1
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Jain SS, Li D, Dressler O, Kotinkaduwa L, Serruys PW, Kappetein AP, Sabik JF, Morice MC, Puskas J, Kandzari DE, Karmpaliotis D, Lembo NJ, Brown WM, Banning AP, Stone GW. Impact of Periprocedural Adverse Events After PCI and CABG on 5-Year Mortality: The EXCEL Trial. JACC Cardiovasc Interv 2023; 16:303-313. [PMID: 36792254 DOI: 10.1016/j.jcin.2022.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 10/04/2022] [Accepted: 10/04/2022] [Indexed: 02/16/2023]
Abstract
BACKGROUND The relative risks for different periprocedural major adverse events (MAE) after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) on subsequent mortality have not been described. OBJECTIVES The aim of this study was to assess the association between periprocedural MAE occurring within 30 days postprocedure and early and late mortality after left main coronary artery revascularization by PCI and CABG. METHODS In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, patients with left main disease were randomized to PCI vs CABG. The associations between 12 prespecified nonfatal MAE and subsequent 5-year all-cause and cardiovascular death in 1,858 patients were examined using logistic regression. RESULTS One or more nonfatal MAE occurred in 111 of 935 patients (11.9%) after PCI and 419 of 923 patients (45.4%) after CABG (P < 0.0001). Patients with MAE were older and had more baseline comorbidities. Within 5 years, all-cause death occurred in 117 and 87 patients after PCI and CABG, respectively. Experiencing an MAE was a strong independent predictor of 5-year mortality after both PCI (adjusted OR: 4.61; 95% CI: 2.71-7.82) and CABG (adjusted OR: 3.25; 95% CI: 1.95-5.41). These associations were present within the first 30 days and between 30 days and 5 years postprocedure. Major or minor bleeding with blood transfusion ≥2 U was an independent predictor of 5-year mortality after both procedures. Stroke, unplanned revascularization for ischemia, and renal failure were significantly associated with mortality only after CABG. CONCLUSIONS In the EXCEL trial, nonfatal periprocedural MAE were strongly associated with early and late mortality after both PCI and CABG for left main disease.
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Affiliation(s)
- Sneha S Jain
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Ditian Li
- Cardiovascular Research Foundation, New York, New York, USA
| | | | | | - Patrick W Serruys
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Joseph F Sabik
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - John Puskas
- Mount Sinai Heart at Mount Sinai Saint Luke's, New York, New York, USA
| | | | - Dimitri Karmpaliotis
- Cardiovascular Research Foundation, New York, New York, USA; NewYork-Presbyterian Hospital and Columbia University Medical Center, New York, New York, USA
| | - Nicholas J Lembo
- Cardiovascular Research Foundation, New York, New York, USA; NewYork-Presbyterian Hospital and Columbia University Medical Center, New York, New York, USA
| | | | - Adrian P Banning
- John Radckiffe, Oxford University Hospitals, Oxford, United Kingdom
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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2
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Bainey KR, Marquis-Gravel G, Mehta SR, Tanguay JF. The Evolution of Anticoagulation for Percutaneous Coronary Intervention: A 40-Year Journey. Can J Cardiol 2022; 38:S89-S98. [PMID: 35850382 DOI: 10.1016/j.cjca.2022.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 07/09/2022] [Accepted: 07/12/2022] [Indexed: 12/30/2022] Open
Abstract
The selection of antithrombotic strategies continue to be of utmost importance during percutaneous coronary intervention (PCI) and have evolved over the past 40 years. Although the backbone of therapy during PCI continues to be a combination of oral antiplatelets and parenteral anticoagulants, a variety of different approaches have been tested over time. In particular, different choices of anticoagulation management have been tested in the stable ischemic heart disease and acute coronary syndrome setting. Evaluation of alternative regimens in the quest to balance ischemic and bleeding risk have undoubtedly improved patient care with PCI. In the current review we highlight the evolution of evidence-based therapeutic options over the past 40 years from the beginning of coronary angioplasty to contemporary PCI. We provide insight into future therapeutic options and provide a contemporary overview of anticoagulation choices for patients who require PCI on the basis of up-to-date evidence balancing ischemic and bleeding risk and according to clinical presentation.
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Affiliation(s)
- Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| | | | - Shamir R Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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3
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Simonsson M, Alfredsson J, Szummer K, Jernberg T, Ueda P. Association of Ischemic and Bleeding Events With Mortality Among Patients in Sweden With Recent Acute Myocardial Infarction Receiving Antithrombotic Therapy. JAMA Netw Open 2022; 5:e2220030. [PMID: 36036452 PMCID: PMC9425148 DOI: 10.1001/jamanetworkopen.2022.20030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Antithrombotic treatment after myocardial infarction (MI) should be individualized based on the patient's risk of ischemic and bleeding events. Uncertainty remains regarding the relative prognostic importance of the 2 types of events, and further study would be useful. OBJECTIVES To compare the association of ischemic vs bleeding events with mortality in patients with a recent MI and assess whether the relative mortality risk for the 2 types of events has changed over the past 2 decades. DESIGN, SETTING, AND PARTICIPANTS A cohort study based on nationwide registers in Sweden, 2012-2017, was conducted. Data were analyzed between July 2021 and May 2022. Patients with MI who were discharged alive with antithrombotic therapy (antiplatelet therapy or oral anticoagulation) were included in the analysis. MAIN OUTCOMES AND MEASURES The incidence of a first ischemic event (hospitalization for MI or ischemic stroke) or bleeding event (hospitalization with bleeding) up to 1 year after discharge and the mortality risk up to 1 year after each type of event were assessed. Cox proportional hazards regression models were used to estimate adjusted hazard ratios (aHRs) for 1-year mortality after an ischemic and bleeding event vs no event, and after an ischemic vs bleeding event. Adjusted HRs for mortality after ischemic vs bleeding events were compared among patients discharged in 1997-2000, 2001-2011, and 2012-2017. RESULTS Of 86 736 patients discharged after MI in 2012-2017 (median age, 71 [IQR, 62-80] years; 57 287 [66.0%] men), 4039 individuals experienced a first ischemic event (5.7 per 100 person-years) and 3399 experienced a first bleeding event (4.8 per 100 person-years). The mortality rate was 46.2 per 100 person-years after an ischemic event and 27.1 per 100 person-years after a bleeding event. The aHR for 1-year mortality vs no event was 4.16 (95% CI, 3.91-4.43) after an ischemic event and 3.43 (95% CI, 3.17-3.71) after a bleeding event. When the 2 types of events were compared, the aHR was 1.27 (95% CI, 1.15-1.40) for an ischemic vs bleeding event. There was no statistically significant difference in the aHR of an ischemic vs bleeding event in 1997-2000, 2001-2011, and 2012-2017. CONCLUSIONS AND RELEVANCE In this nationwide cohort study of patients with a recent MI, postdischarge ischemic events were more common and associated with higher mortality risk compared with bleeding events.
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Affiliation(s)
- Moa Simonsson
- Department of Clinical Sciences, Cardiology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Karolina Szummer
- Department of Medicine, Karolinska Institutet, Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Cardiology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Peter Ueda
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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4
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Fitzgerald S, Thiele H. Primary and Rescue PCI in STEMI. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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5
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Li P, Zhang H, Luo C, Ji Z, Zheng Z, Li Z, Wu F, Li J, Hong L. Occurrence and Risk Factors of Adverse Drug Reactions in Patients Receiving Bivalirudin as Anticoagulant During Percutaneous Coronary Intervention: A Prospective, Multi-Center, Intensive Monitoring Study. Front Cardiovasc Med 2022; 8:781632. [PMID: 35573935 PMCID: PMC9099409 DOI: 10.3389/fcvm.2021.781632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/27/2021] [Indexed: 01/04/2023] Open
Abstract
BackgroundBivalirudin is a common anticoagulant during percutaneous coronary intervention (PCI); however, since its application in China, it still lacks comprehensive evaluation of adverse events (AEs) or adverse drug reactions (ADRs) under the real-clinical setting conditions with a large-sample-size population. Therefore, this prospective, multi-center, intensive monitoring study aimed to comprehensively investigate the occurrence and risk factors of AEs and ADRs during PCI with bivalirudin as an anticoagulant.MethodsA total of 3,049 patients who underwent PCI with bivalirudin as anticoagulant from 27 Chinese medical centers were enrolled. Safety data (AEs/ADRs) were collected from hospital admission to 72 h after bivalirudin administration; then, patients were followed up at the 30th day with the safety data collected as well.ResultsA total of 414 (13.58%) patients occurred AEs, among which 31 (1.02%) cases suffered from severe AEs and 8 (0.26%) cases died due to AEs. Importantly, 118 (3.87%) patients occurred bivalirudin related ADRs, among which 7 (0.23%) cases suffered from severe ADRs while no case (0%) died due to ADRs. Of note, 7 (0.23%) patients showed new ADRs, 34 (1.12%) patients experienced bleeding, and 79 (2.59%) patients had thrombocytopenia. Furthermore, age, renal function impairment, CRUSADE high risk stratification independently correlated with total ADRs risk; CRUSADE high risk stratification, emergency operation, full dose bivalirudin independently associated with bleeding risk; age, renal function impairment independently related to thrombocytopenia risk.ConclusionBivalirudin is well-tolerated as an anticoagulant for PCI procedure; meanwhile, older age, renal function impairment, and CRUSADE high risk stratification serve as independent risk factors of bivalirudin related ADRs.
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Affiliation(s)
- Ping Li
- Department of Cardiology, The First People's Hospital of Yulin, Yulin, China
| | - Hongyan Zhang
- Department of Cardiology, Affiliated Hospital of Qilu Medical University (The People's Hospital of Xin Tai City), Xintai, China
| | - Caidong Luo
- Department of Cardiology, Mianyang Central Hospital, Mianyang, China
| | - Zheng Ji
- First Department of Cardiology, Tangshan Workers' Hospital, Tangshan, China
| | - Zeqi Zheng
- Department of Cardiology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhenyong Li
- Department of Cardiology, Xuzhou Central Hospital, Xuzhou, China
| | - Fan Wu
- Second Department of Cardiology, Xuchang Central Hospital, Xuchang, China
| | - Jinlong Li
- Department of Cardiology, The Affiliated Taian City Central Hospital of Qingdao University, Tai'an, China
- Jinlong Li
| | - Lang Hong
- Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
- *Correspondence: Lang Hong
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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7
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 521] [Impact Index Per Article: 173.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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8
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Piccolo R, Oliva A, Avvedimento M, Franzone A, Windecker S, Valgimigli M, Esposito G, Jüni P. Mortality after bleeding versus myocardial infarction in coronary artery disease: a systematic review and meta-analysis. EUROINTERVENTION 2021; 17:550-560. [PMID: 33840639 PMCID: PMC9725060 DOI: 10.4244/eij-d-20-01197] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Bleeding is the principal safety concern of antithrombotic therapy and occurs frequently among patients with coronary artery disease (CAD). AIMS We aimed to evaluate the prognostic impact of bleeding on mortality compared with that of myocardial infarction (MI) in patients with CAD. METHODS We searched Medline and Embase for studies that included patients with CAD and that reported both the association between the occurrence of bleeding and mortality, and between the occurrence of MI and mortality within the same population. Adjusted hazard ratios (HRs) for mortality associated with bleeding and MI were extracted and ratios of hazard ratios (rHRs) were pooled by using inverse variance weighted random effects meta-analyses. Early events included periprocedural or within 30-day events after revascularisation or acute coronary syndrome (ACS). Late events included spontaneous or beyond 30-day events after revascularisation or ACS. RESULTS A total of 141,059 patients were included across 16 studies; 128,660 (91%) underwent percutaneous coronary intervention. Major bleeding increased the risk of mortality to the same extent as MI (rHRsbleedingvsMI 1.10, 95% CI: 0.71-1.71, p=0.668). Early bleeding was associated with a higher risk of mortality than early MI (rHRsbleedingvsMI 1.46, 95% CI: 1.13-1.89, p=0.004), although this finding was not present when only randomised trials were included. Late bleeding was prognostically comparable to late MI (rHRsbleedingvsMI 1.14, 95% CI: 0.87-1.49, p=0.358). CONCLUSIONS Compared with MI, major and late bleeding is associated with a similar increase in mortality, whereas early bleeding might have a stronger association with mortality.
