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Krishnakumar H, Mascitelli J, Hassan A, Leary J, Son C. Treatment of cerebral aneurysms with flow diversion or stent assisted coiling in patients on concurrent oral anticoagulation. Neuroradiol J 2023; 36:464-469. [PMID: 36409963 PMCID: PMC10588601 DOI: 10.1177/19714009221114443] [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] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Flow diversion and stent assisted coiling are increasingly utilized strategies in the endovascular treatment of cerebral aneurysms. Ischemic and hemorrhagic complications play an important role in the outcome following such embolizations. Little is published regarding patients on concurrent oral anticoagulation and undergoing such embolizations and the rates of complications and patient outcomes. MATERIALS AND METHODS Retrospective data for consecutive patients on concurrent oral anticoagulation undergoing flow diversion or stent assisted coiling for cerebral aneurysms was accessed from databases at the participating sites. Patient demographics, comorbidities, antiplatelet regimens, aneurysm characteristics, complications, and radiographic results were recorded and descriptive statistics reported. RESULTS Eleven patients were identified undergoing embolization in the setting of preoperative anticoagulant use and included seven patients undergoing flow diversion and four patients undergoing stent assisted coiling. There was a wide range of antiplatelet and anticoagulant management strategies. There were four major complications in three patients (27.2%) to include two serious bleeding events in addition to ischemic strokes. Both serious bleeding events occurred in patients continued on oral anticoagulation with the addition of antiplatelets. At a mean follow-up of 9.6 months, three aneurysms had continued filling for a good radiographic outcome of 72.7%. CONCLUSIONS Anticoagulant and antiplatelet use in the setting of flow diversion or stent assisted coiling may carry increased risks as compared to historical norms and, for flow diversion, offer decreased efficacy.
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Affiliation(s)
- Hari Krishnakumar
- Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Ameer Hassan
- Department of Neurology, University of Texas Rio Grande Valley Medical School, Harlingen, TX, USA
- Valley Baptist Medical Center, Harlingen, TX, USA
| | - Jonathan Leary
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Colin Son
- Neurosurgical Associates of San Antonio, San Antonio, TX, USA
- School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX, USA
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Chow JK, Bagai A, Tan MK, Har BJ, Yip AMC, Paniagua M, Elbarouni B, Bainey KR, Paradis JM, Maranda R, Cantor WJ, Eisenberg MJ, Dery JP, Madan M, Cieza T, Matteau A, Roth S, Lavi S, Glanz A, Gao D, Tahiliani R, Welsh RC, Kim HH, Robinson SD, Daneault B, Chong AY, Le May MR, Ahooja V, Gregoire JC, Nadeau PL, Laksman Z, Heilbron B, Yung D, Minhas K, Bourgeois R, Overgaard CB, Bonakdar H, Logsetty G, Lavoie AJ, De LaRochelliere R, Mansour S, Spindler C, Yan AT, Goodman SG. Antithrombotic therapies in Canadian atrial fibrillation patients with concomitant coronary artery disease: Insights from the CONNECT AF + PCI-II program. J Cardiol 2023; 82:153-161. [PMID: 36931433 DOI: 10.1016/j.jjcc.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 03/04/2023] [Accepted: 03/07/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Selecting the appropriate antithrombotic regimen for patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) or have had medically managed acute coronary syndrome (ACS) remains complex. This multi-centre observational study evaluated patterns of antithrombotic therapies utilized among Canadian patients with AF post-PCI or ACS. METHODS AND RESULTS By retrospective chart audit, 611 non-valvular AF patients [median (interquartile range) age 76 (69-83) years, CHADS2 score 2 (1-3)] who underwent PCI or had medically managed ACS between August 2018 and December 2020 were identified by 68 cardiologists across eight provinces in Canada. Overall, triple antithrombotic therapy [TAT: combined oral anticoagulation (OAC) and dual antiplatelet therapy (DAPT)] was the most common initial antithrombotic strategy, with use in 53.8 % of patients, followed by dual pathway therapy (32.7 % received OAC and a P2Y12 inhibitor, and 4.1 % received OAC and aspirin) and DAPT (9.3 %). Median duration of TAT was 30 (7, 30) days. Compared to the previous CONNECT AF + PCI-I program, there was an increased use of dual pathway therapy relative to TAT over time (P-value <.0001). DOACs (direct oral anticoagulants) represented 90.3 % of all OACs used overall, with apixaban being the most utilized (50.5 %). Proton pump inhibitors were used in 57.0 % of all patients, and 70.1 % of patients on ASA. Planned antithrombotic therapies at 1 year were: 76.2 % OAC monotherapy, 8.3 % OAC + ASA, 7.9 % OAC + P2Y12 inhibitor, 4.3 % DAPT, 1.3 % ASA alone, and <1 % triple therapy. CONCLUSION In accordance with recent Canadian Cardiovascular Society guideline recommendations, we observed an increased use of dual pathway therapy relative to TAT over time in both AF patients post-PCI (elective and emergent) and in those with medically managed ACS. Additionally, DOACs have become the prevailing form of anticoagulation across all antithrombotic regimens. Our findings suggest that Canadian physicians are integrating evidence-based approaches to optimally manage the bleeding and thrombotic risks of AF patients post-PCI and/or ACS.
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Affiliation(s)
| | - Akshay Bagai
- University of Toronto, Toronto, Canada; St Michael's Hospital, Toronto, Canada
| | - Mary K Tan
- Canadian Heart Research Centre, Toronto, Canada
| | - Bryan J Har
- Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | | | | | - Basem Elbarouni
- St Boniface Hospital, University of Manitoba, Winnipeg, Canada
| | - Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Jean-Michel Paradis
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | | | - Warren J Cantor
- University of Toronto, Toronto, Canada; Southlake Regional Health Centre, Newmarket, Canada
| | | | - Jean-Pierre Dery
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Mina Madan
- University of Toronto, Toronto, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Tomas Cieza
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Alexis Matteau
- Centre hospitalier de l'université de Montréal (CHUM), Montreal, Canada
| | - Sherryn Roth
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Scarborough Health Network, Toronto, Canada
| | | | | | | | - Ravi Tahiliani
- Central East Regional Cardiac Care Program, Oshawa, Canada
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Hahn Hoe Kim
- St. Mary's General Hospital, Kitchener-Waterloo, Canada
| | - Simon D Robinson
- Royal Jubilee Hospital, University of British Columbia, Victoria, Canada
| | - Benoit Daneault
- Centre hospitalier Universitaire de Sherbrooke, Sherbrooke University, Sherbrooke, Canada
| | | | | | | | | | | | | | - Brett Heilbron
- University of British Columbia, Vancouver, Canada; St. Paul's Hospital, Vancouver, Canada
| | - Derek Yung
- Scarborough Health Network, Toronto, Canada
| | - Kunal Minhas
- St Boniface Hospital, University of Manitoba, Winnipeg, Canada
| | - Ronald Bourgeois
- Moncton Hospital, Dalhousie University Faculty of Medicine, Moncton, Canada
| | | | - Hamid Bonakdar
- St Boniface Hospital, University of Manitoba, Winnipeg, Canada
| | | | - Andrea J Lavoie
- Regina General Hospital - Prairie Vascular Research Network, Regina, Canada
| | - Robert De LaRochelliere
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Samer Mansour
- Centre hospitalier de l'université de Montréal (CHUM), Montreal, Canada
| | | | - Andrew T Yan
- University of Toronto, Toronto, Canada; St Michael's Hospital, Toronto, Canada.
| | - Shaun G Goodman
- University of Toronto, Toronto, Canada; St Michael's Hospital, Toronto, Canada; Canadian Heart Research Centre, Toronto, Canada.
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Choi Y, Lee Y, Kim SH, Kim S, Kim JY, Kim TS, Hwang Y, Kim JH, Jang SW, Lee MY, Oh YS. Single direct oral anticoagulant therapy in stable patients with atrial fibrillation beyond 1 year after coronary stent implantation. Heart 2021; 108:285-291. [PMID: 33990409 DOI: 10.1136/heartjnl-2020-318750] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 04/01/2021] [Accepted: 04/04/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Optimal antithrombotic therapy in patients with atrial fibrillation (AF) beyond 1 year after coronary stent implantation has not been well established in the era of direct oral anticoagulant (DOAC). METHODS Using Korean National Health Insurance Service data, we analysed 4294 patients with AF who were prescribed DOAC beyond 1 year after coronary stent implantation. Subjects were classified into the monotherapy group (DOAC single therapy, n=1221) or the combination therapy group (DOAC with an antiplatelet agent, n=3073). The primary ischaemic endpoint was defined as a composite of cardiovascular death, myocardial infarction, stroke or systemic thromboembolism. The secondary endpoints were all-cause death, major bleeding defined as a bleeding event requiring hospitalisation and net adverse clinical events. Propensity score matching was performed to balance baseline covariates. RESULTS Among included patients, 94% had drug-eluting coronary stents. During a median follow-up of 19 (7-32) months, the monotherapy group had a similar risk of the primary ischaemic endpoint (HR 0.828, 95% CI 0.660 to 1.038) and all-cause death (HR 1.076, 95% CI 0.895 to 1.294) compared with the combination therapy group. Risk of major bleeding was lower in the monotherapy group (HR 0.690, 95% CI 0.481 to 0.989), which was mostly driven by reduced gastrointestinal bleeding (HR 0.562, 95% CI 0.358 to 0.883). There was no significant difference in net adverse clinical events between the two groups. CONCLUSIONS DOAC monotherapy showed similar efficacy in preventing ischaemic events and was associated with lower major bleeding events compared with combination therapy in patients with AF beyond 1 year after coronary stent implantation.
