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Khanal R, Hamza M, Najam M, Basit SA, Wajid Z, Rashdi A, Patel N, Razzaq S, Shah R, Harmouch KM, Alyami B, Bahar Y, Aamir M, Abu-Mahfouz M, Sattar Y, Alraies MC. Gender-based disparities in outcomes of coronary bifurcation stenting in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2024; 14:136-143. [PMID: 39021520 PMCID: PMC11249663 DOI: 10.62347/ybjn2231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 05/16/2024] [Indexed: 07/20/2024]
Abstract
INTRODUCTION Around 15-20% of lesions necessitating percutaneous coronary interventions (PCI) are attributed to coronary bifurcation lesions. We aim to study gender-based differences in PCI outcomes among bifurcation stents. METHODS 3 studies were included after thorough systematic search using MEDLINE (EMBASE and PubMed). CRAN-R software using the Metabin module was used for statistical analysis. Pooled odds ratios (OR) were calculated using the random effect model and the Mantel-Haenszel method, with a 95% confidence interval (CI) used to determine statistical significance. Heterogeneity was assessed using Higgins I2. RESULT Women exhibited a higher risk of in-hospital mortality (OR 0.67, 95% CI 0.58-0.76, I2 = 0%, P < 0.0001), post-procedural bleeding (OR 0.53, 95% CI 0.47-0.6, I2 = 0%, P < 0.0001) and post-procedure stroke (OR 0.72, 95% CI 0.52-1.0, I2 = 0%, P < 0.06) as compared to men. However, there were no significant differences in terms of myocardial infarction (OR 0.84, 95% CI 0.22-3.27, I2 = 49.4%, P < 0.80) and cardiac tamponade (OR 0.63, 95% CI 0.06; 5.72, I2 = 0%, P < 0.6821) in both groups. CONCLUSION Our study reveals a noteworthy increase in in-hospital mortality in women, which could be attributed to a higher rate of major bleeding, advanced age, increased co-morbidities, and complex pathophysiology of the lesion in comparison to men. Further studies are required to gain a better understanding of the precise mechanisms thus enhancing procedural outcomes.
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Affiliation(s)
- Resha Khanal
- Department of Internal Medicine, Wayne Health University/Detroit Medical CenterDetroit, MI, USA
| | | | - Maria Najam
- Department of Internal Medicine, University of Texas Rio Grande ValleyWeslaco, TX, USA
| | | | | | | | - Neel Patel
- New York Medical College/Landmark Medical CenterWoonsocket, RI, USA
| | - Saman Razzaq
- Detroit Medical Center/Wayne State UniversityDetroit, MI, USA
| | - Rajendra Shah
- University of Florida/Malcolm Randall Veterans Affairs Medical CenterGainesville, FL, USA
| | | | - Bandar Alyami
- Department of Cardiology, West Virginia UniversityMorgantown, WV, USA
| | | | - Muhammad Aamir
- Department of Cardiology, Lehigh Valley Health NetworkAllentown, PA, USA
| | | | - Yasar Sattar
- Department of Cardiology, West Virginia UniversityMorgantown, WV, USA
| | - M Chadi Alraies
- Cardiovascular Institute, Detroit Medical CenterDetroit, MI, USA
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Medzikovic L, Azem T, Sun W, Rejali P, Esdin L, Rahman S, Dehghanitafti A, Aryan L, Eghbali M. Sex Differences in Therapies against Myocardial Ischemia-Reperfusion Injury: From Basic Science to Clinical Perspectives. Cells 2023; 12:2077. [PMID: 37626887 PMCID: PMC10453147 DOI: 10.3390/cells12162077] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023] Open
Abstract
Mortality from myocardial infarction (MI) has declined over recent decades, which could be attributed in large part to improved treatment methods. Early reperfusion is the cornerstone of current MI treatment. However, reoxygenation via restored blood flow induces further damage to the myocardium, leading to ischemia-reperfusion injury (IRI). While experimental studies overwhelmingly demonstrate that females experience greater functional recovery from MI and decreased severity in the underlying pathophysiological mechanisms, the outcomes of MI with subsequent reperfusion therapy, which is the clinical correlate of myocardial IRI, are generally poorer for women compared with men. Distressingly, women are also reported to benefit less from current guideline-based therapies compared with men. These seemingly contradicting outcomes between experimental and clinical studies show a need for further investigation of sex-based differences in disease pathophysiology, treatment response, and a sex-specific approach in the development of novel therapeutic methods against myocardial IRI. In this literature review, we summarize the current knowledge on sex differences in the underlying pathophysiological mechanisms of myocardial IRI, including the roles of sex hormones and sex chromosomes. Furthermore, we address sex differences in pharmacokinetics, pharmacodynamics, and pharmacogenetics of current drugs prescribed to limit myocardial IRI. Lastly, we highlight ongoing clinical trials assessing novel pharmacological treatments against myocardial IRI and sex differences that may underlie the efficacy of these new therapeutic approaches.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Mansoureh Eghbali
- Department of Anesthesiology & Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Ave, CHS BH-550 CHS, Los Angeles, CA 90095, USA (W.S.)
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3
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Delewi R, Vogel RF, Wilschut JM, Lemmert ME, Diletti R, van Vliet R, van der Waarden NWPL, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Doevendans PA, Van Mieghem NM, Smits PC, Vlachojannis GJ. Sex-stratified differences in early antithrombotic treatment response in patients presenting with ST-segment elevation myocardial infarction. Am Heart J 2023; 258:17-26. [PMID: 36596332 DOI: 10.1016/j.ahj.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 05/11/2023]
Abstract
BACKGROUND The mechanisms underlying the increased risk of bleeding that female patients with ST-segment Elevation Myocardial Infarction (STEMI) exhibit, remains unclear. The present report assessed sex-related differences in response to pre-hospital dual antiplatelet therapy (DAPT) initiation in patients with STEMI. METHODS The COMPARE CRUSH trial randomized patients presenting with STEMI to receive a pre-hospital loading dose of crushed or integral prasugrel tablets in the ambulance. In this substudy, we compared platelet reactivity levels and the occurrence of high platelet reactivity (HPR; defined as platelet reactivity ≥208) between sexes at 4 prespecified time points after DAPT initiation, and evaluated post-PCI bleeding between groups. RESULTS Out of 633 STEMI patients, 147 (23%) were female. Females compared with males presented with significantly higher levels of platelet reactivity and higher HPR rates at baseline (232 [IQR, 209-256] vs 195 [IQR, 171-220], P < .01, and 76% vs 41%, OR 4.58 [95%CI, 2.52-8.32], P < .01, respectively). Moreover, female sex was identified as the sole independent predictor of HPR at baseline (OR 5.67 [95%CI, 2.56-12.53], P < .01). Following DAPT initiation, levels of platelet reactivity and the incidence of HPR were similar between sexes. Post-PCI bleeding occurred more frequently in females compared with males (10% vs 2%, OR 6.02 [95%CI, 2.61-11.87], P < .01). Female sex was an independent predictor of post-PCI bleeding (OR 3.25 [95%CI, 1.09-9.72], P = .04). CONCLUSIONS In this contemporary STEMI cohort, female STEMI patients remain at risk of bleeding complications after primary PCI. However, this is not explained by sex-specific differences in the pharmacodynamic response to pre-hospital DAPT initiation.
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Affiliation(s)
- Ronak Delewi
- Department of cardiology, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | - Rosanne F Vogel
- Department of cardiology, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands; Department of cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jeroen M Wilschut
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Miguel E Lemmert
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of cardiology, Isala Hospital, Zwolle, the Netherlands
| | - Roberto Diletti
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | - Rutger-Jan Nuis
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Dimitrios Alexopoulos
- Department of cardiology, National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Felix Zijlstra
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Gilles Montalescot
- ACTION group, Sorbonne University, Groupe Hospitalier Pitie-Salpetriere Hospital (AP-HP), Paris, France
| | | | | | - Pieter A Doevendans
- Department of cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nicolas M Van Mieghem
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Georgios J Vlachojannis
- Department of cardiology, University Medical Center Utrecht, Utrecht, the Netherlands; Maasstad Hospital, Rotterdam, the Netherlands.
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4
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Vetrovec GW, Kaki A, Wollmuth J, Dahle TG. Strategies for Reducing Vascular and Bleeding Risk for Percutaneous Left Ventricular Assist Device-supported High-risk Percutaneous Coronary Intervention. Heart Int 2022; 16:105-111. [PMID: 36741103 PMCID: PMC9872781 DOI: 10.17925/hi.2022.16.2.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 12/16/2022] [Indexed: 12/25/2022] Open
Abstract
In patients at high risk for haemodynamic instability during percutaneous coronary intervention (PCI), practitioners are increasingly opting for prophylactic mechanical circulatory support, such as the Impella® heart pump (Abiomed, Danvers, MA, USA). Though Impella-supported high-risk PCI (HRPCI) ensures haemodynamic stability during the PCI procedure, access-related complication rates have varied significantly in published studies. Reported variability in complication rates relates to many factors, including anticoagulation practices, access and closure strategy, post-procedure care and variations in event definitions. This article aims to outline optimal strategies to minimize vascular and bleeding complications during Impella-supported HRPCI based on previously identified clinical, procedural and postprocedural risk factors. Practices to reduce complications include femoral skills training, standardized protocols to optimize access, closure, anticoagulation management and post-procedural care, as well as the application of techniques and technological advances. Protocols integrating these strategies to mitigate access-related bleeding and vascular complications for Impella-supported procedures can markedly limit vascular access risk as a barrier to appropriate large-bore mechanical circulatory support use in HRPCI.
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Affiliation(s)
- George W Vetrovec
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Amir Kaki
- Division of Cardiology, St. John’s Hospital, Wayne State University, Detroit, MI, USA
| | - Jason Wollmuth
- Providence Heart and Vascular Institute, Providence, OR, USA
| | - Thom G Dahle
- CentraCare Heart & Vascular Center, St. Cloud Hospital, St. Cloud, MN, USA
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5
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Vogel RF, Delewi R, Badimon L, Angiolillo DJ, Vlachojannis GJ. Current Status and Future Direction of Antithrombotic Therapy for Patients with STEMI Undergoing Primary PCI. Rev Cardiovasc Med 2022; 23:297. [PMID: 39077705 PMCID: PMC11262351 DOI: 10.31083/j.rcm2309297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/30/2022] [Accepted: 07/26/2022] [Indexed: 07/31/2024] Open
Abstract
Since the introduction of the first pharmacological therapy for the treatment of patients with acute myocardial infarction in the early 20th century, treatment of myocardial infarction has evolved extensively throughout the years. Mechanical revascularization therapies such as the percutaneous transluminal coronary angioplasty, combined with the ongoing development of pharmacological therapies have successfully improved the survival of patients with acute myocardial infarction. To date, antiplatelet therapy (consisting of aspirin and an oral P2Y 12 inhibitor) and anticoagulation therapy represent the main stay of pharmacological treatment in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). The routine use of clopidogrel as antiplatelet agent has been largely replaced by the use of the more potent P2Y 12 inhibitors ticagrelor and prasugrel. Unfractionated heparin remains the preferred anticoagulant therapy, despite the development of other anticoagulants, including enoxaparin and bivalirudin. To date, limited evidence exists supporting a pre-hospital initiation of antiplatelet and anticoagulant therapy in STEMI patients. The use of potent intravenous antiplatelet agents, including the glycoprotein IIb/IIIa inhibitors and the intravenous P2Y 12 inhibitor cangrelor, is currently restricted to specific clinical settings. While several potent antithrombotic agents already exist, the search for novel potent antithrombotic agents continues, with a focus on balancing antithrombotic properties with an improved safety profile to reduce excess bleeding. This review provides an overview of currently available pharmacological therapies for the treatment of STEMI patients undergoing primary PCI, and an outlook for the ongoing development of novel agents in this field.
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Affiliation(s)
- Rosanne F. Vogel
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, 3584CX Utrecht, The Netherlands
- Department of Cardiology, Amsterdam UMC location AMC, University of Amsterdam, 1105AZ Amsterdam, The Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC location AMC, University of Amsterdam, 1105AZ Amsterdam, The Netherlands
| | - Lina Badimon
- Cardiovascular Science Program (ICCC), IR-Hospital de la Santa Creu I Santa Pau-IIBSantPau, CiberCV, Autonomous University of Barcelona, 08025 Barcelona, Spain
| | - Dominick J. Angiolillo
- Department of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Georgios J. Vlachojannis
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, 3584CX Utrecht, The Netherlands
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6
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Shah T, Kapadia S, Lansky AJ, Grines CL. ST-Segment Elevation Myocardial Infarction: Sex Differences in Incidence, Etiology, Treatment, and Outcomes. Curr Cardiol Rep 2022; 24:529-540. [PMID: 35286662 DOI: 10.1007/s11886-022-01676-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Although there have been marked improvements in the standard of care for treatment of ST-elevation myocardial infarction, women, especially younger women, continue to have significantly worse outcomes than men. RECENT FINDINGS This review highlights the current sex differences in presentation, etiology, treatment, and outcomes among these patients in order to make providers aware of the heterogeneous entities that cause ST-elevation myocardial infarction particularly in women and of disparities in treatment that lead to poorer outcomes in women. Furthermore, it emphasizes evidence-based strategies including standardized protocols for early revascularization, mechanical circulatory support, and access methodology that can reduce sex-based disparities in treatments and outcomes.
