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Erriquez A, Campo G, Guiducci V, Escaned J, Moreno R, Casella G, Menozzi M, Cerrato E, Sacchetta G, Menozzi A, Santos IA, Ibañes EG, Scarsini R, Vadalà G, Andò G, Díez-Gil JL, d’Amore SM, Capecchi A, Colaiori I, Gallo F, Pavasini R, Marrone A, Pompei G, Lanzilotti V, Dudek D, Barbato E, Tebaldi M, Biscaglia S. Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction and High Bleeding Risk: A Randomized Clinical Trial. JAMA Cardiol 2024; 9:565-573. [PMID: 38717753 PMCID: PMC11079791 DOI: 10.1001/jamacardio.2024.0804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 03/12/2024] [Indexed: 05/12/2024]
Abstract
Importance Patients with high bleeding risk (HBR) have a poor prognosis, and it is not known if they may benefit from complete revascularization after myocardial infarction (MI). Objective To investigate the benefit of physiology-guided complete revascularization vs a culprit-only strategy in patients with HBR, MI, and multivessel disease. Design, Setting, and Participants This was a prespecified analysis of the Functional Assessment in Elderly MI Patients With Multivessel Disease (FIRE) randomized clinical trial data. FIRE was an investigator-initiated, open-label, multicenter trial. Patients 75 years or older with MI and multivessel disease were enrolled at 34 European centers from July 2019 through October 2021. Physiology treatment was performed either by angiography- or wire-based assessment. Patients were divided into HBR or non-HBR categories in accordance with the Academic Research Consortium HBR document. Interventions Patients were randomized to either physiology-guided complete revascularization or culprit-only strategy. Main Outcomes and Measures The primary outcome comprised a composite of death, MI, stroke, or revascularization at 1 year. Secondary outcomes included a composite of cardiovascular death or MI and Bleeding Academic Research Consortium (BARC) types 3 to 5. Results Among 1445 patients (mean [SD] age, 81 [5] years; 917 male [63%]), 1025 (71%) met HBR criteria. Patients with HBR were at higher risk for the primary end point (hazard ratio [HR], 2.01; 95% CI, 1.47-2.76), cardiovascular death or MI (HR, 1.89; 95% CI, 1.26-2.83), and BARC types 3 to 5 (HR, 3.28; 95% CI, 1.40-7.64). The primary end point was significantly reduced with physiology-guided complete revascularization as compared with culprit-only strategy in patients with HBR (HR, 0.73; 95% CI, 0.55-0.96). No indication of interaction was noted between revascularization strategy and HBR status for primary and secondary end points. Conclusions and Relevance HBR status is prevalent among older patients with MI, significantly increasing the likelihood of adverse events. Physiology-guided complete revascularization emerges as an effective strategy, in comparison with culprit-only revascularization, for mitigating ischemic adverse events, including cardiovascular death and MI. Trial Registration ClinicalTrials.gov Identifier: NCT03772743.
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Affiliation(s)
- Andrea Erriquez
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Vincenzo Guiducci
- Cardiology Unit, Azienda USL-IRCCS Reggio Emilia, S. Maria Nuova Hospital, Reggio Emilia, Italy
| | - Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Calle del Prof Martin Lagos s/n, Madrid, Spain
| | - Raul Moreno
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain, Instituto de Investigación Hospital La Paz, University Hospital La Paz, Madrid, Spain
| | - Gianni Casella
- Cardiology Unit, Ospedale Maggiore, Largo Nigrisoli 2, Bologna, Italy
| | - Mila Menozzi
- Cardiovascular Department, Infermi Hospital, Rimini, Italy
| | - Enrico Cerrato
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano, and Rivoli Infermi Hospital ASLTO3, Rivoli, Turin, Italy
| | | | - Alberto Menozzi
- S. C. Cardiologia, Ospedale Sant’Andrea, ASL5 Liguria, La Spezia, Italy
| | - Ignacio Amat Santos
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Cardiology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Enrique Gutiérrez Ibañes
- Centro de Investigation Biomedica end Red en Enfermedades Cardiovasculares, Cardiology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Roberto Scarsini
- Azienda Ospedaliero Universitaria Integrata di Verona, Verona, Italy
| | - Giuseppe Vadalà
- Azienda Ospedaliero Universitaria Policlinico Paolo Giaccone, Palermo, Italy
| | - Giuseppe Andò
- Azienda Ospedaliero Universitaria Policlinico Gaetano Martino, Messina, Italy
| | - José Luis Díez-Gil
- Centro de Investigation Biomedica en Red en Enfermedades Cardiovasculares, Cardiology Department, H. Universitario y Politécnico La Fe, Valencia, Spain
| | - Sergio Musto d’Amore
- Cardiology Unit, Azienda USL-IRCCS Reggio Emilia, S. Maria Nuova Hospital, Reggio Emilia, Italy
| | | | - Iginio Colaiori
- Cardiology Unit, Ospedale Santa Maria Goretti, Via Lucia Scaravelli, Latina, Italy
| | - Francesco Gallo
- Interventional Cardiology, Department of Cardio-Thoracic and Vascular Sciences, Ospedale dell’Angelo, Via Paccagnella, Venice, Italy
| | - Rita Pavasini
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Andrea Marrone
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Graziella Pompei
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | | | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Roma, Italy
| | - Matteo Tebaldi
- Interventional Cardiology Unit, Presidio Ospedaliero San Salvatore di Pesaro, Pesaro, Italy
| | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
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Wienemann H, Meincke F, Vach M, Heeger CH, Meyer A, Spangenberg T, Kuck KH, Ghanem A. Outcome of a polymer-free drug-coated coronary stent in bifurcation lesions-Pilot registry with serial OCT imaging. Herz 2023; 48:292-300. [PMID: 35397659 DOI: 10.1007/s00059-022-05109-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/24/2022] [Accepted: 03/16/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Polymer-free and carrier-free drug-coated stents (DCS) represent a novel therapeutic option for the treatment of coronary artery disease. The objective of this pilot registry is to evaluate the safety and efficacy of DCS implantation in bifurcation lesions. METHODS Overall, 23 consecutive patients with 24 lesions received a Biolimus A9-coated DCS for coronary bifurcation lesions. Patients were examined with quantitative coronary angiography (QCA) and optical coherence tomography (OCT) at 3-6 months of follow-up. RESULTS A total of 23 patients with 24 bifurcation lesions were included in this study. Nine (33.3%) lesions of eight patients revealed angiographical target lesion failure due to in-stent restenosis (ISR). In total, 19 patients with 20 bifurcation lesions were suitable for OCT analysis. A total of 2936 struts were analyzed and 14 struts (0.47%) were classified as malapposed. The mean luminal area (mm2) was not different in lesions with ISR vs. lesions with no ISR (5.07 ± 2.0 vs. 5.73 ± 1.34, p = 0.39) at follow-up. Lesions with ISR showed higher mean neointimal burden (27.11 ± 10.59 vs. 13.93 ± 9.16%, respectively; p = 0.009). All of the patients who presented with significant ISR required percutaneous re-intervention. CONCLUSIONS We observed a high rate of DCS ISR in bifurcation lesions, possibly related to increased inflammation and neoatherosclerosis. The small size of the study warrants careful interpretation of our results. Larger trials are necessary to expand knowledge of these findings.
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Affiliation(s)
- Hendrik Wienemann
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany.
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Cologne, Germany.
| | - Felix Meincke
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- Department of Cardiology, Asklepios Klinik Altona, Hamburg, Germany
| | - Marius Vach
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Christian-Hendrik Heeger
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- Department of Rhythmology, University Heart Center Lübeck, UKSH Lübeck, Lübeck, Germany
| | - Annika Meyer
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Cologne, Germany
| | - Tobias Spangenberg
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- Department of Cardiology, Asklepios Klinik Altona, Hamburg, Germany
| | - Karl Heinz Kuck
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- Department of Rhythmology, University Heart Center Lübeck, UKSH Lübeck, Lübeck, Germany
| | - Alexander Ghanem
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
- Department of Cardiology, Asklepios Klinik Nord, Hamburg, Germany
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Tam CC, Tse HF. Antiplatelet Therapy Aims and Strategies in Asian Patients with Acute Coronary Syndrome or Stable Coronary Artery Disease. J Clin Med 2022; 11:jcm11247440. [PMID: 36556067 PMCID: PMC9784545 DOI: 10.3390/jcm11247440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 11/30/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) has been the mainstay treatment to reduce ischemic events, such as myocardial infarction or stroke, in patients with coronary artery disease (CAD). The development of potent P2Y12 inhibitors (ticagrelor and prasugrel) has helped to further reduce ischemic events, particularly among high-risk patients. Meanwhile, the evolution of newer generations of drug-eluting stents are also improving outcomes of percutaneous coronary intervention. Research studies on antiplatelet therapy in recent years have focused on balancing ischemic and bleeding risks through different strategies, which include P2Y12 inhibitor monotherapy, escalation and de-escalation, and extended DAPT. Because results from the large number of clinical studies may sometimes appear conflicting, this review aims to summarize recent advances, and demonstrate that they are aligned by a general principle, namely, strategies may be adopted based on treatment aims for specific patients at several time points. Another aim of this review is to outline the important considerations for using antiplatelet therapy in Asian patients, in whom there is a greater prevalence of CYP2C19 loss-of-function mutations, and a common increased risk of bleeding, despite high platelet reactivity (the so-called "East Asian Paradox").
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Affiliation(s)
- Chor-Cheung Tam
- Division of Cardiology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
- Correspondence:
| | - Hung-Fat Tse
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Coronary Stenting: Reflections on a 35-Year Journey. Can J Cardiol 2022; 38:S17-S29. [PMID: 34375695 DOI: 10.1016/j.cjca.2021.07.224] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 01/09/2023] Open
Abstract
Stenting was introduced as a therapy for coronary artery disease 35 years ago, and is currently the most commonly performed minimally invasive procedure globally. Percutaneous coronary revascularization, initially with plain old balloon angioplasty and later with stenting, has dramatically affected the outcomes of acute myocardial infarction and acute coronary syndromes. Coronary stenting is probably the most intensively studied therapy in medicine on the basis of the number of randomized clinical trials for a broad range of indications. Continuous improvements in stent materials, design, and coatings concurrent with procedural innovations have truly been awe-inspiring. The story of stenting is replete with high points and some low points, such as the initial experience with stent thrombosis and restenosis, and the more recent disappointment with bioabsorbable scaffolds. History has shown rapid growth of stent use with expansion of indications followed by contraction of some uses in response to clinical trial evidence in support of bypass surgery or medical therapy. In this review we trace the constantly evolving story of the coronary stent from the earliest experience until the present time. Undoubtedly, future iterations of stent design and materials will continue to move the stent story forward.
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Polymer-Based Versus Polymer-Free Stents in High Bleeding Risk Patients: Final 2-Year Results From Onyx ONE. JACC Cardiovasc Interv 2022; 15:1153-1163. [PMID: 35680195 DOI: 10.1016/j.jcin.2022.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 03/10/2022] [Accepted: 04/04/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Resolute Onyx polymer-based zotarolimus-eluting stents (ZES) were noninferior in safety and effectiveness to BioFreedom polymer-free biolimus A9-coated stents (DCS) in high-bleeding-risk (HBR) patients treated with 1-month dual antiplatelet therapy (DAPT) followed by single antiplatelet therapy (SAPT) at 1 year. OBJECTIVES This study reports the final 2-year results of the randomized Onyx ONE trial. METHODS The Onyx ONE (A Randomized Controlled Trial With Resolute Onyx in One Month Dual Antiplatelet Therapy (DAPT) for High-Bleeding Risk Patients) trial randomly assigned HBR patients to treatment with ZES or DCS. Following 1-month DAPT, event-free patients received SAPT (either aspirin or a P2Y12 inhibitor at physician discretion). The primary safety endpoint, a composite of cardiac death, myocardial infarction, or stent thrombosis at 1 year, was determined at 1 year. Rates of primary and secondary endpoints were calculated after final follow-up at 2 years. RESULTS A total of 1,003 patients were randomly allocated to ZES and 993 patients to DCS. Follow-up was complete in 980 (97.7%) ZES patients and 962 (96.9%) DCS patients at 2 years. The primary safety endpoint occurred in 208 (21.2%) patients in the ZES group and 199 (20.7%) patients in the DCS group (risk difference: 0.5%; 95% CI: -3.1% to 4.2%; P = 0.78) at 2 years without significant differences in individual components of the composite endpoint. The secondary effectiveness endpoint occurred in 217 (22.1%) patients in the ZES group and 202 (21.0%) patients in the DCS group (risk difference: 1.1%; 95% CI: -2.5% to 4.8%; P = 0.54). CONCLUSIONS Among patients at HBR treated with 1-month DAPT followed by SAPT, the Resolute Onyx polymer-based ZES had similar 2-year outcomes for the primary safety and secondary effectiveness endpoint compared with the BioFreedom polymer-free DCS. (A Randomized Controlled Trial With Resolute Onyx in One Month Dual Antiplatelet Therapy [DAPT] for High-Bleeding Risk Patients [Onyx ONE]; NCT03344653).
