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Erbay MI, Pyrpyris N, Susarla S, Ulusan S, Mares AC, Wilson TP, Lee D, Sood A, Gupta R. Comparative safety review of antithrombotic treatment options for patients with atrial fibrillation undergoing percutaneous coronary intervention. Expert Opin Drug Saf 2024; 23:149-160. [PMID: 38214282 DOI: 10.1080/14740338.2024.2305367] [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: 11/01/2023] [Accepted: 01/10/2024] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Balancing antithrombotic therapy for atrial fibrillation (AF) patients undergoing percutaneous coronary intervention (PCI) remains a clinical challenge due to coexisting thrombogenic risks. This review emphasizes the delicate balance required to prevent ischemic events while minimizing bleeding complications, particularly in the context of risk assessment. AREAS COVERED This review spans from 2010 to October 2023, exploring the complexities of antithrombotic management for AF patients undergoing PCI. It stresses the need for personalized treatment decisions to optimize antithrombotic therapies effectively. EXPERT OPINION The evolving evidence supports double antithrombotic therapy (DAT) over triple antithrombotic therapy (TAT) for these patients, showcasing a more favorable safety profile without compromising efficacy. Non-vitamin K antagonist oral anticoagulant (NOAC)-based DAT strategies exhibit superiority in reducing major bleeding events while effectively preventing ischemic events. Recommendations from the 2023 European Society of Cardiology (ESC) Guidelines advocate for NOAC-based DAT post-PCI, endorsing safer antithrombotic profiles.Challenges persist for specific patient categories requiring both oral anticoagulants and antiplatelets, necessitating personalized approaches. Future advances in intravascular imaging and novel coronary stent technologies offer promising avenues to optimize outcomes and influence antithrombotic strategies in AF-PCI patients.
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Affiliation(s)
- Muhammed Ibrahim Erbay
- Division of Cardiovascular Medicine, Cerrahpasa School of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey
- Department of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Nikolaos Pyrpyris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Shriraj Susarla
- Department of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Sebahat Ulusan
- Faculty of Medicine, Suleyman Demirel University, Isparta, Isparta Province, Turkey
| | - Adriana C Mares
- Division of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven CT, USA
| | - Tasha Phillips Wilson
- Department of Internal Medicine, St. George's University School of Medicine, True Bule, Greneda
| | - Duo Lee
- Department of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Aayushi Sood
- Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, PA USA
| | - Rahul Gupta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA USA
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One-Year Outcomes in Anticoagulated Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention: Insights From the Greek Antiplatelet Atrial Fibrillation Registry. J Cardiovasc Pharmacol 2023; 81:141-149. [PMID: 36410034 DOI: 10.1097/fjc.0000000000001389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/29/2022] [Indexed: 11/22/2022]
Abstract
ABSTRACT GReek-AntiPlatElet Atrial Fibrillation registry is a multicenter, observational, noninterventional study of atrial fibrillation patients undergoing percutaneous coronary intervention. Primary endpoint included clinically significant bleeding rate at 12 months between different antithrombotic regimens prescribed at discharge; secondary endpoints included major adverse cardiovascular events and net adverse clinical events. A total of 647 patients were analyzed. Most (92.9%) were discharged on novel oral anticoagulants with only 7.1% receiving the vitamin K antagonist. A little over half of patients (50.4%) received triple antithrombotic therapy (TAT)-mostly (62.9%) for ≤1 month-whereas the rest (49.6%) received dual antithrombotic therapy (DAT). Clinically significant bleeding risk was similar between TAT and DAT [Hazard ratio (HR) = 1.08; 95% confidence interval (CI), 0.66-1.78], although among TAT-receiving patients, the risk was lower in those receiving TAT for ≤1 month (HR = 0.50; 95% CI, 0.25-0.99). Anticoagulant choice (novel oral anticoagulant vs. vitamin K antagonist) did not significantly affect bleeding rates ( P = 0.258). Age, heart failure, leukemia/myelodysplasia, and acute coronary syndrome were associated with increased bleeding rates. Risk of major adverse cardiovascular events and net adverse clinical events was similar between ΤAT and DAT (HR = 1.73; 95% CI, 0.95-3.18, P = 0.075 and HR = 1.39; 95% CI, 0.93-2.08, P = 0.106, respectively). In conclusion, clinically significant bleeding and ischemic rates were similar between DAT and TAT, although TAT >1 month was associated with higher bleeding risk.
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Basmaji S, Samuel M, Shohoudi A, Hamilton RM, Aboulhosn J, Broberg CS, Chaix MA, Cohen S, Cook S, Dore A, Fernandes SM, Fortier A, Fournier A, Guertin MC, Kay J, Mondésert B, Mongeon FP, Opotowsky AR, Proietti A, Ting J, Zaidi A, Khairy P. Time in Therapeutic Range With Vitamin K Antagonists in Congenital Heart Disease: A Multicentre Study. Can J Cardiol 2022; 38:1751-1758. [PMID: 35964887 DOI: 10.1016/j.cjca.2022.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vitamin K antagonists (VKAs) are frequently prescribed to patients with congenital heart disease (CHD) for atrial arrhythmias or Fontan palliation, but there is a paucity of data regarding time spent in the therapeutic range (TTR). We sought to determine the TTR in patients with CHD and atrial arrhythmias or Fontan palliation prescribed VKAs and explore associations with thromboembolic and bleeding events. METHODS A multicentre North American cohort study was conducted on patients with CHD who received VKAs for sustained atrial arrhythmia or Fontan palliation. TTR was calculated using the Rosendaal linear interpolation method. Generalized estimating equations were used to explore factors associated with time outside the therapeutic range. RESULTS A total of 567 patients, aged 33 ± 17 years, 56% female, received VKAs for 11.5 ± 8.4 years for atrial arrhythmias (63.0%) or Fontan palliation (58.0%). CHD was simple, moderate, and complex in 10.8%, 20.3%, and 69.0%, respectively. Site investigators perceived good control over international normalized ratio (INR) levels in most patients (75.3%), with no or minor compliance or adherence issues (85.6%). The mean TTR was 41.9% (95% confidence interval [CI], 39.0%-44.8%). Forty-seven (8.3%) and 34 (6.0%) patients had thromboembolic and bleeding events, respectively. Thromboembolic events were associated with a higher proportion of time below the therapeutic range (31.3% vs 19.1%, P = 0.003) and bleeding complications with a higher proportion of time above the therapeutic range (32.5% vs 19.5%, P = 0.006). CONCLUSIONS Patients with CHD who receive VKAs spend < 42% of their time with INR levels in the therapeutic range, with repercussions regarding thromboembolic and bleeding complications.
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Affiliation(s)
- Samir Basmaji
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Michelle Samuel
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Azadeh Shohoudi
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Robert M Hamilton
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Marie-A Chaix
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Scott Cohen
- The Wisconsin Adult Congenital Heart (WAtCH) Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stephen Cook
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Annie Dore
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Annik Fortier
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Anne Fournier
- Hôpital Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | | | - Joseph Kay
- University of Colorado Denver, Aurora, Colorado, USA
| | - Blandine Mondésert
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Alexander R Opotowsky
- Boston Adult Congenital Heart Service, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Proietti
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Jennifer Ting
- Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Ali Zaidi
- Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
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Sciahbasi A, Gargiulo G, Talarico GP, Cesaro A, Zilio F, De Rosa S, Talanas G, Tebaldi M, Andò G, Rigattieri S, Misuraca L, Cortese B, Imperadore F, Lucci V, Guiducci V, Renda G, Zezza L, Versaci F, Giannico MB, Caruso M, Spaccarotella C, Calabrò P, Esposito G, Tarantini G, Musumeci G, Rubboli A. Design of the PERSEO Registry on the management of patients treated with oral anticoagulants and coronary stent. J Cardiovasc Med (Hagerstown) 2022; 23:738-743. [PMID: 36166340 DOI: 10.2459/jcm.0000000000001372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIM Percutaneous coronary intervention with stent implantation (PCI-S) in patients requiring chronic oral anticoagulant therapy (OAC) is associated with an increased risk of bleeding and ischemic complications. Different randomized studies showed a significant advantage of a double antithrombotic therapy and superiority of direct oral anticoagulant (DOAC) compared with warfarin, but real-world data are limited. Aim is to evaluate the antithrombotic management and clinical outcome of patients with an indication for OAC who undergo PCI-S in a 'real-world' setting. METHODS The multicentre prospective observational PERSEO (PERcutaneouS coronary intErventions in patients treated with Oral anticoagulant therapy) Registry (ClinicalTrials.gov Identifier: NCT03392948) has been designed to enrol patients requiring OAC treated by PCI-S in 25 Italian centres. A target of at least 1080 patients will be followed for 1 year and data on thromboembolic and bleeding events and changes in antithrombotic therapy will be registered. The primary end point is a combined measure of efficacy and safety outcome (NACE), including major bleeding events and major adverse cardiac and cerebral events at 1-year follow-up in patients treated with DOAC (and dual or triple antiplatelet therapy) compared with the corresponding strategies with vitamin K antagonists. A secondary prespecified analysis has been defined to evaluate NACE in dual versus triple antithrombotic therapy after hospital discharge at 1-year follow-up. CONCLUSION The PERSEO Registry will investigate in a 'real world' setting the safety and efficacy of DOAC versus warfarin and dual versus triple antithrombotic therapy in patients with indication for oral anticoagulant therapy who undergo PCI-S.