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Affiliation(s)
- Tayyab Shah
- Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Cindy L Grines
- Northside Hospital Cardiovascular Institute, Atlanta, GA, USA.
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7
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Meta-Analysis Comparing Gender-Based Cardiovascular Outcomes of Transradial Versus Transfemoral Access of Percutaneous Coronary Intervention. Am J Cardiol 2022; 162:49-57. [PMID: 34903346 DOI: 10.1016/j.amjcard.2021.08.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/22/2022]
Abstract
Transradial (TR) access for percutaneous coronary intervention (PCI) improves outcomes and reduces the risk of major bleeding compared with transfemoral (TF) access. However, data on gender-stratified outcomes based on vascular access are limited. Databases were queried to find relevant articles. Primary outcomes, including major bleeding complications, mortality, and secondary outcome including major adverse cardiovascular events (MACEs), myocardial infarction, and cerebrovascular accidents, were analyzed using a random-effect model to calculate unadjusted odds ratio (OR) of TR-PCI and TF-PCI between the genders. A total of 9 studies comprising 3,889,257 patients (389,580 in the TR arm and 3,499,677 in the TF arm) were included. Males comprised 73% and 67% of the TR and TF arms, respectively. TR-PCI was associated with lower major bleeding (pooled OR 0.51, 95% CI 0.40 to 0.64, p = 0.00; female OR 0.49, 95% CI 0.34 to 0.71, p = 0.00; male OR 0.54, 95% CI 0.40 to 0.73, p = 0.00) and mortality (pooled OR 0.54, 95% CI 0.45 to 0.66, p = 0.00; female OR 0.56, 95% CI 0.44 to 0.71, p = 0.27; male OR 0.54, 95% CI 0.39 to 0.75, p = 0.00) regardless of gender as compared with TF-PCI. Furthermore, TR-PCI also showed lower MACE (pooled OR 0.74, 95% CI 0.66 to 0.84, p = 0.00; female OR 0.64, 95% CI 0.59 to 0.70, p = 0.00; male OR 0.81, 95% CI 0.66 to 0.98, p = 0.00) as compared with TF-PCI in both genders. On analysis of interaction magnitude of the difference of favor of female and male for TR-PCI showed no statistically significant measurable difference. Periprocedural myocardial infarction and cerebrovascular accidents were not statistically different in TR and TF-PCI and were not different based on gender. In conclusion, TR-PCI was associated with a lower risk of major bleeding, mortality, and MACE irrespective of gender. In conclusion, TR-PCI should be the default access.
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8
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Is It Safe to Mobilize Patients Very Early After Transfemoral Coronary Procedures? (SAMOVAR): A Randomized Clinical Trial. J Cardiovasc Nurs 2021; 37:E114-E121. [PMID: 34321432 DOI: 10.1097/jcn.0000000000000845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Coronary angiography (CAG) and percutaneous coronary intervention (PCI) are performed via the femoral or radial arteries. In patients examined via transfemoral access, closure devices facilitate hemostasis, but it is unknown whether it is safe to mobilize these patients immediately and how acceptable this may be in terms of patient comfort. OBJECTIVE The aims of this study were to investigate bleeding complications in patients mobilized immediately after transfemoral CAG or PCI compared with patients on bed rest (BR) for 2 hours after the procedure and, furthermore, to investigate patient comfort in relation to mobilization and BR. METHODS SAMOVAR was a noninferiority trial with patients randomized to immediate mobilization (IM) or 2 hours of BR after transfemoral CAG or PCI and use of the AngioSeal as a closure device and reversal of heparin effect. The primary end point was development of hematoma greater than 5 cm, pseudoaneurysm, or bleeding requiring blood transfusion. Secondary end points were oozing from the puncture site, small hematoma, and patient comfort. RESULTS Of 2027 patients (IM, 1010; BR, 1017), 40% underwent PCI. The primary outcome was recorded in 0.7% patients randomized to IM versus 0.5% in BR (P = .58). There was no difference in the incidence of small hematoma, whereas persistent oozing was seen slightly more often after IM compared with BR (12% vs 9%, P = .04). Patients mobilized immediately reported less back pain and micturition problems (P < .001). CONCLUSIONS In patients who had CAG and PCI performed through transfemoral access, reversal of anticoagulation and use of closure devices allowed IM with low rates of complications and improved patient comfort.
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Chaudry HI, Lee J, Li SX, Gasperetti A, Lee KM, Zbib NH, Amakiri IC, Andrus BW, DeVries JT. Sex Differences in Acute Bleeding and Vascular Complications Following Percutaneous Coronary Intervention Between 2003 and 2016: Trends From the Dartmouth Dynamic Registry. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 28:32-38. [DOI: 10.1016/j.carrev.2020.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/07/2020] [Accepted: 07/22/2020] [Indexed: 12/25/2022]
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10
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Outcomes and Procedural Considerations for Women Undergoing PCI. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-020-00888-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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11
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A sex paradox in clinical outcomes following complex percutaneous coronary intervention. Int J Cardiol 2020; 329:67-73. [PMID: 33278415 DOI: 10.1016/j.ijcard.2020.11.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/17/2020] [Accepted: 11/27/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although the number of complex percutaneous coronary intervention (CPCI) procedures is increasing, data regarding sex-related outcomes following CPCI are scarce. METHODS We retrospectively analyzed data of patients enrolled in a single-center registry between 2009 and 2017. Patients were divided into two groups (CPCI and non-CPCI) stratified by sex. CPCI was defined as any PCI procedure with ≥1 of the following characteristics: ≥3 target vessels/lesions, ≥3 stents implanted, bifurcation with ≥2 stents, stent length > 60 mm, or chronic total occlusion. The primary outcome was major adverse cardiac events (MACE), a composite of all-cause death, myocardial infarction (MI), and target vessel revascularization, at oneon-year follow-up. RESULTS Among 20,419 patients, 5004 (24.5%) underwent CPCI of whom 25.6% (n = 1281) women and 74.4% (n = 3723) men. Women presented with more comorbidities yet less complex coronary anatomy than men (syntax score: 19.5 ± 10.3 vs. 20.6 ± 10.7, p = 0.009). Moreover, women were more likely to fulfill a single rather than multiple CPCI criteria. At one year, a higher rate of MACE occurred in women (14.0% vs. 11.6%, p = 0.02). After multivariable adjustment for confounders, the risk of MACE at one year was similar among both sexes (HR:1.04, 95% CI [0.85-1.26], p = 0.71), without significant interaction between the complexity of the procedure and sex (p-interaction = 0.96). Nonetheless, the risk of MI was significantly higher in women than men undergoing CPCI (HR:1.63, 95% CI [1.12-2.38], p = 0.01). CONCLUSIONS Despite presenting with less challenging lesions than men, women had a higher rate of MI at one year following CPCI, even after adjusting for potential confounders.
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12
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Huang WY, Saver JL, Wu YL, Lin CJ, Lee M, Ovbiagele B. Major bleeding risk with non-vitamin K antagonist oral anticoagulant vs. aspirin in heart failure: network meta-analysis. ESC Heart Fail 2020; 7:3962-3970. [PMID: 32924283 PMCID: PMC7754774 DOI: 10.1002/ehf2.12994] [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: 12/09/2019] [Revised: 06/30/2020] [Accepted: 08/17/2020] [Indexed: 11/10/2022] Open
Abstract
Aims Relative bleeding risks of different antithrombotic agents in heart failure (HF) patients is an important consideration in treatment decision making, making detailed comparative analysis desirable. The aim of this study was to conduct a network meta‐analysis to investigate the major bleeding risk for individual novel oral anticoagulants (NOACs) vs. aspirin among patients with HF. Methods and results We searched Pubmed, EMBASE, Cochrane Collaboration Central Register of Controlled Clinical Trials, and Clinicaltrials.gov from 1966 to November 2019 to identify relevant randomized clinical trials. Studies comparing individual NOACs vs. aspirin were analysed using direct study‐level meta‐analysis. Studies comparing aspirin to warfarin and NOACs to warfarin were then additionally added using network (direct and indirect) study‐level meta‐analysis. Primary endpoint was major bleeding. Final analysis included nine trials with 34 367 participants, including one direct comparison trial (apixaban vs. aspirin) and eight indirect comparison trials against the shared warfarin comparator (four aspirin trials and one trial each of apixaban, dabigatran, rivaroxaban, and edoxaban). For apixaban, network meta‐analysis combing direct and indirect comparison showed that major bleeding risk might not be different between apixaban and aspirin (odds ratio, 1.18 [95% confidence interval, 0.38 to 3.65]) in HF patients. In contrast, indirect‐comparison meta‐analysis showed dabigatran, rivaroxaban, and edoxaban compared with aspirin might be associated with a higher risk of major bleeding in HF patients. Conclusions In network meta‐analysis, apixaban might be associated with a comparable risk of major bleeding compared with aspirin in patients with HF, while other NOACs might be associated with a higher risk. However, such results were not strongly convincing because of lack of direct comparison in an original trial and small sample size of trials and participants. A clinical trial directly comparing apixaban vs. aspirin in patients with HF and sinus rhythm may be worth undertaking.
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Affiliation(s)
- Wen-Yi Huang
- Department of Neurology, College of Medicine, Chang Gung University, Chang Gung Memorial Hospital, Keelung Branch, No.222, Mai-Jin Road, Keelung, 204, Taiwan
| | - Jeffrey L Saver
- UCLA Stroke Center, University of California, 300 Medical Plaza Driveway B200, Los Angeles, CA, 90095, USA
| | - Yi-Ling Wu
- Institute of Population Health Sciences, National Health Research Institutes, No. 35, Keyan Road, Zhunan, Miaoli County, 350, Taiwan
| | - Chun-Jen Lin
- Department of Neurology, Taipei Veterans General Hospital, National Yang-Ming University, No. 201, Sec. 2, Shipai Road, Beitou District Taipei, 112, Taiwan
| | - Meng Lee
- Department of Neurology, College of Medicine, Chang Gung University, Chang Gung Memorial Hospital, Chiayi Branch, 6 West Section, Chiapu Road, Puzi, 613, Taiwan
| | - Bruce Ovbiagele
- Department of Neurology, University of California, 505 Parnassus Ave, San Francisco, CA, 94143, USA
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13
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Ghare MI, Tirziu D, Abbott JD, Altin E, Yang Y, Ng V, Grines C, Lansky A. Sex-Specific Outcomes in Cardiovascular Device Evaluations. J Womens Health (Larchmt) 2020; 29:1246-1255. [PMID: 32543268 DOI: 10.1089/jwh.2019.8068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Females have historically been underrepresented in cardiovascular device trials. As a result, differences in outcomes for males and females are not possible to be determined in subanalyses. Materials and Methods: Against a backdrop of troubling trends in cardiovascular outcomes for females, we provide a narrative review on the differences in outcomes observed in females undergoing device evaluations in multiple fields of cardiovascular medicine, including coronary revascularization, structural heart disease, and heart failure. We also review predictors of cardiovascular trial nonparticipation as it may provide avenues by which female enrollment in cardiovascular device trials can be improved. Results: Advances have been made in structural heart therapy, where female representation in transcatheter aortic valve replacement studies was nearly 50%. For other indications, coronary revascularization and heart failure, there was clearly a disparity in female recruitment. On average, female representation was 25% in major clinical trials evaluating drug eluting stents, implantable cardioverter defibrillators, cardiac resynchronization defibrillators, and ventricular assist devices. As a result, the best treatment recommendations for females in these fields are currently guided by outcomes evaluated primarily in males. Conclusions: Female enrollment in device clinical trials for coronary revascularization and heart failure has lagged, leaving uncertainty in making benefit/risk assessments of device therapy. The predictors of female nonparticipation in clinical trials can inform a comprehensive strategy to facilitate and enrich the enrollment of females in cardiovascular device trials. This is critical to ensure that sex differences can be considered in treatment selection, so that patients can receive the best available care.