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Baber U. Polymer-Based Versus Polymer-Free Stents in High Bleeding Risk Patients: Less Is Not Always More. JACC Cardiovasc Interv 2022; 15:1164-1166. [PMID: 35680196 DOI: 10.1016/j.jcin.2022.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Usman Baber
- University of Oklahoma Health Sciences Center, Department of Medicine, Cardiovascular Section, Oklahoma City, Oklahoma, USA.
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7
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Delewi R, de Winter RJ. The Biolimus Stent Family. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch34] [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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Costa JR, Goel R, Meneguz‐Moreno RA, Abizaid AA. Novel Drug‐Eluting Stent Systems. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Hansen KN, Maeng M, Raungaard B, Engstrøm T, Veien KT, Kristensen SD, Ellert‐Gregersen J, Jensen SE, Junker A, Kahlert J, Jakobsen L, Christiansen EH, Jensen LO. Impact of diabetes on 1‐year clinical outcome in patients undergoing revascularization with the BioFreedom stents or the Orsiro stents from the SORT OUT IX trial. Catheter Cardiovasc Interv 2022; 99:1095-1103. [DOI: 10.1002/ccd.30090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/25/2021] [Indexed: 11/09/2022]
Affiliation(s)
| | - Michael Maeng
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Bent Raungaard
- Department of Cardiology Aalborg University Hospital Aalborg Denmark
| | | | | | | | | | | | - Anders Junker
- Department of Cardiology Odense University Hospital Odense Denmark
| | - Johnny Kahlert
- Department of Clinical Epidemiology Aarhus University Hospital Aarhus Denmark
| | - Lars Jakobsen
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
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Dai Y, Wang R, Chen F, Zhang Y, Liu Y, Huang H, Yang P, Zhang R, Zheng B, Gao C, Chen Y, Tao L. Clinical outcomes in 2481 unselected real-world patients treated with a polymer-free sirolimus-eluting stent: 3 years results from the NANO multicenter Registry. BMC Cardiovasc Disord 2021; 21:537. [PMID: 34772347 PMCID: PMC8588634 DOI: 10.1186/s12872-021-02356-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 10/28/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives To evaluate the 3-year clinical outcomes of a polymer-free sirolimus-eluting, Nano plus stent for the treatment of coronary artery disease in the NANO multicenter Registry. Background The long-term clinical data evaluating the safety and efficacy of the novel polymer-free sirolimus-eluting Nano plus stent (Lepu Medical, Beijing, China) is limited. Methods The NANO all-comers Registry trial was a prospective, multicenter clinical registry conducted in 26 centers in China between August 2016 and January 2017. A total of 2481 consecutive patients were exclusively treated with the Nano plus stent. The primary clinical endpoint, target lesion failure (TLF, defined as cardiac death, target vessel nonfatal myocardial infarction, and clinically driven target lesion revascularization [CD-TLR]), was analyzed at 3 years. Results At 3 years, 2295 patients (92.5%) were followed. The incidence of TLF was 6.8% (168/2481). The rate of cardiac death was 3.8% (94/2481), target vessel nonfatal myocardial infarction 0.7% (18/2481), and CD-TLR 2.9% (68/2481). The rate of definite/probable stent thrombosis was 0.5% (13/2481). The risk factors of diabetes mellitus, acute myocardial infarction, age, chronic renal failure, in-stent restenosis, chronic total occlusion, and left ventricular ejection fraction < 40% were the independent predictors of 3-year TLF. Conclusions At three years, the rate of TLF was relatively low in patients treated with the polymer-free Nano plus stent. The polymer-free Nano plus stent showed a favorable safety and efficacy profile in real-world patients. Clinical trial registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02929030.
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Affiliation(s)
- Yi Dai
- Medical School of Nankai University, Tianjin, China
| | - Rutao Wang
- Department of Cardiology, The First Affiliated Hospital of The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Fengying Chen
- Department of Cardiology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Yaojun Zhang
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Yi Liu
- Department of Cardiology, The First Affiliated Hospital of The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - He Huang
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
| | - Ping Yang
- Department of Cardiology, China Japan Union Hospital of Jilin University, Changchun, China
| | - Ruining Zhang
- Department of Cardiology, The First Affiliated Hospital of The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Bo Zheng
- Department of Cardiology, The First Affiliated Hospital of The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Chao Gao
- Department of Cardiology, The First Affiliated Hospital of The Fourth Military Medical University, Xi'an, Shaanxi, China. .,Xijing Hospital, 127 Changle west road, Xi'an, 710032, China.
| | - Yundai Chen
- Medical School of Nankai University, Tianjin, China. .,Department of Cardiology, The Chinese PLA General Hospital, 28 Fu xing road, Beijing, 100853, China.
| | - Ling Tao
- Department of Cardiology, The First Affiliated Hospital of The Fourth Military Medical University, Xi'an, Shaanxi, China. .,Xijing Hospital, 127 Changle west road, Xi'an, 710032, China.
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Mandal AP, Mandal PK. Specific and nonspecific binding of drug eluted from a half-embedded stent in presence of atherosclerotic plaque. Comput Methods Biomech Biomed Engin 2021; 25:922-935. [PMID: 34615426 DOI: 10.1080/10255842.2021.1986813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
This study is dealt with the two-phase binding (specific and nonspecific) of drug eluted from a half- embedded drug-eluting stent in presence of atherosclerotic plaque. The specific binding due to the interaction of drug molecules with specific receptors and nonspecific binding caused by the trapping of drug in the extra-cellular matrix have been paid due attention. An idealised wall consisting of a plaque and a healthy tissue region has been considered. Moreover, a Dirichlet release condition is imposed on the strut surface. In this investigation, a two-dimensional model governing drug transport and its two-phase binding in cylindrical polar coordinate system has been solved numerically by a finite-difference method. Our simulation predicts that plaque behaves like a physical barrier in two types of the binding process and there is an inverse relationship between bound drug concentration and plaque thickness. Simulations show that a single peak profile of drug is noted when the struts are situated one-strut radius apart and as the inter-strut distance increases, the peak concentration falls and distinct peak profiles over each strut are visualised. The model also reveals that in the region downstream of a strut, the concentration of both bound drug forms in the plaque and healthy regions increases, and eventually, the saturation length of binding sites increases. Predicted results show for smaller Damköhler number, the rapid saturation of binding sites takes place and the stent having thinner strut may perform well in terms of effectiveness as well as efficacy in the stent-based delivery.
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Affiliation(s)
- Akash Pradip Mandal
- Department of Mathematics, Ananda Chandra College, North Bengal University, Jalpaiguri, West Bengal, India
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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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Sorrentino S, Salerno N, Leo I, Polimeni A, Sabatino J, Spaccarotella CAM, Mongiardo A, De Rosa S, Indolfi C. New antithrombotic strategies and coronary stent technologies for patients at high bleeding risk undergoing percutaneous coronary intervention. Curr Vasc Pharmacol 2021; 20:37-45. [PMID: 34370641 DOI: 10.2174/1570161119666210809163404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/11/2021] [Accepted: 06/14/2021] [Indexed: 11/22/2022]
Abstract
Patients at high bleeding risk (HBR) are a sizable part of the population undergoing percutaneous coronary intervention (PCI) and stent implantation. This population historically lacks standardized definition, thus limiting trial design, data generalizability, and clinical decision-making. To overcome this limitation the Academic Research Consortium (ARC) has recently released comprehensive guidelines defining HBR criteria for study design purpose and daily clinical practice. Furthermore, several risk scores have been developed aiming to discriminate HBR patients and support physicians for clinical decision making when faced with this complex subset of patients. Accordingly, the first part of this review article will explore guideline-recommended risk scoring as well as ARC-HBR criteria and their relative application for daily clinical practice. The second part of this review article will explore the complex interplay between risk of bleeding, and coronary thrombotic events in patients deemed at HBR. Indeed, several features that identify these patients, are also independent predictors of recurrent ischemic events, thus challenging revascularization strategies and optimal antithrombotic therapy. Accordingly, several clinical trials have been conducted to evaluate the safety and efficacy of the new generation of coronary platforms and different antithrombotic strategies for HBR patients to minimize both ischemic and bleeding events. Accordingly, in this part we discuss current guidelines, trials and observational data evaluating antithrombotic strategies and stent technologies for patients at HBR.
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Affiliation(s)
- Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Nadia Salerno
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Isabella Leo
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Alberto Polimeni
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Jolanda Sabatino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | | | - Annalisa Mongiardo
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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15
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2643] [Impact Index Per Article: 881.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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16
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Urban P, Gregson J, Owen R, Mehran R, Windecker S, Valgimigli M, Varenne O, Krucoff M, Saito S, Baber U, Chevalier B, Capodanno D, Morice MC, Pocock S. Assessing the Risks of Bleeding vs Thrombotic Events in Patients at High Bleeding Risk After Coronary Stent Implantation: The ARC-High Bleeding Risk Trade-off Model. JAMA Cardiol 2021; 6:410-419. [PMID: 33404627 PMCID: PMC7788509 DOI: 10.1001/jamacardio.2020.6814] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Patients who are candidates for percutaneous coronary intervention (PCI) and are at high bleeding risk constitute a therapeutic challenge because they often also face an increased risk of thrombotic complications. Objectives To develop and validate models to predict the risks of major bleeding (Bleeding Academic Research Consortium [BARC] types 3 to 5 bleeding) and myocardial infarction (MI) and/or stent thrombosis (ST) for individual patients at high bleeding risk and provide assistance in defining procedural strategy and antithrombotic regimens. Design, Setting, and Participants This prognostic study used individual patient data from 6 studies conducted from July 1, 2009, to September 5, 2017, for 6641 patients at more than 200 centers in Europe, the US, and Asia who underwent PCI and were identified as being at high bleeding risk using the Academic Research Consortium criteria. In 1 year of follow-up (excluding periprocedural events), individual patient risks of MI and/or ST and major bleeding were evaluated using 33 baseline variables. To validate these models, a subgroup of 1458 patients at high bleeding risk from the ONYX ONE trial were analyzed. Statistical analysis was performed from February 1, 2019, to April 30, 2020. Exposures All patients underwent PCI with bare metal, drug-coated, or drug-eluting stent implants. Main Outcomes and Measures Forward, stepwise multivariable proportional hazards models were used to identify highly significant predictors of MI and/or ST and BARC types 3 to 5 bleeding. Results A total of 6641 patients (4384 men [66.0%]; median age, 77.9 years [interquartile range, 70.0-82.6 years]) were included in this study. Over 365 days, nonperiprocedural MI and/or ST occurred in 350 patients (5.3%), and BARC types 3 to 5 bleeding occurred in 381 patients (5.7%). Eight independent baseline predictors of risk of MI and/or ST and 8 predictors for risk of BARC types 3 to 5 bleeding were identified. Four of these predictors were in both risk models. Both risk models showed moderate discrimination: C statistic = 0.69 for predicting MI and/or ST and 0.68 for predicting BARC types 3 to 5 bleeding. Applying these same models to the validation cohort gave a similar strength of discrimination (C statistic = 0.74 for both MI and/or ST and BARC types 3-5 bleeding). Patients with MI and/or ST had a mortality hazard ratio of 6.1 (95% CI, 4.8-7.7), and those with BARC types 3 to 5 bleeding had a mortality hazard ratio of 3.7 (95% CI, 2.9-4.8) compared with patients free of both events. Taking these data into account, the risk scores facilitate investigation of the individual patient trade-off between these 2 risks: 2931 patients (44.1%) at high bleeding risk in the 6 studies had a greater risk of MI and/or ST than of BARC 3 to 5 bleeding, 1555 patients (23.4%) had a greater risk of BARC 3 to 5 bleeding than of MI and/or ST, and 2155 (32.4%) had a comparable risk of both events. Conclusions and Relevance In a large cohort of patients at high bleeding risk undergoing PCI, 2 prognostic models have been developed to identify individual patients' risk of major coronary thrombotic and bleeding events. In future clinical practice, using an application on a smartphone to evaluate the trade-off between these 2 quantifiable risks for each patient may help clinicians choose the most appropriate revascularization strategy and tailor the duration and intensity of antithrombotic regimens.