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Affiliation(s)
- Young Choi
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yunhee Lee
- Department of Occupational and Environmental Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Hwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sunhwa Kim
- Division of Cardiology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, South Korea
| | - Ju Youn Kim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, South Korea
| | - Tae-Seok Kim
- Division of Cardiology, Department of Internal Medicine, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, South Korea
| | - Youmi Hwang
- Division of Cardiology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, South Korea
| | - Ji-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, South Korea
| | - Sung-Won Jang
- Division of Cardiology, Department of Internal Medicine, Eunpyeong St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Man Young Lee
- Division of Cardiology, Department of Internal Medicine, Yeouido St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yong-Seog Oh
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Characteristics and outcomes in patients with atrial fibrillation and acute coronary syndrome treated with ticagrelor and novel oral anticoagulants. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Koycu A, Vural O, Bahcecitapar M, Jafarov S, Beyazpinar G, Beyazpinar DS. Device-related epistaxis risk: continuous-flow left ventricular assist device-supported patients. Eur Arch Otorhinolaryngol 2020; 277:2767-2773. [PMID: 32556786 DOI: 10.1007/s00405-020-06127-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/10/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to analyze the effect of device-dependent factors on epistaxis episodes comparing patients supported with a continuous-flow left ventricular assist device (CF-LVAD) to patients under the same antithrombotic therapy. METHODS Patients who underwent CF-LVAD between 2012 and 2018 were reviewed retrospectively from the institutionally adopted electronic database. Patients who underwent mitral valve replacement (MVR) surgery receiving the same anticoagulant and antiaggregant therapy were included as a control group. Demographics, epistaxis episodes, and nonepistaxis bleeding between the two groups were compared. RESULTS A total of 179 patients met the inclusion criteria (61 patients CF-LVAD group, 118 patients MVR group). The median (range) follow-up periods for the study (CF-LVAD) and control (MVR) groups were 370 (2819) and 545.70 (2356) days, respectively. There was a significant difference for frequency of bleeding episodes per month between CF-LVAD and MVR groups (p = 0.003 < 0.05). The most common site of bleeding was the anterior septum in both groups (90.9% for the CF-MVR group and 100% for the MVR group). While 14 patients (23%) had nonepistaxis bleeding in the CF-LVAD group, only two patients (1.7%) had nonepistaxis bleeding in the MVR group. There were significant differences in nonepistaxis bleeding rates between the CF-LVAD and MVR groups (χ2=19.79, p < 0.001). CONCLUSION Both epistaxis and nonepistaxis bleeding rates were higher in the CF-LVAD group than in the MVR group. This suggests that the use of CF-LVAD support could directly increase the risk of hemorrhagic complications. LEVEL OF EVIDENCE 2A (Etiology/Harm).
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Affiliation(s)
- Alper Koycu
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Baskent University, Ankara, 06490, Turkey
| | - Omer Vural
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Baskent University, Ankara, 06490, Turkey.
| | - Melike Bahcecitapar
- Department of Statistics, Faculty of Science, Hacettepe University, Ankara, 06800, Turkey
| | - Sabuhi Jafarov
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Baskent University, Ankara, 06490, Turkey
| | - Gulfem Beyazpinar
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Baskent University, Ankara, 06490, Turkey
| | - Deniz Sarp Beyazpinar
- Department of Cardiovascular Surgery, Faculty of Medicine, Baskent University, Ankara, 06490, Turkey
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Chua SK, Chen LC, Shyu KG, Cheng JJ, Hung HF, Chiu CZ, Lin CM. Antithrombotic Strategies in Patients with Atrial Fibrillation Following Percutaneous Coronary Intervention: A Systemic Review and Network Meta-Analysis of Randomized Controlled Trials. J Clin Med 2020; 9:jcm9041062. [PMID: 32276535 PMCID: PMC7231136 DOI: 10.3390/jcm9041062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 12/16/2022] Open
Abstract
Up to 10% of patients with atrial fibrillation (AF) undergo percutaneous coronary intervention (PCI). A systematic review and network meta-analysis were conducted by searching PubMed, Embase, and the Cochrane database of systematic reviews for randomized control trials that studied the safety and efficacy of different antithrombotic strategies in these patients. Six studies, including 12,158 patients were included. Compared to that in the triple antithrombotic therapy group (vitamin K antagonist (VKA) plus P2Y12 inhibitor and aspirin), thrombolysis in myocardial infarction (TIMI) major bleeding was significantly reduced in the dual antithrombotic therapy (non-vitamin K oral anticoagulants (NOACs) plus P2Y12 inhibitor) group by 47% (Odds ratio (OR), 0.53; 95% credible interval [CrI], 0.35–0.78; I2 = 0%). Besides, NOAC plus a P2Y12 inhibitor was associated with less intracranial hemorrhage compared to VKA plus single antiplatelet therapy (OR: 0.20, 95% CrI: 0.05–0.77). There was no significant difference in the trial-defined major adverse cardiac events or the individual outcomes of all-cause mortality, cardiovascular death, myocardial infarction, stroke or stent thrombosis among all antithrombotic strategies. In conclusion, antithrombotic strategy of NOACs plus P2Y12 inhibitor is safer than, and as effective as, the strategies including aspirin when used in AF patients undergoing PCI.
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Affiliation(s)
- Su-Kiat Chua
- School of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan;
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Lung-Ching Chen
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Kou-Gi Shyu
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Jun-Jack Cheng
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Huei-Fong Hung
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Chiung-Zuan Chiu
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Correspondence: (C.-Z.C.); (C.-M.L.); Tel.: +886–2–2833–2211 (C.-Z.C. & C.-M.L.)
| | - Chiu-Mei Lin
- School of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan;
- Department of Emergency Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Correspondence: (C.-Z.C.); (C.-M.L.); Tel.: +886–2–2833–2211 (C.-Z.C. & C.-M.L.)
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7
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Kozieł M, Potpara TS, Lip GYH. Triple therapy in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention/stenting. Res Pract Thromb Haemost 2020; 4:357-365. [PMID: 32211570 PMCID: PMC7086461 DOI: 10.1002/rth2.12319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 11/25/2022] Open
Abstract
Patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) are at high risk of stroke, recurrent coronary ischemic events, and cardiovascular mortality. The composition of antithrombotic therapy including an oral anticoagulant and antiplatelet drug(s) should be tailored according to the individual patient's risk profile, to reduce the bleeding risk and maintain antithrombotic effect. There is no single antithrombotic treatment regimen that would fit to all patients with AF and ACS. However, available data promote the use of full-dose direct oral anticoagulants (DOACs) (dabigatran 150 mg twice daily or apixaban 5 mg twice daily) or rivaroxaban 15 mg once daily in patients with AF and ACS or percutaneous coronary intervention (PCI). For many patients, a DOAC plus P2Y12 inhibitor early after ACS and/or PCI would be optimal, whereas a longer course of triple therapy should be used in patients at high thrombotic risk.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
- Division of Medical Sciences in ZabrzeDepartment of CardiologyCongenital Heart Diseases and ElectrotherapyMedical University of SilesiaKatowicePoland
| | - Tatjana S. Potpara
- Cardiology ClinicClinical Center of SerbiaBelgradeSerbia
- School of MedicineBelgrade UniversityBelgradeSerbia
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
- Division of Medical Sciences in ZabrzeDepartment of CardiologyCongenital Heart Diseases and ElectrotherapyMedical University of SilesiaKatowicePoland
- School of MedicineBelgrade UniversityBelgradeSerbia
- Aalborg Thrombosis Research UnitDepartment of Clinical MedicineAalborg UniversityAalborgDenmark
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Gibson WJ, Gibson CM, Yee MK, Korjian S, Daaboul Y, Plotnikov AN, Burton P, Braunwald E. Safety and Efficacy of Rivaroxaban When Added to Aspirin Monotherapy Among Stabilized Post‐Acute Coronary Syndrome Patients: A Pooled Analysis Study of ATLAS ACS‐TIMI 46 and ATLAS ACS 2‐TIMI 51. J Am Heart Assoc 2019. [PMCID: PMC6474929 DOI: 10.1161/jaha.118.009451] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background A residual risk of ischemic events following an acute coronary syndrome (ACS) remains despite antiplatelet therapy. The addition of an antithrombin as part of a “dual pathway” approach may further improve outcomes as thrombin generation persists for several months post‐ACS. The present study evaluates the safety and efficacy of “dual pathway” therapy (rivaroxaban plus aspirin) as compared with aspirin monotherapy among post‐ACS patients. Methods and Results A total of 1477 patients were analyzed in a pooled analysis of subsets of the ATLAS ACS‐TIMI (Anti‐Xa Therapy to Lower cardiovascular events in addition to Aspirin with or without thienopyridine therapy in Subjects with Acute Coronary Syndrome – Thrombolysis in Myocardial Infarction) 46 and ATLAS ACS 2‐TIMI 51 trials including post‐ACS patients receiving aspirin monotherapy and randomized to either rivaroxaban 2.5 mg BID or rivaroxaban 5 mg BID or placebo. The primary efficacy end point was a composite of cardiovascular death, myocardial infarction (MI), or stroke (ischemic, hemorrhagic, or of uncertain cause). The primary safety end point was TIMI‐non‐coronary artery bypass (CABG) major bleeding. The combined rivaroxaban group (2.5 or 5 mg BID) among stabilized post‐ACS patients on a background of aspirin monotherapy was associated with a significant reduction in the primary end point as compared with placebo (hazard ratio=0.65, 95% CI=0.45–0.92, P=0.016). Although the combined rivaroxaban dose groups were associated with higher rates of non‐CABG TIMI major bleeding, the 2.5 mg dose group was not, and the overall number of patients experiencing a non‐CABG TIMI major bleeding event was low (1.5%). Conclusions Among patients in the immediate post‐ACS period, a “dual pathway” approach using aspirin and low‐dose rivaroxaban may reduce the risk of secondary atherothrombotic events, but increase bleeding risk. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifiers: NCT00402597; NCT00809965. See Editorial by Harrison and Newby
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Affiliation(s)
- William J. Gibson
- PERFUSE Study Group, Cardiovascular Division Department of Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston MA
- Department of Internal Medicine Brigham and Women's Hospital Harvard Medical School Boston MA
| | - C. Michael Gibson
- PERFUSE Study Group, Cardiovascular Division Department of Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston MA
| | - Megan K. Yee
- PERFUSE Study Group, Cardiovascular Division Department of Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston MA
| | - Serge Korjian
- PERFUSE Study Group, Cardiovascular Division Department of Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston MA
| | - Yazan Daaboul
- PERFUSE Study Group, Cardiovascular Division Department of Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston MA
| | | | | | - Eugene Braunwald
- The TIMI Study Group, Cardiovascular Division Department of Medicine Brigham and Women's Hospital Harvard Medical School Boston MA
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9
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Baturina OA, Andreev DA, Ananicheva NA, Gilyarov MY, Sychev DA, Syrkin AL, Shchekochihin DY. Prevalence of Atrial Fibrillation and use of Oral Antithrombotic Therapy in Patients with Acute Coronary Syndrome. KARDIOLOGIYA 2019; 59:40-48. [PMID: 30710988 DOI: 10.18087/cardio.2019.1.10213] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 01/27/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE To assess the prevalence of atrial fibrillation (AF) and use of antithrombotic agents in adult patients with acute coronary syndrome (ACS). MATERIALS AND METHODS We consecutively enrolled all ACS patients (n=1155) who were hospitalized in two Moscowbased percutaneous coronary intervention centers (each center performs over 500 PCIs a year) between October 2017 and February 2018. AF was diagnosed in 204 patients (17.7%). The risk of thromboembolic complications was assessed using the CHA2DS2-VASc Score. The risk of hemorrhagic complications was assessed using the HAS-BLED Score. The data were processed using StatSoft Statistica 10.0 and IBM SPSS Statistics v.23 software. RESULTS The prevalence of diagnosed AF was 13.6%, while the prevalence of undiagnosed AF was 4.1%. Of the 179 discharged patients with AF, only 2 had a low risk of ischemic stroke (IS). One hundred and fifty patients (83.8%) eligible for oral anticoagulant therapy received oral anticoagulants. Patients with diagnosed AF were administered oral anticoagulants (OACs) significantly more often than patients with undiagnosed AF [125 (91.9%) vs. 25 (58.1%), р<0.001]. Novel oral anticoagulants (NOACs) were administered four times more often than vitamin K antagonists [120 (80.0%) vs. 29 (19.3%), р<0.001]. Rivaroxaban was used in 51.3% of cases. Of the 29 patients treated with warfarin, only 3 (10.3%) achieved the target international normalized ratio (INR) at discharge. Of the 107 patients who underwent percutaneous coronary intervention (PCI), 77 patients (80%) received an OAC and two antiplatelet agents (with 74% receiving this three-agent therapy for one month), 11 patients (10.3%) received an OAC and an antiplatelet agent, and 18 patients (16.8%) received two antiplatelet agents. The only antiplatelet agent used as part of the three-agent therapy was clopidogrel. The three-agent therapy without PCI was administered in 43.1% of cases. CONCLUSION We found that the prevalence of AF in patients with ACS was high. The fact that doctors administered NOACs suggests that they are aware of the need to use these agents to prevent thromboembolic complications in AF patients.