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Affiliation(s)
- Mohammed Imran Ghare
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniela Tirziu
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jinnette Dawn Abbott
- Department of Medicine, Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Elissa Altin
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Yiping Yang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Vivian Ng
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, New York, New York, USA
| | - Cindy Grines
- Northside Cardiovascular Institute, Atlanta, Georgia, USA
| | - Alexandra Lansky
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Barts Heart Center, St Bartholomew's Hospital and William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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14
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D'Ascenzo F, Bertaina M, Fioravanti F, Bongiovanni F, Raposeiras-Roubin S, Abu-Assi E, Kinnaird T, Ariza-Solé A, Manzano-Fernández S, Templin C, Velicki L, Xanthopoulou I, Cerrato E, Rognoni A, Boccuzzi G, Omedè P, Montabone A, Taha S, Durante A, Gili S, Magnani G, Autelli M, Grosso A, Blanco PF, Garay A, Quadri G, Varbella F, Queija BC, Paz RC, Fernández MC, Pousa IM, Gallo D, Morbiducci U, Dominguez-Rodriguez A, Valdés M, Cequier A, Alexopoulos D, Iñiguez-Romo A, Gaita F, Rinaldi M, Lüscher TF. Long versus short dual antiplatelet therapy in acute coronary syndrome patients treated with prasugrel or ticagrelor and coronary revascularization: Insights from the RENAMI registry. Eur J Prev Cardiol 2020; 27:696-705. [DOI: 10.1177/2047487319836327] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Introduction The benefits of short versus long-term dual antiplatelet therapy (DAPT) based on the third generation P2Y12 antagonists prasugrel or ticagrelor, in patients with acute coronary syndromes treated with percutaneous coronary intervention remain to be clearly defined due to current evidences limited to patients treated with clopidogrel. Methods All acute coronary syndrome patients from the REgistry of New Antiplatelets in patients with Myocardial Infarction (RENAMI) undergoing percutaneous coronary intervention and treated with aspirin, prasugrel or ticagrelor were stratified according to DAPT duration, that is, shorter than 12 months (D1 group), 12 months (D2 group) and longer than 12 months (D3 group). The three groups were compared before and after propensity score matching. Net adverse clinical events (NACEs), defined as a combination of major adverse cardiac events (MACEs) and major bleedings (including therefore all cause death, myocardial infarction and Bleeding Academic Research Consortium (BARC) 3–5 bleeding), were the primary end points, MACEs (a composite of all cause death and myocardial infarction) the secondary one. Single components of NACEs were co-secondary end points, along with BARC 2–5 bleeding, cardiovascular death and stent thrombosis. Results A total of 4424 patients from the RENAMI registry with available data on DAPT duration were included in the model. After propensity score matching, 628 patients from each group were selected. After 20 months of follow up, DAPT for 12 months and DAPT for longer than 12 months significantly reduced the risk of NACE (D1 11.6% vs. D2 6.7% vs. D3 7.2%, p = 0.003) and MACE (10% vs. 6.2% vs. 2.4%, p < 0.001) compared with DAPT for less than 12 months. These differences were driven by a reduced risk of all cause death (7.8% vs. 1.3% vs. 1.6%, p < 0.001), cardiovascular death (5.1% vs. 1.0% vs. 1.2%, p < 0.0001) and recurrent myocardial infarction (8.3% vs. 5.2% vs. 3.5%, p = 0.002). NACEs were lower with longer DAPT despite a higher risk of BARC 2–5 bleedings (4.6% vs. 5.7% vs. 6.2%, p = 0.04) and a trend towards a higher risk of BARC 3–5 bleedings (2.4% vs. 3.3% vs. 3.9%, p = 0.06). These results were not consistent for female patients and those older than 75 years old, due to an increased risk of bleedings which exceeded the reduction in myocardial infarction. Conclusion In unselected real world acute coronary syndrome patients treated with percutaneous coronary intervention, DAPT with prasugrel or ticagrelor prolonged beyond 12 months markedly reduces fatal and non-fatal ischaemic events, offsetting the increased risk deriving from the higher bleeding risk. On the contrary, patients >75 years old and female ones showed a less favourable risk–benefit ratio for longer DAPT due to excess of bleedings.
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Affiliation(s)
- Fabrizio D'Ascenzo
- Department of Cardiology, Department of Medical Sciences, University of Torino, Italy
| | - Maurizio Bertaina
- Department of Cardiology, Department of Medical Sciences, University of Torino, Italy
| | - Francesco Fioravanti
- Department of Cardiology, Department of Medical Sciences, University of Torino, Italy
| | - Federica Bongiovanni
- Department of Cardiology, Department of Medical Sciences, University of Torino, Italy
| | | | - Emad Abu-Assi
- Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain
| | - Tim Kinnaird
- Cardiology Department, University Hospital of Wales, Cardiff, UK
| | - Albert Ariza-Solé
- Department of Cardiology, University Hospital de Bellvitge, Barcelona, Spain
| | | | - Christian Templin
- University Heart Centre, Department of Cardiology, University Hospital Zurich, Switzerland
| | - Lazar Velicki
- Medical faculty, University of Novi Sad, Novi Sad, Serbia and Institute of cardiovascular diseases Vojvodina, Sremska Kamenica, Serbia
| | | | - Enrico Cerrato
- Interventional Unit, San Luigi Gonzaga University Hospital, Orbassano and Infermi Hospital, Rivoli (Torino), Italy
| | - Andrea Rognoni
- Catheterization Laboratory, Maggiore della Carità Hospital, Novara, Italy
| | | | - Pierluigi Omedè
- Department of Cardiology, Department of Medical Sciences, University of Torino, Italy
| | | | - Salma Taha
- Department of Cardiology, Faculty of Medicine, Assiut University, Egypt
| | | | - Sebastiano Gili
- University Heart Centre, Department of Cardiology, University Hospital Zurich, Switzerland
| | - Giulia Magnani
- University Heart Centre, Department of Cardiology, University Hospital Zurich, Switzerland
| | - Michele Autelli
- Department of Cardiology, Department of Medical Sciences, University of Torino, Italy
| | - Alberto Grosso
- Department of Cardiology, Department of Medical Sciences, University of Torino, Italy
| | - Pedro Flores Blanco
- Department of Cardiology, University Hospital Virgen Arrtixaca, Murcia, Spain
| | - Alberto Garay
- Department of Cardiology, University Hospital de Bellvitge, Barcelona, Spain
| | - Giorgio Quadri
- Interventional Unit, San Luigi Gonzaga University Hospital, Orbassano and Infermi Hospital, Rivoli (Torino), Italy
| | - Ferdinando Varbella
- Interventional Unit, San Luigi Gonzaga University Hospital, Orbassano and Infermi Hospital, Rivoli (Torino), Italy
| | | | - Rafael Cobas Paz
- Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain
| | | | - Isabel Muñoz Pousa
- Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain
| | - Diego Gallo
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Italy
| | - Umberto Morbiducci
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Italy
| | | | - Mariano Valdés
- Department of Cardiology, University Hospital Virgen Arrtixaca, Murcia, Spain
| | - Angel Cequier
- Department of Cardiology, University Hospital de Bellvitge, Barcelona, Spain
| | | | | | - Fiorenzo Gaita
- Department of Cardiology, Department of Medical Sciences, University of Torino, Italy
| | - Mauro Rinaldi
- Department of Cardiology, Department of Medical Sciences, University of Torino, Italy
| | - Thomas F Lüscher
- Royal Brompton and Harefield Hospitals Trust and Imperial College, London, UK
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15
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Manzo-Silberman S. Percutaneous coronary intervention in women: is sex still an issue? Minerva Cardioangiol 2020; 68:393-404. [PMID: 32326680 DOI: 10.23736/s0026-4725.20.05203-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Coronary artery disease among women presents differences in terms of clinical presentation and pathophysiology. To date, women present worse prognoses with more events and higher mortality rate. One the one hand, they are less likely addressed for invasive therapy. One the other hand, revascularization procedures, whether by bypass or by percutaneous coronary intervention, are associated with higher rates of complications and poorer prognosis. Despite higher risk factor burden and comorbidity, women are less affected by obstructive disease and plaque characteristics are more favorable than among men. Abnormalities of endothelial function and micro vascular flow reserve could explain part of the high prevalence of symptoms of angina observed among women. Due to the worse prognosis of microvascular dysfunction, particularly in women, proper diagnosis is mandatory and deserve invasive management. Outcome following ST elevation myocardial infarction is still more severe among women with higher in-hospital mortality, but sex discrepancies are observed even in elective percutaneous coronary intervention. However, improvement of techniques, drugs and devices benefited to both men and women and tend to decrease gender gap. Especially, changes in the design of newer-generation drug-eluting stents (DES) may be particularly important for women. Female sex remains a potent predictor of higher risk of bleeding and vascular complication; thus important efforts should be promoted to develop bleeding avoidance strategies. Sex-based differences still deserve dedicated investigations in terms of physiopathology, particular hormonal impacts, and specific responses to drugs and devices.
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Affiliation(s)
- Stéphane Manzo-Silberman
- Service of Cardiology, Lariboisière University Hospital, Paris, France - .,UMRS 942, University of Paris, Paris, France -
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16
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Daugherty SL, Carter JR, Bourjeily G. Cardiovascular Disease in Women Across the Lifespan: The Importance of Sleep. J Womens Health (Larchmt) 2020; 29:452-460. [PMID: 32096682 PMCID: PMC7097694 DOI: 10.1089/jwh.2020.8331] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular disease (CVD) and sleep disturbances are both common and associated with significant morbidity and mortality. Compared with men, women are more likely to report insufficient sleep. During the 2018 Research Conference on Sleep and the Health of Women sponsored by the National Heart, Lung, and Blood Institute, researchers in cardiology, integrative physiology and sleep medicine reviewed the current understanding of how sleep and sleep disturbances influence CVD in women across the lifespan. Women may be particularly vulnerable to the negative effects of sleep disturbances at important stages of their life, including during pregnancy and after menopause. The proposed pathways linking sleep disturbances and adverse cardiovascular outcomes in women are numerous and the complex interaction between them is not well understood. Future research focused on understanding the scope of sleep disorders in women, defining the underlying mechanisms, and testing interventions to improve sleep are critical for improving the cardiovascular health of all women.
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Affiliation(s)
- Stacie L. Daugherty
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
- Adult and Children Center for Outcomes Research and Delivery Sciences (ACCORDS), University of Colorado School of Medicine, Aurora, Colorado
- Colorado Cardiovascular Outcomes Research Group, Denver, Colorado
| | - Jason R. Carter
- Department of Kinesiology and Integrative Physiology, Michigan Technological University, Houghton, Michigan
| | - Ghada Bourjeily
- Divisions of Pulmonary, Critical Care and Sleep Medicine, and Obstetric Medicine, Department of Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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17
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Gewalt SM, Helde SM, Ibrahim T, Mayer K, Schmidt R, Bott-Flügel L, Hoppe K, Ott I, Hieber J, Morath T, Byrne RA, Kufner S, Cassese S, Hoppmann P, Fusaro M, Schunkert H, Laugwitz KL, Kastrati A, Schüpke S. Comparison of Vascular Closure Devices Versus Manual Compression After Femoral Artery Puncture in Women. Circ Cardiovasc Interv 2019; 11:e006074. [PMID: 30354782 DOI: 10.1161/circinterventions.117.006074] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The value of vascular closure devices (VCD) in women undergoing transfemoral catheterization has not been sufficiently investigated. METHODS AND RESULTS This is a sex-specific analysis of 1395 women enrolled in a large-scale, randomized, multicenter trial, in which patients undergoing transfemoral diagnostic coronary angiography were randomly assigned in a 1:1:1 ratio to arteriotomy closure with an intravascular VCD, extravascular VCD, or manual compression (MC). Primary objective was to assess the safety and efficacy of 2 different VCD compared with MC regarding vascular access-site complications at 30 days. A secondary comparison was between 2 different types of contemporary VCD. Overall, women were at higher risk for vascular access-site complications compared with men (9.0% versus 6.4%; P=0.002). Vascular access-site complications were comparable in women assigned to VCD and MC (8.6% versus 9.8%; P=0.451). There was no interaction of treatment effect and sex ( Pinteraction=0.970). Time to hemostasis was significantly shortened with VCD compared with MC (1 [interquartile range, 0.5-2.0] minutes) versus 11 [interquartile range, 10-15] minutes; P<0.001); however, more women with VCD required repeat MC (2.4% versus 0.6%; P=0.018). The use of the intravascular compared with the extravascular VCD was associated with a numerical reduction in vascular access-site complications (6.6% versus 10.7%; P=0.027) and significant reductions in time to hemostasis and VCD failure. CONCLUSIONS In women undergoing diagnostic coronary angiography via the common femoral artery, VCD and MC provided comparable safety, while time to hemostasis was reduced with VCD. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01389375.
