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Guan X, Chen M, Li Y, Zhang J, Xu L, Sun H, Zhang D, Wang L, Yang X. Comparison of Safety between Different Kinds of Heparins in Patients Receiving Intra-Aortic Balloon Counterpulsation. Thorac Cardiovasc Surg 2020; 69:511-517. [PMID: 32998166 PMCID: PMC8455177 DOI: 10.1055/s-0040-1716390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background
The present study aimed to compare the effectiveness and safety of low molecular-weight-heparin (LMWH) and unfractionated heparin (UFH) in acute myocardial infarction (AMI) patients receiving intra-aortic balloon counterpulsation (IABP).
Materials and Methods
We retrospectively analyzed a total of 344 patients receiving IABP for cardiogenic shock, severe heart failure, ventricular septal rupture, or mitral valve prolapse due to AMI. A total of 161 patients received UFH (a bolus injection 70 U/kg immediately after IABP, followed by infusion at a rate of 15 U/kg/hour and titration to for 50 to 70 seconds of activated partial thromboplastin time. A total of 183 patients received LMWH (subcutaneous injection of 1.0 mg/kg every 12 hours for 5 to 7 days and 1.0 mg/kg every 24 hours thereafter). Events of ischemia, arterial thrombosis or embolism, and bleeding during IABP were evaluated. Major bleeding was defined as a hemoglobin decrease by >50 g/L (vs. prior to IABP) or bleeding that caused hemodynamic shock or life-threatening or requiring blood transfusion.
Results
Subjects receiving UFH and LMWH did not differ in baseline characteristics. Ischemia was noted in five (3.1%) and two (1.1%) subjects in UFH and LMWH groups, respectively. Arterial thromboembolism occurred in three (1.9%) subjects in the UFH group, but not in the LMWH group. Logistic regression analysis failed to reveal an association between ischemia or bleeding with heparin type. Major bleeding occurred in 16 (9.9%) and six (3.3%) patients in the UFH and LWMH groups, respectively (
p
= 0.014). Regression analysis indicated that LMWH is associated with less major bleeding.
Conclusion
LMWH could reduce the risk of major bleeding in patients receiving IABP. Whether LMWH could reduce arterial thromboembolism needs further investigation.
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Affiliation(s)
- Xiaonan Guan
- Center of Cardiology, Beijing Chaoyang Hospital, Beijing, People's Republic of China
| | - Mulei Chen
- Center of Cardiology, Beijing Chaoyang Hospital, Beijing, People's Republic of China
| | - Yanbing Li
- Center of Cardiology, Beijing Chaoyang Hospital, Beijing, People's Republic of China
| | - Jianjun Zhang
- Center of Cardiology, Beijing Chaoyang Hospital, Beijing, People's Republic of China
| | - Li Xu
- Center of Cardiology, Beijing Chaoyang Hospital, Beijing, People's Republic of China
| | - Hao Sun
- Center of Cardiology, Beijing Chaoyang Hospital, Beijing, People's Republic of China
| | - Dapeng Zhang
- Center of Cardiology, Beijing Chaoyang Hospital, Beijing, People's Republic of China
| | - Lefeng Wang
- Center of Cardiology, Beijing Chaoyang Hospital, Beijing, People's Republic of China
| | - Xinchun Yang
- Center of Cardiology, Beijing Chaoyang Hospital, Beijing, People's Republic of China
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2
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Feldman DN, Wang TY, Chen AY, Swaminathan RV, Kim LK, Wong SC, Minutello RM, Bergman G, Singh HS, Madias C. In-Hospital Bleeding Outcomes of Myocardial Infarction in the Era of Warfarin and Direct Oral Anticoagulants for Atrial Fibrillation in the United States: A Report From the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry. J Am Heart Assoc 2020; 8:e011606. [PMID: 30955406 PMCID: PMC6507194 DOI: 10.1161/jaha.118.011606] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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 We sought to examine patient characteristics, peri‐infarction invasive and pharmacologic management, and in‐hospital major bleeding in myocardial infarction patients with atrial fibrillation or flutter, based on home anticoagulant use. Methods and Results We stratified patients by home anticoagulant: (1) no anticoagulant, (2) warfarin, and (3) direct oral anticoagulants (DOACs) among ST‐segment–elevation myocardial infarction (STEMI) and non‐STEMI (NSTEMI) patients with atrial fibrillation or flutter treated at 761 US hospitals in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry from January 2015 to December 2016. The primary outcome of our study was in‐hospital major bleeding. Multivariable logistic regression was used to examine the independent association between home anticoagulant and in‐hospital major bleeding. Among 6471 STEMI patients with atrial fibrillation or flutter, 15.7% were on warfarin and 13.0% on DOACs; among 19 954 NSTEMI patients, 22.8% were on warfarin and 15.4% on DOACs. In STEMI, door‐to‐balloon times were slightly higher in those on anticoagulant, with similar rates of angiography within 24 hours in the 3 groups. NSTEMI patients on anticoagulant were less likely to undergo angiography (49.3% no anticoagulant, 33.4% on warfarin, 36.4% on DOACs; P<0.01) or percutaneous coronary intervention within 24 hours (21.1% no anticoagulant, 14.3% on warfarin, 15.9% on DOACs; P<0.01). After multivariate adjustment, use of home warfarin (odds ratio: 1.00 [95% CI, 0.79–1.27] in STEMI and 1.13 [95% CI, 0.97–1.30] in NSTEMI) or DOAC (odds ratio: 0.93 [95% CI, 0.73–1.20] in STEMI and 0.97 [95% CI, 0.81–1.16] in NSTEMI) was not associated with increased in‐hospital major bleeding compared with no anticoagulant. Conclusions In routine clinical practice, home warfarin or DOAC therapy is not associated with an increased risk of in‐hospital bleeding compared with no anticoagulant.
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Affiliation(s)
- Dmitriy N Feldman
- 1 Weill Cornell Medical College New York Presbyterian Hospital New York NY
| | - Tracy Y Wang
- 2 Duke Clinical Research Institute Duke University Medical Center Durham NC
| | - Anita Y Chen
- 2 Duke Clinical Research Institute Duke University Medical Center Durham NC
| | | | - Luke K Kim
- 1 Weill Cornell Medical College New York Presbyterian Hospital New York NY
| | - S Chiu Wong
- 1 Weill Cornell Medical College New York Presbyterian Hospital New York NY
| | - Robert M Minutello
- 1 Weill Cornell Medical College New York Presbyterian Hospital New York NY
| | - Geoffrey Bergman
- 1 Weill Cornell Medical College New York Presbyterian Hospital New York NY
| | - Harsimran S Singh
- 1 Weill Cornell Medical College New York Presbyterian Hospital New York NY
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Mason PJ, Shah B, Tamis-Holland JE, Bittl JA, Cohen MG, Safirstein J, Drachman DE, Valle JA, Rhodes D, Gilchrist IC. An Update on Radial Artery Access and Best Practices for Transradial Coronary Angiography and Intervention in Acute Coronary Syndrome: A Scientific Statement From the American Heart Association. Circ Cardiovasc Interv 2019; 11:e000035. [PMID: 30354598 DOI: 10.1161/hcv.0000000000000035] [Citation(s) in RCA: 304] [Impact Index Per Article: 60.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Transradial artery access for percutaneous coronary intervention is associated with lower bleeding and vascular complications than transfemoral artery access, especially in patients with acute coronary syndromes. A growing body of evidence supports adoption of transradial artery access to improve acute coronary syndrome-related outcomes, to improve healthcare quality, and to reduce cost. The purpose of this scientific statement is to propose and support a "radial-first" strategy in the United States for patients with acute coronary syndromes. This document also provides an update to previously published statements on transradial artery access technique and best practices, particularly as they relate to the management of patients with acute coronary syndromes.
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4
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Utility of the HAS-BLED score for risk stratification of patients with acute coronary syndrome. Heart Vessels 2019; 34:1621-1630. [PMID: 30969359 DOI: 10.1007/s00380-019-01405-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 04/05/2019] [Indexed: 12/12/2022]
Abstract
HAS-BLED score was developed for bleeding prediction in patients with atrial fibrillation (AF). Recently, it was also used in patients undergoing percutaneous coronary interventions (PCI). This study analyzes the HAS-BLED predictivity for bleedings and mortality in patients with acute coronary syndromes (ACS) without AF, and evaluates the utilization of alternative criteria for renal dysfunction. The study population was composed of 704 patients with ACS. Six-hundred and eleven patients completed the follow-up. The HAS-BLED score was calculated both using the original definition of renal dysfunction, both using three alternative eGFR thresholds (< 30, < 60 and ≤ 90 ml/min/1.73 mq). In-hospital and post-discharge bleedings and mortality were recorded, and calibration and discrimination of the various risk models were evaluated using the Hosmer-Lemeshow test and the C-statistic. In-hospital bleedings were 4.7% and mortality was 2.7%. Post-discharge bleedings were 3.1% and mortality was 4.4%. Regarding bleeding events and in-hospital mortality, the HAS-BLED original risk model demonstrated a moderate-to-good discriminative performance (C-statistics from 0.65 to 0.76). No significant differences were found in predictive accuracy when applying alternative definitions of renal dysfunction based on eGFR, with the exception of post-discharge mortality, for which HAS-BLED model assuming an eGFR value < 60 ml/min/1.73 mq showed a discriminative performance significantly higher in comparison to the other risk models (C-statistic 0.71 versus 0.64-0.66). In conclusion, in our ACS population, the HAS-BLED risk score showed a fairly good predictive accuracy regarding in-hospital and follow-up bleeding events and in-hospital mortality. The use of renal dysfunction alternative criteria based on eGFR values resulted in out-of hospital mortality predictive accuracy enhancement.