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Affiliation(s)
- O A Baturina
- Sechenov First Moscow State Medical University (Sechenov University).
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10
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Jaberi N, Soleimani A, Pashirzad M, Abdeahad H, Mohammadi F, Khoshakhlagh M, Khazaei M, Ferns GA, Avan A, Hassanian SM. Role of thrombin in the pathogenesis of atherosclerosis. J Cell Biochem 2018; 120:4757-4765. [DOI: 10.1002/jcb.27771] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 09/06/2018] [Indexed: 01/22/2023]
Affiliation(s)
- Najmeh Jaberi
- Department of Medical Biochemistry Faculty of Medicine, Mashhad University of Medical Sciences Mashhad Iran
| | - Atena Soleimani
- Department of Medical Biochemistry Faculty of Medicine, Mashhad University of Medical Sciences Mashhad Iran
| | - Mehran Pashirzad
- Department of Medical Biochemistry Faculty of Medicine, Mashhad University of Medical Sciences Mashhad Iran
| | - Hosein Abdeahad
- Department of Medical Biochemistry Faculty of Medicine, Mashhad University of Medical Sciences Mashhad Iran
| | - Fariba Mohammadi
- Department of Medical Biochemistry Faculty of Medicine, Mashhad University of Medical Sciences Mashhad Iran
| | - Mahdieh Khoshakhlagh
- Department of Medical Biochemistry Faculty of Medicine, Mashhad University of Medical Sciences Mashhad Iran
| | - Majid Khazaei
- Department of Medical Physiology Faculty of Medicine, Mashhad University of Medical Sciences Mashhad Iran
| | - Gordon A Ferns
- Division of Medical Education Brighton and Sussex Medical School Sussex UK
| | - Amir Avan
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences Mashhad Iran
- Department of Modern Sciences and Technologies School of Medicine, Mashhad University of Medical Sciences Mashhad Iran
| | - Seyed Mahdi Hassanian
- Department of Medical Biochemistry Faculty of Medicine, Mashhad University of Medical Sciences Mashhad Iran
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences Mashhad Iran
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11
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Benito-González T, Estévez-Loureiro R, de Prado AP, Minguito-Carazo C, Del Castillo García S, Garrote-Coloma C, Iglesias-Gárriz I, Alonso-Rodríguez D, Cardona JG, Ramón CC, Benito ML, Estévez JV, Fernández-Vázquez F. Incidence and prognostic implications of late bleeding events after percutaneous mitral valve repair. IJC HEART & VASCULATURE 2018; 21:16-21. [PMID: 30255126 PMCID: PMC6148729 DOI: 10.1016/j.ijcha.2018.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/04/2018] [Accepted: 09/11/2018] [Indexed: 11/26/2022]
Abstract
Objectives MitraClip is an established therapy for patients with mitral regurgitation (MR) that are considered of high-risk or inoperable. However, late bleeding events (BE) after hospital discharge and their impact on prognosis in this cohort of patients have been poorly investigated. Our purpose is to address the incidence, related factors and clinical implications of BE after hospital discharge in patients treated with MitraClip. Methods Prospective registry of all consecutive patients (n = 80) who underwent MitraClip implantation in our Institution between June 2014 and December 2017. BE were defined according to MVARC definitions. A combined clinical end-point including admission for heart failure (HF) and all-cause mortality was established to analyze prognostic implications of BE. Results During a median follow up of 523.5 days, 41 BE were reported in 21 patients. Atrial fibrillation (AF, HR 4.54, CI95% 1.20–17.10) and combined antithrombotic therapy at discharge (HR 3.52, CI95% 1.03–11.34) were independently associated with BE. In the study period, 15 (18.8%) patients died, 20 (25%) were admitted for HF and 29 (36.3%) presented the combined end-point. After multivariable adjustment BE remained independently associated with an adverse outcome (HR 3.80, CI 95% 1.66–8.72). In the subgroup of patients with AF, HAS-BLED score was higher among subjects with BE (3.1 ± 1.3 vs 2.1 ± 0.9, p = 0.003). HAS-BLED score had a significant discrimination power for the occurrence BE (AUC: 0.677 [0.507–0.848]) in this subgroup. Conclusions BE are common after MitraClip and are associated with an impaired outcome. Strategies to reduce bleeding events are paramount in this cohort of patients.
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Affiliation(s)
| | - Rodrigo Estévez-Loureiro
- Department of Cardiology, University Hospital of León, León, Spain.,Department of Cardiology, University Hospital Puerta de Hierro-Majadahonda, Madrid, Spain
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12
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Angiolillo DJ, Goodman SG, Bhatt DL, Eikelboom JW, Price MJ, Moliterno DJ, Cannon CP, Tanguay JF, Granger CB, Mauri L, Holmes DR, Gibson CM, Faxon DP. Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention. Circulation 2018; 138:527-536. [DOI: 10.1161/circulationaha.118.034722] [Citation(s) in RCA: 184] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The optimal antithrombotic treatment regimen for patients with atrial fibrillation undergoing percutaneous coronary intervention with stent implantation represents a challenge in clinical practice. In 2016, an updated opinion of selected experts from the United States and Canada on the treatment of patients with atrial fibrillation undergoing percutaneous coronary intervention was reported. After the 2016 North American consensus statement on the management of antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention, results of pivotal clinical trials assessing the type of oral anticoagulant agent and the duration of antiplatelet treatment have been published. On the basis of these results, this focused update on the antithrombotic management of patients with atrial fibrillation undergoing percutaneous coronary intervention recommends that a non–vitamin K antagonist oral anticoagulant be preferred over a vitamin K antagonist as the oral anticoagulant of choice. Moreover, a double-therapy regimen (oral anticoagulant plus single antiplatelet therapy with a P2Y
12
inhibitor) by the time of hospital discharge should be considered for most patients, whereas extending the use of aspirin beyond hospital discharge (ie, triple therapy) should be considered only for selected patients at high ischemic/thrombotic and low bleeding risks and for a limited period of time. The present document provides a focused updated on the rationale for the new expert consensus–derived recommendations on the antithrombotic management of patients with atrial fibrillation treated with oral anticoagulation undergoing percutaneous coronary intervention.
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Affiliation(s)
| | - Shaun G. Goodman
- St. Michael’s Hospital, University of Toronto, and the Canadian Heart Research Centre, Canada (S.G.G.)
- Canadian Virtual Coordinating Centre for Global Collaborative Cardiovascular Research Centre, University of Alberta, Canada (S.G.G.)
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., L.M., D.P.F.)
| | - John W. Eikelboom
- Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, Canada (J.W.E.)
| | - Matthew J. Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA (M.J.P.)
| | - David J. Moliterno
- Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.)
| | - Christopher P. Cannon
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., L.M., D.P.F.)
| | - Jean-Francois Tanguay
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Canada (J.-F.T.)
| | | | - Laura Mauri
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., L.M., D.P.F.)
| | | | - C. Michael Gibson
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - David P. Faxon
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., L.M., D.P.F.)