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Affiliation(s)
| | - Giuseppe Gargiulo
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II
| | | | - Arturo Cesaro
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano,' Caserta
| | - Filippo Zilio
- Department of Cardiology, Santa Chiara Hospital, Trento
| | - Salvatore De Rosa
- Division of Cardiology, Research Center for Cardiovascular Diseases, University Magna Graecia, Catanzaro
| | - Giuseppe Talanas
- Clinical and Interventional Cardiology, Sassari University Hospital
| | - Matteo Tebaldi
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona
| | - Giuseppe Andò
- Cardiology, Department of Clinical and Experimental Medicine, University of Messina
| | | | | | - Bernardo Cortese
- Department of Cardiology, San Carlo Clinic, Fondazione Ricerca e Innovazione Cardiovascolare Milan
| | | | - Valerio Lucci
- Interventional Cardiology San Filippo and Nicola Hospital, Avezzano
| | | | - Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences, G. D'Annunzio University of Chieti-Pescara
| | | | | | | | - Marco Caruso
- Division of Interventional Cardiology, ARNAS Civico Hospital, Palermo
| | - Carmen Spaccarotella
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II
| | - Paolo Calabrò
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano,' Caserta
| | - Giovanni Esposito
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua
| | - Giuseppe Musumeci
- Division of Cardiology, Azienda Ospedaliera Ordine Mauriziano di Torino, Turin
| | - Andrea Rubboli
- Department of Cardiovascular Diseases-AUSL Romagna, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
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Bor WL, de Veer AJW, Olie RH, Rikken SA, Chan Pin Yin DR, Herrman JPR, Vrolix M, Meuwissen M, Vandendriessche T, van Mieghem C, Magro M, Bennaghmouch N, Hermanides R, Adriaenssens T, Dewilde WJ, ten Berg JM. Dual versus triple antithrombotic therapy after percutaneous coronary intervention: the prospective multicentre WOEST 2 Study. EUROINTERVENTION 2022; 18:e303-e313. [PMID: 35370126 PMCID: PMC9980408 DOI: 10.4244/eij-d-21-00703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND For patients on oral anticoagulants (OAC) undergoing percutaneous coronary intervention (PCI), European guidelines have recently changed their recommendations to dual antithrombotic therapy (DAT; P2Y12 inhibitor and OAC) without aspirin. AIMS The prospective WOEST 2 registry was designed to obtain contemporary real-world data on antithrombotic regimens and related outcomes after PCI in patients with an indication for OAC. METHODS In this analysis, we compare DAT (P2Y12 inhibitor and OAC) to triple antithrombotic therapy (TAT; aspirin, P2Y12 inhibitor, and OAC) on thrombotic and bleeding outcomes after one year. Clinically relevant bleeding was defined as Bleeding Academic Research Consortium classification (BARC) grade 2, 3, or 5; major bleeding as BARC grade 3 or 5. Major adverse cardiac and cerebrovascular events (MACCE) was defined as a composite of all-cause mortality, myocardial infarction, stent thrombosis, ischaemic stroke, and transient ischaemic attack. RESULTS A total of 1,075 patients were included between 2014 and 2021. Patients used OAC for atrial fibrillation (93.6%) or mechanical heart valve prosthesis (4.7%). Non-vitamin K oral anticoagulants (NOAC) were prescribed in 53.1% and vitamin K antagonists in 46.9% of patients. At discharge, 60.9% received DAT, and 39.1% TAT. DAT was associated with less clinically relevant and similar major bleeding (16.8% vs 23.4%; p<0.01 and 7.6% vs 7.7%, not significant), compared to TAT. The difference in MACCE between the two groups was not statistically significant (12.4% vs 9.7%; p=0.17). Multivariable adjustment and propensity score matching confirmed these results. CONCLUSIONS Dual antithrombotic therapy is associated with a substantially lower risk of clinically relevant bleeding without a statistically significant penalty in ischaemic events.
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Affiliation(s)
- Willem Lambertus Bor
- Department of Cardiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
| | | | - Renske H. Olie
- Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sem A.O.F. Rikken
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands,Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | | | - Mathias Vrolix
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | | | - Carlos van Mieghem
- Cardiovascular Research Center Aalst, OLV Clinic, Aalst, Belgium,Department of Cardiology, AZ Groeninge, Kortrijk, Belgium
| | - Michael Magro
- Department of Cardiology, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Naoual Bennaghmouch
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Rick Hermanides
- Department of Cardiology, Isala Hospital, Zwolle, the Netherlands
| | - Tom Adriaenssens
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Jurriën Maria ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands,Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
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Wu Y, Liu H, Qin L, Wang Y, Zhang S, Wang Z, Zou Y, Yin T. Efficacy and Safety of Antithrombotic Therapy With Oral Anticoagulants in Real-World Elderly Patients With Acute Coronary Syndrome and Atrial Fibrillation. Front Cardiovasc Med 2022; 9:923684. [PMID: 35845074 PMCID: PMC9276998 DOI: 10.3389/fcvm.2022.923684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe efficacy and safety of antithrombotic treatment with oral anticoagulants (OACs) in elderly patients with comorbidities of acute coronary syndrome (ACS) and atrial fibrillation (AF) are unclear.MethodsA cohort of hospitalized elderly patients (≥65 years of age) diagnosed with ACS and AF and treated with oral antithrombotic agents were consecutively recruited. Follow-up was performed for at least 1 year. Major adverse cardiac events (MACEs) were defined as a composite of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, and systemic embolism. The safety outcomes of bleeding were defined according to the Bleeding Academic Research Consortium (BARC) criteria.ResultsA cohort of 548 eligible patients (76 ± 6.6 years) was analyzed. Compared to the patients with OAC treatment (n = 184, 33.6%), patients treated without OAC (n = 364, 66.4%) were older, had a lower prevalence of persistent AF and unstable angina (UA), and more often presented with paroxysmal AF, acute myocardial infarction (AMI), stent implantation and dual antiplatelet therapy (DAPT). Compared to the patients without OAC treatment (n = 364, 66.4%), patients treated with OAC (n = 184, 33.6%) had a lower risk of MACEs at both the 1-year (4.3 vs. 15.1%, adjusted HR: 0.34, 95% CI: 0.15–0.80, p = 0.014) and 5-year (17.5 vs. 48.4%, adjusted HR: 0.36, 95% CI: 0.19–0.67, p = 0.001) follow-up. No significant difference was observed for bleeding events of BARC ≥2 between the groups (8.0 vs. 9.0%, adjusted HR: 1.17, 95% CI: 0.58–2.34, p = 0.667). Compared with warfarin-treated patients, the non-vitamin K antagonist oral anticoagulant-treated patients had lower risks of all-cause mortality (2.1 vs. 9.5%, HR: 0.18, 95% CI: 0.03–0.98, p = 0.047) and bleeding events of BARC ≥ 3 (2.1 vs. 4.8%, HR: 0.14, 95% CI: 0.02–1.10, p = 0.062).ConclusionsAntithrombotic therapy with OACs in elderly patients with ACS and AF was associated with a lower risk of ischemic events without an increase in bleeding events. In real-world practice, the clinical awareness of anticoagulation treatments in elderly patients with ACS and AF needs to be strengthened.
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Affiliation(s)
- Yangxun Wu
- Institute of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | - Haiping Liu
- Institute of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | - Liu'an Qin
- Institute of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | - Yuyan Wang
- Institute of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | - Shizhao Zhang
- Institute of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | - Ziqian Wang
- Institute of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | - Yuting Zou
- Institute of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | - Tong Yin
- Institute of Geriatrics, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
- *Correspondence: Tong Yin
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7
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De Luca L, Rubboli A, Lettino M, Tubaro M, Leonardi S, Casella G, Valente S, Rossini R, Sciahbasi A, Natale E, Trambaiolo P, Navazio A, Cipriani M, Corda M, De Nardo A, Francese GM, Napoletano C, Tizzani E, Nardi F, Roncon L, Caldarola P, Riccio C, Gabrielli D, Oliva F, Massimo Gulizia M, Colivicchi F. ANMCO position paper on antithrombotic treatment of patients with atrial fibrillation undergoing intracoronary stenting and/or acute coronary syndromes. Eur Heart J Suppl 2022; 24:C254-C271. [PMID: 35663586 PMCID: PMC9155223 DOI: 10.1093/eurheartj/suac020] [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] [Indexed: 11/16/2022]
Abstract
Patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) with or without acute coronary syndromes (ACS) represent a subgroup with a challenging pharmacological management. Indeed, if on the one hand, antithrombotic therapy should reduce the risk related to recurrent ischaemic events and/or stent thrombosis; on the other hand, care must be taken to avoid major bleeding events. In recent years, several trials, which overall included more than 12 000 patients, have been conducted demonstrating the safety of different therapeutic combinations of oral antiplatelet and anticoagulant agents. In the present ANMCO position paper, we propose a decision-making algorithm on antithrombotic strategies based on scientific evidence and expert consensus to be adopted in the periprocedural phase, at the time of hospital discharge, and in the long-term follow-up of patients with AF undergoing PCI with/without ACS.
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Affiliation(s)
- Leonardo De Luca
- Cardiology, Department of Cardio-Thoraco-Vascular, Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense, 87, 00152 Roma, Italy
| | - Andrea Rubboli
- Cardiology, Cardiovascular Department, Ospedale S. Maria delle Croci, Ravenna, Italy
| | - Maddalena Lettino
- Department of Cardiology, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Marco Tubaro
- CCU, Intensive and Interventional Cardiology Department, P.O. San Filippo Neri, Roma, Italy
| | - Sergio Leonardi
- University of Pavia and IRCCS S. Matteo Foundation General Hospital, Pavia, Italy
| | - Gianni Casella
- Cardiology Department, Ospedale Maggiore, Azienda USL di Bologna, Bologna, Italy
| | - Serafina Valente
- Cardio-Thoracic Department, A.O.U. Senese, Ospedale Santa Maria alle Scotte, Siena, Italy
| | - Roberta Rossini
- Emergency Department and Critical Areas, Azienda Ospedaliera Santa Croce e Carle, Cuneo, Italy
| | | | - Enrico Natale
- Cardiology, Department of Cardio-Thoraco-Vascular, Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense, 87, 00152 Roma, Italy
| | - Paolo Trambaiolo
- Cardiology Department, Ospedale Sandro Pertini, ASL RM2, Roma, Italy
| | - Alessandro Navazio
- Hospital Cardiology Department, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, Italy
| | - Manlio Cipriani
- Cardiology 2-Heart Failure and Transplants, Dipartimento Cardiotoracovascolare "A. De Gasperis", ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Marco Corda
- Cardiology Department, Azienda Ospedaliera G. Brotzu, Cagliari, Italy
| | - Alfredo De Nardo
- Cardiology-ICU Department, Ospedale Civile "G. Jazzolino", Vibo Valentia, Italy
| | - Giuseppina Maura Francese
- Cardiology Department, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania, Italy
| | - Cosimo Napoletano
- Cardiology-ICU Department-Cath Lab, Presidio Ospedaliero "G. Mazzini", Teramo, Italy
| | | | - Federico Nardi
- Cardiology Department, Ospedale Santo Spirito, Casale Monferrato (AL), Italy
| | - Loris Roncon
- Cardiology Department, Ospedale Santa Maria della Misericordia, Rovigo, Italy
| | | | - Carmine Riccio
- Follow-up of the Post-Acute Patient, Cardio-Vascular Department, AORN Sant'Anna and San Sebastiano, Caserta, Italy
| | - Domenico Gabrielli
- Cardiology, Department of Cardio-Thoraco-Vascular, Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense, 87, 00152 Roma, Italy
| | - Fabrizio Oliva
- Cardiology 2-Heart Failure and Transplants, Dipartimento Cardiotoracovascolare "A. De Gasperis", ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, Presidio Ospedaliero San Filippo Neri, ASL Roma 1, Roma, Italy
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8
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Suo N, Yang YM, Wang J, Zhang H, Shao XH, Wu S, Zhu J. Evolving Antithrombotic Treatment Patterns for Patients With Nonvalvular Atrial Fibrillation and Acute Coronary Syndrome or Underwent Percutaneous Coronary Intervention in China: A Cross-Sectional Study. Front Cardiovasc Med 2022; 9:846803. [PMID: 35369345 PMCID: PMC8971844 DOI: 10.3389/fcvm.2022.846803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/28/2022] [Indexed: 11/27/2022] Open
Abstract
Objective Antithrombotic therapy in patients with nonvalvular atrial fibrillation (NVAF) concomitant with the acute coronary syndrome (ACS) or underwent percutaneous coronary intervention (PCI) is challenging and has evolved in recent years. However, real-world data on this issue about antithrombotic regimens at discharge and its evolving trend were relatively scarce, especially in China. Methods A total of 2,182 patients with NVAF and ACS/PCI were enrolled from 2017 to 2019. A total of 1,979 patients were finally analyzed and divided in three sequential cohorts: cohort 1 (2017), n = 674; cohort 2 (2018), n = 793; and cohort 3 (2019), n = 512. Baseline characteristics and antithrombotic therapy at discharge were analyzed by cohort. Results In our cross-sectional study, the majority of patients (59.6%) received dual antiplatelet therapy (DAPT). Over the 3 years, DAPT prescription reduced from nearly 70% to <50% (P trend < 0.001), while triple therapy (TT)/double therapy (DT) increased from 27.2 to 50.0% (P trend < 0.001). This trend was also seen in different subgroups stratified by CHA2DS2-VASc score, HAS-BLED score, coronary artery disease type, or management type, and was validated after multivariate adjustment. Persistent atrial fibrillation and history of congestive heart failure, hypertension, diabetes mellitus, and stroke/transient ischemic attack/systemic embolism were the independent predictors of TT/DT use, while ACS, PCI, or advanced chronic kidney disease was related with more DAPT prescription. Conclusion There is a shift of antithrombotic regime at discharge for patients with NVAF with recent ACS/PCI with reducing DAPT prescription and increasing TT/DT prescription. While the appropriate antithrombotic regimen for patients with NVAF having ACS/PCI is still underused in China.