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5
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Higuchi S, Matsushita K, Niina Y, Sakata K, Satoh T, Yoshino H. Myocardial Injury Caused by Severe Blow: Importance of Carefulness in Accurate Diagnosis. Int Heart J 2018; 59:845-847. [PMID: 29794383 DOI: 10.1536/ihj.17-345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Blunt chest trauma may lead to cardiac involvement such as myocardial contusion, coronary artery dissection, cardiac rupture, or myocardial infarction. Early detection and treatment of complications such as these are essential. We describe a case status post collision with an iron ball and discuss how to detect myocardial infarction. We emphasize the importance of careful interview, physical examination, and electrocardiogram even in seemingly healthy patients. A severe blow, such as that described, can impair coronary artery flow and may potentially cause myocardial infarction.
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Affiliation(s)
- Satoshi Higuchi
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine
| | - Kenichi Matsushita
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine
| | - Yoshihiro Niina
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine
| | - Konomi Sakata
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine
| | - Toru Satoh
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine
| | - Hideaki Yoshino
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine
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6
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Comparison of CRUSADE and ACUITY-HORIZONS Bleeding Risk Scores in Patients With Acute Coronary Syndromes. Heart Lung Circ 2018. [PMID: 29526417 DOI: 10.1016/j.hlc.2018.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Compare the discriminative performance of two validated bleeding risk models for in-hospital bleeding events in a non-selected cohort of acute coronary syndrome (ACS) patients. METHODS CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) and ACUITY-HORIZONS (Acute Catheterization and Urgent Intervention Triage strategY-Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) scores were calculated in 501 consecutive patients (median age 68 years (IQR 57-77), 31% female) admitted for ACS to the coronary care unit (CCU) of San Paolo Hospital in Milan (Italy). In-hospital haemorrhagic events and mortality were recorded and calibration and discrimination of the two risk models were evaluated using the Hosmer-Lemeshow test and the C-statistic, respectively. RESULTS Overall bleeding events were observed in 32 patients and major bleedings in 11 (with an incidence of 6.4% and 2.2%, respectively). In-hospital mortality was 2.6%. Regarding major bleedings both risk scores demonstrated an adequate calibration (H-L test p>0.20) and a moderate discrimination with no significant difference in predictive accuracy between the two models (C-statistic 0.69 for CRUSADE and 0.73 for ACUITY-HORIZONS). We also tested the performance of the two risk models in predicting in-hospital mortality, showing an adequate calibration and a very good discrimination (C-statistic 0.88 and 0.89 for the CRUSADE and ACUITY-HORIZONS scores, respectively), with no significant difference in predictive accuracy. CONCLUSIONS In our ACS population the CRUSADE and the ACUITY-HORIZONS risk scores showed a fairly good and comparable predictive accuracy regarding in-hospital bleeding events and they appeared to be very good predictors of in-hospital mortality.
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7
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Capodanno D, Caterina RD. Bivalirudin for acute coronary syndromes: premises, promises and doubts. Thromb Haemost 2017; 113:698-707. [DOI: 10.1160/th14-09-0765] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 10/10/2014] [Indexed: 12/30/2022]
Abstract
SummaryBivalirudin is a valuable anticoagulant option in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention. Advantages over heparin as a parenteral anticoagulant include more predictable pharmacokinetics and pharmacodynamics, shorter half-life, no need for cofactors, some degree of antiplatelet effect, and the ability to inhibit clot-bound thrombin. Clinical evidence supporting the use of bivalirudin over heparin in current ACS guidelines, however, derives mostly from early randomised trials that may no longer reflect current management patterns, now including the use of oral antiplatelet agents more potent than clopidogrel (i.e. prasugrel or ticagrelor) and a broader implementation of strategies to reduce bleeding (i.e. radial access for percutaneous coronary intervention, and use of glycoprotein IIb/IIIa inhibitors only in bailout situations). Defining the fine balance between bivalirudin efficacy and safety over heparins in the context of other antithrombotic treatments remains a challenge in clinical practice, particularly in a fast-evolving scenario, such as ACS, where numerous new trials have been presented in very recent times. Here we provide an up-to-date overview of the evidence on the use of bivalirudin in ACS, with focus on new data, open issues, and future directions.
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Cornara S, Somaschini A, De Servi S, Crimi G, Ferlini M, Baldo A, Camporotondo R, Gnecchi M, Ferrario Ormezzano M, Oltrona Visconti L, De Ferrari GM. Prognostic Impact of in-Hospital-Bleeding in Patients With ST-Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention. Am J Cardiol 2017; 120:1734-1741. [PMID: 28865893 DOI: 10.1016/j.amjcard.2017.07.076] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/14/2017] [Accepted: 07/20/2017] [Indexed: 12/01/2022]
Abstract
Several studies established a link between bleeding and mortality in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI); however, it is unclear whether bleeding has a direct role in worsening the prognosis or if it is simply a marker of patient frailty. We investigated whether bleeding is an independent predictor of mortality in patients with STEMI treated with pPCI. The relationship between the presence of heart failure on presentation (Killip classification), bleeding occurrence, and outcome was also assessed. Bleeding was defined as the combination of Thrombolysis in Myocardial Infarction major and minor bleeding. Short- and long-term mortalities were estimated using the Kaplan-Meyer analysis. Multivariable analysis was performed by the Cox regression model. As an alternative method to address the potential confounding factors, we performed a propensity-matched analysis adjusted for all variables included in the CRUSADE score. In the 1,911 consecutive patients with STEMI considered, bleeding (observed in 11.4% of patients) was an independent predictor of 30-day (hazard ratio 2.61, 95% confidence interval 1.30 to 5.25, p = 0.007) and 1-year mortality (hazard ratio 1.98, 95% confidence interval 1.13 to 3.47, p = 0.017) but not in a landmark analysis starting from 30 days to 1 year. Bleeding was significantly associated with higher 30-day and 1-year mortality in patients with Killip class ≥II, but not in patients with Killip class I. In conclusion, in-hospital bleeding is independently associated with increased mortality in the early period after STEMI, also after adjusting for variables associated with the risk of bleeding. Bleeding was associated with increased mortality in patients with signs of heart failure at admission, whereas it had no effects in patients with Killip class I.
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Affiliation(s)
- Stefano Cornara
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, Unit of Cardiology, University of Pavia, Pavia, Italy
| | - Alberto Somaschini
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, Unit of Cardiology, University of Pavia, Pavia, Italy
| | | | - Gabriele Crimi
- Division of Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marco Ferlini
- Division of Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Baldo
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, Unit of Cardiology, University of Pavia, Pavia, Italy
| | - Rita Camporotondo
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Massimiliano Gnecchi
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, Unit of Cardiology, University of Pavia, Pavia, Italy
| | | | | | - Gaetano M De Ferrari
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, Unit of Cardiology, University of Pavia, Pavia, Italy.
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Baeza-Román A, de Miguel-Balsa E, Latour-Pérez J, Carrillo-López A. Predictive power of the grace score in population with diabetes. Int J Cardiol 2017; 248:73-76. [PMID: 28747270 DOI: 10.1016/j.ijcard.2017.06.083] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 06/20/2017] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Current clinical practice guidelines recommend risk stratification in patients with acute coronary syndrome (ACS) upon admission to hospital. Diabetes mellitus (DM) is widely recognized as an independent predictor of mortality in these patients, although it is not included in the GRACE risk score. OBJECTIVES The objective of this study is to validate the GRACE risk score in a contemporary population and particularly in the subgroup of patients with diabetes, and to test the effects of including the DM variable in the model. MATERIAL AND METHODS Retrospective cohort study in patients included in the ARIAM-SEMICYUC registry, with a diagnosis of ACS and with available in-hospital mortality data. We tested the predictive power of the GRACE score, calculating the area under the ROC curve. We assessed the calibration of the score and the predictive ability based on type of ACS and the presence of DM. Finally, we evaluated the effect of including the DM variable in the model by calculating the net reclassification improvement. RESULTS The GRACE score shows good predictive power for hospital mortality in the study population, with a moderate degree of calibration and no significant differences based on ACS type or the presence of DM. Including DM as a variable did not add any predictive value to the GRACE model. CONCLUSIONS The GRACE score has an appropriate predictive power, with good calibration and clinical applicability in the subgroup of diabetic patients.
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Affiliation(s)
- Anna Baeza-Román
- Intensive Care Unit, Hospital General Universitario de Elche, Elche, Spain.