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Affiliation(s)
| | - John Gregson
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ruth Owen
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Olivier Varenne
- Service de Cardiologie, DMU CARTE, Hôpital Cochin, Assistance Publique–Hôpitaux de Paris, Paris, France
- Cardiology Department, Université Paris Descartes, Sorbonne Paris-Cité, Paris, France
| | - Mitchell Krucoff
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Usman Baber
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bernard Chevalier
- Hôpital Privé Jacques Cartier, Institut Cardiovasculaire Paris-Sud Ramsay-Générale de Santé, Massy, France
| | - Davide Capodanno
- Cardio-Thoracic-Vascular Department, Centro Alte Specialità e Trapianti, Catania, Italy
- Azienda Ospedaliero Universitario “Vittorio Emanuele-Policlinico,” University of Catania, Catania, Italy
| | | | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Impact of renal function in high bleeding risk patients undergoing percutaneous coronary intervention: a patient-level stratified analysis from four post-approval studies. J Thromb Thrombolysis 2021; 52:419-428. [PMID: 33709255 DOI: 10.1007/s11239-020-02321-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 10/21/2022]
Abstract
Data on ischemic and bleeding outcomes after percutaneous coronary intervention (PCI) in high bleeding risk (HBR) patients with chronic kidney disease (CKD) are scarce. We aimed to evaluate the association between CKD and ischemic and bleeding outcomes in HBR patients who underwent PCI. Among 10,502 patients in the four post-approval registries evaluating patients undergoing PCI, 2,300 patients presented with at least one major or two minor ARC-HBR criteria. CKD was defined as eGFR < 60 mL/min/1.73 m2. These HBR patients were divided into 3 groups: eGFR < 30 mL/min/1.73 m2 defined as severe CKD (N = 221), eGFR 30- < 60 mL/min/1.73 m2 defined as moderate CKD (N = 970), eGFR ≥ 60 mL/min/1.73 m2 defined as no CKD (N = 1,109). The primary endpoint was the composite of cardiac death, myocardial infarction, or stent thrombosis, and the safety endpoint was major bleeding up to 4-year follow-up. HBR patients with CKD were more often female and had higher rates of comorbidities compared to those without CKD. Reduced renal function was associated with higher rates of the primary endpoint (severe CKD vs. moderate CKD vs. no CKD: 30.2% vs. 12.5% vs. 9.1%, P < 0.01) as well as major bleeding (10.3% vs. 8.9% vs. 6.4%, P = 0.03). After adjustment, severe CKD and moderate CKD in HBR patients remained independent predictors for the primary endpoint (HR [95%CI] 2.84 [1.94-4.16], P < 0.01, 1.48 [1.10-2.00], P < 0.01) compared to those with no CKD. However, decreased renal function was no longer significantly associated with major bleeding after adjustment. In conclusions, in HBR patients undergoing PCI, CKD has an important impact on major ischemic events after PCI.
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Abstract
Cardiac oncology is a subspecialty of cardiology engaging cardiologists and oncologists alike, in order to provide the best possible oncologic treatment for patients at high cardiovascular risk or developing cardio-toxicity during the course of their treatment, thus avoiding discontinuing it, and aiming at improving survival and quality of life. Early diagnosis and the effectiveness of the newer cancer treatments delivered an increasing number of long-term survivors (presently almost 30 million worldwide), at high risk of developing cardiovascular diseases. This predisposition has been correlated not only to the toxic side effects of the oncologic treatment but also to a real vulnerability to the risk factors in this patients population. For decades, the concept of cardio-toxicity in cardiac oncology has been restricted to ventricular dysfunction, but during the last few years the Food and Drug Administration has approved hundreds of new molecules and cardiac oncology has escalated its complexity. The introduction of new target therapy, proteasome inhibitors, immuno-modulators, and inhibitors of the immunitary checkpoint, magnified the concept of cardio-toxicity to a wider definition of ‘cardiovascular toxicity’ incorporating arterial hypertension, ischaemia, cardiomyopathy, myocarditis, arrhythmic complications, long QT, and arterial and venous thrombosis. We are still lacking guidelines on the new and varied forms of toxicity, as well as monitoring strategies in the short- and long-term follow-up.
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Affiliation(s)
- Irma Bisceglia
- Servizi Cardiologici Integrati, Azienda Ospedaliera San Camillo - Forlanini di Roma, Roma, Italy
| | - Domenico Cartoni
- Servizi Cardiologici Integrati, Azienda Ospedaliera San Camillo - Forlanini di Roma, Roma, Italy
| | - Sandro Petrolati
- Servizi Cardiologici Integrati, Azienda Ospedaliera San Camillo - Forlanini di Roma, Roma, Italy
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Spione F, Brugaletta S. Second generation drug-eluting stents: a focus on safety and efficacy of current devices. Expert Rev Cardiovasc Ther 2021; 19:107-127. [PMID: 33417509 DOI: 10.1080/14779072.2021.1874352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Percutaneous coronary intervention (PCI) represents the most frequent procedure performed in medicine. Second generation drug eluting stents (DES) have been developed to reduce the rates of late and very late complications of first generation DES.Areas covered: To improve long-term efficacy and safety of patients undergoing PCI, second generation DES have been developed with novel stent platforms, biocompatible durable and biodegradable polymers and newer antiproliferative agents. In this review we provide an overview of second generation DES and their clinical trials, discussing safety and effectiveness of these devices, and outlining clinical indication for use.Expert commentary: Numerous clinical trials have demonstrated the safety and efficacy of second generation DES over the last decade. These devices represent the gold standard treatment in stable and acute coronary syndromes.
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Affiliation(s)
- Francesco Spione
- Division of University Cardiology, Cardiothoracic Department, Policlinico University Hospital, Bari, Italy
| | - Salvatore Brugaletta
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
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20
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Lunardi M, Gao C, Hara H, Ono M, Kawashima H, Wang R, Wijns W, Serruys PW, Onuma Y. Coronary interventions in 2020: the year in review. EUROINTERVENTION 2021; 16:e1215-e1226. [PMID: 33478939 PMCID: PMC9724941 DOI: 10.4244/eij-d-20-01343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Mattia Lunardi
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland,Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Charlie Gao
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland,Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hironori Hara
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland,Amsterdam UMC, University of Amsterdam, Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Masafumi Ono
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland,Amsterdam UMC, University of Amsterdam, Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Hideyuki Kawashima
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland,Amsterdam UMC, University of Amsterdam, Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Rutao Wang
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland,Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - William Wijns
- The Lambe Institute for Translational Medicine (Floor 2), University Road, National University of Ireland Galway, Galway, Ireland, H91 TK33
| | - Patrick W. Serruys
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland,NHLI, Imperial College London, London, United Kingdom
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
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Verdoia M, Khedi E, Suryapranata H, De Luca G. Tratamiento antiagregante de muy corta duración tras la ICP y nuevos SLF: metanálisis de 5 estudios aleatorizados. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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22
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Hertault A, Chai F, Maton M, Sobocinski J, Woisel P, Maurel B, Lyskawa J, Blanchemain N. In vivo evaluation of a pro-healing polydopamine coated stent through an in-stent restenosis rat model. Biomater Sci 2021; 9:212-220. [PMID: 33179639 DOI: 10.1039/d0bm01204a] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Drug-eluting stents have demonstrated efficiency in in-stent restenosis (ISR) but induced a risk of late acute thrombosis by delaying strut re-endothelialization. Polydopamine (PDA), a biocompatible polymer inspired from adhesive proteins of mussels, has been reported to promote endothelial cell (EC) proliferation while limiting SMC proliferation in vitro, thus suggesting the pro-healing potential. This study aimed at evaluating in vivo the impact of the pro-healing PDA-coated stent on ISR and on the quality of the strut re-endothelialization in a rat model. PDA-coated stents demonstrated a significant reduction in ISR in vivo compared to bare metal stents (ratio neointima/media = 0.48 (±0.26) versus 0.83 (±0.42), p < 0.001). Western blot analyses identified a trend towards an increased activation of p38 MAPK phosphorylation and its anti-proliferative effects on vascular SMC that could explain the results observed in morphological analyses. This bioinspired and biocompatible polydopamine layer could intrinsically limit ISR. In addition, according to its latent reactivity, PDA offers the possibility to immobilize some relevant drugs on the PDA-functionalized stent to provide potential synergistic effects.
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Affiliation(s)
- Adrien Hertault
- Univ. Lille, INSERM, CHU Lille, U1008 - Controlled Drug Delivery Systems and Biomaterials, F-59000 Lille, France.
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Shima Y, Miura K, Shimada T, Ohya M, Murai R, Kubo S, Tada T, Tanaka H, Fuku Y, Kadota K. Impact of ischemic risk factors on long-term outcomes in patients with and without high bleeding risk. Int J Cardiol 2020; 326:12-18. [PMID: 33152414 DOI: 10.1016/j.ijcard.2020.10.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 11/20/2022]
Abstract
Background The current guidelines have recommended to shorten the dual antiplatelet therapy duration in patients at high bleeding risk (HBR) to minimize the bleeding complications. The impact of ischemic risk factors (IRF) on long-term ischemic events in patients with and without HBR after percutaneous coronary intervention remains unclear. Methods The study population comprised 1219 patients who were treated with everolimus-eluting stents between 2010 and 2011. The mean follow-up period was 2996 ± 433 days. HBR was defined as set by the Academic Research Consortium. IRF was defined as high-risk features of stent-driven recurrent ischemic events endorsed in the 2017 European Society of Cardiology Guidelines. Major bleeding was defined as the occurrence of Bleeding Academic Research Consortium type 3 or 5 bleeding. Primary ischemic events included myocardial infarction, definite stent thrombosis, and cardiac death. Results The 1219 patients were divided into two groups: 614 patients at HBR (HBR group) and 605 patients at no HBR (non-HBR group). The rate of IRF patients was significantly higher in the HBR group than in the non-HBR group (81.4% versus 47.6%, P < 0.001). The cumulative rate of ischemic events in the HBR group was significantly higher in IRF patients than in non-IRF patients (21.0% versus 7.0%, log rank P < 0.001), whereas that in the non-HBR group was not significantly different between IRF and non-IRF patients (10.1% versus 6.3%, log rank P = 0.09). Conclusions More than 80% of HBR patients treated with everolimus-eluting stents were at IRF. A combination of HBR and IRF may increase the risk of long-term ischemic events.
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Affiliation(s)
- Yuki Shima
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan.
| | - Katsuya Miura
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Takenobu Shimada
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Masanobu Ohya
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Ryosuke Murai
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Syunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Takeshi Tada
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Hiroyuki Tanaka
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Yasushi Fuku
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
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Biscaglia S, Guiducci V, Santarelli A, Amat Santos I, Fernandez-Aviles F, Lanzilotti V, Varbella F, Fileti L, Moreno R, Giannini F, Colaiori I, Menozzi M, Redondo A, Ruozzi M, Gutiérrez Ibañes E, Díez Gil JL, Maietti E, Biondi Zoccai G, Escaned J, Tebaldi M, Barbato E, Dudek D, Colombo A, Campo G. Physiology-guided revascularization versus optimal medical therapy of nonculprit lesions in elderly patients with myocardial infarction: Rationale and design of the FIRE trial. Am Heart J 2020; 229:100-109. [PMID: 32822656 PMCID: PMC7434365 DOI: 10.1016/j.ahj.2020.08.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 08/11/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Myocardial infarction (MI) in elderly patients is associated with unfavorable prognosis, and it is becoming an increasingly prevalent condition. The prognosis of elderly patients is equally impaired in ST-segment elevation (STE) or non-STE (NSTE), and it is markedly worsened by the common presence of multivessel disease (MVD). Given the limited evidence available for elderly patients, it has not yet been established whether, as for younger patients, a complete revascularization strategy in MI patients with MVD should be advocated. We present the design of a dedicated study that will address this research gap. METHODS AND DESIGN The FIRE trial is a prospective, randomized, international, multicenter, open-label study with blinded adjudicated evaluation of outcomes. Patients aged 75 years and older, with MI (either STE or NSTE), MVD at coronary artery angiography, and a clear culprit lesion will be randomized to culprit-only treatment or to physiology-guided complete revascularization. The primary end point will be the patient-oriented composite end point of all-cause death, any MI, any stroke, and any revascularization at 1 year. The key secondary end point will be the composite of cardiovascular death and MI. Quality of life and physical performance will be evaluated as well. All components of the primary and key secondary outcome will be tested also at 3 and 5 years. The sample size for the study is 1,400 patients. IMPLICATIONS The FIRE trial will provide evidence on whether a specific revascularization strategy should be applied to elderly patients presenting MI and MVD to improve their clinical outcomes.