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9
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Berns SA, Barbarash OL. How to level the risk of bleeding while taking anticoagulant therapy in patients with atrial fibrillation? CONSILIUM MEDICUM 2022. [DOI: 10.26442/20751753.2022.1.201474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Atrial fibrillation (AF) is one of the most common types of cardiac arrhythmias, while AF is the main risk factor for ischemic stroke. For a long time, vitamin K antagonists, primarily warfarin, have been the standard for the prevention of thromboembolic complications in patients with AF. 5 years ago, dabigatran, rivaroxaban and apixaban occupied the 2nd place in the structure of anticoagulant prescribing (AC), giving way to warfarin. The well-known reason for the inadequate use of AC is the risk of bleeding. There are a large number of validated scales for assessing the risk of hemorrhagic complications, in particular HAS-BLED, ABC, HEMORRHR2HAGES, ATRIA, ORBIT, but the estimated high risk of bleeding should not be the only and absolute limitation to the appointment of AC. Despite the real risk of bleeding on the background of taking AC in patients with AF, an integrated approach taking into account not only the risk factors of the thromboembolic complications, but also hemorrhagic complications, with an emphasis on the existing comorbidities, the presence of comorbidity, old age, etc., will allow an individual approach to the choice of AC and its dose, contributing to the optimization of the management of such kind of patients.
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10
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Dawwas GK, Barnes GD, Dietrich E, Cuker A, Leonard CE, Genuardi MV, Lewis JD. Cardiovascular and major bleeding outcomes with antiplatelet and direct oral anticoagulants in patients with acute coronary syndrome and atrial fibrillation: A population-based analysis. Am Heart J 2021; 242:71-81. [PMID: 34450051 DOI: 10.1016/j.ahj.2021.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are replacing warfarin for stroke prevention in patients with atrial fibrillation (AF). OBJECTIVE To assess the effectiveness and safety of concomitant treatment with antiplatelet-DOAC compared to antiplatelet-warfarin in patients with acute coronary syndrome (ACS) and AF. DESIGN Retrospective propensity score-matched cohort study using United States-based commercial healthcare database from January 2016 to June 2019. PARTICIPANTS New-users of antiplatelet-DOAC and antiplatelet-warfarin who initiated the combined therapy within 30 days following incident ACS diagnosis. MEASUREMENTS Primary study outcomes were recurrent cardiovascular diseases (CVD) (ie, a composite of stroke and myocardial infarction) and major bleeding events identified via discharge diagnoses. We controlled for potential confounders via propensity score matching (PSM). We generated marginal hazard ratios (HRs) via Cox proportional hazards regression using a robust variance estimator while adjusting for calendar time. RESULTS After PSM, a total of 2,472 persons were included (1,236 users of antiplatelet-DOAC and 1,236 users of antiplatelet-warfarin). The use of antiplatelet-DOAC (vs. antiplatelet-warfarin) was associated with a reduced rate of recurrent CVD (adjusted HR 0.72, 95% confidence interval [CI], 0.56-0.92) and major bleeding events (adjusted HR, 0.49, 95% CI 0.33-0.72). LIMITATIONS Residual confounding. CONCLUSIONS In real-world data of AF patients with concurrent ACS, the use of antiplatelet-DOAC following ACS diagnosis was associated with a lower rate of recurrent CVD and major bleeding events compared with antiplatelet-warfarin. These findings highlight a potential promising role for DOACs in patients with ACS and AF requiring combined antiplatelet therapy.
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11
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Petersen JK, Haider Butt J, Yafasova A, Torp-Pedersen C, Sørensen R, Kruuse C, Vinding NE, Gundlund A, Køber L, Loldrup Fosbøl E, Østergaard L. Incidence of ischaemic stroke and mortality in patients with acute coronary syndrome and first-time detected atrial fibrillation: a nationwide study. Eur Heart J 2021; 42:4553-4561. [PMID: 34477838 DOI: 10.1093/eurheartj/ehab575] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 04/06/2021] [Accepted: 08/14/2021] [Indexed: 01/25/2023] Open
Abstract
AIMS The aim of this study was to examine contemporary data on the 1-year prognosis of patients surviving acute coronary syndrome (ACS) and concomitant first-time detected atrial fibrillation (AF). METHODS AND RESULTS Using Danish nationwide registries, we identified all patients surviving a first-time admission with ACS from 2000 to 2018 and grouped them into (i) those without AF prior to or during ACS; (ii) those with a history of AF; and (iii) those with first-time detected AF during admission with ACS. With 1 year of follow-up, rates of ischaemic stroke, death, and bleeding were compared between study groups using multivariable adjusted Cox proportional hazards analysis. We included 161 266 ACS survivors: 135 878 (84.2%) without AF, 18 961 (11.8%) with history of AF, and 6427 (4.0%) with first-time detected AF at admission with ACS. Compared to those without AF, the adjusted 1-year rates of outcomes were as follows: ischaemic stroke [hazard ratio (HR) 1.38 (95% CI 1.22-1.56) for patients with history of AF and HR 1.67 (95% CI 1.38-2.01) for patients with first-time detected AF]; mortality [HR 1.25 (95% CI 1.21-1.31) for patients with history of AF and HR 1.52 (95% CI 1.43-1.62) for patients with first-time detected AF]; and bleeding [HR 1.22 (95% CI 1.14-1.30) for patients with history of AF and HR 1.28 (95% CI 1.15-1.43) for patients with first-time detected AF]. CONCLUSION In patients with ACS, first-time detected AF appeared to be at least as strongly associated with the 1-year rates of ischaemic stroke, mortality, and bleeding as compared with patients with a history of AF.
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Affiliation(s)
- Jeppe Kofoed Petersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Jawad Haider Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Adelina Yafasova
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjællands Hospital, Dyrehavevej 29, Hillerød 3400, Denmark.,Department of Cardiology, Aalborg University Hospital, Hobrovej 18, Aalborg 9000, Denmark
| | - Rikke Sørensen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Christina Kruuse
- Department of Neurology, Herlev Gentofte University Hospital, Borgmester Ib Juuls vej 1, Herlev 2730, Denmark.,University of Copenhagen, Institute of Clinical Medicine, Nørre Allé 20, Copenhagen 2200, Denmark
| | - Naja Emborg Vinding
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Anna Gundlund
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Lauge Østergaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
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Marazzato J, Verdecchia P, Golino M, Blasi F, Crippa M, De Ponti R, Angeli F. An update on antithrombotic therapy in atrial fibrillation patients in long-term ambulatory setting after percutaneous coronary intervention: where do we go from here? Expert Opin Pharmacother 2021; 22:2033-2051. [PMID: 34074195 DOI: 10.1080/14656566.2021.1937119] [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: 10/21/2022]
Abstract
INTRODUCTION In the treatment of patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI), it is unclear which combination of antithrombotic drugs is preferable and which is the optimal duration of treatment. AREAS COVERED The authors review the available evidence in this area resulting from single studies and meta-analyses. In the absence of direct head-to-head comparisons between different non-vitamin K oral anticoagulants (NOAC), the authors review the available studies with NOACS in these patients and derived indirect comparisons. EXPERT OPINION In patients with AF who undergo PCI, a dual antithrombotic strategy which includes a NOAC plus single antiplatelet therapy with a P2Y12 inhibitor (preferably clopidogrel) should be considered as the preferred treatment option in most cases. Oral anticoagulation associated with dual antiplatelet therapy (triple antithrombotic therapy) should be offered for no longer than 30 days to patients with very high thrombotic and low hemorrhagic risk. It is unclear whether the dual antithrombotic strategy should be continued beyond 12 months in patients at high risk of thrombotic events. Additional data from adequately powered controlled studies are needed to support the long-term efficacy of this strategy and to establish the best patient-tailored approach in this complex scenario.