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Affiliation(s)
- Senta M Gewalt
- Deutsches Herzzentrum München, Technische Universität München, Germany (S.M.G., S.M.H., K.M., I.O., J.H., T.M., R.A.B., S.K., S.C., M.F., H.S., A.K., S.S.)
| | - Sandra M Helde
- Deutsches Herzzentrum München, Technische Universität München, Germany (S.M.G., S.M.H., K.M., I.O., J.H., T.M., R.A.B., S.K., S.C., M.F., H.S., A.K., S.S.).,Klinikum Landkreis Erding, Abteilung Kardiologie und Pneumologie, Germany (S.M.H., L.B.-F.)
| | - Tareq Ibrahim
- I. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Germany (T.I., P.H., K.-L.L.)
| | - Katharina Mayer
- Deutsches Herzzentrum München, Technische Universität München, Germany (S.M.G., S.M.H., K.M., I.O., J.H., T.M., R.A.B., S.K., S.C., M.F., H.S., A.K., S.S.)
| | - Roland Schmidt
- Krankenhaus der Barmherzigen Brüder, Innere Medizin II, Munich, Germany (R.S.)
| | - Lorenz Bott-Flügel
- Klinikum Landkreis Erding, Abteilung Kardiologie und Pneumologie, Germany (S.M.H., L.B.-F.)
| | - Katharina Hoppe
- German Center for Cardiovascular Diseases (DZHK), Partner Site Munich Heart Alliance (H.S., K.-L.L., A.K., S.S.)
| | - Ilka Ott
- Deutsches Herzzentrum München, Technische Universität München, Germany (S.M.G., S.M.H., K.M., I.O., J.H., T.M., R.A.B., S.K., S.C., M.F., H.S., A.K., S.S.)
| | - Julia Hieber
- Deutsches Herzzentrum München, Technische Universität München, Germany (S.M.G., S.M.H., K.M., I.O., J.H., T.M., R.A.B., S.K., S.C., M.F., H.S., A.K., S.S.)
| | - Tanja Morath
- Deutsches Herzzentrum München, Technische Universität München, Germany (S.M.G., S.M.H., K.M., I.O., J.H., T.M., R.A.B., S.K., S.C., M.F., H.S., A.K., S.S.)
| | - Robert A Byrne
- Deutsches Herzzentrum München, Technische Universität München, Germany (S.M.G., S.M.H., K.M., I.O., J.H., T.M., R.A.B., S.K., S.C., M.F., H.S., A.K., S.S.)
| | - Sebastian Kufner
- Deutsches Herzzentrum München, Technische Universität München, Germany (S.M.G., S.M.H., K.M., I.O., J.H., T.M., R.A.B., S.K., S.C., M.F., H.S., A.K., S.S.).,German Center for Cardiovascular Diseases (DZHK), Partner Site Munich Heart Alliance (H.S., K.-L.L., A.K., S.S.)
| | - Salvatore Cassese
- Deutsches Herzzentrum München, Technische Universität München, Germany (S.M.G., S.M.H., K.M., I.O., J.H., T.M., R.A.B., S.K., S.C., M.F., H.S., A.K., S.S.)
| | - Petra Hoppmann
- I. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Germany (T.I., P.H., K.-L.L.)
| | - Massimiliano Fusaro
- Deutsches Herzzentrum München, Technische Universität München, Germany (S.M.G., S.M.H., K.M., I.O., J.H., T.M., R.A.B., S.K., S.C., M.F., H.S., A.K., S.S.)
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Technische Universität München, Germany (S.M.G., S.M.H., K.M., I.O., J.H., T.M., R.A.B., S.K., S.C., M.F., H.S., A.K., S.S.)
| | - Karl-Ludwig Laugwitz
- I. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Germany (T.I., P.H., K.-L.L.).,German Center for Cardiovascular Diseases (DZHK), Partner Site Munich Heart Alliance (H.S., K.-L.L., A.K., S.S.)
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Germany (S.M.G., S.M.H., K.M., I.O., J.H., T.M., R.A.B., S.K., S.C., M.F., H.S., A.K., S.S.).,German Center for Cardiovascular Diseases (DZHK), Partner Site Munich Heart Alliance (H.S., K.-L.L., A.K., S.S.)
| | - Stefanie Schüpke
- Deutsches Herzzentrum München, Technische Universität München, Germany (S.M.G., S.M.H., K.M., I.O., J.H., T.M., R.A.B., S.K., S.C., M.F., H.S., A.K., S.S.).,German Center for Cardiovascular Diseases (DZHK), Partner Site Munich Heart Alliance (H.S., K.-L.L., A.K., S.S.)
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18
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Kim HL, Jang JS, Kim MA, Seo JB, Chung WY, Kim SH, Park SJ, Youn TJ, Yoon MH, Lee JH, Chang K, Jeong MH, Choi RK, Hong MK, Kim HS. Gender differences of in-hospital outcomes in patients undergoing percutaneous coronary intervention in the drug-eluting stent era. Medicine (Baltimore) 2019; 98:e15557. [PMID: 31096458 PMCID: PMC6531253 DOI: 10.1097/md.0000000000015557] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Most studies on gender difference of the in-hospital outcome of percutaneous coronary intervention (PCI) were performed in the pre-drug-eluting stents (DES) era. This study was performed to investigate whether gender influences the in-hospital outcome of PCI in the DES era.A total of 44,967 PCI procedure between January and December of 2014 from the nationwide PCI registry database in Korea were analyzed. The study population was male predominant (70.2%). We examined the association of gender with unadjusted and adjusted in-hospital mortality and composite events of PCI, including mortality, nonfatal myocardial infarction, stent thrombosis, stroke, urgent repeat PCI and bleeding requiring transfusion.Most of the study patients (91.3%) received DES. The incidence rates of in-hospital mortality (2.95% vs 1.99%, P <.001) and composite events (7.01% vs 5.48%, P <.001) were significantly higher in women compared to men. Unadjusted analyses showed that women had a 1.49 times higher risk of in-hospital mortality and a 1.30 times higher risk of composite events than men (P <.001 for each). After adjustment for potential confounders, female gender was not a risk factor for mortality (P = .258), but the risk of composite events remained 1.20 times higher in women than in men (P = .008).Among patients undergoing PCI in the contemporary DES era, female gender was associated with an increased risk of in-hospital composite events, but not in-hospital mortality. More careful attention should be emphasized to minimize procedure-related risks and to improve prognosis in women undergoing PCI.
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Affiliation(s)
- Hack-Lyoung Kim
- Division of Cardiology, Boramae Medical Center, Seoul National University College of Medicine, Seoul
| | - Jae-Sik Jang
- Division of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan
| | - Myung-A Kim
- Division of Cardiology, Boramae Medical Center, Seoul National University College of Medicine, Seoul
| | - Jae-Bin Seo
- Division of Cardiology, Boramae Medical Center, Seoul National University College of Medicine, Seoul
| | - Woo-Young Chung
- Division of Cardiology, Boramae Medical Center, Seoul National University College of Medicine, Seoul
| | - Sang-Hyun Kim
- Division of Cardiology, Boramae Medical Center, Seoul National University College of Medicine, Seoul
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul
| | - Tae-Jin Youn
- Cardiovascular Center, Seoul National University Bundang Hospital and Seoul National University College of Medicine, Seongnam
| | - Myeong-Ho Yoon
- Department of Cardiology, Ajou University School of Medicine, Suwon
| | - Jae-Hwan Lee
- Department of Cardiology, Chungnam National University School of Medicine, Chungnam National University Hospital, Daejeon
| | - Kiyuk Chang
- Division of Cardiology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul
| | - Myung Ho Jeong
- Department of Internal Medicine and Heart Center, Chonnam National University Hospital, Gwangju
| | - Rak Kyeong Choi
- Division of Cardiology, Mediplex Sejong General Hospital, Incheon
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Hyo-Soo Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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Venetsanos D, Sederholm Lawesson S, Fröbert O, Omerovic E, Henareh L, Robertsson L, Linder R, Götberg M, James S, Alfredsson J, Erlinge D, Swahn E. Sex-related response to bivalirudin and unfractionated heparin in patients with acute myocardial infarction undergoing percutaneous coronary intervention: A subgroup analysis of the VALIDATE-SWEDEHEART trial. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 8:502-509. [DOI: 10.1177/2048872618803760] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims: Our aim was to study the impact of sex on anticoagulant treatment outcomes during percutaneous coronary intervention in acute myocardial infarction patients. Methods: This study was a prespecified analysis of the Bivalirudin versus Heparin in ST-Segment and Non ST-Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence-based Care in Heart Disease Evaluated according to Recommended Therapies Registry Trial (VALIDATE-SWEDEHEART) trial, in which patients with myocardial infarction were randomised to bivalirudin or unfractionated heparin during percutaneous coronary intervention. The primary outcome was the composite of death, myocardial infarction or major bleeding at 180 days. Results: There was a lower risk of the primary outcome in women assigned to bivalirudin than to unfractionated heparin (13.6% vs 17.1%, hazard ratio 0.78, 95% confidence interval (0.60–1.00)) with no significant difference in men (11.8% vs 11.2%, hazard ratio 1.06 (0.89–1.26), p for interaction 0.05). The observed difference was primarily due to lower risk of major bleeding (Bleeding Academic Research Consortium definition 2, 3 or 5) associated with bivalirudin in women (8.9% vs 11.8%, hazard ratio 0.74 (0.54–1.01)) but not in men (8.5% vs 7.3%, hazard ratio 1.16 (0.94–1.43) in men, p for interaction 0.02). Conversely, no significant difference in the risk of Bleeding Academic Research Consortium 3 or 5 bleeding, associated with bivalirudin, was found in women 4.5% vs 5.4% (hazard ratio 0.84 (0.54–1.31)) or men 2.9% vs 2.1% (hazard ratio 1.36 (0.93–1.99)). Bleeding Academic Research Consortium 2 bleeding occurred significantly less often in women assigned to bivalirudin than to unfractionated heparin. The risk of death or myocardial infarction did not significantly differ between randomised treatments in men or women. Conclusion: In women, bivalirudin was associated with a lower risk of adverse outcomes, compared to unfractionated heparin, primarily due to a significant reduction in Bleeding Academic Research Consortium 2 bleeds.
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Affiliation(s)
- D Venetsanos
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - S Sederholm Lawesson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - O Fröbert
- Department of Cardiology, Örebro University, Sweden
| | - E Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - L Henareh
- Department of Medicine, Karolinska Institute, Sweden
| | - L Robertsson
- Department of Cardiology, Södra Älvsborgs Sjukhus, Sweden
| | - R Linder
- Department of Cardiology, Danderyd Hospital, Sweden
| | - M Götberg
- Department of Cardiology, Skåne University Hospital, Sweden
| | - S James
- Department of Medical Sciences, Uppsala University, Sweden
| | - J Alfredsson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - D Erlinge
- Department of Cardiology, Skåne University Hospital, Sweden
| | - E Swahn
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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Outcomes After Coronary Stenting or Bypass Surgery for Men and Women With Unprotected Left Main Disease. JACC Cardiovasc Interv 2018; 11:1234-1243. [DOI: 10.1016/j.jcin.2018.03.051] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 03/19/2018] [Accepted: 03/27/2018] [Indexed: 01/24/2023]
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21
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Vascular Access-Related Complications in Women: Temporal Trends, Emerging Data, and the Current State of Interventional Cardiology Practice. Curr Atheroscler Rep 2018; 20:41. [DOI: 10.1007/s11883-018-0741-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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22
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Min L, Tian Q, Lu X, An J, Duan H. An openEHR based approach to improve the semantic interoperability of clinical data registry. BMC Med Inform Decis Mak 2018; 18:15. [PMID: 29589572 PMCID: PMC5872380 DOI: 10.1186/s12911-018-0596-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Clinical data registry is designed to collect and manage information about the practices and outcomes of a patient population for improving the quality and safety of care and facilitating novel researches. Semantic interoperability is a challenge when integrating the data from more than one clinical data registry. The openEHR approach can represent the information and knowledge semantics by multi-level modeling, and it advocates the use of collaborative modeling to facilitate reusing existing archetypes with consistent semantics so as to be a potential solution to improve the semantic interoperability. Methods This paper proposed an openEHR based approach to improve the semantic interoperability of clinical data registry. The approach consists of five steps: clinical data registry meta-information collection, data element definition, archetype modeling, template editing, and implementation. Through collaborative modeling and maximum reusing of existing archetype at the archetype modeling step, the approach can improve semantic interoperability. To verify the feasibility of the approach, this paper conducted a case study of building a Coronary Computed Tomography Angiography (CCTA) registry that can interoperate with an existing Electronic Health Record (EHR) system. Results The CCTA registry includes 183 data elements, which involves 20 archetypes. A total number of 45 CCTA data elements and EHR data elements have semantic overlap. Among them, 38 (84%) CCTA data elements can be found in the 10 reused EHR archetypes. These corresponding clinical data can be collected from the EHR system directly without transformation. The other 7 (16%) CCTA data elements correspond to one coarse-grained EHR data elements, and these clinical data can be collected with mapping rules. The results show that the approach can improve semantic interoperability of clinical data registry. Conclusions Using an openEHR based approach to develop clinical data registry can improve the semantic interoperability. Meanwhile, some challenges for broader semantic interoperability are identified, including domain experts’ involvement, archetype sharing and reusing, and archetype semantic mapping. Collaborative modeling, easy-to-use tools, and semantic relationship establishment are potential solutions for these challenges. This study provides some experience and insight about clinical modeling and clinical data registry development.