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Affiliation(s)
- Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Corso Umberto I 40, 80138 Naples, Italy
| | - Angelo Oliva
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Marisa Avvedimento
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Peter Jüni
- Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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9
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Brener SJ, Lembo NJ, Kandzari DE, Sabaté M, Gershlick AH, Banning AP, Buszman PE, Kosmidou I, Simonton CA, Morice MC, Ben-Yehuda O, Dressler O, Zhang Z, Sabik JF, Kappetein AP, Serruys PW, Stone GW. Antithrombotic regimens for percutaneous coronary intervention of the left main coronary artery: The EXCEL trial. Catheter Cardiovasc Interv 2021; 97:766-773. [PMID: 32181569 DOI: 10.1002/ccd.28858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/11/2020] [Accepted: 03/07/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVES We compared the effect of bivalirudin or heparin and use or nonuse of glycoprotein IIb/IIIa inhibitors (GPI) on the outcome of left main coronary artery (LMCA) percutaneous coronary intervention (PCI) in the randomized EXCEL trial. BACKGROUND The optimal antithrombotic regimen to support PCI of the LMCA remains controversial because of low representation of this subset in clinical trials. METHODS The PCI cohort (n = 928) in EXCEL was divided according to bivalirudin versus heparin antithrombin treatment and compared for the primary composite endpoint of death, myocardial infarction (MI), or stroke at 30 days and 5 years. RESULTS Bivalirudin was used in 319 patients (34.4%). The composite endpoint at 30 days occurred in 7.2% versus 3.8% bivalirudin and heparin patients, respectively, p = .02; at 5 years, the composite endpoint occurred in 26.3% versus 19.9% bivalirudin and heparin patients, respectively, p = .02. Major bleeding was more frequent in bivalirudin patients (4.1% versus 1.3%, p = .008). There were no differences in stent thrombosis between the groups. Bivalirudin use was an independent predictor of the 30-day composite endpoint (OR 2.88, 95% CI 1.28-6.48, p = .01) but not of the 5-year composite endpoint (OR 1.30, 95% CI 0.84-2.02, p = .23). GPI use was infrequent (n = 67, 7.2%) and was not associated with adverse outcomes. CONCLUSION Among patients undergoing LMCA PCI in the EXCEL trial, procedural use of bivalirudin was associated with greater rates of periprocedural MI and the 30-day composite endpoint without reducing bleeding complications. Five-year outcomes were similar. GPIs were used infrequently and were not associated with clinical outcomes.
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Affiliation(s)
- Sorin J Brener
- NewYork-Presbyterian Brooklyn Methodist Hospital, New York, New York, USA
| | - Nicholas J Lembo
- Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA.,Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | | | - Manel Sabaté
- University Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | | | - Paweł E Buszman
- Department of Epidemiology and Statistics, Medical School of Silesia, Katowice, Poland.,Department of Cardiovascular Research and Development, American Heart of Poland, Ustron, Poland
| | - Ioanna Kosmidou
- Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA.,Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | | | | | - Ori Ben-Yehuda
- Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA.,Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Ovidiu Dressler
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Zixuan Zhang
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Joseph F Sabik
- Department of Surgery, UH Cleveland Medical Center, Cleveland, Ohio, USA
| | | | | | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.,Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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10
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Song J, Murugiah K, Hu S, Gao Y, Li X, Krumholz HM, Zheng X. Incidence, predictors, and prognostic impact of recurrent acute myocardial infarction in China. Heart 2020; 107:heartjnl-2020-317165. [PMID: 32938773 PMCID: PMC7873426 DOI: 10.1136/heartjnl-2020-317165] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/01/2020] [Accepted: 08/05/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Incidence, predictors, and prognostic impact of recurrent acute myocardial infarction (AMI) after initial AMI remain poorly understood. Data on recurrent AMI in China is unknown. METHODS Using the China Patient-centred Evaluative Assessment of Cardiac Events (PEACE)-Prospective AMI Study, we studied 3387 patients admitted to 53 hospitals for AMI and discharged alive. The association of recurrent AMI with 1-year mortality was evaluated using time-dependent Cox regression. Recurrent AMI events were classified as early (1-30 days), late (31-180 days), and very late (181-365 days). Their impacts on 1-year mortality were estimated by Kaplan-Meier methodology and compared by the log-rank test. Multivariable modelling was used to identify factors associated with recurrent AMI. RESULTS The mean (SD) age was 60.7 (11.9) years and 783 (23.1%) were women. The observed 1-year recurrent AMI rate was 2.5% (95% CI 2.00 to 3.07) with 35.7% events occurring within the first 30 days. Recurrent AMI was associated with 1-year mortality with an adjusted HR of 25.42 (95% CI 15.27 to 42.34). Early recurrent AMI was associated with the highest 1-year mortality rate of 53.3% (log-rank p<0.001). Predictors of recurrent AMI included age 75-84, in-hospital percutaneous coronary intervention, heart rate >90 min/beats at initial admission, renal dysfunction, and not being prescribed any of guideline-based medications at discharge. CONCLUSIONS One-third of recurrent AMI events occurred early. Recurrent AMI is strongly associated with 1-year mortality, particularly if early. Heightened surveillance during this early period and improving prescription of recommended discharge medications may reduce recurrent AMI in China.
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Affiliation(s)
- Jiali Song
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Karthik Murugiah
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
- Yale-New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut, United States
| | - Shuang Hu
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Yan Gao
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Xi Li
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
- Yale-New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut, United States
- Yale School of Public Health, Yale University School of Medicine, and Yale-New Haven Hospital, New Haven, Connecticut, United States
| | - Xin Zheng
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
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11
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Su W, Wang M, Zhu J, Li W, Ding X, Chen H, Li HW, Zhao XQ. Underweight Predicts Greater Risk of Cardiac Mortality Post Acute Myocardial Infarction. Int Heart J 2020; 61:658-664. [PMID: 32641636 DOI: 10.1536/ihj.19-635] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Increased body mass index (BMI) is a well-established risk factor for cardiovascular disease; however, patients with elevated BMI, in comparison to those with low BMI, seem to have better survival, a phenomenon reported as "obesity paradox," which remains controversial. We investigated the effect of BMI on cardiac mortality post acute myocardial infarction (AMI).In this analysis, 3562 AMI patients were included and classified into four groups based on BMI values. The primary endpoint was cardiac death. Compared to normoweight group, overweight and obese group subjects were younger, mostly men, and more likely to receive percutaneous coronary intervention (PCI) and had higher levels of glucose and lipids, but lower level of NTproBNP. Subjects in the underweight group were older, were mostly women, had lower Barthel index (BI), were less likely to receive PCI, and had lower levels of glucose and lipids, but higher level of N-terminal pro-brain natriuretic peptide (NTproBNP) and higher rates of left ventricular ejection fraction (LVEF) < 50%. During a median follow-up period of 1.9 years, cardiac death occurred significantly more in the underweight group (30.0%, 10.6%, 7.0%, and 5.0% among the four groups from underweight to obese; P < 0.001 for trend). The Cox analysis revealed that underweight was an independent predictor of subsequent cardiac death (odds ratio (OR), 1.86; 95% confidence interval (CI), 1.07-3.25) and identified that older age, BI < 60, higher levels of cardiac troponin I (cTnI), LVEF < 50%, and not receiving PCI were independently associated with increased risk of cardiac death.Patients who were underweight were at greater risk of cardiac death post AMI. In addition, older age, frail, higher levels of cTnI, LVEF < 50%, and not receiving PCI also independently predicted cardiac mortality post AMI.
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Affiliation(s)
- Wen Su
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University
| | - Man Wang
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University
| | - Jiegao Zhu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University
| | - Weiping Li
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University
| | - Xiaosong Ding
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University
| | - Hui Chen
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University
| | - Hong-Wei Li
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University.,Department of Internal Medicine, Medical Health Center, Beijing Friendship Hospital, Capital Medical University
| | - Xue-Qiao Zhao
- Clinical Atherosclerosis Research Laboratory, Division of Cardiology, University of Washington
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12
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Wester A, Attar R, Mohammad MA, Andell P, Hofmann R, Jensen J, Szummer K, Erlinge D, Koul S. Impact of Baseline Anemia in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention: A Prespecified Analysis From the VALIDATE-SWEDEHEART Trial. J Am Heart Assoc 2019; 8:e012741. [PMID: 31387441 PMCID: PMC6759912 DOI: 10.1161/jaha.119.012741] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The impact of baseline anemia in a contemporary acute coronary syndrome (ACS) population undergoing percutaneous coronary intervention in the era of predominant radial artery access, potent P2Y12 inhibition, and rare use of glycoprotein IIb/IIIa inhibitors has not been adequately studied. Methods and Results ACS patients who underwent percutaneous coronary intervention between 2014 and 2016 in the VALIDATE‐SWEDEHEART (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 without missing values for hemoglobin were included (n=5482). Mortality, myocardial reinfarction, and major bleeding at 180 days were assessed using Cox regression models and propensity score matching. All studied comorbidities were more common in ACS patients who had anemia (n=792). ACS patients with anemia had higher rates of 180‐day mortality (6.9% versus 2.1%; hazard ratio, 1.9; 95% CI, 1.3–2.7; P<0.001), myocardial reinfarction (4.3% versus 1.9%; hazard ratio, 1.7; 95% CI, 1.1–2.7; P=0.013), and major bleeding (13.4% versus 8.2%; hazard ratio, 1.3; 95% CI, 1.0–1.6; P=0.041). The results were most evident in patients with a hemoglobin value <100 g/L, who had a nearly 10 times higher mortality rate. Conclusions Baseline anemia in ACS patients undergoing percutaneous coronary intervention, treated according to current practice including routine radial artery access, constitutes a high‐risk feature for both ischemic events, bleeding events, and mortality. A multidisciplinary approach is warranted to maximize benefit and minimize patient risk. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02311231.