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Tsujimura T, Ishihara T, Okuno S, Iida O, Kurata N, Asai M, Masuda M, Okamoto S, Nanto K, Kanda T, Matsuda Y, Hata Y, Mano T. Angioscopic assessments and clinical outcomes one year after polymer-free biolimus A9-coated coronary stent implantation. J Cardiol 2020; 77:457-464. [PMID: 33121798 DOI: 10.1016/j.jjcc.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/31/2020] [Accepted: 09/14/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Polymer-free biolimus A9-coated coronary stent (DCS) has novel features which lead to the expectation of better arterial healing. However, comparisons of intravascular status between DCS and drug-eluting stents (DES), and robust real-word clinical assessments of DCS have been lacking to date. METHODS From September 2017 to September 2018, we evaluated the intra-vascular status of 74 DCS implanted in 55 lesions from 43 patients using coronary angioscopy (CAS) approximately one year after implantation from a cohort of 219 lesions in 158 patients. We set 239 second-generation durable-polymer DES (DP-DES) implanted in 211 lesions from 180 patients from a cohort of 2652 lesions in 1914 patients as the control. Angioscopic images were analyzed to determine (1) the dominant degree of neointimal coverage (NIC) over the stent; (2) the heterogeneity of NIC; (3) yellow color grade of the stented segment; and (4) the presence of intra-stent thrombus. The primary outcome was the incidence of thrombus and secondary outcomes were the other CAS findings, and the 1-year clinical outcomes which included target lesion revascularization (TLR) and major adverse cardiac events (MACE). To minimize inter-group differences in baseline characteristics, propensity score matching was performed for clinical outcomes. RESULTS Incidence of thrombus adhesion was similar in DCS and DP-DES groups (28.4% versus 22.6%, p=0.31). However, the dominant NIC grade was significantly higher in DCS (p<0.001), while NIC was more heterogeneous in DCS than in DP-DES (p=0.001). Maximum yellow color grade was similar (p=0.22). After propensity score matching, 202 lesion pairs from 146 patient pairs were retained for analysis. The cumulative incidence of TLR (4.6% versus 3.8%, p=0.38) and MACE (11.6% versus 11.7%, p=0.84) was similar for DCS and DP-DES. CONCLUSIONS DCS showed thrombus adhesion and clinical outcomes at 1 year similar to DP-DES. DCS can thus be used with similar safety and efficacy as DP-DES.
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Affiliation(s)
| | | | - Shota Okuno
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Osamu Iida
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Naoya Kurata
- Department of Clinical Engineering, Kansai Rosai Hospital, Amagasaki, Japan
| | - Mitsutoshi Asai
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Masaharu Masuda
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Shin Okamoto
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Kiyonori Nanto
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Takashi Kanda
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | | | - Yosuke Hata
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Toshiaki Mano
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
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Price MJ. Abbreviated Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in High Bleeding Risk Patients: LEADERS-FREE and ONYX ONE. Interv Cardiol Clin 2020; 9:441-449. [PMID: 32921368 DOI: 10.1016/j.iccl.2020.06.002] [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: 11/29/2022]
Abstract
The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) has been the focus of much discussion. The risk of late stent thrombosis appears less with newer-generation stents, and polymer-free drug-coated stents (DCS) may improve clinical efficacy relative to a bare metal stent without the potential long-term hazards associated with a durable polymer. Based on the outcomes of recent clinical trials, risk stratification to identify high bleeding risk patients and appropriate selection of a polymer-free drug-coated or durable-polymer zotarolimus-eluting stent may optimize clinical outcomes in patients who require an abbreviated DAPT regimen.
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Affiliation(s)
- Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, 9898 Genesee Avenue, AMP-200, La Jolla, CA 92037, USA.
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Mauler-Wittwer S, Garot P. The Biolimus A9-coated BioFreedom ™ stent: from clinical efficacy to real-world evidence. Future Cardiol 2020; 17:239-255. [PMID: 32893680 DOI: 10.2217/fca-2020-0069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In this state-of-the-art review, we present the findings and a critical analysis of the Leaders Free trial program, evaluating outcomes of a new stent-generation based on polymer-free technology, in this case the BioFreedom™ (Biosensors Europe, Switzerland), in patients at high bleeding risk (HBR). Polymer-free drug-coated stents were designed to obtain a device with the antirestenotic benefits of drug-eluting stents but without the polymer coating as potential trigger for delayed arterial wall healing and subsequent late ischemic adverse events, causing a prolonged dependence on dual antiplatelet therapy after stenting. This offers therefore the potential of a promising device-based strategy in a complex growing population of patients with combined HBR and high thrombosis risk, due to the possible reduction of antithrombotic duration.
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Affiliation(s)
- Sarah Mauler-Wittwer
- Hôpital Privé Jacques Cartier, Institut Cardio-vasculaire Paris-sud (ICPS), Ramsay-Santé, Massy, France
| | - Philippe Garot
- Hôpital Privé Jacques Cartier, Institut Cardio-vasculaire Paris-sud (ICPS), Ramsay-Santé, Massy, France
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28
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Kobo O, Mohamed MO, Farmer AD, Alraies CM, Patel T, Sharma K, Nolan J, Bagur R, Roguin A, Mamas MA. Outcomes of Percutaneous Coronary Intervention in Patients With Crohn's Disease and Ulcerative Colitis (from a Nationwide Cohort). Am J Cardiol 2020; 130:30-36. [PMID: 32665130 DOI: 10.1016/j.amjcard.2020.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/17/2020] [Accepted: 06/01/2020] [Indexed: 02/08/2023]
Abstract
Patients with inflammatory bowel disease (IBD) are at an increased risk of ischemic heart disease. However, there is limited evidence on how their outcomes after percutaneous coronary intervention (PCI) compare with those without IBD. All PCI-related hospitalizations from the National Inpatient Sample from 2004 to 2015 were included, stratified into 3 groups: no-IBD, Crohn's disease (CD), and ulcerative colitis (UC). We assessed the association between IBD subtypes and in-hospital outcomes. A total of 6,689,292 PCI procedures were analyzed, of which 0.3% (n = 18,910) had an IBD diagnosis. The prevalence of IBD increased from 0.2% (2004) to 0.4% (2015). Patients with IBD were less likely to have conventional cardiovascular risk factors and more likely to undergo PCI for an acute indication, and to receive bare metal stents. In comparison to patients without IBD, those with IBD had reduced or similar adjusted odds ratios (OR) of major adverse cardiovascular and cerebrovascular events (CD OR 0.69, 95% confidence interval (CI) 0.62 to 0.78; UC OR 0.75, 95% CI 0.66 to 0.85), mortality (CD: OR 0.94, 95% CI 0.79 to 1.11; UC OR 0.35, 95% CI 0.27 to 0.45) or acute cerebrovascular accident (CD: OR 0.73, 95% CI 0.60 to 0.89; UC: OR 0.94, 95% CI 0.77 to 1.15). However, IBD patients had an increased odds for major bleeding (CD: OR 1.42 95% CI 1.23 to 1.63, and UC: OR 1.35 95% CI 1.16 to 1.58). In summary, IBD is associated with a decreased risk of in-hospital post-PCI complications other than major bleeding that was significantly higher in this group. Long term follow-up is required to evaluate the safety of PCI in IBD patients from both bleeding and ischemic perspectives.
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Mehran R, Chandrasekhar J, Urban P, Lang IM, Windhoevel U, Spaulding C, Copt S, Stoll HP, Morice MC. Sex-Based Outcomes in Patients With a High Bleeding Risk After Percutaneous Coronary Intervention and 1-Month Dual Antiplatelet Therapy: A Secondary Analysis of the LEADERS FREE Randomized Clinical Trial. JAMA Cardiol 2020; 5:939-947. [PMID: 32432718 DOI: 10.1001/jamacardio.2020.0285] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Female sex has been identified as a risk factor for bleeding after percutaneous coronary intervention (PCI) and may have contributed to the underuse of drug-eluting stents in women. This risk may be further enhanced among patients with a high bleeding risk. Objective To assess the 2-year outcomes by sex in patients with a high bleeding risk who were enrolled in the LEADERS FREE trial. Design, Setting, and Participants This cohort study is a prespecified, sex-based secondary analysis of the LEADERS FREE double-blind, randomized clinical trial that was conducted at 68 sites in 20 countries from December 2012 to May 2014. Patients with a high bleeding risk who underwent PCI and met the trial eligibility criteria were enrolled at the participating sites and followed up for up to 2 years. Interventions Patients were randomized 1:1 to either a bare-metal stent or a polymer-free, biolimus A9-eluting drug-coated stent with 1-month of dual antiplatelet therapy. Main Outcomes and Measures The primary safety end point was a composite of cardiac death, myocardial infarction, or stent thrombosis. The primary efficacy end point was clinically driven target lesion revascularization. Bleeding was assessed using the Bleeding Academic Research Consortium (BARC) scale, and the source of bleeding was recorded. Results A total of 2432 patients with a high bleeding risk were included in the study. Of these patients, the mean (SD) age was 75 (9) years, and 1694 (69.7%) were men and 738 (30.3%) were women. Women and men had similar incidence of the 2-year primary safety (14.7% vs 13.6%; P = .37) and efficacy (9.2% vs 9.5%; P = .70) end points. The drug-coated stent was found to be superior to the bare-metal stent in both sexes, with lower target lesion revascularization (women: 6.3% vs 12.1%; men: 7.0% vs 12.0%; P for interaction = .70) and similar rates of the primary safety end point (women: 12.4% vs 17.0%; men: 12.6% vs 14.5%; P for interaction = .40). Overall, 2-year BARC types 3 to 5 major bleeding (10.2% vs 8.6%; P = .14) was not statistically different between the sexes, but women experienced greater BARC types 3 to 5 major bleeding within the first 30 days (5.1% vs 2.4%; P = .007) and greater vascular access site major bleeding than men (2.2% vs 0.5%; P < .001). In both sexes, vascular (women: hazard ratio [HR], 3.45 [95% CI, 1.51-7.87]; men: HR, 4.14 [95% CI, 1.33-12.95]) and nonvascular major bleeding (women: HR, 3.76 [95% CI, 2.17- 6.53]; men: HR, 4.62 [95% CI, 3.23-6.61]) were associated with greater 2-year mortality. Conclusions and Relevance This study found no sex differences in the ischemic outcomes of patients with a high bleeding risk after PCI, but women appeared to demonstrate greater early bleeding and major bleeding from the vascular access site. Both women and men with major bleeding seemed to experience worse 2-year mortality, suggesting that bleeding avoidance strategies should be uniformly adopted for all patients, with close attention dedicated to women to avoid denying them the benefits of PCI. Trial Registration ClinicalTrials.gov Identifier: NCT02843633.
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Affiliation(s)
- Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.,Associate Editor, JAMA Cardiology
| | - Jaya Chandrasekhar
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.,Amsterdam University Medical Center, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | | | | | | | - Christian Spaulding
- European Hospital Georges Pompidou, Assistance Publique Hôpitaux de Paris, Sudden Death Expert Center INSERM U 970, Paris Descartes University, Paris, France
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30
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Dudek D, Dziewierz A, Stone G, Wijns W. The year in cardiology 2018: coronary interventions. Eur Heart J 2020; 40:195-203. [PMID: 30601991 DOI: 10.1093/eurheartj/ehy882] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/27/2018] [Indexed: 02/06/2023] Open
Affiliation(s)
- Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, 17 Kopernika Street, Krakow, Poland
| | - Artur Dziewierz
- 2nd Department of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Gregg Stone
- New York Presbyterian Hospital and Columbia University Medical Center, New York, NY, USA.,The Cardiovascular Research Foundation, New York, NY, USA
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, Saolta University Healthcare Group, National University of Ireland Galway, Galway, Ireland
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31
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Fong LCW, Ford TJ, da Costa BR, Jüni P, Berry C. Bias and Loss to Follow-Up in Cardiovascular Randomized Trials: A Systematic Review. J Am Heart Assoc 2020; 9:e015361. [PMID: 32646264 PMCID: PMC7660731 DOI: 10.1161/jaha.119.015361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Loss to follow-up (LTFU) is common in randomized controlled trials. However, its potential impact on primary outcomes from cardiovascular randomized controlled trials is not known. Methods and Results We conducted a prospective systematic review (PROSPERO: CRD42019121959) for randomized controlled trials published in 8 leading journals over 5 years from January 2014 to December 2018. Extent, reporting, and handling of LTFU data were recorded, and the proportion of a trial's primary outcome results that lose statistical significance was calculated after making plausible assumptions for the intervention and control arms. These assumptions could drive differential treatment effects between the groups considering relative event incidence between LTFU participants and those included in the primary outcome. We identified 117 randomized controlled trials of which 91 (78%) trials reported LTFU, 23 (20%) reported no LTFU, and 3 (3%) trials did not report on whether LTFU occurred. The median percentage of study participants lost to follow-up was 2% (interquartile range, 0.33%-5.3%). Only 10 trials (9%) had a low cluster of risk factors for impairment in trial quality. The percentage of trials losing statistical significance varied from 2% when the relative event incidence for LTFU between the randomized groups was 1 for the intervention arm and 1.5 for the control arm to 16% when the relative event incidence was 3 for the intervention arm and 1 for the control arm. Conclusions Almost 1 in 6 (16%) cardiovascular randomized trials published in leading journals may have a change in the primary outcome if plausible assumptions are made about differential event rates of participants lost to follow up. There is scope for improvement arising from LTFU in randomized trials in cardiovascular medicine. Registration URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42019121959.