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13
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Chen J, Verni CC, Jouppila A, Lassila R, Diamond SL. Dual antiplatelet and anticoagulant (APAC) heparin proteoglycan mimetic with shear-dependent effects on platelet-collagen binding and thrombin generation. Thromb Res 2018; 169:143-151. [PMID: 30071479 DOI: 10.1016/j.thromres.2018.07.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/28/2018] [Accepted: 07/24/2018] [Indexed: 11/16/2022]
Abstract
Heparin proteoglycans (HEP-PGs) carry standard heparin-mediated anticoagulant properties as well as novel antiplatelet functions, a combination that may be significant for targeting multiple pathways in a single therapy. Recent work developing semisynthetic HEP-PG mimetics has shown promising results also in vivo, however flow conditions in vitro that replicate in vivo hemodynamics have not been reported. In this work, we present several assays (platelet calcium mobilization, aggregometry, microfluidic tests at venous and arterial hemodynamics) to characterize specific mechanistic effects of dual antiplatelet and anticoagulant (APAC) constructs as mimetics of HEP-PGs. Three APACs with different conjugation levels of heparin chains (CL10, CL18, HICL) were shown to decrease platelet deposition to collagen surfaces in PPACK-treated whole blood at venous shear rate (200 s-1). FXIIa-inhibited whole blood (CTI: corn trypsin inhibitor, 40 μg/mL) perfused over collagen/tissue factor showed reduced both platelet and fibrin deposition when treated with APACs. IC50 values for platelet and fibrin inhibition were calculated for each molecule at venous shear rate. Increasing the shear rate to arterial flows (1000 s-1) and using APAC as the sole anticoagulant, resulted in a more potent antiplatelet effect of APAC, suggesting an added effect on von Willebrand Factor (vWF) function. Additionally, APAC caused an inhibition of calcium mobilization specific to thrombin and collagen stimulation and a dose-dependent reduction in collagen-mediated platelet aggregation. Understanding the sensitivity of APAC activity to shear rate, platelet signaling and procoagulant pathways is important for applications in which APAC administration may have beneficial therapeutic effects.
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Affiliation(s)
- Jason Chen
- Department of Chemical and Biomolecular Engineering, Institute for Medicine and Engineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher C Verni
- Department of Chemical and Biomolecular Engineering, Institute for Medicine and Engineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Annukka Jouppila
- Helsinki University Central Hospital Research Institute, Helsinki, Finland
| | - Riitta Lassila
- Coagulation Disorders Unit, University of Helsinki, Departments of Hematology and Clinical Chemistry (HUSLAB Laboratory Services), Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland; Aplagon Oy, Helsinki, Finland
| | - Scott L Diamond
- Department of Chemical and Biomolecular Engineering, Institute for Medicine and Engineering, University of Pennsylvania, Philadelphia, PA, USA.
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14
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Hu C, Zhang X, Liu Y, Gao Y, Zhao X, Zhou H, Luo Y, Liu Y, Wang X. Vasodilator-stimulated phosphoprotein-guided Clopidogrel maintenance therapy reduces cardiovascular events in atrial fibrillation patients requiring anticoagulation therapy and scheduled for percutaneous coronary intervention: a prospective cohort study. BMC Cardiovasc Disord 2018; 18:120. [PMID: 29914380 PMCID: PMC6006722 DOI: 10.1186/s12872-018-0853-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 05/31/2018] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND In a previous study, we found that titrating clopidogrel maintenance doses (MDs) according to vasodilator-stimulated phosphoprotein (VASP) monitoring minimised the rate of major adverse cardiovascular and cerebral events (MACCE) after percutaneous coronary intervention (PCI) without increasing bleeding in patients with high on-treatment platelet reaction to clopidogrel. This study aimed to investigate whether VASP-guided clopidogrel MD could reduce thromboembolism and bleeding in atrial fibrillation (AF) patients requiring anticoagulation and scheduled for PCI. METHODS AF patients scheduled for PCI were recruited between July 2014 and July 2016. These patients were allocated into VASP-guided (n = 250) and control (n = 253) groups depending on the clopidogrel MD profile. In the VASP-guided group, clopidogrel MD was titrated by the platelet reactivity index (PRI), whereas in the control group, clopidogrel MD was fixed at 75 mg per day. The primary endpoint was MACCE and secondary endpoints were thrombolysis in myocardial infarction (TIMI) major and minor bleeding 1 year after PCI. RESULTS Five hundred and three patients were included in the present study, with 1-year data available for 95.6% patients. The average CHA2DS2-VASc score of the whole population was 3.7 ± 0.7 and the average HAS-BLED score was 3.2 ± 0.4. MACCE was less in the VASP-guided group than in the control group (2.5% vs. 5.0%, P = 0.02). The incidence of major bleeding was comparable between both groups (3.0% vs. 2.8%, P = 0.72) and minor bleeding was higher in the VASP-guided group than in the control group (15.3% vs. 9.7%, P = 0.03). Kaplan-Meier analysis indicated that there was no difference in survival between both groups (log-rank test, P = 0.68). CONCLUSIONS In AF patients requiring anticoagulation and scheduled for PCI, VASP-guided antiplatelet therapy reduced major cardiovascular and cerebral adverse events, accompanied by increased minor bleeding events. TRIAL REGISTRATION The present study was retrospectively registered in the Chinese Clinical Trial Registry, A Primary Registry of the International Clinical Trial Registry Platform, World Health Organisation (Registration no: ChiCTR-IOR-17013854 ). The registered date was December 11, 2117.
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Affiliation(s)
- Chaoyue Hu
- Key Laboratory of Arrhythmias of the Ministry of Education of China, Tongji University School of Medicine, Shanghai, 200092 China
| | - Xumin Zhang
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Shanghai, 200120 China
| | - Yonghua Liu
- Cardiovascular Medicine of Baoshan People’s Hospital of Yunnan Province, Baoshan, 678000 China
| | - Yang Gao
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Shanghai, 200120 China
| | - Xiaohong Zhao
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Shanghai, 200120 China
| | - Hua Zhou
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Shanghai, 200120 China
| | - Yu Luo
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Shanghai, 200120 China
| | - Yaling Liu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, 160 Pujian Road, Shanghai, 200127 China
| | - Xiaodong Wang
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Shanghai, 200120 China
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15
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Abegaz TM, Birru EM, Mekonnen GB. Potentially inappropriate prescribing in Ethiopian geriatric patients hospitalized with cardiovascular disorders using START/STOPP criteria. PLoS One 2018; 13:e0195949. [PMID: 29723249 PMCID: PMC5933717 DOI: 10.1371/journal.pone.0195949] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 04/03/2018] [Indexed: 12/18/2022] Open
Abstract
Background There was a paucity of data on the magnitude of potentially inappropriate prescriptions (PIPs) among Ethiopian elderly cardiovascular patients. Objective The aim of this study was to assess PIPs and associated factors in the elderly population with cardiovascular disorders using the START/STOPP screening criteria. Methods A hospital-based cross-sectional study was conducted at medical wards of a teaching hospital in Ethiopia from 1 December 2016–30 May 2017. Included patients were hospitalized elderly patients aged 65 years or older with cardiovascular disorders; their medications were evaluated using the START/STOPP screening criteria from admission to discharge. Multivariable logistic regression was applied to identify factors associated with inappropriate medications. One Way Analysis Of Variance (ANOVA) was carried out to test significant differences on the number of PIPs per individual diagnosis. Results Two hundred thirty-nine patients were included in the analysis. More-than a third of the patients were diagnosed with heart failure, 88 (36.82%). A total of 221 PIPs were identified in 147 patients, resulting in PIP prevalence of 61.5% in the elderly population. Of the total number of PIPs, occurrence of one, two and three PIPs accounted for 83 (56.4%), 52(35.4%), and 12(8.2%) respectively. One way ANOVA test showed significant differences on the mean number of PIPs per individual diagnosis (f = 5.718, p<0.001). Angiotensin Converting Enzyme Inhibitors (ACEIs) were the most common inappropriately prescribed medications, 32(14.5%). Hospital stay, AOR: 1.086 (1.016–1.160), number of medications at discharge, AOR: 1.924 (1.217–3.041) and the presence of co-morbidities, AOR: 3.127 (1.706–5.733) increased the likelihood of PIP. Conclusion Approximately, two-thirds of elderly cardiovascular patients encountered potentially inappropriate prescriptions. ACEIs were the most commonly mis-prescribed medications. Longer hospital stay, presence of comorbidities and prescription of large number of medications at discharge have been correlated with the occurrence of inappropriate medication. It is essential to evaluate patients’ medications during hospital stay using the STOPP and START tool to reduce PIPs.
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Affiliation(s)
- Tadesse Melaku Abegaz
- Department of clinical pharmacy, school of pharmacy, college of medicine and health sciences, university of Gondar, Gondar, Ethiopia
- * E-mail:
| | - Eshetie Melese Birru
- Department of pharmacology, school of pharmacy, college of medicine and health sciences, university of Gondar, Gondar, Ethiopia
| | - Gashaw Binega Mekonnen
- Department of clinical pharmacy, school of pharmacy, college of medicine and health sciences, university of Gondar, Gondar, Ethiopia
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16
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Meta-Analysis Comparing the Safety and Efficacy of Dual Versus Triple Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Am J Cardiol 2018; 121:718-724. [PMID: 29373105 DOI: 10.1016/j.amjcard.2017.12.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/03/2017] [Accepted: 12/07/2017] [Indexed: 11/22/2022]
Abstract
In patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI), the effectiveness and safety of dual compared with triple antithrombotic therapy are a matter of debate, especially when considering the prevention of end points at low incidence, such as myocardial infarction (MI), stent thrombosis, or mortality. This study-level meta-analysis included 4 controlled randomized trials and 6,036 patients with a clinical indication to chronic oral anticoagulation (OAC) after PCI, mainly for atrial fibrillation. Patients receiving dual therapy with a single antiplatelet agent, essentially a P2Y12 inhibitor, plus OAC were compared with those treated with triple therapy (aspirin, a P2Y12 inhibitor, and OAC). The incidence of the following outcomes was evaluated: Thrombolysis In Myocardial Infarction major and minor bleeding, MI, stent thrombosis, stroke, cardiovascular, and all-cause death. Occurrence of Thrombolysis In Myocardial Infarction major bleeding was significantly lower in patients treated with dual therapy: 1.97% versus 3.53% in those on triple therapy (odds ratios 0.55, 95% confidence interval 0.39 to 0.78, p = 0.0007); rates of minor bleeding were also decreased in the former (57% relative reduction). With dual therapy, there was not a statistically significant difference in all-cause and cardiovascular mortality (3.81% vs 4.01%, p = 0.37 and 1.62% vs 2.02%, p = 0.42, respectively). Incidence of MI (3.25% vs 2.78%, p = 0.61), definite stent thrombosis (0.92% vs 0.66%, p = 0.46), and stroke (1.28% vs 1.32%, p = 0.85) was similar in the 2 treatment strategies. In patients with long-term indication to OAC after PCI, compared with triple therapy, dual antithrombotic therapy reduces bleeding, without an excess in thromboembolic and ischemic cardiac events.
