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Bonaca MP, Barnes GD, Bauersachs R, Bessada Y, Conte MS, Dua A, Hess CN, Serhal M, Mena-Hurtado C, Weitz JI, Beckman JA. Antithrombotic Strategies for Patients With Peripheral Artery Disease: JACC Scientific Statement. J Am Coll Cardiol 2024; 84:936-952. [PMID: 39197984 DOI: 10.1016/j.jacc.2024.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 06/06/2024] [Accepted: 06/21/2024] [Indexed: 09/01/2024]
Abstract
Patients with peripheral artery disease (PAD) experience major cardiovascular and limb events. Antithrombotic strategies including antiplatelets and anticoagulants remain a cornerstone of treatment and prevention. Recent trials have shown heterogeneity in the response to antithrombotic therapies in patients presenting primarily with PAD when compared to those presenting primarily with coronary artery disease. In addition, there is observed heterogeneity with regards to the effects of antiplatelets and anticoagulants with respect to different outcomes including cardiovascular and major adverse limb events. This, coupled with risks of bleeding, requires a patient-centered and holistic assessment of benefit-risk when selecting antithrombotic strategies for patients with PAD. A global multidisciplinary work group was convened to evaluate antithrombotic strategies in PAD and to summarize the current state of the art. Common clinical scenarios around antithrombotic decision making were provided. Finally, insights with regard to implementation future investigation were described.
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Affiliation(s)
- Marc P Bonaca
- CPC Clinical Research, Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA.
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Rupert Bauersachs
- Cardioangiology Center Bethanien, Frankfurt, Germany, and the Center for Vascular Research, Munich, Germany
| | - Youssef Bessada
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
| | - Michael S Conte
- Vascular Surgery and Center for Limb Preservation, University of California-San Francisco, San Francisco, California, USA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Connie N Hess
- CPC Clinical Research, Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Maya Serhal
- Cardiovascular Division, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Department of Internal Medicine, Section of Cardiology, Yale University, New Haven, Connecticut, USA
| | - Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Joshua A Beckman
- Vascular Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
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2
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Cohen M, Jones C. Patient and Physician Perspectives on the Benefits and Risks of Antiplatelet Therapy for Acute Coronary Syndrome. Cardiol Ther 2024; 13:631-643. [PMID: 38907182 PMCID: PMC11333664 DOI: 10.1007/s40119-024-00372-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 05/30/2024] [Indexed: 06/23/2024] Open
Abstract
This article is co-authored by a patient with acute coronary syndrome (ACS) who is receiving long-term antiplatelet therapy in the USA and a cardiologist who routinely treats patients with ACS. The patient describes his experience from diagnosis to the present day and discusses his concerns regarding treatment and management of the condition, including the balance between the benefits and risks of antiplatelet therapy. The patient also describes his work as an advocate for cardiac health. The physician perspective on treating and managing patients with ACS is provided by a cardiologist based in the USA who is and was not involved in this patient's care. The physician reviews the benefits and risks of antiplatelet therapies for the treatment of patients with ACS and discusses his own clinical experience of managing these patients, including how issues such as treatment adherence, as well as the potential inertia to prescribing certain medications that may be seen among physicians, could be overcome.
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Affiliation(s)
- Marc Cohen
- Newark Beth Israel Medical Center, 201 Lyons Avenue at Osborne Terrace, Newark, NJ, USA.
- Rutgers New Jersey Medical School, Medical Science Building, 185 South Orange Avenue, Newark, NJ, USA.
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3
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Eikelboom JW, Yi Q, McIntyre WF, Bosch J, Whitlock R, Connolly SJ, Scheier TC, Muehlhofer E, Pap ÁF, Pocock SJ, Bangdiwala SI. Results of the COMPASS Trial Analyzed Using Win Ratio Compared With Conventional Analytic Approaches. Can J Cardiol 2024:S0828-282X(24)00522-1. [PMID: 39002945 DOI: 10.1016/j.cjca.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/21/2024] [Accepted: 07/04/2024] [Indexed: 07/15/2024] Open
Abstract
BACKGROUND Win ratio (WR) is a newer analytic approach for trials with composite end points that accounts for the relative importance of individual components. Our objective was to compare the results of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial analyzed using WR with those obtained using conventional statistical approaches. METHODS We used an unmatched WR analysis for first and total (first plus recurrent) events to examine effects of rivaroxaban with aspirin and rivaroxaban alone vs aspirin alone on primary efficacy (cardiovascular death, stroke, myocardial infarction), safety (modified International Society on Thrombosis and Haemostasis major bleeding), and net clinical benefit (primary efficacy plus fatal or critical organ bleeding) end points. We compared the WR results with those obtained using the Cox proportional hazards regression model for first events and Anderson-Gill method for total events. We calculated the win difference to estimate absolute treatment effects. RESULTS The WR approach produced results consistent with those obtained using conventional statistical methods for the primary composite end point (first event: WR, 1.32 [95% confidence interval (CI), 1.14-1.52]; 1/Cox hazard ratio, 1.32 [95% CI, 1.16-1.52]; total [first plus recurrent] events: WR, 1.32 [95% CI, 1.14-1.52]; 1/Anderson-Gill hazard ratio, 1.32 [95% CI, 1.16-1.54]) as well as for main safety and net clinical benefit end points. The absolute benefits of the combination of rivaroxaban and aspirin compared with aspirin alone calculated using the win difference were greatest in those with multiple high-risk features. CONCLUSIONS Reanalysis of the COMPASS trial results using WR produced results that were consistent with those obtained using conventional statistical approaches. CLINICAL TRIAL REGISTRATION NCT01776424.
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Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Qilong Yi
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jacqueline Bosch
- Population Health Research Institute, Hamilton, Ontario, Canada; School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Richard Whitlock
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Shrikant I Bangdiwala
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Chilbert MR, Woodruff AE, Rogers KC. A Practical Guide to Understanding and Treating Peripheral Artery Disease. J Cardiovasc Pharmacol 2024; 83:565-579. [PMID: 38452186 DOI: 10.1097/fjc.0000000000001556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 02/20/2024] [Indexed: 03/09/2024]
Abstract
ABSTRACT Peripheral arterial disease (PAD) is the third leading cause of atherosclerotic morbidity after coronary heart disease and stroke yet is widely underdiagnosed and undertreated. Treatment of risk factors such as diabetes and cigarette smoking can benefit patients with PAD. Patients should have adequate blood pressure and lipid control to decrease clinical manifestations and symptoms of PAD. Use of antithrombotic medications should be individualized to the patient depending on the presence of symptoms, revascularization, and comorbidities. All patient care providers, including physicians, pharmacists, nurse practitioners, and physician assistants, should incorporate PAD screening in their at-risk patients to improve access for appropriate earlier diagnosis, initiation of guideline directed therapy, and risk factor modification to reduce both major adverse CV and limb outcomes. The purpose of this narrative review is to provide an overview of PAD and summarize clinical trial evidence and guideline recommendations for screening and treatment to increase awareness among health care providers to ultimately have a positive impact on patient care.
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Affiliation(s)
- Maya R Chilbert
- Department of Pharmacy, University at Buffalo, School of Pharmacy and Pharmaceutical Sciences, Buffalo General Medical Center; and
| | - Ashley E Woodruff
- Department of Pharmacy, University at Buffalo, School of Pharmacy and Pharmaceutical Sciences, Buffalo General Medical Center; and
| | - Kelly C Rogers
- The University of Tennessee Health Science Center College of Pharmacy
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Scierka LE, Peri-Okonny PA, Romain G, Cleman J, Spertus JA, Fitridge R, Secemsky E, Patel MR, Gosch KL, Mena-Hurtado C, Smolderen KG. Psychosocial and socioeconomic factors are most predictive of health status in patients with claudication. J Vasc Surg 2024; 79:1473-1482.e5. [PMID: 38266885 PMCID: PMC11180544 DOI: 10.1016/j.jvs.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 01/12/2024] [Accepted: 01/17/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND As a key treatment goal for patients with symptomatic peripheral artery disease (PAD), improving health status has also become an important end point for clinical trials and performance-based care. An understanding of patient factors associated with 1-year PAD health status is lacking in patients with PAD. METHODS The health status of 1073 consecutive patients with symptomatic PAD in the international multicenter PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry was measured at baseline and 1 year with the Peripheral Artery Questionnaire (PAQ). The association of 47 patient characteristics with 1-year PAQ scores was assessed using a random forest algorithm. Variables of clinical significance were retained and included in a hierarchical multivariable linear regression model predicting 1-year PAQ summary scores. RESULTS The mean age of patients was 67.7 ± 9.3 years, and 37% were female. Variables with the highest importance ranking in predicting 1-year PAQ summary score were baseline PAQ summary score, Patient Health Questionnaire-8 depression score, Generalized Anxiety Disorder-2 anxiety score, new onset symptom presentation, insurance status, current or prior diagnosis of depression, low social support, initial invasive treatment, duration of symptoms, and race. The addition of 19 clinical variables in an extended model marginally improved the explained variance in 1-year health status (from R2 0.312 to 0.335). CONCLUSIONS Patients' 1-year PAD-specific health status, as measured by the PAQ, can be predicted from 10 mostly psychosocial and socioeconomic patient characteristics including depression, anxiety, insurance status, social support, and symptoms. These characteristics should be validated and tested in other PAD cohorts so that this model can inform risk adjustment and prediction of PAD health status in comparative effectiveness research and performance-based care.
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Affiliation(s)
- Lindsey E Scierka
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Poghni A Peri-Okonny
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Gaelle Romain
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Jacob Cleman
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO; Departments of Biomedical and Health Informatics and Internal Medicine, Section of Cardiovascular Disease, University of Missouri-Kansas City, Kansas City, MO
| | - Robert Fitridge
- Vascular Surgery, University of Adelaide, Adelaide, SA, Australia
| | - Eric Secemsky
- Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Kensey L Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT; Department of Psychiatry, Section of Psychology, Yale University, New Haven, CT.
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Oral anticoagulants and antiplatelet treatment in different settings. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:171-172. [PMID: 38563454 DOI: 10.1093/ehjcvp/pvae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 04/04/2024]
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Würtz M, Olesen KKW, Bhatt DL, Yusuf S, Muehlhofer E, Eikelboom JW, Maeng M. Net clinical benefit of extended dual pathway inhibition according to baseline risk in patients with chronic coronary syndrome: a COMPASS substudy. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:201-209. [PMID: 38453426 DOI: 10.1093/ehjcvp/pvae017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/29/2024] [Accepted: 03/05/2024] [Indexed: 03/09/2024]
Abstract
AIMS Guidelines recommend extended dual pathway inhibition (DPI) with aspirin and rivaroxaban in patients with chronic coronary syndrome (CCS) at high ischaemic risk. The CHADS-P2A2RC score improves risk prediction and enables antithrombotic treatment allocation in these patients. This study evaluated the net clinical benefit of DPI treatment according to baseline risk as classified by the CHADS-P2A2RC score in patients with CCS included in the COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial. METHODS AND RESULTS COMPASS patients with CCS (n = 14 670), randomized to aspirin alone or DPI, were stratified according to cardiovascular risk using the CHADS-P2A2RC score. Endpoints were major adverse cardiovascular events (MACE), all-cause death, fatal/critical organ bleeding, and composite adverse events (MACE and bleeding). Net clinical benefit was the 30-month risk difference of MACE and bleeding. Thirty-month incidences of MACE [7.9% vs. 3.9%, hazard ratio (HR) 2.01, 95% confidence interval (CI) 1.83-2.18] and fatal/critical organ bleeding (1.2% vs. 0.8%, HR 1.49, 95% CI 1.06-1.92) were higher in high-risk (CHADS-P2A2RC ≥ 4) than in low/moderate-risk (CHADS-P2A2RC < 4) patients. DPI reduced MACE (low/moderate risk: HR 0.62, 95% CI 0.47-0.82; high risk: HR 0.82, 95% CI 0.68-0.99, P for interaction 0.09) and all-cause death (low/moderate risk: HR 0.65, 95% CI 0.46-0.91; high risk: HR 0.81, 95% CI 0.65-1.00, P for interaction 0.29), without substantially increasing fatal/critical organ bleeding (low/moderate risk: HR 1.35, 95% CI 0.72-2.53; high risk: HR 1.18, 95% CI 0.73-1.90, P for interaction 0.73). DPI provided net clinical benefit of similar magnitude in low/moderate-risk (-1.81%, 95% CI -3.00 to -0.62) and high-risk (-1.96%, 95% CI -3.60 to -0.33) CCS patients. CONCLUSION As classified by the CHADS-P2A2RC score, low/moderate- and high-risk patients with CCS derived similar net clinical benefit and reduction in all-cause death from DPI treatment.