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Affiliation(s)
- Lucas Chun Wah Fong
- West of Scotland Heart and Lung Centre Golden Jubilee National Hospital Glasgow Scotland.,British Heart Foundation Glasgow Cardiovascular Research Centre Institute of Cardiovascular and Medical Sciences University of Glasgow United Kingdom
| | - Thomas J Ford
- British Heart Foundation Glasgow Cardiovascular Research Centre Institute of Cardiovascular and Medical Sciences University of Glasgow United Kingdom.,Department of Cardiology Gosford Hospital Gosford NSW Australia.,Faculty of Medicine University of Newcastle Callaghan NSW Australia
| | - Bruno R da Costa
- Institute of Health Policy, Management, and Evaluation Dalla Lana School of Public Health University of Toronto.,Applied Health Research Center (AHRC) Li Ka Shing Knowledge Institute, St Michael's Hospital Toronto Ontario Canada.,Institute of Primary Health Care (BIHAM) University of Bern Bern Switzerland
| | - Peter Jüni
- Department of Medicine University of Toronto Canada
| | - Colin Berry
- West of Scotland Heart and Lung Centre Golden Jubilee National Hospital Glasgow Scotland.,British Heart Foundation Glasgow Cardiovascular Research Centre Institute of Cardiovascular and Medical Sciences University of Glasgow United Kingdom
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32
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Jiménez Díaz VA, Hovasse T, Íñiguez A, Copt S, Byrne J, Brunel P, Morice MC, Abizaid A, Tespilli M, Walters D, Ortiz Sáez A, Bastos Fernández G, Stoll HP, Urban P. Impacto del acceso vascular en el pronóstico tras la angioplastia coronaria en pacientes con alto riesgo hemorrágico: subanálisis predefinido del estudio LEADERS FREE. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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33
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Marquis-Gravel G, Dalgaard F, Jones AD, Lokhnygina Y, James SK, Harrington RA, Wallentin L, Steg PG, Lopes RD, Storey RF, Goodman SG, Mahaffey KW, Tricoci P, White HD, Armstrong PW, Ohman EM, Alexander JH, Roe MT. Post-Discharge Bleeding and Mortality Following Acute Coronary Syndromes With or Without PCI. J Am Coll Cardiol 2020; 76:162-171. [DOI: 10.1016/j.jacc.2020.05.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/24/2020] [Accepted: 05/15/2020] [Indexed: 10/23/2022]
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Jensen LO, Maeng M, Raungaard B, Kahlert J, Ellert J, Jakobsen L, Villadsen AB, Veien KT, Kristensen SD, Ahlehoff O, Carstensen S, Christensen MK, Terkelsen CJ, Engstroem T, Hansen KN, Bøtker HE, Aaroe J, Thim T, Thuesen L, Freeman P, Aziz A, Eftekhari A, Junker A, Jensen SE, Lassen JF, Hansen HS, Christiansen EH, Thygesen K, Sørensen JT, Andersen HR. Randomized Comparison of the Polymer-Free Biolimus-Coated BioFreedom Stent With the Ultrathin Strut Biodegradable Polymer Sirolimus-Eluting Orsiro Stent in an All-Comers Population Treated With Percutaneous Coronary Intervention. Circulation 2020; 141:2052-2063. [DOI: 10.1161/circulationaha.119.040241] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
In patients with increased bleeding risk, the biolimus A9-coated BioFreedom stent, a stainless steel drug-coated stent free from polymer, has shown superiority compared with a bare-metal stent. The aim of this study was to investigate whether the BioFreedom stent is noninferior to a modern ultrathin strut biodegradable polymer cobalt-chromium sirolimus-eluting Orsiro stent in an all-comers patient population treated with percutaneous coronary intervention.
Methods:
The SORT OUT IX trial (Scandinavian Organization for Randomized Trials With Clinical Outcome IX), was a large-scale, registry-based, randomized, multicenter, single-blind, 2-arm, noninferiority trial. The primary end point, major adverse cardiovascular events, was defined as the composite of cardiac death, myocardial infarction not related to any segment other than the target lesion, or target lesion revascularization within 1 year, analyzed by intention-to-treat. The trial was powered to assess noninferiority for major adverse cardiovascular events of the BioFreedom stent compared with the Orsiro stent with a predetermined noninferiority margin of 0.021.
Results:
Between December 14, 2015 and April 21, 2017, 3151 patients were assigned to treatment with the BioFreedom stent (1572 patients, 1966 lesions) or to the Orsiro stent (1579 patients, 1985 lesions). Five patients were lost to follow-up because of emigration (99.9% follow-up rate). Mean age was 66.3±10.9, diabetes mellitus was seen in 19.3% of patients, and 53% of the patients had acute coronary syndromes. At 1 year, intention-to-treat analysis showed that 79 (5.0%) patients, who were assigned the BioFreedom stent, and 59 (3.7%), who were assigned the Orsiro stent, met the primary end point (absolute risk difference 1.29% [upper limit of one-sided 95% CI 2.50%];
P
noni
nferiority
=0.14). Significantly more patients in the BioFreedom stent group had target lesion revascularization than those in the Orsiro stent group (55 [3.5%] vs 20 [1.3%], rate ratio 2.77 [95% CI, 1.66–4.62];
P
<0.0001).
Conclusions:
The biolimus A9-coated BioFreedom polymer-free stent did not meet criteria for noninferiority for major adverse cardiovascular events at 12 months when compared with the ultrathin strut biodegradable polymer sirolimus-eluting Orsiro stent in an all-comers population
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT02623140.
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Affiliation(s)
- Lisette Okkels Jensen
- Department of Cardiology, Odense University Hospital, Denmark (L.O.J., J.E., K.T.V., O.A., K.N.H., A.A., A.J., J.F.L., H.S.H.)
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Denmark (M.M., L.J., S.D.K., S.C., C.J.T., H.E.B., T.T., A.E., E.H.C.)
| | - Bent Raungaard
- Department of Cardiology, Aalborg University Hospital, Denmark (B.R., A.B.V., M.K.C., J.A., L.T., P.F., S.E.J.)
| | - Johnny Kahlert
- Department of Clinical Epidemiology, Aarhus University, Denmark (J.K.)
| | - Julia Ellert
- Department of Cardiology, Odense University Hospital, Denmark (L.O.J., J.E., K.T.V., O.A., K.N.H., A.A., A.J., J.F.L., H.S.H.)
| | - Lars Jakobsen
- Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Denmark (M.M., L.J., S.D.K., S.C., C.J.T., H.E.B., T.T., A.E., E.H.C.)
| | - Anton Boel Villadsen
- Department of Cardiology, Aalborg University Hospital, Denmark (B.R., A.B.V., M.K.C., J.A., L.T., P.F., S.E.J.)
| | - Karsten Tange Veien
- Department of Cardiology, Odense University Hospital, Denmark (L.O.J., J.E., K.T.V., O.A., K.N.H., A.A., A.J., J.F.L., H.S.H.)
| | - Steen Dalby Kristensen
- Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Denmark (M.M., L.J., S.D.K., S.C., C.J.T., H.E.B., T.T., A.E., E.H.C.)
| | - Ole Ahlehoff
- Department of Cardiology, Odense University Hospital, Denmark (L.O.J., J.E., K.T.V., O.A., K.N.H., A.A., A.J., J.F.L., H.S.H.)
| | - Steen Carstensen
- Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Denmark (M.M., L.J., S.D.K., S.C., C.J.T., H.E.B., T.T., A.E., E.H.C.)
| | - Martin Kirk Christensen
- Department of Cardiology, Aalborg University Hospital, Denmark (B.R., A.B.V., M.K.C., J.A., L.T., P.F., S.E.J.)
| | - Christian Juhl Terkelsen
- Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Denmark (M.M., L.J., S.D.K., S.C., C.J.T., H.E.B., T.T., A.E., E.H.C.)
| | | | - Knud Nørregaard Hansen
- Department of Cardiology, Odense University Hospital, Denmark (L.O.J., J.E., K.T.V., O.A., K.N.H., A.A., A.J., J.F.L., H.S.H.)
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Denmark (M.M., L.J., S.D.K., S.C., C.J.T., H.E.B., T.T., A.E., E.H.C.)
| | - Jens Aaroe
- Department of Cardiology, Aalborg University Hospital, Denmark (B.R., A.B.V., M.K.C., J.A., L.T., P.F., S.E.J.)
| | - Troels Thim
- Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Denmark (M.M., L.J., S.D.K., S.C., C.J.T., H.E.B., T.T., A.E., E.H.C.)
| | - Leif Thuesen
- Department of Cardiology, Aalborg University Hospital, Denmark (B.R., A.B.V., M.K.C., J.A., L.T., P.F., S.E.J.)
| | - Philip Freeman
- Department of Cardiology, Aalborg University Hospital, Denmark (B.R., A.B.V., M.K.C., J.A., L.T., P.F., S.E.J.)
| | - Ahmed Aziz
- Department of Cardiology, Odense University Hospital, Denmark (L.O.J., J.E., K.T.V., O.A., K.N.H., A.A., A.J., J.F.L., H.S.H.)
| | - Ashkan Eftekhari
- Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Denmark (M.M., L.J., S.D.K., S.C., C.J.T., H.E.B., T.T., A.E., E.H.C.)
| | - Anders Junker
- Department of Cardiology, Odense University Hospital, Denmark (L.O.J., J.E., K.T.V., O.A., K.N.H., A.A., A.J., J.F.L., H.S.H.)
| | - Svend Eggert Jensen
- Department of Cardiology, Aalborg University Hospital, Denmark (B.R., A.B.V., M.K.C., J.A., L.T., P.F., S.E.J.)
| | - Jens Flensted Lassen
- Department of Cardiology, Odense University Hospital, Denmark (L.O.J., J.E., K.T.V., O.A., K.N.H., A.A., A.J., J.F.L., H.S.H.)
- Department of Cardiology, Copenhagen University Hospital, Denmark (J.F.L.)
| | - Henrik Steen Hansen
- Department of Cardiology, Odense University Hospital, Denmark (L.O.J., J.E., K.T.V., O.A., K.N.H., A.A., A.J., J.F.L., H.S.H.)
| | - Evald Høj Christiansen
- Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Denmark (M.M., L.J., S.D.K., S.C., C.J.T., H.E.B., T.T., A.E., E.H.C.)
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Bisceglia I, Canale ML, Lestuzzi C, Parrini I, Russo G, Colivicchi F, Gabrielli D, Gulizia MM, Iliescu CA. Acute coronary syndromes in cancer patients. J Cardiovasc Med (Hagerstown) 2020; 21:944-952. [PMID: 32520859 DOI: 10.2459/jcm.0000000000000993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
: Cardiovascular disease and cancer are responsible for the majority of deaths in the Western world. These two entities share common risk factors and their intersection will be more and more frequent in future due to general population aging and long-term cancer control. Clinical presentation, management and outcome of acute coronary syndromes (ACS) in cancer patients could differ from noncancer ones. Cancer patients were frequently excluded from clinical trials and so the paucity of data further complicates the scenario. The management of ACS in cancer patients represents a unique setting in which the risk/benefit ratio of invasive treatment should be carefully evaluated. This review focused on the available evidence of all aspects of ACS in cancer patients providing a guide to a multidisciplinary approach.
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Affiliation(s)
- Irma Bisceglia
- Servizi Cardiologici Integrati Cardiology Department, Azienda Ospedaliera San Camillo-Forlanini, Roma
| | - Maria Laura Canale
- Division of Cardiology, Azienda USL Toscana Nord Ovest, Versilia Hospital, Lido di Camaiore
| | - Chiara Lestuzzi
- Cardiology Unit, Oncology Department, CRO National Cancer Institute, Aviano
| | - Iris Parrini
- Divisione di Cardiologia, Ospedale Mauriziano, Torino
| | - Giulia Russo
- SC Centro Cardiovascolare Ospedale Maggiore, Cardiology Department, Trieste
| | - Furio Colivicchi
- Division of Cardiology, San Filippo Neri Hospital, ASL Roma 1, Rome
| | | | | | - Cezar A Iliescu
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Very short dual antiplatelet therapy after PCI and new DES: a meta-analysis of 5 randomized trials. ACTA ACUST UNITED AC 2020; 74:140-148. [PMID: 32482558 DOI: 10.1016/j.rec.2020.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 03/17/2020] [Indexed: 01/05/2023]
Abstract
INTRODUCTION AND OBJECTIVES Very early (1-3 months) discontinuation of dual antiplatelet therapy (DAPT) has been recently proposed in percutaneous coronary interventions with modern drug-eluting stents (DES), with contrasting results. The aim of the present meta-analysis was to evaluate the prognostic impact of very short DAPT regimens vs the standard 12-month regimen in patients undergoing percutaneous coronary intervention with new DES. METHODS Literature and main scientific session abstracts were searched for randomized clinical trials (RCT). The primary efficacy endpoint was mortality, and the primary safety endpoint was major bleeding events. A prespecified analysis was conducted according to the long-term antiplatelet agent. RESULTS We included 5 RCTs, with a total of 30 621 patients; 49.97% were randomized to very short (1-3 months) DAPT, followed by aspirin or P2Y12I monotherapy. Shorter DAPT duration significantly reduced the rate of major bleeding (2% vs 3.1%, OR, 0.62; 95%CI, 0.46-0.84; P=.002; Phet=.02), but did not significantly condition overall mortality (1.3% vs 2%, OR, 0.97; 95%CI, 0.73-1.29; P=.84; Phet=.18). The reduction in bleeding events was even more significant in trials randomizing event-free patients at the time of DAPT discontinuation. The occurrence of myocardial infarction and stent thrombosis was similar between shorter vs standard 12-month DAPT. CONCLUSIONS Based on the current meta-analysis, a very short (1-3 months) period is associated with a significant reduction in major bleeding compared with the standard 12-month therapy, with no increase in major ischemic events and comparable survival.