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Affiliation(s)
- Axel Wester
- Department of Cardiology Clinical Sciences Lund University Skåne University Hospital Lund Sweden
| | - Rubina Attar
- Department of Cardiology Clinical Sciences Lund University Skåne University Hospital Lund Sweden.,Department of Cardiology Clinical Medicine Aalborg University Aalborg Denmark
| | - Moman Aladdin Mohammad
- Department of Cardiology Clinical Sciences Lund University Skåne University Hospital Lund Sweden
| | - Pontus Andell
- Department of Cardiology Clinical Sciences Lund University Skåne University Hospital Lund Sweden.,Unit of Cardiology Department of Medicine Karolinska Institute Stockholm Sweden.,Heart and Vascular Division Karolinska University Hospital Stockholm Sweden
| | - Robin Hofmann
- Division of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institute Stockholm Sweden
| | - Jens Jensen
- Department of Clinical Science and Education Södersjukhuset Karolinska Institute Stockholm Sweden.,Unit of Cardiology Capio S:t Göran Hospital Stockholm Sweden
| | - Karolina Szummer
- Unit of Cardiology Department of Medicine Karolinska Institute Stockholm Sweden.,Heart and Vascular Division Karolinska University Hospital Stockholm Sweden
| | - David Erlinge
- Department of Cardiology Clinical Sciences Lund University Skåne University Hospital Lund Sweden
| | - Sasha Koul
- Department of Cardiology Clinical Sciences Lund University Skåne University Hospital Lund Sweden
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13
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Bhogal S, Mukherjee D, Bagai J, Truong HT, Panchal HB, Murtaza G, Zaman M, Sachdeva R, Paul TK. Bivalirudin Versus Heparin During Intervention in Acute Coronary Syndrome: A Systematic Review of Randomized Trials. Cardiovasc Hematol Disord Drug Targets 2019; 20:3-15. [PMID: 31241442 PMCID: PMC7360918 DOI: 10.2174/1871529x19666190626124057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 05/04/2019] [Accepted: 06/06/2019] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Bivalirudin and heparin are the two most commonly used anticoagulants used during Percutaneous Coronary Intervention (PCI). The results of Randomized Controlled Trials (RCTs) comparing bivalirudin versus heparin monotherapy in the era of radial access are controversial, questioning the positive impact of bivalirudin on bleeding. The purpose of this systematic review is to summarize the results of RCTs comparing the efficacy and safety of bivalirudin versus heparin with or without Glycoprotein IIb/IIIa Inhibitors (GPI). METHODS This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA statements for reporting systematic reviews. We searched the National Library of Medicine PubMed, Clinicaltrial.gov and the Cochrane Central Register of Controlled Trials to include clinical studies comparing bivalirudin with heparin in patients undergoing PCI. Sixteen studies met inclusion criteria and were reviewed for the summary. FINDINGS Several RCTs and meta-analyses have demonstrated the superiority of bivalirudin over heparin plus routine GPI use in terms of preventing bleeding complications but at the expense of increased risk of ischemic complications such as stent thrombosis. The hypothesis of post- PCI bivalirudin infusion to mitigate the risk of acute stent thrombosis has been tested in various RCTs with conflicting results. In comparison, heparin offers the advantage of having a reversible agent, of lower cost and reduced incidence of ischemic complications. CONCLUSION Bivalirudin demonstrates its superiority over heparin plus GPI with better clinical outcomes in terms of less bleeding complications, thus making it as anticoagulation of choice particularly in patients at high risk of bleeding. Further studies are warranted for head to head comparison of bivalirudin to heparin monotherapy to establish an optimal heparin dosing regimen and post-PCI bivalirudin infusion to affirm its beneficial effect in reducing acute stent thrombosis.
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Affiliation(s)
- Sukhdeep Bhogal
- Department of Medicine, Division of Cardiology, East Tennessee State University, Johnson City, TN 37614, United States
| | - Debabrata Mukherjee
- Division of Cardiology, Department of Internal Medicine, Texas Tech University, TX 79409, United States
| | - Jayant Bagai
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Huu T Truong
- University of Arizona College of Medicine, Tucson, AZ 85721, United States
| | - Hemang B Panchal
- Columbia University at Mount Sinai Medical Center, Miami Beach, FL 10027, United States
| | - Ghulam Murtaza
- Department of Medicine, Division of Cardiology, East Tennessee State University, Johnson City, TN 37614, United States
| | | | - Rajesh Sachdeva
- Morehouse School of Medicine, Atlanta, GA 30310, United States
| | - Timir K Paul
- Department of Medicine, Division of Cardiology, East Tennessee State University, Johnson City, TN 37614, United States
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14
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Sim DS, Jeong MH, Kim HS, Gwon HC, Seung KB, Rha SW, Chae SC, Kim CJ, Cha KS, Park JS, Yoon JH, Chae JK, Joo SJ, Choi DJ, Hur SH, Seong IW, Cho MC, Kim DI, Oh SK, Ahn TH, Hwang JY. Utility of GRACE and ACUITY-HORIZONS risk scores to guide dual antiplatelet therapy in Korean patients with acute myocardial infarction undergoing drug-eluting stenting. J Cardiol 2018; 72:411-419. [DOI: 10.1016/j.jjcc.2018.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/07/2018] [Accepted: 04/16/2018] [Indexed: 12/22/2022]
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15
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Venetsanos D, Lawesson SS, James S, Koul S, Erlinge D, Swahn E, Alfredsson J. Bivalirudin versus heparin with primary percutaneous coronary intervention. Am Heart J 2018; 201:9-16. [PMID: 29910059 DOI: 10.1016/j.ahj.2018.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 03/21/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Optimal adjunctive therapy in ST-segment elevation myocardial infarction (STEMI) patients treated with primary PCI (PPCI) remains a matter of debate. Our aim was to compare the efficacy and safety of bivalirudin to unfractionated heparin (UFH), with or without glycoprotein IIb/IIIa inhibitors (GPI) in a large real-world population, using data from the Swedish national registry, SWEDEHEART. METHOD From 2008 to 2014 we identified 23,800 STEMI patients presenting within 12 hours from symptom onset treated with PPCI and UFH ± GPI or bivalirudin±GPI. Primary outcomes included 30-day all-cause mortality and major in-hospital bleeding. Multivariable regression models and propensity score modelling were utilized to study adjusted association between treatment and outcome. RESULTS Treatment with UFH ± GPI was associated with similar risk of 30-day mortality compared to bivalirudin±GPI (5.3% vs 5.5%, adjusted HR 0.94; 95% CI 0.82-1.07). The adjusted risk for 1-year mortality, 30-day and 1-year stent thrombosis and re-infarction did not differ significantly between UFH ± GPI and bivalirudin±GPI. In contrast, treatment with UFH ± GPI was associated with a significant higher risk of major in-hospital bleeding (adjusted OR 1.62; 95% CI 1.30-2.03). When including GPI use in the multivariable analysis, the difference was attenuated and no longer significant (adjusted OR 1.25; 95% CI 0.92-1.70). CONCLUSION Bivalirudin±GPI was associated with significantly lower risk for major inhospital bleeding but no significant difference in 30-day or one year mortality, stent thrombosis or re-infarction compared with UFH ± GPI. The bleeding reduction associated with bivalirudin could be explained by the greater GPI use with UFH.
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Affiliation(s)
- Dimitrios Venetsanos
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | - Sofia Sederholm Lawesson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Stefan James
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Eva Swahn
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Joakim Alfredsson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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16
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Tegtmeyer R, Borst O, Gawaz M, Rath D. Individualized antithrombotic therapy in high-risk cardiovascular patients. Per Med 2018; 15:223-236. [PMID: 29798711 DOI: 10.2217/pme-2017-0081] [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: 11/21/2022]
Abstract
Recent guidelines suggest dual antiplatelet therapy (DAPT) after 'drug-eluting' stent (DES) implantation for 6 months in stable patients and for 12 months in patients after acute coronary syndrome. Serious complications after stent implantation include stent thrombosis, recurrent myocardial infarction, ischemic stroke, cardiovascular death and bleeding. These complications also occur beyond 1 year after coronary intervention. Thus, it is important to consider whether a prolonged DAPT (>12 months after percutaneous coronary intervention) is of benefit to lower thrombo-ischemic events in high-risk patients. This review addresses the results of recent randomized clinical studies (DAPT, ITALIC, OPTIDUAL and PEGASUS) and meta-analyses to support the author's view of which patient collectives might benefit from prolonged DAPT.
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Affiliation(s)
- Roland Tegtmeyer
- Department of Cardiology & Cardiovascular Medicine, University of Tuebingen, Tuebingen, Germany
| | - Oliver Borst
- Department of Cardiology & Cardiovascular Medicine, University of Tuebingen, Tuebingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology & Cardiovascular Medicine, University of Tuebingen, Tuebingen, Germany
| | - Dominik Rath
- Department of Cardiology & Cardiovascular Medicine, University of Tuebingen, Tuebingen, Germany
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17
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Onwordi ENC, Gamal A, Zaman A. Anticoagulant Therapy for Acute Coronary Syndromes. Interv Cardiol 2018; 13:87-92. [PMID: 29928314 PMCID: PMC5980649 DOI: 10.15420/icr.2017:26:1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 03/27/2018] [Indexed: 12/16/2022] Open
Abstract
Anticoagulation in conjunction with antiplatelet therapy is central to the management of acute coronary syndromes (ACS). When used effectively it is associated with a reduction in recurrent ischaemic events including myocardial infarction and stent thrombosis as well as a reduction in death. Effective ischaemic risk reduction whilst balancing bleeding risk remains a clinical challenge. This article reviews the current available evidence for anticoagulation in ACS and recommendations from the European Society of Cardiology.
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Affiliation(s)
| | - Amr Gamal
- Freeman Hospital and Newcastle University and Newcastle Upon Tyne Hospitals NHS TrustNewcastle, UK
| | - Azfar Zaman
- Freeman Hospital and Newcastle University and Newcastle Upon Tyne Hospitals NHS TrustNewcastle, UK
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18
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van Geuns RJ, Sideris G, Van Royen N, El Mahmoud R, Diletti R, Bal Dit Sollier C, Garot J, Van Der Hoeven NW, Cortese B, Ding L, Lechthaler I, Deliargyris EN, Anthopoulos P, Drouet L. Bivalirudin infusion to reduce ventricular infarction: the open-label, randomised Bivalirudin Infusion for Ventricular InfArction Limitation (BIVAL) study. EUROINTERVENTION 2017; 13:e540-e548. [PMID: 28506937 DOI: 10.4244/eij-d-17-00307] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of the study was to investigate whether bivalirudin versus unfractionated heparin (UFH) reduces infarct size (IS) for primary percutaneous coronary intervention (PPCI) in large acute myocardial infarction (AMI). METHODS AND RESULTS This multicentre open-label trial randomised 78 patients undergoing PPCI for large AMI to bivalirudin or UFH. The primary endpoint was IS, assessed by cardiac magnetic resonance (CMR) five days after PPCI. Secondary endpoints included index of microcirculatory resistance (IMR), CMR-assessed microvascular obstruction (MVO) and ejection fraction, and biomarkers for thrombin activity and cell injury. No difference was observed in mean IS at five days (25.0±19.7 g for bivalirudin vs. 27.1±20.7 g for UFH; p=0.75). Early MVO was numerically lower with bivalirudin (5.3±5.8 g vs. 7.7±6.3 g; p=0.17), with no significant difference in ejection fraction at 90 days (54.6±12.0% vs. 49.1±12.1%; p=0.11). In the biomarkers, thrombin-antithrombin complexes were reduced by 4.8 ug/L over the first day for bivalirudin versus an increase of 1.9 ug/L in the heparin arm (p=0.0003). Acute IMR was lower (43.5±21.6 vs. 68.7±35.8 mmHg×s, respectively; p=0.014). In a planned interim analysis, an approximate 11% reduction in IS was observed with bivalirudin; the trial was discontinued for futility. CONCLUSIONS This study did not achieve its primary endpoint of significant infarct size reduction in PPCI by prolonged bivalirudin infusion compared to UFH, even though complete thrombin inhibition was achieved in the acute phase, with a lower myocardial microcirculation resistance at the end of the procedure.