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Splicing of platelet resident pre-mRNAs upon activation by physiological stimuli results in functionally relevant proteome modifications. Sci Rep 2018; 8:498. [PMID: 29323256 PMCID: PMC5765118 DOI: 10.1038/s41598-017-18985-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 12/19/2017] [Indexed: 12/12/2022] Open
Abstract
Platelet activation triggers thrombus formation in physiological and pathological conditions, such as acute coronary syndromes. Current therapies still fail to prevent thrombotic events in numerous patients, indicating that the mechanisms modulating platelet response during activation need to be clarified. The evidence that platelets are capable of de novo protein synthesis in response to stimuli raised the issue of how megakaryocyte-derived mRNAs are regulated in these anucleate cell fragments. Proteogenomics was applied here to investigate this phenomeon in platelets activated in vitro with Collagen or Thrombin Receptor Activating Peptide. Combining proteomics and transcriptomics allowed in depth platelet proteome characterization, revealing a significant effect of either stimulus on proteome composition. In silico analysis revealed the presence of resident immature RNAs in resting platelets, characterized by retained introns, while unbiased proteogenomics correlated intron removal by RNA splicing with changes on proteome composition upon activation. This allowed identification of a set of transcripts undergoing maturation by intron removal during activation and resulting in accumulation of the corresponding peptides at exon-exon junctions. These results indicate that RNA splicing events occur in platelets during activation and that maturation of specific pre-mRNAs is part of the activation cascade, contributing to a dynamic fine-tuning of the transcriptome.
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Diener HC, Hohnloser SH. Dabigatran for stroke prevention in atrial fibrillation. Hamostaseologie 2017; 32:216-20. [DOI: 10.5482/ha-1196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 06/04/2012] [Indexed: 02/02/2023] Open
Abstract
SummaryDabigatran is a novel direct thrombin inhibitor that has recently been approved for primary and secondary stroke prevention and prevention of systemic embolism in patients with atrial fibrillation. In the pivotal RE-LY study, dabigatran 110 mg BID was demonstrated to be associated with a stroke rate similar to that observed with warfarin (INR target 2.0 to 3.0), but with a lower rate of major haemorrhage. Dabigatran administered at a dose of 150 mg BID was significantly more effective in stroke prevention than warfarin and showed a similar rate of major hemorrhages. Of note, both dosages resulted in an approximately 60–70% relative risk reduction of haemorrhagic stroke. The dosage of 110 mg BID should be preferably used in patients aged 75–80 years or older as the rate of extracranial bleeding events tends to increase with dabigatran 150 mg BID above this age limit. In RE-LY, myocardial infarcts occurred at a very low incidence. There were numerically more myocardial infarcts in dabigatran-treated patients than in warfarin patients; however, other myocardial ischaemic events were similar in the three treatment arms.
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Angiolillo DJ, Goodman SG, Bhatt DL, Eikelboom JW, Price MJ, Moliterno DJ, Cannon CP, Tanguay JF, Granger CB, Mauri L, Holmes DR, Gibson CM, Faxon DP. Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A North American Perspective-2016 Update. Circ Cardiovasc Interv 2017; 9:CIRCINTERVENTIONS.116.004395. [PMID: 27803042 DOI: 10.1161/circinterventions.116.004395] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The optimal antithrombotic treatment regimen for patients with atrial fibrillation undergoing percutaneous coronary intervention with stent implantation is an emerging clinical problem. Currently, there is limited evidenced-based data on the optimal antithrombotic treatment regimen, including antiplatelet and anticoagulant therapies, for these high-risk patients with practice guidelines, thus, providing limited recommendations. Over the past years, expert consensus documents have provided guidance to clinicians on how to manage patients with atrial fibrillation undergoing percutaneous coronary intervention. Given the recent advancements in the field, the current document provides an updated opinion of selected North American experts from the United States and Canada on the treatment of patients with atrial fibrillation undergoing percutaneous coronary intervention. In particular, this document provides the current views on (1) embolic/stroke risk, (2) ischemic/thrombotic cardiac risk, and (3) bleeding risk, which are pivotal for discerning the choice of antithrombotic therapy. In addition, we describe the recent advances in pharmacology, stent designs, and clinical trials relevant to the field. Ultimately, we provide expert consensus-derived recommendations, using a pragmatic approach, on the management of patients with atrial fibrillation undergoing percutaneous coronary intervention.
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Affiliation(s)
- Dominick J Angiolillo
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.).
| | - Shaun G Goodman
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Deepak L Bhatt
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - John W Eikelboom
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Matthew J Price
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - David J Moliterno
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Christopher P Cannon
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Jean-Francois Tanguay
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Christopher B Granger
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Laura Mauri
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - David R Holmes
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - C Michael Gibson
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - David P Faxon
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
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Patti G, Rubboli A. Antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting: Suggested strategies tailored to an integrated evaluation of different risk profiles. Eur J Intern Med 2017; 41:e10-e11. [PMID: 28365223 DOI: 10.1016/j.ejim.2017.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 03/24/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Giuseppe Patti
- Unit of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Italy.
| | - Andrea Rubboli
- Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Bologna, Italy
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Pelliccia F, Rollini F, Marazzi G, Greco C, Gaudio C, Angiolillo DJ, Rosano G. New oral anticoagulants and dual antiplatelet therapy: Focus on apixaban. Int J Cardiol 2016; 225:154-158. [PMID: 27723533 DOI: 10.1016/j.ijcard.2016.09.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 09/28/2016] [Accepted: 09/30/2016] [Indexed: 10/20/2022]
Abstract
The combination of AF and coronary artery disease not only is a common clinical setting, it is also a complex setting to deal with anticoagulation and antiplatelet therapy, and it is associated with significantly higher mortality rates. Unfortunately, there are no sufficient data available to optimally guide clinical practice in such settings. This review focuses specifically on newer oral anticoagulants (NOACs) associated with dual antiplatelet therapy (DAPT) in patients with coronary artery disease undergoing percutaneous coronary intervention (PCI). There are no randomized studies comparing vitamin K antagonists and NOACs in patients with AF undergoing PCI either for acute coronary syndromes or for stable patients, i.e. those patients who have an indication to receive DAPT. Moreover, new antiplatelet agents such as ticagrelor and prasugrel have entered the market for acute coronary syndromes. So far, there are no large-scale randomized studies published evaluating these newer antiplatelet agents in patients with AF receiving either vitamin K antagonists or NOACs, adding to the uncertainty on how to use these antithrombotics in combination when both coronary artery disease (unstable or stable patients) and AF converge in a given patient. The lack of large outcome trials and the large number of possible combinations are reflected in the wide variety of practices in the real world. To date, given the lack of data, watchfulness when using NOACs as component of DAPT or triple oral antithrombotic therapy is warranted.
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Affiliation(s)
| | - Fabiana Rollini
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, United States
| | | | - Cesare Greco
- Department 'Attilio Reale', Sapienza University, Rome, Italy
| | - Carlo Gaudio
- Department 'Attilio Reale', Sapienza University, Rome, Italy; Eleonora Lorillard Spencer Cenci Foundation, Rome, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Giuseppe Rosano
- IRCCS San Raffaele Pisana, Rome, Italy; Cardiovascular and Cell Sciences Research Institute, St. George's, University of London, London, UK
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22
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Yost GW, Steinhubl SR. Monitoring and Reversal of Anticoagulation and Antiplatelet Agents. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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23
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Sra S, Tan MK, Mehta SR, Fisher HN, Déry JP, Welsh RC, Eisenberg MJ, Overgaard CB, Rose BF, Siega AJD, Cheema AN, Wong BYL, Henderson MA, Lutchmedial S, Lavi S, Goodman SG, Yan AT. Ischemic and bleeding events in patients with myocardial infarction undergoing percutaneous coronary intervention who require oral anticoagulation: Insights from the Canadian observational AntiPlatelet sTudy. Am Heart J 2016; 180:82-9. [PMID: 27659886 DOI: 10.1016/j.ahj.2016.07.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 07/30/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Since the introduction of newer, more potent P2Y12 receptor inhibitors (P2Y12ris), practice patterns and associated clinical outcomes in patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI) and also requiring oral anticoagulation (OAC) have not been fully characterized. METHODS The Canadian Observational Antiplatelet Study was a prospective, multicenter, longitudinal, observational study (26 hospitals, December 2011 to May 2013) describing P2Y12ri treatment patterns and outcomes in patients with ST-elevation and non-ST-elevation MI undergoing PCI. We describe the clinical characteristics, treatment patterns, bleeding, and ischemic outcomes over the 15-month follow-up within and between the subgroups of patients discharged on either dual-antiplatelet therapy (DAPT) (acetyl salicylic acid [ASA]+P2Y12ri) or triple therapy (ASA+P2Y12ri+OAC). RESULTS Of the 2,034 patients at discharge, 86% (n = 1,757) were on DAPT, whereas 14% (n = 277) were on triple therapy (50% warfarin, 50% non-vitamin K OAC [NOAC]). The frequency of newer P2Y12ri use (prasugrel or ticagrelor) was similar in the DAPT and triple therapy groups (28% vs 26%, respectively). In the triple therapy group, NOAC use was higher in those receiving a new P2Y12ri compared to those receiving clopidogrel (75% vs 41%, respectively, P < .0001). The unadjusted and adjusted events of major cardiovascular event (MACE) and bleeding were higher in the triple therapy group. For patients on triple therapy, the bleeding or MACE events were not significantly different between those on clopidogrel versus those on ticagrelor or prasugrel. CONCLUSION In this observational study of MI patients requiring PCI, 1 in 8 were discharged on triple antithrombotic therapy, of whom 26% were on newer P2Y12ris. Patients on triple therapy had higher risk at baseline, with higher unadjusted and adjusted MACE and bleeding events compared to those on DAPT alone. Among triple therapy-treated patients, there was no difference in the MACE and bleeding events regardless of the P2Y12ri used.