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Affiliation(s)
- Lingtong Min
- College of Biomedical Engineering and Instrument Science, Zhejiang University, Zheda Road, Hanghzou, 310027, China
| | - Qi Tian
- College of Biomedical Engineering and Instrument Science, Zhejiang University, Zheda Road, Hanghzou, 310027, China
| | - Xudong Lu
- College of Biomedical Engineering and Instrument Science, Zhejiang University, Zheda Road, Hanghzou, 310027, China.
| | - Jiye An
- College of Biomedical Engineering and Instrument Science, Zhejiang University, Zheda Road, Hanghzou, 310027, China
| | - Huilong Duan
- College of Biomedical Engineering and Instrument Science, Zhejiang University, Zheda Road, Hanghzou, 310027, China
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23
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Thompson LE, Maddox TM, Lei L, Grunwald GK, Bradley SM, Peterson PN, Masoudi FA, Turchin A, Song Y, Doros G, Davis MB, Daugherty SL. Sex Differences in the Use of Oral Anticoagulants for Atrial Fibrillation: A Report From the National Cardiovascular Data Registry (NCDR ®) PINNACLE Registry. J Am Heart Assoc 2017; 6:e005801. [PMID: 28724655 PMCID: PMC5586299 DOI: 10.1161/jaha.117.005801] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 04/28/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite higher thromboembolism risk, women with atrial fibrillation have lower oral anticoagulation (OAC) use compared to men. The influence of the CHA2DS2-VASc score or the introduction of non-vitamin K OACs on this relationship is not known. METHODS AND RESULTS Using the PINNACLE National Cardiovascular Data Registry from 2008 to 2014, we compared the association of sex with OAC use (warfarin or non-vitamin K OACs) overall and by CHA2DS2-VASc score and examined temporal trends in OAC use by sex. Multivariable regression models assessed the association between sex and OAC use in those with CHA2DS2-VASc scores ≥2. Temporal analyses assessed changes in OAC use by sex over time. Of the 691 906 atrial fibrillation patients, 48.5% were women. Women were significantly less likely than men to use any OAC overall (56.7% versus 61.3%; P<0.001) and at all levels of CHA2DS2-VASc score (adjusted risk ratio 9% to 33% lower, all P<0.001). Compared to other thromboembolic risk factors, female sex was associated with lower use of OAC (risk ratio 0.90, 95%CI 0.90-0.91). Over time, non-vitamin K OAC use increased at a slightly higher rate in women (56.2% increase per year, 95%CI 54.6% to 57.9%) compared to men (53.6% increase per year, 95%CI 52.0% to 55.2%), yet women remained less likely to receive any OAC at all time points (P<0.001). CONCLUSIONS Among patients with atrial fibrillation, women were significantly less likely to receive OAC at all levels of the CHA2DS2-VASc score. Despite increasing non-vitamin K OAC use, women had persistently lower rates of OAC use compared to men over time.
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Affiliation(s)
- Lauren E Thompson
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Colorado Cardiovascular Outcomes Research Consortium , Denver, CO
| | - Thomas M Maddox
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Colorado Cardiovascular Outcomes Research Consortium , Denver, CO
- VA Eastern Colorado Health Care System, Denver, CO
| | - Lanyu Lei
- Harvard Clinical Research Institute, Boston, MA
| | - Gary K Grunwald
- Colorado Cardiovascular Outcomes Research Consortium , Denver, CO
- VA Eastern Colorado Health Care System, Denver, CO
- Department of Biostatistics and Informatics, University of Colorado Denver, Aurora, CO
| | | | - Pamela N Peterson
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Colorado Cardiovascular Outcomes Research Consortium , Denver, CO
- Division of Cardiology, Denver Health Medical Center, Denver, CO
| | - Frederick A Masoudi
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Colorado Cardiovascular Outcomes Research Consortium , Denver, CO
| | - Alexander Turchin
- Harvard Clinical Research Institute, Boston, MA
- Division of Endocrinology, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Yang Song
- Harvard Clinical Research Institute, Boston, MA
| | | | - Melinda B Davis
- Division of Cardiology, University of Michigan, Ann Arbor, MI
| | - Stacie L Daugherty
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Colorado Cardiovascular Outcomes Research Consortium , Denver, CO
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24
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Lau ES, Braunwald E, Murphy SA, Wiviott SD, Bonaca MP, Husted S, James SK, Wallentin L, Clemmensen P, Roe MT, Ohman EM, Harrington RA, Mega JL, Bhatt DL, Sabatine MS, O'Donoghue ML. Potent P2Y 12 Inhibitors in Men Versus Women: A Collaborative Meta-Analysis of Randomized Trials. J Am Coll Cardiol 2017; 69:1549-1559. [PMID: 28335837 DOI: 10.1016/j.jacc.2017.01.028] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 11/11/2016] [Accepted: 01/01/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND Sex-specific differences in response to antiplatelet therapies have been described. Whether women and men derive comparable benefit from intensification of antiplatelet therapy remains uncertain. OBJECTIVES The study investigated the efficacy and safety of the potent P2Y12 inhibitors in patients with coronary artery disease. METHODS A collaborative sex-specific meta-analysis was conducted of phase III or IV randomized trials of potent P2Y12 inhibitors, including prasugrel, ticagrelor, and intravenous cangrelor. Seven trials were included that enrolled a total of 24,494 women and 63,346 men. Major adverse cardiovascular events (MACE) were defined as the primary endpoint for each trial. RESULTS Potent P2Y12 inhibitors significantly reduced the risk of MACE by 14% in women (hazard ratio [HR]: 0.86; 95% confidence interval [CI]: 0.78 to 0.94) and by 15% in men (HR: 0.85; 95% CI: 0.80 to 0.90; p interaction = 0.93). Treatment reduced the risk of myocardial infarction by 13% in women (HR: 0.87; 95% CI: 0.78 to 0.96) and 16% in men (HR: 0.84; 95% CI: 0.77 to 0.91; p interaction = 0.65), and the risk of stent thrombosis by 51% in women (HR: 0.49; 95% CI: 0.37 to 0.65) and 41% in men (HR: 0.59; 95% CI: 0.42 to 0.84; p interaction = 0.85). Directional consistency was seen for cardiovascular death in women (HR: 0.87; 95% CI: 0.76 to 1.01) and men (HR: 0.85; 95% CI: 0.77 to 0.95; p interaction = 0.86). The potent P2Y12 inhibitors increased major bleeding in women (HR: 1.28; 95% CI: 0.87 to 1.88) and men (HR: 1.52; 95% CI: 1.12 to 2.07; p interaction = 0.62). CONCLUSIONS In randomized trials, the efficacy and safety of the potent P2Y12 inhibitors were comparable between men and women. Given these data, sex should not influence patient selection for the administration of potent P2Y12 inhibitors.
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Affiliation(s)
- Emily S Lau
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marc P Bonaca
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Steen Husted
- Department of Cardiology, Århus University Hospital, Århus, Denmark
| | - Stefan K James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Lars Wallentin
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Peter Clemmensen
- Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Hamburg, Germany; Department of Medicine, Nykoebing F Hospital, University of Southern Denmark, Odense, Denmark
| | - Matthew T Roe
- Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
| | - E Magnus Ohman
- Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
| | | | | | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.
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25
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Humphries KH, Izadnegahdar M, Sedlak T, Saw J, Johnston N, Schenck-Gustafsson K, Shah RU, Regitz-Zagrosek V, Grewal J, Vaccarino V, Wei J, Bairey Merz CN. Sex differences in cardiovascular disease - Impact on care and outcomes. Front Neuroendocrinol 2017; 46:46-70. [PMID: 28428055 PMCID: PMC5506856 DOI: 10.1016/j.yfrne.2017.04.001] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/31/2017] [Accepted: 04/13/2017] [Indexed: 02/07/2023]
Affiliation(s)
- K H Humphries
- Division of Cardiology, University of British Columbia, Vancouver, Canada; BC Centre for Improved Cardiovascular Health, Vancouver, Canada.
| | - M Izadnegahdar
- BC Centre for Improved Cardiovascular Health, Vancouver, Canada
| | - T Sedlak
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - J Saw
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - N Johnston
- Department of Medical Sciences, Cardiology, Uppsala University Hospital, Uppsala, Sweden
| | - K Schenck-Gustafsson
- Department of Medicine, Cardiac Unit and Centre for Gender Medicine, Karolinska University Hospital and Karolinska Institutet, Sweden
| | - R U Shah
- Division of Cardiovascular Medicine, University of Utah School of Medicine, USA
| | - V Regitz-Zagrosek
- Institute of Gender in Medicine (GIM) and Center for Cardiovascular Research (CCR) Charité, University Medicine Berlin and DZHK, Partner Site Berlin, Germany
| | - J Grewal
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - V Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - J Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - C N Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
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26
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Farmer MM, Stanislawski MA, Plomondon ME, Bean-Mayberry B, Joseph NT, Thompson LE, Zuchowski JL, Daugherty SL, Yano EM, Ho PM. Sex Differences in 1-Year Outcomes After Percutaneous Coronary Intervention in the Veterans Health Administration. J Womens Health (Larchmt) 2017; 26:1062-1068. [PMID: 28498792 DOI: 10.1089/jwh.2016.6057] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Advancements in percutaneous coronary intervention (PCI) for treating obstructive coronary artery disease have reduced major adverse events, including mortality. Yet, evidence as to whether women and men experience similar outcomes is mixed. The objective was to examine sex differences in 1-year major adverse cardiac outcomes for the national population of patients undergoing PCI at Veterans Health Administration (VA) cardiac catheterization laboratories. METHODS All Veterans undergoing PCI at VA hospitals between October 1, 2007 and September 30, 2013 (N = 64,757; Women = 1,040) were included. Cox proportional hazards models compared 1-year postprocedural outcomes [rehospitalization for myocardial infarction (MI), all-cause mortality, and major adverse cardiovascular events (MACE)] by sex. RESULTS Women Veterans undergoing PCI were more likely to be younger, black, obese, and have chronic depression and less likely to have common cardiovascular risk factors and to have had prior cardiac events than Veteran men. One-year rates for women versus men were 2.1% and 2.5% for rehospitalization (p-value = 0.57); 3.5% and 4.9% for mortality (p-value = 0.14), and 5.4% and 6.9% for MACE (p-value = 0.18). There were no significant sex differences in any of the outcomes in Cox proportional hazards models. CONCLUSIONS Despite differences in clinical risk factors at the time of PCI, women and men Veterans treated at VA cardiac catheterization laboratories experienced comparable 1-year rehospitalization for MI, mortality, and MACE post-PCI. These results demonstrated similar 1-year post-PCI outcomes for men and women in a national population of patients who have more comorbidities and mental health issues than the general population.
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Affiliation(s)
- Melissa M Farmer
- 1 VA HSR&D Center for the Study of Healthcare Innovation , Implementation & Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California
| | | | | | - Bevanne Bean-Mayberry
- 1 VA HSR&D Center for the Study of Healthcare Innovation , Implementation & Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California.,3 Department of Medicine, UCLA David Geffen School of Medicine , Los Angeles, California
| | - Nataria T Joseph
- 4 Social Sciences Division, Pepperdine University , Malibu, California
| | - Lauren E Thompson
- 5 Division of Cardiology, School of Medicine, University of Colorado , Aurora, Colorado.,6 Colorado Cardiovascular Outcomes Research (CCOR) Consortium , Colorado
| | - Jessica L Zuchowski
- 1 VA HSR&D Center for the Study of Healthcare Innovation , Implementation & Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California
| | - Stacie L Daugherty
- 5 Division of Cardiology, School of Medicine, University of Colorado , Aurora, Colorado.,6 Colorado Cardiovascular Outcomes Research (CCOR) Consortium , Colorado
| | - Elizabeth M Yano
- 1 VA HSR&D Center for the Study of Healthcare Innovation , Implementation & Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California.,7 Department of Health Policy and Management, UCLA Fielding School of Public Health , Los Angeles, California
| | - P Michael Ho
- 2 VA Eastern Colorado Health Care System , Denver, Colorado.,5 Division of Cardiology, School of Medicine, University of Colorado , Aurora, Colorado.,6 Colorado Cardiovascular Outcomes Research (CCOR) Consortium , Colorado
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27
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Wintzer-Wehekind J, Milouchi S, Rouge A, Monségu J. [Radial approach in women]. Ann Cardiol Angeiol (Paris) 2017; 65:457-461. [PMID: 28340900 DOI: 10.1016/j.ancard.2016.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Since the first series of coronary angiographies through the radial approach reported by Campeau in 1989, the radial route has become a major approach, used in up to 95 % of PCIs in some centers. As documented by this clinical case, and although registries show that the radial approach is underused in women compared to men, women benefit from the radial approach mainly by reducing the bleeding risk. Indeed, despite more frequent difficulties encountered by using this approach in women, the radial approach has to be preferred because it reduces haemorrhagic complications and death in comparison to the femoral route.
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Affiliation(s)
- J Wintzer-Wehekind
- Service de cardiologie, groupe hospitalier mutualiste de Grenoble, 8, rue du Dr-Calmette, 38028 Grenoble cedex 1, France
| | - S Milouchi
- Service de cardiologie, hôpital régional de Medenine, 4131 Medenine, Tunisie
| | - A Rouge
- Service de cardiologie, groupe hospitalier mutualiste de Grenoble, 8, rue du Dr-Calmette, 38028 Grenoble cedex 1, France
| | - J Monségu
- Service de cardiologie, groupe hospitalier mutualiste de Grenoble, 8, rue du Dr-Calmette, 38028 Grenoble cedex 1, France.