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Affiliation(s)
- Morten Würtz
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus, Denmark
- Department of Cardiology, Regional Hospital Gødstrup, Hospitalsparken 15, DK-7400, Herning, Denmark
| | - Kevin Kris Warnakula Olesen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus, Denmark
- Department of Cardiology, Regional Hospital Gødstrup, Hospitalsparken 15, DK-7400, Herning, Denmark
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, USA
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, L8L 2X2 Ontario, Canada
| | - Eva Muehlhofer
- Research & Development, Bayer AG Pharmaceuticals, 42117 Wuppertal, Germany
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, L8L 2X2 Ontario, Canada
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, DK-8200, Aarhus, Denmark
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Breitenstein A, Gay A, Vogtländer K, Fox KAA, Steffel J. The Net Clinical Outcome of Dual-Pathway Inhibition in Clinical Practice: The "Xarelto plus Acetylsalicylic Acid: Treatment Patterns and Outcomes in Patients with Atherosclerosis" Registry. J Clin Med 2024; 13:1956. [PMID: 38610724 PMCID: PMC11012443 DOI: 10.3390/jcm13071956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/17/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Background: In the COMPASS trial, the combination of acetylsalicylic acid (ASA) plus 2.5 mg rivaroxaban twice daily (dual-pathway inhibition, DPI) has been shown to be superior to ASA monotherapy for the reduction in ischemic major adverse cardiovascular events (MACEs, i.e., cardiovascular death, stroke, or myocardial infarction). Methods: The international XATOA registry (Xarelto plus Acetylsalicylic acid: Treatment patterns and Outcomes in patients with Atherosclerosis) is a prospective post-approval registry that investigates the cardiovascular outcomes of patients taking ASA plus 2.5 mg rivaroxaban. The aim of this pre-specified analysis was to determine the net clinical outcome (NCO), i.e., a combination of MACEs and bleeding events, of DPI in patients from daily clinical practice. Results: Among the 5615 patients, the presence of multiple risk factors resulted in an increase in the total risk of experiencing an NCO event, e.g., from 1.27% (one risk factor) to 2.18% (two risk factors) and 4.07% (three or more risk factors), respectively, with ischemic MACE representing the primary driver of bleeding complications. Conclusions: In the real-world XATOA registry, the annual rate of NCO events was low and numerically similar to those seen in the treatment group in the randomized COMPASS trial.
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Affiliation(s)
- Alexander Breitenstein
- Department of Cardiology, University Hospital Zurich, 8091 Zurich, Switzerland;
- University of Zurich, 8006 Zurich, Switzerland
| | | | | | - Keith A. A. Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4TJ, UK;
| | - Jan Steffel
- University of Zurich, 8006 Zurich, Switzerland
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Anand SS, Aboyans V, Bosch J, Debus S, Gay A, Patel MR, Vogtländer K, Welsh RC, Zeymer U, Fox KAA. Identifying the highest risk vascular patients: Insights from the XATOA registry. Am Heart J 2024; 269:191-200. [PMID: 38218425 DOI: 10.1016/j.ahj.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND Patients with coronary and peripheral artery disease (PAD) have a residual risk of major adverse cardiovascular and limb events despite standards of care. Among patients with coronary artery disease (CAD) and/or PAD selected for low dose rivaroxaban (2.5 mg BID) and aspirin, we sought to determine the highest risk vascular patients. METHODS Xarelto pluc Acetylsalicylic acid: Treatment patterns and Outcomes in patients with Atherosclerosis (XATOA) is a single-arm registry of CAD and/or PAD patients. All participants were initiated on low dose rivaroxaban (2.5 mg BID) and aspirin. We report the incidence risk of major adverse cardiovascular events (MACE) or major adverse limb events (MALE) and major bleeding. A classification and regression tree analysis determined independent subgroups. RESULTS Between November 2018 and May 2020, 5,808 participants were enrolled in XATOA; 5,532 were included in the full analysis. The median follow-up (interquartile range) was 462 (371-577) days. The incidence risk per 100 patient-years of MACE or MALE was highest among participants with polyvascular disease (2 or more vascular beds affected, n = 2,889). The incidence risk was 9.16 versus 2.48 per 100 patient-years in polyvascular and nonpolyvascular patients respectively. Other subgroups of high-risk patients included participants 75 years or older, with a history of diabetes, heart failure, or chronic renal insufficiency (CRI). Rates of major bleeding were low overall. A classification and regression tree analysis showed that polyvascular disease was the most dominant factor separating higher from lower risk participants, and this was heightened with CRI or diabetes. CONCLUSION Patients with polyvascular disease represent a substantial subset of patients in clinical practice and should be prioritized to receive maximal medical therapy including low dose rivaroxaban (2.5 mg BID) and aspirin.
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Affiliation(s)
- Sonia S Anand
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and Inserm 1094/IRD270, Limoges University, Limoges, France
| | - Jackie Bosch
- Population Health Research Institute, Hamilton, Ontario, Canada; School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Robert C Welsh
- Mazankowski Alberta Heart Insitute and University of Alberta, Edmonton, Alberta, Canada
| | - Uwe Zeymer
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh United Kingdom
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10
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Li ZH, Zhong WF, Qiu CS, Yang P, Song WQ, Shen D, Zhang XR, Liu D, Chen YJ, Chen PL, Huang QM, Chen Q, Wang XM, Chung VCH, Gao X, Kraus VB, Liu SD, Mao C. Association between regular proton pump inhibitors use and cardiovascular outcomes: A large prospective cohort study. Int J Cardiol 2024; 395:131567. [PMID: 37935336 DOI: 10.1016/j.ijcard.2023.131567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 10/02/2023] [Accepted: 10/27/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are widely prescribed for gastroesophageal reflux disease and peptic ulcer disease. However, the association between the regular PPIs use and the risk of cardiovascular disease (CVD) outcomes remains unclear. We aimed to determine whether regular proton pump inhibitors (PPIs) use is associated with an altered incidence of cardiovascular disease (CVD) in the general population. METHODS This prospective cohort study included 459,207 participants (mean [SD] age, 56.2 [8.1] years) from the UK Biobank study without prevalent CVD who enrolled between 2006 and 2010 and were followed until 2018. Hazard ratios (HRs) and 95% confidence intervals (CIs) for incident CVD and its components (coronary heart disease [CHD], stroke, heart failure, atrial fibrillation, and venous thromboembolism) were obtained using Cox proportional hazards models with adjustment for potential confounding factors, including demographic factors, lifestyle behaviors, prevalent comorbidities, and clinical indicators for PPIs use. RESULTS During the follow-up period, we recorded 26,346 incident CVD events (including 13,749 CHD events, 4144 stroke events, 5812 atrial fibrillation events, 1159 heart failure events, and 4206 venous thromboembolism events). The fully adjusted HRs (and 95% CIs) associated with PPIs users compared to nonusers were 1.44 (95% CI 1.39-1.50) for incident CVD, 1.65 (95% CI 1.57-1.74) for CHD, 1.21 (95% CI 1.09-1.33) for stroke, 1.17 (95% CI 1.08-1.28) for atrial fibrillation, 1.61 (95% CI 1.37-1.89) for heart failure, and 1.36 (95% CI 1.24-1.50) for venous thromboembolism. CONCLUSIONS Regular PPIs use was associated with higher risk of CVD outcomes. Clinicians should therefore exercise caution when prescribing PPIs.
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Affiliation(s)
- Zhi-Hao Li
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Wen-Fang Zhong
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Cheng-Shen Qiu
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Pei Yang
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Wei-Qi Song
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Dong Shen
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Xi-Ru Zhang
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Dan Liu
- Department of Nutrition, School of Medicine, Jinan University, Guangzhou, Guangdong, China
| | - Ying-Jun Chen
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Pei-Liang Chen
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Qing-Mei Huang
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Qing Chen
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Xiao-Meng Wang
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Vincent C H Chung
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Xiang Gao
- Nutritional Epidemiology Laboratory, Pennsylvania State University, University Park, PA, USA
| | - Virginia Byers Kraus
- Duke Molecular Physiology Institute and Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Si-De Liu
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Chen Mao
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China; Microbiome Medicine Center, Department of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China.
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Shah A, Dabbous F, Shah S, Ashton V, Kharat A. Assessment of clinical and economic impact of rivaroxaban plus aspirin vs. aspirin alone as a secondary prophylaxis in patients with chronic and symptomatic peripheral arterial disease in the United States. J Med Econ 2024; 27:10-15. [PMID: 38044632 DOI: 10.1080/13696998.2023.2290386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/29/2023] [Indexed: 12/05/2023]
Abstract
AIM The objective in this study was to assess the clinical and economic implications of the inclusion of rivaroxaban as a secondary prophylaxis in patients with chronic or symptomatic peripheral artery disease (PAD) in the United States (US). METHODS A cost-consequence model was adapted to evaluate the economic impact of rivaroxaban plus aspirin in a hypothetical 1-million-member health plan. The model inputs were taken from multiple sources: efficacy and safety of rivaroxaban + aspirin vs. aspirin alone were abstracted from COMPASS and VOYAGER randomized clinical trials; the prevalence of chronic and symptomatic PAD and incidence rates of clinical events (major adverse cardiac events [MACE], major adverse limb events [MALE], and major bleeding), were abstracted from the analysis of claims data; healthcare costs of clinical events and wholesale acquisition costs for rivaroxaban were abstracted from the literature and Red Book, respectively (2022 USD). One-way sensitivity analyses and subgroup analyses were also conducted. RESULTS Over one year, with a 5% uptake of rivaroxaban, the model estimated rivaroxaban + aspirin to reduce 21 MACE/MALE events in the PAD patient population. The reduction in these clinical events offsets the increased risk of major bleeding (16 additional events), demonstrating a positive health benefit of the rivaroxaban addition. These benefits led to a $0.27 incremental cost per member per month (PMPM) to a US plan. The major driver of the incremental cost was the cost of rivaroxaban. In a subgroup of patients with the presence of any high-risk factor (heart failure, diabetes, renal insufficiency, or history of vascular disease affecting two or more vascular beds), the incremental PMPM cost was $0.13. CONCLUSIONS Rivaroxaban + aspirin was found to provide positive net clinical benefit on the annual number of MACE/MALE avoided, with a modest increase in the PMPM cost.
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12
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Desai U, Babcock A, Wang Y, Akbarnejad H, Lemus Wirtz E, Laliberte F, Lefebvre P, Kharat A. Real-World Incidence of Adverse Clinical Outcomes Among People With Coronary Artery Disease and/or Peripheral Artery Disease in Relation to Vascular Risk in the United States. Am J Cardiol 2023; 208:44-52. [PMID: 37812866 DOI: 10.1016/j.amjcard.2023.08.110] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 10/11/2023]
Abstract
Presence of polyvascular disease, diabetes, heart failure, or renal insufficiency in patients with chronic coronary artery disease (CAD) and peripheral artery disease (PAD) are associated with increased risks of adverse events, including major adverse cardiovascular events (MACEs) and major adverse limb events (MALEs). In this retrospective observational study using administrative claims data from Optum's deidentified Clinformatics Data Mart Database from January 2016 to September 2021, we described the incidence rates of MACEs, MALEs, and major thrombotic vascular events in patients with CAD or PAD stratified by the presence of risk factors (i.e., polyvascular disease, diabetes, heart failure, or renal insufficiency). A total of 1,435,241 patients (77% CAD and 34% PAD) met the inclusion and exclusion criteria. Patients with 0 risk factors were deemed the low-risk group (47%; n = 681,333) and patients with ≥1 risk factor were deemed the high-risk group (53%; n = 753,908). The mean age was 71.8 and 73.6 years, and 42% and 44% were female in the low- and high-risk groups, respectively. Compared with the low-risk group, the high-risk group had a 72% higher hazard of developing MACEs (adjusted hazard ratio 1.72, 95% confidence interval 1.70 to 1.74), 82% higher hazard of developing major thrombotic vascular events (1.82, 1.80 to 1.84), and 146% higher hazard of developing MALEs (2.46, 2.39 to 2.53) (all p <0.001). In conclusion, in patients with CAD or PAD, the presence of 1 or more risk factors was associated with higher risks of MACEs, MALEs, and major thrombotic vascular events, underscoring the need to improve management of underlying diseases in this population.
