the increased risk of bleeding. Current American College of Cardiology/American Heart Association guidelines recommend its use as an adjunct in high-risk patients who are undergoing percutaneous coronary intervention with traditional anticoagulants (heparin or enoxaparin), who are not otherwise at high risk of bleeding. In patients receiving bivalirudin (a newer safer anticoagulant), routine use of eptifibatide is discouraged except in select situations (eg, angiographic complications). Although older pharmacoeconomic studies favor eptifibatide, in the current era of P2Y12 inhibitors and newer safer anticoagulants, the increased costs associated with bleeding make the routine use of eptifibatide an economically nonviable option. The cost-effectiveness of eptifibatide with the use of strategies that decrease the bleeding risk (eg, transradial access) is unknown. This review provides an overview of key clinical and economic studies of eptifibatide well into the current era of potent antiplatelet agents, novel safer anticoagulants, and contemporary percutaneous coronary intervention.
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Affiliation(s)
- Tilak Pasala
- The Heart and Vascular Center, Case Western Reserve University/MetroHealth, Cleveland, OH, USA
| | | | - Pradeep K Bhat
- The Heart and Vascular Center, Case Western Reserve University/MetroHealth, Cleveland, OH, USA
| | - Ganesh Athappan
- The Heart and Vascular Center, Case Western Reserve University/MetroHealth, Cleveland, OH, USA
| | - Sanjay Gandhi
- The Heart and Vascular Center, Case Western Reserve University/MetroHealth, Cleveland, OH, USA
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Gao L, Hu X, Liu YQ, Xue Q, Feng QZ. Percutaneous coronary intervention in the elderly with ST-segment elevation myocardial infarction. Clin Interv Aging 2014; 9:1241-6. [PMID: 25114518 PMCID: PMC4124048 DOI: 10.2147/cia.s62642] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
As a result of increased life expectancy, octogenarians constitute an increasing proportion of patients admitted to hospital for ST-segment elevation myocardial infarction (STEMI). Primary percutaneous coronary intervention is currently the treatment of choice for octogenarians presenting with STEMI. The recent literature on this topic has yielded controversial results, even though advances in drug-eluting stents and new types of antithrombotic agents are improving the management of STEMI and postoperative care. In this paper, we review the current status of percutaneous coronary intervention in the elderly with STEMI, including the reasons for their high mortality and morbidity, predictors of mortality, and strategies to improve outcomes.
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Affiliation(s)
- Lei Gao
- Institute of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Xin Hu
- Institute of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Yu-Qi Liu
- Institute of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Qiao Xue
- Institute of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Quan-Zhou Feng
- Institute of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, People’s Republic of China
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Donahue M, Briguori C. Coronary artery stenting in elderly patients: where are we now. Interv Cardiol 2014. [DOI: 10.2217/ica.14.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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