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Affiliation(s)
- Jacopo Marazzato
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Paolo Verdecchia
- Fondazione Umbra Cuore E Ipertensione-ONLUS and Division of Cardiology, Hospital S. Maria Della Misericordia, Perugia, Italy
| | - Michele Golino
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Federico Blasi
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Matteo Crippa
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Roberto De Ponti
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, Varese, Italy.,Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institutes, IRCCS, Tradate, Varese, Italy
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Krittayaphong R, Boonyapiphat T, Wongvipaporn C, Sairat P. Age-Related Clinical Outcomes of Patients with Non-Valvular Atrial Fibrillation: Insights from the COOL-AF Registry. Clin Interv Aging 2021; 16:707-719. [PMID: 33953549 PMCID: PMC8089026 DOI: 10.2147/cia.s302389] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/24/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose We aimed to compare the rate of clinical outcomes among three age groups (<65, 65–74, and ≥75 years) of adult patients with non-valvular atrial fibrillation (NVAF). Patients and Methods We prospectively enrolled NVAF patients from 27 Thailand medical centers. The following were collected at baseline: demographic data, risk factors, comorbid conditions, laboratory data, and medications. The clinical outcomes were ischemic stroke (IS) or transient ischemic attack (TIA), major bleeding (MB), intracerebral hemorrhage (ICH), heart failure (HF), and death. All events were adjudicated. Patients were categorized according to age group into three groups; age <65, 65–74, and ≥75 years. Results Among the 3402 patients that were enrolled during 2014–2017, the mean age was 67.4±11.3 years, and 2073 (60.9%) were older. The average follow-up was 25.7±10.6 months. Oral anticoagulants were given in 75.4% of patients (91.1% of OAC was warfarin). The incidence rate of IS/TIA, MB, ICH, HF, and death was 1.43 (1.17–1.74), 2.11 (1.79–2.48), 0.70 (0.52–0.92), 3.03 (2.64–3.46), and 3.77 (3.33–4.24) per 100 person-years, respectively. The risk of IS/TIA, MB, ICH, HF, and death increased with age both before and after adjustment for potential confounders. Even though OAC reduced the risk of IS/TIA, it increased the risk of MB. Net clinical benefit (NCB) analysis favored oral anticoagulant (OAC) in the high-risk subset of older adults. Conclusion Older adult NVAF patients had a significantly increased risk of IS/TIA, MB, ICH, HF, and death compared to younger NVAF before and after adjustment for potential confounders. Strategies to reduce overall risk, including OAC use and choice and integrated care, should be implemented.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thanita Boonyapiphat
- Division of Cardiology, Department of Medicine, Lampang Hospital, Lampang, Thailand
| | - Chaiyasith Wongvipaporn
- Division of Cardiology, Department of Medicine,Srinakarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Poom Sairat
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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14
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Venetsanos D, Skibniewski M, Janzon M, Lawesson SS, Charitakis E, Böhm F, Henareh L, Andell P, Karlson LO, Simonsson M, Völz S, Erlinge D, Omerovic E, Alfredsson J. Uninterrupted Oral Anticoagulant Therapy in Patients Undergoing Unplanned Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2021; 14:754-763. [PMID: 33826495 DOI: 10.1016/j.jcin.2021.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVES This study sought to compare interrupted and uninterrupted oral anticoagulant therapy (I-OAC vs. U-OAC) in patients on OAC undergoing percutaneous coronary intervention. BACKGROUND There is a paucity of data regarding the optimal peri-procedural management of OAC-treated patients. METHODS In the SWEDEHEART registry, all patients on OAC who were admitted acutely and underwent percutaneous coronary intervention or coronary angiography with a diagnostic procedure, from 2005 to 2017, were included. Outcomes were major adverse cardiac and cerebrovascular events (MACCE; death, myocardial infarction, or stroke) and bleeds at 120 days. Propensity score was used to adjust for the nonrandomized treatment selection. RESULTS The study included 6,485 patients: 3,322 in the I-OAC group and 3,163 in the U-OAC group. The cumulative incidence of MACCE was 8.2% (269 events) versus 8.2% (254 events) in the I-OAC and the U-OAC groups, respectively. The adjusted risk for MACCE did not differ between the groups (I-OAC vs. U-OAC hazard ratio: 0.89; 95% confidence interval: 0.71 to 1.12). Similarly, no difference was found in the risk for MACCE or bleeds (12.6% vs. 12.9%, adjusted hazard ratio: 0.87; 95% confidence interval: 0.70 to 1.07). The risk for major or minor in-hospital bleeds did not differ between the groups. However, U-OAC was associated with a significantly shorter duration of hospitalization: 4 (3 to 7) days versus 5 (3 to 8) days; p < 0.01. CONCLUSIONS I-OAC and U-OAC were associated with equivalent risk for MACCE and bleeding complications. An U-OAC strategy was associated with shorter length of hospitalization. These data support U-OAC as the preferable strategy in patients on OAC undergoing coronary intervention.
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Affiliation(s)
- Dimitrios Venetsanos
- Department of Cardiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
| | - Mikolaj Skibniewski
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - Magnus Janzon
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - Sofia S Lawesson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - Emmanouil Charitakis
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - Felix Böhm
- Department of Cardiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Loghman Henareh
- Department of Cardiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Pontus Andell
- Department of Cardiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Lars O Karlson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - Moa Simonsson
- Department of Cardiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Sebastian Völz
- Department of Cardiology, Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - David Erlinge
- Department of Cardiology, Lund University Hospital, Skåne, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Joakim Alfredsson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
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15
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Shah S, Shah K, Turagam MK, Sharma A, Natale A, Lakkireddy D, Garg J. Direct oral anticoagulants to treat left ventricular thrombus-A systematic review and meta-analysis: ELECTRAM investigators. J Cardiovasc Electrophysiol 2021; 32:1764-1771. [PMID: 33772939 DOI: 10.1111/jce.15016] [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: 12/06/2020] [Revised: 02/23/2021] [Accepted: 03/16/2021] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Though current guidelines currently recommend using warfarin, there is also a growing interest in the utilization of direct oral anticoagulants (DOACs) to treat left ventricular (LV) thrombus. METHODS We performed a systematic search using PubMed, SCOPUS, EMBASE, Google Scholar, and ClinicalTrials.gov from inception to September 30, 2020, for studies that had reported outcomes in patients with left ventricular thrombus treated with DOACs (PROSPERO registration number CRD42020219761). RESULTS Twelve studies (n = 867 patients) were included in the analysis. The pooled incidence of the systemic embolic events (SEE) with DOACs was 2.7%, whereas the thrombus resolution rate was 86.6%. The pooled incidence of overall bleeding (composite of major and minor bleeding) and major bleeding with DOACs were 5.6% and 1.1%, respectively. No significant difference was observed in terms of SEE (OR 0.81, 95% confidence interval [CI] 0.44-1.52, p = .54), major bleeding (OR 0.29, 95% CI 0.07-1.26, p = .24), and failure of LV thrombus resolution (OR 0.86, 95% CI 0.28-2.58, p = .68); whereas overall bleeding was significantly low in patients with LV thrombus treated with DOACs compared to vitamin K antagonists (VKAs) (OR 0.33, 95% CI 0.14-0.81, p = .02). CONCLUSION Our study demonstrates no significant difference in SEE, major bleeding, or failure of LV thrombus resolution between the two groups, thus demonstrating that DOACs are an efficacious and safe alternative for the treatment of LV thrombus compared to VKAs. However, further well-designed prospective trials are needed to answer important clinical questions-optimal dosing/duration of DOACs and its safety in the background of antiplatelet therapy.
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Affiliation(s)
- Siddharth Shah
- Division of Cardiology, State University of New York Upstate Medical Center, Syracuse, New York
| | - Kuldeep Shah
- Department of Cardiovascular Medicine, Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
| | - Mohit K Turagam
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Abhinav Sharma
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andrea Natale
- Cardiac Arrhythmia Service, Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas
| | - Dhanunjaya Lakkireddy
- Cardiac Arrhythmia Service, Kansas City Heart Rhythm Institute and Research Foundation, Kansas City, Kansas
| | - Jalaj Garg
- Division of Cardiology, Cardiac Arrhythmia Service, Medical College of Wisconsin, Milwaukee, Wisconsin
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16
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Gawałko M, Lodziński P, Budnik M, Tymińska A, Wancerz A, Ozierański K, Kapłon-Cieślicka A, Grabowski M, Opolski G, Lenarczyk R, Kalarus Z, Lip GYH, Balsam P. Vascular disease in patients with atrial fibrillation. A report from Polish participants in the EORP-AF General Long-Term Registry. Int J Clin Pract 2021; 75:e13701. [PMID: 32915461 DOI: 10.1111/ijcp.13701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 08/06/2020] [Accepted: 09/02/2020] [Indexed: 11/26/2022] Open
Abstract
AIMS This study aimed to (1) define the prevalence of vascular disease (VD; coronary (CAD) and/or peripheral artery disease (PAD)) and associated risk factors in patients with atrial fibrillation (AF); (2) establish the relationship of VD and associated treatment patterns on adverse events in AF. METHODS Data from 701 Polish AF patients enrolled in the EORP-AF General Long-Term Registry in the years 2013-2016 were included in this analysis. During the one-year follow-up, the occurrence of major adverse events (MAE; all-cause death, thromboembolic event, myocardial infraction) and its components was evaluated. RESULTS VD was recorded in 293 (44%) patients and based on multivariate logistic analysis was associated with age >75, diabetes, hypercholesterolemia, heart failure (HF). There was no significant difference in rates of MAE between patients with and without VD based on Fisher's exact test (8.8% vs 5.7%, P = .16), as well as between patients with concomitant CAD and PAD, PAD and CAD alone based on the Chi-square test (21% vs 7.5% vs 6.7%; P = .09). A higher risk of MAE was associated with HF, chronic kidney disease (in all study group), age >75, HF, diabetes (VD group),chronic obstructive pulmonary disease (non-VD group) based on the multivariate logistic analysis. Relative to patients with VD on vitamin K antagonists (VKA), those treated with non-VKA-oral anticoagulants (NOAC) had lower absolute rate of MAE according to Fisher's exact test (1.4% vs 10%, P = .02) but similar risks for thromboembolic and hemorrhagic events. The concomitant use of triple therapy was associated with increased risk of MAE as compared with those on OAC alone or dual therapy based on the Chi-square test (20% vs 4.8%, 3.2%, P = .02). CONCLUSION VD was prevalent in almost two-fifths of AF patients. The incidence of MAE was higher in patients with VD on VKA (vs NOAC) and on triple therapy (vs dual therapy, OAC alone) within one-year follow-up.
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Affiliation(s)
- Monika Gawałko
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Lodziński
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Monika Budnik
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Agata Tymińska
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Anna Wancerz
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | | | - Marcin Grabowski
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Opolski
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Radosław Lenarczyk
- 1st Department of Cardiology and Angiology, Silesian Center for Heart Disease, Zabrze, Poland
| | - Zbigniew Kalarus
- Department of Cardiology, DMS in Zabrze, Medical University of Silesia, Katowice, Poland, Zabrze, Poland
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Paweł Balsam
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
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Qian J, Zan J, Kuang L, Che L, Yu Y, Shen T, Tang J, Chen F, Liu X. A predictive nomogram of bleeding risk in patients with atrial fibrillation after drug-eluting stent implantation. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:193. [PMID: 33708820 PMCID: PMC7940957 DOI: 10.21037/atm-20-3971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 11/02/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND The use of anticoagulants and antiplatelet therapies is associated with a higher risk of bleeding in atrial fibrillation (AF) patients after percutaneous coronary intervention, especially after stent implantation. However, no accurate bleeding risk prediction tool has been developed for these patients. The aim of this study was thus to establish a bleeding risk prediction model (predictive nomogram) for patients with AF after stent implantation. METHODS Construction of the predictive nomogram was based on a retrospective study, which enrolled 943 AF patients who underwent drug-eluting stent implantation between May 2012 and September 2016. A range of factors, including demographics, comorbidities, medication strategies, arterial access, and laboratory tests, were collected as baseline data. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analysis were used to identify the key clinical features for construction of the predictive nomogram. The concordance index (C-index) and internal validation were used to evaluate the efficacy of the nomogram. RESULTS Of the 943 AF patients that underwent stent implantation, the occurrence of bleeding events was 8.2% (77 out of 943). Key predictors included the number of antiplatelet drugs, peptic ulcer, cerebral infarction, type 2 diabetes, thrombocytopenia, anemia, prior myocardial infarction, sex (male), use of anticoagulant drugs, liver dysfunction, hypertension, and acute myocardial infarction. These predictors were used to construct the nomogram. The C-index for the prediction of bleeding risk by the nomogram was 0.841 (95% CI: 0.79-0.89), which indicated good discrimination and calibration. The C-index of internal validation was 0.795, which demonstrated good efficacy of the model. CONCLUSIONS This study suggests that our novel nomogram can accurately predict bleeding risk in AF patients after stent implantation during hospitalization, thereby helping to avoid complications. The nomogram may also be helpful for the creation of individualized post-discharge medication strategies.