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Affiliation(s)
- Steven Sra
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mary K Tan
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Shamir R Mehta
- Population Health Research Institute, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | | | - Jean-Pierre Déry
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Quebec, Canada
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Canadian VIGOUR Centre, Edmonton, Alberta, Canada
| | - Mark J Eisenberg
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Christopher B Overgaard
- University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Barry F Rose
- Eastern Health, Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Anthony J Della Siega
- Royal Jubilee Hospital and Victoria Heart Institute, Victoria, British Columbia, Canada
| | - Asim N Cheema
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Mark A Henderson
- Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ontario, Canada
| | - Sohrab Lutchmedial
- New Brunswick Heart Centre, CardioVascular Research NB, Saint John, New Brunswick, Canada
| | - Shahar Lavi
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Shaun G Goodman
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Heart Research Centre, Toronto, Ontario, Canada.
| | - Andrew T Yan
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Ain QU, Khan H, Mubarak MS, Pervaiz A. Plant Alkaloids as Antiplatelet Agent: Drugs of the Future in the Light of Recent Developments. Front Pharmacol 2016; 7:292. [PMID: 27713699 PMCID: PMC5032615 DOI: 10.3389/fphar.2016.00292] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/22/2016] [Indexed: 11/13/2022] Open
Abstract
An alkaloid is a class of naturally occurring organic nitrogen-containing compounds that are frequently found in the plant kingdom. Many alkaloids are valuable medicinal agents that can be utilized to treat various diseases including malaria, diabetics, cancer, cardiac dysfunction etc. Similarly, platelet aggregation beyond the purpose of homeostasis is the underlying cause of blood clotting related diseases. This review presents a thorough understanding of alkaloids as antiplatelet agents with a possible mechanism of action based on the literature of the last decade. In addition, this review will address the antiplatelet activity of alkaloids and their medicinal usage as potent antiplatelet agents with a description of structural relationship activity and possible lead compounds for future drug discovery.
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Affiliation(s)
- Qurrat-Ul- Ain
- Department of Pharmacy, Abdul Wali Khan University Mardan Mardan, Pakistan
| | - Haroon Khan
- Department of Pharmacy, Abdul Wali Khan University Mardan Mardan, Pakistan
| | | | - Aini Pervaiz
- Department of Pharmacy, Abdul Wali Khan University Mardan Mardan, Pakistan
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Uhl E, Donati A, Reviakine I. Platelet Immobilization on Supported Phospholipid Bilayers for Single Platelet Studies. LANGMUIR : THE ACS JOURNAL OF SURFACES AND COLLOIDS 2016; 32:8516-8524. [PMID: 27438059 DOI: 10.1021/acs.langmuir.6b01852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The worldwide cardiovascular disease (CVD) epidemic is of grave concern. A major role in the etiology of CVDs is played by the platelets (thrombocytes). Platelets are anuclear cell fragments circulating in the blood. Their primary function is to catalyze clot formation, limiting traumatic blood loss in the case of injury. The same process leads to thrombosis in the case of CVDs, which are commonly managed with antiplatelet therapy. Platelets also have other, nonhemostatic functions in wound healing, inflammation, and tissue regeneration. They play a role in the early stages of atherosclerosis and the spread of cancer through metastases. Much remains to be learned about the regulation of these diverse platelet functions under physiological and pathological conditions. Breakthroughs in this regard are expected to come from single platelet studies and systems approaches. The immobilization of platelets at surfaces is advantageous for developing such approaches, but platelets are activated when they come in contact with foreign surfaces. In this work, we develop and validate a protocol for immobilizing platelets on supported lipid bilayers without activation due to immobilization. Our protocol can therefore be used for studying platelets with a wide variety of surface-sensitive techniques.
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Affiliation(s)
- Eva Uhl
- Institute of Functional Interfaces (IFG), Karlsruhe Institute of Technology (KIT) , Hermann-von-Helmholtz-Platz 1, 76344 Eggenstein-Leopoldshafen, Germany
| | - Alessia Donati
- Institute of Functional Interfaces (IFG), Karlsruhe Institute of Technology (KIT) , Hermann-von-Helmholtz-Platz 1, 76344 Eggenstein-Leopoldshafen, Germany
| | - Ilya Reviakine
- Institute of Functional Interfaces (IFG), Karlsruhe Institute of Technology (KIT) , Hermann-von-Helmholtz-Platz 1, 76344 Eggenstein-Leopoldshafen, Germany
- Department of Bioengineering, University of Washington , Seattle, Washington 98105, United States
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Reviakine I, Jung F, Braune S, Brash JL, Latour R, Gorbet M, van Oeveren W. Stirred, shaken, or stagnant: What goes on at the blood-biomaterial interface. Blood Rev 2016; 31:11-21. [PMID: 27478147 DOI: 10.1016/j.blre.2016.07.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 07/08/2016] [Accepted: 07/12/2016] [Indexed: 01/15/2023]
Abstract
There is a widely recognized need to improve the performance of vascular implants and external medical devices that come into contact with blood by reducing adverse reactions they cause, such as thrombosis and inflammation. These reactions lead to major adverse cardiovascular events such as heart attacks and strokes. Currently, they are managed therapeutically. This need remains unmet by the biomaterials research community. Recognized stagnation of the blood-biomaterial interface research translates into waning interest from clinicians, funding agencies, and practitioners of adjacent fields. The purpose of this contribution is to stir things up. It follows the 2014 BloodSurf meeting (74th International IUVSTA Workshop on Blood-Biomaterial Interactions), offers reflections on the situation in the field, and a three-pronged strategy integrating different perspectives on the biological mechanisms underlying blood-biomaterial interactions. The success of this strategy depends on reengaging clinicians and on the renewed cooperation of the funding agencies to support long-term efforts.
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Affiliation(s)
- Ilya Reviakine
- Institute of Functional Interfaces (IFG), Karlsruhe Institute of Technology (KIT), Hermann von Helmholtz Platz 1, 76344 Eggenstein-Leopoldshafen, Germany; Department of Bioengineering, University of Washington, Seattle, WA 98105, USA.
| | - Friedrich Jung
- Institute of Biomaterial Science and Berlin-Brandenburg Centre for Regenerative Therapies (BCRT), Helmholtz Zentrum Geesthacht, Kantstrasse 55, 14513 Teltow, Germany
| | - Steffen Braune
- Institute of Biomaterial Science and Berlin-Brandenburg Centre for Regenerative Therapies (BCRT), Helmholtz Zentrum Geesthacht, Kantstrasse 55, 14513 Teltow, Germany
| | - John L Brash
- Department of Chemical Engineering, School of Biomedical Engineering, McMaster University, Hamilton, Ontario, L8S 4L8, Canada
| | - Robert Latour
- Rhodes Engineering Research Center, Department of Bioengineering, Clemson University, Clemson, SC 29634, USA
| | - Maud Gorbet
- Department of Systems Design Engineering, Biomedical Engineering, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada
| | - Wim van Oeveren
- HaemoScan, Stavangerweg 23-23, 9723JC Groningen, The Netherlands
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Koskinas KC, Räber L, Zanchin T, Pilgrim T, Stortecky S, Hunziker L, Blöchlinger S, Billinger M, Gartwyl F, Moro C, Moschovitis A, Jüni P, Heg D, Windecker S. Duration of Triple Antithrombotic Therapy and Outcomes Among Patients Undergoing Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2016; 9:1473-83. [DOI: 10.1016/j.jcin.2016.04.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/30/2016] [Accepted: 04/21/2016] [Indexed: 12/22/2022]
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Patti G, Cavallari I. Patients with atrial fibrillation and CHA2DS2-VASc score 1: “To anticoagulate or not to anticoagulate? That is the question!”. Heart Rhythm 2015; 12:2515-20. [DOI: 10.1016/j.hrthm.2015.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Indexed: 10/23/2022]
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30
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Jackson LR, Ju C, Zettler M, Messenger JC, Cohen DJ, Stone GW, Baker BA, Effron M, Peterson ED, Wang TY. Outcomes of Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention Receiving an Oral Anticoagulant and Dual Antiplatelet Therapy. JACC Cardiovasc Interv 2015; 8:1880-9. [DOI: 10.1016/j.jcin.2015.08.018] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 08/13/2015] [Indexed: 10/22/2022]
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Susen S, Rauch A, Van Belle E, Vincentelli A, Lenting PJ. Circulatory support devices: fundamental aspects and clinical management of bleeding and thrombosis. J Thromb Haemost 2015; 13:1757-67. [PMID: 26302994 DOI: 10.1111/jth.13120] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/02/2015] [Indexed: 12/01/2022]
Abstract
Circulatory support devices are increasingly being used to overcome cardiac or respiratory failure. Long-term devices are used either as a 'bridge to transplant' to support patients who are unable to wait any longer for a heart transplant, or, more recently, as 'destination therapy' for older patients suffering from end-stage heart failure and who have contraindications to heart transplantation. Short-term support devices for high-risk percutaneous coronary intervention, or as a 'bridge for decision' for patients suffering from refractory cardiogenic shock, have also been developed. The clinical benefit of such assist devices has been demonstrated in several important studies, but, unfortunately, thrombotic and bleeding complications are two major clinical issues in patients requiring these devices. Overcoming these issues is of major importance to allow the safe and broad use of these devices, and to consider them as true alternatives to heart transplantation. The present review focuses on thrombotic and bleeding complications, and describes how the risk of thrombosis and bleeding may vary according to the clinical indication, but also according to the type of device. We describe the current knowledge of the mechanisms underlying the occurrence of these complications, provide some guidance for choosing the most appropriate anticoagulation regimen to prevent their occurrence for each type of device and indication, and provide some recommendations for the management of patients when the complication occurs.