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19
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Shah N, Cox D. Controversies in the Management of ST Elevation Myocardial Infarction: Thrombin Inhibition. Interv Cardiol Clin 2017; 5:497-511. [PMID: 28581998 DOI: 10.1016/j.iccl.2016.06.008] [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: 11/24/2022]
Abstract
Anticoagulation is essential in patients with ST elevation myocardial infarction (STEMI) to prevent further thrombosis and to maintain patency of the infarct-related artery after reperfusion. The various anticoagulant medications available for use in patients with STEMI include unfractionated heparin (UFH), low-molecular-weight heparin, fondaparinux, and bivalirudin, a direct thrombin inhibitor. The authors review the current anticoagulation strategies for patients with STEMI undergoing primary percutaneous coronary intervention (PCI), fibrinolysis, or no reperfusion. The authors present the latest evidence and controversies on this topic, with a focus on bivalirudin versus UFH in the setting of primary PCI for STEMI.
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Affiliation(s)
- Neeraj Shah
- Department of Cardiology, Lehigh Valley Heath Network, 1250 S Cedar Crest Boulevard, Allentown, PA 18103, USA
| | - David Cox
- Department of Cardiology, Lehigh Valley Heath Network, 1250 S Cedar Crest Boulevard, Allentown, PA 18103, USA.
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20
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Jovin IS, Shah RM, Patel DB, Rao SV, Baklanov DV, Moussa I, Kennedy KF, Secemsky EA, Yeh RW, Kontos MC, Vetrovec GW. Outcomes in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction Via Radial Access Anticoagulated With Bivalirudin Versus Heparin. JACC Cardiovasc Interv 2017; 10:1102-1111. [DOI: 10.1016/j.jcin.2017.03.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 02/27/2017] [Accepted: 03/09/2017] [Indexed: 10/19/2022]
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21
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Mina GS, Firouzbakht T, Modi K, Dominic P. Gender-based outcomes of bivalirudin versus heparin in patients undergoing percutaneous coronary interventions: Meta-analysis of randomized controlled trials. Catheter Cardiovasc Interv 2017; 90:735-742. [PMID: 28339139 DOI: 10.1002/ccd.26985] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 10/26/2016] [Accepted: 01/22/2017] [Indexed: 01/26/2023]
Abstract
OBJECTIVES We aimed to perform a gender-based meta-analysis of the outcome of bivalirudin versus heparin in patients undergoing percutaneous coronary interventions (PCI). BACKGROUND Bivalirudin has been shown to decrease major bleeding when compared to heparin ± glycoprotein IIb/IIIa inhibitors (GPI) in patients undergoing PCI. It is unclear, however, if those differences in outcomes are the same for men and women. METHODS We included randomized controlled trials (RCTs) that compared bivalirudin to heparin with or without GPI in patients undergoing PCI and reported outcome data that were stratified by gender. Random effect model was used to pool odds ratio (OR) and 95% confidence intervals (CI). RESULTS We included 9 trials with 33,224 patients. Bivalirudin decreased major bleeding when compared to heparin plus routine GPI in both men (OR: 0.51, P < 0.001) and women (OR: 0.55, P < 0.001). However, when GPI were used selectively with heparin, the bleeding lowering effect of bivalirudin was statistically significant in men (OR: 0.69, P = 0.02) but not in women (OR: 0.71, P = 0.21). When compared to heparin ± GPI, there was a nonstatistically significant trend toward lower all-cause mortality with bivalirudin in both men (OR: 0.76, P = 0.055) and women (OR: 0.79, P = 0.21). There were no significant differences in major adverse cardiovascular events between heparin and bivalirudin in both men and women. CONCLUSION Bivalirudin decreases major bleeding in both men and women when compared to heparin plus routine GPI. However, when compared to heparin alone, the bleeding lowering benefit of bivalirudin is less evident in women. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- George S Mina
- Department of Cardiology, LSUHSC-Shreveport, Shreveport, Louisiana
| | - Tina Firouzbakht
- Department of Medicine, LSUHSC-Shreveport, Shreveport, Louisiana
| | - Kalgi Modi
- Department of Cardiology, LSUHSC-Shreveport, Shreveport, Louisiana
| | - Paari Dominic
- Department of Cardiology, LSUHSC-Shreveport, Shreveport, Louisiana
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22
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Andreou C, Maniotis C, Koutouzis M. The Rise and Fall of Anticoagulation with Bivalirudin During Percutaneous Coronary Interventions: A Review Article. Cardiol Ther 2017; 6:1-12. [PMID: 28105561 PMCID: PMC5446815 DOI: 10.1007/s40119-017-0082-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Indexed: 01/26/2023] Open
Abstract
Bivalirudin is a direct thrombin inhibitor used during percutaneous coronary intervention (PCI). Treatment with bivalirudin compared to heparin plus glycoprotein IIb/IIIa inhibitors (GPI) reduced bleeding complications, but resulted in higher rates of ischemic events, including acute stent thrombosis in ST segment elevation myocardial infarction (STEMI) patients. Thus, it may be considered a reasonable alternative antithrombotic agent in patients at high risk of bleeding undergoing PCI. However its superiority over heparin alone is questioned particularly in the era of novel antiplatelet agents and transradial PCI.
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Affiliation(s)
- Constantinos Andreou
- Cardiology Department, Leiden University Medical Center, Leiden, The Netherlands
| | - Christos Maniotis
- 2nd Cardiology Department, Hellenic Red Cross General Hospital, Athens, Greece
| | - Michael Koutouzis
- 2nd Cardiology Department, Hellenic Red Cross General Hospital, Athens, Greece.
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23
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Lupi A, Schaffer A, Rognoni A, Cavallino C, Bongo AS, Cortese B, Jaffe AS, Angiolillo DJ, Porto I. Intracoronary Bivalirudin Bolus in ST-Elevation Myocardial Infarction Patients Treated with Primary Angioplasty: Theoretical Bases, Clinical Experience, and Future Applications. Am J Cardiovasc Drugs 2016; 16:391-397. [PMID: 27541144 DOI: 10.1007/s40256-016-0186-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Intracoronary thrombus is a common finding in acute coronary syndromes and often correlates with adverse prognosis and complications during percutaneous coronary interventions (PCIs). Bivalirudin, a direct thrombin inhibitor, is one of the recommended antithrombotic treatments for PCI in ST-elevation myocardial infarction (STEMI). The intracoronary administration of a bivalirudin loading dose, even if off-label, offers theoretical advantages over the standard intravenous route, providing a very high drug concentration in the infarct-related artery without increasing the total dose of the drug administered. After the description in case reports of such an approach, a larger scale experience was recently reported in a large cohort of patients with STEMI treated during primary PCI with a bivalirudin intracoronary loading dose followed by the standard intravenous maintenance infusion. As a control group, a propensity score-matched cohort of patients undergoing primary PCI treated with intravenous bivalirudin in the same institution was selected. Compared with the intravenous bolus, the intracoronary administration of bivalirudin was associated with improved ST-segment resolution, lower post-procedural peak CK-MB levels, and better Thrombolysis in Myocardial Infarction (TIMI) frame count values, without difference in bleeding rates. Thus, this new promising antithrombotic strategy, based on the intracoronary administration of a bivalirudin loading dose during primary PCI, appeared safe, improved myocardial reperfusion, and mitigated enzymatic myocardial infarct size compared with the standard intravenous protocol. Randomized trials are warranted to confirm these results and evaluate the possible long-term clinical benefits.
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Affiliation(s)
- Alessandro Lupi
- Cardiologia II, AOU Maggiore della Carità, C.so Mazzini 18, 28100, Novara, Italy.
- Cardiology Division, ASL VCO, Domodossola, Italy.
| | - Alon Schaffer
- Cardiologia II, AOU Maggiore della Carità, C.so Mazzini 18, 28100, Novara, Italy
| | - Andrea Rognoni
- Cardiologia II, AOU Maggiore della Carità, C.so Mazzini 18, 28100, Novara, Italy
| | | | - Angelo S Bongo
- Cardiologia II, AOU Maggiore della Carità, C.so Mazzini 18, 28100, Novara, Italy
| | | | - Allan S Jaffe
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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24
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Arora S, Panaich SS, Patel N, Patel NJ, Lahewala S, Thakkar B, Savani C, Jhamnani S, Singh V, Patel N, Patel S, Sonani R, Patel A, Tripathi B, Deshmukh A, Chothani A, Patel J, Bhatt P, Mohamad T, Remetz MS, Curtis JP, Attaran RR, Mena CI, Schreiber T, Grines C, Cleman M, Forrest JK, Badheka AO. Impact of Glycoprotein IIb/IIIa Inhibitors Use on Outcomes After Lower Extremity Endovascular Interventions From Nationwide Inpatient Sample (2006-2011). Catheter Cardiovasc Interv 2016; 88:605-616. [PMID: 26914274 DOI: 10.1002/ccd.26452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 10/18/2015] [Accepted: 01/18/2016] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The aim of our study was to study the impact of glycoprotein IIb/IIIa inhibitors (GPI) on in-hospital outcomes. BACKGROUND There is paucity of data regarding the impact of GPI on the outcomes following peripheral endovascular interventions. METHODS The study cohort was derived from Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database between the years 2006 and 2011. Peripheral endovascular interventions and GPI utilization were identified using appropriate ICD-9 Diagnostic and procedural codes. Two-level hierarchical multivariate mixed models were created. The study outcomes were: primary (in-hospital mortality and amputation studied separately) and secondary (composite of in-hospital mortality and postprocedural complications). Hospitalization costs were also assessed. RESULTS GPI utilization (OR, 95% CI, P-value) was independently predictive of lower amputation rates (0.36, 0.27-0.49, <0.001). There was no significant difference in terms of in-hospital mortality (0.59, 0.31-1.14, P 0.117), although GPI use predicted worse secondary outcomes (1.23, 1.03-1.47, 0.023). Following propensity matching, the amputation rate was lower (3.2% vs. 8%, P < 0.001), while hospitalization costs were higher in the cohort that received GPI ($21,091 ± 404 vs. 19,407 ± 133, P < 0.001). CONCLUSIONS Multivariate analysis revealed GPI use in peripheral endovascular interventions to be suggestive of an increase in composite end-point of in-hospital mortality and postprocedural complications, no impact on in-hospital mortality alone, significantly lower rate of amputation, and increase in hospitalization costs. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | | | - Nilay Patel
- Saint Peter's University Hospital, New Brunswick, New Jersey
| | | | | | - Badal Thakkar
- Tulane School of Public Health & Tropical Medicine, New Orleans, Louisiana
| | | | | | - Vikas Singh
- University of Miami Miller School of Medicine, Miami, Florida
| | - Nish Patel
- University of Miami Miller School of Medicine, Miami, Florida
| | - Samir Patel
- Western Reserve Health System, Youngstown, Ohio
| | - Rajesh Sonani
- Public Health Department, Emory University School of Medicine, Atlanta, Georgia
| | - Achint Patel
- Icahn School of Medicine at Mount Sinai, New York
| | | | - Abhishek Deshmukh
- Mayo Clinic, Rochester, Minnesota.,MedStar Washington Hospital Center, Washington, DC
| | | | - Jay Patel
- Detroit Medical Center, Detroit, Michigan
| | - Parth Bhatt
- Tulane School of Public Health & Tropical Medicine, New Orleans, Louisiana
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25
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Savonitto S, De Luca G, Goldstein P, van T' Hof A, Zeymer U, Morici N, Thiele H, Montalescot G, Bolognese L. Antithrombotic therapy before, during and after emergency angioplasty for ST elevation myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:173-190. [PMID: 26124456 DOI: 10.1177/2048872615590148] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The first three hours after symptom onset hold the maximum potential for myocardial reperfusion and salvage in ST-elevation myocardial infarction (STEMI) patients. During this period timely primary percutaneous coronary intervention (PPCI) or, when PPCI is not promptly feasible, pre-hospital administration of fibrinolyis or a glycoprotein IIb/IIIa-inhibitor (GPI) have been shown to restore coronary patency and reperfusion and even result in myocardial infarction (MI) abortion. On the other hand, oral antiplatelet therapy may not yet guarantee sufficient platelet inhibition. Patients presenting after this golden time have less, if any, benefit from an aggressive antithrombotic treatment prior to PPCI. Antithrombotic treatment during primary angioplasty should be tailored on the basis of the coronary thrombotic burden, vascular approach and the patient's risk of bleeding complications. A GPI-based approach may be favourable in patients presenting early with large MI and high thrombus burden, whereas a bivalirudin-based approach without GPI may be preferred in patients with higher bleeding risk. There are no data to support the use of GPI in bailout conditions. The powerful oral P2Y12 inhibitors, prasugrel and ticagrelor, have been clearly shown to prevent stent thrombosis and recurrent ischaemic events after emergency percutaneous coronary intervention in STEMI patients. Open issues remaining are the treatment of patients with high bleeding risk, such as the elderly and those requiring anticoagulation, as well as the duration of dual antiplatelet therapy after STEMI.