| | | | - Jaime Latour-Pérez
- Intensive Care Unit, Hospital General Universitario de Elche, Elche, Spain
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10
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De Luca L, Colivicchi F, Gulizia MM, Pugliese FR, Ruggieri MP, Musumeci G, Cibinel GA, Romeo F. Clinical pathways and management of antithrombotic therapy in patients with acute coronary syndrome (ACS): a Consensus Document from the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Cardiology (SIC), Italian Society of Emergency Medicine (SIMEU) and Italian Society of Interventional Cardiology (SICI-GISE). Eur Heart J Suppl 2017; 19:D130-D150. [PMID: 28751840 PMCID: PMC5520755 DOI: 10.1093/eurheartj/sux013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antiplatelet therapy is the cornerstone of the pharmacologic management of patients with acute coronary syndrome (ACS). Over the last years, several studies have evaluated old and new oral or intravenous antiplatelet agents in ACS patients. In particular, research was focused on assessing superiority of two novel platelet ADP P2Y12 receptor antagonists (i.e., prasugrel and ticagrelor) over clopidogrel. Several large randomized controlled trials have been undertaken in this setting and a wide variety of prespecified and post-hoc analyses are available that evaluated the potential benefits of novel antiplatelet therapies in different subsets of patients with ACS. The aim of this document is to review recent data on the use of current antiplatelet agents for in-hospital treatment of ACS patients. In addition, in order to overcome increasing clinical challenges and implement effective therapeutic interventions, this document identifies all potential specific care pathway for ACS patients and accordingly proposes individualized therapeutic options.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, San Giovanni Evangelista Hospital, Via Parrozzani, 3, 00019 Tivoli, Rome, Italy
| | | | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | | | | | - Giuseppe Musumeci
- Division of Cardiology, Papa Giovanni XXIII Hospital, Bergamo, Italy
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11
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Safley DM, Venkitachalam L, Kennedy KF, Cohen DJ. Impact of Glycoprotein IIb/IIIa Inhibition in Contemporary Percutaneous Coronary Intervention for Acute Coronary Syndromes: Insights From the National Cardiovascular Data Registry. JACC Cardiovasc Interv 2016; 8:1574-82. [PMID: 26493250 DOI: 10.1016/j.jcin.2015.04.031] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/13/2015] [Accepted: 04/23/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study investigates the effects of glycoprotein IIb/IIIa inhibitors (GPIs) on outcomes after percutaneous coronary intervention (PCI). BACKGROUND Ischemic complications are reduced after PCI when a GPI is added to heparin. However, there are limited data on the safety and efficacy in contemporary PCI. METHODS We used the National Cardiovascular Data Registry CathPCI Registry data to assess the association between GPI use and PCI outcomes for acute coronary syndrome between July 2009 and September 2011. The primary outcome was all-cause in-hospital mortality. The secondary outcome was major bleeding. To adjust for potential bias, we used multivariable logistic regression, propensity-matched (PM) analysis, and instrumental variable analysis (IVA). RESULTS There were 970,865 patients included; 326,283 (33.6%) received a GPI. Unadjusted mortality and major bleeding were more common with a GPI (2.4% vs. 1.4% and 3.7% vs. 1.5%, respectively; p < 0.001 for both). In contrast, GPI use was associated with lower mortality on adjusted analyses; relative risks range from 0.72 (95% confidence interval [CI]: 0.50 to 0.97) with IVA to 0.90 (95% CI: 0.86 to 0.95) with PM. The association of GPI use with bleeding remained in adjusted analyses (multivariable relative risk: 1.93, 95% CI: 1.83 to 2.04; PM relative risk: 1.83, 95% CI: 1.74 to 1.92; and IVA relative risk: 1.53, 95% CI: 1.27 to 2.13). Subgroup analysis revealed enhanced risk reduction with ST-segment elevation myocardial infarction, high predicted mortality, and heparin-based anticoagulation. CONCLUSIONS In unselected acute coronary syndrome patients undergoing PCI, GPI use was associated with reduced in-hospital mortality and increased bleeding. In the modern era of PCI, there may still be a role for the judicious use of GPIs.
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Affiliation(s)
- David M Safley
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri.
| | - Lakshmi Venkitachalam
- Department of Biomedical & Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - David J Cohen
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
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12
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Fahrni G, Wolfrum M, De Maria GL, Banning AP, Benedetto U, Kharbanda RK. Prolonged High-Dose Bivalirudin Infusion Reduces Major Bleeding Without Increasing Stent Thrombosis in Patients Undergoing Primary Percutaneous Coronary Intervention: Novel Insights From an Updated Meta-Analysis. J Am Heart Assoc 2016; 5:JAHA.116.003515. [PMID: 27451466 PMCID: PMC5015387 DOI: 10.1161/jaha.116.003515] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background The optimal antithrombotic therapy in patients with ST‐segment‐elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI) remains a matter of debate. This updated meta‐analysis investigated the impact of (1) bivalirudin (with and without prolonged infusion) and (2) prolonged PCI‐dose (1.75 mg/hg per hour) bivalirudin infusion compared with conventional antithrombotic therapy on clinical outcomes in patients undergoing primary PCI. Methods and Results Eligible randomized trials were searched through MEDLINE, EMBASE, Cochrane database, and proceedings of major congresses. Prespecified outcomes were major bleeding (thrombolysis in myocardial infarction major and Bleeding Academic Research Consortium 3–5), acute stent thrombosis, as well as all‐cause and cardiac mortality at 30 days. Six randomized trials (n=17 294) were included. Bivalirudin compared with heparin (+/− glycoprotein‐IIb/IIIa inhibitor) was associated with reduction in major bleeding (odds ratio [OR]: 0.65, 95% CI: 0.48–0.88, P=0.006, derived from all 6 trials), increase in acute stent thrombosis (OR: 2.75, 95% CI: 1.46–5.18, P=0.002, 5 trials), and lower rate of all‐cause mortality (OR: 0.81, 95% CI: 0.67–0.98, P=0.03, 6 trials) as well as cardiac mortality (OR: 0.69, 95% CI: 0.55–0.87, P=0.001, 5 trials). The incidence of acute stent thrombosis did not differ between the prolonged PCI‐dose bivalirudin and comparator group (OR: 0.81, 95% CI: 0.27–2.46, P=0.71, 3 trials), whereas the risk of bleeding was reduced despite treatment with high‐dose bivalirudin infusion (OR: 0.28, 95% CI: 0.13–0.60, P=0.001, 3 trials). Conclusions Bivalirudin (with and without prolonged infusion) compared with conventional antithrombotic therapy in ST‐segment‐elevation myocardial infarction patients undergoing primary PCI reduces major bleeding and death, but increases the rate of acute stent thrombosis. However, prolonging the bivalirudin infusion at PCI‐dose (1.75 mg/kg per hour) for 3 hours eliminates the excess risk of acute stent thrombosis, while maintaining the bleeding benefits.
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Affiliation(s)
- Gregor Fahrni
- Oxford Heart Centre, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Mathias Wolfrum
- Oxford Heart Centre, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | | | - Adrian P Banning
- Oxford Heart Centre, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Umberto Benedetto
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, UK
| | - Rajesh K Kharbanda
- Oxford Heart Centre, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
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Kikkert WJ, van Brussel PM, Damman P, Claessen BE, van Straalen JP, Vis MM, Baan J, Koch KT, Peters RJ, de Winter RJ, Piek JJ, Tijssen JGP, Henriques JPS. Influence of chronic kidney disease on anticoagulation levels and bleeding after primary percutaneous coronary intervention in patients treated with unfractionated heparin. J Thromb Thrombolysis 2016; 41:441-51. [PMID: 26238770 PMCID: PMC4799790 DOI: 10.1007/s11239-015-1255-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Unfractionated heparin (UFH) plasma protein binding and elimination might be impaired in patients with chronic kidney disease (CKD-defined as creatinine clearance <60 ml/min). It is currently unknown at which UFH bolus dose persistent prolongation of activated partial thromboplastin time (aPTT) occurs in ST-segment elevation myocardial infarction (STEMI) patients with CKD. We investigated the effect of different UFH bolus doses on the first aPTT measured within 6 and 12 h after PPCI in 1071 STEMI patients with and without CKD undergoing primary percutaneous coronary intervention (PPCI) between 1-1-2003 and 31-07-2008. In the first 6 h after PPCI, aPTT ratio was 5.1 for patients with CKD versus 3.4 for those without (p < 0.001). The proportion of patients with markedly high aPTTs (aPTT ratio ≥ 4 times control) increased with increasing heparin bolus and beyond 130 IU/kg there was a marked difference between patients with and without CKD (74.1 and 42.3 % respectively, p < 0.001). By multivariable analysis, CKD was associated with an increased risk of markedly high aPTTs (odds ratio (OR) 2.04; 95 % confidence interval (CI) 1.27-3.27), driven largely by an increased risk of aPTT prolongation in patients treated with UFH boluses ≥130 IU/kg (OR 3.69; 95 % CI 1.85-7.36; p for interaction = 0.009). In conclusion, CKD is associated with severe persistent aPTT prolongation in STEMI patients undergoing PPCI, possibly due to impaired plasma protein binding and reduced UFH elimination. A lower heparin bolus dose might result in lower aPTTs and less bleeding complications in patients with CKD undergoing PPCI.