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Affiliation(s)
- Urvi Desai
- Analysis Group, Inc., Boston, Massachusetts.
| | - Aram Babcock
- Janssen Scientific Affairs, LLC, Titusville, New Jersey
| | - Yao Wang
- Analysis Group, Inc., Boston, Massachusetts
| | | | | | | | | | - Akshay Kharat
- Janssen Scientific Affairs, LLC, Titusville, New Jersey
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13
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Denegri A, Magnani G, Kraler S, Bruno F, Klingenberg R, Mach F, Gencer B, Räber L, Rodondi N, Rossi VA, Matter CM, Nanchen D, Obeid S, Lüscher TF. History of peripheral artery disease and cardiovascular risk of real-world patients with acute coronary syndrome: Role of inflammation and comorbidities. Int J Cardiol 2023; 382:76-82. [PMID: 36958395 DOI: 10.1016/j.ijcard.2023.03.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/23/2023] [Accepted: 03/20/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Patients with acute coronary syndromes (ACS) remain at risk of cardiovascular disease (CVD) recurrences. Peripheral artery disease (PAD) may identify a very high risk (VHR) group who may derive greater benefit from intensified secondary prevention. METHODS Among ACS-patients enrolled in the prospective multi-center Special Program University Medicine (SPUM), we assessed the impact of PAD on major cardiovascular events (MACE: composite of myocardial infarction, stroke and all-cause death) and major bleeding. Multivariate analysis tested the relation of each significant variable with MACE, as well as biomarkers of inflammation and novel markers of atherogenesis. RESULTS Out of 4787 ACS patients, 6.0% (n = 285) had PAD. PAD-patients were older (p < 0.001), with established CVD and signs of increased persistent inflammation (hs-CRP; 23.6 ± 46.5 vs 10.4 ± 27.2 mg/l, p < 0.001 and sFlt-1; 1399.5 ± 1501.3 vs 1047.2 ± 1378.6 ng/l, p = 0.018). In-hospital-death (3.2% vs 1.4%, p = 0.022) and -MACE (5.6% vs 3.0%, p = 0.017) were higher in PAD-patients. MACE at 1 year (18.6% vs 7.9%,p < 0.001) remained increased even after adjustment for confounders (Adj. HR 1.53, 95% CI: 1.14-2.08, p = 0.005). Major bleeding did not differ between groups (Adj. HR 1.18; 95% CI 0.71-1.97, p = 0.512). Although PAD predicted MACE, PAD-patients were prescribed less frequently for secondary prevention at discharge. CONCLUSIONS In this real-world ACS patient cohort, concomitant PAD is a marker of VHR and is associated with increased and persistent inflammation, higher risk for MACE without an increased risk of major bleeding. Therefore, a history of PAD may be useful to identify those ACS patients at VHR who require more aggressive secondary prevention.
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Affiliation(s)
- Andrea Denegri
- Department of Cardiology, Parma University Hospital, Parma, Italy
| | - Giulia Magnani
- Department of Cardiology, Parma University Hospital, Parma, Italy
| | - Simon Kraler
- Center for Molecular Cardiology, University of Zurich, Switzerland
| | - Francesco Bruno
- Royal Brompton and Harefield Hospitals, Imperial College and Kings College, London, United Kingdom; Division of Cardiology, "Città della Salute e della Scienza di Torino" Hospital, Department of Medical Sciences, University of Turin, Turin 10126, Italy
| | - Roland Klingenberg
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Kerckhoff-Klinik, Campus of the Justus Liebig University of Giessen, Germany; DZHK (German Center for Cardiovascular Research), partner site Rhine-Main, Bad Nauheim, Germany
| | - Francois Mach
- Department of Cardiology, University Hospital Geneva, Switzerland
| | - Baris Gencer
- Department of Cardiology, University Hospital Geneva, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, University Hospital, Bern, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | - David Nanchen
- Center for Primary Care and Public Health, University of Lausanne, Switzerland
| | - Slayman Obeid
- Division of Cardiology, Cantonal Hospital, Aarau, Switzerland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zurich, Switzerland; Royal Brompton and Harefield Hospitals, Imperial College and Kings College, London, United Kingdom.
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14
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El-Hussein MT, Hakkola J. Management of Stable Angina: A Treatment Strategy Mnemonic. J Nurse Pract 2023. [DOI: 10.1016/j.nurpra.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
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15
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Debus ES, von Kodolitsch Y, Behrendt CA, Kölbel T, Sachweh A, Preuß M. [Vascular surgery in old people]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:10-16. [PMID: 36459217 DOI: 10.1007/s00104-022-01770-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 12/05/2022]
Abstract
The age pyramid in Germany is upside down. According to the Federal Statistical Office this development will continue in the coming years, which presents a challenge for surgeons to surgically treat increasingly more and increasingly older people. Particularly in vascular surgery, which is a surgery of old people, this fact represents a special challenge. The frailty of old people is, among other things, due to a series of comorbidities, which must be taken into consideration within the framework of surgical treatment. They can have an important influence on the perioperative planning, the operation, the postoperative treatment and the outcome of the patient. This treatment planning becomes more and more challenging, because due to the progress in endovascular surgery there will soon be no limits to what is feasible; however, the question arises whether the feasible is also reasonable? Within the scope of this article the authors try to give answers to the treatment of old patients in vascular surgery and to find strategies for planning and to establish an individualized optimal treatment.
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Affiliation(s)
- E S Debus
- Klinik und Poliklinik für Gefäßmedizin (Gefäßchirurgie - Angiologie - Endovaskuläre Therapie), Universitären Herzzentrum Hamburg-Eppendorf, Deutsches Aortenzentrum des Universitären Herzzentrums Hamburg, Gebäude O70, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - Y von Kodolitsch
- Klinik und Poliklinik für Gefäßmedizin (Gefäßchirurgie - Angiologie - Endovaskuläre Therapie), Universitären Herzzentrum Hamburg-Eppendorf, Deutsches Aortenzentrum des Universitären Herzzentrums Hamburg, Gebäude O70, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Ch-A Behrendt
- Klinik und Poliklinik für Gefäßmedizin (Gefäßchirurgie - Angiologie - Endovaskuläre Therapie), Universitären Herzzentrum Hamburg-Eppendorf, Deutsches Aortenzentrum des Universitären Herzzentrums Hamburg, Gebäude O70, Martinistraße 52, 20246, Hamburg, Deutschland
| | - T Kölbel
- Klinik und Poliklinik für Gefäßmedizin (Gefäßchirurgie - Angiologie - Endovaskuläre Therapie), Universitären Herzzentrum Hamburg-Eppendorf, Deutsches Aortenzentrum des Universitären Herzzentrums Hamburg, Gebäude O70, Martinistraße 52, 20246, Hamburg, Deutschland
| | - A Sachweh
- Universitäres Herz- und Gefäßzentrum, UKE Hamburg-Eppendorf, Hamburg, Deutschland
| | - M Preuß
- Klinik und Poliklinik für Gefäßmedizin (Gefäßchirurgie - Angiologie - Endovaskuläre Therapie), Universitären Herzzentrum Hamburg-Eppendorf, Deutsches Aortenzentrum des Universitären Herzzentrums Hamburg, Gebäude O70, Martinistraße 52, 20246, Hamburg, Deutschland
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16
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Sheth MS, Yu B, Chu A, Porter J, Tam DY, Ferreira‐Legere LE, Goodman SG, Farkouh ME, Ko DT, Abdel‐Qadir H, Udell JA. Eligibility and Implementation of Rivaroxaban for Secondary Prevention of Atherothrombosis in Clinical Practice-Insights From the CANHEART Study. J Am Heart Assoc 2022; 11:e026553. [PMID: 36515238 PMCID: PMC9798819 DOI: 10.1161/jaha.122.026553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial decreased major adverse cardiovascular events with very low-dose rivaroxaban and aspirin in patients with coronary artery disease and peripheral artery disease. We examined the eligibility and potential real-world impact of this strategy on the COMPASS-eligible population. Methods and Results COMPASS eligibility criteria were applied to the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) registry, a population-based cohort of Ontario adults. We compared 5-year major adverse cardiovascular events and major bleeding rates stratified by COMPASS eligibility and by clinical risk factors. We applied COMPASS trial rivaroxaban/aspirin arm hazard ratios to estimate the potential impact on the COMPASS-eligible cohort. Among 362 797 patients with coronary artery disease or peripheral artery disease, 38% were deemed eligible, 47% ineligible, and 15% indeterminate. Among eligible patients, a greater number of risk factors was associated with higher rates of cardiovascular outcomes, whereas bleeding rates increased minimally. Over 5 years, applying COMPASS treatment effects to eligible patients resulted in a 2.4% absolute risk reduction of major adverse cardiovascular events and a number needed to treat of 42, and a 1.3% absolute risk increase of major bleeding and number needed to harm (NNH) of 77. Those with at least 2 risk factors had a 3.0% absolute risk reduction of major adverse cardiovascular events (number needed to treat =34) and a 1.6% absolute risk increase of major bleeding (number needed to harm =61). Conclusions Implementation of very-low-dose rivaroxaban therapy would potentially impact ≈$$ \approx $$2 in 5 patients with atherosclerotic disease in Ontario. Eligible individuals with ≥$$ \ge $$2 comorbidities represent a high-risk subgroup that may derive the greatest benefit-to-risk ratio. Selection of patients with high-risk predisposing factors appears appropriate in routine practice.
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Affiliation(s)
- Maya S. Sheth
- Women’s College Research InstituteTorontoCanada,Dalla Lana School of Public HealthUniversity of TorontoCanada
| | | | | | | | - Derrick Y Tam
- ICESTorontoCanada,Schulich Heart Centre, Sunnybrook Health Sciences CentreTorontoCanada,Institute of Health Policy, Management, and EvaluationUniversity of TorontoCanada
| | | | - Shaun G. Goodman
- Applied Health Research Centre, Li Ka Shing Knowledge InstituteSt Michael’s HospitalTorontoCanada,Department of Medicine, Faculty of MedicineUniversity of TorontoCanada
| | - Michael E. Farkouh
- Applied Health Research Centre, Li Ka Shing Knowledge InstituteSt Michael’s HospitalTorontoCanada,Department of Medicine, Faculty of MedicineUniversity of TorontoCanada,Peter Munk Cardiac CentreUniversity Health NetworkTorontoCanada
| | - Dennis T. Ko
- ICESTorontoCanada,Schulich Heart Centre, Sunnybrook Health Sciences CentreTorontoCanada,Institute of Health Policy, Management, and EvaluationUniversity of TorontoCanada
| | - Husam Abdel‐Qadir
- Women’s College Research InstituteTorontoCanada,ICESTorontoCanada,Institute of Health Policy, Management, and EvaluationUniversity of TorontoCanada,Department of Medicine, Faculty of MedicineUniversity of TorontoCanada,Peter Munk Cardiac CentreUniversity Health NetworkTorontoCanada,Cardiovascular Division, Department of MedicineWomen’s College HospitalTorontoCanada
| | - Jacob A. Udell
- Women’s College Research InstituteTorontoCanada,ICESTorontoCanada,Institute of Health Policy, Management, and EvaluationUniversity of TorontoCanada,Applied Health Research Centre, Li Ka Shing Knowledge InstituteSt Michael’s HospitalTorontoCanada,Department of Medicine, Faculty of MedicineUniversity of TorontoCanada,Peter Munk Cardiac CentreUniversity Health NetworkTorontoCanada,Cardiovascular Division, Department of MedicineWomen’s College HospitalTorontoCanada
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17
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Fox KAA, Aboyans V, Debus ES, Zeymer U, Cowie MR, Patel M, Welsh RC, Bosch J, Gay A, Vogtländer K, Anand SS. Patients selected for dual pathway inhibition in clinical practice have similar characteristics and outcomes to those included in the COMPASS randomized trial: The XATOA Registry. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:825-836. [PMID: 35594542 DOI: 10.1093/ehjcvp/pvac028] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/24/2022] [Indexed: 12/29/2022]
Abstract
AIMS To determine the characteristics of patients with coronary artery disease (CAD), peripheral artery disease (PAD), or both, initiating dual pathway inhibition (DPI) using rivaroxaban 2.5 mg twice daily plus aspirin, and to report their clinical outcomes and bleeding rates in clinical practice compared to the COMPASS randomized trial, which provided the basis for using DPI in this patient population. METHODS AND RESULTS XATOA is a prospective registry of 5532 patients: of which, 72.7% had CAD, 58.9% had PAD, and 31.6% had both. The mean age of patients was 68 years and 25.5% were women. The mean follow-up period was 15 months. The most frequently reported reason for initiating DPI was the presence of existing, worsening or newly diagnosed risk characteristics (n = 4753, 85.9%). Before initiating DPI, 75.3% received a single antiplatelet and 18.3% received various antiplatelet combinations. The incidence of major adverse cardiovascular events (MACE), major adverse limb events (MALE) and acute or severe limb ischaemia was 2.26, 3.57, and 1.54 per 100 patient-years, respectively, among the 5532 patients in XATOA. Corresponding rates in COMPASS were 2.18, 0.19, and 0.12 per 100 patient-years, respectively. Major bleeding rates were 0.95 and 1.67 per 100 patient-years in XATOA and COMPASS, respectively. CONCLUSION High-risk vascular patients are prioritized for DPI in clinical practice, and rates of MACE are similar to COMPASS, but MALE rates are higher in XATOA, consistent with the greater proportion of PAD patients. Major bleeding rates were lower in XATOA. The findings provide support for favourable net clinical benefit of DPI in high-risk vascular patients. ONE-SENTENCE SUMMARY The characteristics of patients initiated on dual pathway inhibition (DPI: rivaroxaban 2.5 mg twice daily plus aspirin) have not previously been defined in clinical practice and the XATOA registry findings demonstrate patient outcomes are consistent with those of the COMPASS trial, despite geographic differences in recruitment and the higher proportion of PAD patients.