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Affiliation(s)
| | | | | | | | - Uwe Zeymer
- 5 Klinikum Ludwigshafen, Ludwigshafen, Germany
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Affiliation(s)
- Sahil A Parikh
- From the Division of Cardiovascular Medicine, Department of Medicine, University Hospitals Case Medical Center, Harrington Heart and Vascular Institute and Case Western Reserve University School of Medicine, Cleveland, OH (S.A.P.); and Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.D.).
| | - Douglas E Drachman
- From the Division of Cardiovascular Medicine, Department of Medicine, University Hospitals Case Medical Center, Harrington Heart and Vascular Institute and Case Western Reserve University School of Medicine, Cleveland, OH (S.A.P.); and Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (D.E.D.)
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Schussler JM, Vasudevan A, von Bose LJ, Won JI, McCullough PA. Comparative Efficacy of Transradial Versus Transfemoral Approach for Coronary Angiography and Percutaneous Coronary Intervention. Am J Cardiol 2016; 118:482-8. [PMID: 27378143 DOI: 10.1016/j.amjcard.2016.05.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/23/2016] [Accepted: 05/23/2016] [Indexed: 10/21/2022]
Abstract
Transradial artery (TRA) approach is associated with fewer vascular complications and reduced mortality in patients at high risk compared with transfemoral approach (TFA). The objective of our study was to compare the characteristics and outcomes of patients who had coronary angiography by TRA and TFA over the course of hospital implementation of this approach. We included 12,928 patients from Baylor University Medical Center and Baylor Heart and Vascular Hospital, Dallas, Texas, who underwent a coronary angiography from January 2008 to March 2015. To control for selection bias and the learning curve, a nested matched study design was used for patients with percutaneous coronary intervention (PCI) with TRA patients matched with TFA by age (±2 years) and calendar year of the procedure in a ratio of 1:3. TRA for PCI increased from nearly 0% in 2008 to 9% in 2014. Including patients from 2011 to 2015 for the analysis, patients with TFA were older (65 ± 12 vs 64 ± 11) and had lower mean body mass index (30 ± 7 vs 33 ± 9 kg/m(2)) than patients with TRA. Patients with TRA had less bleeding, dialysis, pseudoaneurysm, and access site hematomas than the patients with TRA (0.7% vs 0%; p = 0.02). By a conditional logistic regression, we observed fewer complications, readmissions, and in-hospital deaths among TRA patients than the matched TFA patients. In conclusion, patients undergoing angiography with/without PCI through TRA had fewer complications, readmissions, and a shorter length of hospital stay after procedure versus TFA at our hospital.
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Fahrni G, Wolfrum M, De Maria GL, Banning AP, Benedetto U, Kharbanda RK. Prolonged High-Dose Bivalirudin Infusion Reduces Major Bleeding Without Increasing Stent Thrombosis in Patients Undergoing Primary Percutaneous Coronary Intervention: Novel Insights From an Updated Meta-Analysis. J Am Heart Assoc 2016; 5:JAHA.116.003515. [PMID: 27451466 PMCID: PMC5015387 DOI: 10.1161/jaha.116.003515] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background The optimal antithrombotic therapy in patients with ST‐segment‐elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI) remains a matter of debate. This updated meta‐analysis investigated the impact of (1) bivalirudin (with and without prolonged infusion) and (2) prolonged PCI‐dose (1.75 mg/hg per hour) bivalirudin infusion compared with conventional antithrombotic therapy on clinical outcomes in patients undergoing primary PCI. Methods and Results Eligible randomized trials were searched through MEDLINE, EMBASE, Cochrane database, and proceedings of major congresses. Prespecified outcomes were major bleeding (thrombolysis in myocardial infarction major and Bleeding Academic Research Consortium 3–5), acute stent thrombosis, as well as all‐cause and cardiac mortality at 30 days. Six randomized trials (n=17 294) were included. Bivalirudin compared with heparin (+/− glycoprotein‐IIb/IIIa inhibitor) was associated with reduction in major bleeding (odds ratio [OR]: 0.65, 95% CI: 0.48–0.88, P=0.006, derived from all 6 trials), increase in acute stent thrombosis (OR: 2.75, 95% CI: 1.46–5.18, P=0.002, 5 trials), and lower rate of all‐cause mortality (OR: 0.81, 95% CI: 0.67–0.98, P=0.03, 6 trials) as well as cardiac mortality (OR: 0.69, 95% CI: 0.55–0.87, P=0.001, 5 trials). The incidence of acute stent thrombosis did not differ between the prolonged PCI‐dose bivalirudin and comparator group (OR: 0.81, 95% CI: 0.27–2.46, P=0.71, 3 trials), whereas the risk of bleeding was reduced despite treatment with high‐dose bivalirudin infusion (OR: 0.28, 95% CI: 0.13–0.60, P=0.001, 3 trials). Conclusions Bivalirudin (with and without prolonged infusion) compared with conventional antithrombotic therapy in ST‐segment‐elevation myocardial infarction patients undergoing primary PCI reduces major bleeding and death, but increases the rate of acute stent thrombosis. However, prolonging the bivalirudin infusion at PCI‐dose (1.75 mg/kg per hour) for 3 hours eliminates the excess risk of acute stent thrombosis, while maintaining the bleeding benefits.
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Affiliation(s)
- Gregor Fahrni
- Oxford Heart Centre, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Mathias Wolfrum
- Oxford Heart Centre, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | | | - Adrian P Banning
- Oxford Heart Centre, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Umberto Benedetto
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, UK
| | - Rajesh K Kharbanda
- Oxford Heart Centre, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
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Brener SJ, Kirtane AJ, Stuckey TD, Witzenbichler B, Rinaldi MJ, Neumann FJ, Metzger DC, Henry TD, Cox DA, Duffy PL, Mazzaferri EL, Mehran R, Parvataneni R, Brodie BR, Stone GW. The Impact of Timing of Ischemic and Hemorrhagic Events on Mortality After Percutaneous Coronary Intervention: The ADAPT-DES Study. JACC Cardiovasc Interv 2016; 9:1450-7. [PMID: 27372190 DOI: 10.1016/j.jcin.2016.04.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 03/29/2016] [Accepted: 04/07/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The aim of this study was to understand the impact of the timing of ischemic and hemorrhagic events after percutaneous coronary intervention (PCI) with drug-eluting stents on subsequent mortality. BACKGROUND These events have been strongly associated with subsequent death. METHODS In the multicenter, prospective ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug Eluting Stents) study, patients at 11 clinical sites with successful PCI with drug-eluting stents underwent assessment of platelet function and were followed for 2 years. Events occurring after PCI-definite or probable stent thrombosis (ST), myocardial infarction (MI) not related to ST, and clinically relevant bleeding (CB)-were classified as early (≤30 days), late (31 to 365 days), or very late (>365 days). Mortality within 30 days of each event was estimated by Kaplan-Meier methodology. Cox regression multivariate modeling was used to analyze the relationship between each event (as a time-updated variable) and mortality over the entire study period. RESULTS Among 8,582 patients, 1,060 (12.4%) had events-691 (8.1%) had CB, 294 (3.4%) had MI, and 75 (0.9%) had ST-and 7,522 (87.6%) had no events. The highest risk was associated with early ST (38.5% mortality at 30 days after the event), whereas very late MI (7.5%) and late CB (7.3%) were less dangerous. By multivariate analysis, each event was independently predictive of death, with hazard ratios of 2.4, 1.8, and 11.4, respectively (p < 0.0001). CONCLUSIONS Approximately 1 in 8 patients successfully undergoing PCI with drug-eluting stents had CB, MI, or ST during the ensuing 2 years. These events are associated with an increased hazard of mortality, particularly within the first 30 days following the event, warranting efforts to prevent their occurrence.
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Affiliation(s)
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, New York; New York Presbyterian-Columbia University Medical Center, New York, New York
| | - Thomas D Stuckey
- LeBauer Cardiovascular Research Foundation/Cone Health, Greensboro, North Carolina
| | | | - Michael J Rinaldi
- Sanger Heart & Vascular Institute/Carolinas HealthCare System, Charlotte, North Carolina
| | | | | | - Timothy D Henry
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota; Cedars-Sinai Heart Institute, Los Angeles, California
| | - David A Cox
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Peter L Duffy
- Reid Heart Center, First Health of the Carolinas, Pinehurst, North Carolina
| | | | - Roxana Mehran
- Cardiovascular Research Foundation, New York, New York; Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Bruce R Brodie
- LeBauer Cardiovascular Research Foundation/Cone Health, Greensboro, North Carolina
| | - Gregg W Stone
- Cardiovascular Research Foundation, New York, New York; New York Presbyterian-Columbia University Medical Center, New York, New York
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Picchi A, Ferlini M, Limbruno U, De Servi S. Which long-term antiplatelet regimen for patients with acute coronary syndromes? Cardiovasc Drugs Ther 2016; 30:333-8. [PMID: 27192996 DOI: 10.1007/s10557-016-6667-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Dual antiplatelet therapy (DAPT ) is recommended up to 12 months in patients with acute coronary syndromes, but the risk of cardiovascular events in this group of subjects remains high, also in the long-term follow-up. The potential benefit of a prolonged period of DAPT has recently been assessed in three large-volume randomized clinical trials (PEGASUS, DAPT-MI, TRA2P-TIMI 50) but final results are quite difficult to interpret and clear indications for the clinical practice are so far lacking. A direct comparison of the three studies is challenging since relevant differences exist as to clinical features and risk profile of the study populations. Different anti-platelet drugs have been tested in addition to aspirin making it difficult to understand which antithrombotic regimen guarantees the best balance between thrombotic and haemorragic events. Finally, specific designs of these trials, evaluating complex composite end-points, may generate further difficulties in the interpretation of data. We believe that the use of total mortality rather than cardiovascular death as end-point, would better describe the long-term outcome incorporating the catastrophic consequences of bleeding. This review seeks to highlight strengths and weaknesses of these three large-volume trials and tries to establish whether or not prolonging DAPT beyond 12 months in patients with acute coronary syndromes is useful and which anti-thrombotic regimen would offer the best balance between thrombotic and bleeding risk.