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Affiliation(s)
- Wouter J Kikkert
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Peter M van Brussel
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Peter Damman
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Bimmer E Claessen
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jan P van Straalen
- Department of Clinical Chemistry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marije M Vis
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jan Baan
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Karel T Koch
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ron J Peters
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jan J Piek
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jan G P Tijssen
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jose P S Henriques
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Millar JA, Gee ALK. Estimation of clinical and economic effects of prophylaxis against venous thromboembolism in medical patients, including the effect of targeting patients at high-risk. Intern Med J 2016; 46:315-24. [DOI: 10.1111/imj.12995] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 10/07/2015] [Accepted: 01/02/2016] [Indexed: 01/10/2023]
Affiliation(s)
- J. A. Millar
- Department of Medicine; Albany Regional Hospital; Albany Australia
- Medical Education; Curtin University; Perth Western Australia Australia
| | - A. L. K. Gee
- Department of Medicine; Royal Perth Hospital; Perth Western Australia Australia
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Kadakia MB, Rao SV, McCoy L, Choudhuri PS, Sherwood MW, Lilly S, Kobayashi T, Kolansky DM, Wilensky RL, Yeh RW, Giri J. Transradial Versus Transfemoral Access in Patients Undergoing Rescue Percutaneous Coronary Intervention After Fibrinolytic Therapy. JACC Cardiovasc Interv 2015; 8:1868-76. [DOI: 10.1016/j.jcin.2015.07.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 07/08/2015] [Accepted: 07/30/2015] [Indexed: 11/25/2022]
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17
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García ÁA, Muñoz ÓM, Urrea JK, Burbano PX. Validación de la escala CRUSADE para evaluar el riesgo de sangrado en pacientes con infarto agudo de miocardio sin elevación del ST. REVISTA COLOMBIANA DE CARDIOLOGÍA 2015. [DOI: 10.1016/j.rccar.2015.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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18
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Khan R, Lopes RD, Neely ML, Stevens SR, Harrington RA, Diaz R, Cools F, Jansky P, Montalescot G, Atar D, Lopez-Sendon J, Flather M, Liaw D, Wallentin L, Alexander JH, Goodman SG. Characterising and predicting bleeding in high-risk patients with an acute coronary syndrome. Heart 2015; 101:1475-84. [DOI: 10.1136/heartjnl-2014-307346] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 05/27/2015] [Indexed: 12/22/2022] Open
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Arnold SV, Li SX, Alexander KP, Spertus JA, Nallamothu BK, Curtis JP, Kosiborod M, Gupta A, Wang TY, Lin H, Dharmarajan K, Strait KM, Lowe TJ, Krumholz HM. Hospital variability in use of anticoagulant strategies during acute myocardial infarction treated with an early invasive strategy. J Am Heart Assoc 2015; 4:e002009. [PMID: 26077589 PMCID: PMC4599539 DOI: 10.1161/jaha.115.002009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background During a myocardial infarction, no single best approach of systemic anticoagulation is recommended, likely due to a lack of comparative effectiveness studies and trade-offs between treatments. Methods and Results We investigated the patterns of use and site-level variability in anticoagulant strategies (unfractionated heparin [UFH] only, low-molecular-weight heparin [LMWH] only, UFH+LMWH, any bivalirudin) of 63 796 patients with a principal diagnosis of myocardial infarction treated with an early invasive strategy with percutaneous coronary intervention at 257 hospitals. About half (47%) of patients received UFH only, 6% UFH+LMWH, 7% LMWH only, and 40% bivalirudin. Compared with UFH, the median odds ratio was 2.90 for LMWH+UFH, 4.70 for LMWH only, and 3.09 for bivalirudin, indicating that 2 “identical” patients would have a 3- to 4-fold greater likelihood of being treated with anticoagulants other than UFH at one hospital compared with another. We then categorized hospitals as low- or high-users of LMWH and bivalirudin. Using hierarchical, multivariate regression models, we found that low bivalirudin-using hospitals had higher unadjusted bleeding rates, but the risk-adjusted and anticoagulant-adjusted bleeding rates did not differ across the hospital anticoagulation phenotypes. Risk-standardized mortality and risk-standardized length of stay also did not differ across hospital phenotypes. Conclusions We found substantial site-level variability in the choice of anticoagulants for invasively managed acute myocardial infarction patients, even after accounting for patient factors. No single hospital-use pattern was found to be clinically superior. More studies are needed to determine which patients would derive the greatest benefit from various anticoagulants and to support consistent treatment of patients with the optimal anticoagulant strategy.
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Affiliation(s)
- Suzanne V Arnold
- Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas CityKansas City, MO (S.V.A., J.A.S., M.K.)
| | - Shu-Xia Li
- Center for Outcomes Research and Evaluation, Yale-New Haven HospitalNew Haven, CT (S.-X.L., J.P.C., K.D., K.M.S., H.M.K.)
| | | | - John A Spertus
- Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas CityKansas City, MO (S.V.A., J.A.S., M.K.)
| | | | - Jeptha P Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven HospitalNew Haven, CT (S.-X.L., J.P.C., K.D., K.M.S., H.M.K.)
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of MedicineNew Haven, CT (J.P.C., K.D., H.M.K.)
| | - Mikhail Kosiborod
- Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas CityKansas City, MO (S.V.A., J.A.S., M.K.)
| | - Aakriti Gupta
- Department of Internal Medicine, Yale University School of MedicineNew Haven, CT (A.G.)
| | - Tracy Y Wang
- Duke Clinical Research InstituteDurham, NC (K.P.A., T.Y.W.)
| | - Haiqun Lin
- Department of Biostatistics, Yale School of Public HealthNew Haven, CT (H.L.)
| | - Kumar Dharmarajan
- Center for Outcomes Research and Evaluation, Yale-New Haven HospitalNew Haven, CT (S.-X.L., J.P.C., K.D., K.M.S., H.M.K.)
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of MedicineNew Haven, CT (J.P.C., K.D., H.M.K.)
| | - Kelly M Strait
- Center for Outcomes Research and Evaluation, Yale-New Haven HospitalNew Haven, CT (S.-X.L., J.P.C., K.D., K.M.S., H.M.K.)
| | | | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven HospitalNew Haven, CT (S.-X.L., J.P.C., K.D., K.M.S., H.M.K.)
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of MedicineNew Haven, CT (J.P.C., K.D., H.M.K.)
- Department of Health Policy and Management, Yale School of Public Health, Yale University School of MedicineNew Haven, CT (H.M.K.)
- Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of MedicineNew Haven, CT (H.M.K.)
- Premier, IncCharlotte, NC (T.J.L., H.M.K.)
- Correspondence to: Harlan M. Krumholz, MD, SM, 1 Church Street, Suite 200, New Haven, CT 06510. E-mail:
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Armstrong PW, Zheng Y, Westerhout CM, Rosell-Ortiz F, Sinnaeve P, Lambert Y, Lopes RD, Bluhmki E, Danays T, Van de Werf F. Reduced dose tenecteplase and outcomes in elderly ST-segment elevation myocardial infarction patients: Insights from the STrategic Reperfusion Early After Myocardial infarction trial. Am Heart J 2015; 169:890-898.e1. [PMID: 26027628 DOI: 10.1016/j.ahj.2015.03.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 03/16/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Elderly patients with ST-segment elevation myocardial infarction (STEMI) have worse outcomes and a greater risk of intracranial bleeding than nonelderly patients. Baseline characteristics, clinical outcomes, and the relationship of the tenecteplase (TNK) dose reduction to the efficacy, safety, and electrocardiographic indicators of reperfusion efficacy were evaluated in STEMI patients ≥75 years. METHODS The STREAM trial evaluated early presenting STEMI patients who could not undergo primary percutaneous coronary intervention within 1 hour of first medical contact. Because of excess intracranial hemorrhage (ICH) in patients ≥75 years, the dose of TNK was reduced by 50%. RESULTS Before dose amendment, there were 3 (7.1%) of 42 elderly patients with ICH; 2 of these were fatal, whereas no ICH occurred in the 93 elderly patients who received half-dose TNK postamendment. The median extent of ST-segment elevation resolution (≥50%) and proportion of patients with ≥2 mm in the electrocardiogram lead with greatest ST-segment elevation was comparable in elderly patients preamendment and postamendment (63.2% vs 56.0% and 43.6% vs 40.0%, respectively). Patients requiring rescue coronary intervention after TNK was also similar (42.9% vs 44.1%). The primary composite end point (30-day all-cause death, cardiogenic shock, congestive heart failure, and reinfarction) was 31.0% before versus 24.7% postamendment. CONCLUSIONS Our data, from a modest-sized population of elderly STEMI patients, indicate that half-dose TNK reduces the likelihood of ICH without compromising reperfusion efficacy. These observations are hypothesis generating and warrant further confirmation in randomized clinical trials in the elderly.
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Affiliation(s)
- Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
| | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Peter Sinnaeve
- Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Yves Lambert
- Centre Hospitalier de Versailles, SAMU 78 and Mobile Intensive Care Unit, Versailles, France
| | - Renato D Lopes
- Duke University Medical Centre, Duke Clinical Research Institute, Durham, NC
| | | | | | - Frans Van de Werf
- Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium
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21
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Su D, Yan B, Guo L, Peng L, Wang X, Zeng L, Ong H, Wang G. Intra-aortic balloon pump may grant no benefit to improve the mortality of patients with acute myocardial infarction in short and long term: an updated meta-analysis. Medicine (Baltimore) 2015; 94:e876. [PMID: 25984680 PMCID: PMC4602565 DOI: 10.1097/md.0000000000000876] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 04/15/2015] [Accepted: 04/17/2015] [Indexed: 11/26/2022] Open
Abstract
Intra-aortic balloon pump (IABP) has been extensively used in clinical practice as a circulatory-assist device. However, current literature demonstrated significantly varied indications for IABP application and prognosis.The objective of the study was to assess the potential benefits or risks of IABP treatment for acute myocardial infarction (AMI) complicated with or without cardiogenic shock.MEDLINE and EMBASE database were systematically searched until November 2014, using the terms as follows: IABP, IABC (intra-aortic balloon counterpulsation), AMI, heart infarction, coronary artery disease, ischemic heart disease, and acute coronary syndrome. Only randomized controlled trials (RCTs) that compared the use of IABP or non-IABP support in AMI with or without cardiogenic shock were included. Two researchers performed data extraction independently, and at the mean time, the risk of bias among those RCTs was also assessed.Of 3026 citations, 17 studies (n = 3226) met the inclusion criteria. There is no significant difference between IABP group and control group on the short-term mortality (relative risk [RR], 0.90; 95% confidence interval [CI], 0.77-1.06; P = 0.214) and long-term mortality (RR, 0.91; 95% CI, 0.79-1.04; P = 0.155) in AMI patients with or without cardiogenic shock. These results were consistent when the analysis was performed on studies that only included patients with cardiogenic shock, both on short-term mortality (RR, 0.91; 95% CI, 0.77-1.08; P = 0.293) and long-term mortality (RR, 0.95; 95% CI, 0.83-1.10; P = 0.492). Similar result was also observed in AMI patients without cardiogenic shock. Furthermore, the risks of hemorrhage (RR, 1.49; 95% CI, 1.09-2.04; P = 0.013) and recurrent ischemia (RR 0.54, 95% CI 0.37 to 0.79; P = 0.002) were significantly higher in IABP group compared with control group.We did not observe substantial benefit from IABP application in reducing the short- and long-term mortality, while it might promote the risks of hemorrhage and recurrent ischemia. Therefore, IABP may be not an optimal therapy in AMI with or without cardiogenic shock until more elaborate classification is used for selecting appropriate patients.