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Affiliation(s)
- Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and Inserm U1094, Limoges, France
| | - E Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery, Angiology, Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Uwe Zeymer
- Klinikum der Stadt Ludwigshafen, Medizinische Klinik B, and Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany
| | - Martin R Cowie
- Royal Brompton Hospital and King's College London, London, UK
| | - Manesh Patel
- Division of Cardiology, Duke Clinical Research Institute, Duke University, Durham NC
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute and University of Alberta, Edmonton, Alberta, Canada
| | - Jackie Bosch
- School of Rehabilitation Science, Chanchlani Research Centre and the Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Sonia S Anand
- School of Rehabilitation Science, Chanchlani Research Centre and the Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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18
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Eikelboom JW, Bosch J, Connolly SJ, Tyrwitt J, Fox KAA, Muehlhofer E, Neumann C, Tasto C, Bangdiwala SI, Diaz R, Alings M, Dagenais GR, Leong DP, Lonn EM, Avezum A, Piegas LS, Widimsky P, Parkhomenko AN, Bhatt DL, Branch KRH, Probstfield JL, Lopez-Jaramillo P, Rydén L, Pogosova N, Keltai K, Keltai M, Ertl G, Stoerk S, Dans AL, Lanas F, Liang Y, Zhu J, Torp-Pedersen C, Maggioni AP, Commerford PJ, Guzik TJ, Vanassche T, Verhamme P, O'Donnell M, Tonkin AM, Varigos JD, Vinereanu D, Felix C, Kim JH, Ibrahim KS, Lewis BS, Metsarinne KP, Aboyans V, Steg PG, Hori M, Kakkar A, Anand SS, Lamy A, Sharma M, Yusuf S. Long-Term Treatment with the Combination of Rivaroxaban and Aspirin in Patients with Chronic Coronary or Peripheral Artery Disease: Outcomes During the Open Label Extension of the COMPASS trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:786-795. [PMID: 35383832 DOI: 10.1093/ehjcvp/pvac023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/13/2022] [Accepted: 03/31/2022] [Indexed: 12/29/2022]
Abstract
AIMS To describe outcomes of patients with chronic coronary artery disease (CAD) and/or peripheral artery disease (PAD) enrolled in the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) randomized trial who were treated with the combination of rivaroxaban 2.5 mg twice daily and aspirin 100 mg once daily during long-term open-label extension (LTOLE). METHODS AND RESULTS Of the 27 395 patients enrolled in COMPASS, 12 964 (mean age at baseline 67.2 years) from 455 sites in 32 countries were enrolled in LTOLE and treated with the combination of rivaroxaban and aspirin for a median of 374 additional days (range 1-1191 days). During LTOLE, the incident events per 100 patient years were as follows: for the primary outcome [cardiovascular death, stroke, or myocardial infarction (MI)] 2.35 [95% confidence interval (CI) 2.11-2.61], mortality 1.87 (1.65-2.10), stroke 0.62 (0.50-0.76), and MI 1.02 (0.86-1.19), with CIs that overlapped those seen during the randomized treatment phase with the combination of rivaroxaban and aspirin. The incidence rates for major and minor bleeding were 1.01 (0.86-1.19) and 2.49 (2.24-2.75), compared with 1.67 (1.48-1.87) and 5.11 (95% CI 4.77-5.47), respectively, during the randomized treatment phase with the combination. CONCLUSION In patients with chronic CAD and/or PAD, extended combination treatment for a median of 1 year and a maximum of 3 years was associated with incidence rates for efficacy and bleeding that were similar to or lower than those seen during the randomized treatment phase, without any new safety signals.
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Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Jacqueline Bosch
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada.,School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Jessica Tyrwitt
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Eva Muehlhofer
- Bayer AG Pharmaceuticals, Research & Development, Wuppertal, Germany
| | - Christoph Neumann
- Bayer AG Pharmaceuticals, Research & Development, Wuppertal, Germany
| | - Christoph Tasto
- Bayer AG Pharmaceuticals, Research & Development, Wuppertal, Germany
| | - Shrikant I Bangdiwala
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Rafael Diaz
- Estudios Clínicos Latino América and Instituto Cardiovascular de Rosario, Rosaria, Argentina
| | - Marco Alings
- Division of Cardiology, Amphia ziekenhuis, Breda, Netherlands and Werkgroep Cardiologische centra Nederland (WCN), Utrecht, the Netherlands
| | - Gilles R Dagenais
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, Canada
| | - Darryl P Leong
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Eva M Lonn
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Petr Widimsky
- Cardiocenter, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Alexander N Parkhomenko
- Emergency Cardiology Dept., National Scientific Center Institute of Cardiology, Kyiv, Ukraine
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kelley R H Branch
- University of Washington Medical Centre, Division of Cardiology, Seattle, WA, USA
| | - Jeffrey L Probstfield
- University of Washington SOM, Division of Cardiology/Department of Medicine, Seattle WA, USA
| | - Patricio Lopez-Jaramillo
- Research Institute, Fundación Oftalmológica de Santander (FOSCAL)-Bucaramanga, Bucaramanga, Colombia
| | - Lars Rydén
- Department of Medicine K2, Karolinska Institutet, Stockholm, Sweden
| | - Nana Pogosova
- National Medical Research Center of Cardiology, Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Katalin Keltai
- Hungarian Cardiovascular Institute, Semmelweis University, Budapest, Hungary
| | - Matyas Keltai
- Hungarian Cardiovascular Institute, Semmelweis University, Budapest, Hungary
| | - Georg Ertl
- Deutsches Zentrum für Herzinsuffizienz, Medizinische Klinik I, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Stefan Stoerk
- Deutsches Zentrum für Herzinsuffizienz, Medizinische Klinik I, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Antonio L Dans
- College of Medicine, University of Philippines, Manila, Philippines
| | - Fernando Lanas
- Universidad de La Frontera, Division of Cardiology, Internal Medicine Department, Temuco, Chile
| | - Yan Liang
- Fuwai Hospital, CAMS & PUMC, Beijing, China
| | - Jun Zhu
- Dept of Clinical Medicine, University of Aalborg, Copenhagen, Denmark
| | | | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Patrick J Commerford
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital and the University of Cape Town, Cape Town, South Africa
| | - Tomasz J Guzik
- Department of Medicine, Jagiellonian University Medical College Krakow, Poland.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
| | | | - Andrew M Tonkin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - John D Varigos
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila; University and Emergency Hospital, Bucharest, Romania
| | - Camillo Felix
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
| | - Jae-Hyung Kim
- Catholic University of Korea, Department of Medicine, Seoul, South Korea
| | | | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Kaj P Metsarinne
- Division of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital & INSERM 1094, Limoges, France
| | - Phillippe Gabriel Steg
- Université de Paris, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Masatsugu Hori
- Department of Oncocardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Ajay Kakkar
- Thrombosis Research Institute and University College London, London, UK
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Andre Lamy
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Mukul Sharma
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
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19
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Zhou X, Yu L, Zhao Y, Ge J. Panvascular medicine: an emerging discipline focusing on atherosclerotic diseases. Eur Heart J 2022; 43:4528-4531. [PMID: 35947920 DOI: 10.1093/eurheartj/ehac448] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Xiang Zhou
- Department of Cardiology, The Second Affiliated Hospital of Soochow University, No. 1055 Sanxiang Road, Suzhou 215004, China
| | - Linchan Yu
- Department of Cardiology, The Second Affiliated Hospital of Soochow University, No. 1055 Sanxiang Road, Suzhou 215004, China
| | - Yiheng Zhao
- Department of Cardiology, The Second Affiliated Hospital of Soochow University, No. 1055 Sanxiang Road, Suzhou 215004, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, No. 180 Fenglin Road, Shanghai 200032, China
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20
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Choi SH, Kim M, Kim H, Kim DH, Baek YS. Cardiovascular and renal protective effects of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation. PLoS One 2022; 17:e0275103. [PMID: 36227869 PMCID: PMC9560050 DOI: 10.1371/journal.pone.0275103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 09/11/2022] [Indexed: 11/18/2022] Open
Abstract
Aim Data on the use of non-vitamin K antagonist oral anticoagulants (NOACs) in relation to the risk of cardiovascular (CV) disease and renal protection among patients with atrial fibrillation (AF), are relatively sparse. We aimed to compare the effectiveness and safety of NOACs with those of warfarin for vascular protection in a large-scale, nationwide Asian population with AF. Methods and results Patients with AF who were prescribed oral anticoagulants according to the Korean Health Insurance Review and Assessment database between 2014 and 2017 were analyzed. The warfarin and NOAC groups were balanced using propensity score weighting. Clinical outcomes included ischemic stroke, myocardial infarction, angina pectoris, peripheral artery disease, chronic kidney disease (CKD), end-stage renal disease (ESRD), CV death, and all-cause death. NOAC use was associated with a lower risk of angina pectoris (HR, 0.79 [95% CI, 0.69–0.89] p<0.001), CKD stage 4 (HR, 0.5 [95% CI, 0.28–0.89], p = 0.02), and ESRD (HR, 0.15[95% CI, 0.08–0.32], p<0.001) than warfarin use. NOACs and warfarin did not significantly differ with respect to stroke reduction (HR, 1.05 [95% CI, 0.88–1.25], p = 0.19). NOAC use was associated with a lower risk of intracranial hemorrhage (HR, 0.6 [95% CI, 0.44–0.83], p = 0.0019), CV death (HR, 0.55 [95% CI, 0.43–0.70], p<0.001), and all-cause death (HR, 0.6 [95% CI, 0.52–0.69], p<0.001) than warfarin use. Conclusion NOACs were associated with a significantly lower risk of adverse CV and renovascular outcomes than warfarin in patients with AF.
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Affiliation(s)
- Seong Huan Choi
- Inha University College of Medicine and Inha University Hospital, Incheon, Republic of Korea
| | - Mina Kim
- Data Science Team, Hanmi Pharm. Co., Ltd., Seoul, Republic of Korea
| | - Hoseob Kim
- Data Science Team, Hanmi Pharm. Co., Ltd., Seoul, Republic of Korea
| | - Dae-Hyeok Kim
- Inha University College of Medicine and Inha University Hospital, Incheon, Republic of Korea
| | - Yong-Soo Baek
- Inha University College of Medicine and Inha University Hospital, Incheon, Republic of Korea
- * E-mail:
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21
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Camm AJ, Sabbour H, Schnell O, Summaria F, Verma A. Managing thrombotic risk in patients with diabetes. Cardiovasc Diabetol 2022; 21:160. [PMID: 35996159 PMCID: PMC9396895 DOI: 10.1186/s12933-022-01581-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/25/2022] [Indexed: 12/24/2022] Open
Abstract
It is well known that diabetes is a prominent risk factor for cardiovascular (CV) events. The level of CV risk depends on the type and duration of diabetes, age and additional co-morbidities. Diabetes is an independent risk factor for atrial fibrillation (AF) and is frequently observed in patients with AF, which further increases their risk of stroke associated with this cardiac arrhythmia. Nearly one third of patients with diabetes globally have CV disease (CVD). Additionally, co-morbid AF and coronary artery disease are more frequently observed in patients with diabetes than the general population, further increasing the already high CV risk of these patients. To protect against thromboembolic events in patients with diabetes and AF or established CVD, guidelines recommend optimal CV risk factor control, including oral anticoagulation treatment. However, patients with diabetes exist in a prothrombotic and inflammatory state. Greater clinical benefit may therefore be seen with the use of stronger antithrombotic agents or innovative drug combinations in high-risk patients with diabetes, such as those who have concomitant AF or established CVD. In this review, we discuss CV risk management strategies in patients with diabetes and concomitant vascular disease, stroke prevention regimens in patients with diabetes and AF and how worsening renal function in these patients may complicate these approaches. Accumulating evidence from clinical trials and real-world evidence show a benefit to the administration of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with diabetes and AF.