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Affiliation(s)
- S Susen
- Department of Hematology and Transfusion, Lille University Hospital, Lille, France
- Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France
| | - A Rauch
- Department of Hematology and Transfusion, Lille University Hospital, Lille, France
- Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France
| | - E Van Belle
- Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France
- Department of Cardiology, Lille University Hospital, Lille, France
| | - A Vincentelli
- Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France
- Department of Cardiology, Lille University Hospital, Lille, France
- Department of Cardiac Surgery, Lille University Hospital, Lille, France
| | - P J Lenting
- Inserm U1176 & UMR_S 1176, University Paris-Sud, Le Kremlin Bicêtre, France
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Hess CN, Peterson ED, Peng SA, de Lemos JA, Fosbol EL, Thomas L, Bhatt DL, Saucedo JF, Wang TY. Use and Outcomes of Triple Therapy Among Older Patients With Acute Myocardial Infarction and Atrial Fibrillation. J Am Coll Cardiol 2015; 66:616-27. [DOI: 10.1016/j.jacc.2015.05.062] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 05/28/2015] [Accepted: 05/29/2015] [Indexed: 10/23/2022]
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Reviakine I. New horizons in platelet research: Understanding and harnessing platelet functional diversity. Clin Hemorheol Microcirc 2015; 60:133-52. [DOI: 10.3233/ch-151942] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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A clinical and pharmacologic assessment of once-daily versus twice-daily dosing for rivaroxaban. J Thromb Thrombolysis 2015; 38:137-49. [PMID: 24293106 DOI: 10.1007/s11239-013-1029-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Altering doses and regimens of a drug has consequences for the drug's pharmacokinetic and pharmacodynamic profile. Based on a half-life of 5-13 h, it is expected that the Factor Xa inhibitor rivaroxaban would be best suited to a twice-daily rather than a once-daily dose regimen. However, although rivaroxaban is used as a twice-daily regimen for the initial treatment of venous thromboembolism (VTE) and secondary prevention after acute coronary syndromes, the approved dosing is once-daily for prevention of VTE after orthopaedic surgery, long-term secondary prevention of VTE and stroke prevention in patients with non-valvular atrial fibrillation. Rivaroxaban dosing was based on the evaluation of the efficacy and safety of several rivaroxaban doses and regimens in phase II trials. A clear overall advantage of twice-daily dosing compared with once-daily dosing was not documented for indications for which once-daily dosing was subsequently selected. Once-daily dosing was therefore selected for these indications because it is expected to be associated with better compliance than twice-daily dosing, and potentially, with improved outcomes. These studies and data obtained with another Factor Xa inhibitor, edoxaban, in addition to previous experience with low molecular weight heparins, indicate that the clinical impact of once-daily versus twice-daily doses on outcome in terms of efficacy and safety cannot be reliably predicted from pharmacology data, e.g. elimination half-life, obtained during pre-clinical and early phase I clinical studies but rather should be ascertained empirically in phase II and III clinical trials.
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Simsekyilmaz S, Liehn EA, Militaru C, Vogt F. Progress in interventional cardiology: challenges for the future. Thromb Haemost 2015; 113:464-72. [PMID: 25608683 DOI: 10.1160/th14-07-0599] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 12/10/2014] [Indexed: 01/11/2023]
Abstract
Cardiovascular disease is the leading cause of death in the western and developing countries. Percutaneous transluminal coronary interventions have become the most prevalent treatment option for coronary artery disease; however, due to serious complications, such as stent thrombosis and in-stent restenosis (ISR), the efficacy and safety of the procedure remain important issues to address. Strategies to overcome these aspects are under extensive investigation. In this review, we summarise relevant milestones during the time to overcome these limitations of coronary stents, such as the development of polymer-free drug-eluting stents (DES) to avoid pro-inflammatory response due to the polymer coating or the developement of stents with cell-directing drugs to, simultaneously, improve re-endothelialisation and inhibit ISR amongst other techniques most recently developed, which have not fully entered the clinical stage. Also the novel concept of fully biodegradable DES featured by the lack of a permanent foreign body promises to be a beneficial and applicable tool to restore a natural vessel with maintained vasomotion and to enable optional subsequent surgical revascularisation.
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Affiliation(s)
| | | | | | - Felix Vogt
- Felix Vogt, MD, Department of Cardiology, Pulmonology, Intensive Care and Vascular Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany, Tel.: +49 241 80 35525, Fax: +49 241 80 82716, E-mail:
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Braun OÖ, Bico B, Chaudhry U, Wagner H, Koul S, Tydén P, Scherstén F, Jovinge S, Svensson PJ, Gustav Smith J, van der Pals J. Concomitant use of warfarin and ticagrelor as an alternative to triple antithrombotic therapy after an acute coronary syndrome. Thromb Res 2015; 135:26-30. [DOI: 10.1016/j.thromres.2014.10.016] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 10/01/2014] [Accepted: 10/13/2014] [Indexed: 01/19/2023]
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Combined low-dose aspirin and warfarin anticoagulant therapy of postoperative atrial fibrillation following mechanical heart valve replacement. ACTA ACUST UNITED AC 2014; 34:902-906. [DOI: 10.1007/s11596-014-1371-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 10/18/2014] [Indexed: 10/24/2022]
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Miller S, Nitzki-George D, Caprini JA. Balancing the risk of complications in foot and ankle surgical patients taking antithrombotic medication. Foot Ankle Spec 2014; 7:507-14. [PMID: 25053792 DOI: 10.1177/1938640014543356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
UNLABELLED This review intends to provide guidance regarding perioperative management of anticoagulation and antiplatelet drug therapy as they relate to foot and ankle surgery. Venous and arterial thromboembolism are conditions in which the blood clots inappropriately, causing considerable morbidity and mortality. With an increase in awareness of thromboembolic risk factors and expansion of therapeutic options, more patients are routinely taking antithrombotic medication. When these patients require invasive procedures, a decision needs to be made if antithrombotic medication should be held perioperatively and if additional precautions are needed in the interim. Understanding the factors affecting the management of thromboembolism during the perioperative period can reduce the potential for complications. LEVELS OF EVIDENCE Therapeutic, Level V: Expert opinion.
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Affiliation(s)
- Steven Miller
- Skokie Foot & Ankle Specialists, Skokie, Illinois (SM)Thrombosis and Anticoagulation Unit of Glenbrook Hospital, NorthShore University HealthSystem, Glenview, Illinois (DNG)Division of Vascular Surgery, NorthShore University HealthSystem, Evanston, Illinois (JAC)
| | - Diane Nitzki-George
- Skokie Foot & Ankle Specialists, Skokie, Illinois (SM)Thrombosis and Anticoagulation Unit of Glenbrook Hospital, NorthShore University HealthSystem, Glenview, Illinois (DNG)Division of Vascular Surgery, NorthShore University HealthSystem, Evanston, Illinois (JAC)
| | - Joseph A Caprini
- Skokie Foot & Ankle Specialists, Skokie, Illinois (SM)Thrombosis and Anticoagulation Unit of Glenbrook Hospital, NorthShore University HealthSystem, Glenview, Illinois (DNG)Division of Vascular Surgery, NorthShore University HealthSystem, Evanston, Illinois (JAC)
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De Luca L, Bolognese L, Valgimigli M, Ceravolo R, Danzi GB, Piccaluga E, Rakar S, Cremonesi A, Bovenzi FM, Abbate R, Andreotti F, Bolognese L, Biondi-Zoccai G, Bovenzi FM, Capodanno D, Caporale R, Capranzano P, Carrabba N, Casella G, Cavallini C, Ceravolo R, Colombo P, Conte MR, Cordone S, Cremonesi A, Danzi GB, Del Pinto M, De Luca G, De Luca L, De Servi S, Di Lorenzo E, Di Pasquale G, Esposito G, Farina R, Fiscella A, Formigli D, Galli S, Giudice P, Gonzi G, Greco C, Grieco NB, La Vecchia L, Lazzari M, Lettieri C, Lettino M, Limbruno U, Lupi A, Macchi A, Marini M, Marzilli M, Montinaro A, Musumeci G, Navazio A, Olivari Z, Oltrona Visconti L, Oreglia JA, Ottani F, Parodi G, Pasquetto G, Patti G, Perkan A, Perna GP, Piccaluga E, Piscione F, Prati F, Rakar S, Ravasio R, Ronco F, Rossini R, Rubboli A, Saia F, Sardella G, Satullo G, Savonitto S, Sbarzaglia P, Scorcu G, Signore N, Tarantini G, Terrosu P, Testa L, Tubaro M, Valente S, Valgimigli M, Varbella F, Vatrano M. ANMCO/SICI-GISE paper on antiplatelet therapy in acute coronary syndrome. Eur Heart J Suppl 2014. [DOI: 10.1093/eurheartj/suu030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Camuglia AC, Waddell-Smith KE, Hammett CJ, Aylward PE. The potential role of anticoagulant therapy for the secondary prevention of ischemic events post-acute coronary syndrome. Curr Med Res Opin 2014; 30:2151-67. [PMID: 25140867 DOI: 10.1185/03007995.2014.949647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract The use of dual antiplatelet therapy has led to a substantial reduction in ischemic events post-acute coronary syndrome (ACS). Despite this, recurrent event rates remain high. Recent research has combined antiplatelet with anticoagulant therapy to reduce recurrent event rates further. Compared with standard medical therapy, rivaroxaban demonstrated improved efficacy outcomes and significantly reduced mortality after an ACS. Although clear benefits of novel oral anticoagulants post-ACS have been proven, concerns regarding bleeding are still a barrier to widespread use. This review explores key trials of dual antiplatelet therapy and examines the latest research in anticoagulation aiming to optimize clinical outcomes post-ACS.
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Affiliation(s)
- A C Camuglia
- Royal Brisbane and Women's Hospital and the University of Queensland , Queensland , Australia
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Jaguszewski M, Manes C, Puippe G, Salzberg S, Müller M, Falk V, Lüscher T, Luft A, Alkadhi H, Landmesser U. Cardiac CT and echocardiographic evaluation of peri-device flow after percutaneous left atrial appendage closure using the AMPLATZER cardiac plug device. Catheter Cardiovasc Interv 2014; 85:306-12. [PMID: 25205611 DOI: 10.1002/ccd.25667] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 07/15/2014] [Accepted: 09/06/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The aim of the study was to examine frequency, size, and localization of peri-device leaks after percutaneous left atrial appendage (LAA)-closure with the AMPLATZER-Cardiac-Plug (ACP) by using a multimodal imaging approach, i.e. combined cardiac-CT and TEE follow-up. BACKGROUND Catheter-based LAA-occlusion using ACP aims to reduce the risk of stroke in patients with atrial fibrillation. Detection of peri-device leaks after ACP implantation by TEE is challenging, the few available data are inconsistent and the frequency of LAA leaks after ACP implantation remains therefore unclear. METHODS Cardiac-CT using a multi-phase protocol and a second-generation dual-source-CT-system was performed in 24 patients with non-valvular atrial fibrillation starting 3 months after LAA-closure by ACP. Color Doppler multiplane TEE was used to evaluate peri-device flow. RESULTS Cardiac-CT follow-up detected any persistent LAA contrast filling in 62% of patients (n = 15), but leak-sizes were small (1.5 ± 1.4 mm). Peri-device leaks were almost exclusively localized at the posterior portion of the LAA-orifice (>90%). TEE follow-up revealed peri-device flow in 36% of patients (jet-sizes: ≤ 4 mm). ACP-lobe compression (>10%) and perpendicular ACP-lobe orientation to the LAA-neck axis, that was also dependent on LAA anatomy, were substantially more frequent in patients with complete LAA closure. CONCLUSION The present study evaluates for the first time peri-device flow after LAA closure by ACP using a combined cardiac-CT and TEE follow-up. Persistent LAA-perfusion was frequently detected, leak-sizes were small and were less frequent when lobe compression was >10% and lobe orientation was perpendicular to the LAA-neck axis, that was also related to the LAA anatomy. The clinical significance of these small leaks after LAA-closure using ACP needs to be further evaluated in future studies.