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28
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Saad M, Nairooz R, Rashed A, Abdelaziz HK, Mentias A, Abbott JD. Bivalirudin versus heparin in women undergoing percutaneous coronary intervention: A systematic review and meta-analysis of randomized clinical trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:418-424. [PMID: 28291727 DOI: 10.1016/j.carrev.2017.02.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 02/18/2017] [Accepted: 02/23/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND The anticoagulant of choice during percutaneous coronary intervention (PCI) in women is not well established. METHODS An electronic search was conducted for trials that randomized patients undergoing PCI to bivalirudin versus heparin, and reported outcomes of interest in women. Random effects DerSimonian-Laird risk ratios (RR) were calculated. Main outcome was net adverse clinical events (NACE) at 30-days. Other outcomes included major adverse cardiac events (MACE), all-cause mortality, myocardial infarction (MI), target vessel revascularization (TVR), and major bleeding at 30-days. 1-year all-cause mortality and MACE were also examined. RESULTS Nine trials that randomized women undergoing PCI to bivalirudin (n=3960) versus heparin (n=4050) were included. At 30-days, bivalirudin was associated with reduced risk of NACE (RR=0.85; 95% CI 0.73-0.98; p=0.03), mainly driven by reduction in major bleeding (RR=0.59; 95% CI 0.49-0.71; p<0.001) compared with heparin. No difference in MACE (p=0.92), all-cause mortality (p=0.23), MI (p=0.86); or TVR (p=0.53) was demonstrated between both groups. At 1-year, the risk of MACE and all-cause mortality was similar in both groups. On a subgroup analysis, the benefit associated with bivalirudin appeared to be less evident when Glycoprotein IIb/IIIa inhibitors (GPI) was used as bailout therapy with heparin, however without significant interaction. Furthermore, in STEMI population, no difference in NACE, MACE, or major bleeding was observed between both groups. CONCLUSION In women undergoing PCI, bivalirudin is associated with reduced risk of major bleeding and NACE compared with heparin especially when GPI is routinely used.
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Affiliation(s)
- Marwan Saad
- Department of Medicine, Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ramez Nairooz
- Department of Medicine, Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ahmed Rashed
- Department of Medicine, Division of Cardiovascular Medicine, Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - Hesham K Abdelaziz
- Department of Cardiovascular Medicine, Blackpool Teaching Hospital NHS Foundation Trust, Lancashire Cardiac Centre, Blackpool, UK
| | - Amgad Mentias
- Department of Medicine, Division of Cardiovascular Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - J Dawn Abbott
- Division of Cardiovascular Medicine, Rhode Island Hospital, Brown Medical School, Providence, RI, USA.
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29
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Numasawa Y, Inohara T, Ishii H, Kuno T, Kodaira M, Kohsaka S, Fujii K, Uemura S, Amano T, Kadota K, Nakamura M. Comparison of Outcomes of Women Versus Men With Non-ST-elevation Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention (from the Japanese Nationwide Registry). Am J Cardiol 2017; 119:826-831. [PMID: 28040190 DOI: 10.1016/j.amjcard.2016.11.034] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/17/2016] [Accepted: 11/17/2016] [Indexed: 01/20/2023]
Abstract
Previous studies have reported that women have worse outcomes than men after percutaneous coronary intervention (PCI), especially in patients with ST-elevation myocardial infarction. However, gender-related differences in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) have not been thoroughly investigated. In the Japanese nationwide registry, a total of 43,239 patients with NSTE-ACS from 861 hospitals underwent PCI in 2014. Overall, 11,326 patients (26.2%) were women. The women were older (75.0 ± 10.3 vs 68.7 ± 11.4 years, p <0.001) and had a higher prevalence of hypertension (p <0.001), hyperlipidemia (p = 0.003), and heart failure (p <0.001) compared with men. For inpatient outcomes, women had a higher rate of overall complications (3.3% vs 2.4%, p <0.001) and bleeding complications that required blood transfusion (0.6% vs 0.2%, p <0.001). On multivariate analysis, female gender was an independent predictor of overall (odds ratio [OR] 1.20, 95% CI 1.04 to 1.38; p = 0.011) and bleeding complications (OR 1.94, 95% CI 1.35 to 2.79; p <0.001) after adjustment but was not associated with in-hospital mortality (OR 1.05, 95% CI 0.79 to 1.40; p = 0.747). In conclusion, in patients with NSTE-ACS who underwent PCI, women were at greater risk than men for in-hospital complications, especially in bleeding complications.
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Affiliation(s)
- Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan.
| | - Taku Inohara
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshiki Kuno
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Masaki Kodaira
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Kenshi Fujii
- Division of Cardiology, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
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30
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Incidence and predictors of bleeding complications after percutaneous coronary intervention. J Cardiol 2017; 69:272-279. [DOI: 10.1016/j.jjcc.2016.05.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 04/01/2016] [Accepted: 05/02/2016] [Indexed: 02/03/2023]
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31
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Wimmer NJ, Secemsky EA, Mauri L, Roe MT, Saha-Chaudhuri P, Dai D, McCabe JM, Resnic FS, Gurm HS, Yeh RW. Effectiveness of Arterial Closure Devices for Preventing Complications With Percutaneous Coronary Intervention: An Instrumental Variable Analysis. Circ Cardiovasc Interv 2016; 9:e003464. [PMID: 27059685 DOI: 10.1161/circinterventions.115.003464] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/21/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Bleeding is associated with poor outcomes after percutaneous coronary intervention (PCI). Although arterial closure devices (ACDs) are widely used in clinical practice, whether they are effective in reducing bleeding complications during transfemoral PCI is uncertain. The objective of this study was to evaluate the effectiveness of ACDs for the prevention of vascular access site complications in patients undergoing transfemoral PCI using an instrumental variable approach. METHODS AND RESULTS We performed a retrospective analysis of the CathPCI Registry from 2009 to 2013 at 1470 sites across the United States. Variation in the proportion of ACDs used by each individual physician operator was used as an instrumental variable to address potential confounding. A 2-stage instrumental variable analysis was used as the primary approach. The main outcome measure was vascular access site complications, and nonaccess site bleeding was used as a falsification end point (negative control) to evaluate for potential confounding. A total of 1 053 155 ACDs were used during 2 056 585 PCIs during the study period. The vascular access site complication rate was 1.5%. In the instrumental variable analysis, the use of ACDs was associated with a 0.40% absolute risk reduction in vascular access site complications (95% confidence interval, 0.31-0.42; number needed to treat=250). Absolute differences in nonaccess site bleeding were negligible (risk difference, 0.04%; 95% confidence interval, 0.01-0.07), suggesting acceptable control of confounding in the comparison. CONCLUSIONS ACDs are associated with a modest reduction in major bleeding after PCI. The number needed to treat with ACDs to prevent 1 major bleeding event is high.
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Affiliation(s)
- Neil J Wimmer
- From the Division of Cardiology, Department of Medicine, Christiana Care Health System, Newark, DE (N.J.W.); Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.A.S.); Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (L.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., D.D.); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, CA (P.S.-C.); Division of Cardiology, Department of Medicine, University of Washington, Seattle (J.M.M.); Division of Cardiology, Department of Medicine, Lahey Clinic, Burlington, MA (F.S.R.); Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor (H.S.G.); and Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (R.W.Y.)
| | - Eric A Secemsky
- From the Division of Cardiology, Department of Medicine, Christiana Care Health System, Newark, DE (N.J.W.); Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.A.S.); Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (L.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., D.D.); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, CA (P.S.-C.); Division of Cardiology, Department of Medicine, University of Washington, Seattle (J.M.M.); Division of Cardiology, Department of Medicine, Lahey Clinic, Burlington, MA (F.S.R.); Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor (H.S.G.); and Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (R.W.Y.)
| | - Laura Mauri
- From the Division of Cardiology, Department of Medicine, Christiana Care Health System, Newark, DE (N.J.W.); Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.A.S.); Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (L.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., D.D.); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, CA (P.S.-C.); Division of Cardiology, Department of Medicine, University of Washington, Seattle (J.M.M.); Division of Cardiology, Department of Medicine, Lahey Clinic, Burlington, MA (F.S.R.); Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor (H.S.G.); and Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (R.W.Y.)
| | - Matthew T Roe
- From the Division of Cardiology, Department of Medicine, Christiana Care Health System, Newark, DE (N.J.W.); Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.A.S.); Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (L.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., D.D.); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, CA (P.S.-C.); Division of Cardiology, Department of Medicine, University of Washington, Seattle (J.M.M.); Division of Cardiology, Department of Medicine, Lahey Clinic, Burlington, MA (F.S.R.); Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor (H.S.G.); and Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (R.W.Y.)
| | - Paramita Saha-Chaudhuri
- From the Division of Cardiology, Department of Medicine, Christiana Care Health System, Newark, DE (N.J.W.); Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.A.S.); Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (L.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., D.D.); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, CA (P.S.-C.); Division of Cardiology, Department of Medicine, University of Washington, Seattle (J.M.M.); Division of Cardiology, Department of Medicine, Lahey Clinic, Burlington, MA (F.S.R.); Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor (H.S.G.); and Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (R.W.Y.)
| | - David Dai
- From the Division of Cardiology, Department of Medicine, Christiana Care Health System, Newark, DE (N.J.W.); Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.A.S.); Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (L.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., D.D.); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, CA (P.S.-C.); Division of Cardiology, Department of Medicine, University of Washington, Seattle (J.M.M.); Division of Cardiology, Department of Medicine, Lahey Clinic, Burlington, MA (F.S.R.); Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor (H.S.G.); and Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (R.W.Y.)
| | - James M McCabe
- From the Division of Cardiology, Department of Medicine, Christiana Care Health System, Newark, DE (N.J.W.); Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.A.S.); Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (L.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., D.D.); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, CA (P.S.-C.); Division of Cardiology, Department of Medicine, University of Washington, Seattle (J.M.M.); Division of Cardiology, Department of Medicine, Lahey Clinic, Burlington, MA (F.S.R.); Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor (H.S.G.); and Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (R.W.Y.)
| | - Frederic S Resnic
- From the Division of Cardiology, Department of Medicine, Christiana Care Health System, Newark, DE (N.J.W.); Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.A.S.); Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (L.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., D.D.); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, CA (P.S.-C.); Division of Cardiology, Department of Medicine, University of Washington, Seattle (J.M.M.); Division of Cardiology, Department of Medicine, Lahey Clinic, Burlington, MA (F.S.R.); Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor (H.S.G.); and Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (R.W.Y.)
| | - Hitinder S Gurm
- From the Division of Cardiology, Department of Medicine, Christiana Care Health System, Newark, DE (N.J.W.); Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.A.S.); Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (L.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., D.D.); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, CA (P.S.-C.); Division of Cardiology, Department of Medicine, University of Washington, Seattle (J.M.M.); Division of Cardiology, Department of Medicine, Lahey Clinic, Burlington, MA (F.S.R.); Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor (H.S.G.); and Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (R.W.Y.)
| | - Robert W Yeh
- From the Division of Cardiology, Department of Medicine, Christiana Care Health System, Newark, DE (N.J.W.); Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.A.S.); Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (L.M.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., D.D.); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, CA (P.S.-C.); Division of Cardiology, Department of Medicine, University of Washington, Seattle (J.M.M.); Division of Cardiology, Department of Medicine, Lahey Clinic, Burlington, MA (F.S.R.); Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor (H.S.G.); and Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (R.W.Y.).
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Comparisons of the uptake and in-hospital outcomes associated with second-generation drug-eluting stents between men and women. Coron Artery Dis 2016; 27:442-8. [DOI: 10.1097/mca.0000000000000376] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bates ER. Bleeding Avoidance Strategies, Performance Measures, and the Emperor's New Clothes. JACC Cardiovasc Interv 2016; 9:780-783. [PMID: 27101905 DOI: 10.1016/j.jcin.2016.02.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 02/25/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Eric R Bates
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan.
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Grines CL, Schreiber T. Women Are Complex Creatures. JACC Cardiovasc Interv 2016; 9:685-6. [PMID: 27056306 DOI: 10.1016/j.jcin.2016.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 01/19/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Cindy L Grines
- Heart Hospital, The Detroit Medical Center, Detroit, Michigan.
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Vora AN, Peterson ED, McCoy LA, Garratt KN, Kutcher MA, Marso SP, Roe MT, Messenger JC, Rao SV. The Impact of Bleeding Avoidance Strategies on Hospital-Level Variation in Bleeding Rates Following Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2016; 9:771-779. [DOI: 10.1016/j.jcin.2016.01.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 01/14/2016] [Indexed: 11/24/2022]
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Mamas MA, Nolan J, de Belder MA, Zaman A, Kinnaird T, Curzen N, Kwok CS, Buchan I, Ludman P, Kontopantelis E. Changes in Arterial Access Site and Association With Mortality in the United Kingdom: Observations From a National Percutaneous Coronary Intervention Database. Circulation 2016; 133:1655-67. [PMID: 26969759 DOI: 10.1161/circulationaha.115.018083] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 02/19/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The transradial access (TRA) site has become the default access site for percutaneous coronary intervention in the United Kingdom, with randomized trials and national registry data showing reductions in mortality associated with TRA use. This study evaluates regional changes in access site practice in England and Wales over time, examines whether changes in access site practice have been uniform nationally and across different patient subgroups, and provides national estimates for the potential number of lives saved or lost associated with regional differences in access site practice. METHODS AND RESULTS Using the British Cardiovascular Intervention Society database, we investigated outcomes for growth of TRA in different regions in England and Wales in 448 853 patients who underwent percutaneous coronary intervention from 2005 to 2012. Multiple logistic regression was used to quantify the effect of TRA on 30-day mortality and quantify lives saved and lost by differences in TRA adoption. TRA use increased from 14.0% to 58.6% in 417 038 PCI patients with large variations in different parts of the country. TRA was independently associated with a decreased risk of 30-day mortality (odds ratio=0.70; 95% confidence interval=0.66-0.74), with significant but small differences observed across different regions. The number of estimated lives saved was 450 (95% confidence interval=275-650), and we estimate that an additional 264 (95% confidence interval=153-399) lives would have been saved if TRA adoption were uniform nationally. CONCLUSIONS TRA has become the dominant percutaneous coronary intervention approach in the United Kingdom, with a wide variation in different parts of the country. Changes in practice have contributed to mortality reductions, and inequalities have resulted in missed opportunities for further improvements.