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Affiliation(s)
- A John Camm
- Division of Cardiac and Vascular Sciences, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, Cranmer Terrace, SW17 0RE, UK.
| | - Hani Sabbour
- Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Warren Alpert School of Medicine, Brown University, Rhode Island, USA
| | - Oliver Schnell
- Forschergruppe Diabetes e.V., Neuherberg, Munich, Germany
| | | | - Atul Verma
- Southlake Regional Health Centre, Newmarket, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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22
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Geisler T, Branch K, Nikol S. Clinical experience with dual pathway inhibition therapy: case series and mini review. Eur Heart J Case Rep 2022; 6:ytac201. [PMID: 35854882 PMCID: PMC9278337 DOI: 10.1093/ehjcr/ytac201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/30/2021] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
Background Dual pathway inhibition (DPI) with rivaroxaban 2.5 mg twice daily plus aspirin has demonstrated reductions in major adverse cardiovascular and limb events in eligible patients with chronic coronary artery disease (CAD), peripheral artery disease, or both. Patients with polyvascular disease, heart failure, renal impairment, or diabetes can benefit particularly from this therapy. We present our clinical experience to elucidate practical issues regarding the selection of patients eligible for DPI and the timing of initiation. Case summary The first patient was at high risk of recurrent cardiovascular events due to his history of multi-vessel CAD, myocardial infarction, heart failure, and diabetes. Following a period of post-myocardial infarction dual antiplatelet therapy, he was transitioned to DPI therapy. The second patient was at high risk of cardiovascular events due to his history of polyvascular disease, diffuse CAD, and diabetes. He was hospitalized for unstable angina, which was medically managed because no target lesion was identified. DPI was initiated a day after admission. The third patient was at high risk of cardiovascular events due to an extensive history of polyvascular disease, revascularization, and renal impairment. Although the patient was asymptomatic at routine follow-up, DPI was initiated to reduce the risk of further cardiovascular events. Discussion In eligible patients who are at high risk of cardiovascular events, DPI therapy with low-dose rivaroxaban should be considered. Treatment can be started at various times, including at the end of dual antiplatelet therapy, at routine follow-up, or after new events or diagnoses.
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Affiliation(s)
- Tobias Geisler
- Department of Cardiology and Angiology, University Hospital Tübingen , Tübingen , Germany
| | - Kelley Branch
- Division of Cardiology, University of Washington , Seattle, WA , USA
| | - Sigrid Nikol
- Department of Clinical and Interventional Angiology, Asklepios Klinik St. Georg , Hamburg , Germany
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23
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Golledge J, Fernando ME, Armstrong DG. Current Management of Peripheral Artery Disease: Focus on Pharmacotherapy. Drugs 2022; 82:1165-1177. [PMID: 35960432 DOI: 10.1007/s40265-022-01755-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2022] [Indexed: 11/03/2022]
Abstract
Peripheral artery disease (PAD) is the occlusion or narrowing of the arteries supplying the lower extremities. Peripheral artery disease has been estimated to affect approximately 240 million people worldwide, approximately 70% of whom are within low- or middle-income countries. Due to the ageing population and diabetes epidemic, the prevalence of PAD is rapidly rising. The symptoms of PAD are heterogeneous and thus a high index of suspicion is needed to prevent delays in diagnosis and treatment. Measurement of ankle brachial pressure index or arterial duplex ultrasound are traditionally used to diagnose PAD. Patients with PAD have a high risk of major adverse cardiovascular events. Early diagnosis and implementation of secondary cardiovascular prevention is therefore critical. This includes therapies to reduce low-density lipoprotein cholesterol, such as statins, ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, blood-pressure reducing medications and anti-thrombotic drugs. Treatments to facilitate smoking cessation and control blood sugar if relevant and an exercise programme are also critical in reducing cardiovascular risk. Currently, these treatments are not well implemented. This review summarises the clinical presentation, risk factors and medical management of PAD. Global efforts are needed to reduce the burden from the growing PAD epidemic by implementing best practices and improving outcomes through further research.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, QLD, Australia
| | - Malindu E Fernando
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Faculty of Health and Medicine, School of Health Sciences, University of Newcastle, Newcastle, NSW, Australia
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, 1500 San Pablo St, Los Angeles, CA, 90033, USA
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, 1500 San Pablo St, Los Angeles, CA, 90033, USA.
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Opportunità cliniche e impatto sul sistema sanitario di un trattamento ottimale del paziente post-sindrome coronarica acuta. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2022; 9:17-26. [PMID: 36628067 PMCID: PMC9796606 DOI: 10.33393/grhta.2022.2391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/23/2022] [Indexed: 01/13/2023] Open
Abstract
Despite the improvement of revascularization procedures, patients with acute coronary syndrome often develop recurrent ischemic events, suggesting a high residual cardiovascular risk in these patients, which requires a strict clinical monitoring as well as an optimal control of modifiable risk factors. To this aim, an optimal management of index event and appropriate preventive measures are equally important. Hospital care by cardiologists should be followed by outpatient management by general practitioners, as established by specific diagnostic and therapeutic pathways, which should warrant an optimal support to the patient. A strict collaboration between hospital and primary care is crucial to monitor and adapt drug therapy after the acute event and improve adherence of the patients to prescribed treatments and implementation of life-style modifications, with benefits also in term of cost-effectiveness. In this context, individualized rehabilitation programs should also be offered to patients with acute coronary syndromes, in order to improve survival and quality of life.
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25
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Li Y, Zhao C, Xiong C, Gao Y. Clinical Effect of Nicorandil Combined with Aspirin in the Treatment of Myocardial Ischemia. BIOMED RESEARCH INTERNATIONAL 2022; 2022:2214411. [PMID: 35647186 PMCID: PMC9132652 DOI: 10.1155/2022/2214411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/17/2022] [Accepted: 05/03/2022] [Indexed: 11/18/2022]
Abstract
Objective To investigate the clinical effect of nicorandil combined with aspirin in the treatment of myocardial ischemia. Methods A total of 104 patients with myocardial ischemia were admitted to our hospital from June 2019 to August 2020. These patients were selected as the research objects and randomly divided into two groups: the control group and the observation group. The control group was given asilin, and the observation group was given nicorandil tablets based on the control group. Both groups were given continuous treatment for 3 months. The curative effect, cardiac function indexes, dynamic electrocardiogram, and the occurrence of adverse reactions were observed in the two groups. Results The total effective rate of the observation group was 96.15% (50/52), which was higher than that of the control group (61.54%, 32/52), and the difference was statistically significant (P < 0.05). After treatment, left ventricular ejection fraction (LVEF) and peak early/late diastolic flow velocity (E/A) were increased (P < 0.05), while peak early diastolic flow velocity to peak mitral annular root movement velocity (E/Ea) was decreased (P < 0.05). After treatment, LVEF and E/A in the observation group were higher than those in the control group, while E/Ea was lower than that in the control group (P < 0.05). The frequency, duration of ST segment, and a total load of myocardial ischemia in the ST segment within 24 h after treatment were decreased compared with those before treatment (P < 0.05). The frequency and duration of ST segment decreased, and the total load of myocardial ischemia in the observation group was lower than those in the control group within 24 h after treatment (P < 0.05). After treatment, the total occurrence of adverse reactions in the observation group was lower than that in the control group (P < 0.05). Conclusion Nicorandil combined with aspirin in the treatment of patients with myocardial ischemia has a significant effect, which can effectively improve the electrocardiogram and cardiac function indicators of patients and reduce the incidence of adverse reactions and is worthy of clinical application.
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Affiliation(s)
- Yue Li
- Department of Cardiology, Third Hospital of Shanxi Medical University, Key Laboratory of Cellular Physiology (Shanxi Medical University), Ministry of Education, China
| | - Chen Zhao
- Department of Cardiology, Third Hospital of Shanxi Medical University, Key Laboratory of Cellular Physiology (Shanxi Medical University), Ministry of Education, China
| | - Chengxin Xiong
- School of Computer Science, Hefei University of Technology, China
| | - Yuping Gao
- Department of Cardiology, Third Hospital of Shanxi Medical University, Key Laboratory of Cellular Physiology (Shanxi Medical University), Ministry of Education, China
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26
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Abramson BL, Al-Omran M, Anand SS, Albalawi Z, Coutinho T, de Mestral C, Dubois L, Gill HL, Greco E, Guzman R, Herman C, Hussain MA, Huckell VF, Jetty P, Kaplovitch E, Karlstedt E, Kayssi A, Lindsay T, Mancini GBJ, McClure G, McMurtry MS, Mir H, Nagpal S, Nault P, Nguyen T, Petrasek P, Rannelli L, Roberts DJ, Roussin A, Saw J, Srivaratharajah K, Stone J, Szalay D, Wan D, Cox H, Verma S, Virani S. Canadian Cardiovascular Society 2022 Guidelines for Peripheral Arterial Disease. Can J Cardiol 2022; 38:560-587. [PMID: 35537813 DOI: 10.1016/j.cjca.2022.02.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 12/24/2022] Open
Abstract
Patients with widespread atherosclerosis such as peripheral artery disease (PAD) have a high risk of cardiovascular and limb symptoms and complications, which affects their quality of life and longevity. Over the past 2 decades there have been substantial advances in diagnostics, pharmacotherapy, and interventions including endovascular and open surgical to aid in the management of PAD patients. To summarize the evidence regarding approaches to diagnosis, risk stratification, medical and intervention treatments for patients with PAD, guided by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework, evidence was synthesized, and assessed for quality, and recommendations provided-categorized as weak or strong for each prespecified research question. Fifty-six recommendations were made, with 27% (15/56) graded as strong recommendations with high-quality evidence, 14% (8/56) were designated as strong recommendations with moderate-quality evidence, and 20% (11/56) were strong recommendations with low quality of evidence. Conversely 39% (22/56) were classified as weak recommendations. For PAD patients, strong recommendations on the basis of high-quality evidence, include smoking cessation interventions, structured exercise programs for claudication, lipid-modifying therapy, antithrombotic therapy with a single antiplatelet agent or dual pathway inhibition with low-dose rivaroxaban and aspirin; treatment of hypertension with an angiotensin converting enzyme or angiotensin receptor blocker; and for those with diabetes, a sodium-glucose cotransporter 2 inhibitor should be considered. Furthermore, autogenous grafts are more effective than prosthetic grafts for surgical bypasses for claudication or chronic limb-threatening ischemia involving the popliteal or distal arteries. Other recommendations indicated that new endovascular techniques and hybrid procedures be considered in patients with favourable anatomy and patient factors, and finally, the evidence for perioperative risk stratification for PAD patients who undergo surgery remains weak.
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Affiliation(s)
- Beth L Abramson
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Mohammed Al-Omran
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | | | | | - Thais Coutinho
- Canadian Women's Heart Health Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - Luc Dubois
- LHSC and Western University, London, Ontario, Canada
| | | | - Elisa Greco
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Randolph Guzman
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Mohamad A Hussain
- Centre for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Victor F Huckell
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Prasad Jetty
- Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Eric Kaplovitch
- University Health Network/Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Erin Karlstedt
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Thomas Lindsay
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - G B John Mancini
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Hassan Mir
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Sudhir Nagpal
- Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Patrice Nault
- McGill University, Campus Outaouais, Gatineau, Quebec, Canada, Alberta, Canada
| | - Thang Nguyen
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Paul Petrasek
- Cumming School of Medicine, University of Calgary, Peter Lougheed Hospital, Alberta Health Services, Calgary, Alberta, Canada
| | | | - Derek J Roberts
- University of Ottawa, The Ottawa Hospital, and The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Jacqueline Saw
- Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - James Stone
- University of Calgary, Calgary, Alberta, Canada
| | | | - Darryl Wan
- McMaster University, Hamilton, Ontario, Canada
| | - Heather Cox
- Peterborough Regional Hospital, Peterborough, Ontario, Canada
| | - Subodh Verma
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sean Virani
- University of British Columbia, Vancouver, British Columbia, Canada
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Ceramides and phospholipids in plasma extracellular vesicles are associated with high risk of major cardiovascular events after carotid endarterectomy. Sci Rep 2022; 12:5521. [PMID: 35365690 PMCID: PMC8975809 DOI: 10.1038/s41598-022-09225-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 02/28/2022] [Indexed: 11/26/2022] Open
Abstract
Ceramides and phosphatidylcholines (PCs) are bioactive lipids and lipid bilayer membrane components. Distinct ceramides/PCs (ratios) predict cardiovascular outcome in patients with coronary artery disease. Extracellular vesicles (EVs) are proposed biomarkers for cardiovascular disease and contain ceramides/PCs. Ceramides/PCs have not been studied in patients undergoing carotid endarterectomy (CEA) nor in EVs. We therefore investigated whether levels of ceramides/PCs in plasma and EVs are associated with postoperative risk of major adverse cardiovascular events (MACE) following CEA. In 873 patients undergoing CEA of the Athero-Express biobank, we quantitatively measured seven ceramides/PCs in preoperative blood samples: Cer(d18:1/16:0), Cer(d18:1/18:0), Cer(d18:1/24:0), Cer(d18:1/24:1), PC(14:0/22:6), PC(16:0/16:0) and PC(16:0/22:5) in plasma and two plasma EV-subfractions (LDL and TEX). We analyzed the association of ceramides, PCs and their predefined ratios with the three-year postoperative risk of MACE (including stroke, myocardial infarction and cardiovascular death). A total of 138 patients (16%) developed MACE during the three-year follow-up. In the LDL-EV subfraction, higher levels of Cer(d18:1/24:1) and Cer(d18:1/16:0)/PC(16:0/22:5) ratio were significantly associated with an increased risk of MACE (adjusted HR per SD [95% CI] 1.24 [1.01–1.53] and 1.26 [1.04–1.52], respectively). In the TEX-EV subfraction, three ratios Cer(d18:1/16:0)/Cer(d18:1/24:0), Cer(d18:1/18:0)/Cer(d18:1/24:0) and Cer(d18:1/24:1)/Cer(d18:1/24:0) were positively associated with MACE (adjusted HR per SD 1.34 [1.06–1.70], 1.24 [1.01–1.51] and 1.31 [1.08–1.58], respectively). In conclusion, distinct ceramides and PCs in plasma EVs determined in preoperative blood were independently associated with an increased 3-year risk of MACE after CEA. These lipids are therefore potential markers to identify high-risk CEA patients qualifying for secondary preventive add-on therapy.