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Affiliation(s)
- Dan Su
- From the Departments of Cardiology (DS) and Emergency Medicine (BY, LP, GW), the Second Affiliated Hospital; Intensive Care Unit, the First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China (LG, XW); Cardiovascular Division, King's College London, British Heart Foundation Centre, London, United Kingdom (LZ); and Department of Cardiology, Khoo Teck Puat Hospital, Singapore (HYO)
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De Luca L, Leonardi S, Smecca IM, Formigli D, Lucci D, Gonzini L, Tuccillo B, Olivari Z, Gulizia MM, Bovenzi FM, De Servi S. Contemporary antithrombotic strategies in patients with acute coronary syndromes managed without revascularization: insights from the EYESHOT study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 1:168-78. [PMID: 27533991 DOI: 10.1093/ehjcvp/pvv006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 02/18/2015] [Indexed: 02/05/2023]
Affiliation(s)
- Leonardo De Luca
- Department of Cardiovascular Sciences, European Hospital, Via Portuense 700, Rome, Italy
| | - Sergio Leonardi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Dario Formigli
- Division of Cardiology, Azienda Ospedaliera 'G. Rummo', Benevento, Italy
| | | | | | | | - Zoran Olivari
- Department of Cardiology, Ca' Foncello Hospital, Treviso, Italy
| | | | | | - Stefano De Servi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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23
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Armstrong PW, Willerson JT. Treatment of Acute ST-Elevation Myocardial Infarction. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Paiva L, Providência R, Barra SN, Dinis P, Faustino AC, Costa M, Gonçalves L. Improving risk stratification in non-ST-segment elevation myocardial infarction with combined assessment of GRACE and CRUSADE risk scores. Arch Cardiovasc Dis 2014; 107:681-9. [DOI: 10.1016/j.acvd.2014.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 06/12/2014] [Accepted: 06/24/2014] [Indexed: 11/28/2022]
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De Luca L, Bolognese L, Valgimigli M, Ceravolo R, Danzi GB, Piccaluga E, Rakar S, Cremonesi A, Bovenzi FM, Abbate R, Andreotti F, Bolognese L, Biondi-Zoccai G, Bovenzi FM, Capodanno D, Caporale R, Capranzano P, Carrabba N, Casella G, Cavallini C, Ceravolo R, Colombo P, Conte MR, Cordone S, Cremonesi A, Danzi GB, Del Pinto M, De Luca G, De Luca L, De Servi S, Di Lorenzo E, Di Pasquale G, Esposito G, Farina R, Fiscella A, Formigli D, Galli S, Giudice P, Gonzi G, Greco C, Grieco NB, La Vecchia L, Lazzari M, Lettieri C, Lettino M, Limbruno U, Lupi A, Macchi A, Marini M, Marzilli M, Montinaro A, Musumeci G, Navazio A, Olivari Z, Oltrona Visconti L, Oreglia JA, Ottani F, Parodi G, Pasquetto G, Patti G, Perkan A, Perna GP, Piccaluga E, Piscione F, Prati F, Rakar S, Ravasio R, Ronco F, Rossini R, Rubboli A, Saia F, Sardella G, Satullo G, Savonitto S, Sbarzaglia P, Scorcu G, Signore N, Tarantini G, Terrosu P, Testa L, Tubaro M, Valente S, Valgimigli M, Varbella F, Vatrano M. ANMCO/SICI-GISE paper on antiplatelet therapy in acute coronary syndrome. Eur Heart J Suppl 2014. [DOI: 10.1093/eurheartj/suu030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abu-Assi E, Raposeiras-Roubín S, García-Acuña JM, González-Juanatey JR. Bleeding risk stratification in an era of aggressive management of acute coronary syndromes. World J Cardiol 2014; 6:1140-1148. [PMID: 25429326 PMCID: PMC4244611 DOI: 10.4330/wjc.v6.i11.1140] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 04/02/2014] [Accepted: 10/10/2014] [Indexed: 02/06/2023] Open
Abstract
Major bleeding is currently one of the most common non-cardiac complications observed in the treatment of patients with acute coronary syndrome (ACS). Hemorrhagic complications occur with a frequency of 1% to 10% during treatment for ACS. In fact, bleeding events are the most common extrinsic complication associated with ACS therapy. The identification of clinical characteristics and particularities of the antithrombin therapy associated with an increased risk of hemorrhagic complications would make it possible to adopt prevention strategies, especially among those exposed to greater risk. The international societies of cardiology renewed emphasis on bleeding risk stratification in order to decide strategy and therapy for patients with ACS. With this review, we performed an update about the ACS bleeding risk scores most frequently used in daily clinical practice.
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Loh JP, Pendyala LK, Torguson R, Chen F, Satler LF, Pichard AA, Waksman R. Incidence and correlates of major bleeding after percutaneous coronary intervention across different clinical presentations. Am Heart J 2014; 168:248-55. [PMID: 25173534 DOI: 10.1016/j.ahj.2014.05.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 05/14/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Bleeding after percutaneous coronary intervention (PCI) is identified as a strong predictor for adverse events, including mortality. This study aims to compare the incidence and correlates of post-PCI bleeding across different clinical presentations. METHODS The study included 23,943 consecutive PCI patients categorized according to their clinical presentation: stable angina pectoris (n = 6,741), unstable angina pectoris (UAP) (n = 5,215), non-ST-segment elevation myocardial infarction (NSTEMI) (n = 8,418), ST-segment elevation myocardial infarction (STEMI) (n = 2,721), and cardiogenic shock (CGS) (n = 848). RESULTS Severity of clinical presentation was associated with a greater use of preprocedural anticoagulation, glycoprotein IIb/IIIa inhibitors, and intraaortic balloon pump (IABP). TIMI-defined major bleeding increased with increasing severity of clinical presentation: stable angina pectoris, 0.7%; UAP, 1.0%; NSTEMI, 1.6%; STEMI, 4.6%; and CGS, 13.5% (P < .001). On multivariable analysis, CGS (odds ratio [OR], 4.67; 95% CI [2.62-8.34]), STEMI (OR, 3.39; 95% CI [2.07-5.55]), and NSTEMI (OR, 2.00; 95% CI [1.29-3.10]) remained correlated with major bleeding even after adjusting for baseline and procedural differences, whereas UAP did not. The multivariable model also identified the use of IABP, female gender, congestive heart failure, no prior PCI, increased baseline hematocrit, and increased procedure time as correlates for major bleeding. CONCLUSIONS In patients undergoing PCI, the worsening severity of clinical presentation corresponds to an increase in incidence of post-PCI major bleeding. The increased risk with CGS, STEMI, and NSTEMI persisted despite adjusting for more aggressive pharmacotherapy and use of IABP. Careful attention to antithrombotic pharmacotherapy is warranted in this high-risk population.
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Khan R, Ly HQ. Transradial percutaneous coronary interventions in acute coronary syndrome. Am J Cardiol 2014; 114:160-8. [PMID: 24925803 DOI: 10.1016/j.amjcard.2014.04.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 04/03/2014] [Accepted: 04/03/2014] [Indexed: 01/26/2023]
Abstract
Transradial access (TRA) is becoming increasingly used worldwide for percutaneous coronary intervention (PCI) after acute coronary syndromes (ACS). TRA compared with transfemoral access has been noted to improve clinical outcomes in clinical trials and large registry cohort studies. However, much of the benefits of TRA PCI are noted in patients with ST elevation myocardial infarction (STEMI) undergoing primary PCI, where TRA PCI has been associated with reductions in major bleeding events and potentially lower short- and long-term mortality rates. Although much less data exist for TRA PCI in unstable angina and/or non-ST elevation myocardial infarction, similar reductions in bleeding and mortality have not been consistently described. Differences in outcome benefit with TRA PCI among various ACS subtypes may be attributable to the potentially increased inherent risk of periprocedural bleeding in STEMI compared with unstable angina and/or non-ST elevation myocardial infarction. Pre- and intra-procedural factors associated with STEMI treatment, such as use of pharmacoinvasive therapy and aggressive antithrombotic regimens likely increase bleeding risk in patients. In conclusion, this review describes the evidence for TRA PCI across the spectrum of ACS and highlights why differences in clinical benefit may exist among ACS subtypes.
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Hess CN, Schulte PJ, Newby LK, Steg PG, Dalby AJ, Schweiger MJ, Lewis BS, Armstrong PW, Califf RM, van de Werf F, Harrington RA. Duration of eptifibatide infusion after percutaneous coronary intervention and outcomes among high-risk patients with non-ST-segment elevation acute coronary syndrome: insights from EARLY ACS. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 2:246-55. [PMID: 24222836 DOI: 10.1177/2048872612474922] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Eptifibatide is indicated during percutaneous coronary intervention (PCI) with continuation for 18-24 hours post procedure but is associated with bleeding. We examined the efficacy and safety of shorter post-PCI eptifibatide infusions in high-risk non-ST-segment elevation acute coronary syndrome (NSTE ACS) patients. METHODS EARLY ACS patients treated with PCI and eptifibatide were grouped by post-procedure infusion duration: <10, 10-13, 13-17, and 17-25 (per protocol) hours. Adjusted estimated event rates for 96-hour death/myocardial infarction (MI)/recurrent ischaemia requiring urgent revascularization (RIUR), 30-day death/MI, post-PCI packed red blood cell (PRBC) transfusion, and GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) moderate/severe bleeding were obtained using inverse-propensity weighting to account for informative censoring of infusions. RESULTS Among 3271 eptifibatide-treated PCI patients, there were 66 96-hour death/MI/RIUR events, 94 30-day death/MI events, 127 PRBC transfusions, and 115 GUSTO moderate/severe bleeds. Compared with per protocol, patients receiving post-PCI infusions <10 hours had similar adjusted estimated rates of 96-hour death/MI/RIUR (absolute difference 0.021 higher; 0.040 vs. 0.019, 95% CI -0.023 to 0.064; p=0.35) and 30-day death/MI (0.020 higher; 0.046 vs. 0.026, 95% CI -0.021 to 0.062; p=0.34). There were also no differences in ischaemic outcomes between infusions of 10-17 hours and per-protocol infusions. Adjusted estimated rates of PRBC transfusion were higher for the <10-hour infusion group compared with per protocol (0.048 higher; 0.079 vs. 0.031, 95% CI 0.005 to 0.091, p=0.03) but were similar for other groups. Adjusted GUSTO moderate/severe bleeding rates were similar to per-protocol rates for all groups. CONCLUSIONS In high-risk NSTE ACS patients, post-PCI eptifibatide infusions <18 hours were not associated with worse ischaemic outcomes. Shorter eptifibatide infusions in this population may be feasible.