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Affiliation(s)
| | - Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | | | - Stefano De Servi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Dangas GD, Schoos MM, Steg PG, Mehran R, Clemmensen P, van ‘t Hof A, Prats J, Bernstein D, Deliargyris EN, Stone GW. Early Stent Thrombosis and Mortality After Primary Percutaneous Coronary Intervention in ST-Segment–Elevation Myocardial Infarction. Circ Cardiovasc Interv 2016; 9:e003272. [DOI: 10.1161/circinterventions.115.003272] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 03/28/2016] [Indexed: 11/16/2022]
Affiliation(s)
- George D. Dangas
- From the Division of Cardiology, Mount Sinai Medical Center, New York, NY (G.D.D., M.M.S., R.M.); Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (G.D.D., R.M., G.W.S.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (M.M.S., P.C.); French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire Fibrosis, Inflammation, Remodelling, Université Paris-Diderot, Paris, France (P.G.S.); INSERM U-1148, Paris, France (P.G.S.); Department of Cardiology,
| | - Mikkel M. Schoos
- From the Division of Cardiology, Mount Sinai Medical Center, New York, NY (G.D.D., M.M.S., R.M.); Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (G.D.D., R.M., G.W.S.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (M.M.S., P.C.); French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire Fibrosis, Inflammation, Remodelling, Université Paris-Diderot, Paris, France (P.G.S.); INSERM U-1148, Paris, France (P.G.S.); Department of Cardiology,
| | - Philippe Gabriel Steg
- From the Division of Cardiology, Mount Sinai Medical Center, New York, NY (G.D.D., M.M.S., R.M.); Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (G.D.D., R.M., G.W.S.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (M.M.S., P.C.); French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire Fibrosis, Inflammation, Remodelling, Université Paris-Diderot, Paris, France (P.G.S.); INSERM U-1148, Paris, France (P.G.S.); Department of Cardiology,
| | - Roxana Mehran
- From the Division of Cardiology, Mount Sinai Medical Center, New York, NY (G.D.D., M.M.S., R.M.); Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (G.D.D., R.M., G.W.S.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (M.M.S., P.C.); French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire Fibrosis, Inflammation, Remodelling, Université Paris-Diderot, Paris, France (P.G.S.); INSERM U-1148, Paris, France (P.G.S.); Department of Cardiology,
| | - Peter Clemmensen
- From the Division of Cardiology, Mount Sinai Medical Center, New York, NY (G.D.D., M.M.S., R.M.); Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (G.D.D., R.M., G.W.S.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (M.M.S., P.C.); French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire Fibrosis, Inflammation, Remodelling, Université Paris-Diderot, Paris, France (P.G.S.); INSERM U-1148, Paris, France (P.G.S.); Department of Cardiology,
| | - Arnoud van ‘t Hof
- From the Division of Cardiology, Mount Sinai Medical Center, New York, NY (G.D.D., M.M.S., R.M.); Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (G.D.D., R.M., G.W.S.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (M.M.S., P.C.); French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire Fibrosis, Inflammation, Remodelling, Université Paris-Diderot, Paris, France (P.G.S.); INSERM U-1148, Paris, France (P.G.S.); Department of Cardiology,
| | - Jayne Prats
- From the Division of Cardiology, Mount Sinai Medical Center, New York, NY (G.D.D., M.M.S., R.M.); Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (G.D.D., R.M., G.W.S.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (M.M.S., P.C.); French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire Fibrosis, Inflammation, Remodelling, Université Paris-Diderot, Paris, France (P.G.S.); INSERM U-1148, Paris, France (P.G.S.); Department of Cardiology,
| | - Debra Bernstein
- From the Division of Cardiology, Mount Sinai Medical Center, New York, NY (G.D.D., M.M.S., R.M.); Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (G.D.D., R.M., G.W.S.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (M.M.S., P.C.); French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire Fibrosis, Inflammation, Remodelling, Université Paris-Diderot, Paris, France (P.G.S.); INSERM U-1148, Paris, France (P.G.S.); Department of Cardiology,
| | - Efthymios N. Deliargyris
- From the Division of Cardiology, Mount Sinai Medical Center, New York, NY (G.D.D., M.M.S., R.M.); Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (G.D.D., R.M., G.W.S.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (M.M.S., P.C.); French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire Fibrosis, Inflammation, Remodelling, Université Paris-Diderot, Paris, France (P.G.S.); INSERM U-1148, Paris, France (P.G.S.); Department of Cardiology,
| | - Gregg W. Stone
- From the Division of Cardiology, Mount Sinai Medical Center, New York, NY (G.D.D., M.M.S., R.M.); Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (G.D.D., R.M., G.W.S.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (M.M.S., P.C.); French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire Fibrosis, Inflammation, Remodelling, Université Paris-Diderot, Paris, France (P.G.S.); INSERM U-1148, Paris, France (P.G.S.); Department of Cardiology,
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Zeymer U, Rao SV, Montalescot G. Anticoagulation in coronary intervention. Eur Heart J 2016; 37:3376-3385. [DOI: 10.1093/eurheartj/ehw061] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 01/28/2016] [Accepted: 01/28/2016] [Indexed: 01/16/2023] Open
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Abstract
PURPOSE OF REVIEW Thrombus formation, usually on a ruptured atherosclerotic plaque, is pivotal in the pathogenesis of ST segment elevation myocardial infarction (STEMI). This thrombus formation provides the milieu for re-occlusion of the infarct-related artery, the main location of re-infarction post-STEMI. Although rates of re-infarction are lower after reperfusion by primary percutaneous coronary intervention (PCI) than after fibrinolytic therapy, re-infarction remains a major cause of morbidity and mortality. RECENT FINDINGS The predominant cause of re-infarction after primary PCI is stent thrombosis. Two recent trials [A Prospective, Randomized Trial of Ambulance Initiation of Bivalirudin vs. Heparin ± Glycoprotein IIb/IIIa Inhibitors in Patients with STEMI Undergoing Primary PCI (EUROMAX) and Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI)] have each reported higher rates of stent thrombosis in the first 24 h after primary PCI in patients assigned to receive bivalirudin, which affects the balance of risks and benefit of bivalirudin post-STEMI. Also, in a subanalysis of the Platelet Inhibition And Patient Outcomes trial, ticagrelor reduces re-infarction compared with clopidogrel in patients with STEMI after primary PCI. Other nonpharmacological or mechanical interventions during primary PCI, with the exception of newer-generation drug-eluting stents in the Swedish Coronary Angiography and Angioplasty Registry, have not affected rates of re-infarction. SUMMARY Re-infarction remains a major cause of morbidity and mortality. Re-infarction rates are altered by pharmacological strategy and stent selection in primary PCI. The design of future trials to detect possible treatment differences in relatively low event rates will provide challenges, and may require more novel strategies such as administrative data collection for patient characteristics and key outcomes.
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Kimmelstiel C, Pinto D, Aronow HD, Weintraub AR, Dangas G, Fan W, Prats J, Deliargyris EN, Katzen BT. Bivalirudin Is Associated With Improved In-Hospital Outcomes Compared With Heparin in Percutaneous Vascular Interventions. Circ Cardiovasc Interv 2016; 9:e002823. [DOI: 10.1161/circinterventions.115.002823] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Peripheral vascular interventions are increasingly preferred for the treatment of patients with symptomatic peripheral arterial disease because they are associated with similar clinical outcomes and lower morbidity than open surgical procedures. The objective of this study was to assess the comparative effectiveness of procedural anticoagulation with bivalirudin compared with unfractionated heparin in patients undergoing peripheral vascular interventions.
Methods and Results—
This was a retrospective, observational study using the Premier Hospital administrative database. We examined 23 934 consecutive patients undergoing lower extremity peripheral vascular interventions between January 2008 and December 2012 who were treated with either bivalirudin or unfractionated heparin. In-hospital end points included death, myocardial infarction, transfusion, stroke, amputation, and the composite end points of major adverse cardiovascular events, and net adverse clinical events. Propensity score matching was performed to control for baseline imbalances and yielded 3649 matched pairs. After propensity score matching, patients treated with bivalirudin had lower in-hospital event rates with significantly lower mortality (odds ratio, 0.40;
P
=0.017), need for blood product transfusion (odds ratio, 0.74;
P
=0.009), major adverse cardiovascular events (odds ratio, 0.64;
P
=0.003), and net adverse clinical events (odds ratio, 0.72;
P
<0.001). These associations were observed consistently across clinically relevant subgroups.
Conclusions—
In patients undergoing peripheral vascular interventions, procedural anticoagulation with bivalirudin may result in more favorable in-hospital outcomes compared with unfractionated heparin, the current standard of care. These observations will require prospective confirmation in a randomized, controlled trial.
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Affiliation(s)
- Carey Kimmelstiel
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - Duane Pinto
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - Herbert D. Aronow
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - Andrew R. Weintraub
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - George Dangas
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - Weihong Fan
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - Jayne Prats
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - Efthymios N. Deliargyris
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - Barry T. Katzen
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
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Shah R, Rogers KC, Matin K, Askari R, Rao SV. An updated comprehensive meta-analysis of bivalirudin vs heparin use in primary percutaneous coronary intervention. Am Heart J 2016; 171:14-24. [PMID: 26699596 DOI: 10.1016/j.ahj.2015.10.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 10/14/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Despite several randomized controlled trials and meta-analyses, the ideal anticoagulant for patients undergoing primary percutaneous coronary intervention (PCI) remains controversial. We performed an updated meta-analysis including recently reported randomized clinical trials that compare bivalirudin and heparin with or without provisional administration of a glycoprotein IIb/IIIa inhibitor (GPI) for primary PCI. METHODS AND RESULTS Scientific databases and Web sites were searched for randomized clinical trials. Data from 6 trials involving 14,095 patients were included. The pooled risk ratios (RRs) were calculated using random-effects models. Moderator analyses examined the impact of routine use of GPI, radial access, and P2Y12 inhibitors on safety outcomes. At 30 days, patients receiving bivalirudin had rates of major adverse cardiac events similar to those receiving heparin with or without provisional GPI (RR 1.02, 95% CI 0.87-1.19, P = .800), myocardial infarction (RR 1.41, 95% CI 0.94-2.11, P = .089), target vessel revascularization (RR 1.37, 95% CI 0.91-2.04, P = .122), and net adverse clinical events (RR 0.81, 95% CI 0.64-1.01, P = .069). However, bivalirudin use decreased the risk of all-cause mortality (RR 0.81, 95% CI 0.67-0.99, P = .041) and cardiac mortality (RR 0.68, 95% CI 0.51-0.91, P = .009) at 30 days, There were higher rates of acute stent thrombosis (RR 3.31, 95% CI 1.79-6.10, P < .001) in patients receiving bivalirudin. Bivalirudin use also decreased the risk of major bleeding at 30 days by 37% (RR 0.63, 95% CI 0.44-0.90, P = .012), but bleeding risk varied depending on routine GPI use with heparin (RR 0.44, 95% CI 0.23-0.81, P = .009) vs bailout (RR 0.73, 95% CI 0.42-1.25, P = .252), predominantly radial access (RR 0.54, 95% CI 0.25-1.15, P = .114) vs non-radial access (RR 0.60, 95% CI 0.36-0.99, P = .049), and second-generation P2Y12 inhibitor use with bivalirudin (RR 0.70, 95% CI 0.40-1.24, P = .226) vs clopidogrel use (RR 0.39, 95% CI 0.18-0.85, P = .018). CONCLUSIONS In primary PCI, relative to heparin, bivalirudin reduces the risk for all-cause mortality, cardiac mortality, and major bleeding but yields similar rates of major adverse cardiac event and net adverse clinical event at 30 days. However, the benefit of a reduction in bleeding with bivalirudin appears to be modulated by the concurrent administration of second-generation P2Y12 inhibitors with bivalirudin, using radial access, and avoiding routine GPI use with heparin.