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Richardt G, Abdelghani M, Allali A, Toelg R, Abdellaoui M, Krackhardt F, Wiseth R, Morice MC, Copt S, Stoll HP, Urban P. Polymer-free drug-coated vs. bare-metal coronary stents in patients undergoing non-cardiac surgery: a subgroup analysis of the LEADERS FREE trial. Clin Res Cardiol 2020; 110:162-171. [PMID: 32440723 DOI: 10.1007/s00392-020-01672-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
AIMS To compare the outcomes of patients undergoing non-cardiac surgery (NCS) after PCI with either a drug-coated stent (DCS) or a bare-metal stent (BMS), followed by 1-month dual antiplatelet therapy and to explore the impact of the timing of NCS. METHODS This is a subgroup analysis of the LEADERS FREE trial. The primary safety end point was a composite of cardiac death, myocardial infarction, or stent thrombosis, and the primary efficacy end point was clinically driven target lesion revascularization (TLR). RESULTS Out of 2432 patients included in the LEADERS FREE trial, 278 (11.4%) underwent NCS within 1 year after PCI. Among NCS patients, the 1-year safety end point was numerically lower with DCS; however, this difference was not significant as compared to BMS (4.7% vs. 10.1%, HR: 0.459 [0.178-1.183], p = 0.099), clinically driven TLR was significantly lower after DCS (2.4% vs. 8.3%, HR: 0.281 [0.079-0.996], p = 0.036), and BARC 3-5 bleeding was similar with DCS vs. BMS (10.2% vs. 7.5%, p = 0.438). In patients treated with BMS, NCS within 3 months after PCI was associated with higher incidence of the safety end point than NCSs performed later: 14.9% vs. 4.4%, HR: 3.586 [1.012-12.709], p = 0.034. The timing of surgery had no impact on patients treated with DCS (4.7% vs. 4.7%, p = 0.947). CONCLUSIONS Among patients undergoing NCS after PCI, DCS-treated patients had a lower probability of clinically driven TLR compared with BMS. However, there was no significant difference in the occurrence of the primary composite safety end point or bleeding complications. Early NCS after BMS-PCI was associated with impaired safety, while the timing of NCS had no such influence after DCS implantation.
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Affiliation(s)
- Gert Richardt
- Heart Center, Segeberger Kliniken, Am Kurpark 1, 23795, Bad Segeberg, Germany
| | - Mohammad Abdelghani
- Heart Center, Segeberger Kliniken, Am Kurpark 1, 23795, Bad Segeberg, Germany.,Cardiology Department, Amesterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Cardiology Department, Al-Azhar University, Cairo, Egypt
| | - Abdelhakim Allali
- Heart Center, Segeberger Kliniken, Am Kurpark 1, 23795, Bad Segeberg, Germany.
| | - Ralph Toelg
- Heart Center, Segeberger Kliniken, Am Kurpark 1, 23795, Bad Segeberg, Germany
| | | | | | - Rune Wiseth
- Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Samuel Copt
- Biosensors Clinical Research, Morges, Switzerland
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Pavasini R, Maietti E, Tonet E, Bugani G, Tebaldi M, Biscaglia S, Cimaglia P, Serenelli M, Ruggiero R, Vitali F, Galvani M, Minarelli M, Rubboli A, Bernucci D, Volpato S, Campo G. Bleeding Risk Scores and Scales of Frailty for the Prediction of Haemorrhagic Events in Older Adults with Acute Coronary Syndrome: Insights from the FRASER study. Cardiovasc Drugs Ther 2020; 33:523-532. [PMID: 31549262 DOI: 10.1007/s10557-019-06911-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE Hitherto, no study has yielded important information on whether the scales of frailty may improve the ability to discriminate the risk of haemorrhages in older adults admitted to hospital for acute coronary syndrome (ACS). The aim of this study is to investigate whether frailty scales would predict the 1-year occurrence of haemorrhagic events and if they confer a significant incremental prognostic value over the bleeding risk scores. METHODS The present study involved 346 ACS patients aged ≥ 70 years enrolled in the FRASER study. Seven different scales of frailty and PARIS, PRECISE-DAPT and BleeMACS bleeding risk scores were available for each patient. The outcomes were the 1-year BARC 3-5 and 2 bleeding events. RESULTS Adherence to antiplatelet treatment at 1, 6 and 12 months was 98%, 87% and 78%, respectively. At 1-year, 14 (4%) and 30 (9%) patients presented BARC 3-5 and 2 bleedings, respectively. Bleeding risk scores and four scales of frailty (namely Short Physical Performance Battery, Columbia, Edmonton and Clinical Frailty Scale) significantly discriminated the occurrence of BARC 3-5 events. The addition of the scales of frailty to bleeding risk scores did not lead to a significant improvement in the ability to predict BARC 3-5 bleedings. Neither the bleeding risk scores nor the scales of frailty predicted BARC 2 bleedings. CONCLUSIONS Both the bleeding risk scores and the scales of frailty predicted BARC 3-5 haemorrhages. However, integrating the scales of frailty with the bleeding risk scores did not improve their discriminative ability. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov: NCT02386124.
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Affiliation(s)
- Rita Pavasini
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro 8, 44124, Cona, Fe, Italy
| | - Elisa Maietti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- Department of Medical Science, University of Ferrara, Ferrara, Italy
| | - Elisabetta Tonet
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro 8, 44124, Cona, Fe, Italy
| | - Giulia Bugani
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro 8, 44124, Cona, Fe, Italy
| | - Matteo Tebaldi
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro 8, 44124, Cona, Fe, Italy
| | - Simone Biscaglia
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro 8, 44124, Cona, Fe, Italy
| | - Paolo Cimaglia
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro 8, 44124, Cona, Fe, Italy
| | - Matteo Serenelli
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro 8, 44124, Cona, Fe, Italy
| | - Rossella Ruggiero
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro 8, 44124, Cona, Fe, Italy
| | - Francesco Vitali
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro 8, 44124, Cona, Fe, Italy
| | - Marcello Galvani
- Unità Operativa di Cardiologia, Ospedale GB Morgagni, Forlì, Italy
| | - Monica Minarelli
- Department of Emergency, Division of Cardiology, Delta Hospital, Azienda Unità Sanitaria Locale di Ferrara, Ferrara, Italy
| | - Andrea Rubboli
- Division of Cardiology, S. Maria Delle Croci Hospital, Ravenna, Italy
| | - Davide Bernucci
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro 8, 44124, Cona, Fe, Italy
| | - Stefano Volpato
- Department of Medical Science, University of Ferrara, Ferrara, Italy
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro 8, 44124, Cona, Fe, Italy.
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, RA, Italy.
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Kobo O, Saada M, Meisel SR, Hellou E, Frimerman A, Fanne RA, Mohsen J, Danon A, Roguin A. Modern Stents: Where Are We Going? Rambam Maimonides Med J 2020; 11:RMMJ.10403. [PMID: 32374258 PMCID: PMC7202450 DOI: 10.5041/rmmj.10403] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Coronary artery stenting is the treatment of choice for patients requiring coronary angioplasty. We describe the major advancements with this technology. There have been significant developments in the design of stents and adjunctive medical therapies. Newer-generation drug-eluting stents (DES) have almost negligible restenosis rates and, when combined with proper anti-platelet treatment and optimal deployment, a low risk of stent thrombosis. The introduction of newer-generation DES with thinner stent struts, novel durable or biodegradable polymer coatings, and new antiproliferative agents has further improved the safety profile of early-generation DES. In parallel the effectiveness has been kept, with a significant reduction in the risk of target lesion revascularization compared with the early-generation DES. However, to date, the development of completely bioresorbable vascular scaffolds has failed to achieve further clinical benefits and has been associated with increased thrombosis. Newer-generation DES-including both durable polymer as well as biodegradable polymer-have become the standard of care in all patient and lesion subsets, with excellent long-term results.
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Affiliation(s)
- Ofer Kobo
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera, Israel
| | - Majdi Saada
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera, Israel
| | - Simcha R. Meisel
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Elias Hellou
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Aaron Frimerman
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Rami Abu Fanne
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Jameel Mohsen
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera, Israel
| | - Asaf Danon
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Ariel Roguin
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- To whom correspondence should be addressed. E-mail:
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Krucoff MW, Urban P, Tanguay JF, McAndrew T, Zhang Y, Rao SV, Morice MC, Price MJ, Cohen DJ, Abdel-Wahab M, Mehta SR, Faurie B, McLaurin B, Diaz C, Stoll HP, Pocock S, Leon MB. Global Approach to High Bleeding Risk Patients With Polymer-Free Drug-Coated Coronary Stents: The LF II Study. Circ Cardiovasc Interv 2020; 13:e008603. [PMID: 32279567 DOI: 10.1161/circinterventions.119.008603] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND High bleeding risk (HBR) patients undergoing percutaneous coronary intervention have been widely excluded from randomized device registration trials. The LF study (LEADERS FREE) reported superior outcomes of HBR patients receiving 30-day dual antiplatelet therapy after percutaneous coronary intervention with a polymer-free drug-coated stent (DCS). LFII was designed to assess the reproducibility and generalizability of the benefits of DCS observed in LF to inform the US Food and Drug Administration in a device registration decision. METHODS LFII was a single-arm study using HBR inclusion/exclusion criteria and 30-day dual antiplatelet therapy after percutaneous coronary intervention with DCS, identical to LF. The 365-day rates of the primary effectiveness (clinically indicated target lesion revascularization) and safety (composite cardiac death and myocardial infarction) end points were reported using a propensity-stratified analysis compared with the LF bare metal stent arm patients as controls. RESULTS A total of 1203 LFII patients were enrolled with an average 1.7 HBR criteria per patient, including 60.7% >75 years of age, 34.1% on anticoagulants, and 14.7% with renal failure. Propensity-adjusted 365-day clinically indicated target lesion revascularization was significantly lower with DCS (7.2% versus 9.2%; hazard ratio, 0.72 [95% CI, 0.52-0.98]; P=0.0338 for superiority), as was the primary safety (cardiac death and myocardial infarction) composite (9.3% versus 12.4%; hazard ratio, 0.72 [95% CI, 0.55-0.94]; P=0.0150 for superiority). Stent thrombosis rates were 2.0% DCS and 2.2% bare metal stent. Major bleeding at 1 year occurred in 7.2% DCS patients and 7.2% bare metal stent. CONCLUSIONS LFII reproduces the results of the DCS arm of LF in an independent, predominantly North American cohort of HBR patients.
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Affiliation(s)
- Mitchell W Krucoff
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.W.K., S.V.R.)
| | | | | | - Thomas McAndrew
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (T.M., Y.Z.)
| | - Yiran Zhang
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (T.M., Y.Z.)
| | - Sunil V Rao
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.W.K., S.V.R.)
| | - Marie-Claude Morice
- Générale de Santé, Institut Cardiovasculaire Paris Sud, Massy, France (M.-C.M.)
| | | | | | | | - Shamir R Mehta
- McMaster University and Hamilton Health Sciences, Ontario, Canada (S.R.M.)
| | - Benjamin Faurie
- Department of Cardiology, Groupe Hospitalier Mutualiste de Grenoble, France (B.F.)
| | | | | | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, Keppel Street, United Kingdom (S.P.)
| | - Martin B Leon
- Columbia University Medical Center/New York-Presbyterian Hospital (M.B.L.)
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Dual Antiplatelet Therapy Duration in Acute Coronary Syndrome Patients: The State of the Art and Open Issues. Cardiovasc Ther 2020; 2020:6495036. [PMID: 32328172 PMCID: PMC7166288 DOI: 10.1155/2020/6495036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 12/29/2019] [Accepted: 02/10/2020] [Indexed: 12/01/2022] Open
Abstract
Conflicting results have been reported so far in pooled analyses and studies evaluating the optimum duration of dual antiplatelet therapy (DAPT) in acute coronary syndrome (ACS) patients. However, randomized clinical trials dedicated to this specific setting of higher thrombotic risk patients have only recently been completed, pointing at the noninferiority of a shorter strategy as compared to the traditional 12-month DAPT, furthermore allowing to reduce the risk of major bleeding complications. Therefore, a reconsideration of current clinical practice and guidelines should be certainly be advocated in light of the most recent updates, especially among ACS patients treated with percutaneous coronary intervention (PCI) and modern drug-eluting stents (DES). Our aim was to provide a comprehensive review of the available evidence on the optimal DAPT duration in ACS patients.