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Alexopoulos D, Xanthopoulou I, Deftereos S, Sitafidis G, Kanakakis I, Hamilos M, Karayannis G, Angelidis C, Stavrou K, Vavuranakis M, Goudevenos JA, Stefanadis C. Bivalirudin Use and One-Month Outcome in the Context of Contemporary Antiplatelet Treatment: Insights from the Greek Antiplatelet Registry. Cardiovasc Ther 2014; 32:120-6. [DOI: 10.1111/1755-5922.12068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
| | | | - Spyridon Deftereos
- Department of Cardiology; Athens General Hospital “G. Gennimatas”; Athens Greece
| | - George Sitafidis
- Department of Cardiology; Larissa University Hospital; Larissa Greece
| | | | - Michalis Hamilos
- Department of Cardiology; Iraklion University Hospital; Iraklion Greece
| | - George Karayannis
- Department of Cardiology; Larissa University Hospital; Larissa Greece
| | - Christos Angelidis
- Department of Cardiology; Athens General Hospital “G. Gennimatas”; Athens Greece
| | - Katerina Stavrou
- Department of Cardiology; Patras University Hospital; Patras Greece
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Abstract
BACKGROUND Australia has two published national guidelines for general medical thromboprophylaxis (MT), but the two differ in detail and the basis for patient selection remains uncertain. Several aspects of current guidelines are controversial, as is the proposed design of a dedicated prescribing box in the National Inpatient Medication Chart. AIM To discuss and comment on the current standing of medical thromboprophylaxis in Australia. METHOD We have marshalled literature known to us from our previous published research, and have applied this knowledge to discuss shortcomings, which, in our opinion, exist in current medical thromboprophylaxis practice, and to suggest solutions. CONCLUSION Australian guidelines are flawed because they are based on unsuitable evidence (incidence of subclinical thrombotic disease) and define eligibility broadly, such that about 80 per cent of patients are considered eligible. They urge that prescribers should "consider" prophylaxis without supplying an adequate basis for doing so. They do not provide grounds for assessing the balance between hazard (in the form of major bleeds) and benefit (thrombotic events avoided). Other clinical factors promoting unnecessary use of medical thromboprophylaxis include the use of age as a risk factor and proposed inclusion of a new DVT prophylaxis section in the National Inpatient Medication Chart (NIMC), which implicitly discourages non-prescription of prophylaxis.
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Affiliation(s)
- Sophie E Noel
- Department of Medicine, Albany Regional Hospital, Albany, Western Australia 6330, Australia
| | - J Alasdair Millar
- Department of Medicine, Albany Regional Hospital, Albany, Western Australia 6330, Australia
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32
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Lessons learned from negative clinical trials evaluating antithrombotic therapy for ischemic heart disease. J Cardiovasc Transl Res 2014; 7:112-25. [PMID: 24464592 DOI: 10.1007/s12265-013-9532-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 12/12/2013] [Indexed: 10/25/2022]
Abstract
The clinical trials that failed to demonstrate significant efficacy may not result in development of new therapy but contribute to better understanding of antithrombotic therapy for ischemic heart disease. Negative trials provide important messages about how to interpret and understand the results of clinical trials and apply these results to clinical practices. Although every aspect of clinical trials may influence the outcomes of trials and interpretation of their results, selection of study subjects, endpoints, and measuring risk/benefit are crucial to success of clinical trial. We will review the recent key negative trials on antithrombotic therapy for ischemic heart disease and discuss about their results and implications. The challenge in the future for the development of antithrombotic therapies is to leverage these "lessons learned" from negative clinical trials to improve the design, conduct, and interpretation of future randomized clinical trials.
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de Andrade PB, E Mattos LAP, Tebet MA, Rinaldi FS, Esteves VC, Nogueira EF, França JÍD, de Andrade MVA, Barbosa RA, Labrunie A, Abizaid AAC, Sousa AGDMR. Design and rationale of the AngioSeal versus the Radial approach In acute coronary SyndromE (ARISE) trial: a randomized comparison of a vascular closure device versus the radial approach to prevent vascular access site complications in non-ST-segment elevation acute coronary syndrome patients. Trials 2013; 14:435. [PMID: 24345099 PMCID: PMC3878328 DOI: 10.1186/1745-6215-14-435] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 12/02/2013] [Indexed: 01/31/2023] Open
Abstract
Background Arterial access is a major site of bleeding complications after invasive coronary procedures. Among strategies to decrease vascular complications, the radial approach is an established one. Vascular closure devices provide more comfort to patients and decrease hemostasis and need for bed rest. However, the inconsistency of data proving their safety limits their routine adoption as a strategy to prevent vascular complications, requiring evidence through adequately designed randomized trials. The aim of this study is to compare the radial versus femoral approach using a vascular closure device for the incidence of arterial puncture site vascular complications among non-ST-segment elevation acute coronary syndrome patients submitted to an early invasive strategy. Methods ARISE is a national, multicenter, non-inferiority randomized clinical trial. Two hundred patients with non-ST-segment elevation acute coronary syndrome will be randomized to either radial or femoral access using a vascular closure device. The primary outcome is the occurrence of vascular complications at an arterial puncture site 30 days after the procedure, including major bleeding, retroperitoneal hematoma, compartment syndrome, hematoma ≥ 5 cm, pseudoaneurysm, arterio-venous fistula, infection, limb ischemia, arterial occlusion, adjacent nerve injury or the need for vascular surgical repair. Results Enrollment was initiated in September 2012, and until October 2013 91 patients were included. The inclusion phase is expected to last until the second half of 2014. Conclusions The ARISE trial will help define the role of a vascular closure device as a bleeding avoidance strategy in patients with NSTEACS. Trial registration ClinicalTrials.gov identifier: NCT01653587
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Affiliation(s)
- Pedro Beraldo de Andrade
- Invasive Cardiology, Santa Casa de Marília, Avenida Vicente Ferreira, 828 - Cascata, Marília, São Paulo 17515-900, Brazil.
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Giglia TM, Massicotte MP, Tweddell JS, Barst RJ, Bauman M, Erickson CC, Feltes TF, Foster E, Hinoki K, Ichord RN, Kreutzer J, McCrindle BW, Newburger JW, Tabbutt S, Todd JL, Webb CL. Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease. Circulation 2013; 128:2622-703. [DOI: 10.1161/01.cir.0000436140.77832.7a] [Citation(s) in RCA: 202] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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35
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Steg PG, van ‘t Hof A, Clemmensen P, Lapostolle F, Dudek D, Hamon M, Cavallini C, Gordini G, Huber K, Coste P, Thicoipe M, Nibbe L, Steinmetz J, Ten Berg J, Eggink GJ, Zeymer U, Campo dell' Orto M, Kanic V, Deliargyris EN, Day J, Schuette D, Hamm CW, Goldstein P. Design and methods of European Ambulance Acute Coronary Syndrome Angiography Trial (EUROMAX): an international randomized open-label ambulance trial of bivalirudin versus standard-of-care anticoagulation in patients with acute ST-segment-elevation myocardial infarction transferred for primary percutaneous coronary intervention. Am Heart J 2013; 166:960-967.e6. [PMID: 24268209 DOI: 10.1016/j.ahj.2013.08.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 08/26/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND In patients with ST-segment elevation myocardial infarction (STEMI) triaged to primary percutaneous coronary intervention (PCI), anticoagulation often is initiated in the ambulance during transfer to a PCI site. In this prehospital setting, bivalirudin has not been compared with standard-of-care anticoagulation. In addition, it has not been tested in conjunction with the newer P2Y12 inhibitors prasugrel or ticagrelor. DESIGN EUROMAX is a randomized, international, prospective, open-label ambulance trial comparing bivalirudin with standard-of-care anticoagulation with or without glycoprotein IIb/IIIa inhibitors in 2200 patients with STEMI and intended for primary percutaneous coronary intervention (PCI), presenting either via ambulance or to centers where PCI is not performed. Patients will receive either bivalirudin given as a 0.75 mg/kg bolus followed immediately by a 1.75-mg/kg per hour infusion for ≥30 minutes prior to primary PCI and continued for ≥4 hours after the end of the procedure at the reduced dose of 0.25 mg/kg per hour, or heparins at guideline-recommended doses, with or without routine or bailout glycoprotein IIb/IIIa inhibitor treatment according to local practice. The primary end point is the composite incidence of death or non-coronary-artery-bypass-graft related protocol major bleeding at 30 days by intention to treat. CONCLUSION The EUROMAX trial will test whether bivalirudin started in the ambulance and continued for 4 hours after primary PCI improves clinical outcomes compared with guideline-recommended standard-of-care heparin-based regimens, and will also provide information on the combination of bivalirudin with prasugrel or ticagrelor.