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Goldin M, Koulas I, Weitz JI, Spyropoulos A. State-of-the-art-mini review: Dual pathway inhibition to reduce arterial and venous thromboembolism. Thromb Haemost 2022; 122:1279-1287. [DOI: 10.1055/a-1778-1083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Venous thromboembolism (VTE) and arterial thromboembolism (ATE) are linked by the common mechanism of thrombin generation. Historically these entities have been treated as separate pathophysiologic processes requiring different treatments: VTE, as the formation of fibrin-/coagulation-factor-derived thrombus in low flow vasculature, requiring anticoagulants; versus ATE, as largely platelet-derived thrombus in high flow vasculature, requiring antiplatelet agents. Observational studies have elucidated shared risk factors and co-morbidities predisposing individuals with VTE to ATE, and vice versa, and have bolstered the strategy of dual pathway inhibition (DPI) – the combination of low dose anticoagulants with antiplatelet agents – to reduce thrombotic outcomes on both sides of the vasculature. Randomized clinical trials have evaluated the efficacy and safety of such regimens - mostly rivaroxaban and aspirin - in high-risk groups of patients, including those with recent acute or chronic coronary syndrome, as well as those with peripheral artery disease with or without revascularization. Studies of extended VTE prophylaxis in acutely ill medical patients have also contributed to the evidence evaluating DPI. The totality of available data supports the concept that DPI can reduce major and fatal thromboembolic outcomes, including stroke, myocardial infarction, VTE, and cardiovascular death in key patient cohorts, with acceptable risk of bleeding. Further data are needed to refine which patients derive the best net clinical benefit from such an approach. At the same time, other novel agents such as contact pathway inhibitors that reduce thrombin generation without affecting hemostasis - and thus maximize safety - should be assessed in appropriate populations.
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Affiliation(s)
- Mark Goldin
- Medicine, Northwell Health, New Hyde Park, United States
| | - Ioannis Koulas
- Northwell Health Feinstein Institutes for Medical Research, Manhasset, United States
| | - Jeffrey I Weitz
- The Thrombosis and Atherosclerosis Research Institute, Hamilton, Canada
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
| | - Alex Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, Hofstra, Northwell School of Medicine, NY, United States
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Evaluation of definitions for oral anticoagulant-associated major bleeding: A population-based cohort study. Thromb Res 2022; 213:57-64. [DOI: 10.1016/j.thromres.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 02/14/2022] [Accepted: 02/19/2022] [Indexed: 11/23/2022]
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30
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Building your Peripheral Artery Disease Tool Kit: Medical Management of PAD in 2022. Can J Cardiol 2022; 38:634-644. [DOI: 10.1016/j.cjca.2022.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/24/2022] [Accepted: 02/05/2022] [Indexed: 12/24/2022] Open
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McClure GR, Kaplovitch E, Chan N, Anand SS. Antithrombotic Therapy in Peripheral Arterial Disease:Risk Stratification and Clinical Decision Making. Can J Cardiol 2022; 38:654-661. [DOI: 10.1016/j.cjca.2022.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/24/2022] [Accepted: 02/09/2022] [Indexed: 12/24/2022] Open
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Kobo O, Saada M, Laanmets P, Karageorgiev D, Routledge H, Crowley J, Baello P, Requena JB, Spanó F, Perez L, Jimenez Mazuecos JM, Mamas MA, Roguin A. Impact of peripheral artery disease on prognosis after percutaneous coronary intervention: Outcomes from the multicenter prospective e-ULTIMASTER registry. Atherosclerosis 2022; 344:71-77. [DOI: 10.1016/j.atherosclerosis.2022.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/14/2021] [Accepted: 01/14/2022] [Indexed: 11/02/2022]
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33
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Hamad AS. Non-vitamin K antagonist oral anticoagulants for COVID-19 thrombosis. JOURNAL OF ACUTE DISEASE 2022. [DOI: 10.4103/2221-6189.362812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Moll MA, Zwerger D, Grassl KJ, Westreicher W, Neururer SB, Moll CW, Wipper SH, Klocker J. Prevalence of VOYAGER PAD trial exclusion criteria in unselected patients undergoing lower limb revascularisation. INT ANGIOL 2021; 41:56-62. [PMID: 34913631 DOI: 10.23736/s0392-9590.21.04816-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The VOYAGER PAD trial investigated data on dual pathway inhibition after lower limb revascularisation for peripheral arterial disease (PAD). Multiple exclusion criteria were applied. However, neither data on the prevalence of exclusion criteria nor on the total number of patients screened for inclusion was discussed. METHODS We performed a single-center prospective observational study in unselected PAD patients undergoing lower limb revascularisation. Demographic and disease-specific data was collected. RESULTS 150 patients were included with only 29 patients (19.3%) as potential candidates for the VOYAGER PAD study medication. Poorly controlled diabetes or severe uncontrolled hypertension (33.3%), major tissue loss (18.7%), acute limb ischaemia within prior 2 weeks (17.3%) and a history of intracranial haemorrhage, stroke or TIA (16%) were amongst the exclusion criteria most frequently met. Compared to VOYAGER PAD study patients, significant differences regarding sex (36.7% female vs. 25.8%), renal insufficiency (29.0% vs. 20.1%), previous myocardial infarction (16.7% vs. 11.1%) and known carotid artery disease (18.7% vs. 8.6%) revealed. Patients presented significantly more frequently with critical limb ischemia (56.7% vs. 30.4%) and a history of previous peripheral revascularisation (72.0% vs. 35.9%). Fewer endovascular interventions (52% vs. 65.5%) and more surgeries (58% vs. 34.5%) were performed. CONCLUSIONS In unselected patients undergoing revascularisation for peripheral arterial disease, the majority presents with characteristics that, at present, preclude prescription of rivaroxaban in addition to aspirin. This patient cohort represents a population with higher rates of comorbidities and more complex vascular interventions, but might also benefit from dual pathway inhibition strategy.
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Affiliation(s)
- Maria A Moll
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniela Zwerger
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Kristina J Grassl
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Werner Westreicher
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Sabrina B Neururer
- Department of Clinical Epidemiology, Tyrolean Federal Institute for Integrated Care, Tirol Kliniken GmbH, Innsbruck, Austria
| | - Clemens Wi Moll
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Sabine H Wipper
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Josef Klocker
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria -
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Cesaro A, Gragnano F, Calabrò P, Moscarella E, Santelli F, Fimiani F, Patti G, Cavallari I, Antonucci E, Cirillo P, Pignatelli P, Palareti G, Pelliccia F, Bossone E, Pengo V, Gresele P, Marcucci R. Prevalence and clinical implications of eligibility criteria for prolonged dual antithrombotic therapy in patients with PEGASUS and COMPASS phenotypes: Insights from the START-ANTIPLATELET registry. Int J Cardiol 2021; 345:7-13. [PMID: 34695525 DOI: 10.1016/j.ijcard.2021.10.138] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 12/28/2022]
Abstract
AIM To analyze the prevalence and clinical implications of the eligibility criteria for prolonged dual antithrombotic therapy with ticagrelor 60 mg twice daily and/or rivaroxaban 2.5 mg twice daily in a contemporary real-world ACS registry. METHODS Patients from the START-ANTIPLATELET registry (NCT02219984) were stratified according to the eligibility criteria of the PEGASUS and COMPASS studies to investigate the proportion of patients eligible for prolonged dual antithrombotic therapy at discharge and after 1-year of DAPT. Net adverse clinical events (NACE), defined as all-cause death, myocardial infarction, stroke, and major bleeding, at 1 year were also evaluated and compared among groups. RESULTS 1844 were considered for the analysis at baseline. Out of 849 event-free patients continually receiving dual antiplatelet therapy for at least 1 year, 577 (68%) and 583 (68.7%) met at least one eligibility criterion for ticagrelor and rivaroxaban, respectively. In the PEGASUS-like patients, age was the most common criterion (71% of cases). The presence ≥2 cardiovascular risk factors was the most common eligibility criterion in the COMPASS-like patients (80.8%). At 1-year follow-up, 211 (11.4%) and 119 (6.5%) patients experienced NACE and MACE, respectively. The incidence of NACEs was higher in the PEGASUS-only group (15.4% vs. 8.4%; p = 0.008) and numerically higher in the COMPASS-only group (10.9% vs. 8.4%; p = 0.299). CONCLUSIONS In a contemporary real-world ACS cohort, approximately two-thirds of patients that complete 1-year DAPT met the eligibility criteria for ticagrelor 60 mg twice daily or rivaroxaban 2.5 mg twice daily, showing a higher risk of NACEs.
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Affiliation(s)
- Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy.
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Francesco Santelli
- Department of Political Science, "Federico II" University, Naples, Italy
| | - Fabio Fimiani
- Unit of Inherited and Rare Cardiovascular Diseases, A.O.R.N. Dei Colli "V. Monaldi", Naples, Italy
| | - Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Ilaria Cavallari
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Italy
| | | | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, School of Medicine, "Federico II" University, Naples, Italy
| | - Pasquale Pignatelli
- I Clinica Medica, Atherothrombosis Centre, Department of Clinical Internal, Anesthesiologic, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Francesco Pelliccia
- Department of Cardiovascular Sciences, University Sapienza of Rome, Rome, Italy
| | | | - Vittorio Pengo
- Department of Cardiothoracic and Vascular Sciences, University Hospital of Padua, Padua, Italy
| | - Paolo Gresele
- Department of Medicine and Surgery, Division of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, Center for Atherothrombotic diseases, University of Florence, Florence, Italy
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Medical Therapy Following Urgent/Emergent Revascularization in Peripheral Artery Disease Patients (Canadian Acute Limb Ischemia Registry [CANALISE I]). CJC Open 2021; 3:1325-1332. [PMID: 34901800 PMCID: PMC8640583 DOI: 10.1016/j.cjco.2021.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/08/2021] [Indexed: 12/24/2022] Open
Abstract
Background Following severe limb ischemia requiring urgent/emergent revascularization, peripheral arterial disease patients suffer a high risk of recurrent atherothrombosis. Methods Patients discharged from Hamilton General Hospital (Hamilton, Ontario) between April 2016 and September 2017 following severe limb ischemia requiring urgent/emergent revascularization were identified via the Local Health Integration Network CorHealth database, with supplemental information from chart review. Results A total of 158 patients admitted for urgent/emergent revascularization were identified (148 alive at discharge). Among patients without a pre-existing indication for anticoagulation, 38.8% (n = 47) were discharged on single-antiplatelet therapy, 27.3% (n = 33) on dual-antiplatelet therapy, 19.8% (n = 24) on anticoagulants plus antiplatelet therapy, 6.6% (n = 8) on anticoagulants alone, and 2.6% (n = 3) on unknown therapy. Patients who received angioplasty with stenting were more likely be discharged on dual-antiplatelet therapy (hazard ratio [HR]: 7.14; 95% confidence interval [CI]: 2.87-17.76; P < 0.01); patients who received an embolectomy/thrombectomy were more likely be discharged on an anticoagulant alone (HR: 2.61; 95% CI: 1.00-6.81; P = 0.049); and patients who received peripheral bypass grafting were more likely be discharged on single-antiplatelet therapy (HR: 2.28; 95% CI: 1.11-4.69; P = 0.024). Neither statins (60.8% vs 56.3%; P = 0.23) nor renin–angiotensin–aldosterone system inhibitors (48.7% vs 50.6%; P = 0.58) were prescribed at higher rates at discharge, compared with the rate at admission. Conclusions Substantial heterogeneity exists in antithrombotic prescription following urgent/emergent revascularization. No intensification of non-antithrombotic vascular protective medications occurred during hospitalization. Clinical trials and health system interventions to optimize medical therapy in peripheral arterial disease patients are urgently needed.