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Affiliation(s)
- Milosz Jaguszewski
- Division of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
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Estudio aleatorizado para comparar el stent bioactivo de titanio con el stent de everolimus en pacientes diabéticos (TITANIC XV), resultados a 1 año. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.10.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Pharmacology, benefits, unaddressed questions, and pragmatic issues of the newer oral anticoagulants for stroke prophylaxis in non-valvular atrial fibrillation and proposal of a management algorithm. Int J Cardiol 2014; 174:471-83. [DOI: 10.1016/j.ijcard.2014.04.179] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 03/06/2014] [Accepted: 04/17/2014] [Indexed: 12/16/2022]
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A randomized study to compare bioactive titanium stents and everolimus-eluting stents in diabetic patients (TITANIC XV): 1-year results. ACTA ACUST UNITED AC 2014; 67:522-30. [PMID: 24952391 DOI: 10.1016/j.rec.2013.10.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 10/22/2013] [Indexed: 10/25/2022]
Abstract
INTRODUCTION AND OBJECTIVES Up to 25% of patients who undergo a percutaneous coronary intervention show some limitation in the use of drug-eluting stents. The aim of this study was to evaluate if titanium-nitride-oxide-coated stents could be a good alternative to everolimus-eluting stents in diabetic patients. METHODS A total of 173 diabetic patients with lesions at moderate risk of restenosis (exclusion criteria: diameter < 2.5 mm or length > 28 mm in vessels < 3mm, chronic occlusion) were randomized to a titanium group (83 patients) or an everolimus group (90 patients). RESULTS Baseline characteristics were well balanced; 28.3% of patients were insulin dependent. At 1 year, the incidence of major adverse cardiac events (death, nonfatal myocardial infarction, stroke, or repeat target vessel revascularization) was significantly higher in the titanium group than in the everolimus group (total, 14.5% vs 4.4%; P = .02; noninsulin-dependent subgroup, 9.7% vs 3.2%; P = .14; insulin-dependent subgroup, 28.6% vs 7.1%; P = .04). The incidence of death, nonfatal myocardial infarction, stroke, or any revascularization was 16.9% in the titanium group and 7.8% in the everolimus group (P = .06). Target lesion and vessel revascularizations occurred in 8.4% compared with 3.3% (P = .15) and in 13.3% compared with 3.3% (P = .01) in the titanium and everolimus groups, respectively. Angiographic follow-up at 9 months showed significantly less late lumen loss in the everolimus group (in-segment, 0.52 [standard deviation, 0.58) mm vs -0.05 [0.32] mm; in-stent, 0.76 [0.54] mm vs 0.13 [0.31] mm; P < .0001). CONCLUSIONS The everolimus-eluting stent is superior to the titanium stent for clinical and angiographic end points in diabetic patients with lesions at moderate risk of restenosis.
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Rationale and design of The Intracoronary Stenting and Antithrombotic Regimen-Testing of a six-week versus a six-month clopidogrel treatment Regimen In Patients with concomitant aspirin and oraL anticoagulant therapy following drug-Eluting stenting (ISAR-TRIPLE) study. Am Heart J 2014; 167:459-465.e1. [PMID: 24655693 DOI: 10.1016/j.ahj.2014.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 01/06/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND An increasing number of patients undergoing coronary stenting need lifelong anticoagulation and therefore require a triple therapy typically consisting of aspirin, clopidogrel, and a vitamin K antagonist. Triple therapy confers an elevated bleeding risk as compared with dual therapy; however, omission of either antiplatelet or anticoagulation therapy might increase the risk of stent thrombosis or thrombembolic events. Although guidelines recommend a duration of dual antiplatelet therapy of 6 to 12months after drug-eluting stent (DES) implantation, the optimal duration of dual antiplatelet therapy in patients receiving oral anticoagulation is not known. HYPOTHESIS We postulate that 6-week clopidogrel therapy after DES implantation as compared with 6-month therapy is associated with improved clinical outcomes in patients undergoing DES implantation receiving concomitant aspirin and vitamin K antagonists. STUDY DESIGN The ISAR-TRIPLE is a randomized, open-label trial that examines the restriction of clopidogrel therapy from 6 months to 6 weeks after DES implantation in the setting of concomitant aspirin and oral anticoagulant. Patients are randomized in a 1:1 fashion to either 6-week or 6-month clopidogrel therapy. The primary end point is a composite of death, myocardial infarction, definite stent thrombosis, stroke, or major bleeding. The secondary end point comprises ischemic and bleeding complications. According to sample size calculations, a total of 600 patients are required to be enrolled. Clinical follow-up is scheduled at 6 weeks and at 6 and 9 months after randomization. SUMMARY There is clinical equipoise regarding the optimal duration of triple therapy after DES implantation in patients who need vitamin K antagonist therapy. The ISAR-TRIPLE trial aims to test the hypothesis that a 6-week triple therapy compared with a 6-month triple therapy improves net clinical outcomes.
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Gerinnungsmanagement in der Herzchirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2014. [DOI: 10.1007/s00398-013-1064-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Ice DS, Shapiro TA, Gnall EM, Kowey PR. Unanswered questions in patients with concurrent atrial fibrillation and acute coronary syndrome. Am J Cardiol 2014; 113:888-96. [PMID: 24528617 DOI: 10.1016/j.amjcard.2013.11.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 11/14/2013] [Accepted: 11/14/2013] [Indexed: 11/19/2022]
Abstract
The best regimen for the long-term management of patients with atrial fibrillation who present with an acute coronary syndrome or require placement of a coronary stent remains unclear. Clinicians need to understand the risk of stroke, stent thrombosis, and major bleeding associated with treating these patients. Numerous studies and risk assessment schemes provide clinicians with an estimation of the risk of stroke, stent thrombosis, and major bleeding that may be associated with the use or avoidance of dual antiplatelet therapy with concurrent anticoagulation therapy (triple therapy). This review discusses the special antithrombotic needs in patients who have atrial fibrillation and either acute coronary syndrome or a requirement for percutaneous coronary intervention, including the published evidence for non-vitamin K oral anticoagulants, and the unanswered questions in this patient population. In conclusion, until the results of additional ongoing or planned randomized trials are known, clinicians must continue to rely on expert opinion and their own clinical judgment when treating these patients.
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Affiliation(s)
- Daniel S Ice
- Division of Cardiovascular Diseases, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, Jefferson Medical College, Philadelphia, Pennsylvania.
| | - Timothy A Shapiro
- Division of Cardiovascular Diseases, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, Jefferson Medical College, Philadelphia, Pennsylvania
| | - Eric M Gnall
- Division of Cardiovascular Diseases, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, Jefferson Medical College, Philadelphia, Pennsylvania
| | - Peter R Kowey
- Division of Cardiovascular Diseases, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, Jefferson Medical College, Philadelphia, Pennsylvania
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Weber R, Diener HC, Weimar C. Prevention of cardioembolic stroke in patients with atrial fibrillation. Expert Rev Cardiovasc Ther 2014; 8:1405-15. [DOI: 10.1586/erc.10.103] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tilly P, Charles AL, Ludwig S, Slimani F, Gross S, Meilhac O, Geny B, Stefansson K, Gurney ME, Fabre JE. Blocking the EP3 receptor for PGE2 with DG-041 decreases thrombosis without impairing haemostatic competence. Cardiovasc Res 2013; 101:482-91. [PMID: 24323317 DOI: 10.1093/cvr/cvt276] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AIMS Haemostasis interrupts bleeding from disrupted blood vessels by activating platelet aggregation and coagulation. A similar mechanism termed thrombosis generates obstructive thrombi inside diseased arteries. As a consequence of this similarity, current anti-thrombotic agents increase the risk of bleeding. Atherosclerotic plaques produce significant amounts of prostaglandin E2 (PGE2), which activates its receptor EP3 on platelets and aggravates atherothrombosis. We investigated whether blocking EP3 could dissociate atherothrombosis from haemostasis. METHODS AND RESULTS Inhibiting in vivo the receptor EP3 for PGE2 with the blocking agent DG-041 reduced murine thrombosis triggered by local delivery of arachidonic acid or ferric chloride on healthy arteries. Importantly, it also reduced thrombosis triggered by scratching murine atherosclerotic plaques. PGE2 was not produced at the bleeding site after tail clipping. Consistently, blocking EP3 did not alter murine tail, liver, or cerebral haemostasis. Furthermore, blocking EP3 reduced murine pulmonary embolism and intensified platelet inhibition by clopidogrel leaving tail bleeding times unchanged. Human atherosclerotic plaques produced PGE2, which facilitated platelet aggregation in human blood and rescued the function of P2Y12-blocked platelets. Finally, in healthy patients, DG-041 reduced platelet aggregation, but did not significantly alter the cutaneous bleeding time at doses up to eight times the dose that inhibited the facilitating effect of PGE2 on platelets. CONCLUSION In mice, blocking EP3 inhibited atherothrombosis without affecting haemostasis and intensified efficiency of conventional anti-platelet treatment without aggravating the bleeding risk. In patients, blocking EP3 should improve the prevention of cardiovascular diseases, which is currently limited by the risk of bleeding.
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Affiliation(s)
- Peggy Tilly
- Institut de Génétique et de Biologie Moléculaire et Cellulaire, Institut National de la Santé et de la Recherche Médicale U596, Centre National de la Recherche Scientifique UMR7104, Université Louis Pasteur, 67400 Illkirch, France
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