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Affiliation(s)
- Jun Qian
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jiyong Zan
- Department of Gastroenterology, Huazhong University of Science and Technology Union Shenzhen Hospital (Nanshan Hospital), Shenzhen, China
| | - Lijun Kuang
- Department of Ultrasound, Luwan Branch, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lin Che
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yunan Yu
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ting Shen
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jiani Tang
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fei Chen
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xuebo Liu
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
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18
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Kwon S, Jung JH, Choi EK, Lee SW, Park J, Lee SR, Kang J, Han K, Park KW, Oh S, Lip GYH. Impact of Non-Vitamin K Antagonist Oral Anticoagulants on the Change of Antithrombotic Regimens in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Korean Circ J 2021; 51:409-422. [PMID: 33764010 PMCID: PMC8112178 DOI: 10.4070/kcj.2020.0407] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/30/2020] [Accepted: 12/16/2020] [Indexed: 12/12/2022] Open
Abstract
Background and Objectives Antithrombotic therapy after percutaneous coronary intervention (PCI) in patients with atrial fibrillation (AF) has changed in recent years with new data from large randomized trials and updates to clinical guidelines. This study aimed to investigate the trends in periprocedural antithrombotic regimens in Korean patients with AF undergoing PCI with non-vitamin K antagonist oral anticoagulants (NOACs). Methods Using the claims database of the Health Insurance Review and Assessment during 2013–2018, 27,594 patients with AF undergoing PCI were identified. The annual prevalence of PCI and prescriptions of each antithrombotic agent, including antiplatelet agents and oral anticoagulants, within 30 days after PCI were investigated. Results During 2013–2018, the number of patients with AF undergoing PCI increased up to 1.3-fold (from 3,913 to 5,075 patients per year). After the introduction of NOACs, the proportion of dual antiplatelet therapy (DAPT) decreased from 71.9% to 49.8% but still occupied the largest proportion among antithrombotic regimens. Triple antithrombotic therapy (TAT) use increased from 25.4% to 46.0%, and NOAC has rapidly replaced warfarin as the oral anticoagulant of choice. TAT was preferred to DAPT for patients with CHA2DS2-VASc score ≥2. Among various factors, prior intracranial hemorrhage was the most powerful predictor of favoring DAPT use over TAT. Conclusion Since the introduction of NOACs, the patterns of periprocedural antithrombotic regimens have changed rapidly toward more use of TAT, specifically with NOAC-based regimen. Appropriate stroke prevention with oral anticoagulants is still underutilized in patients with AF undergoing PCI in Korea.
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Affiliation(s)
- Soonil Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jin Hyung Jung
- Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eue Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
| | - Seung Woo Lee
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
| | - Jiesuck Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - So Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jeehoon Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Gregory Y H Lip
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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19
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Double or Triple Antithrombotic Treatment in Atrial Fibrillation Patients with Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention. Am J Cardiovasc Drugs 2021; 21:11-20. [PMID: 32170515 DOI: 10.1007/s40256-020-00403-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) have traditionally received triple antithrombotic therapy (TAT) consisting of aspirin and a P2Y12 inhibitor plus an oral anticoagulant (OAC) to reduce atherothrombotic events, even though this strategy is associated with a high risk of severe bleeding. Recent trials have indicated that dual antithrombotic therapy (DAT), consisting of a P2Y12 inhibitor plus an OAC, may be superior to TAT in terms of bleeding risk; however, the trade-off regarding ischemic complications may be questionable. Patients who have had a myocardial infarction (MI) before undergoing PCI warrant special consideration because of the accompanying high ischemic risk, including stent thrombosis, which might be exacerbated by an aspirin-free strategy such as DAT. In particular, in the acute phase of ST-segment elevation MI (STEMI), the highly prothrombotic milieu may necessitate initial TAT, though durations may vary, making a tailored antithrombotic regimen for this high-risk subset of patients a fairly challenging and difficult scenario for clinicians. Since patients with MI, especially STEMI, are underrepresented in randomized trials, data regarding the optimal antithrombotic treatment in such patients are sparse. This review aims to analyze the outcomes of different antithrombotic regimens in patients with MI and AF undergoing PCI, define the role of DAT versus TAT regarding safety and efficacy outcomes, and address controversial issues and future perspectives.
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20
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Benetou DR, Varlamos C, Ktenas D, Tsiafoutis I, Koutouzis M, Bampali T, Mantis C, Zarifis J, Skalidis E, Aravantinos D, Varvarousis D, Lianos I, Kanakakis J, Pisimisis E, Ziakas A, Davlouros P, Alexopoulos D. Trends of Antithrombotic Treatment in Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention: Insights from the GReek-AntiPlatElet Atrial Fibrillation (GRAPE-AF) Registry. Cardiovasc Drugs Ther 2020; 35:11-20. [PMID: 33034806 DOI: 10.1007/s10557-020-07090-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE Patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) are a high-risk subset of patients, whose optimal antithrombotic treatment strategy, involving a combination of anticoagulant and antiplatelet agents, has not been well defined. Our study aims to investigate contemporary "real-world" trends of antithrombotic treatment strategies in AF patients undergoing PCI, as well as identify factors affecting decision-making at hospital discharge. METHODS "Real-world" data were retrieved from the GReek-AntiPlatElet Atrial Fibrillation (GRAPE-AF) registry, a contemporary, nationwide, multicenter, observational study of AF patients undergoing PCI. Characteristics of patients discharged on triple antithrombotic therapy (TAT) or dual antithrombotic therapy (DAT) were compared in order to identify factors that could influence treatment decisions. RESULTS A total of 654 patients were enrolled (42% with stable coronary artery disease, 58% with acute coronary syndrome). TAT was adopted in 49.9% and DAT in 49.2% of patients at discharge. Regarding anticoagulants, the vast majority of patients (92.9%) received non-vitamin K antagonist oral anticoagulants (NOACs) and only 7.1% received vitamin K antagonists (VKAs). Dyslipidemia, insulin-dependent diabetes mellitus, prior myocardial infarction, acute coronary syndrome at presentation, and regional variations were predictive of TAT adoption, whereas the use of NOACs or ticagrelor was predictive of DAT adoption. CONCLUSION Contemporary "real-world" data concerning antithrombotic treatment in AF patients undergoing PCI indicate a strong shift towards the use of NOACs instead of VKAs, along with a large subset of patients adopting an aspirin-free strategy early after index PCI, with clinical as well as treatment characteristics affecting decision-making. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03362788 (First Posted: December 5, 2017).
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Affiliation(s)
- Despoina-Rafailia Benetou
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Rimini 1, Chaidari, 12462, Athens, Greece
| | - Charalampos Varlamos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Rimini 1, Chaidari, 12462, Athens, Greece
| | - Dionysios Ktenas
- Cardiology Department, Patras University Hospital, Patras, Greece
| | - Ioannis Tsiafoutis
- Cardiology Department, Hellenic Red Cross General Hospital, Athens, Greece
| | - Michael Koutouzis
- Cardiology Department, Hellenic Red Cross General Hospital, Athens, Greece
| | - Theodora Bampali
- Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
| | - Christos Mantis
- Department of Cardiology, Konstantopoulion Hospital, Athens, Greece
| | - John Zarifis
- Cardiology Department, George Papanikolaou General Hospital, Thessaloniki, Greece
| | - Emmanouil Skalidis
- Department of Cardiology, Heraklion University Hospital, Heraklion, Greece
| | - Dionysios Aravantinos
- Department of Cardiology, Sismanoglio-Amalia Fleming General Hospital of Athens, Athens, Greece
| | | | - Ioannis Lianos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Rimini 1, Chaidari, 12462, Athens, Greece
| | - John Kanakakis
- Department of Clinical Therapeutics, "Alexandra" University Hospital, Athens, Greece
| | - Evangelos Pisimisis
- Department of Cardiology, "Tzaneio" General Hospital of Piraeus, Piraeus, Greece
| | - Antonios Ziakas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Dimitrios Alexopoulos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Rimini 1, Chaidari, 12462, Athens, Greece.
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21
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Iqbal H, Straw S, Craven TP, Stirling K, Wheatcroft SB, Witte KK. Direct oral anticoagulants compared to vitamin K antagonist for the management of left ventricular thrombus. ESC Heart Fail 2020; 7:2032-2041. [PMID: 32583975 PMCID: PMC7524136 DOI: 10.1002/ehf2.12718] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/18/2020] [Accepted: 03/31/2020] [Indexed: 11/26/2022] Open
Abstract
AIMS Left ventricular (LV) thrombus is increasingly detected in patients with and without ischaemic heart disease due to the increased availability of cardiac magnetic resonance imaging. Risk factors include anterior ST elevation myocardial infarction, delayed reperfusion therapy, and non-ischaemic cardiomyopathy with severe LV systolic dysfunction. We aimed to report the characteristics and outcomes of patients with LV thrombus treated with either vitamin K antagonist (VKA) or direct oral anticoagulants (DOAC) with a view to describing differences in efficacy, specifically, subsequent thromboembolic events, thrombus resolution, and also side effects of therapy including clinically significant bleeding. METHODS AND RESULTS We conducted a retrospective, observational cohort study of patients diagnosed with LV thrombus between 1 December 2012 and 30 June 2018 and treated with either DOAC or VKA. We recorded patient demographics, past medical history, prescribed medications, and baseline investigations. The primary outcomes were rates of thromboembolism and clinically significant bleeding, with secondary outcomes of thrombus resolution on repeat cardiac imaging, repeat hospitalization, and all-cause mortality. During the study period, 84 patients were diagnosed with and managed for LV thrombus. Of these, 62 received VKA and 22 DOAC including 13 prescribed rivaroxaban, eight apixaban, and one dabigatran. Most patients 75 (89%) were male with an average age of 62 ± 14 years. Ischaemic heart disease was the cause of LV impairment in 73 (87%) patients. Baseline characteristics were similar between groups at baseline. Most n = 55 (65%) were co-prescribed a single antiplatelet agent and 32 (38%) received dual-antiplatelet therapy. During an average follow-up of 3.0 ± 1.4 years, there were no statistically significant differences between VKA and DOAC in rates of stroke (2% vs. 0%, P = 0.55), other thromboemboli (2% vs. 0%, P = 0.55), or clinically significant bleeding (10% vs. 0%, P = 0.13). The average interval to cardiac imaging follow-up was 233 ± 251 days and was not different between groups (P = 0.83), and there was no difference in the rate of resolution of thrombus (76% vs. 65% P = 0.33). Rehospitalization (50% vs. 45%: P = 0.53) and all-cause mortality (10% vs. 14%; P = 0.61) were also similar. CONCLUSIONS Our data suggest that DOACs are likely to be at least as effective and safe as VKA for stroke prevention in patients with LV thrombus and, despite their lack of a licence for this indication, are therefore likely to represent a reasonable and more convenient option for this setting. The optimal timing and type of anticoagulation for LV thrombus, as well as the role of screening for high-risk patients, should be tested in prospective, randomized trials.