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Affiliation(s)
- Mamas A Mamas
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.).
| | - James Nolan
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Mark A de Belder
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Azfar Zaman
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Tim Kinnaird
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Nick Curzen
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Chun Shing Kwok
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Iain Buchan
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Peter Ludman
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Evangelos Kontopantelis
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
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Boyum JH, Atwell TD, Schmit GD, Poterucha JJ, Schleck CD, Harmsen WS, Kamath PS. Incidence and Risk Factors for Adverse Events Related to Image-Guided Liver Biopsy. Mayo Clin Proc 2016; 91:329-35. [PMID: 26837481 DOI: 10.1016/j.mayocp.2015.11.015] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 11/09/2015] [Accepted: 11/13/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine the incidence of major adverse events related to a large volume of image-guided liver biopsies performed at our institution over a 12-year period and to identify risk factors for major bleeding events. PATIENTS AND METHODS A retrospective analysis of an internally maintained biopsy registry was performed. The analysis revealed that 6613 image-guided liver biopsies were performed in 5987 adult patients between December 7, 2001, and December 31, 2013. Liver biopsies were performed using real-time ultrasound guidance and a spring-loaded biopsy device, with rare exceptions. Adverse events considered major and included in this study were hematoma, infection, pneumothorax, hemothorax, and death. Using data from the biopsy registry, we evaluated statistically significant risk factors (P<.05) for hematoma related to image-guided liver biopsy, including coagulation status, biopsy technique, and medications. RESULTS A total of 49 acute and delayed major adverse events (0.7%) occurred after 6613 liver biopsy events. The incidence of hematoma requiring transfusion and/or angiographic intervention was 0.5% (34 of 6613). The incidence of infection was 0.1% (8 of 6613), and that of hemothorax was 0.06% (4 of 6613). No patient (0%) incurred a pneumothorax after biopsy. Three patients (0.05%) died within 30 days of liver biopsy, 1 being directly related to biopsy. Thirty-eight of 46 major adverse events (83%) presented acutely (within 24 hours). More than 2 biopsy passes, platelets 50,000/μL or less, and female sex were statistically significant risk factors for postbiopsy hemorrhage. CONCLUSION Image-guided liver biopsy performed by subspecialized interventionalists at a tertiary medical center is safe when the platelet count is greater than 50,000/μL. With appreciation of specific risk factors, safety outcomes of this procedure can be optimized in both general and specialized centers.
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Affiliation(s)
| | | | | | - John J Poterucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Cathy D Schleck
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - W Scott Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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Khambatta S, Othman H, Seth M, Lalonde T, Rosman HS, Gurm HS, Mehta RH. Association Of Bleeding Avoidance Strategies with age-related bleeding and In-hospital mortality in patients undergoing percutaneous coronary Interventions. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2016; 17:233-40. [PMID: 26994504 DOI: 10.1016/j.carrev.2016.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/13/2016] [Accepted: 02/24/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The association of bleeding avoidance strategy (BAS) (consisting of a combination of radial access, bivalirudin [rather than heparin +/- glycoprotein GPIIb/IIIa antagonists], and/or vascular closure devices after femoral access) with bleeding and in-hospital outcomes has not been evaluated among elderly patients undergoing percutaneous coronary interventions (PCI). METHODS We studied BAS use, bleeding and in-hospital mortality among 121,635 patients categorized by age (<50, 50-59, 60-69, 70-79, and ≥80years) undergoing PCI from the BMC2 registry (1/2010-12/2013). RESULTS The use of BAS decreased marginally with age and despite improved utilization over time, remained lower among the elderly. BAS was used in a much lower risk cohort among all age groups. Nonetheless, compared with no BAS, the use of this strategy was associated with lower bleeding (adjusted OR 0.984, 95% CI 0.980-0.985) and in-hospital mortality (adjusted OR 0.996, 95% CI 0.994-0.997) among all age-groups. Similar relative reduction in the risk of bleeding was observed among all age groups with BAS use with lowest risk (thus greatest absolute risk reduction given their highest risk for bleeding) for the oldest cohort. CONCLUSIONS BAS use decreased with age among patients undergoing PCI despite its association with lower in-hospital mortality. Although overall utilization improved over time, it still remained lower in the elderly cohort, a group likely to benefit most from it. These data identified an opportunity to design strategies to improve BAS use particularly among high-risk elderly patients undergoing PCI so as to decrease bleeding and reduce related adverse events and costs.
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Affiliation(s)
| | - Hussein Othman
- St. John Hospital and Medical Center, Detroit, Michigan.
| | - Milan Seth
- University of Michigan, Ann, Arbor, Michigan
| | | | | | | | - Rajendra H Mehta
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
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Mehta LS, Beckie TM, DeVon HA, Grines CL, Krumholz HM, Johnson MN, Lindley KJ, Vaccarino V, Wang TY, Watson KE, Wenger NK. Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association. Circulation 2016; 133:916-47. [PMID: 26811316 DOI: 10.1161/cir.0000000000000351] [Citation(s) in RCA: 745] [Impact Index Per Article: 93.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cardiovascular disease is the leading cause of mortality in American women. Since 1984, the annual cardiovascular disease mortality rate has remained greater for women than men; however, over the last decade, there have been marked reductions in cardiovascular disease mortality in women. The dramatic decline in mortality rates for women is attributed partly to an increase in awareness, a greater focus on women and cardiovascular disease risk, and the increased application of evidence-based treatments for established coronary heart disease. This is the first scientific statement from the American Heart Association on acute myocardial infarction in women. Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. This statement provides a comprehensive review of the current evidence of the clinical presentation, pathophysiology, treatment, and outcomes of women with acute myocardial infarction.
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Huang FY, Huang BT, Wang PJ, Zhang C, Zuo ZL, Liao YB, Xia TL, Gui YY, Peng Y, Liu W, Chen M, Zhu Y. Gender Disparity in the Safety and Efficacy of Radial and Femoral Access for Coronary Intervention: A Systematic Review and Meta-Analysis. Angiology 2015; 67:810-9. [PMID: 26668187 DOI: 10.1177/0003319715621164] [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] [Indexed: 02/05/2023]
Abstract
Our aim was to investigate the gender disparity in the safety and efficacy of transradial percutaneous coronary intervention (PCI; TRI) and transfemoral PCI (TFI) by a meta-analysis. MEDLINE, Embase, and CENTRAL were searched to identify studies on vascular access with sex-specific events available or studies on sex difference with the events reported by vascular access. Fifteen studies involving 3 921 848 participants were included. Transradial PCI significantly reduced the risk of bleeding complications in both sexes (TRI-versus-TFI odds ratio [OR]: 0.37 in females vs 0.47 in males) and major adverse cardiac events (MACE) in females (OR: 0.70, P < .001) but not in males (OR: 0.83, P = .15) compared to TFI. Transradial PCI diminished the sex difference in the incidence of bleeding complications (female-versus-male OR: 1.82 with TRI vs 2.39 with TFI; interaction P = .01) and MACE (female-versus-male OR: 1.21 with TRI vs 1.41 with TFI; interaction P = .003) compared to TFI. Females were associated with higher crossover rate in the TRI subgroup but not in the TFI subgroup (interaction P = .05). In conclusion, TRI may improve the safety and efficacy of outcomes in both sexes and be an effective means to cut down the gender difference in prognosis.
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Affiliation(s)
- Fang-Yang Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Bao-Tao Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Peng-Ju Wang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Chen Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhi-Liang Zuo
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yan-Biao Liao
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Tian-Li Xia
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi-Yue Gui
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Liu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ye Zhu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
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Bavry AA, Elgendy IY, Mahmoud A, Jadhav MP, Huo T, Limacher MC, Pepine CJ. Safety of Routine Invasive Versus Selective Invasive Therapy in Women with Non-ST-Elevation Acute Coronary Syndrome. Cardiol Ther 2015; 5:43-50. [PMID: 26661893 PMCID: PMC4906082 DOI: 10.1007/s40119-015-0055-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Indexed: 12/14/2022] Open
Abstract
Introduction Prior studies suggested that a routine invasive approach in the management of non-ST-elevation acute coronary syndrome (NSTE-ACS) is beneficial in men, but the data are less conclusive in women. One study conducted exclusively in women found that routine invasive therapy was associated with a markedly increased risk of major bleeding. This pilot randomized controlled trial compared the safety of a routine invasive versus a selective invasive strategy among women. Methods Women with NSTE-ACS and an additional high-risk characteristic were randomized to a routine invasive versus a selective invasive strategy. The primary outcome was the risk of major bleeding. The secondary outcome was the first occurrence of all-cause death, myocardial infarction, stroke, re-hospitalization for ACS, or major bleeding within 6 months. Results Twenty-three women were assigned to routine invasive therapy and 17 to selective invasive therapy. Twenty-seven women (68%) had elevated troponin T (mean 0.33 ng/mL) and/or creatinine kinase-MB (mean 23 ng/mL). The risk of major bleeding was similar with both approaches (P = 0.99). At 6 months, the secondary outcome occurred in 9% of the routine invasive group versus 18% of the selective invasive group (risk ratio = 0.49, 95% confidence interval 0.09–2.63, P = 0.63). Conclusion This pilot study demonstrated that a routine invasive approach is safe in women. There was suggestion of benefit from routine invasive therapy compared with selective invasive therapy. These data could be used to design an appropriately powered trial to determine the optimal management strategy among women with NSTE-ACS. Electronic supplementary material The online version of this article (doi:10.1007/s40119-015-0055-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anthony A Bavry
- North Florida/South Georgia Veterans Affairs Health System, Gainesville, FL, USA.
- Department of Medicine, University of Florida, Gainesville, FL, USA.
| | - Islam Y Elgendy
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Ahmed Mahmoud
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Manoj P Jadhav
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Tianyao Huo
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Carl J Pepine
- Department of Medicine, University of Florida, Gainesville, FL, USA
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Regitz-Zagrosek V, Oertelt-Prigione S, Prescott E, Franconi F, Gerdts E, Foryst-Ludwig A, Maas AHEM, Kautzky-Willer A, Knappe-Wegner D, Kintscher U, Ladwig KH, Schenck-Gustafsson K, Stangl V. Gender in cardiovascular diseases: impact on clinical manifestations, management, and outcomes. Eur Heart J 2015; 37:24-34. [PMID: 26530104 DOI: 10.1093/eurheartj/ehv598] [Citation(s) in RCA: 420] [Impact Index Per Article: 46.7] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 10/12/2015] [Indexed: 01/08/2023] Open
Affiliation(s)
| | - Vera Regitz-Zagrosek
- Institute of Gender in Medicine, Center for Cardiovascular Research, Charité - Universitätsmedizin Berlin, Hessische Str. 3-4, 10115 Berlin, Germany International Society for Gender Medicine DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany
| | - Sabine Oertelt-Prigione
- Institute of Gender in Medicine, Center for Cardiovascular Research, Charité - Universitätsmedizin Berlin, Hessische Str. 3-4, 10115 Berlin, Germany International Society for Gender Medicine DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany
| | - Eva Prescott
- Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Flavia Franconi
- International Society for Gender Medicine Dep Scienze Biomediche, Regione Basilicata and National Laboratory of Gender Medicine, Consorzio Interuniversitario INBB, University of Sassari, Via Muroni 23a, 07100 Sassari, Italy
| | - Eva Gerdts
- Department of Clinical Science, University of Bergen, PO Box 7804, 5020 Bergen, Norway
| | - Anna Foryst-Ludwig
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany Institute of Pharmacology, Center for Cardiovascular Research, Charité - Universitätsmedizin Berlin, Hessische Str. 3-4, 10115 Berlin, Germany
| | - Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein-Zuid 10, Route 616, 6525 GA Nijmegen, The Netherlands
| | - Alexandra Kautzky-Willer
- International Society for Gender Medicine Gender Medicine Unit, Internal Medicine III, Endocrinology, Medical University of Vienna, International Society for Gender Medicine, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Dorit Knappe-Wegner
- International Society for Gender Medicine University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Ulrich Kintscher
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany Institute of Pharmacology, Center for Cardiovascular Research, Charité - Universitätsmedizin Berlin, Hessische Str. 3-4, 10115 Berlin, Germany
| | - Karl Heinz Ladwig
- Helmholtz Center Munich, Institute of Epidemiology II, German Research Center for Environmental Health, Ingolstädter Landstr. 1, 85764 Neuherberg, Germany
| | - Karin Schenck-Gustafsson
- International Society for Gender Medicine Karolinska Institutet Stockholm, Centre for Gender Medicine, Thorax N3:05, International Society for Gender Medicine, 17176 Stockholm, Sweden
| | - Verena Stangl
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany Clinic for Cardiology and Angiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
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Perdoncin E, Seth M, Dixon S, Cannon L, Khandelwal A, Riba A, David S, Wohns D, Gurm H. The comparative efficacy of bivalirudin is markedly attenuated by use of radial access: insights from Blue Cross Blue Shield of Michigan Cardiovascular Consortium. Eur Heart J 2015; 37:1902-9. [PMID: 26377400 DOI: 10.1093/eurheartj/ehv434] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Accepted: 08/12/2015] [Indexed: 11/14/2022] Open
Abstract
AIM The purpose of our study was to evaluate the relative impact of bivalirudin on bleeding outcomes associated with trans-radial interventions (TRI) in real world practice. METHODS AND RESULTS Data for patients undergoing percutaneous coronary intervention (PCI) between January 2010 and March 2014 at the 47 hospitals participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) were utilized. Propensity matching was used within cohorts defined by access site. The impact of bivalirudin use on in-hospital outcomes was evaluated with Fisher's exact tests. Among patients undergoing trans-femoral interventions (TFI), use of bivalirudin was associated with a reduction in bleeding compared with both glycoprotein IIb/IIIa inhibitors (GPI; 1.67 vs. 3.46%, absolute risk reduction (ARR) 1.79%, odds ratio, OR, 0.47, confidence interval, CI, 0.41-0.54, number needed to treat, NNT 56, P < 0.001) and heparin (1.26 vs. 1.76%, ARR 0.5%, OR 0.71, CI 0.61-0.82, NNT 197, P < 0.001). Among patients undergoing TRI, there was a more modest absolute reduction in bleeding with bivalirudin compared with GPI (0.79 vs. 1.41%, ARR 0.62%, OR 0.56, CI 0.34-0.90, NNT 161, P = 0.016) and no difference in bleeding compared with heparin (0.46 vs. 0.46%, OR 1, CI 0.54-1.84, P = 1). CONCLUSION Bivalirudin is markedly efficacious in reducing bleeding in patients undergoing TFI. The reduction in bleeding associated with bivalirudin use is minimal to absent in patients undergoing TRI. Given its lower cost and comparable outcomes, heparin should be the preferred anticoagulation strategy in those undergoing radial PCI.