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36
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CRUSADE bleeding risk score validation for ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Thromb Res 2013; 132:652-8. [DOI: 10.1016/j.thromres.2013.09.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Revised: 08/16/2013] [Accepted: 09/18/2013] [Indexed: 12/19/2022]
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37
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Abu-Assi E, Raposeiras-Roubin S, Lear P, Cabanas-Grandío P, Girondo M, Rodríguez-Cordero M, Pereira-López E, Romaní SG, González-Cambeiro C, Alvarez-Alvarez B, García-Acuña JM, González-Juanatey JR. Comparing the predictive validity of three contemporary bleeding risk scores in acute coronary syndrome. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 1:222-31. [PMID: 24062910 DOI: 10.1177/2048872612453924] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Accepted: 06/15/2012] [Indexed: 01/07/2023]
Abstract
AIMS Haemorrhagic complications are strongly linked with adverse outcomes in acute coronary syndrome (ACS) patients. Various risk scores (RS) are available to predict bleeding risk in these patients. We compared the performance of three contemporary bleeding RS in ACS. METHODS We studied 4500 consecutive patients with ACS. We calculated the ACTION, CRUSADE, and Mehran et al. (2010) bleeding RS, and evaluated their performance for predicting their own major bleeding events and TIMI serious (major or minor) bleeding episodes, in patients with either non-ST-elevation ACS (NSTEACS) or ST-elevation myocardial infarction (STEMI). Calibration (Hosmer-Lemeshow test, HL) and discrimination (c-statistic) for the three RS were computed and compared. RESULTS For RS-specific major bleeding, ACTION and CRUSADE showed the best prognostic discrimination in STEMI (c=0.734 and 0.791, respectively; p=0.04), and in NSTEACS (c=0.791 and 0.810; p=0.4); being CRUSADE significantly superior to Mehran et al. in both ACS types (p<0.05). All RS performed well in patients undergoing coronary arteriography using either a radial or femoral approach (all c≥0.718); however, their discriminative capacity was modest in patients not undergoing coronary arteriography and in those previously on oral anticoagulant (all c<0.70). For TIMI serious bleeding, ACTION and CRUSADE displayed the highest c-index values in both STEMI (0.724 and 0.703, respectively; p=0.3) and NSTEACS (c=0.733 and 0.744, respectively; p=0.6); however, calibration of ACTION was poor in both ACS types (HL p<0.05). CONCLUSIONS Of contemporary bleeding RS, the CRUSADE score was found to be the most accurate quantitative tool for NSTEACS and STEMI patients undergoing coronary arteriography.
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Affiliation(s)
- Emad Abu-Assi
- Hospital Clínico de Santiago, Santiago de Compostela, Spain
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38
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Diercks DB, Kontos MC, Hollander JE, Mumma BE, Holmes DN, Wiviott S, Saucedo JF, de Lemos JA. ED administration of thienopyridines in non-ST-segment elevation myocardial infarction: results from the NCDR. Am J Emerg Med 2013; 31:1005-11. [PMID: 23702070 PMCID: PMC4045403 DOI: 10.1016/j.ajem.2013.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 02/14/2013] [Accepted: 03/01/2013] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE American Heart Association/American College of Cardiology guidelines recommend that patients with definite unstable angina or non-ST-segment elevation myocardial infarction (NSTEMI) receive dual antiplatelet therapy on presentation to the hospital when undergoing early invasive management or "as soon as possible" after admission when being managed conservatively. The guidelines do not specify whether these medications should be administered in the emergency department (ED). Our aim was to determine whether ED administration of a thienopyridine was associated with clinical outcomes among patients with NSTEMI. METHODS We examined thienopyridine use in 39454 patients with NSTEMI who received a thienopyridine within 24 hours of presentation in the National Cardiovascular Data Registry's Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines Registry from January 2007 to June 2010. Patients who were not seen initially in the ED, were transferred in, or were missing time data were excluded. We analyzed the association between ED administration of thienopyridines and outcomes and patient demographics. RESULTS Of the cohort receiving a thienopyridine within 24 hours, 9534 (24.2%) received it in the ED. Emergency department administration of a thienopyridine was not associated with in-hospital major bleeding (multivariable adjusted odds ratio, 0.99; 95% confidence interval, 0.91-1.09) or in-hospital mortality (adjusted 1.02; 95% confidence interval, 0.86-1.20). Independent predictors most strongly associated with ED thienopyridine administration were elevated troponin, ED length of stay, prior percutaneous coronary intervention, and initial electrocardiogram showing ischemic changes. CONCLUSIONS There was no association between ED thienopyridine administration and in-hospital major bleeding or mortality. Emergency department length of stay, electrocardiographic changes, and elevated troponin were associated with ED thienopyridine administration.
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Affiliation(s)
- Deborah B. Diercks
- From the Department of Emergency Medicine, University of California Davis Medical Center, Sacramento
| | - Michael C. Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA
| | - Judd E. Hollander
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bryn E. Mumma
- From the Department of Emergency Medicine, University of California Davis Medical Center, Sacramento
| | | | - Stephen Wiviott
- Division of Cardiology, Brigham and Women’s Hospital, Boston, MA
| | - Jorge F. Saucedo
- Division of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - James A. de Lemos
- Division of Cardiology, University of Texas Southwestern, Dallas, TX
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39
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De Servi S, Mariani G, Mariani M, D’Urbano M. The bivalirudin paradox. J Cardiovasc Med (Hagerstown) 2013; 14:334-41. [DOI: 10.2459/jcm.0b013e32835f1915] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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40
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Sergie Z, Lefèvre T, Van Belle E, Kakoulides S, Baber U, Deliargyris EN, Mehran R, Grube E, Reinöhl J, Dangas GD. Current periprocedural anticoagulation in transcatheter aortic valve replacement: could bivalirudin be an option? Rationale and design of the BRAVO 2/3 studies. J Thromb Thrombolysis 2013; 35:483-93. [DOI: 10.1007/s11239-013-0890-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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41
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De Servi S, Mariani G, Mariani M, D'Urbano M. How to reduce mortality in ST-elevation myocardial infarction patients treated with primary percutaneous coronary interventions: cut the bleeding. Curr Med Res Opin 2013; 29:189-94. [PMID: 23350949 DOI: 10.1185/03007995.2013.770389] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND In-hospital mortality for ST-elevation myocardial infarction (STEMI) has declined thanks to a greater use of primary percutaneous coronary interventions (PCI) associated with more effective antiplatelet and anticoagulant drugs. In this regard, bivalirudin has been shown to decrease total and cardiac mortality as compared to unfractionated heparin (UFH). OBJECTIVE The primary purpose of this analysis is to evaluate the hypothesis that the reduction of in-hospital bleeding is the most plausible explanation for the improved survival of STEMI patients treated with bivalirudin during primary PCI. The secondary objective is to reconsider the prognostic significance of the radial access alone or in association with bivalirudin on the basis of the published data. METHODS We have done a comprehensive evaluation of the main and related publications of the HORIZONS-AMI trial in addition to an extensive research by Medline of randomized trials evaluating the prognostic impact of radial access as compared with the femoral one in primary PCI. RESULTS In the HORIZONS-AMI trial bivalirudin resulted in significantly lower rates of the 30 day primary endpoint (defined as major adverse ischemic outcomes plus major bleeding) over UFH plus GPI, largely due to the significantly lower rate of the protocol-defined major bleeding. All-cause and cardiac mortality were also reduced in the bivalirudin arm at 3 year follow-up. Recent studies have also shown that the use of the radial instead of the femoral approach for primary PCI is associated with reduced bleeding as well as reduced mortality. CONCLUSIONS Our research suggests that decreasing bleeding by either a pharmacologic strategy (use of bivalirudin) or a technical approach (the transradial access) improves survival in STEMI patients undergoing primary PCI. The validity of this hypothesis should be confirmed by specific randomized trials.
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Affiliation(s)
- Stefano De Servi
- Department of Cardiovascular Diseases, Ospedale Civile di Legnano, Milan, Italy.
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42
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012; 127:e362-425. [PMID: 23247304 DOI: 10.1161/cir.0b013e3182742cf6] [Citation(s) in RCA: 1059] [Impact Index Per Article: 88.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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43
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2012; 61:e78-e140. [PMID: 23256914 DOI: 10.1016/j.jacc.2012.11.019] [Citation(s) in RCA: 2176] [Impact Index Per Article: 181.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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44
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Hibbert B, MacDougall A, Labinaz M, O’Brien ER, So DY, Dick A, Glover C, Froeschl M, Marquis JF, Wells GA, Blondeau M, Le May MR. Bivalirudin for Primary Percutaneous Coronary Interventions. Circ Cardiovasc Interv 2012; 5:805-12. [DOI: 10.1161/circinterventions.112.968966] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Data from randomized trials has demonstrated the superiority of bivalirudin to glycoprotein IIb/IIIa inhibitors plus heparin in patients undergoing primary percutaneous coronary intervention. Real-world performance of bivalirudin in primary percutaneous coronary intervention and the benefit of bivalirudin over heparin remain unknown in an era of routine dual antiplatelet therapy.
Methods and Results—
From July 2004 to December 2010, 2317 consecutive patients were indexed in the University of Ottawa Heart Institute ST-segment–elevation myocardial infarction registry. During this period 748 patients received bivalirudin, 699 patients received glycoprotein IIb/IIIa inhibitors, and 676 patients received unfractionated heparin alone. The primary outcome was the rate of noncoronary artery bypass graft related thrombolysis in myocardial infarction major bleeding. Bivalirudin significantly reduced the primary outcome compared with heparin plus glycoprotein IIb/IIIa inhibitors (2.7% versus 7.3%, adjusted OR 2.96, 95% CI: 1.61–5.45,
P
<0.001) and the composite end point of death, stroke, reinfarction and major bleed (OR 1.66, 95% CI: 1.12–2.45,
P
=0.01). Compared with heparin alone, a reduction in major bleeds (OR 1.21, 95% CI: 0.60–2.44,
P
=0.59) or the composite end point (1.05, 95% CI: 0.68–1.63,
P
=0.83) with bivalirudin could not be demonstrated. Notably, major bleeding was associated with a 5-fold increase in the risk of mortality both in-hospital (3.5% versus 20.6%) and out to 180 days (5.6% versus 25.8%).