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Affiliation(s)
- Hansa Iqbal
- School of MedicineUniversity of LeedsLeedsUK
| | - Sam Straw
- Leeds Institute of Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
| | - Thomas P. Craven
- Leeds Institute of Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
| | - Katherine Stirling
- Medicines Management and Pharmacy ServiceLeeds Teaching Hospitals NHS TrustLeedsUK
| | | | - Klaus K. Witte
- Leeds Institute of Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
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22
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Gunasekaran K, Rajasurya V, Devasahayam J, Singh Rahi M, Chandran A, Elango K, Talari G. A Review of the Incidence Diagnosis and Treatment of Spontaneous Hemorrhage in Patients Treated with Direct Oral Anticoagulants. J Clin Med 2020; 9:jcm9092984. [PMID: 32942757 PMCID: PMC7563837 DOI: 10.3390/jcm9092984] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 12/25/2022] Open
Abstract
Anticoagulation carries a tremendous therapeutic advantage in reducing morbidity and mortality with venous thromboembolism and atrial fibrillation. For over six decades, traditional anticoagulants like low molecular weight heparin and vitamin K antagonists like warfarin have been used to achieve therapeutic anticoagulation. In the past decade, multiple new direct oral anticoagulants have emerged and been approved for clinical use. Since their introduction, direct oral anticoagulants have changed the landscape of anticoagulants. With increasing indications and use in various patients, they have become the mainstay of treatment in venous thromboembolic diseases. The safety profile of direct oral anticoagulants is better or at least similar to warfarin, but several recent reports are focusing on spontaneous hemorrhages with direct oral anticoagulants. This narrative review aims to summarize the incidence of spontaneous hemorrhage in patients treated with direct oral anticoagulants and also offers practical management strategies for clinicians when patients receiving direct oral anticoagulants present with bleeding complications.
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Affiliation(s)
- Kulothungan Gunasekaran
- Division of Pulmonary Diseases and Critical Care, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT 06610, USA;
- Correspondence: ; Tel.: +203-384-5009; Fax: 203-330-7498
| | - Venkat Rajasurya
- Division of Pulmonary Diseases and Critical Care, Multi-Care Pulmonary Specialists, Puyallup, WA 98372, USA;
| | - Joe Devasahayam
- Division of Pulmonary Diseases and Critical Care, Avera Medical Group, Sioux Falls, SD 57105, USA;
| | - Mandeep Singh Rahi
- Division of Pulmonary Diseases and Critical Care, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT 06610, USA;
| | - Arul Chandran
- Division of Pulmonary Diseases and Critical Care, Hurley Medical Center, Flint, MI 48532, USA;
| | - Kalaimani Elango
- Division of Cardiology, University of Nevada, Las Vegas, NV 89154, USA;
| | - Goutham Talari
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI 48202, USA;
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23
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Nakamura M, Yamashita T, Hayakawa A, Matsumoto T, Takita A, Hasegawa C, Uchino K, Sekine T, Iizuka T, Tanabe H, Kogure S. Bleeding risks associated with anticoagulant therapies after percutaneous coronary intervention in Japanese patients with ischemic heart disease complicated by atrial fibrillation: A comparative study. J Cardiol 2020; 77:186-194. [PMID: 32943280 DOI: 10.1016/j.jjcc.2020.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 07/20/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current guidelines recommend early termination of triple therapy and the use of direct oral anticoagulants (DOAC) for non-valvular atrial fibrillation (NVAF) patients who undergo percutaneous coronary intervention (PCI), due to safety concerns. However, to date, real-world medication usage and safety outcomes (specifically bleeding) in NVAF patients with stent implantation have not been well assessed. METHODS This was a retrospective, observational, medical database cohort study in Japanese ischemic heart disease (IHD) patients with NVAF who underwent PCI between 2012 and 2017. The primary outcome was clinically relevant bleeding; secondary outcomes included individual bleeding events. A multivariate analysis was conducted to identify risk factors affecting the occurrence of clinically relevant bleeding events. RESULTS The analysis population comprised 5695 patients [3530 received DOACs and 2165 received vitamin K antagonists (VKAs)]. The incidence of primary outcome events (clinically relevant bleeding/100 patient-years) was 6.05 in the DOAC group and 8.42 in the VKA group, resulting in a nonsignificant 21% lower risk in the DOAC group. The DOAC group also had a nonsignificant 24%, 24%, and 34% lower risk of bleeding requiring transfusion, intracranial bleeding, and lower gastrointestinal bleeding, respectively, compared with the VKA group. A multivariate analysis of the primary outcome showed a significantly higher risk of bleeding among older patients and those with lower body weight and abnormal renal function. CONCLUSIONS In this retrospective real-world evaluation of IHD patients with NVAF and PCI, DOAC-treated patients had a lower risk of developing clinically relevant bleeding compared with the VKA group.
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Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan.
| | | | - Akiko Hayakawa
- Safety and Risk Management Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Takuyuki Matsumoto
- Safety and Risk Management Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Atsushi Takita
- Biostatistics and Data Management Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Chie Hasegawa
- Pharmacovigilance Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Kazuhiro Uchino
- Post Marketing Study Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Toru Sekine
- Post Marketing Study Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Tomoko Iizuka
- Post Marketing Study Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Hirokazu Tanabe
- Safety and Risk Management Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Seiji Kogure
- Safety and Risk Management Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
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24
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Antithrombotic Therapy in Patients With Atrial Fibrillation and Coronary Artery Disease Undergoing Percutaneous Coronary Intervention. J Cardiovasc Pharmacol 2020; 74:82-90. [PMID: 31306367 DOI: 10.1097/fjc.0000000000000697] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AIM The objective of this article is to review the contemporary literature on the use of antithrombotic therapy in patients with atrial fibrillation (AF) and coronary artery disease after undergoing percutaneous coronary intervention (PCI). Special consideration was given to the type and duration of therapy, treatment strategies for the elderly (≥65 years of age), and strategies to reduce bleeding. METHODS Relevant studies were searched through MEDLINE/PubMed, Web of Science, Cochrane Library, ClinicalTrials.gov, and Google Scholar. Of the 236 publications retrieved, 76 were considered relevant including 35 randomized controlled trials, 17 meta-analyses, 16 observational studies, and 8 published major guidelines. RESULTS Most trials, meta-analyses, and guidelines support 1 month of triple therapy (TT) with an oral anticoagulant (OAC), dual antiplatelet agents (DAPT) with aspirin (ASA)/clopidogrel, and, afterward, dual therapy (DT) with OAC and single antiplatelet agent for an additional 11 months, or alternatively DT alone for 12 months after PCI. Individual consideration is given to the risk and impact of stent thrombosis (ST), thromboembolism, and bleeding. Several trials and meta-analyses have also suggested that shorter DAPT duration (≤6 months) may be safer than longer therapy (≥6 months) when weighing the risk of bleeding with ischemic outcomes, especially with newer generation drug-eluting stents. The selective use of proton-pump inhibitors in patients prone to gastrointestinal bleeding who are subjected to prolonged exposure with TT or DT may be beneficial. In the elderly, the risk of bleeding from TT, compared with DT, outweighs the benefit of reducing ischemic events. CONCLUSIONS In conclusion, tailoring therapy to the individual patient is recommended considering the ischemic and bleeding risk as well as the risk of thromboembolism. For most patients with AF, 1 month of TT and subsequently DT for additional 11 months are recommended.
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25
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Santoso A, Raharjo SB. Combination of Oral Anticoagulants and Single Antiplatelets versus Triple Therapy in Nonvalvular Atrial Fibrillation and Acute Coronary Syndrome: Stroke Prevention among Asians. Int J Angiol 2020; 29:88-97. [PMID: 32499669 DOI: 10.1055/s-0040-1708477] [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: 10/24/2022] Open
Abstract
Atrial fibrillation (AF), the most prevalent arrhythmic disease, tends to foster thrombus formation due to hemodynamic disturbances, leading to severe disabling and even fatal thromboembolic diseases. Meanwhile, patients with AF may also present with acute coronary syndrome (ACS) and coronary artery disease (CAD) requiring stenting, which creates a clinical dilemma considering that majority of such patients will likely receive oral anticoagulants (OACs) for stroke prevention and require additional double antiplatelet treatment (DAPT) to reduce recurrent cardiac events and in-stent thrombosis. In such cases, the gentle balance between bleeding risk and atherothromboembolic events needs to be carefully considered. Studies have shown that congestive heart failure, hypertension, age ≥ 75 years (doubled), diabetes mellitus, and previous stroke or transient ischemic attack (TIA; doubled)-vascular disease, age 65 to 74 years, sex category (female; CHA 2 DS 2 -VASc) scores outperform other scoring systems in Asian populations and that the hypertension, abnormal renal/liver function (1 point each), stroke, bleeding history or predisposition, labile international normalized ratio (INR), elderly (>65 years), drugs/alcohol concomitantly (1 point each; HAS-BLED) score, a simple clinical score that predicts bleeding risk in patients with AF, particularly among Asians, performs better than other bleeding scores. A high HAS-BLED score should not be used to rule out OAC treatment but should instead prompt clinicians to address correctable risk factors. Therefore, the current review attempted to analyze available data from patients with nonvalvular AF who underwent stenting for ACS or CAD and elaborate on the direct-acting oral anticoagulant (DOAC) and antiplatelet management among such patients. For majority of the patients, "triple therapy" comprising OAC, aspirin, and clopidogrel should be considered for 1 to 6 months following ACS. However, the optimal duration for "triple therapy" would depend on the patient's ischemic and bleeding risks, with DOACs being obviously safer than vitamin-K antagonists.