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Tomassini F, Charrier L, Varbella F, Cerrato E, Gagnor A, Rolfo C, Echavarria-Pinto M, Restrepo SP, Nevola R, Baricocchi D, Escaned J, Minniti D, Conte MR, Berchialla P, Gianino MM. Temporal changes in the current practice of primary angioplasty: a real life experience of a single high-volume center. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2016; 17:5-9. [DOI: 10.1016/j.carrev.2015.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 10/18/2015] [Accepted: 10/20/2015] [Indexed: 11/16/2022]
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Sirker A, Mamas M, Robinson D, Anderson SG, Kinnaird T, Stables R, de Belder MA, Ludman P, Hildick-Smith D. Bivalirudin, glycoprotein inhibitor, and heparin use and association with outcomes of primary percutaneous coronary intervention in the United Kingdom. Eur Heart J 2015; 37:1312-20. [PMID: 26685133 DOI: 10.1093/eurheartj/ehv631] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 10/29/2015] [Indexed: 11/12/2022] Open
Abstract
AIMS The HORIZONS trial reported a survival advantage for bivalirudin over heparin-with-glycoprotein inhibitors (GPIs) in primary PCI for ST elevation myocardial infarction. This drove an international shift in clinical practice. Subsequent studies have produced divergent findings on mortality benefits with bivalirudin. We investigated this issue in a larger population than studied in any of these trials, using the United Kingdom national PCI registry. METHODS AND RESULTS 61 136 primary PCI procedures were performed between January 2008 and January 2012. Demographic and procedural data were obtained from the registry. Mortality information was obtained through the UK Office of National Statistics. Multivariable logistic regression and propensity analysis modelling were utilized to study the association of different anti-thrombotic strategies with outcomes. Unadjusted data demonstrated near-identical survival curves for bivalirudin and heparin-plus-GPI groups. Significantly higher early and late mortality was found in patients treated with heparin alone ( ITALIC! P < 0.0001) but this group had a markedly higher baseline risk. After propensity matching, the bivalirudin vs. heparin-plus-GPI groups still demonstrated very similar adjusted mortality (odds ratio 1.00 at 30 days, and 0.96 at 1 year). Patients treated with heparin alone continued to show higher mortality after adjustment, although effect size was considerably diminished (odds ratio vs. other groups 1.17-1.24 at 30 days). CONCLUSIONS Analysis of recent UK data showed no significant difference in short- or medium-term mortality between ST elevation myocardial infarction patients treated with bivalirudin vs. heparin-plus-GPI at primary PCI.
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Affiliation(s)
- Alex Sirker
- University College London Hospitals and St. Bartholomew's Hospital, London, UK
| | - Mamas Mamas
- Keele University, Staffordshire, UK University of Manchester, Manchester, UK
| | | | - Simon G Anderson
- University of Manchester, Manchester, UK University of Oxford, Oxford, UK
| | | | - Rod Stables
- Liverpool Heart and Chest Hospital, Merseyside, UK
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Bittl JA, He Y, Lang CD, Dangas GD. Factors Affecting Bleeding and Stent Thrombosis in Clinical Trials Comparing Bivalirudin With Heparin During Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2015; 8:e002789. [DOI: 10.1161/circinterventions.115.002789] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John A. Bittl
- From the Cardiac Catherization Laboratory, Munroe Regional Medical Center, Ocala, FL (J.A.B.); Office of Research and Methodology, National Center for Health Statistics, Hyattsville, MD (Y.H.); Division of Cardiology, Eastern Maine Medical Center, Bangor, ME (C.D.L.); and Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (G.D.D.)
| | - Yulei He
- From the Cardiac Catherization Laboratory, Munroe Regional Medical Center, Ocala, FL (J.A.B.); Office of Research and Methodology, National Center for Health Statistics, Hyattsville, MD (Y.H.); Division of Cardiology, Eastern Maine Medical Center, Bangor, ME (C.D.L.); and Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (G.D.D.)
| | - Christopher D. Lang
- From the Cardiac Catherization Laboratory, Munroe Regional Medical Center, Ocala, FL (J.A.B.); Office of Research and Methodology, National Center for Health Statistics, Hyattsville, MD (Y.H.); Division of Cardiology, Eastern Maine Medical Center, Bangor, ME (C.D.L.); and Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (G.D.D.)
| | - George D. Dangas
- From the Cardiac Catherization Laboratory, Munroe Regional Medical Center, Ocala, FL (J.A.B.); Office of Research and Methodology, National Center for Health Statistics, Hyattsville, MD (Y.H.); Division of Cardiology, Eastern Maine Medical Center, Bangor, ME (C.D.L.); and Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (G.D.D.)
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Thomas JL, French WJ. Current State of ST-Segment Myocardial Infarction: Evidence-based Therapies and Optimal Patient Outcomes in Advanced Systems of Care. Heart Fail Clin 2015; 12:49-63. [PMID: 26567974 DOI: 10.1016/j.hfc.2015.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Advances in reperfusion therapy for ST-segment elevation myocardial infarction (STEMI) provide optimal patient outcomes. Reperfusion therapies, including contemporary primary percutaneous coronary intervention, represent decades of clinical evidence development in large clinical trials and national databases. However, rapid identification of STEMI and guideline-directed management of patients across broad populations have been best achieved in advanced systems of care. Current outcomes in STEMI reflect the evolution of both clinical data and idealized health care delivery networks.
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Affiliation(s)
- Joseph L Thomas
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; Division of Cardiology, Harbor UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA
| | - William J French
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; Division of Cardiology, Harbor UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA.
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Wang CH, Chen NC, Tsai MS, Yu PH, Wang AY, Chang WT, Huang CH, Chen WJ. Therapeutic Hypothermia and the Risk of Hemorrhage: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Medicine (Baltimore) 2015; 94:e2152. [PMID: 26632746 PMCID: PMC5059015 DOI: 10.1097/md.0000000000002152] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Current guidelines recommend a period of moderate therapeutic hypothermia (TH) for comatose patients after cardiac arrest to improve clinical outcomes. However, in-vitro studies have reported platelet dysfunction, thrombocytopenia, and coagulopathy, results that might discourage clinicians from applying TH in clinical practice. We aimed to quantify the risks of hemorrhage observed in clinical studies.Medline and Embase were searched from inception to October 2015.Randomized controlled trials (RCTs) comparing patients undergoing TH with controls were selected, irrespective of the indications for TH. There were no restrictions for language, population, or publication year.Data on study characteristics, which included patients, details of intervention, and outcome measures, were extracted.Forty-three trials that included 7528 patients were identified from 2692 potentially relevant references. Any hemorrhage was designated as the primary outcome and was reported in 28 studies. The pooled results showed no significant increase in hemorrhage risk associated with TH (risk difference [RD] 0.005; 95% confidence interval [CI] -0.001-0.011; I, 0%). Among secondary outcomes, patients undergoing TH were found to have increased risk of thrombocytopenia (RD 0.109; 95% CI 0.038-0.179; I 57.3%) and transfusion requirements (RD 0.021; 95% CI 0.003-0.040; I 0%). The meta-regression analysis indicated that prolonged duration of cooling may be associated with increased risk of hemorrhage.TH was not associated with increased risk of hemorrhage despite the increased risk of thrombocytopenia and transfusion requirements. Clinicians should cautiously assess each patient's risk-benefit profile before applying TH.
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Affiliation(s)
- Chih-Hung Wang
- From the Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Douliu City, Yunlin County (C-HW), Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Zhongzheng Dist., Taipei City (C-HW), Department of Emergency Medicine, Tao Yuan General Hospital, Ministry of Health and Welfare, Taoyuan Dist, Taoyuan City (N-CC), Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Zhongzheng Dist., Taipei City (M-ST, A-YW, W-TC, C-HH, W-JC), Department of Emergency Medicine, Taipei Hospital, Ministry of Health and Welfare, Xinzhuang Dist., New Taipei City (P-HY); and Department of Emergency Medicine, Lotung Poh-Ai Hospital, Luodong Township, Yilan County, Taiwan (R.O.C.) (W-JC)
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O'Connor CT, Kiernan TJ, Yan BP. Investigational new drugs for the treatment of acute coronary syndrome. Expert Opin Investig Drugs 2015; 24:1557-70. [PMID: 26414862 DOI: 10.1517/13543784.2015.1094459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Ischemic heart disease is the most common cause of death worldwide. Despite improvements in interventional and pharmacological therapy for acute coronary syndrome (ACS), the risk of recurrent myocardial ischemia and mortality early after ACS remains high. Our improved understanding of the increasing role of inflammation in the pathogenesis of ACS and its relationship to atherosclerotic plaque rupture and thrombosis has led to the development of more potent anti-thrombotic and novel anti-inflammatory therapies for the treatment of ACS. AREAS COVERED In this review, the authors explore: the developing pharmacotherapy in the field of cardiology for ACS; antiplatelet agents (both further development of classical modalities together with pioneering agents); evolving use of anticoagulation in its treatment, and exploration in the use of novel anti-inflammatories and biological agents. EXPERT OPINION Data from trials involving the use of immunological and cellular-based treatments show promising results and herald further possible reduction in infarct burden in ACS alongside the possibility of recovery in cardiac function following infarction.
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Affiliation(s)
| | - Thomas J Kiernan
- a 1 University Hospital Limerick - Cardiology , Limerick, Ireland
| | - Bryan P Yan
- b 2 The Chinese University of Hong Kong, Prince of Wales Hospital, The Department of Medicine & Therapeutics , Hong Kong, China +852 26 32 38 78 ;
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Lupi A, Rognoni A, Cavallino C, Secco GG, Reale D, Cossa G, Rosso R, Bongo AS, Cortese B, Angiolillo DJ, Jaffe AS, Porto I. Intracoronary vs intravenous bivalirudin bolus in ST-elevation myocardial infarction patients treated with primary angioplasty. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 5:487-96. [DOI: 10.1177/2048872615594499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 06/15/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Alessandro Lupi
- 2nd Division of Cardiology, “Maggiore della Carità” University Hospital, Italy
| | - Andrea Rognoni
- 2nd Division of Cardiology, “Maggiore della Carità” University Hospital, Italy
| | | | - Gioel G Secco
- 2nd Division of Cardiology, “Maggiore della Carità” University Hospital, Italy
| | - Danilo Reale
- Divisione di Cardiologia, Ospedale S. Andrea, Italy
| | | | - Roberta Rosso
- 2nd Division of Cardiology, “Maggiore della Carità” University Hospital, Italy
| | - Angelo S Bongo
- 2nd Division of Cardiology, “Maggiore della Carità” University Hospital, Italy
| | | | | | - Allan S Jaffe
- Division of Cardiovascular Diseases, Mayo Clinic, USA
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Palmerini T, Benedetto U, Bacchi-Reggiani L, Della Riva D, Biondi-Zoccai G, Feres F, Abizaid A, Hong MK, Kim BK, Jang Y, Kim HS, Park KW, Genereux P, Bhatt DL, Orlandi C, De Servi S, Petrou M, Rapezzi C, Stone GW. Mortality in patients treated with extended duration dual antiplatelet therapy after drug-eluting stent implantation: a pairwise and Bayesian network meta-analysis of randomised trials. Lancet 2015; 385:2371-82. [PMID: 25777667 DOI: 10.1016/s0140-6736(15)60263-x] [Citation(s) in RCA: 298] [Impact Index Per Article: 33.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Despite recent studies, the optimum duration of dual antiplatelet therapy (DAPT) after coronary drug-eluting stent placement remains uncertain. We performed a meta-analysis with several analytical approaches to investigate mortality and other clinical outcomes with different DAPT strategies. METHODS We searched Medline, Embase, Cochrane databases, and proceedings of international meetings on Nov 20, 2014, for randomised controlled trials comparing different DAPT durations after drug-eluting stent implantation. We extracted study design, inclusion and exclusion criteria, sample characteristics, and clinical outcomes. DAPT duration was categorised in each study as shorter versus longer, and as 6 months or shorter versus 1 year versus longer than 1 year. Analyses were done by both frequentist and Bayesian approaches. FINDINGS We identified ten trials published between Dec 16, 2011, and Nov 16, 2014, including 31,666 randomly assigned patients. By frequentist pairwise meta-analysis, shorter DAPT was associated with significantly lower all-cause mortality compared with longer DAPT (HR 0·82, 95% CI 0·69-0·98; p=0·02; number needed to treat [NNT]=325), with no significant heterogeneity apparent across trials. The reduced mortality with shorter compared with longer DAPT was attributable to lower non-cardiac mortality (0·67, 0·51-0·89; p=0·006; NNT=347), with similar cardiac mortality (0·93, 0·73-1·17; p=0.52). Shorter DAPT was also associated with a lower risk of major bleeding, but a higher risk of myocardial infarction and stent thrombosis. We noted similar results in a Bayesian framework with non-informative priors. By network meta-analysis, patients treated with 6-month or shorter DAPT and 1-year DAPT had higher risk of myocardial infarction and stent thrombosis but lower risk of mortality compared with patients treated with DAPT for longer than 1 year. Patients treated with DAPT for 6 months or shorter had similar rates of mortality, myocardial infarction, and stent thrombosis, but lower rates of major bleeding than did patients treated with 1-year DAPT. INTERPRETATION Although treatment with DAPT beyond 1 year after drug-eluting stent implantation reduces myocardial infarction and stent thrombosis, it is associated with increased mortality because of an increased risk of non-cardiovascular mortality not offset by a reduction in cardiac mortality. FUNDING None.