Conclusions—
Bivalirudin use compared with glycoprotein IIb/IIIa inhibitors plus heparin as an antithrombotic strategy in primary percutaneous coronary intervention results in less major bleeding in contemporary practice. A benefit of bivalirudin over heparin could not be established with this registry and requires additional investigations to either confirm or refute.
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Affiliation(s)
- Benjamin Hibbert
- From the Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada (B.H., A.M., M.B., E.R.O., D.Y.F.S., M.C., A.D., C.G., M.F., J.M., G.A.W., M.R.L.); and Division of Cardiology, Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada (E.R.O.)
| | - Andrea MacDougall
- From the Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada (B.H., A.M., M.B., E.R.O., D.Y.F.S., M.C., A.D., C.G., M.F., J.M., G.A.W., M.R.L.); and Division of Cardiology, Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada (E.R.O.)
| | - Marino Labinaz
- From the Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada (B.H., A.M., M.B., E.R.O., D.Y.F.S., M.C., A.D., C.G., M.F., J.M., G.A.W., M.R.L.); and Division of Cardiology, Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada (E.R.O.)
| | - Edward R. O’Brien
- From the Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada (B.H., A.M., M.B., E.R.O., D.Y.F.S., M.C., A.D., C.G., M.F., J.M., G.A.W., M.R.L.); and Division of Cardiology, Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada (E.R.O.)
| | - Derek Y.F. So
- From the Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada (B.H., A.M., M.B., E.R.O., D.Y.F.S., M.C., A.D., C.G., M.F., J.M., G.A.W., M.R.L.); and Division of Cardiology, Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada (E.R.O.)
| | - Alexander Dick
- From the Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada (B.H., A.M., M.B., E.R.O., D.Y.F.S., M.C., A.D., C.G., M.F., J.M., G.A.W., M.R.L.); and Division of Cardiology, Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada (E.R.O.)
| | - Christopher Glover
- From the Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada (B.H., A.M., M.B., E.R.O., D.Y.F.S., M.C., A.D., C.G., M.F., J.M., G.A.W., M.R.L.); and Division of Cardiology, Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada (E.R.O.)
| | - Michael Froeschl
- From the Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada (B.H., A.M., M.B., E.R.O., D.Y.F.S., M.C., A.D., C.G., M.F., J.M., G.A.W., M.R.L.); and Division of Cardiology, Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada (E.R.O.)
| | - Jean-Francois Marquis
- From the Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada (B.H., A.M., M.B., E.R.O., D.Y.F.S., M.C., A.D., C.G., M.F., J.M., G.A.W., M.R.L.); and Division of Cardiology, Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada (E.R.O.)
| | - George A. Wells
- From the Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada (B.H., A.M., M.B., E.R.O., D.Y.F.S., M.C., A.D., C.G., M.F., J.M., G.A.W., M.R.L.); and Division of Cardiology, Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada (E.R.O.)
| | - Melissa Blondeau
- From the Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada (B.H., A.M., M.B., E.R.O., D.Y.F.S., M.C., A.D., C.G., M.F., J.M., G.A.W., M.R.L.); and Division of Cardiology, Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada (E.R.O.)
| | - Michel R. Le May
- From the Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada (B.H., A.M., M.B., E.R.O., D.Y.F.S., M.C., A.D., C.G., M.F., J.M., G.A.W., M.R.L.); and Division of Cardiology, Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada (E.R.O.)
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Millar JA. Measures of risk and their relationship to the relative size of a high-risk group: application to medical thromboprophylaxis. Clin Epidemiol 2012; 4:275-81. [PMID: 23152704 PMCID: PMC3496331 DOI: 10.2147/clep.s37527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The aim of this study was to establish the meaning of "high-risk" when the subgroup so defined by risk factor analysis is a substantial proportion of the population. This is clinically important when patients, deemed to be at high risk as a result of risk factor analysis, become eligible for a clinical intervention to decrease the risk, especially if the intervention has adverse effects. One example in clinical practice is the assessment of eligibility for medical thromboprophylaxis. METHODS Equations were derived relating risk and the proportion of the population (F) deemed to be at high risk on risk factor analysis, based on the formula for weighted average. The equations were validated for the population of medical inpatients at high- or low-risk of thromobembolic events using a spreadsheet model of thrombosis risk containing known risk factors for venous thromboembolism in this population. RESULTS The validated equations define an upper limit of absolute and incremental risk (risk relative to the whole population) in the high-risk group that is a function of or equal to 1/F, respectively. The added risk in the high-risk group declines to zero as F tends to 1, because it must be balanced by the diminishing risk in the progressively smaller low-risk group while maintaining the population average. CONCLUSION The results of this study have implications for the validity of the published eligibility criteria for medical thromboprophylaxis.
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Affiliation(s)
- J Alasdair Millar
- Medical Department, Albany Regional Hospital, Albany, Western Australia, Australia
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Sergie Z, Gukathasan N, Yu JJ, Mehran R. The Use of Bivalirudin in ST-Segment Elevation Myocardial Infarction: Advantages and Limitations. Interv Cardiol Clin 2012; 1:441-451. [PMID: 28581962 DOI: 10.1016/j.iccl.2012.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The incidence of ST-segment elevation myocardial infarction (STEMI) is a common, albeit declining, manifestation of coronary heart disease. Significant improvements in cardiovascular outcomes and mortality in STEMI patients have occurred in recent years, reflecting evolution in the understanding of the pathophysiological mechanisms and therapeutic targets of this disease. Nonetheless, the risks of recurrent ischemia and bleeding complications in this population remain substantial. This review focuses on the adjunctive anticoagulant agents used in the management of STEMI. Major insights from the HORIZONS-AMI trial regarding the impact of bivalirudin on both hemorrhagic and ischemic outcomes in STEMI patients are discussed.
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Affiliation(s)
- Ziad Sergie
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Nilusha Gukathasan
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Jennifer J Yu
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Roxana Mehran
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA; Cardiovascular Research Foundation, 111 East 59th Street, New York, NY 10022, USA.
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Abstract
PURPOSE OF REVIEW Major bleeding in the setting of acute coronary syndromes and percutaneous coronary intervention has been associated with increased short-term and long-term risk for adverse cardiac events and mortality. Recent studies on antithrombotic agents in this setting have highlighted their differential impact on ischemic and hemorrhagic complications. RECENT FINDINGS To measure bleeding events consistently, an updated standardized definition has been developed by the Bleeding Academic Research Consortium (BARC) representatives. Additionally, the antithrombin agent bivalirudin has emerged as a frontrunner in the invasive management of acute coronary syndromes because of fewer bleeding complications, lower long-term mortality, and similar efficacy compared with heparin plus a glycoprotein IIb/IIIa inhibitor. The mortality benefit with bivalirudin is most likely correlated with reductions in major bleeding, including in-hospital, access-site, and nonaccess site bleeding, and despite the use of preprocedural unfractionated heparin. SUMMARY The BARC definition is an improved version of prior bleeding classifications, and will likely play a significant role in comparing different anticoagulation strategies in future clinical trials and registry analyses. Bivalirudin has been shown to reduce bleeding events in a multitude of diverse clinical settings and bleeding definitions, and has become the preferred antithrombotic agent in the setting of acute coronary syndromes.
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Millar JA, Lett JE, Bagley LJ, Densie IK. Eligibility for medical thromboprophylaxis based on risk‐factor weights, and clinical thrombotic event rates. Med J Aust 2012; 196:457-61. [DOI: 10.5694/mja11.10737] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- J Alasdair Millar
- Albany Regional Hospital, Albany, WA
- Southland Hospital, Invercargill, New Zealand
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Da Pozzo E, Barsotti MC, Bendinelli S, Martelli A, Calderone V, Balbarini A, Martini C, Di Stefano R. Differential effects of fondaparinux and bemiparin on angiogenic and vasculogenesis-like processes. Thromb Res 2012; 130:e113-22. [PMID: 22497885 DOI: 10.1016/j.thromres.2012.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 02/14/2012] [Accepted: 03/13/2012] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Conventional therapy for venous thromboembolism or acute coronary syndrome involves the administration of glycoanticoagulants (heparins) or oligosaccharides (fondaparinux). We evaluated the effects of such drugs on angiogenesis and vasculogenesis-like models. MATERIALS AND METHODS Human umbilical vein endothelial cells or human endothelial progenitor cells were treated with bemiparin, fondaparinux or unfractionated heparin, at concentrations reflecting the doses used in clinical practice. After 24h, cell viability, proliferation, tubule formation and angiogenic molecular mechanisms, such as activation of the serine/threonine kinase AKT, were assessed. In vivo angiogenesis was studied using a Matrigel sponge assay in mice. RESULTS Bemiparin gave a significant decrease of in vitro angiogenesis as shown by the reduction of endothelial cell tubule network, while both fondaparinux and unfractionated heparin did not show any significant effect. In assays of Matrigel sponge invasion in mice, unfractionated heparin was able to stimulate angiogenesis and, conversely, bemiparin inhibited angiogenesis. Furthermore, both bemiparin and fondaparinux caused a significant reduction in an in vitro vasculogenesis-like model, as demonstrated by the decrease of tubule network after co-seeding of endothelial progenitor cells and human umbilical vein endothelial cells. In addition, unfractionated heparin but not bemiparin was able to increase AKT phosphorylation. CONCLUSIONS In in vitro experiments, bemiparin was the only drug to show an anti-angiogenic and vasculogenic-like effect, unfractionated heparin showed only a trend to increase in angiogenesis assay and fondaparinux affected only the vasculogenesis-like model. Notably, the in vivo experiments corroborated these data. Such results are important for the choice of a patient-tailored therapy.
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Affiliation(s)
- Eleonora Da Pozzo
- Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa, Pisa, Italy.
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