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Affiliation(s)
- Emily Perdoncin
- Division of Cardiovascular Medicine, University of Michigan Health System, 2A394, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5853, USA
| | - Milan Seth
- Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Simon Dixon
- Division of Cardiovascular Medicine, Beaumont Health System, Royal Oak, MI, USA
| | - Louis Cannon
- Cardiac and Vascular Research Center of Northern Michigan, Petoskey, MI, USA
| | - Akshay Khandelwal
- Outpatient Cardiovascular Services, Henry Ford Hospital, Detroit, MI, USA
| | - Arthur Riba
- Division of Cardiovascular Medicine, Oakwood Hospital, Dearborn, MI, USA
| | - Shukri David
- Division of Cardiovascular Medicine, St. John Providence Hospital, Detroit, MI, USA
| | - David Wohns
- Division of Cardiovascular Medicine, Spectrum Health, Grand Rapids, MI, USA
| | - Hitinder Gurm
- Division of Cardiovascular Medicine, University of Michigan Health System and Veteran Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Effect of access site, gender, and indication on clinical outcomes after percutaneous coronary intervention: Insights from the British Cardiovascular Intervention Society (BCIS). Am Heart J 2015; 170:164-72, 172.e1-5. [PMID: 26093878 DOI: 10.1016/j.ahj.2015.04.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 04/14/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Gender is a strong predictor of periprocedural major bleeding complications after percutaneous coronary intervention (PCI). The access site represents an important site of such bleeding complications, which has driven adoption of the transradial access (TRA) use during PCI, although female gender is an independent predictor of transradial PCI failure. This study sought to define gender differences in access site practice and study associations between access site choice and clinical outcomes for PCI over a 6-year period, through the analysis of the British Cardiovascular Intervention Society observational database. METHODS AND RESULTS In-hospital major adverse cardiovascular events (a composite of in-hospital mortality and in-hospital myocardial reinfarction and target vessel revascularization), in-hospital bleeding complications, and 30-day mortality were studied based on gender and access site choice (transfemoral access, TRA) in 412,122 patients who underwent PCI between 2007 and 2012 in the United Kingdom. Use of TRA increased in both genders over time, although this lagged behind in women (21% in 2007 to 58% in 2012) compared with men (24% in 2007 to 64% in 2012). In both men and women, TRA was independently associated with a lower in-hospital major adverse cardiovascular event (odds ratio [OR] 0.82, 95% CI 0.76-0.90; OR 0.75, 95% CI 0.66-0.84), in-hospital major bleeding (OR 0.54, 95% CI 0.44-0.66; OR 0.26, 95% CI 0.20-0.33), and 30-day mortality (OR 0.80, 95% CI 0.73-0.89; OR 0.82, 95% CI 0.71-0.94), respectively. CONCLUSIONS Where possible, TRA should be considered as the preferred access site choice for PCI, particularly in women in whom the greatest reductions bleeding end points were observed across all indications.
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Solinas E, Vignali L, Ortolani P, Guastaroba P, Marzocchi A, Manari A, De Palma R, Mehran R, Paoli G, Notarangelo MF, Caminiti C, Ardissino D, Merlini PA. Association of bleeding, mortality and sex in acute coronary syndromes. J Cardiovasc Med (Hagerstown) 2015; 16:347-54. [DOI: 10.2459/jcm.0000000000000174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Singh M. Bleeding Avoidance Strategies During Percutaneous Coronary Interventions. J Am Coll Cardiol 2015; 65:2225-38. [DOI: 10.1016/j.jacc.2015.03.567] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 03/31/2015] [Accepted: 03/31/2015] [Indexed: 12/27/2022]
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Numasawa Y, Kohsaka S, Miyata H, Kawamura A, Noma S, Suzuki M, Nakagawa S, Momiyama Y, Naito K, Fukuda K. Impact of body mass index on in-hospital complications in patients undergoing percutaneous coronary intervention in a Japanese real-world multicenter registry. PLoS One 2015; 10:e0124399. [PMID: 25874887 PMCID: PMC4397046 DOI: 10.1371/journal.pone.0124399] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 03/01/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Obesity is associated with advanced cardiovascular disease. However, some studies have reported the "obesity paradox" after percutaneous coronary intervention (PCI). The relationship between body mass index (BMI) and clinical outcomes after PCI has not been thoroughly investigated, especially in Asian populations. METHODS We studied 10,142 patients who underwent PCI at 15 Japanese hospitals participating in the JCD-KICS registry from September 2008 to April 2013. Patients were divided into four groups according to BMI: underweight, BMI <18.5 (n=462); normal, BMI ≥ 18.5 and <25.0 (n=5,945); overweight, BMI ≥ 25.0 and <30.0 (n=3,100); and obese, BMI ≥ 30.0 (n=635). RESULTS Patients with a high BMI were significantly younger (p<0.001) and had a higher incidence of coronary risk factors such as hypertension (p<0.001), hyperlipidemia (p<0.001), diabetes mellitus (p<0.001), and current smoking (p<0.001), than those with a low BMI. Importantly, patients in the underweight group had the worst in-hospital outcomes, including overall complications (underweight, normal, overweight, and obese groups: 20.4%, 11.5%, 8.4%, and 10.2%, p<0.001), in-hospital mortality (5.8%, 2.1%, 1.2%, and 2.7%, p<0.001), cardiogenic shock (3.5%, 2.0%, 1.5%, and 1.6%, p=0.018), bleeding complications (10.0%, 4.5%, 2.6%, and 2.8%, p<0.001), and receiving blood transfusion (7.6%, 2.7%, 1.6%, and 1.7%, p<0.001). BMI was inversely associated with bleeding complications after adjustment by multivariate logistic regression analysis (odds ratio, 0.95; 95% confidence interval, 0.92-0.98; p=0.002). In subgroup multivariate analysis of patients without cardiogenic shock, BMI was inversely associated with overall complications (OR, 0.98; 95% CI, 0.95-0.99; p=0.033) and bleeding complications (OR, 0.95; 95% CI, 0.91-0.98; p=0.006). Furthermore, there was a trend that BMI was moderately associated with in-hospital mortality (OR, 0.94; 95% CI, 0.88-1.01; p=0.091). CONCLUSIONS Lean patients, rather than obese patients are at greater risk for in-hospital complications during and after PCI, particularly for bleeding complications.
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Affiliation(s)
- Yohei Numasawa
- Department of Cardiology, Ashikaga Red Cross Hospital, Tochigi, Japan
- * E-mail:
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hiroaki Miyata
- University of Tokyo, Healthcare Quality Assessment, Tokyo, Japan
| | - Akio Kawamura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shigetaka Noma
- Department of Cardiology, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Masahiro Suzuki
- Department of Cardiology, National Hospital Organization, Saitama National Hospital, Saitama, Japan
| | - Susumu Nakagawa
- Department of Cardiology, Saiseikai Central Hospital, Tokyo, Japan
| | - Yukihiko Momiyama
- Department of Cardiology, National Hospital Organization, Tokyo Medical Center, Tokyo, Japan
| | - Kotaro Naito
- Department of Cardiology, Keiyu Hospital, Kanagawa, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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Katz DF, Turakhia MP, Sauer WH, Tzou WS, Heath RR, Zipse MM, Aleong RG, Varosy PD, Kao DP. Safety of ventricular tachycardia ablation in clinical practice: findings from 9699 hospital discharge records. Circ Arrhythm Electrophysiol 2015; 8:362-70. [PMID: 25688143 PMCID: PMC9893573 DOI: 10.1161/circep.114.002336] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 02/03/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Outcomes of ventricular tachycardia (VT) ablation have been described in clinical trials and single-center studies. We assessed the safety of VT ablation in clinical practice. METHODS AND RESULTS Using administrative hospitalization data between 1994 and 2011, we identified hospitalizations with primary diagnosis of VT (International Classification of Diseases-9 Clinical Modification code: 427.1) and cardiac ablation (International Classification of Diseases-9 Clinical Modification code: 37.34). We quantified in-hospital adverse events (AEs), including death, stroke, intracerebral hemorrhage, pericardial complications, hematoma or hemorrhage, blood transfusion, or cardiogenic shock. Secondary outcomes included major AEs (stroke, tamponade, or death) and death. Multivariable mixed effects models identified patient and hospital characteristics associated with AEs. Of 9699 hospitalizations with VT ablations (age, 56.5 ± 17.6; 60.1% men), AEs were reported in 825 (8.5%), major AEs in 295 (3.0%), and death in 110 (1.1%). Heart failure had the strongest association with death (odds ratio, 5.52; 95% confidence interval, 2.97-10.3) and major AE (odds ratio, 2.99; 95% confidence interval, 2.15-4.16). Anemia (odds ratio, 4.84; 95% confidence interval, 3.79-6.19) and unscheduled admission (odds ratio, 1.64; 95% confidence interval, 1.37-1.97) were associated with AEs. During the study period, incidence of AEs increased from 9.2% to 12.8% as did the burden of AE risk factors (0.034 patient/y; P < 0.001). Hospital volume > 25 cases/y was associated with fewer AEs compared with lower volume centers (6.4% versus 8.8%; P = 0.008). CONCLUSIONS VT ablation-associated AE rates in clinical practice are similar to those reported in the literature. Over time rates have increased as have the number of AE risk factors per patient. Ablations done electively and at hospitals with higher procedural volume are associated with lower incidence of AEs.
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Affiliation(s)
| | | | | | | | | | | | | | - Paul D. Varosy
- University of Colorado, Aurora, CO,Eastem Colorado VA Medical Center, Denver, CO
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Abtahian F, Waldo S, Jang IK. Comparison of heparin and bivalirudin in patients undergoing percutaneous coronary intervention without use of glycoprotein IIb/IIIa inhibitors. Catheter Cardiovasc Interv 2015; 86:390-6. [PMID: 25753749 DOI: 10.1002/ccd.25911] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 02/28/2015] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The primary objective of this study is the compare the association between bleeding and the use unfractionated heparin (UFH) versus bivalirudin during percutaneous coronary intervention (PCI). BACKGROUND In patients undergoing PCI, the risk of bleeding with use of bivalirudin compared with UFH in the absence of glycoprotein IIb/IIIa inhibitors is not well defined. METHODS Patients undergoing PCI with either UFH or bivalirudin monotherapy at a single institution between 2007 and 2014 were included (n = 6,143). Propensity score matching was used to adjust for baseline characteristics yielding 2,984 well matched patients (1,492 in each group). The primary endpoint was major non-coronary artery bypass graft (non-CABG) related bleeding as defined by a Bleeding Academic Consortium type 3 or 5. Secondary outcomes included combined major and minor bleeding, in-hospital death, periprocedural myocardial infarction, and recurrent ischemia requiring urgent revascularization (repeat PCI). RESULTS In the propensity matched cohort, there was no difference in major bleeding between UFH and bivalirudin monotherapy (1.8% versus 2.4%, P = 0.305). Combined major and minor bleeding was also similar between the two groups (4.3% versus 4.3%, P = 1.0). Likewise, no differences were observed between the bivalirudin and UFH groups in terms of in-hospital death (0.4% versus 0.5%, P = 0.592), periprocedural myocardial infarction (1.5% versus 2.0%, P = 0.332) and repeat PCI (0.7% versus 0.8%, P = 0.669). CONCLUSION Among patients undergoing PCI, there was no significant difference in rate of bleeding between bivalirudin and heparin monotherapy in a real-world setting.
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Affiliation(s)
- Farhad Abtahian
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachuttes
| | - Stephen Waldo
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachuttes
| | - Ik-Kyung Jang
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachuttes
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