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Sorrentino S, Sartori S, Baber U, Claessen BE, Giustino G, Chandrasekhar J, Chandiramani R, Cohen DJ, Henry TD, Guedeney P, Ariti C, Dangas G, Gibson CM, Krucoff MW, Moliterno DJ, Colombo A, Vogel B, Chieffo A, Kini AS, Witzenbichler B, Weisz G, Steg PG, Pocock S, Urban P, Mehran R. Bleeding Risk, Dual Antiplatelet Therapy Cessation, and Adverse Events After Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2020; 13:e008226. [DOI: 10.1161/circinterventions.119.008226] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background:
Whether the underlying risk of bleeding influences the associations between patterns of dual antiplatelet therapy (DAPT) cessation and adverse events after percutaneous coronary intervention is unknown.
Methods:
Patients enrolled in the prospective, international, multicenter PARIS registry (Patterns of Non-Adherence to Anti-Platelet Regimens in Stented Patients) were categorized according to their risk of bleeding using the PARIS bleeding risk score. We evaluated the incidence, patterns, and association between modes of DAPT cessation and outcomes across bleeding risk groups. Modes of DAPT cessations were defined as physician-guided DAPT discontinuation, brief interruption (<14 days) or disruption for bleeding, or noncompliance. The primary end point of interest was major adverse cardiac events, defined as the composite of cardiac death, myocardial infarction, or definite-probable stent thrombosis.
Results:
From a total of 5018 patients, 513 (10.2%) were classified as high, 2058 (41.0%) as intermediate, and 2447 (48.8%) as low risk for bleeding. High bleeding risk (HBR) patients were older and had greater prevalence of comorbidities. Compared with non-HBR, HBR patients had higher rates of both ischemic and bleeding events. The cumulative incidence of DAPT cessation was higher in HBR patients, mostly driven by physician-guided discontinuation and disruption. Of note, DAPT disruption occurred in 17.7%, 10.4%, and 7.8% at 1 year and 22.0%, 15.1%, and 12.0% at 2 years (
P
<0.0001) in high, intermediate, and low bleeding risk groups, respectively. Physician-guided DAPT discontinuation was not associated with increased risk of major adverse cardiac events in both HBR and non-HBR patients, while DAPT disruption was associated with an increased risk of major adverse cardiac events across all bleeding risk groups. There was no interaction between bleeding risk status and clinical outcomes for any cessation mode.
Conclusions:
Patients at HBR remain at higher risk of adverse events. Disruption of DAPT is associated with an increased risk of major adverse cardiac events irrespective of the underlying bleeding risk. Physician-guided discontinuation of DAPT appears to be safe, irrespective of HBR.
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Affiliation(s)
- Sabato Sorrentino
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (S. Sorrentino, S. Sartori, U.B., B.E.C., G.G., J.C., J.C., P.G., G.D., B.V., A.S.K., R.M.)
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy (S. Sorrentino)
| | - Samantha Sartori
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (S. Sorrentino, S. Sartori, U.B., B.E.C., G.G., J.C., J.C., P.G., G.D., B.V., A.S.K., R.M.)
| | - Usman Baber
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (S. Sorrentino, S. Sartori, U.B., B.E.C., G.G., J.C., J.C., P.G., G.D., B.V., A.S.K., R.M.)
| | - Bimmer E. Claessen
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (S. Sorrentino, S. Sartori, U.B., B.E.C., G.G., J.C., J.C., P.G., G.D., B.V., A.S.K., R.M.)
| | - Gennaro Giustino
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (S. Sorrentino, S. Sartori, U.B., B.E.C., G.G., J.C., J.C., P.G., G.D., B.V., A.S.K., R.M.)
| | - Jaya Chandrasekhar
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (S. Sorrentino, S. Sartori, U.B., B.E.C., G.G., J.C., J.C., P.G., G.D., B.V., A.S.K., R.M.)
| | | | - David J. Cohen
- Department of Internal Medicine, Section: Cardiovascular Disease, St. Luke’s Mid America Heart Institute, University of Missouri-Kansas City, The Christ Hospital Heart and Vascular Center, (D.J.C.)
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH (T.D.H.)
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.)
| | - Paul Guedeney
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (S. Sorrentino, S. Sartori, U.B., B.E.C., G.G., J.C., J.C., P.G., G.D., B.V., A.S.K., R.M.)
| | - Cono Ariti
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (C.A., S.P.)
| | - George Dangas
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (S. Sorrentino, S. Sartori, U.B., B.E.C., G.G., J.C., J.C., P.G., G.D., B.V., A.S.K., R.M.)
- Department of Cardiology, National and Kapodistrian University of Athens, Greece (G.D.)
| | - C. Michael Gibson
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Mitchell W. Krucoff
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC (M.W.K.)
| | - David J. Moliterno
- Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington (D.J.M.)
| | - Antonio Colombo
- Interventional Cardiology Unit, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy (A.C.)
| | - Birgit Vogel
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (S. Sorrentino, S. Sartori, U.B., B.E.C., G.G., J.C., J.C., P.G., G.D., B.V., A.S.K., R.M.)
| | - Alaide Chieffo
- Cardio-Thoracic Department, San Raffaele Scientific Institute, Milan, Italy (A.C.)
| | - Annapoorna S. Kini
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (S. Sorrentino, S. Sartori, U.B., B.E.C., G.G., J.C., J.C., P.G., G.D., B.V., A.S.K., R.M.)
| | | | - Giora Weisz
- Cardiology Department, Shaare Zedek Medical Center, Jerusalem, Israel (G.W.)
| | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (C.A., S.P.)
| | - Philip Urban
- Cardiology Department, Hopital LaTour, Geneva, Switzerland (P.U.)
| | - Roxana Mehran
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (S. Sorrentino, S. Sartori, U.B., B.E.C., G.G., J.C., J.C., P.G., G.D., B.V., A.S.K., R.M.)
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Giannini F, Pagnesi M, Campo G, Donahue M, Ferri LA, Briguori C, Stefanini GG, Scardala R, Sardella G, De Rosa S, Figini F, Monello A, Pastormerlo LE, Testa L, Nicolino A, Ielasi A, Durante A, Leone A, Tzanis G, Mangieri A, Ciccarelli G, Briani M, Reimers B, Ceccacci A, Indolfi C, Sheiban I, Palmieri C, Bedogni F, Tespili M, Latib A, Gallo F, Colombo A. Italian Multicenter Registry of Bare Metal Stent Use in Modern Percutaneous Coronary Intervention Era (AMARCORD): A multicenter observational study. Catheter Cardiovasc Interv 2020; 97:411-420. [PMID: 32198845 DOI: 10.1002/ccd.28798] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 01/21/2020] [Accepted: 02/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES We aimed to evaluate the use of bare metal stent (BMS) implantation in current percutaneous coronary intervention (PCI) era, focusing on indications for use and clinical outcomes. BACKGROUND Limited data on BMS usage in current clinical practice are available. METHODS All patients who underwent PCI with at least one BMS implantation in 18 Italian centers from January 1, 2013 to December 31, 2017, were included in our registry. Rates of BMS use and reasons for BMS implantations were reported for the overall study period and for each year. Primary outcomes were mortality, bleeding (Bleeding Academic Research Consortium-BARC and Thrombolysis in Myocardial Infarction-TIMI non-CABG definitions), and major adverse cardiac events (MACE) defined as the composite of all-cause and cardiac death, any myocardial infarction, target vessel revascularization, or any stent thrombosis. RESULTS Among 58,879 patients undergoing PCI in the study period, 2,117 (3.6%) patients (mean age 73 years, 69.7% males, 73.3% acute coronary syndrome) were treated with BMS implantation (2,353 treated lesions). The rate of BMS implantation progressively decreased from 10.1% (2013) to 0.3% (2017). Main reasons for BMS implantation were: ST-elevation myocardial infarction (STEMI) (23.1%), advanced age (24.4%), and physician's perception of high-bleeding risk (34.0%). At a mean follow-up of 2.2 ± 1.5 years, all-cause and cardiac mortality were 25.6 and 12.7%, respectively; MACE rate was 35.3%, any bleeding rate was 13.0% (BARC 3-5 bleeding 6.3%, TIMI non-CABG major bleeding 6.1%). CONCLUSION In a large, contemporary, real-world, multicenter registry, BMS use progressively reduced over the last 5 years. Main reasons for BMS implantation were STEMI, advanced age, and physician's perception of high-bleeding risk. High rates of mortality and MACE were observed in this real-world high-risk population.
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Affiliation(s)
- Francesco Giannini
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Matteo Pagnesi
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Michael Donahue
- Interventional Cardiology Unit, Policlinico Casilino, Rome, Italy
| | - Luca A Ferri
- Department of Cardiology, Alessandro Manzoni Hospital, Lecco, Italy.,Department of Cardiology, San Leopoldo Mandic Hospital, Merate, Italy
| | - Carlo Briguori
- Interventional Cardiology Unit, Clinica Mediterranea, Naples, Italy
| | | | | | - Gennaro Sardella
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthesiologic and Geriatric Sciences, Policlinico Umberto I, Rome, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Research Center on Cardiovascular Diseases, Magna Graecia University, Catanzaro, Italy
| | - Filippo Figini
- Division of Cardiology, Pederzoli Hospital-Peschiera del Garda, Verona, Italy
| | - Alberto Monello
- Division of Cardiology, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Luigi E Pastormerlo
- Division of Cardiology, Fondazione Gabriele Monasterio CNR-Regione Toscana, Massa, Italy
| | - Luca Testa
- Department of Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Alfonso Ielasi
- Division of Cardiology, ASST Bergamo Est, Bolognini Hospital, Seriate, Italy
| | | | - Angelo Leone
- Division of Cardiology, Ferrari Hospital, Cosenza, Italy
| | - Giorgios Tzanis
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Mangieri
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | | | - Martina Briani
- Cardio Center, Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Bernhard Reimers
- Cardio Center, Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Andrea Ceccacci
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthesiologic and Geriatric Sciences, Policlinico Umberto I, Rome, Italy
| | - Ciro Indolfi
- Division of Cardiology, Research Center on Cardiovascular Diseases, Magna Graecia University, Catanzaro, Italy
| | - Imad Sheiban
- Division of Cardiology, Pederzoli Hospital-Peschiera del Garda, Verona, Italy
| | - Cataldo Palmieri
- Division of Cardiology, Fondazione Gabriele Monasterio CNR-Regione Toscana, Massa, Italy
| | - Francesco Bedogni
- Department of Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Maurizio Tespili
- Division of Cardiology, ASST Bergamo Est, Bolognini Hospital, Seriate, Italy
| | - Azeem Latib
- Department of Cardiology, Montefiore Medical Center, New York, New York, USA.,Division of Cardiology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Francesco Gallo
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Antonio Colombo
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
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Long-Term Safety and Efficacy of Durable Polymer Cobalt-Chromium Everolimus-Eluting Stents in Patients at High Bleeding Risk. Circulation 2020; 141:891-901. [DOI: 10.1161/circulationaha.119.041619] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Long-term outcomes in patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention with a drug-eluting stent are unclear. Therefore, we aimed to evaluate long-term adverse events in HBR patients undergoing percutaneous coronary intervention with cobalt-chromium everolimus-eluting stent implantation.
Methods:
We analyzed stratified data from 4 all-comers postapproval registries. Patients with at least 1 of the following criteria were categorized as HBR: age ≥75 years, history of major bleeding (MB), history of stroke, chronic oral anticoagulant use, chronic kidney disease, anemia, or thrombocytopenia. Additionally, in a separate analysis, patients were categorized according to the recently published Academic Research Consortium HBR criteria. The Kaplan-Meier method was used for time-to-event analyses. Coronary thrombotic events (CTE) included myocardial infarction or definite/probable stent thrombosis. MB was defined according to the TIMI (Thrombolysis in Myocardial Infarction) or GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) scales. Impact of CTE and MB on subsequent risk of mortality was assessed using multivariable Cox regression with MB and CTE included as time-updated covariates.
Results:
Of the total 10 502 patients included, 3507 (33%) were identified as HBR. Compared with non-HBR patients, those at HBR had more comorbidities, higher lesion complexity, and a higher risk of 4-year mortality (Hazard Ratio [HR] 4.38 [95% CI, 3.76–5.11]). Results were qualitatively similar when using Academic Research Consortium criteria to define HBR. Risk of mortality was increased after CTE (HR 5.02 [95% CI, 3.93–6.41]), as well as after MB (HR 4.92 [95% CI, 3.82–6.35]). Of note, this effect was consistent across the spectrum of bleeding risk (
P
-interaction test 0.97 and 0.06, respectively).
Conclusions:
Compared with the non-HBR population, HBR patients experienced worse 4-year outcomes after percutaneous coronary intervention with cobalt-chromium everolimus-eluting stent. Both CTE and MB had a significant impact on subsequent risk of mortality irrespective of bleeding risk.