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Würtz M, Olesen KKW, Mortensen MB, Eikelboom JW, Mohammad MA, Erlinge D, Kristensen SD, Maeng M. Dual antithrombotic treatment in chronic coronary syndrome: European Society of Cardiology criteria vs. CHADS-P2A2RC score. Eur Heart J 2021; 43:996-1004. [PMID: 34871376 DOI: 10.1093/eurheartj/ehab785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 07/28/2021] [Accepted: 10/29/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS According to the 2019 European Society of Cardiology (ESC) guidelines on chronic coronary syndromes (CCS), adding a P2Y12 inhibitor or rivaroxaban to aspirin should be considered in high-risk patients. We estimated the proportion of patients eligible for treatment with the ESC criteria and examined if a recently validated risk score (CHADS-P2A2RC) could improve risk prediction. METHODS AND RESULTS We included 61 338 CCS patients undergoing first-time coronary angiography in Western Denmark (2003-16) and classified them according to the ESC criteria and the CHADS-P2A2RC score. The ESC criteria identified 33.9% as high risk, 53.3% as moderate risk, and 12.8% as low risk. The CHADS-P2A2RC score identified 24.9% as high risk (≥4 points), 48.1% as moderate risk (2-3 points), and 27.0% as low risk (≤1 points). Major adverse cardiovascular events per 100 person-years were 4.8 [95% confidence interval (CI) 4.6-5.0] in patients considered high risk with both schemes, 2.1 (95% CI 2.0-2.2) in patients considered high risk with the ESC but low-to-moderate risk with the CHADS-P2A2RC criteria, 3.8 (95% CI 3.6-4.1) in patients considered low-to-moderate risk with the ESC but high risk with the CHADS-P2A2RC criteria, and 1.5 (95% CI 1.5-1.6) in patients considered low-to-moderate risk with both schemes. The CHADS-P2A2RC score enabled correct downward risk reclassification of 5161 patients (8%) without events, yielding an improved specificity of 9.7%, a loss of sensitivity of 4.4%, and an overall net reclassification index of 0.053. CONCLUSION Based on the 2019 ESC guidelines, dual antithrombotic treatment should be considered in one-third of CCS patients. The CHADS-P2A2RC score improved risk classification and may particularly identify low-risk patients with limited benefit from treatment.
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Affiliation(s)
- Morten Würtz
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
| | | | - Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences 237 Barton Street East Hamilton, ON L8L 2X2, Canada, and McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Moman Aladdin Mohammad
- Department of Cardiology, Clinical Sciences, Skane University Hospital, Entregatan 7, Lund 22185, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Skane University Hospital, Entregatan 7, Lund 22185, Sweden
| | - Steen Dalby Kristensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark.,Department of Clinical Medicine, Faculty of Health, Institute of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
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Al Sayed N, Almahmeed W, Alnouri F, Al Waili K, Sabbour H, Sulaiman K, Zubaid M, Ray KK, Al-Rasadi K. Consensus clinical recommendations for the management of plasma lipid disorders in the Middle East – 2021 update. Atherosclerosis 2021; 343:28-50. [DOI: 10.1016/j.atherosclerosis.2021.11.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 11/20/2021] [Accepted: 11/23/2021] [Indexed: 12/14/2022]
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Abstract
PURPOSE OF REVIEW To provide an overview of new concepts in the pharmacotherapy of patients with peripheral artery disease (PAD). RECENT FINDINGS Modern therapeutic strategies for patients with PAD include specific symptom management and multidisciplinary prevention of cardiovascular events. Low-dose rivaroxaban in combination with aspirin improves outcomes compared with aspirin monotherapy among patients with PAD. Other novel concepts include the use of bosentan, vorapaxar or sildenafil among symptomatic patients with PAD. Likewise, lipid-lowering therapy reduces the risk of major cardiovascular and limb events. SUMMARY Personalized management, identification of risk factors and shared-decision making are crucial in improving the best medical therapy for patients with PAD. Further studies are needed to assess the long-term safety and efficacy of novel strategies in real-world patients.
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Patti G, Ghiglieno C. Prevention of ischaemic events in subjects with polydistrict vascular disease. Eur Heart J Suppl 2021; 23:E103-E108. [PMID: 34650366 PMCID: PMC8503499 DOI: 10.1093/eurheartj/suab102] [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: 11/13/2022]
Abstract
The incidence of new cardiovascular events in patients with chronic coronary syndrome remains high, particularly in the presence of concomitant high thrombotic risk factors (diabetes mellitus, renal failure, multivessel coronary artery disease, multiple district atherosclerosis, recurrent events, heart failure). The risk of such recurrent events can be reduced by implementing various strategies, which include careful individual stratification of ischaemic and haemorrhagic risk and the choice of the most appropriate antithrombotic therapy for the individual patient, also by combining aspirin with a second antiplatelet agent/a low-dose anticoagulant, in order to achieve the maximum net clinical benefit.
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Affiliation(s)
- Giuseppe Patti
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Chiara Ghiglieno
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
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41
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Maksimova MY. [Current opportunities for secondary prevention of atherothrombotic stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:97-105. [PMID: 34481444 DOI: 10.17116/jnevro202112108197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The article is devoted to an urgent medical and social problem - secondary prevention of atherothrombotic stroke and contains current evidence on the use of combined antiplatelet and anticoagulant therapy. In the COMPASS study, the dual-pathway thrombosis inhibition scheme using rivaroxaban in combination with acetylsalicylic acid (ASA) compared with ASA monotherapy demonstrated in patients with established atherosclerotic diseases of the circulatory system, a decrease in the total risk of stroke, death from cardiovascular causes and myocardial infarction by 24%; reduced risk of recurrent stroke by 67%. The incidence of repeated ischemic stroke (IS) in the combination therapy group was 1.1% per year, in the ASA group - 3.4% per year. The total incidence of adverse outcomes included in the combined indicator «net clinical benefit» in the rivaroxaban group in combination with ASA was 20% lower than in the ASA group and confirms the advantages of combination therapy in the prevention of recurrent noncardioembolic IS.
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Eikelboom JW, Bhatt DL, Fox KAA, Bosch J, Connolly SJ, Anand SS, Avezum A, Berkowitz SD, Branch KRH, Dagenais GR, Félix C, Guzik TJ, Hart RG, Maggioni AP, Muehlhofer E, Sharma M, Shestakovska O, Yusuf S. Mortality Benefit of Rivaroxaban Plus Aspirin in Patients With Chronic Coronary or Peripheral Artery Disease. J Am Coll Cardiol 2021; 78:14-23. [PMID: 34210409 DOI: 10.1016/j.jacc.2021.04.083] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The combination of 2.5 mg rivaroxaban twice daily and 100 mg aspirin once daily compared with 100 mg aspirin once daily reduces major adverse cardiovascular (CV) events in patients with chronic coronary artery disease (CAD) or peripheral artery disease (PAD). OBJECTIVES The aim of this work was to report the effects of the combination on overall and cause-specific mortality. METHODS The COMPASS trial enrolled 27,395 patients of whom 18,278 were randomized to the combination (n = 9,152) or aspirin alone (n = 9,126). Deaths were adjudicated by a committee blinded to treatment allocation. Previously identified high-risk baseline features were polyvascular disease, chronic kidney disease, mild or moderate heart failure, and diabetes. RESULTS During a median of 23 months of follow-up (maximum 47 months), 313 patients (3.4%) allocated to the combination and 378 patients (4.1%) allocated to aspirin alone died (hazard ratio [HR]: 0.82; 95% confidence interval [CI]: 0.71-0.96; P = 0.01). Compared with aspirin, the combination reduced CV death (160 [1.7%] vs 203 [2.2%]; HR: 0.78; 95% CI: 0.64-0.96; P = 0.02) but not non-CV death. There were fewer deaths following MI, stroke, and CV procedures, as well as fewer sudden cardiac, other, and unknown causes of CV deaths and coronary heart disease deaths. Patients with 0, 1, 2, and 3 or 4 high-risk features at baseline had 4.2, 4.8, 25.0, and 53.9 fewer deaths, respectively, per 1000 patients treated for 30 months. CONCLUSIONS The combination of rivaroxaban and aspirin compared with aspirin reduced overall and CV mortality with consistent reductions in cause specific CV mortality in patients with chronic CAD or PAD. The absolute mortality benefits are greater with increasing baseline risk. (Cardiovascular Outcomes for People Using Anticoagulant Strategies [COMPASS]; NCT01776424).
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Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, Hamilton Ontario, Canada; Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Jacqueline Bosch
- Population Health Research Institute, Hamilton Ontario, Canada; School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton Ontario, Canada; Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Ontario, Canada; Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | | | - Gilles R Dagenais
- Institut Universitaire de Cardiologie et Pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Camilo Félix
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
| | - Tomasz J Guzik
- Department of Internal and Agricultural Medicine, Jagiellonian University, Collegium Medicum, Krakow, Poland; British Heart Foundation Centre for Cardiovascular Research, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Robert G Hart
- Population Health Research Institute, Hamilton Ontario, Canada; Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Aldo P Maggioni
- Italian Association of Hospital Cardiologists Research Center, Florence, Italy
| | | | - Mukul Sharma
- Population Health Research Institute, Hamilton Ontario, Canada; Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Salim Yusuf
- Population Health Research Institute, Hamilton Ontario, Canada; Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Long-term residual cardiovascular risk after acute coronary syndrome: antithrombotic treatment options. Neth Heart J 2021; 30:38-46. [PMID: 34357557 PMCID: PMC8724500 DOI: 10.1007/s12471-021-01604-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 10/26/2022] Open
Abstract
The residual risk of patients surviving until 1 year after acute coronary syndromes (ACS) is still high, despite secondary prevention. The cornerstone of treatment of patients with ACS is dual antiplatelet therapy (DAPT) consisting of low-dose aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) for 12 months, or less in those patients at higher risk for bleeding. To reduce the residual risk beyond 1 year in those patients not at high bleeding risk who tolerated DAPT and did not suffer an (ischaemic or bleeding) event would intuitively mean to prolong DAPT. However, prolonged DAPT always comes at the cost of more bleeding. Therefore, assessing both ischaemic and bleeding risk in these patients at 1 year after ACS is crucial. In addition, another antithrombotic treatment consisting of low-dose rivaroxaban combined with low-dose aspirin has been shown to reduce ischaemic events. In this review, we describe residual thrombotic risk at 1 year after ACS, evaluate the evidence for antithrombotic options beyond 1 year and provide a practical guide to determine which patients would benefit the most from these therapies.
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ten Cate H, Guzik TJ, Eikelboom J, Spronk HMH. Pleiotropic actions of factor Xa inhibition in cardiovascular prevention: mechanistic insights and implications for anti-thrombotic treatment. Cardiovasc Res 2021; 117:2030-2044. [PMID: 32931586 PMCID: PMC8318102 DOI: 10.1093/cvr/cvaa263] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/10/2020] [Accepted: 09/03/2020] [Indexed: 12/12/2022] Open
Abstract
Atherosclerosis is a chronic inflammatory disease in which atherothrombotic complications lead to cardiovascular morbidity and mortality. At advanced stages, myocardial infarction, ischaemic stroke, and peripheral artery disease, including major adverse limb events, are caused either by acute occlusive atherothrombosis or by thromboembolism. Endothelial dysfunction, vascular smooth muscle cell activation, and vascular inflammation are essential in the development of acute cardiovascular events. Effects of the coagulation system on vascular biology extend beyond thrombosis. Under physiological conditions, coagulation proteases in blood are pivotal in maintaining haemostasis and vascular integrity. Under pathological conditions, including atherosclerosis, the same coagulation proteases (including factor Xa, factor VIIa, and thrombin) become drivers of atherothrombosis, working in concert with platelets and vessel wall components. While initially atherothrombosis was attributed primarily to platelets, recent advances indicate the critical role of fibrin clot and plasma coagulation factors. Mechanisms of atherothrombosis and hypercoagulability vary depending on plaque erosion or plaque rupture. In addition to contributing to thrombus formation, factor Xa and thrombin can affect endothelial dysfunction, oxidative stress, vascular smooth muscle cell function as well as immune cell activation and vascular inflammation. By these mechanisms, they promote atherosclerosis and contribute to plaque instability. In this review, we first discuss the postulated vasoprotective mechanisms of protease-activated receptor signalling induced by coagulation enzymes under physiological conditions. Next, we discuss preclinical studies linking coagulation with endothelial cell dysfunction, thromboinflammation, and atherogenesis. Understanding these mechanisms is pivotal for the introduction of novel strategies in cardiovascular prevention and therapy. We therefore translate these findings to clinical studies of direct oral anticoagulant drugs and discuss the potential relevance of dual pathway inhibition for atherothrombosis prevention and vascular protection.