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Affiliation(s)
- Tullio Palmerini
- Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy
| | | | | | - Diego Della Riva
- Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Fausto Feres
- Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | | | - Myeong-Ki Hong
- Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yangsoo Jang
- Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Philippe Genereux
- Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY, USA; Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Carlotta Orlandi
- Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy
| | | | - Mario Petrou
- Oxford Heart Center, Oxford University, Oxford, UK
| | - Claudio Rapezzi
- Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy
| | - Gregg W Stone
- Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY, USA.
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Cassese S, Byrne RA, Laugwitz KL, Schunkert H, Berger PB, Kastrati A. Bivalirudin versus heparin in patients treated with percutaneous coronary intervention: a meta-analysis of randomised trials. EUROINTERVENTION 2015; 11:196-203. [DOI: 10.4244/eijy14m08_01] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Dauerman HL. Anticoagulation Strategies for Primary Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2015; 8:CIRCINTERVENTIONS.115.001947. [DOI: 10.1161/circinterventions.115.001947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Harold L. Dauerman
- From the Department of Medicine and the Cardiovascular Research Institute, University of Vermont College of Medicine, Burlington
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Nairooz R, Sardar P, Amin H, Chatterjee S, Helmy T, Naidu SS. Short- and long-term outcomes in diabetes patients undergoing percutaneous coronary intervention with bivalirudin compared with heparin and glycoprotein IIb/IIIA inhibitors: A meta-analysis of randomized trials. Catheter Cardiovasc Interv 2015; 86:364-75. [PMID: 25914388 DOI: 10.1002/ccd.25952] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 03/15/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Diabetes patients undergoing percutaneous coronary intervention (PCI) have more complications than nondiabetes patients, including increased long-term mortality. Use of bivalirudin versus heparin and glycoprotein IIb/IIIa inhibitors (GPI) in diabetes patients undergoing PCI and its effect on long-term mortality were evaluated in few randomized trials, but with conflicting results. METHODS We searched the literature for randomized controlled trials that compared heparin and GPI therapy with bivalirudin in diabetes patients undergoing PCI. The incidence of major adverse cardiovascular events (MACE), death from any cause, myocardial infarction (MI), urgent revascularization, major and minor bleeding (at 30 days), as well as all-cause mortality at 1 year were included, and meta-analysis was performed. RESULTS A total of 5,137 patients with diabetes were included in four randomized trials. At 30 days, bivalirudin, compared with heparin and GPI, caused less major bleeding (odds ratio (OR), 0.68; 95% confidence interval (CI), 0.52-0.89; P = 0.005) and less minor bleeding (OR, 0.48; 95% CI, 0.41-0.57; P < 0.00001) and similar rates of MACE (OR, 0.87; 95% CI, 0.70-1.08; P = 0.21), MI (OR, 0.87; 95% CI, 0.68-1.10; P = 0.25), and urgent revascularization (OR, 1.12; 95% CI, 0.76-1.65; P = 0.57). Death from any cause at 30 day was numerically lower with bivalirudin use but not statistically significant (OR, 0.72; 95% CI, 0.46-1.13; P = 0.15). Mortality at 1 year was significantly lower in diabetes patients treated with bivalirudin compared with heparin and GPI (OR, 0.72; 95% CI, 0.52-0.99; P = 0.04). A secondary analysis suggests that the major bleeding benefit with bivalirudin may be driven by mandated use of GPI in heparin arm. CONCLUSION Among patients with diabetes undergoing PCI, bivalirudin caused less major and minor bleeding compared with heparin and GPI, with similar rates of MACE, death, MI, and urgent revascularization at 30 days, but significantly lower mortality rates at 1 year.
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Affiliation(s)
- Ramez Nairooz
- Department of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Partha Sardar
- Department of Cardiology, University of Utah, Salt Lake City, Utah
| | - Hossam Amin
- Department of Medicine, New York Medical College-Metropolitan Hospital Center, New York City, New York
| | - Saurav Chatterjee
- Department of Cardiology, St. Luke's-Roosevelt Hospital Center of the Mount Sinai Health System, New York City, New York
| | - Tarek Helmy
- Department of Cardiology, University of Cincinnati, Cincinnati, Ohio
| | - Srihari S Naidu
- Department of Cardiology, Winthrop University Hospital, Mineola, New York
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Mavrakanas TA, Chatzizisis YS. Bivalirudin in stable angina and acute coronary syndromes. Pharmacol Ther 2015; 152:1-10. [PMID: 25857452 DOI: 10.1016/j.pharmthera.2015.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 03/31/2015] [Indexed: 01/05/2023]
Abstract
A parenteral anticoagulant is indicated in patients with acute coronary syndromes. Which anticoagulant should be preferred in each setting is not clearly established. Bivalirudin administration was considered in acute coronary syndromes after several clinical trials showed decreased bleeding risk with its use compared with the association of unfractionated heparin (UFH) with glycoprotein IIb/IIIa inhibitors (GPIs). Most recent data demonstrate that the bleeding benefit identified in the previous studies was not due to bivalirudin's properties but to higher bleeding incidence in the comparator arm due to the disproportional use of GPIs with heparin. This paper reviews clinical evidence on bivalirudin as anticoagulant in stable angina and acute coronary syndromes.
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Affiliation(s)
- Thomas A Mavrakanas
- McGill University Health Center, Montreal, Canada; General Internal Medicine Division, Geneva University Hospitals, Geneva, Switzerland
| | - Yiannis S Chatzizisis
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.
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Verdoia M, Schaffer A, Barbieri L, Suryapranata H, De Luca G. Bivalirudin as compared to unfractionated heparin in patients undergoing percutaneous coronary revascularization: A meta-analysis of 22 randomized trials. Thromb Res 2015; 135:902-15. [PMID: 25772138 DOI: 10.1016/j.thromres.2015.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 01/19/2015] [Accepted: 03/03/2015] [Indexed: 12/28/2022]
Abstract
UNLABELLED Bivalirudin has gained ground against unfractionated heparin (UFH) in percutaneous coronary interventions (PCI), due to a reported better safety profile. However, whether bivalirudin may provide also advantages in clinical outcome beyond the known benefits in major bleedings, is still a debated matter and was, therefore, the aim of present meta-analysis of randomized trials, evaluating efficacy and safety of bivalirudin as compared with UFH in PCI. METHODS AND STUDY OUTCOMES Literature archives (Pubmed, EMBASE, Cochrane) and main scientific sessions were scanned. Primary endpoint was overall mortality. Secondary endpoints were: 1) mortality within 30-days; 2) overall and within 30-days non fatal myocardial infarction; 3) overall and within 30-days stent thrombosis. Safety endpoints were major bleedings (per protocol definition or TIMI classification). A prespecified analysis was conducted according to clinical presentation (Elective, ACS, STEMI). RESULTS A total of 22 randomized clinical were finally included, involving 40156 patients randomized to bivalirudin (52.9%) or to UFH (47.1%). Death occurred in 1100 (2.8%) of patients, with no difference between bivalirudin and UFH (2.7% vs 2.8% OR[95%C]=0.94[0.83,-.06], p=0.32, phet=0.48). The results did not change according to clinical presentation. By meta-regression analysis, the effects on mortality were not related to patients risk profile (r=-0.38(-0.89-0.14), p=0.15) or the reduction in bleeding complications (r=-0.008(-0.86-0.85), p=0.98). A significant increase in short-term stent thrombosis was observed with bivalirudin (OR[95%CI]=1.42 [1.10-1.83], p=0.006). However, Bivalirudin significantly reduced bleedings according to both study protocol definition (OR[95%CI]=0.62[0.56-0.69],p<0.00001; phet=0.0003) or TIMI major criteria (OR[95%CI]=0.65[0.53-0.79],p<0.0001, phet=0.95). CONCLUSIONS In present meta-analysis, among patients undergoing PCI, bivalirudin, as compared with UFH, is associated with a significant reduction in major bleeding complications that, however, does not translate into mortality benefits. Furthermore, bivalirudin is associated with higher rate of 30-days stent thrombosis and recurrent MI among STEMI patients.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Alon Schaffer
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Lucia Barbieri
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | | | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
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Kim M, Chu A, Khan Y, Malik S. Predicting and preventing vascular complications following percutaneous coronary intervention in women. Expert Rev Cardiovasc Ther 2015; 13:163-72. [PMID: 25553577 DOI: 10.1586/14779072.2015.995635] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The development of vascular complications is associated with increased morbidity and mortality in patients undergoing percutaneous coronary intervention. While the incidence of percutaneous coronary intervention-related vascular complications has greatly improved over time, female sex still persists as a significant and independent predictor of periprocedural vascular complications, which in turn is associated with a greater risk of short- and long-term mortality. This review provides a contemporary overview of the data on the important issues regarding the risk of percutaneous coronary intervention in women. It examines the intrinsic sex-related factors that may be contributing to women's heightened bleeding risk while also examining the various pharmacologic and procedural bleeding avoidance strategies currently in the literature, with a focus on their potential role and benefit in women specifically.
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Affiliation(s)
- Melvie Kim
- University of California, Irvine, CA, USA
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50
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Bivalirudin Versus Heparin With or Without Glycoprotein IIb/IIIa Inhibitors in Patients With STEMI Undergoing Primary Percutaneous Coronary Intervention. J Am Coll Cardiol 2015; 65:27-38. [DOI: 10.1016/j.jacc.2014.10.029] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 09/29/2014] [Accepted: 10/01/2014] [Indexed: 01/02/2023]
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