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45
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Harada Y, Schneider S, Colleran R, Rai H, Bohner J, Kuna C, Kufner S, Giacoppo D, Schüpke S, Joner M, Ibrahim T, Laugwitz KL, Kastrati A, Byrne RA. Resultado del tratamiento percutáneo de la reestenosis de stents farmacoactivos: ¿depende de si el stent tenía o no recubrimiento polimérico? Rev Esp Cardiol (Engl Ed) 2020. [DOI: 10.1016/j.recesp.2019.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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46
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Chatzantonis G, Chatzantonis G, Findeisen H, Paul M, Samol A, Bisdas T, Fischer D. Real-world analysis of a Biolimus A9 polymer-free drug-coated stent with very short dual antiplatelet therapy in patients at high bleeding risk. Herz 2020; 46:242-249. [PMID: 31965195 DOI: 10.1007/s00059-019-04882-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/18/2019] [Accepted: 12/06/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patients at high risk of bleeding requiring percutaneous coronary intervention (PCI) need careful evaluation of both their thrombotic and their bleeding risks. In these patients, a polymer-free metallic stent coated with biolimus-A9 (BA9-DCS) followed by 1‑month dual antiplatelet therapy (DAPT) could be a safe option; however, real-world data are still lacking. We analyzed the performance of the device in a real-world scenario. METHODS Patients assessed as being at high risk of bleeding with an indication for PCI were treated with BA9-DCS and DAPT consisting of aspirin (100 mg/day) and clopidogrel (75 mg/day) for at least 1 month, followed by either oral anticoagulation or single antiplatelet therapy. No exclusion criteria were used. The primary endpoint was the occurrence of an adverse event after PCI, i.e. severe bleeding requiring hospitalization, ischemic or hemorrhagic stroke, clinically driven stent thrombosis, myocardial infarction or cardiac death. RESULTS Overall, 89 patients were enrolled in this study [median age 75 (66-81) years; 27 females (30%)] and 171 interventions were performed. During a median follow-up of 203 (145-273) days the primary endpoint occurred in 20 patients (23%): 12 (13%) had clinically significant bleeding, four (5%) ischemic stroke and four (5%) died from cardiac causes related neither to stent thrombosis nor to acute myocardial infarction. Female gender emerged as the only statistically significant predictor of an adverse event (adjusted hazard ratio (HR) 3.3; 95% confidence interval (CI): 1.2-8.7, p = 0.017). CONCLUSION In real-world patients at high risk of bleeding, implantation of the polymer-free metallic stent coated with Biolimus-A9 (Biofreedom®; Biosensors Europe, Morges, Switzerland) followed by 1 -month DAPT showed encouraging results without any stent thrombosis.
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Affiliation(s)
- Grigorios Chatzantonis
- Department of Cardiology I-Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
| | | | - Hannes Findeisen
- Department of Cardiology I-Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Matthias Paul
- Department of Cardiology I-Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Alexander Samol
- Department of Cardiology and Critical Care Medicine, Johannes Wesling University Hospital, Ruhr University Bochum, 32429, Minden, Germany
| | - Theodosios Bisdas
- Clinic of Advanced Endovascular Services, Athens Medical Centre, Athens, Greece
| | - Dieter Fischer
- Department of Cardiology I-Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
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47
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Feldman DA, Shroff AR, Bao H, Curtis JP, Minges KE, Ardati AK. Stent selection among patients with chronic kidney disease: Results from the NCDR CathPCI Registry. Catheter Cardiovasc Interv 2020; 96:1213-1221. [PMID: 31909543 DOI: 10.1002/ccd.28698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 12/20/2019] [Indexed: 11/05/2022]
Abstract
OBJECTIVES This study sought to define contemporary rates of drug eluting stent (DES) usage in patients with chronic kidney disease (CKD). BACKGROUND Among patients with CKD undergoing percutaneous coronary interventions (PCIs), outcomes are superior for those who receive DES compared to those who receive bare metal stents (BMSs). However, perceived barriers may limit the use of DES in this population. METHODS All adult PCI cases from the NCDR CathPCI Registry involving coronary stent placement between July 1, 2009 and December 31, 2015 were analyzed. The rate of DES usage was then compared among four groups, stratified by CKD stage (I/II, III, IV, and V). Subgroup analysis was conducted based on PCI status and indication. Cases were linked to Medicare claims data to assess 1-year mortality. RESULTS A total of 3,650,333 PCI cases met criteria for analysis. DES usage significantly declined as renal function worsened (83.0%, 79.9%, 75.6%, and 75.6%, respectively, in the four CKD stages; p < .001). DES usage was universally lower across the four groups in the setting of ST-Elevation Myocardial Infarction (STEMI) (70.6%, 66.5%, 58.7%, 58.0%; p < .001) and higher in the setting of elective PCI (87.6%, 84.9%, 82.3%, 77.9%; p < .0001). DES was associated with improved 1-year survival, and usage increased over time across each group. CONCLUSIONS DESs are underutilized in patients with advanced renal dysfunction. Although DES usage has increased over time, variation still exists between patients with normal renal function and those with CKD.
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Affiliation(s)
- Daniel A Feldman
- Section of Cardiology, Adventist Health Portland, Portland, Oregon
| | - Adhir R Shroff
- Division of Cardiology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Haikun Bao
- Center for Outcomes Research and Evaluation, Yale-New Haven Health Services Corporation, New Haven, Connecticut
| | - Jeptha P Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Health Services Corporation, New Haven, Connecticut.,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Karl E Minges
- Center for Outcomes Research and Evaluation, Yale-New Haven Health Services Corporation, New Haven, Connecticut.,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Amer K Ardati
- Division of Cardiology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois
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48
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Impact of Insulin-Treated and Noninsulin-Treated Diabetes Mellitus in All-Comer Patients Undergoing Percutaneous Coronary Interventions With Polymer-Free Biolimus-Eluting Stent (from the RUDI-FREE Registry). Am J Cardiol 2019; 124:1518-1527. [PMID: 31547997 DOI: 10.1016/j.amjcard.2019.08.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/30/2019] [Accepted: 08/02/2019] [Indexed: 02/06/2023]
Abstract
Patients with diabetes mellitus (DM) have worse outcomes after percutaneous coronary intervention (PCI). Recent evidences suggest a differential impact of insulin-treated and noninsulin-treated DM on prognosis. We evaluated the clinical outcome of diabetic patients after PCI with polymer-free biolimus-eluting stent from the RUDI-FREE Registry, investigating a possible different prognostic impact of insulin-treated and noninsulin-treated DM. A total of 1,104 consecutive patients who underwent PCI with polymer-free biolimus-eluting stent, enrolled in the RUDI-FREE observational, multicenter, single-arm registry, were stratified by diabetic status; diabetic population was further divided on the basis of insulin treatment. Primary end points of the study were target lesion failure (TLF; composite of cardiac death, target vessel myocardial infarction, target lesion revascularization) and major adverse cardiac and cerebrovascular events (composite of cardiac death, stroke, and myocardial infarction). Multiple ischemic adverse events were also single-handedly considered as secondary end points. At 1 year, TLF was significantly higher in the diabetic cohort, as compared with nondiabetic patients (6.0% vs 3.1%, p 0.022). None of the end points resulted significantly different between nondiabetics and noninsulin-treated diabetic patients. Divergently, compared with nondiabetic, insulin-treated diabetic patients faced significant higher rates of TLF (10.8% vs 3.1%, p 0.003), major adverse cardiac and cerebrovascular events (10.8% vs 3.4%, p 0.004), and of most of the analyzed adverse events. In conclusion, patients with DM had a higher risk of TLF compared with nondiabetics; nonetheless, the worse outcome of the diabetic population seems to be driven by the insulin-treated diabetic subpopulation. This finding suggests a different risk profile of insulin-treated and noninsulin-treated diabetic patients in the modern era of PCI.
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49
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Jiménez Díaz VA, Hovasse T, Íñiguez A, Copt S, Byrne J, Brunel P, Morice MC, Abizaid A, Tespilli M, Walters D, Ortiz Sáez A, Bastos Fernández G, Stoll HP, Urban P. Impact of vascular access on outcome after PCI in patients at high bleeding risk: a pre-specified sub-analysis of the LEADERS FREE trial. ACTA ACUST UNITED AC 2019; 73:536-545. [PMID: 31563471 DOI: 10.1016/j.rec.2019.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 07/22/2019] [Indexed: 11/16/2022]
Abstract
INTRODUCTION AND OBJECTIVES The prognostic impact of bleeding in high bleeding risk (HBR) patients depending on the location of bleeding and prognosis in nonaccess site bleeding is unknown. We aimed to assess the impact of vascular access site on bleeding complications after percutaneous coronary interventions for HBR patients at 30-day and 2-year follow-up. METHODS The LEADERS FREE trial included 2432 HBR PCI patients. A Biolimus A9 drug-coated stent was superior to a bare-metal stent for safety and efficacy. This is a predefined sub-analysis of the LEADERS FREE trial. RESULTS Transradial access (TRA) was used in 1454 patients (59.8%) and transfemoral access (TFA) in 978 (40.2%), according to operator preference. The safety and benefits of drug-coated stents over bare-metal stents were independent of vascular access. At 30 days and 2 years, major bleeding had occurred in 2.4% and 7.5% of TRA patients and 4.6% and 10.9% of TFA patients (P=.003), respectively. Most of these events in both groups (2.1% and 7.0% for TRA; 3.2% and 9.4% for TFA, respectively) were nonaccess site-related. TRA was associated with a significant reduction in adjusted rates of major bleeding both at 30 days (HR, 1.98; 95%CI, 1.25-3.11; P=.003) and at 2 years of follow-up (HR, 1.51; 95%CI, 1.14-2.01; P=.003). This difference was driven by both access and nonaccess bleeding. CONCLUSIONS Operators preferred TRA for most HBR patients, which was associated with a significant reduction in major bleeding events. However, most of these events in this population are unrelated to vascular access.
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Affiliation(s)
- Víctor Alfonso Jiménez Díaz
- Departamento de Cardiología, Hospital Álvaro Cunqueiro, Hospital Universitario de Vigo, Vigo, Pontevedra, Spain
| | - Thomas Hovasse
- Cardiology Department, Hôpital Privé Jacques Cartier, Massy, France
| | - Andrés Íñiguez
- Departamento de Cardiología, Hospital Álvaro Cunqueiro, Hospital Universitario de Vigo, Vigo, Pontevedra, Spain
| | | | - Jonathan Byrne
- Cardiology Department, King's College, London, United Kingdom
| | | | | | - Alex Abizaid
- Cardiology Department, Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
| | | | - Darren Walters
- Cardiology Department, Prince Charles Hospital, Queensland, Australia
| | - Alberto Ortiz Sáez
- Departamento de Cardiología, Hospital Álvaro Cunqueiro, Hospital Universitario de Vigo, Vigo, Pontevedra, Spain
| | - Guillermo Bastos Fernández
- Departamento de Cardiología, Hospital Álvaro Cunqueiro, Hospital Universitario de Vigo, Vigo, Pontevedra, Spain
| | | | - Philip Urban
- Cardiology Department, Hôpital de la Tour, Geneva, Switzerland.
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50
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McKittrick CM, Cardona MJ, Black RA, McCormick C. Development of a Bioactive Polymeric Drug Eluting Coronary Stent Coating Using Electrospraying. Ann Biomed Eng 2019; 48:271-281. [PMID: 31441008 PMCID: PMC6928095 DOI: 10.1007/s10439-019-02346-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 08/13/2019] [Indexed: 02/05/2023]
Abstract
Drug-eluting stents are now routinely used in the treatment of acute coronary syndromes caused by coronary artery disease. Whilst the sustained release of anti-proliferative drugs from these devices has greatly reduced the need for repeat revascularisation procedures, this approach is not suitable for all patients and appears to delay regrowth of the endothelium, necessitating the use of prolonged dual anti-platelet therapy. Although the development of more advanced stent platforms and drug coatings has produced modest improvements in performance, these devices have not fully addressed the limitations experienced with their first-generation counterparts. In the present study, we developed a novel stent coating that provides controlled sirolimus release from a bioactive polymer (accelerate™ AT) that has previously been shown to support endothelial cell growth in vitro. A bespoke electrospray deposition process provided control over the coating thickness, surface roughness, drug load, and release kinetics. The resultant optimised coating combines rapid release of an anti-proliferative agent from a bioactive polymer coating that promotes re-endothelialisation, thereby offering potential protection against in-stent restenosis and thrombosis. This novel, dual-action coating therefore has significant therapeutic potential, with the enhanced control of drug load and release kinetics offered by electrospray deposition also opening up opportunities for more personalised treatment approaches. Further development and evaluation of these technologies in vitro and in vivo is therefore warranted.
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Affiliation(s)
- C M McKittrick
- Department of Biomedical Engineering, University of Strathclyde, Graham Hills Building, 40 George Street, Glasgow, G1 1QE, UK.
| | - M J Cardona
- Department of Biomedical Engineering, University of Strathclyde, Graham Hills Building, 40 George Street, Glasgow, G1 1QE, UK
| | - R A Black
- Department of Biomedical Engineering, University of Strathclyde, Graham Hills Building, 40 George Street, Glasgow, G1 1QE, UK
| | - C McCormick
- Department of Biomedical Engineering, University of Strathclyde, Graham Hills Building, 40 George Street, Glasgow, G1 1QE, UK
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