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Affiliation(s)
- Hugo ten Cate
- Department of Internal Medicine, Thrombosis Expertise Center, Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 50, PO Box 616, 6200 MD, Maastricht, The Netherlands
- Department of Biochemistry, Thrombosis Expertise Center, Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 50, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Tomasz J Guzik
- Institute of Cardiovascular & Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, Glasgow, UK
- Department of Medicine, Jagiellonian University, Collegium Medicum, Krakow, Poland
| | - John Eikelboom
- Population Health Research Institute, Hamilton General Hospital and McMaster University, Hamilton, L8L 2x2, ON, Canada
| | - Henri M H Spronk
- Department of Internal Medicine, Thrombosis Expertise Center, Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 50, PO Box 616, 6200 MD, Maastricht, The Netherlands
- Department of Biochemistry, Thrombosis Expertise Center, Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 50, PO Box 616, 6200 MD, Maastricht, The Netherlands
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Vinokurov IA. Acute lower limb ischemia in the context of the COVID-19 pandemic. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2021-2932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Halperin JL, Chen H, Olin JW. Antithrombotic Therapy to Reduce Mortality in Patients With Atherosclerosis: 2 Pathways to a Single Goal. J Am Coll Cardiol 2021; 78:24-26. [PMID: 34210410 DOI: 10.1016/j.jacc.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/10/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Jonathan L Halperin
- Cardiovascular Institute, Mount Sinai Medical Center, New York, New York, USA.
| | - Huazhen Chen
- Cardiovascular Institute, Mount Sinai Medical Center, New York, New York, USA
| | - Jeffrey W Olin
- Cardiovascular Institute, Mount Sinai Medical Center, New York, New York, USA
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Ajjan RA, Kietsiriroje N, Badimon L, Vilahur G, Gorog DA, Angiolillo DJ, Russell DA, Rocca B, Storey RF. Antithrombotic therapy in diabetes: which, when, and for how long? Eur Heart J 2021; 42:2235-2259. [PMID: 33764414 PMCID: PMC8203081 DOI: 10.1093/eurheartj/ehab128] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/26/2021] [Accepted: 02/23/2021] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular disease remains the main cause of mortality in individuals with diabetes mellitus (DM) and also results in significant morbidity. Premature and more aggressive atherosclerotic disease, coupled with an enhanced thrombotic environment, contributes to the high vascular risk in individuals with DM. This prothrombotic milieu is due to increased platelet activity together with impaired fibrinolysis secondary to quantitative and qualitative changes in coagulation factors. However, management strategies to reduce thrombosis risk remain largely similar in individuals with and without DM. The current review covers the latest in the field of antithrombotic management in DM. The role of primary vascular prevention is discussed together with options for secondary prevention following an ischaemic event in different clinical scenarios including coronary, cerebrovascular, and peripheral artery diseases. Antiplatelet therapy combinations as well as combination of antiplatelet and anticoagulant agents are examined in both the acute phase and long term, including management of individuals with sinus rhythm and those with atrial fibrillation. The difficulties in tailoring therapy according to the variable atherothrombotic risk in different individuals are emphasized, in addition to the varying risk within an individual secondary to DM duration, presence of complications and predisposition to bleeding events. This review provides the reader with an up-to-date guide for antithrombotic management of individuals with DM and highlights gaps in knowledge that represent areas for future research, aiming to improve clinical outcome in this high-risk population.
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Affiliation(s)
- Ramzi A Ajjan
- The LIGHT Laboratories, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 7JT, UK
| | - Noppadol Kietsiriroje
- The LIGHT Laboratories, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 7JT, UK.,Endocrinology and Metabolism Unit, Internal Medicine Department, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand
| | - Lina Badimon
- Cardiovascular Program ICCC, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Sant Antoni M. Claret 167, 08025 Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Instituto de Salud Carlos III, Sant Antoni M. Claret 167, 08025 Barcelona, Spain.,Cardiovascular Research Chair, Universidad Autónoma Barcelona (UAB), Sant Antoni M. Claret 167, 08025 Barcelona, Spain
| | - Gemma Vilahur
- Cardiovascular Program ICCC, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Sant Antoni M. Claret 167, 08025 Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Instituto de Salud Carlos III, Sant Antoni M. Claret 167, 08025 Barcelona, Spain
| | - Diana A Gorog
- University of Hertfordshire, College Lane Campus Hatfield, Hertfordshire AL10 9AB, UK.,National Heart and Lung Institute, Guy Scadding Building, Dovehouse St, London SW3 6LY, UK
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, 655 West, 8th Street, Jacksonville, FL 32209, USA
| | - David A Russell
- The LIGHT Laboratories, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 7JT, UK.,Leeds Vascular Institute, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK
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48
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Minami HR, Itoga NK, George EL, Garcia-Toca M. Cost-effectiveness analysis of ankle-brachial index screening in patients with coronary artery disease to optimize medical management. J Vasc Surg 2021; 74:2030-2039.e2. [PMID: 34175383 DOI: 10.1016/j.jvs.2021.05.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 05/17/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Screening for peripheral artery disease (PAD) with the ankle-brachial index (ABI) test is currently not recommended in the general population; however, previous studies advocate screening in high-risk populations. Although providers may be hesitant to prescribe low-dose rivaroxaban to patients with coronary artery disease (CAD) alone, given the reduction in cardiovascular events and death associated with rivaroxaban, screening for PAD with the ABI test and accordingly prescribing rivaroxaban may provide additional benefits. We sought to describe the cost-effectiveness of screening for PAD in patients with CAD to optimize this high-risk populations' medical management. METHODS We used a Markov model to evaluate the ABI test in patients with CAD. We assumed that all patients screened would be candidates for low-dose rivaroxaban. We assessed the cost of ABI screening at $100 per patient and added additional charges for physician visits ($100) and rivaroxaban cost ($470 per month). We used a 30-day cycle and performed analysis over 35 years. We evaluated quality-adjusted life years (QALYs) from previous studies and determined the incremental cost-effectiveness ratio (ICER) according to our model. We performed a deterministic and probabilistic sensitivity analyses of variables with uncertainty and reported them in a Tornado diagram showing the variables with the greatest effect on the ICER. RESULTS Our model estimates decision costs to screen or not screen at $94,953 and $82,553, respectively. The QALYs gained from screening was 0.060, generating an ICER of $207,491 per QALY. Factors most influential on the ICER were the reduction in all-cause mortality associated with rivaroxaban and the prohibitively high cost of rivaroxaban. If rivaroxaban cost less than $95 per month, this would make screening cost-effective based on a willingness to pay threshold of $50,000 per QALY. CONCLUSIONS According to our model, screening patients with CAD for PAD to start low-dose rivaroxaban is not currently cost-effective due to insufficient reduction in all-cause mortality and high medication costs. Nevertheless, vascular surgeons have a unique opportunity to prescribe or advocate for low-dose rivaroxaban in patients with PAD to improve cardiovascular outcomes.
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Affiliation(s)
- Hataka R Minami
- Undergraduate Medical Education, Saint Louis University School of Medicine, St Louis, Mo.
| | - Nathan K Itoga
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, Calif
| | - Elizabeth L George
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, Calif
| | - Manuel Garcia-Toca
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, Calif
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Patti G, Fattirolli F, De Luca L, Renda G, Marcucci R, Parodi G, Perna GP, Andreotti F, Ghiglieno C, Fedele F, Marchionni N. Updated antithrombotic strategies to reduce the burden of cardiovascular recurrences in patients with chronic coronary syndrome. Biomed Pharmacother 2021; 140:111783. [PMID: 34102448 DOI: 10.1016/j.biopha.2021.111783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/23/2021] [Accepted: 05/25/2021] [Indexed: 12/24/2022] Open
Abstract
Despite recent achievements in secondary cardiovascular prevention, the risk of further events in patients with chronic coronary syndromes (CCS) remains elevated. Highest risk is seen in patients with recurrent events, comorbidities or multisite atherosclerosis. Optimising antithrombotic strategies in this setting may significantly improve outcomes. The higher the baseline risk, the higher the absolute event reduction with approaches using combined antithrombotic treatments. Tailoring such strategies to the individual patient risk appears crucial to achieve net benefit (i.e., substantial ischaemic event prevention at a limited cost in terms of bleeding). This paper focuses on antithrombotic and non-pharmacological approaches to secondary cardiovascular disease prevention in CCS. In particular, we critically review current evidence on the use of dual antithrombotic therapy, including the newest approach of aspirin plus low-dose anticoagulation and its net clinical outcome according to baseline risk.
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Affiliation(s)
- Giuseppe Patti
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy.
| | - Francesco Fattirolli
- Department of Clinical and Experimental Medicine, University of Florence, Careggi Hospital, Florence, Italy
| | - Leonardo De Luca
- Department of Cardiosciences, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Giulia Renda
- Institute of Cardiology, Department of Neuroscience, Imaging and Clinical Sciences, G. d'Annunzio University, Chieti-Pescara, Italy
| | - Rossella Marcucci
- Department of Clinical and Experimental Medicine, University of Florence, Careggi Hospital, Florence, Italy
| | - Guido Parodi
- Department of Medical Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | | | | | - Chiara Ghiglieno
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Francesco Fedele
- Department of Cardiovascular and Respiratory Sciences-Sapienza University of Rome, Rome, Italy
| | - Niccolò Marchionni
- Department of Clinical and Experimental Medicine, University of Florence, Careggi Hospital, Florence, Italy
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Rahmatian D, Barry AR. Antiplatelet therapy with or without anticoagulant therapy for lower extremity peripheral artery disease: A systematic review. Am J Health Syst Pharm 2021; 78:2132-2141. [PMID: 34059879 DOI: 10.1093/ajhp/zxab226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To identify randomized controlled trials that compared antiplatelet monotherapy to combination antiplatelet plus anticoagulant therapy and evaluated major adverse cardiovascular events (MACE) or major adverse limb events (MALE), death, or bleeding in patients with lower extremity peripheral artery disease (PAD). SUMMARY A systematic search of MEDLINE, Embase, and CENTRAL databases revealed 5 trials. Two trials consisted of patients with stable PAD, while 3 trials examined patients with PAD post revascularization. Antiplatelet therapy was mostly aspirin (81-325 mg daily), and anticoagulation included rivaroxaban 2.5 mg twice daily or warfarin. Duration of follow-up ranged from 12 to 38 months. Two trials had low risk of bias, whereas 3 trials had high/unclear risk of bias. For patients with stable PAD, one trial showed that use of warfarin (or acenocoumarol) with antiplatelet therapy did not reduce MACE, MALE, or cardiovascular or all-cause death but increased the risk of life-threatening bleeding. A second trial demonstrated that low-dose rivaroxaban plus antiplatelet therapy lowered the risk of MACE and MALE, with no effect in preventing cardiovascular or all-cause death, but increased the risk of major bleeding. For patients with PAD post revascularization receiving warfarin and antiplatelet therapy, 2 trials showed no benefit in MACE or MALE but increased or similar rates of all-cause death and major bleeding. In a third trial, low-dose rivaroxaban plus aspirin reduced occurrence of the composite of MACE and MALE but increased major bleeding, with no effect on cardiovascular or all-cause death. CONCLUSION Dual-pathway inhibition with low-dose rivaroxaban and aspirin reduced MACE and MALE in patients with stable or revascularized PAD, but net clinical benefit is questionable.
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Affiliation(s)
- Donna Rahmatian
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada, and St. Paul's Hospital, Lower Mainland Pharmacy Services, Vancouver, Canada
| | - Arden R Barry
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada, and Chilliwack General Hospital, Lower Mainland Pharmacy Services, Chilliwack, Canada
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