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Affiliation(s)
- Anwar Santoso
- Department of Cardiology-Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.,National Cardiovascular Centre, Harapan Kita Hospital, Jakarta, Indonesia
| | - Sunu B Raharjo
- Department of Cardiology-Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.,National Cardiovascular Centre, Harapan Kita Hospital, Jakarta, Indonesia
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Kozieł M, Potpara TS, Lip GYH. Triple therapy in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention/stenting. Res Pract Thromb Haemost 2020; 4:357-365. [PMID: 32211570 PMCID: PMC7086461 DOI: 10.1002/rth2.12319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 11/25/2022] Open
Abstract
Patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) are at high risk of stroke, recurrent coronary ischemic events, and cardiovascular mortality. The composition of antithrombotic therapy including an oral anticoagulant and antiplatelet drug(s) should be tailored according to the individual patient's risk profile, to reduce the bleeding risk and maintain antithrombotic effect. There is no single antithrombotic treatment regimen that would fit to all patients with AF and ACS. However, available data promote the use of full-dose direct oral anticoagulants (DOACs) (dabigatran 150 mg twice daily or apixaban 5 mg twice daily) or rivaroxaban 15 mg once daily in patients with AF and ACS or percutaneous coronary intervention (PCI). For many patients, a DOAC plus P2Y12 inhibitor early after ACS and/or PCI would be optimal, whereas a longer course of triple therapy should be used in patients at high thrombotic risk.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
- Division of Medical Sciences in ZabrzeDepartment of CardiologyCongenital Heart Diseases and ElectrotherapyMedical University of SilesiaKatowicePoland
| | - Tatjana S. Potpara
- Cardiology ClinicClinical Center of SerbiaBelgradeSerbia
- School of MedicineBelgrade UniversityBelgradeSerbia
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
- Division of Medical Sciences in ZabrzeDepartment of CardiologyCongenital Heart Diseases and ElectrotherapyMedical University of SilesiaKatowicePoland
- School of MedicineBelgrade UniversityBelgradeSerbia
- Aalborg Thrombosis Research UnitDepartment of Clinical MedicineAalborg UniversityAalborgDenmark
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Barnes GD, Spranger E, Sippola E, Renner E, Ruff A, Sales AE, Kurlander JE. Assessment of a Best Practice Alert and Referral Process for Preprocedure Antithrombotic Medication Management for Patients Undergoing Gastrointestinal Endoscopic Procedures. JAMA Netw Open 2020; 3:e1920548. [PMID: 32022882 PMCID: PMC7416616 DOI: 10.1001/jamanetworkopen.2019.20548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Management of antithrombotic medications presents a challenge for many clinicians and patients before procedures. Anticoagulation clinic involvement may improve preprocedure coordination, satisfaction on the part of patients and clinicians, last-minute procedure cancellations, and patient safety. OBJECTIVE To assess the implementation of an electronic medical record (EMR) best practice alert (BPA) and anticoagulation clinic referral process to assist with management of antithrombotic medication before gastrointestinal endoscopic procedures. DESIGN, SETTING, AND PARTICIPANTS This multimodal evaluation of a quality improvement intervention using EMRs and survey data included patients using oral antithrombotic medications who were scheduled for elective gastrointestinal endoscopic procedures at an academic medical center along with the clinicians who ordered these procedures. Data were collected from November 1, 2017, through December 19, 2018. Data were analyzed in September 2019. EXPOSURES Following a multidisciplinary intervention, a BPA and referral process for periprocedural antithrombotic medication management was implemented in November 2017. MAIN OUTCOMES AND MEASURES The following implementation outcomes were assessed through EMR review and surveys through December 2018: use of BPAs, patient and clinician satisfaction with preprocedure anticoagulation management, procedure cancelation rates, reach, and spread by patient and clinician characteristics. Multilevel logistic regression was used to estimate variance in BPA use at the clinician level. RESULTS A total of 2082 patients (mean [SD] age, 64.1 [11.9] years) and 144 clinicians were included in the analysis. The BPA was used broadly across the health system, resulting in anticoagulation clinic referral for 1389 patients (66.7%). Referral was more common for patients using anticoagulant vs antiplatelet medications (1041 of 1524 [68.3%] vs 346 of 556 [62.2%]; adjusted odds ratio [aOR], 1.51; 95% CI, 1.15-1.98) and for procedures ordered by gastroenterologists vs primary care clinicians (933 of 1241 [75.2%] vs 365 of 618 [59.1%]; aOR, 2.15; 95% CI, 1.46-3.17). Individual clinician behavior patterns explained 26.5% (95% CI, 18.7%-36.1%) of variation in anticoagulation clinic referrals. Implementation of the intervention was associated with high patient satisfaction and improvements in multidimensional measures of clinician satisfaction (clinician response rate, 44.2% [144 of 326]). In multivariable analysis, the odds of altered or canceled procedures because of medication mismanagement declined after implementation (8 of 50 [16.0%] vs 1 of 52 [1.9%]; aOR, 0.11; 95% CI, 0.01-0.96; P = .02). CONCLUSIONS AND RELEVANCE A newly implemented BPA and anticoagulation clinic referral process was broadly adopted and used, had high satisfaction by patients and clinicians, and was associated with fewer disruptions to planned procedures caused by medication mismanagement.
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Affiliation(s)
- Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Center for Bioethics and Social Science in Medicine, University of Michigan, Ann Arbor
| | - Elizabeth Spranger
- Quality and Continuous Improvement, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Emily Sippola
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor
- Center for Bioethics and Social Science in Medicine, University of Michigan, Ann Arbor
| | - Elizabeth Renner
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Allison Ruff
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Anne E Sales
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Learning Health Sciences, University of Michigan, Ann Arbor
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Jacob E Kurlander
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of Gastroenterology, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor
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Mai L, Wu Y, Luo J, Liu X, Zhu H, Zheng H, Liang G, Zhang Y, Huang Y. A retrospective cohort study of oral anticoagulant treatment in patients with acute coronary syndrome and atrial fibrillation. BMJ Open 2019; 9:e031180. [PMID: 31530618 PMCID: PMC6756322 DOI: 10.1136/bmjopen-2019-031180] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To examine the real-world patterns of oral anticoagulant (OAC) therapy in patients with acute coronary syndrome (ACS) and atrial fibrillation (AF) in Southern China undergoing percutaneous coronary intervention (PCI) and determine the clinical characteristics associated with OAC prescription. DESIGN A retrospective cohort study. SETTING This study was conducted in the Shunde Hospital, Southern Medical University and the second hospital of Zhaoqing, China, from January 2013 to 31 December 2018. PARTICIPANTS Patients were aged ≥18 years, hospitalised for ACS and received PCI treatment. OUTCOME MEASURES AF was diagnosed based on an ECG recording or a Holter monitor. Prescription of OACs and antiplatelets were determined from the discharge medication list. RESULTS A total of 3612 patients with ACS were included: 286 (7.9%) were diagnosed with AF, including 45 (1.2%) with paroxysmal AF, 227 (6.3%) with persistent/permanent AF and 14 (0.4%) with unclassified AF. Although 95.5% of patients with AF were at high risk (CHA2DS2-VASc score ≥2) of stroke, only 21.7% of them were discharged on OACs (10.5% received warfarin and 11.2% received non-vitamin K antagonist OACs). Patients with pre-admission use of OAC, a HAS-BLED score <3, with persistent/permanent AF were more likely to receive OAC treatment at discharge. CONCLUSION We found that approximately 8% of patients who underwent PCI during ACS hospitalisation also demonstrated AF. Anticoagulant therapy was greatly underused. Patients with paroxysmal AF and an increased risk of bleeding were less likely to receive anticoagulant treatment. Further efforts should be made to increase the adherence to guideline recommendations for OACs.
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Affiliation(s)
- Linlin Mai
- Department of Cardiology, Shunde Hospital, Southern Medical University (The first people's hospital of Shunde), Foshan, China
| | - Yu Wu
- Department of Cardiology, Shunde Hospital, Southern Medical University (The first people's hospital of Shunde), Foshan, China
| | - Jianjing Luo
- Department of Cardiology, Shunde Hospital, Southern Medical University (The first people's hospital of Shunde), Foshan, China
- Department of Cardiology, The Second Hospital of Zhaoqing, Zhaoqing, China
| | - Xinyue Liu
- Department of Cardiology, Shunde Hospital, Southern Medical University (The first people's hospital of Shunde), Foshan, China
| | - Hailan Zhu
- Department of Cardiology, Shunde Hospital, Southern Medical University (The first people's hospital of Shunde), Foshan, China
| | - Haoxiao Zheng
- Department of Cardiology, Shunde Hospital, Southern Medical University (The first people's hospital of Shunde), Foshan, China
| | - Guoquan Liang
- Department of Cardiology, The Second Hospital of Zhaoqing, Zhaoqing, China
| | - Yan Zhang
- Department of Cardiology, Shunde Hospital, Southern Medical University (The first people's hospital of Shunde), Foshan, China
| | - Yuli Huang
- Department of Cardiology, Shunde Hospital, Southern Medical University (The first people's hospital of Shunde), Foshan, China
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Olivier CB, Fan J, Askari M, Mahaffey KW, Heidenreich PA, Perino AC, Leef GC, Ho PM, Harrington RA, Turakhia MP. Site Variation and Outcomes for Antithrombotic Therapy in Atrial Fibrillation Patients After Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2019; 12:e007604. [DOI: 10.1161/circinterventions.118.007604] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Patients with atrial fibrillation (AF) treated with percutaneous coronary intervention (PCI) require multiple antithrombotic therapies. The optimal strategy is debated suggesting increased treatment variation. This study sought to characterize site-level variation in antithrombotic therapies in AF patients after PCI and determine the association with outcomes.
Methods:
Using the retrospective TREAT-AF study (The Retrospective Evaluation and Assessment of Therapies in AF) from the Veterans Health Administration, patients with newly diagnosed, nonvalvular AF between 2004 and 2015 followed by a PCI with a P2Y
12
-antagonist prescription were identified. Patients were grouped according to the therapy dispensed 7 days before until 30 days after the PCI: oral anticoagulation plus platelet inhibition (OAC+PI) or platelet inhibition only. A combined outcome of death, myocardial infarction, stroke, or major bleeding was assessed 1 year after PCI and Cox regression was performed to estimate hazard ratios.
Results:
Of 230 762 patients with newly diagnosed AF, 4042 (1.8%) underwent PCI and received a P2Y
12
-antagonist during the observation period (age, 67±9 years; CHA
2
DS
2
-VASc, 2.7±1.7; HAS-BLED, 2.6±1.2). Among these, 47% were prescribed OAC+PI, and 53% platelet inhibition only 7 days before until 30 days after the PCI. Across 63 sites, the use of OAC+PI ranged from 19% to 66%. Prescription of OAC+PI was independently associated with a reduction in the combined outcome of death, myocardial infarction, stroke, or major bleeding compared with platelet inhibition only (adjusted hazard ratio, 0.85; 95% CI, 0.73–0.99;
P
=0.033).
Conclusions:
In patients with established AF undergoing PCI, the use of OAC+PI varied substantially across sites in the 30 days post-PCI. Anticoagulation appeared to be underutilized but was associated with improved outcomes. Strategies to promote OAC+PI and minimize site variation may be useful, particularly in light of recent randomized trials.
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Affiliation(s)
- Christoph B. Olivier
- Department of Medicine, Stanford Center for Clinical Research (C.B.O., K.W.M.), Stanford University School of Medicine, CA
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Germany (C.B.O.)
| | - Jun Fan
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, CA (J.F., M.A., P.A.H., A.C.P., G.C.L., M.P.T.)
| | - Mariam Askari
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, CA (J.F., M.A., P.A.H., A.C.P., G.C.L., M.P.T.)
| | - Kenneth W. Mahaffey
- Department of Medicine, Stanford Center for Clinical Research (C.B.O., K.W.M.), Stanford University School of Medicine, CA
| | - Paul A. Heidenreich
- Department of Medicine (P.A.H., A.C.P., G.C.L., R.A.H., M.P.T.), Stanford University School of Medicine, CA
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, CA (J.F., M.A., P.A.H., A.C.P., G.C.L., M.P.T.)
| | - Alexander C. Perino
- Department of Medicine (P.A.H., A.C.P., G.C.L., R.A.H., M.P.T.), Stanford University School of Medicine, CA
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, CA (J.F., M.A., P.A.H., A.C.P., G.C.L., M.P.T.)
| | - George C. Leef
- Department of Medicine (P.A.H., A.C.P., G.C.L., R.A.H., M.P.T.), Stanford University School of Medicine, CA
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, CA (J.F., M.A., P.A.H., A.C.P., G.C.L., M.P.T.)
| | - P. Michael Ho
- Division of Cardiology, Denver VA Medical Center, CO (P.M.H.)
| | - Robert A. Harrington
- Department of Medicine (P.A.H., A.C.P., G.C.L., R.A.H., M.P.T.), Stanford University School of Medicine, CA
- Department of Medicine, Center for Digital Health (R.A.H., M.P.T.), Stanford University School of Medicine, CA
| | - Mintu P. Turakhia
- Department of Medicine (P.A.H., A.C.P., G.C.L., R.A.H., M.P.T.), Stanford University School of Medicine, CA
- Department of Medicine, Center for Digital Health (R.A.H., M.P.T.), Stanford University School of Medicine, CA
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, CA (J.F., M.A., P.A.H., A.C.P., G.C.L., M.P.T.)
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Rossini R, Quadri G, Rognoni A, Nardi F, Varbella F, Musumeci G. Use of DOACs in real-world challenging settings: a Delphi Consensus from Italian cardiologists. Minerva Cardioangiol 2019; 67:361-373. [PMID: 31343145 DOI: 10.23736/s0026-4725.19.04985-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) represent the first therapeutic option for stroke prevention in patients with non-valvular atrial fibrillation (AF). However, phase 3 trials that demonstrated higher safety and at least similar efficacy of DOACs compared to Warfarin, included a selected population, not entirely representative of real-world. The present Consensus document was aimed at overcoming the uncertainties about DOAC use in challenging setting where data are conflicting or sparse or where a gap between trials and real world exists. METHODS The Delphi method was used to achieve consensus on DOAC use in AF patients throughout 104 Cardiologists in Piedmont, Italy. A questionnaire on 6 commonly encountered clinical settings was administered: 1) the elderly; 2) the "frail" patient; 3) interactions with food/drugs; 4) low-dosages; 5) cancer patients; 6) patients with acute coronary syndrome. RESULTS DOAC use over Warfarin was investigated in the elderly population, in the frail patients and in those with cancer, and clinical consensus was reached on its preferential use. Drug interactions should always be considered when a DOAC is prescribed and dosage should respect the Summary of Product Characteristics. No consensus was reached in patients with severe renal impairment and in those with dynamic clinical characteristics ("borderline patients"). DOACs should be considered as the first-line anticoagulation therapy in patients with high intracranial bleeding risk. CONCLUSIONS DOACs should represent the first-line anticoagulation therapy in non-valvular AF patients in the majority of challenging settings, underexplored by literature. Caution in their prescription is needed in case of severe renal impairment. Dose choice should follow the SmPC, although this is matter of debate in borderline patients.
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Affiliation(s)
- Roberta Rossini
- Division of Cardiology, S. Croce e Carle Hospital, Cuneo, Italy
| | - Giorgio Quadri
- Division of Cardiology, Degli Infermi Hospital, Rivoli, Turin, Italy -
| | - Andrea Rognoni
- Division of Cardiology, Maggiore della Carità Hospital, Novara, Italy
| | - Federico Nardi
- Division of Cardiology, Santo Spirito Hospital, Casale Monferrato, Alessandria, Italy
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Triple, dual, and single antithrombotic therapy for patients with atrial fibrillation undergoing percutaneous coronary intervention. Cardiovasc Interv Ther 2019; 35:44-51. [PMID: 31281936 DOI: 10.1007/s12928-019-00600-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 06/21/2019] [Indexed: 12/21/2022]
Abstract
In patients with atrial fibrillation (AF), concomitant coronary artery disease is often present, and vice versa. Although both AF and coronary artery disease need antithrombotic therapy to reduce ischemic events, optimal antithrombotic regimens for patients with AF undergoing percutaneous coronary intervention (PCI) remain unclear. Triple therapy, a combination of oral anticoagulant plus dual antiplatelet therapy with aspirin and P2Y12 inhibitor, has been used for patients with AF undergoing PCI as an initial antithrombotic strategy in the recent decade. However, triple therapy is well-known to induce severe bleeding events. Recently, several clinical trials have been published and guideline recommendations have been updated. This review article summarizes current evidence concerning antithrombotic therapy in patients with AF undergoing PCI.
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Treatment of atrial fibrillation with concomitant coronary or peripheral artery disease: Results from the outcomes registry for better informed treatment of atrial fibrillation II. Am Heart J 2019; 213:81-90. [PMID: 31129441 DOI: 10.1016/j.ahj.2019.04.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 04/13/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Treatment patterns and outcomes of individuals with vascular disease who have new-onset atrial fibrillation (AF) are not well characterized. METHODS Among patients with new-onset AF, we analyzed treatment and outcomes in those with or without vascular disease in the ORBIT-AF II registry. Vascular disease was defined as coronary disease with or without myocardial infarction (MI) or revascularization, or peripheral artery disease. The primary outcomes included major adverse cardiovascular or neurological events (MACNE) and major bleeding. Cox proportional hazard models were used to adjust the difference in patient characteristics. RESULTS Overall 1920 of 6203 (31.0%) of new-onset AF had vascular disease. In patients with vascular disease, 62.2% of those were treated with direct oral anticoagulants (DOACs) and 23.4% with warfarin. Dual therapy and triple therapy were used in 36.9% and 4.9%, respectively. Vascular disease patients had increased risk of MACNE (adjusted hazard ratio [aHR] 1.83 [95%CIs 1.32-2.55]), but not major bleeding (aHR 1.24 [0.95-1.63]). Among patients with vascular disease, relative to those on warfarin, those treated with DOACs had similar risk for MACNE (aHR 1.20 [0.77-1.87]) but lower risks for bleeding, although it did not reach statistical significance (aHR 0.70 [0.43-1.15]). Concomitant antiplatelet therapy was associated with higher bleeding (aHR 2.27 [1.38-3.73]) with no apparent reduction in MACNE (aHR 1.50 [1.00-2.25]). CONCLUSIONS Most patients with AF and vascular disease were managed with oral anticoagulation. About half of them were also treated with concomitant antiplatelet therapy, which was associated with increased risk of bleeding, without evidence of improved cardiovascular outcomes.
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Alamri Y. Higher bleeding rates in patients taking rivaroxaban following an embolic stroke of undetermined source. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yassar Alamri
- Canterbury District Health Board Christchurch New Zealand
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34
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Rychkov AY, Khorkova NY. [Antithrombotic Therapy in Atrial Fibrillation and Chronic Ischemic Heart Disease]. ACTA ACUST UNITED AC 2019; 59:80-86. [PMID: 31131772 DOI: 10.18087/cardio.2019.5.n493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 05/25/2019] [Indexed: 11/18/2022]
Abstract
The review is devoted to the use of antithrombotic therapy in patients with atrial fibrillation (AF) and chronic ischemic heart disease (IHD). We discuss data of international registries, meta-analyses assessing possibilities of the use of oral anticoagulants for secondary prevention of IHD. We present here results of randomized and observational clinical studies demonstrating advantages of prescription of monotherapy with oral anticoagulants (OAC) in combination of AF and chronic IHD. Modern evidence base of advantages of dual antithrombotic therapy with the use of direct OAC following percutaneous coronary intervention is also presented.
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Affiliation(s)
- A Yu Rychkov
- Tyumen Cardiology Research Center; Tomsk National Research Medical Center, Russian Academy of Science
| | - N Yu Khorkova
- Tyumen Cardiology Research Center; Tomsk National Research Medical Center, Russian Academy of Science
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Douros A, Renoux C, Yin H, Filion KB, Suissa S, Azoulay L. Concomitant Use of Direct Oral Anticoagulants with Antiplatelet Agents and the Risk of Major Bleeding in Patients with Nonvalvular Atrial Fibrillation. Am J Med 2019; 132:191-199.e12. [PMID: 30691551 DOI: 10.1016/j.amjmed.2018.10.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 10/12/2018] [Accepted: 10/15/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Patients with nonvalvular atrial fibrillation commonly have comorbidities requiring concurrent use of oral anticoagulants and antiplatelets. There are no real-world data on the comparative safety of concomitant antithrombotic treatments in the era of direct oral anticoagulant (DOACs). Thus, we compared the incidence of intracranial hemorrhage, gastrointestinal bleeding, and other major bleeding between concomitant DOAC-antiplatelet use and concomitant vitamin K antagonist (VKA)-antiplatelet use in patients with nonvalvular atrial fibrillation. METHODS Using computerized health care databases from Québec, we conducted a cohort study among patients newly diagnosed with nonvalvular atrial fibrillation between January 2011 and March 2014. Cox proportional hazards models yielded hazard ratios (HRs) and 95% confidence intervals (CIs), adjusted for disease risk score, of the study outcomes comparing current concomitant use of DOACs with ≥1 antiplatelet vs current concomitant use of VKAs with ≥1 antiplatelet. RESULTS A total of 5301 patients initiated concomitant DOAC-antiplatelet use, while 9106 patients initiated concomitant VKA-antiplatelet use. During a median follow-up of 1.6 months, concomitant DOAC-antiplatelet use was associated with a similar risk of gastrointestinal bleeding (HR 1.08; 95% CI, 0.81-1.45), but with a decreased risk of intracranial hemorrhage (HR 0.46; 95% CI, 0.24-0.91) and other major bleeding (HR 0.68; 95% CI, 0.51-0.91) compared with concomitant VKA-antiplatelet use. CONCLUSIONS Concomitant DOAC-antiplatelet use was associated with a similar risk of gastrointestinal bleeding, and a lower risk of intracranial hemorrhage and other major bleeding than concomitant VKA-antiplatelet use. These findings could inform physician decision-making in patients requiring concomitant treatment with oral anticoagulants and antiplatelets.
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Affiliation(s)
- Antonios Douros
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Institute of Clinical Pharmacology and Toxicology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christel Renoux
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Hui Yin
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Kristian B Filion
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada.
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Gibson CM, Nafee T, Kerneis M. Conundrum of Using Real-World Observational Data to Inform Real-World Conclusions About Safety and Efficacy. J Am Coll Cardiol 2018; 72:1801-1803. [DOI: 10.1016/j.jacc.2018.07.053] [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: 07/17/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
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